scholarly journals Reduced Mortality From KPC-K.Pneumoniae Bloodstream Infection in High-Risk Patients With Hematological Malignancies Colonized by KPC-K.Pneumoniae

2020 ◽  
Author(s):  
Alessandra Micozzi ◽  
Giuseppe Gentile ◽  
Stefania Santilli ◽  
Clara Minotti ◽  
Saveria Capria ◽  
...  
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Bloodstream Infection ◽  
Active Treatment ◽  
Hematological Malignancies ◽  
Hematological Malignancy ◽  
High Risk Patients ◽  
Period 2 ◽  
Risk Patients ◽  
Related Mortality

Abstract Background. KPC-K.pneumoniae bloodstream infection (KPC-KpBSI) mortality rate in patients with hematological malignancies is reported about 60%. The initial treatment active against KPC-K.pneumoniae is crucial for survival and KPC-K.pneumoniae rectal colonization usually precedes KPC-KpBSI. We evaluated the impact on KPC-KpBSI mortality of the preemptive use of antibiotics active against KPC-K.pneumoniae, as opposed to inactive or standard empiric antibiotics, for the empiric treatment of febrile neutropenia episodes in patients with hematological malignancy identified as KPC-K.pneumoniae intestinal carriers. Methods. We compared the outcomes of KPC-KpBSIs occurring in high-risk patients with hematological malignancy known to be colonized with KPC-K.pneumoniae, during two time periods: March 2012-December 2013 (Period 1, initial approach to KPC-K.pneumoniae spread) and January 2017-October 2018 (Period 2, full application of the preemptive strategy). The relative importance of the various prognostic factors that could influence death rates were assessed by forward stepwise logistic regression models.Results. KPC-KpBSI-related mortality in patients with hematological malignancies identified as KPC-K.pneumoniae carriers dropped from 50% in Period 1 to 6% in Period 2 (p<0.01), from 58% to 9% in acute myeloid leukemia carriers (p<0.01). KPC-KpBSIs developed in patients identified as KPC-K.pneumoniae carriers were treated with initial active therapy in 56% and 100% of cases in Period 1 and Period 2, respectively (p<0.01), consisting in active antibiotic combinations in 39% and 94% of cases, respectively (p<0.01). In Period 1, the 61% of KPC-KpBSI were breakthrough (fatal in the 73% of cases) while no breakthrough KPC-KpBSI was observed in Period 2 (p<0.01). Overall, KPC-KpBSI-related mortality was 88% with no initial active treatment, 11.5% with at least one initial active antibiotic (p<0.01), 9% with initial active combination. Only the initial active treatment resulted independently associated with survival. Conclusions. In high-risk patients with hematological malignancies colonized by KPC-K.pneumoniae, the empiric treatment of febrile neutropenia active against KPC-K.pneumoniae reduced KPC-KpBSI-related mortality to 6% and prevented fatal breakthrough KPC-KpBSI.

Feasibility of Prophylactic Pancreatojejunostomy in Possible High-Risk Patients for Prevention of Pancreatic Fistula during Enucleation or Limited Pancreatic Resection

2018 ◽  
Vol 84 (1) ◽  
pp. 149-153 ◽  
Author(s):  
Takao Ohtsuka ◽  
Yasuhisa Mori ◽  
Takaaki Fujimoto ◽  
Yoshihiro Miyasaka ◽  
Kohei Nakata ◽  
...  
Keyword(s):  
High Risk ◽  
Pancreatic Fistula ◽  
Pancreatic Resection ◽  
Medical Records ◽  
Operation Time ◽  
Postoperative Pancreatic Fistula ◽  
Postoperative Hospital Stay ◽  
High Risk Patients ◽  
Risk Patients ◽  
Related Mortality

The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with ( n = 10) and without ( n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer ( P < 0.01) and blood loss significantly greater ( P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent ( P = 0.02) and postoperative hospital stay was significantly longer ( P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study.

scholarly journals A questionnaire survey on evaluation for penetration and compliance of the Japanese Guideline on Febrile Neutropenia among hematology-oncology physicians and surgeons

2021 ◽  
Author(s):  
Nobu Akiyama ◽  
Takuho Okamura ◽  
Minoru Yoshida ◽  
Shun-ichi Kimura ◽  
Shingo Yano ◽  
...  
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Supportive Care ◽  
Questionnaire Survey ◽  
Primary Treatment ◽  
Beta Lactam ◽  
Clinical Practices ◽  
High Risk Patients ◽  
Mascc Score ◽  
Risk Patients

Abstract Purpose The Japanese Society of Medical Oncology published a guideline (GL) on febrile neutropenia (FN) in 2017. The study’s purpose is to reveal how widely GL penetrated among physicians and surgeons providing chemotherapy. Methods A questionnaire survey was conducted with SurveyMonkey™ for members of the Japanese Association of Supportive Care in Cancer and relevant academic organizations. Each question had four options (always do, do in more than half of patients, do in less than half, do not at all) and a free description form. Responses were analyzed with statistical text-analytics. Result A total of 800 responses were retrieved. Major respondents were experts with more than 10-year experience, physicians 54%, and surgeons 46%. Eighty-seven percent of respondents knew and used GL. Forty-eight percent assessed FN with Multinational Association of Supportive Care in Cancer (MASCC) score “always” or “more than half.” Eighty-one percent chose beta-lactam monotherapy as primary treatment in high-risk patients. Seventy-seven percent did oral antibacterial therapy in low-risk patients ambulatorily. Seventy-eight percent administered primary prophylactic G-CSF (ppG-CSF) in FN frequency ≥ 20% regimen. Fifty-nine percent did ppG-CSF for high-risk patients in FN frequency 10–20% regimen. Ninety-seven percent did not use ppG-CSF in FN frequency < 10% regimen. The medians of complete and complete plus partial compliance rates were 46.4% (range 7.0–92.8) and 77.8% (range 35.4–98.7). The complete compliance rates were less than 30% in seven recommendations, including the MASCC score assessment. Conclusion GL is estimated to be widely utilized, but some recommendations were not followed, presumably due to a mismatch with actual clinical practices in Japan.

scholarly journals Early Ambulatory Multidrug Therapy Reduces Hospitalization and Death in High-Risk Patients with SARS-CoV-2 (COVID-19)

2021 ◽  
Author(s):  
Brian Procter ◽  
Casey Ross ◽  
Vaness Pickard ◽  
Erica Smith ◽  
Cortney Hanson ◽  
...  
Keyword(s):  
High Risk ◽  
Volume Expansion ◽  
Cleveland Clinic ◽  
Multidrug Therapy ◽  
Cumulative Mortality ◽  
High Risk Patients ◽  
Ambulatory Treatment ◽  
Period 2 ◽  
Risk Patients ◽  
Inhaled Budesonide

Background. There is an emergency need for early ambulatory treatment of COVID-19 in acutely ill patients in an attempt to reduce disease progression and the risks of hospitalization and death. Methods and Results. We recently reported results on 320 high-risk (age > 50 with ≥ 1 comorbidity) COVID-19 cases and have updated our results with 549 additional cases in period ending December 16, 2020. Our protocol utilizes at least two agents with antiviral activity against SARS-CoV-2 (zinc, hydroxychloroquine, ivermectin) and one antibiotic (azithromycin, doxycycline, ceftriaxone) along with inhaled budesonide and/or intramuscular dexamethasone. Albuterol nebulizer, inhaled budesonide, intravenous volume expansion with supplemental parenteral thiamine 500 mg, magnesium sulfate 4 grams, folic acid 1 gram, vitamin B12 1 mg, are administered for severely ill patients who either present or return to the clinic with severe symptoms. In period 1 (April-September, 2020) 6/320 (1.9%) and 1/320 (0.3%) patients that were hospitalized and died, respectively. In period 2, (September-December, 2020) 14/549 (2.6%) and 1/549 (0.18%) were hospitalized and died, respectively. For comparison, we used the Cleveland Clinic COVID-19 hospitalization calculator and based on average age and comorbidities the expected rate of hospitalization for both periods was 18.5%. The cumulative mortality among confirmed and suspected COVID-19 in Collin, Dallas, Denton, and Tarrant counties was 0.76, 1.04, 0.90, and 0.97. As a result, our early ambulatory treatment regimen was associated with estimated 87.6% and 74.9% reductions in hospitalization and death respectively, p<0.0001. Conclusions. We conclude that early ambulatory, multidrug therapy is associated with substantial reductions in hospitalization and death compared to available rates in the community. Prompt ambulatory treatment should be offered to high-risk patients with COVID-19 instead of watchful watching and late-stage hospitalization for salvage therapies.

Abstract 2471: Contemporary Results of Isolated Aortic Valve Replacement in High-Risk Patients in the Context of Emerging Percutaneous Approaches

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Pierre Voisine ◽  
Siamak Mohammadi ◽  
Josep Rodés-Cabau ◽  
Patrick Mathieu ◽  
Jean Perron ◽  
...  
Keyword(s):  
High Risk ◽  
Aortic Valve ◽  
Survival Benefit ◽  
Control Group ◽  
Perioperative Mortality ◽  
High Risk Patients ◽  
All Cause Mortality ◽  
Risk Patients ◽  
Related Mortality ◽  
Parsonnet Score

Percutaneous aortic valve replacement (AVR) is emerging as an alternative therapeutic approach for high-risk surgical patients, but criteria for patient selection are not clearly established. We sought to evaluate the perioperative and mid-term outcomes in a contemporary cohort of high-risk patients undergoing isolated AVR. Between 1997 and 2006, 855 consecutive patients underwent isolated AVR at our institution. High-risk patients (n=162, 19%) were defined by a preoperative Parsonnet score ≥ 30 or Euroscore ≥ 9. The remaining 693 patients (81%) composed the control group for comparison of perioperative mortality and mid-term freedom from all-cause and cardiac-related mortality. Mean follow up was 2.9±2.1 years. Perioperative mortality was 8.6% in the high-risk and 2.9% in the control group (p=0.0007), lower than that predicted by both scores (p<0.05). Freedom from all-cause mortality at 1 and 5 years were 94% and 82% for the control group and 87% and 65% for high-risk patients (p<0.0001). Freedom from cardiac-related mortality was also higher in the control (96% at 1 year, 91% at 5 years) than the high-risk (89% and 82%, p=0.0003) group. When considering patients who survived the 3-month perioperative period (537 in control, 114 in high-risk group), freedom from all-cause mortality was still higher in the former group at 1 and 5 years (99% vs 99% and 85% vs 75%, respectively, p=0.005), but freedom from cardiac-related mortality was not different (99% vs 100% and 94% vs 92%, respectively, p=0.3). By multivariate analysis, chronic renal failure, emergent procedures and reoperations were identified as independent predictors of mortality in high-risk patients. Contemporary perioperative mortality for isolated AVR in high-risk patients is lower than predicted by the Parsonnet score and Euroscore. Five-year survival in these patients is acceptable, and survivors of the operation experience the same cardiac-related survival benefit as those with standard perioperative risk. The perioperative survival benefit of percutaneous approaches for high-risk patients undergoing AVR remains to be demonstrated and, if present, should be weighed against mid-term outcome benefits of conventional surgical AVR.

Comorbidity and Outcomes for Patients Over Age 65 Years Treated with Allogeneic Stem Cell Transplantation for Acute Myelogenous Leukemia and Myelodysplastic Syndrome

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2032-2032 ◽  
Author(s):  
Henry J. Conter ◽  
Nhu-Nhu Nguyen ◽  
Gabriela Rondon ◽  
Julianne Chen ◽  
Elizabeth J Shpall ◽  
...  
Keyword(s):  
Stem Cell ◽  
High Risk ◽  
Cumulative Incidence ◽  
Stem Cell Transplant ◽  
Myelogenous Leukemia ◽  
Cell Transplant ◽  
High Risk Patients ◽  
Risk Patients ◽  
Acute Myelogenous ◽  
Related Mortality

Abstract Abstract 2032 Background: Acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) preferentially afflict patients 65 years of age and older. Patients in this age group are likely to have underlying comorbid conditions. These comorbidities affect treatment planning decisions and clinical outcomes. Here we report comorbidity-stratified outcomes of patients older than 64 treated at MD Anderson Cancer Center from 1996 until 2011, inclusive, treated with allogeneic stem cell transplant (ASCT). Methods: 182 patients older than 64 received an ASCT for AML (n=143) or MDS (n=39). Patient charts were reviewed and comorbidity data abstracted using a standardized form. Burden of comorbidity was assessed using the Hematopoetic Stem Cell Transplant-Specific Comorbidity Index (HSCT-CI). Low-risk, intermediate-risk, and high-risk patients were categorised at 0, 1–2, and >=3 points as per the HSCT-CI. 157 patients were evaluable for pre-transplant comorbidity. Outcomes of interest were cumulative incidence of transplant-related mortality (TRM), cumulative incidence of relapse-related mortality (RRM), incidence of acute and chronic graft-versus-host disease (GVHD), and overall survival (OS). These were estimated from the date of transplantation. Results: The median age of transplanted patients was 67 (range 65–79), and 37 patients age 70 and older were treated. The majority of patients were intermediate-risk and high-risk patients (table), 9 patients had HSCT-CI scores of >=5. Median follow-up for alive patients was 12.6 months (n=63; range 0–118). Cumulative incidence of TRM was 6% at 100 days, 14% at 1 year, 23% at 2 years, and 36% at 5 years (figure). Cumulative incidence of RRM was 36% at 1 year, 42% at 2 years, and 47% at 5 years. HSCT-CI did not independently predict for either TRM or RRM (log-rank test p=0.95). The incidence of grade III and IV acute GVHD was 10% of all patients. The cumulative incidence of chronic GVHD was 25% at 1 year, 27% at 2 years, and 30% at 5 years, with no association between GVHD and HSCT-CI comorbidity. Conclusion: ASCT is a curative option for selected patients over age 64. HSCT-CI did not predict TRM or survival on this cohort of high-risk patients. Disease relapse was of greater concern than TRM, and so novel approaches to relapse prevention are needed. Disclosures: No relevant conflicts of interest to declare.

A High Angiopoietin-2/Angiopoietin-1 Ratio Independently Predicts Septic Shock Development in Patients with Chemotherapy-Associated Febrile Neutropenia and Hematological Malignancies.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2154-2154
Author(s):  
Maiara Marx Luz Fiusa ◽  
Carolina Costa-Lima ◽  
Gleice Regina Souza ◽  
Afonso Celso Vigorito ◽  
Francisco J P Aranha ◽  
...  
Keyword(s):  
Septic Shock ◽  
High Risk ◽  
Febrile Neutropenia ◽  
Hematological Malignancies ◽  
Hematologic Malignancies ◽  
Endothelial Barrier ◽  
Prognostic Impact ◽  
Independent Population ◽  
Significant Difference ◽  
Risk Patients

Abstract Abstract 2154 Introduction: Febrile neutropenia (FN) patients with hematologic malignancies present a high risk of septic shock. Clinical scores such as MASCC can identify low-risk patients with FN, mainly in the outpatient setting, but are not very informative for high-risk patients (MASCC<21), which is the category that most patients with hematologic malignancies fit in. Endothelial barrier breakdown is a key element in septic shock, so that proteins involved in this process are currently considered among the most promising biomarkers and therapeutic targets in sepsis. Notably, angiopoietins (Ang) 1 and 2 are key elements of embryonic vascular development, with vessel-stabilizing and -destabilizing properties respectively. In an exploratory study, we previously demonstrated that levels of these proteins are increased in neutropenic patients with septic shock. Materials and Methods: here we prospectively evaluated the significance of VEGF-A, sFlt-1, Ang-1 and Ang-2 levels as biomarkers of septic shock progression in an independent population of patients with chemotherapy-associated FN and hematological malignancies. The study was deliberately designed to mimic real-life conditions in which a sepsis biomarker would be ordered. All patients admitted to the Hematology or BMT wards of our Institution for the treatment of FN between April 2011 and March 2012 were invited to participate. Blood samples were collected in the morning after enrollment, along with the routine blood work-up, by non-study staff. Biomarker levels were obtained by commercially-available ELISA. Primary clinical endpoints were septic shock development or mortality from infection, in 30 days from fever onset. Results: Of the 99 patients that fulfilled the inclusion criteria, 20 (19.8%) developed septic shock and 17 (16.8%) died from infection. Of these, 78 (78.8%) were classified as high-risk according to the MASCC score, a distribution characteristic of hematological malignancies. There were no significant clinical and demographic differences between patients with non-complicated FN and septic shock. No significant difference could be detected in VEGF-A or sFlt-1 levels between outcome groups either. In contrast, Ang-2 concentrations were increased in patients with septic shock (6,494 pg/ml, range 1,730–49,611 pg/ml) compared to non-complicated FN (4,467 pg/ml, range 1,289–37,318 pg/ml; P=0.02), whereas an inverse finding was observed for Ang-1 concentrations, which were lower in patients that developed septic shock (898.8 pg/ml, range 77.87–5,420 pg/ml) than in patients with non-complicated FN (1,220 pg/ml, range 32.55–47,924 pg/ml; P=0.07). Because imbalances between Ang-1 and Ang-2 could be more informative than each isolated biomarker, we calculated the Ang-2/Ang-1 ratio, which was much higher in patients with septic shock (5.29, range 0.58–57.14) than in non-complicated FN (1.99, range 0.06–64.62; P = 0.01). When analyzed as a continuous variable, the Ang-2/Ang-1 ratio proved to be an independent factor for shock septic development. The presence of a threshold level of Ang-2/Ang-1 ratio for an increase in the risk of shock septic could be demonstrated by dichotomizing the ratio by the median and by the optimal cut-off value identified using a ROC procedure (Ang-2/Ang-1=5.0). After adjustment for confounding factors, the multivariate risk for septic shock development was RR=5.47 (CI95% 1.93–15.53) for values above 5.0 and RR=2.99 (CI95%1.02–8.42) for values above the median. Similar results were obtained for 30-day mortality from infection. Conclusion: the prognostic impact of a high Ang-2/Ang-1 ratio as a biomarker for septic shock development was demonstrated in an independent and representative population of high-risk FN patients. The persistence of statistical significance of this association in a much less controlled context than in exploratory studies of biomarker research highlights the strength of the association between this important modulator of endothelial barrier integrity and progression to septic shock. This information has important implications for the clinical management of patients with FN and hematological malignancies, for whom no validated sepsis biomarkers are used in clinical practice, as well as for the development of new therapeutic strategies for the treatment of septic shock. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Management Costs of Febrile Neutropenia in Oncology Patients in Colombia

2021 ◽  
Author(s):  
Mauricio Lema ◽  
Beatriz Preciado ◽  
Diana Quiceno ◽  
Sara Mora ◽  
Natalia Castano Gamboa ◽  
...  
Keyword(s):  
High Risk ◽  
Febrile Neutropenia ◽  
Solid Tumors ◽  
Medical Records ◽  
First Line ◽  
High Risk Patients ◽  
Main Driver ◽  
Risk Patients ◽  
The Cost ◽  
Official Sources

Abstract Purpose: To describe the clinical characteristics, resource utilization, and direct cost of febrile neutropenia (FN) in a healthcare institution in Colombia for patients seen between 2017-2019.Methods: A descriptive and retrospective study of a cohort of patients hospitalized due to FN. Costs were extracted from the review of medical records from diagnosis of FN until discharge or death, and official sources were used to estimate the cost. Results: Forty-four FN episodes were included. Median age was 61 years (IQR: 53-72). Solid tumors accounted for 68.8%. In first-line treatment were 14 (31.8%), same in proportion in adjuvant/neoadjuvant, and 5 (11.4%) in second-line. FN occurred in 15 (34.0%) high-risk patients. Mean LOS per episode was 5.1 ± 2.5 days. All patients were discharged alive. The median overall cost was $925 ± $783 per episode, with hospital stay being the main driver-cost.Conclusion: FN occurred mainly in advanced-stage solid tumors and in low-risk group. Higher costs in this cohort were found in long length of stay and high-risk patients.

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