Transfusion-associated adverse events incidence and severity after the implementation of an active hemovigilance program with 24 h follow-up. A prospective cohort study

BACKGROUND

Hemovigilance (HV) is usually based on voluntary reports (passive HV). Our aim is to ascertain credible incidence, severity, and mortality of transfusion-associated adverse events (TAAEs) using an active HV program.

STUDY DESIGN AND METHODS

Prospective cohort study to estimate transfusion risk after 46,488 transfusions in 5830 patients, using an active HV program with follow-up within the first 24 h after transfusion. We compared these results to those with the previously established passive HV program during the same 30 months of the study. We explored factors associated with the occurrence of TAAEs using generalized estimating equations models.

RESULTS

With the active HV program TAAEs incidence was 57.3 (95% CI, 50.5-64.2) and mortality 1.1 (95% CI, 0.13-2.01) per 10,000 transfusions. Incidence with the new surveillance model was 14.0 times higher than with the passive. Most events occurred when transfusions had already finished (60.2%); especially pulmonary events (80.4%). Three out of five deaths and 50.3% of severe TAAEs were pulmonary. In the multivariate analysis surgical patients had half TAAEs risk when compared to medical patients (OR, 0.53; 95% CI, 0.34-0.78) and women had nearly twice the risk of a pulmonary event compared to men (OR, 1.84; 95% CI, 1.03-3.32). Patient's age, blood component type, or blood component shelf-life were unrelated to TAAEs risk.

DISCUSSION

Active hemovigilance programs provide additional data which may lead to better recognition and understanding of TAAEs and their frequency and severity.

Surgery-first or orthognathic surgery approach: Psychosocial and physical changes

Introduction

Two surgical approaches exist for malocclusion: in the surgery-first approach the orthognathic surgery precedes the orthodontic treatment, treating facial esthetics first and then occlusion, whereas in the conventional approach (the orthodontics-first approach) the orthodontic treatment precedes the orthognathic surgery, treating occlusion first and then facial esthetics. The advantages of the surgery-first approach include the fact that patient's dental function, and facial esthetics are restored and improved soon after the beginning of treatment. Moreover, the entire treatment lasts only 1 to 1.5 years or less and orthodontic management is easier to achieve.

Aims

Our study aims to compare patients undergoing surgery-first or orthognathic surgery approach as for as self-esteem, satisfaction with their appearance in the pre- and postoperative care, quality of life and psychosocial changes, are concerned.

Methods

We recruited 50 patients undergoing surgery-first or orthognathic surgery approach at SC Maxillo-Facciale of Novara between October 2014 and December 2017. Assessment were performed at baseline (T0) and at follow-up (T1: 5 weeks; T2: 5–6 months), with Rosenberg Self-Esteem Scale (RSES), Temperament and Character Inventory (TCI: only at T0), Short Form Health Survey 36 (SF-36), Beck Depression Inventory (BDI-II), Resilience Scale for Adult (RSA), Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ), Oral Health Impact Profile (OHIP-14).

Results

Data collection is still ongoing. We expect to find a better quality of life and higher self-esteem in patients undergoing surgery first approach.

Conclusion

Satisfaction is crucial for patients’ adherence to treatment and to avoid revolving door. Clinical implications will be discussed.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Significant increase in the colonisation of Staphylococcus aureus among medical students during their hospital practices]

INTRODUCTION

Staphylococcus aureus is a pathogen of major concern. The emergence of methicillin-resistant S. aureus (MRSA) has increasingly complicated the therapeutic approach of hospital-acquired infections. Surveillance of MRSA and control measures must be implemented in different healthcare settings, including screening programs for carriers. Our first aim was to determine the prevalence of methicillin-susceptible S. aureus (MSSA) and MRSA nasal carriage in medical students from the Clínico San Carlos Hospital (Madrid). As the MRSA carrier rate in healthcare workers is higher than in the general population, we hypothesised that carrier rate could be increased during their clinical practice in their last three years.

METHODS

We performed an epidemiologic al study of the prevalence of S. aureus colonisation among a group of medical students, who were sampled in 2008 in their third-year, and in 2012 when this class was in its sixth year.

RESULTS

We have found a significant increase in MSSA carriage, from 27% to 46%. There were no MRSA colonisations in the third-year, but one was found in the sixth-year group. The large majority of strains (89%) of strains were resistant to penicillin, and 27% to erythromycin and clindamycin. As 19 coagulase-negative Staphylococcus MR were also identified, a horizontal transfer of genes, such as mecA gene to S. aureus, could have occurred.

CONCLUSIONS

Medical students are both, at risk for acquiring, and a potential source of nosocomial pathogens, mainly MSSA. Therefore, they should take special care for hygienic precautions, such as frequent and proper hand washing, while working in the hospital.

European Collaborative Group on Prostate Brachytherapy: Preliminary Report in 1175 Patients

OBJECTIVE

To establish a multi-centre database of a large number of patients treated with brachytherapy across Europe.

METHODS

A total of 1175 patient files were registered in the database and the completeness of the data on these patients resulted in the majority being included in the analysis.

RESULTS

The database of patients treated with brachytherapy across Europe indicates that optimal patient selection for this procedure has been made, both in terms of outcome and side-effects, which will be subject of future analyses. This should enable refinement of the treatment choice and administration as well as provide useful guidance to other centres that want to establish this procedure for their patients. It will also set the ground for prospective studies.

CONCLUSIONS

The established database indicates that brachytherapy as a treatment option for prostate cancer is well established in many centres.

Seed migration in prostate brachytherapy: a re-implant case report

Seed embolisation to the lung is a possible risk following permanent prostate brachytherapy. The purpose of this work is to analyse a seed migration case and to suggest methods to reduce such occurrences. With this aim, the clinical history of the patient who experienced seed migration, the implant technique and the pre- and post-plan procedures have been investigated. The massive seed migration has been detected in the patient by means of a pelvic X-ray and a CT-scan of the thorax. The use of loose seeds, the implant technique and the presence of unfavourable anatomical characteristics, have been recognised as possible causes of this event. The use of linked seeds embedded in vicryl sutures for the peripheral portions of prostate, and the development of an implant technique based on both transverse and longitudinal ultrasound guidance are proposed in order to reduce seed migration.

Sildenafil taken at bedtime significantly increases nocturnal erections: results of a placebo-controlled study

OBJECTIVES

Nighttime erections occur at all ages and contribute to the maintenance of the morphodynamic integrity of smooth muscle cells within the corpora cavernosa. This study was aimed at evaluating the effect on nocturnal erections of sildenafil versus a placebo taken at bedtime.

METHODS

A double-blind, crossover, placebo-controlled study design was used to examine the effects of sildenafil and placebo on sleep-related erectile activity. Thirty selected patients with erectile dysfunction (vasculogenic etiology, 22 patients [73%]; psychogenic etiology, 8 patients [27%]) were submitted to a polysomnographic recording of nocturnal erections, using a RigiScan device during 3 consecutive nights. After a first night of adaptation, the 2 following nights were used to study patients after the administration of sildenafil (100 mg) or a placebo taken at bedtime.

RESULTS

Twenty-three patients (77%) showed a significantly improved nocturnal erectile activity (according to the calculation of rigidity and tumescence activity units) after the administration of sildenafil (P <0.01), 5 patients (17%) showed comparable nocturnal erections with sildenafil and placebo, and 2 patients (6%) showed a significantly improved nocturnal erectile activity after taking the placebo (P <0.05). Overall, mean rigidity and tumescence activity values at the tip and base of the penis were significantly improved after sildenafil rather than placebo administration (P <0.001). The duration of tip rigidity greater than 60% was significantly longer during the night with sildenafil (P <0. 001). Although the number of erectile episodes was greater during the sildenafil night, this did not reach statistical significance.

CONCLUSIONS

In most patients with good sleep efficiency and who have erectile dysfunction, sildenafil, rather than a placebo, taken at bedtime produces a significantly improved nocturnal erectile activity. Further studies are needed to verify whether this preliminary finding may constitute the basis for the use of sildenafil as a tool for preventing erectile dysfunction.

Low dose bacillus Calmette-Guerin for carcinoma in situ of the bladder: long-term results

PURPOSE

Bacillus Calmette-Guerin (BCG) is standard treatment for carcinoma in situ of the bladder. However, its long-term effectiveness is still debated.

MATERIALS AND METHODS

From January 1987 to January 1995, 70 consecutive patients with primary or secondary carcinoma in situ with or without concomitant solitary or multifocal papillary tumor were treated with weekly instillations of 75 mg. Pasteur strain BCG for 6 weeks after histological diagnosis. An additional induction course was given to patients with relapse. Tumor-free patients were given a maintenance course of monthly instillations for 12 months.

RESULTS

At the end of induction course 1, 56 of the 70 patients (80%) were tumor-free. Of 14 patients given induction course 2, 9 had a complete response (64.2%). A total of 65 patients (92.8%) were disease-free after 1 or 2 courses and given the maintenance course. Median followup for disease-free patients was 74 months (range 17 to 134). Subsequently 50 patients (71.4%) were disease-free, 12 (17.1%) had recurrence and 8 (11.4%) had progression. Mean time was 18 months (range 6 to 69) to treatment failure and 13 months (range 7 to 53) to progression. Of the patients 1 died of disease and 10 of other causes. Crude survival was 84.2%, disease specific mortality 1.4% and nondisease specific mortality 14.2%. The risk of treatment failure was significantly greater for carcinoma in situ associated with stage T1 papillary tumor (p = 0.0001) or severe dysplasia (p = 0.0005), and the risk of disease progression was significantly greater for carcinoma in situ associated with stage T1 papillary tumor (p = 0.0001). The drug was well tolerated with few side effects.

CONCLUSIONS

Intravesical BCG is the best available conservative therapy for patients with carcinoma in situ of the bladder. Low dose BCG is similarly effective, with a lower incidence of side effects and long lasting positive outcome.

Intravesical bacille Calmette-Guérin in Stage T1 grade 3 bladder cancer therapy: a 7-year follow-up

OBJECTIVES

To assess the long-term results of intravesical bacille Calmette-Guérin (BCG) treatment for Stage T1 grade 3 (T1G3) transitional cell carcinoma (TCC) of the bladder.

METHODS

Fifty-one patients with T1G3 TCC were treated with induction plus maintenance BCG courses after transurethral resection and followed up for at least 5 years or until death.

RESULTS

The median follow-up of progression-free patients was 85 months (range 64 to 108). During this period 32 (62.7%) of 51 patients remained progression free, 9 (17.6%) progressed, 8 (15.7%) died of other causes, and 2 (3.9%) were lost to follow-up. Seven patients had extravesical involvement: 5 (9.8%) of 51 had an upper urinary tract tumor and 3 (7.9%) of 38 had prostatic involvement (1 of the 7 had both). The risk of disease progression was significantly higher for patients with a tumor measuring 3 cm or more and those with tumor associated with carcinoma in situ (CIS) in multivariate analyses and for patients with recurrent tumors, solid tumors, or early T1G3 recurrence after BCG in univariate analyses. At last follow-up, 34 patients (66.7%) were alive; 8 (15.7%) had died of causes unrelated to the disease, 7 (13.7%) had died of bladder cancer, and 2 (3.9%) had been lost to follow-up. Disease-specific survival was 86.3%.

CONCLUSIONS

Intravesical BCG is an effective conservative treatment for T1G3 bladder cancer. Patients with negative prognostic factors such as coexisting CIS or large, solid, or recurrent tumor should be followed up closely and if T1G3 recurs early after the BCG induction course, immediate cystectomy should be performed.

Intravesical instillation of mitomycin-C in 242 patients with superficial bladder cancer at high risk of recurrence: long-term results

OBJECTIVE

The present study evaluated the long-term results of intravesical mitomycin C (MMC) instillation after transurethral resection (TUR) in 242 consecutive patients with superficial bladder cancer at high risk of recurrence (stage Ta, grade 1-3, or stage T1, grade 1 and 2, primary multiple or recurrent tumor).

MATERIALS AND METHODS

242 patients were treated with weekly instillations of 40 mg MMC for 8 weeks after TUR. Tumor-free patients then followed a maintenance course with monthly instillations for 3 months.

RESULTS

Median follow-up of disease-free patients is 43.5 (range 23-112) months. The incidence of first recurrence is 59.5% (144/242 patients) with a median time to first recurrence of 29 months. 95 patients (39.3%) remained disease-free. Three had disease progression as the first event. The risk of recurrence was significantly higher for multifocal tumors (p = 0.0023, hazard ratio 1.79, 95% CI 1.23-2.59). Overall, patients have been followed for a median time of 57 (range 10-114) months. During this period the recurrence rate was 4.9. Eleven more patients had disease progression. The progression rate is 5.8% (14/242), with a mean time to progression of 34 months. At present 209 patients are alive, 6 have died of bladder cancer, 16 of causes unrelated to the disease and 11 (4.5%) have been lost to follow-up. Thus the crude survival rate is 86.4%, disease-specific mortality 2.5%, and non-disease-specific mortality 6.6%.

CONCLUSIONS

Patients with multiple tumors seem to benefit the least from MMC instillation. Probably recurrent disease could be better prevented with intravesical bacillus Calmette-Guérin.

Upper urinary tract tumors developing after treatment of superficial bladder cancer: 7-year follow-up of 591 consecutive patients

OBJECTIVES

To evaluate upper urinary tract tumor (UUTT) incidence and characteristics in 591 consecutive patients with low-, intermediate-, or high-risk superficial bladder cancer, who were followed up for at least 5 years or until death.

METHODS

From 1986 to 1992, 591 patients were treated for superficial bladder cancer: 216 patients with primary, solitary, low-grade (G1-G2), and low-stage (Ta-T1) superficial bladder cancer were considered at low risk of disease recurrence and treated with transurethral resection (TUR) alone; 182 patients with recurrent or multifocal superficial bladder cancer were considered at intermediate risk of disease recurrence or progression and treated with intravesical chemotherapy after TUR; 193 patients with carcinoma in situ, high-grade (G3) superficial bladder tumor, or intravesical chemotherapy failure were considered at high risk of disease recurrence or progression and treated with bacille Calmette-Guérin (BCG).

RESULTS

After a median follow-up of 86 months (range 20 to 143), 2 (0.9%) of 216 patients at low risk, 4 (2.2%) of 182 patients at intermediate risk, and 19 (9.8%) of 193 patients at high risk developed UUTTs. The incidence of UUTTs is significantly higher in patients at high risk than in those at low risk (P = 0.0004, odds ratio = 11.6, 95% confidence interval [CI] 2.5 to 40.7) or at intermediate risk (P = 0.004, odds ratio = 4.8, 95% CI 1.5 to 17.2), or both (P = 0.000006, odds ratio = 7.3, 95% CI 2.6 to 20.3). The difference between patients at low risk and those at intermediate risk was not statistically significant (P = 0.5, odds ratio = 0.4, 95% CI 0.02 to 2.6). After a median time of 36 months (range 9 to 119) from UUTT diagnosis, 5 (20%) of 25 patients have died of the disease.

CONCLUSIONS

The incidence of metachronous UUTTs is low in patients with superficial bladder cancer at low or intermediate risk of disease recurrence or progression and significantly higher for patients at high risk. Because UUTT is often asymptomatic, and mortality is high, frequent and lifelong examination of the upper urinary tract is suggested, with an annual intravenous urogram and urinary cytologic analysis every 4 months in patients with superficial bladder cancer at high risk of disease recurrence or progression.

Chemioterapia primaria e trattamento delle masse residue nei tumori germinali non seminomatosi del testicolo. La nostra esperienza

Thanks to the introduction of new chemotherapeutic agents, treatment of non-seminomatous germinal cell tumours (NSGCT) has dramatically improved during the last two decades. The association of chemotherapy and surgery has further increased the therapeutic success rate. The authors report their experience on this subject over the last ten years. Although the number of patients is relatively small and statistically insignificant, the results compare well with those of large centres dealing with this pathology.

Angiomiolipoma renale: Nostra esperienza in 14 casi sottoposti a terapia chirurgica

Renal angiomyolipoma (AML) is an uncommon hamartomatous benign tumour and may present in an isolated form or associated with tuberous sclerosis (Bourneville's disease). Since there is no specific symptomatology when dimensions are small or medium, discovery is often accidental and the tumour may sometimes grow to a considerable size. In the symptomatic forms or larger tumours, surgery may be indicated due to the risk of retroperitoneal hemorrhage, both spontaneous and secondary to lumbar trauma, however slight. As the tumour is benign, kidney-sparing surgery should be as conservative as possible. For this purpose, ultrasound and CT scan are considered essential for a differential diagnosis between AML and parenchymal renal masses. In our experience with 14 cases (12 women and 2 men; minimum age 31 years, maximum 62 years) of monolateral renal AML (10 right kidney AML and 4 left kidney AML) in patients not suffering from tuberous sclerosis, treated surgically between August 1988 and February 1997, the pre-operative ultrasound and CT scan gave a correct diagnosis in 7 cases, a suggestion of renal carcinoma in 5 cases while leaving doubts in 2 cases. The two methods of investigation therefore proved not to be error-free. Following instrumental diagnosis, 12 patients underwent enucleoresection of the tumour while the remaining two underwent extensive nephrectomy. The presence of hemorrhagic areas with AML was considered to be the frequent cause of pre-operative diagnostic error.

Low dose Pasteur bacillus Calmette-Guerin regimen in stage T1, grade 3 bladder cancer therapy

PURPOSE

We assessed the effectiveness of intravesical bacillus Calmette-Guerin (BCG) for high risk transitional cell carcinoma of the bladder.

MATERIALS AND METHODS

A total of 51 patients with stage T1, grade 3 disease was treated with weekly instillations of 75 mg. Pasteur strain BCG for 6 weeks after transurethral resection for bladder cancer. An additional induction course was given to patients with relapse. Tumor-free patients followed a maintenance course with monthly instillations for 12 months.

RESULTS

After the initial induction course 37 of 51 patients (72.5%) remained tumor-free. A second induction course was necessary in 13 patients. After 1 or 2 induction courses 44 of 51 patients (86.3%) were tumor-free. The maintenance course was administered to 44 patients, with 41 remaining tumor-free. After a median followup of 33 months (range 3 to 63) 28 patients (54.9%) were disease-free, 12 (23.5%) had recurrent tumors and 7 (13.7%) had progression. The risk of treatment failure was significantly greater for solid than papillary tumors (p = 0.0006), recurrent than primary tumors (p = 0.0052) and coexisting carcinoma in situ (p = 0.124) in multivariate analysis, and for early recurrence (p = 0.0001) in univariate analysis only. The drug was well tolerated with few side effects.

CONCLUSIONS

Our data suggest that this low dose Pasteur BCG regimen is effective in the treatment of high risk superficial bladder cancer. Some tumor characteristics, such as solid appearance, coexisting carcinoma in situ, history of superficial transitional cell carcinoma and early relapse after the initial induction course, seem to be negative prognostic factors.

The Margins

The gradual increase in indications for radical prostatectomy over these last few years has focussed attention on the issue of surgical margin positivity. In terms of prognosis, a positive surgical margin is comparable to lymph node positivity. The routine adoption of the most advanced anatomo-histological methods has increased our 17.5% of positive surgical margins to 30.2% despite surgical indication having become increasingly more rigid. In addition, more precise preoperative staging by echo-guided biopsy of the seminal vesicles and of periprostatic spaces, has allowed patients with positive lymph nodes to be reduced to just over 1%.

[T1G3 transitional cell carcinoma of the bladder: our experience with 44 patients treated with intravesical BCG after TUR]

Forty-four patients affected by poorly differentiated (G3) superficial TCC invading lamina propria (stage T1) were treated with intravesical BCG. They underwent weekly instillations of 75 mg BCG for six week after trans-urethral resection (TUR) of bladder cancer. An additional induction course was given to patients who relapsed. A maintenance course with monthly instillations for twelve months followed in complete responder patients. After the first induction course, 34/44 patients (77.2%) showed complete response. In 10 patients a second induction course was necessary, with complete response in four. After one or two induction course, 38/44 patients (86.5%) showed complete response. The maintenance course was administered to 38 patients with 35/38 complete responses. After a median follow-up of 30 months, there were 29/44 (65.9%) disease free patients, 11/44 (25%) tumor recurrences and 4/44 (9%) tumor progressions. The drug has been well tolerated with few side effects. Our data suggest that intravescical BCG after TUR is effective in the treatment of high-risk superficial bladder cancer and we believe that it can be used a first approach in treating patients affected by T1G3 bladder cancer.

[Our current indications for radical prostatectomy]

Radical prostatectomy is the golden standard for localized prostate cancer. The identification of patients with intraprostatic disease who can be cured and will live long enough to benefit from a surgical therapy represents the primary goal of the authors. Target of this article is underlining the importance of an accurate preoperative staging through ultrasound-guided biopsy of seminal vesicles and periprostatic spaces. The positivity of the surgical margin after radical prostatectomy is also taken into account as it represents, according to the authors, an extremely important but often overlooked parameter.

Urologist: Clinical information system for urology

“Urologist” was developed to run a Department of Urology. A local area network (LAN), one server and five stations, connects the single functional units of the Department (O.R.; I.C.U.; wards; Spinal Unit and Patient services). A Patient Identification Card integrates both clinical and organisational data. A multidisciplinary group, consisting of medical and non-medical specialists, was necessary to develop this system.

[Conservative therapy of parenchymal renal carcinoma]

From January 1987 to October 1990, 20 patients (16 M. 4 F.) affect by localized renal cell carcinoma, underwent a conservative surgical treatment. This case study includes 8 patients with bilateral (4 synchronous-4 asynchronous), and 12 patients with unilateral renal carcinoma. In the latter group only two patients had a pathological contralateral kidney. A parenchyma sparing operation was performed electively in 10 cases and was necessary in the other 10. The tumors were found to be PT1 or pT2 in all the elective cases, except one unexpected pT3a; 1pT1, 5pT2, 1pT3a and 3pT3b in the remaining group. The follow up ranges between 1 and 36 months, two deaths in bilateral tumors cases were observed. No local recurrences have been detected up to now.

Randomized comparison of different prostaglandin analogues and laminaria tent for preoperative cervical dilatation. World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction: Task Force on Prostaglandins for Fertility Regulation

In an eleven-centre study, 627 nulliparous subjects in the 8th to 12th week of gestation admitted for termination of pregnancy were allocated to one of five treatments to induce pre-operative cervical dilatation. The treatments were: 0.5 mg PGE2 methyl sulphonylamide; 1.0 mg PGE1 methyl ester; 30 mg 9-methylene PGE2 free acid, 0.5 mg 15-methyl PGF2 alpha; a single medium-sized laminaria tent. The results indicate that the three PGE analogues are at least equally effective as one medium sized laminaria tent and more effective than 0.5 mg 15-methyl PGF2 alpha in producing adequate pre-operative cervical dilatation prior to vacuum aspiration. It is concluded that both pre-treatment with prostaglandin analogues and laminaria tent are effective methods for preoperative cervical dilatation and both types of treatment are associated with a low incidence of side effects. Prostaglandin analogue treatment can be administered by paramedical personnel but laminaria tent insertion has to be performed by medical staff.