Antifungal usage in children undergoing intensive treatment for acute myeloid leukemia: analysis of the multicenter clinical trial AML-BFM 93

We retrospectively analyzed the antifungal usage in children with acute myeloid leukemia (AML). Overall, 211 of 304 patients (69.4%) received a total of 389 antifungal treatment episodes. In 234 episodes, initial antifungal treatment consisted of amphotericin B [as monotherapy, n = 193; median dosage (range) of amphotericin B deoxycholate 0.6 mg/kg per day (0.02-1.5 mg/kg per day) and of liposomal amphotericin B 3.0 mg/kg per day (0.6-30 mg/kg per day)], in 149 episodes of fluconazole [as monotherapy, n = 143; 5 mg/kg per day (1-29 mg/kg per day)], in 40 of flucytosine [as monotherapy, n = 1; 150 mg/kg per day (40-370 mg/kg per day)], and in 9 of itraconazole [as monotherapy, n = 8; 6 mg/kg per day (1.6-20 mg/kg per day)]. We conclude that the majority of children with AML receives at least one episode of antifungal therapy. Inappropriate dosing and combination of antimycotics need to be addressed in future educational measures.

Infectious complications in pediatric acute myeloid leukemia: analysis of the prospective multi-institutional clinical trial AML-BFM 93

Infections still remain a major cause of therapy-associated morbidity and mortality in children with acute myeloid leukemia (AML). To improve supportive care measurements, detailed information on frequency and characteristic features of infectious complications is needed. We retrospectively analyzed the medical charts of 304 children, treated in 30 hospitals according to the multi-institutional clinical trial AML-BFM 93. Overall, 855 infectious complications occurred in 304 patients (fever without identifiable source (n=523; 61.2%), clinically (n=57; 6.7%) and microbiologically documented infections (n=275; 32.1%)). Neutropenia was present in 74.1% of the infectious episodes. In all, 20 patients died of infection-associated complications (15/276 (5.4%) patients without and 5/28 (17.9%) with Down syndrome), most of them during early induction therapy (n=11). Blood stream infections occurred in 228 episodes (Gram-positive (n=202) and Gram-negative (n=42) pathogens). Invasive fungal infection was probable or proven in 15 patients. In 113 out of the 855 infectious episodes (13.3%), pneumonia was radiologically diagnosed. Better strategies of supportive care might help to improve overall survival in children undergoing chemotherapy for AML. Therefore, children with AML should be treated in specialized pediatric centers, and there should be a very low threshold to readmit patients, in particular patients with pulmonary symptoms.

Synthetic real estate: bringing corporate finance to health care

The changing landscape of health care has caused hospitals, health care systems, and other health care organizations to look for ways to finance expansions and acquisitions without "tainting" their balance sheets. This search has led health care executives to a financing technique that has been already embraced by Fortune 500 companies for most of this decade and more recently adopted by high-tech companies: synthetic real estate. Select case studies provide examples of the more creative financial structures currently being employed to meet rapidly growing and increasingly complex funding needs.

[Current aspects of secondary and tertiary prevention from the viewpoint of the clinical gerontologist]

Prevention is of importance when the patient is already suffering from a serious disease, e.g., from arterial obstructive disease causing a stroke or an amputation, from a hip fracture or other diseases that might threaten his independence. Prevention covers a wide field of topics. Most importantly, the patient must recover from his acute disease. It is important to avoid complications which are not specific for the disease but are typical for a bedridden old person (decubital ulcer, dehydration etc.). Prevention also means to avoid recurrence of the same disease as well as complications that frequently occur during the clinical course and may influence the outcome (spasticity in stroke patients, muscular calcification following hip replacement).

Capital financing along the integration highway

In the process of reshaping the entire nation's health care delivery system, it is only natural that financing vehicles which we once considered "standard" are evolving as well. The purpose of this article is to explore some of the creative and nontraditional vehicles available to emerging health care organizations and integrated systems to access capital. This brief overview focuses on the organizational structures, financial characteristics, and financial structures of emerging health care delivery networks and providers. Select case studies provide examples of the more creative financial structures currently being employed to meet rapidly growing fund needs.