Should we treat patients with only one set of positive blood cultures for extensively drug-resistant Acinetobacter baumannii the same as multiple sets?

Acinetobacter species are not considered skin commensals and under-treatment is an overriding concern when caring for critically-ill patients who are mostly at risk of extensively drug-resistant Acinetobacter baumannii (XDRAB) infections. Hence even a single blood culture yielding XDRAB will tend to prompt intervention. However, field observations suggest that patients with single-positive blood cultures had milder disease and were more likely to be recruited in interventional studies than those with multiple-positive blood cultures, yet no distinction is made in current clinical or trial recruitment practices. To our knowledge, this is the first study to compare the clinical characteristics and outcomes of patients with single-positive versus multiple-positive blood cultures for XDRAB. In this multicenter prospective cohort study of XDRAB bacteremic patients from July 2010 to June 2015, only patients with at least two simultaneously drawn blood cultures were included. The patients were classified as having single-positive or multiple-positive blood cultures according to the number of positive blood cultures yielding XDRAB. The primary end-point was the 28-day mortality. Of a total of 155 patients enrolled, 69 had a single-positive and 86 had multiple-positive blood cultures. Leukopenia (37.2% vs. 16.2%; P = 0.004), thrombocytopenia (56.0% vs. 26.5%; P < 0.001), higher Pitt bacteremia scores (6.6 vs. 5.5, P = 0.03) and higher 28-day mortality rates (70.9% vs. 43.5%; P = 0.001) distinguished patients with multiple-positive from those with single-positive cultures. Multivariate logistic regression showed that multi-positivity independently predicted 28-day mortality (adjusted odds ratio, 2.34; 95% confidence interval (CI), 1.03–5.28; P = 0.04) and the Cox regression confirmed that multi-positivity (adjusted hazard ratio, 1.80; 95% CI, 1.13–2.85; P = 0.01) predicted rapid mortality. Patients with multiple versus single positive blood cultures yielding XDRAB had greater morbidity and mortality. Investigators and clinicians should be aware that the blood culture positivity rate impacts outcomes of XDRAB bacteremia.

Neoadjuvant chemotherapy followed by concurrent chemoradiotherapy versus concurrent chemoradiotherapy alone in nasopharyngeal carcinoma patients with cervical nodal necrosis

The effectiveness of neoadjuvant chemotherapy (NACT) followed by concurrent chemoradiotherapy (CCRT) compared with CCRT alone in nasopharyngeal carcinoma (NPC) patients who presented with cervical nodal necrosis (CNN) is unknown. A total of 792 patients with stage T1-4N1-3M0 NPC and presented with CNN based on magnetic resonance imaging were retrospectively reviewed. Propensity score matching method was used to balance treatment arms for baseline characteristics. Eventually, 508 patients were propensity-matched on a 1:1 basis to create two groups (NACT + CCRT and CCRT groups). Survival rates were calculated by Kaplan-Meier method and differences were compared by using the log-rank test. The 5-year disease specific survival, disease-free survival and distant metastasis-free survival were significantly higher in NACT + CCRT group relative to the matched CCRT group (82.1% vs. 72.5%, P = 0.021; 70.3% vs. 54.1%, P < 0.001; 81.9% vs. 67.3%, P < 0.001, respectively). Although the rates of grade 3-4 leucopenia and mucositis were higher in NACT + CCRT group than CCRT group, compliance with the combined treatment was good and no significant difference was observed between two groups. NACT followed by CCRT was relatively safe and could achieve better survival than CCRT alone in NPC patients with CNN by reducing the risk of death, tumor progression and distant metastasis.

Risk of Clozapine-Associated Agranulocytosis and Mandatory White Blood Cell Monitoring

Objective:

To provide information for physicians and patients on which to base a decision as to whether to stop mandatory blood testing.

Data Sources:

Articles on drug-induced blood dyscrasias were identified by searches of MEDLINE (1966—September 2005) and review of their bibliographies. Novartis was asked to provide additional data on clozapine, leukopenia, agranulocytosis, and suicidality.

Study Selection and Data Extraction:

Data on the chance of clozapine-induced leukopenia and agranulocytosis were combined with data about possible fatality and compared with the risks associated with other medications and with life in general.

Data Synthesis:

The chance of clozapine-induced leukopenia or agranulocytosis decreases exponentially over time. In the US, the chance in the second 6 months of treatment is 0.70/1000 patient-years and, after the first year, 0.39/1000 patient-years. The case fatality rate of clozapine-induced agranulocytosis is estimated as 4.2–16%, depending on whether a granulocyte colony-stimulating factor is used. Nevertheless, treatment with clozapine reduces overall mortality, probably because it reduces suicidality.

Conclusions:

After at least 6 months' treatment with clozapine, the mortality involved in stopping white blood cell monitoring is about the same as the mortality associated with other medications, such as mianserin or phenylbutazone, and with life in general (traffic or occupational accident). If the patient has been well informed and wishes to stop the monitoring, it is a medically justifiable option to do so and is preferable to stopping treatment with clozapine since this drug reduces overall mortality.

Prognostic value of perioperative leukocyte count in resectable gastric cancer

AIM: To investigate the prognostic significance of perioperative leukopenia in patients with resected gastric cancer.

METHODS: A total of 614 eligible gastric cancer patients who underwent curative D2 gastrectomy and adjuvant chemotherapy were enrolled in this study. The relationship between pre- and postoperative hematologic parameters and overall survival was assessed statistically, adjusted for known prognostic factors.

RESULTS: The mean white blood cell count (WBC) significantly decreased after surgery, and 107/614 (17.4%) patients developed p-leukopenia, which was defined as a preoperative WBC ≥ 4.0 × 10⁹/L and postoperative WBC < 4.0 × 10⁹/L, with an absolute decrease ≥ 0.5 × 10⁹/L. The neutrophil count decreased significantly more than the lymphocyte count. P-leukopenia significantly correlated with poor tumor differentiation and preoperative WBC. A higher preoperative WBC and p-leukopenia were independent negative prognostic factors for survival [hazard ratio (HR) = 1.602, 95% confidence interval (CI): 1.185-2.165; P = 0.002, and HR = 1.478, 95%CI: 1.149-1.902; P = 0.002, respectively] after adjusting for histology, Borrmann type, pTNM stage, vascular or neural invasion, gastrectomy method, resection margins, chemotherapy regimens, and preoperative WBC count. The patients with both higher preoperative WBC and p-leukopenia had a worse prognosis compared to those with lower baseline WBC and no p-leukopenia (27.5 mo vs 57.3 mo, P < 0.001).

CONCLUSION: Preoperative leukocytosis alone or in combination with postoperative leukopenia could be independent prognostic factors for survival in patients with resectable gastric cancer.

Risk factors for leukopenia in patients with gastrointestinal fistula

BACKGROUND

White blood cell count is an important index to the outcome of patients. In hospital, leukopenia is accompanied by high mortality, morbidity and treatment costs. However, in infectious diseases, the reasons responsible for leucopenia was not well elucidated. We investigated patients with gastrointestinal fistula to find risk factors for leukopenia.

METHODS

A prospective case control investigation was carried out in the Gastrointestinal Fistula Center, General Surgical Institute of Jinling Hospital. Cases included gastrointestinal fistula patients with leukopenia (n = 98) and controls composed of gastrointestinal fistula patients with normal white blood cell count (n = 78). The two groups were compared for risk factors of leucopenia by statistical analysis.

RESULTS

Factors associated with an increased risk for leukopenia included bacterial infection (25.5%) and hypoalbuminaemia (61.2%). Multivariable Logistic regression analysis identified bacterial infection (80%), urinary catheter (70%) and central vein catheter (60%) as the independent determinants for mortality in cases.

CONCLUSIONS

In patients with gastrointestinal fistula, two independent factors for leukopenia and three significant predictors of mortality were elucidated. We suggest that clinicians give patients more supportive management and apply prevention strategies to treat and prevent leukopenia.

[Neoadjuvant chemotherapy of invasive cancer of the urinary bladder]

We studied efficacy of a combination of intraosseous and systemic administration of drugs in patients with invasive cancer of the urinary bladder (UB). A total of 20 patients aged 54-79 years with verified had recurrence, 2 had tumors with continuous growth. T2N0M0 UB carcinoma was diagnosed in 7 patients, T3N0M0--in 12, T6N0M0--in 1 patient. All the patients received systemic chemotherapy with gemzar in a single daily dose 800-1000 mg/m2 on day 1, 7 and 14. On day 2 a single intraosseous 100 mg eloxatin was given. A total of three courses of combined chemotherapy with 4-week interval was used. Intravenous gemzar administration was accompanied with mild leukopenia in 4 patients, moderate leukopenia--in 1, allergic reaction--in 2 patients. This required gemzar discontinuation. No side effects were seen in response to intraosseous administration of eloxatin. The combined chemotherapy produced complete regression of UB cancer in 3 of 18 patients, partial regression--in 12, stabilization--in 3 patients. Neither local nor long-term tumor progression was found. Short-term therapeutic efficacy of combined therapy was 70%. Fifteen patients with partial regression or stabilization have undergone transurethral resection. Duration of a recurrence-free period reached 5 to 72 months (mean 17 months). The neoadjuvant chemotherapy proposed by us allows achievement of a high percentage of regression in patients with invasive UB cancer located in UB cervix and provides concervative surgery including patients over 70 years of age.

Gemcitabine, vinorelbine and prednisone for refractory or relapsed aggressive lymphoma,results of a phase II single center study

The optimum therapy for patients with relapsed or refractory aggressive non-Hodgkin's lymphomas (NHL) not qualifying for platinum-based and/or high-dose chemotherapy is not known. We conducted a prospective phase II study evaluating a regimen consisting of gemcitabine (1 g/m2, days 1 and 8), vinorelbine (30 mg/m2, days 1 and 8) and prednisone (100 mg/day, days 1-8) (GVP) given every 21 days. Fifteen patients with a median age of 68 years and a median of three previous therapies were enrolled. Diagnoses included B lymphoblastic (n=1), diffuse large B cell (n=10), anaplastic large T cell (n=2) and peripheral T-cell NHL (n=2). The median international prognostic index score was 3 (six patients with a score of 4 or 5). Five patients achieved a complete remission and three patients a partial remission. The median overall survival was 13.8 months, and the median time to next treatment was 4.4 months. Haematological toxicities of World Health Organisation grades 3/4 were leucopenia in 58%, thrombocytopenia in 33% and anaemia in 17% of all courses. Three patients had grade 3 infections. There was no treatment-related mortality. GVP shows substantial activity in poor prognosis relapsed or refractory aggressive lymphomas and is generally well tolerated, but haematological toxicity is dose limiting.

White cell count and intensive care unit outcome

A high white cell count on admission to the intensive care unit (ICU) is generally perceived to be associated with severe illness and poor outcome, but the implications of a low white cell count are less well recognised. We retrospectively analysed data on 4,165 patients. The white cell count on admission was split into four categories, leucopenic (< 4.0 x 10(9).l(-1)), normal (4.001-10.0 x 10(9).l(-1)), leucemoid (10.001-25.0 x 10(9).l(-1)) and an exaggerated leucemoid response (> 25.001 x 10(9).l(-1)). The mortality of patients with leucopenia on admission to the intensive care unit was higher than those with normal or moderately raised white cell count (37.5% vs. 18.9% and 23.9%, respectively). A leucopenic response, as well as an exaggerated leucemoid response, is associated with an increased mortality.

Mortality risks associated with specific clinical manifestations of systemic lupus erythematosus

BACKGROUND

Mortality in patients with systemic lupus erythematosus (SLE) is often related to disease in particular organ systems. We examined the risks of mortality associated with 8 clinical manifestations of SLE and determined whether these risks differed among patients with different sociodemographic characteristics.

METHODS

Using life table analysis, we determined the associations of hemolytic anemia, leukopenia, thrombocytopenia, arthritis, serositis, nephritis, psychosis, and seizures with both all-cause mortality and SLE-related mortality in a cohort of 408 patients.

RESULTS

Over a median duration of follow-up of 11 years, 144 patients died; 78 deaths (54%) were SLE related. In univariate analyses, the presence of hemolytic anemia, serositis, nephritis, psychosis, and seizures was associated with greater all-cause mortality, while the presence of arthritis was protective. In multivariate analyses that controlled for patient demographic characteristics, nephritis (relative risk, 2.34) and seizures (relative risk, 1.77) were associated with poorer overall survival. Nephritis and seizures, along with thrombocytopenia, were also associated with greater SLE-related mortality, while leukopenia was protective. The risk of death in association with these clinical manifestations did not differ among patient age, sex, race, or socioeconomic subgroups.

CONCLUSIONS

The presence of nephritis and seizures each increased the risk of death in patients with SLE approximately 2-fold. Thrombocytopenia also increased the risk of SLE-related mortality, while leukopenia was protective.

Vincristine is associated with the risk of azoospermia in adult male survivors of childhood malignancies

Of 55 males, currently above 18 years of age, diagnosed with and treated for different malignancies in childhood between 1960 and 1985 at a single institution, 28 (51%) were azoospermic. The age of the patient, testicular irradiation, four different therapeutic agents (L-asparaginase, cyclophosphamide, doxorubicin, vincristine) and one combination (MOPP, nitrogen mustard, vincristine, procarbazine, prednisone) were each associated with the risk of azoospermia. However, in multivariate analysis vincristine had the statistically most significant independent effect on the risk of azoospermia, the risk being 5-fold (95% confidence limits 1.3-18.8, P = 0.02) that in patients who had not received vincristine. The risk of azoospermia in patients who had received cyclophosphamide was 3.4-fold (0.95-12.3, P = 0.06) and in those who had received testicular irradiation it was 8.2-fold (0.75-90.9, P = 0.09) that of others. Normospermia (22% of patients) was not incompatible with any of the more commonly used modes of therapy. We conclude that vincristine may have a previously unrecognised important role in causing azoospermia, possibly irreversible, when administered in childhood or adolescence.

[Clinical course of premature and newborn infants of mothers with HELLP syndrome]

The HELLP-syndrome is complicated by a maternal mortality of 3.5% and a perinatal mortality between 9.5 and 60%. It is a variant of severe preeclampsia which includes hemolysis, elevated liver enzymes and low platelets. It is described in the literature that neonates of mothers with HELLP-syndrome show characteristic symptoms especially thrombocytopenia, leukocytopenia and prenatal somatic dystrophy. In this retrospective investigation of 36 preterm and term infants of mothers with HELLP-syndrome we found the following results: 1. Thrombocytopenia was seen in 11% and leucocytopenia in 12% of the analysed cases. Anemia was seen in 10% of the analysed neonates. They needed transfusion of blood. The rate of prenatal somatic dystrophy was increased (58%). 2. Elevated blood pressure was observed in 29% of the neonates within the analysed interval. The time of artificial ventilation of preterm infants with maternal HELLP-syndrome was in 37% extended in comparison with infants without HELLP-syndrome in pregnancy. 3. The perinatal mortality was 8%. All observed infants during delivery and of the neonatal period in our collective survived.

Outcome of oncology patients in the pediatric intensive care unit

We evaluated the outcome of oncology patients in the Pediatric Intensive Care Unit (PICU) from a total of 72 consecutive admissions. Severity of illness and quantity of care were measured by the Physiologic Stability Index (PSI) and the Therapeutic Intervention Scoring System (TISS), respectively. The overall mortality was 51% and was especially high in patients admitted for acute organ system failure (OSF)-66%. Acute respiratory failure was the most frequent OSF (73%) and the most common cause for PICU admission. A poor outcome was associated with severe leucopenia (less than 1000 WBC/mm3, 91% mortality), acute renal failure (94% mortality) and central nervous system deterioration (83% mortality). When the outcome was predicted using a quantitative algorithm the observed mortality was significantly higher than the predicted for all admissions with a PSI higher than 5. Improved scoring systems are required to enable characterization of pediatric cancer patients admitted to the PICU.

Alcoholism, leukopenia, and pneumococcal sepsis

Pneumococcal bacteremia is associated with a high morbidity and mortality, especially when leukopenia is present. To define further the possible factors associated with death in pneumococcal bacteremia, we reviewed all cases at 2 hospitals over a 1-yr period. Overall, increased mortality was associated with women (p = 0.009), nosocomial acquisition of the disease (p = 0.001), the presence of leukopenia (p = 0.00002) or thrombocytopenia (p = 0.025), shock (p = 4 X 10(-8)), and adult respiratory distress syndrome (p = 2 X 10(-7)). Leukopenic and nonleukopenic patients were compared further to ascertain factors that may predispose to leukopenia. Alcoholism was the only associated condition correlating with the presence of leukopenia (p = 0.036), and alcoholism and leukopenia occurred in a group of younger men. We conclude that the association of alcoholism, leukopenia, and pneumococcal sepsis is a distinct clinical entity seen in younger patients and is associated with a very high mortality.