Presence Of High-risk Factors Research Articles

Using oral tegafur/uracil (UFT) plus leucovorin as adjuvant chemotherapy in stage II colorectal cancer: a propensity score matching study from Taiwan

BackgroundEarly-stage colorectal cancer had excellent outcomes after curative resection, typically. However, a perplexing survival paradox between stage II and stage III was noted. This paradox could be influenced by the administration of routine postoperative adjuvant chemotherapy and the presence of high-risk factors in stage II CRC. The objective of the study was to investigate the influence of high-risk factors on patients with stage II CRC and assess the efficacy of oral tegafur/uracil (UFT) plus leucovorin as adjuvant chemotherapy for stage II CRC patients.MethodsA retrospective study was conducted using propensity score matching at a single medical institution. A total of 1544 patients with stage II colorectal cancer who underwent radical surgery between January 2004 and January 2009 were included. The intervention used was tegafur/uracil plus leucovorin as adjuvant chemotherapy. The main outcome measures were disease-free survival and overall survival.ResultsAfter propensity score matching, 261 patients were included in three groups: no-treatment, half-year treatment, and one-year treatment. The clinical characteristics of each group tended to be more consistent. The Cox proportional hazard models showed that tegafur/uracil treatment or not was a significant independent factor for oncological outcome. Kaplan–Meier analysis also showed significantly better disease-free survival and overall survival. Further investigation revealed that tegafur/uracil duration was an independent factor for oncological outcome. While the survival curve did not reach statistical significance, the one-year UFT treatment group demonstrated the best treatment trend.ConclusionsThis study suggests that tegafur/uracil plus leucovorin is a feasible adjuvant chemotherapy regimen for patients with stage II colorectal cancer after curative surgical treatment. Prolonged tegafur/uracil plus leucovorin treatment for 12 months showed a trend towards better outcomes in patients with stage II colorectal cancer.

Kawasaki disease complicated by peripheral artery thrombosis: a case report and literature review

BackgroundPeripheral gangrene is rarely documented as a possible complication of Kawasaki disease (KD). There are many causes of peripheral gangrene, and the common cause is in situ thrombosis or embolism. Most cases are reported to have regrettable outcomes (amputation or necrotic shedding). Herein, we report the successful management of KD complicated by peripheral artery thrombosis in an older Chinese boy, and a review of all cases of peripheral gangrene in KD in the literature.Case presentationWe found that most of the children with this complication were under 1 year old, had a heavy inflammatory response combined with the use of cortisol and immunoglobulin, and most children had coronary artery lesions. In addition, Peripheral gangrene mainly occurred in the subacute or chronic stage, and the prognosis is poor.ConclusionsIn the presence of high risk factors, we consider it is necessary to monitor coagulation function and administer prophylactic anticoagulation therapy. When peripheral artery thrombosis or embolism occur, heparin and prostaglandins can be used for treatment.

Early Identification of Extubation Failure Using Integrated Pulmonary Index and High-Risk Factors.

Early detection and prevention of extubation failure offers the potential to improve patient outcome. The primary aim of this study was to compare the predictive ability of the Integrated Pulmonary Index and presence of high-risk factors in determining extubation failure. A retrospective cross-sectional study of intubated adult subjects receiving mechanical ventilation for > 24 h was conducted at an academic medical center. The primary outcome was extubation failure, defined as the need for re-intubation or rescue noninvasive ventilation within 48 h after planned extubation. Among 216 subjects, 170 (78.7%) were successfully extubated, and 46 (21.3%) failed extubation. Extubation failure group had higher body mass index (26.21 vs 28.5 kg/m2, P = .033), rapid shallow breathing index during spontaneous breathing trial (43 vs 53.5, P = .02), and APACHE II score (11.86 vs 15.73, P < .001). Presence of ≥3 high-risk factors (odds ratio 3.11 [95% CI 1.32-7.31], P = .009), APACHE II > 12 on extubation day (odds ratio 2.98 [95% CI 1.22-7.27], P = .02), and Integrated Pulmonary Index decrease within 1 h after extubation (odds ratio 7.74 [95% CI 3.45-17.38], P < .001) were independently associated with extubation failure. The failed extubation group had higher ICU mortality (8.8% vs 19.6%; absolute difference 10.7% [95% CI -1.9% to 23.4%], P = .040) and hospital mortality (10% vs 22%; absolute difference 16.1% [95% CI 2.2-30%], P = .005) compared to the successful group. Among subjects receiving mechanical ventilation for > 24 h, decreasing Integrated Pulmonary Index within the first hour postextubation was a predictor of extubation failure and was superior to other weaning variables collected in this retrospective study. The presence of ≥ 3 high-risk factors was also independently associated with extubation failure. Future clinical studies are required to prospectively test the ability of postextubation Integrated Pulmonary Index monitoring to guide additional interventions designed to reduce re-intubation rates and improve patient outcome.

TO STUDY THE EFFECT OF OLIGOHYDRAMNIOS ON MATERNAL AND FETAL OUTCOMES IN 37 WEEKS OR MORE GESTATION PERIOD AT ANMMCH, GAYA, BIHAR

Background : Oligohydramnios is a threatening condition to maternal and fetal health. It is a clinical condition characterized by amniotic uid index (AFI) of ≤ 5cm by sonographic assessment. Aim and objectives: The aim of this study was to compare the maternal and fetal outcome in parturient women with oligohydramnios versus others with normal amniotic uid, and to suggest plan of action in management of oligohydramnios women. Study design: Prospective comparative observational. Method : Antenatal women with gestational age 37 weeks and above and fullling inclusion criteria attending our Out Patient Department or Labour rooms were included in the present study. Detailed antenatal history including presence of high risk factors were elicited from the patients, then they were clinically examined and subjected to ultrasonography. purposive sample of 168 parturient women (84 study group and 84 control group) were taken. The tools used for data collection were; a structured interview sheet, maternal assessment sheet, Partogram, and neonatal assessment record. Results: The results of the present study revealed that the rate of Caesarian section was signicantly higher in oligohydramnios group compared to the control group (44.0% vs. 30.0% respectively). There was signicant increasing in FHR decelerations, low Apgar score at 5 min, low birth weight, admission to NICU. Conclusion: It can be concluded that an amniotic uid index of ≤ 5 cm detected after 37 completed weeks of gestation is an indicator of poor perinatal outcome. It is recommended that determination of AFI through regular antenatal care visits can be used as an adjunct to other fetal surveillance methods to identify those infants at risk of poor perinatal outcome

POS-655 RISK FACTORS FOR IN-HOSPITAL MORTALITY IN CHRONIC PERITONEAL DIALYSIS PATIENTS ADMITTED WITH COVID-19 AT THE NATIONAL KIDNEY AND TRANSPLANT INSTITUTE OF THE PHILIPPINES

COVID-19 declared a pandemic by the WHO on March 15, 2020 has a global mortality rate of 2.39%, mostly afflicting those with co-morbidities. In end stage renal disease patients, the case fatality rate increases to as high as 40.6% for hemodialysis patients and 50% for peritoneal dialysis patients. This study aimed to determine the outcomes and risk factors for in-hospital mortality of chronic PD patients admitted with COVID-19 from March to September 2020 in the institution with the biggest PD population in the Philippines. This retrospective cohort included all adult chronic PD patients admitted with COVID-19 from March 2020 to September 2020. Inclusion criteria are age > 18 years old, on chronic PD for at least 1 month, positive for COVID-19 by RT-PCR, followed-up until 30 days post discharge. PD patients who expired prior to obtaining COVID-19 RT- PCR results and patients with a dysfunctional PD catheter on admission were excluded from the study. Relationship of PD patients’ baseline demographic and clinical characteristics with outcome was obtained using chi square test or Fischer exact tests for categorical variables and t-test for continuous variables. A p-value of less than 0.05 was statistically significant. Univariate and multivariate logistic regression was used to determine the factors that predict in-hospital mortality amongst the subjects. Of the 1199 active PD patients in our institution, 74(6.2%) chronic peritoneal dialysis (PD) patients were admitted for COVID-19 with mean age of 46.67±17.67, slight predominance of males (51.35%) and mean duration of PD of 20.86±18.69 months. Majority (41.8%) had severe COVID-19 infection. The most common presenting symptoms were difficulty of breathing (51.35%), cough (44.59%) and abdominal pain (41.54%). Anemia (9.3±1.98mg/dL vs. 7.84±1.45mg/dL, p=0.0095), lymphopenia (12.12±5.36x103/uL vs. 9.07±4.94x103/uL, p=0.0497), leukocytosis (8.70±4.00x103/uL vs. 12.45 ± 4.72103/uL, p=0.0026) and ultrafiltration failure in both CAPD and CCPD modalities were significantly associated with mortality.Longer days on CAPD (p=0.0403), lower number of exchanges per day (p=0.0065), and a greater volume of ultrafiltration per day (p=0.009) were significantly associated with survival. This would imply that the volume of ultrafiltration per day was more important for survival, compared to the number of exchanges or cycles performed. (Table 2)PD effluent analysis amongst those who presented with abdominal pain showed that 14(46.67%) had concomitant culture negative peritonitis. Among the 8 subjects who died, 6 (75%) had coexisting PD peritonitis. This may suggest a possibility of COVID-related peritonitis leading to ultrafiltration failure and higher mortality. View Large Image Figure ViewerDownload Hi-res image Download (PPT)Average hospital stay was 17.5 days, temporary shifting to HD was required in 32.43% and in-hospital mortality was 20.27%.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Independent risk factors for in-hospital mortality included severity of COVID-19 infection (p=0.003), abdominal pain (p=0.018), oxygen desaturation (p=0.029), leukocytosis (p=0.013) and anemia (p=0.009). (Table 5) COVID-19 in chronic PD patients resulted in a higher mortality rate compared to the general population. Presence of high risk factors warrant close monitoring and aggressive management. Adequate PD ultrafiltration should be achieved and if not possible, early shift to HD may be helpful.

Treatment of mild to moderate COVID-19 in children

Children as such have less infection and less severe covid 19 illness. Majority will be asymptomatic or mildly symptomatic. Symptoms are nonspecific and suspect in children presenting with influenza-like illness (ILI) or children presenting with respiratory difficulty. Children with definite contact with COVID-positive patients or those who had severe illness (irrespective of COVID status) in the past 2 weeks should be subjected to test. The rest of the children may be tested if any of the following are present: 1. The presence of high-risk factor in child such as immunocompromised condition (long-term steroids, cancer chemotherapy, biological agents, and primary or secondary immune deficiency) or chronic illnesses including chronic respiratory illnesses 2. Any person in family who is at risk of developing serious illness (elderly, immunocompromised, diabetic, hypertensive, etc.,). Majority of mild to moderate illness can be managed at home with symptomatic treatment ensuring monitoring for worsening of symptoms. There is no proven benefit of antibiotics, antiviral agents, steroids, hydroxychloroquine or other anti-inflammatory agents.

Perioperative Antibiotic Use and Associated Infectious Outcomes at the Time of Myomectomy.

To report the frequency of perioperative antibiotic use at time of myomectomy and associated risk of infectious outcomes. We conducted a retrospective cohort study including all women who underwent any route of myomectomy from 2009 to 2016 at two academic hospitals in Boston, Massachusetts. Cases involving chromopertubation or conversion to hysterectomy were excluded from further analysis. Medical records were queried for the use or nonuse of perioperative antibiotics, as well as baseline patient factors and perioperative outcomes. Statistical analyses included univariate comparisons between treatment groups, as well as multivariable logistic regression analyses of infectious morbidity controlling for patient age, route of surgery, presence of high-risk factors, any intraoperative complication, myoma weight, and entrance into the endometrial cavity. Matched cohort analysis also was performed to confirm findings in the setting of underlying differences between groups. A total of 1,211 patients were included in the myomectomy cohort, 92.7% of whom received perioperative antibiotics at the time of surgery. Demographic characteristics were similar between the group that received and the group that did not receive antibiotics. The cases with antibiotic use were associated with longer operative times, higher estimated blood loss, and greater myoma burden. No difference was noted with regard to intraoperative or postoperative complications. Surgical site infection occurred more commonly in the group that did not receive antibiotics (2.9% vs 6.8% in the antibiotic and no-antibiotic groups, respectively; effect size 0.43, 95% CI 0.18-0.97 P=.04), representing a nearly fourfold increase in odds of any surgical site infection in the absence of perioperative antibiotic use (adjusted odds ratio 3.77, 95% CI 1.30-10.97, P=.015). A high frequency of antibiotic use was noted at time of myomectomy, despite lack of clear evidence supporting the practice. Patients who received perioperative antibiotics had fewer postoperative infectious outcomes and, in particular, experienced a lower incidence of surgical site infection.

Finding out incidence of deafness among neonates at a tertiary care centre of western Rajasthan, India using otoacoustic emission

Background: Newborn hearing screening is conducted to identify suspected hearing loss and not to confirm the presence/absence of hearing loss or define features of the loss. Speech and hearing are interrelated, i.e., a problem with one could mean a problem with the other as speech and language is acquired normally through auditory system.Methods: A descriptive study conducted in the Department of Paediatrics, Dr. S. N. Medical College, Jodhpur, from June 2016 to December 2017. 5000 neonates were screened using otoacoustic emissions (OAE) in 2 stages at birth during 3rd to 7th day and 15-30 days respectively, followed by BERA at 3 months of age.Results: 1.4 infants per thousand infants had hearing loss. Presence of high-risk factors was seen to be associated be associated with hearing loss more than normal infants on screening with distortion product otoacoustic emissions (DPOAE) tests. However, on testing with BERA no such association was seen.Conclusions: 1.4 per 1000 infants had hearing loss. This study has shown that two stage distortion product otoacoustic emissions (DPOAE) hearing screening followed by british educational research association (BERA) to confirm the hearing deficit, can be successfully implemented as new born hearing screening method in a hospital set-up, for early detection of hearing impaired, on a large scale, to achieve the high-quality standard of screening programs in a resource limited and developing nation like India.

Cardiac causes of chest pain

Because of the life-threatening character and ahigh prevalence in emergency rooms, cardiac causes are important differential diagnoses of acute chest pain with the need for rapid clarification. In this context the working diagnosis "acute coronary syndrome" (ACS) plays a major role. In a synopsis of the clinical presentation, medical history, electrocardiogram and analysis of cardiac biomarkers, ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris can be specified as entities of ACS. The treatment of ACS consists of an immediate anti-ischemic therapy, anti-thrombotic therapy and invasive coronary diagnostics with subsequent interventional or operative revascularization therapy. The timing of invasive management is essentially determined by the individual patient risk, with the exception of STEMI where interventional revascularization must be undertaken within 120 min of diagnosis. In this context the GRACE2.0 and TIMI risk score have become established as reliable tools. Another rare but fatal cause of acute chest pain is aortic dissection. An abrupt onset of tearing and sharp chest pains, deficits in pulse as well as the presence of high-risk factors, such as advanced age, arterial hypertension, atherosclerosis, known collagenosis and previous aortic or coronary artery procedures are highly indicative for aortic dissection and additional diagnostic imaging and the highly sensitive D‑dimer should be undertaken. Additionally, inflammatory diseases, such as pericarditis and myocarditis can be associated with chest pains and mimic the character of ACS and should also be considered in the differential diagnostics.

Sonic hedgehog produced by bone marrow-derived mesenchymal stromal cells supports cell survival in myelodysplastic syndrome.

The role of marrow microenvironment in the pathogenesis of myelodysplastic syndrome (MDS) remains controversial. Therefore, we studied the influence of bone marrow-derived mesenchymal stromal cells (BMSCs) from patients with different risk types of MDS on the survival of the MDS cell lines SKM-1 and MUTZ-1. We first demonstrated that the expression of Sonic hedgehog (Shh), smoothened (Smo), and glioma-associated oncogene homolog 1 (Gli1) was increased in MDS patients (n = 23); the increase in expression was positively correlated with the presence of high-risk factors. The Shh signaling inhibitor, cyclopamine, inhibited high-risk MDS BMSC-induced survival of SKM-1 and MUTZ-1 cells, suggesting a role for Shh signaling in MDS cell survival. Furthermore, cyclopamine-mediated inhibition of Shh signaling in SKM-1 and MUTZ-1 cells resulted in decreased DNMT1 expression and cell survival; however, exogenous Shh peptide had the opposite effect, suggesting that Shh signaling could regulate the expression of DNMT1, thereby modulating cell survival in MDS. In addition, the apoptosis of SKM-1 and MUTZ-1 cell increased significantly when cultured with cyclopamine and a demethylation agent, 5-Aza-2′-deoxycytidine. These findings suggest that Shh signaling from BMSCs is important in the pathogenesis of MDS and could play a role in disease progression by modulating methylation.

Immune Tolerance Induction in Severe Hemophilia a Patients Using Wilate®, a Von Willebrand Factor/Factor VIII Concentrate

Introduction: To prevent and treat bleeding episodes, hemophilia A patients undergo factor VIII (FVIII) replacement therapy with either recombinant FVIII (r-FVIII) or plasma-derived FVIII (pd-FVIII). Approximately 32% of patients develop neutralizing antibodies to the FVIII protein rendering FVIII therapy ineffective (Gouw et al. N Engl J Med. 2013; 368:231-239). Development of these neutralizing antibodies, or ‘inhibitors’ is the most serious and challenging complication in the treatment of hemophilia A patients and represents the highest economic burden for a chronic disease (Gringeri et al. Blood 2003; 102:2358-2363). The standard approach for eradicating inhibitors is to tolerize the patient to FVIII through prolonged, daily exposure to high-dose FVIII – a process termed immune tolerance induction (ITI). Although costly, ITI can successfully eliminate inhibitors in a large proportion of low-risk patients, however there are several risk factors that reduce the likelihood of ITI success. For high-risk patients, the choice of drug product (r-FVIII versus pd-FVIII) may be particularly important. Several small studies have demonstrated the superiority of pd-FVIII for ITI, as these products contain the FVIII stabilizing protein, von Willebrand Factor (VWF) (Gringeri et al., Haemophilia 2007; 13:373-379). Wilate® (Octapharma) is a high-purity pd-FVIII complex that contains the two proteins (VWF and FVIII) in a 1:1 ratio. In this retrospective study, we present the patient history and outcome for four severe hemophilia A patients that have undergone ITI with Wilate®. Patients and Methods. All patients presented with severe FVIII deficiency ( Results. ITI with Wilate was found to be well tolerated, with no reported drug-related adverse events. Although 75% of the patients presented with high-risk factors for poor ITI outcome, Wilate ITI reduced inhibitor levels below 5 BU/mL for 3 out of 4 patients. The clinical outcome of Wilate ITI correlated with the presence and number of high-risk factors. Patient 1 did not respond to Wilate, and was considered a failure. This patient had 3 high risk factors for poor ITI outcome including FVIII gene mutation type, peak historical titer >50, and inhibitor titer at ITI onset > 10 BU/mL. Of the three patients that responded to Wilate ITI, patient 4 experienced a CS to Wilate ITI in 4 months. For the remaining 2 patients, Wilate ITI is currently ongoing. Despite the presence of high risk factors, these two patients have thus far achieved a PS with inhibitor levels stable for several months at or below 1 BU/mL. One of these patients (patient 2) presented with 5 high-risk factors, including having failed a previous ITI attempt. The frequency of bleeding episodes were significantly reduced upon commencement of Wilate ITI, allowing for the eventual cessation of FEIBA prophylaxis. Conclusion. Despite the presence of high-risk factors, 3 out of 4 patients (75%) experienced a clinical response to Wilate ITI. The patients experienced improved quality of life. Wilate ITI resulted in a significant reduction in bleed episodes in a high-risk patient. The type of FVIII product to use during ITI has been debated, however, some have observed a higher success rate when plasma-derived FVIII products containing VWF are used. From our experience, we conclude that Wilate for ITI in patients with inhibitors is effective and produces high rates of ITI success in high-risk patients. Disclosures Wu:Bayer: Honoraria, Membership on an entity9s Board of Directors or advisory committees, Research Funding; Baxter: Honoraria; Pfizer: Membership on an entity9s Board of Directors or advisory committees; Biogen Idec: Honoraria, Membership on an entity9s Board of Directors or advisory committees; Novo Nordisk: Honoraria, Membership on an entity9s Board of Directors or advisory committees; Octapharma: Honoraria, Membership on an entity9s Board of Directors or advisory committees; CSL Behring: Honoraria, Membership on an entity9s Board of Directors or advisory committees. Woo:Bayer: Honoraria, Membership on an entity9s Board of Directors or advisory committees; Baxter: Honoraria, Membership on an entity9s Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity9s Board of Directors or advisory committees. Crilly:Bayer: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Baxter: Consultancy, Honoraria, Membership on an entity9s Board of Directors or advisory committees; Octapharma: Honoraria, Membership on an entity9s Board of Directors or advisory committees.

Sensory nerve paresthesia following third molar surgery: Effectiveness of an evidence based protocol

Objective: To assess the incidence of inferior alveolar and lingual nerve paresthesia following third molar surgeries and to assess the effectiveness of a set departmental protocol for reducing the incidence of these paresthesia. Study Design: The study included 110 patients who underwent surgery for third molar removal. All cases followed a protocol which included using a standard Ward's incision, raising a lingual flap, use of minimal ostectomy and tooth sectioning in all cases. A standardized data form was used to record the patient's age, sex, Pederson's difficulty index, distance between the root apices and inferior alveolar canal, the length of the redline and operating time. Results: Postoperative inferior alveolar nerve paresthesia occurred in five cases (4.5%) and lingual nerve paresthesia occurred in one case (0.9%). Paresthesia was significantly related to the duration of the surgical procedure, but unrelated to the other variables recorded. Conclusion: The current protocol followed appears to be effective in reducing the incidence of inferior alveolar and lingual nerve paresthesia to an acceptable level even in the presence of high risk factors.

High-risk histomorphological features in retinoblastoma and their association with p53 expression: An Indian experience.

Introduction:Histopathological features in retinoblastoma are considered high-risk factors (HRF) for tumor progression and metastasis, thus their presence becomes an indication for adjuvant chemotherapy. Present study was undertaken to evaluate the incidence of HRF in retinoblastoma and to correlate them with p53 expression.Materials and Methods:This was a retrospective study where 17 diagnosed cases of retinoblastoma were included. Cases were re-evaluated for various histomorphological parameters. Immuno-histochemical analysis was done with p53 antibody by Streptavidin biotin method.Results:The patients were in the age range of 1.5-50 years. Common histological features included necrosis (70.5%), calcification (64.7%), and retinal detachment (58.8%). Incidence of various morphological parameters was anterior chamber seeding (47.2%), ciliary body involvement (29.4%), iris involvement (29.4%), choroid involvement (58.8%), scleral invasion (29.4%), extrascleral invasion (11.8%), and optic nerve infiltration (23.5%). p53 expression was present in four cases out of 13 cases (30.7%) and showed a significant association with choroid invasion (P = 0.02).Discussion:The presence of HRF should alert the physician for a possible metastasis, and such patients should be kept on regular follow-up to detect an early recurrence. p53 expression, a known poor prognostic indicator, showed significant association with choroid invasion, however, no association was seen with other HRF.Conclusion:Histopathological HRF have significant therapeutic and prognostic implications. The incidence of HRF is higher in developing countries as patients present with a more advanced stage of disease. p53 expression is significantly associated with choroid invasion out of all HRF.

Secretory cell expansion with aging: Risk for pelvic serous carcinogenesis

ObjectiveRecent advances suggest that precancerous lesions of pelvic serous carcinoma (PSC) originate from tubal secretory cells. The purpose of our study was to determine if increased number of secretory cells shows difference in age and location and to examine their association with serous neoplasia. Materials and methodsThree groups (benign control, high-risk, and PSC) of patients with matched ages were studied. The age data was stratified into 10-year intervals ranging from age 20 to older than 80. The number of secretory and ciliated cells from both tubal fimbria and ampulla segments was counted by microscopy and immunohistochemical staining methods. The data was analyzed by standard contingency table and Poisson distribution methods after age justification. ResultsWe found that the absolute number of tubal secretory cells increased significantly with age within each age group. Age remained a significant risk factor for serous neoplasia after age adjustment. In addition, a dramatic increase of secretory cells was observed in high-risk and PSC patients. Further, secretory cell expansion (SCE) was more prevalent than secretory cell outgrowth in both fimbria and ampulla tubal segments and was significantly associated with serous neoplasia (p<0.001). ConclusionsThese findings suggest that SCE could potentially serve as a sensitive biomarker for early serous carcinogenesis within the fallopian tube. Findings support a relationship between serous neoplasia and increased secretory to ciliated cell ratios. Findings also support a relationship between frequency of SCE and increasing age, presence of high-risk factors and co-existing serous cancers.

Use of Autogenous Bone Graft Compared With RhBMP in High-risk Patients

A retrospective study. To evaluate whether recombinant human bone morphogenetic protein (rhBMP-2) can improve fusion rates and time to fusion in high-risk patients when compared with autograft in lumbar posterolateral fusion. The use of rhBMP-2 in the general population for posterolateral fusion has resulted in relatively good reported outcomes; however, it is currently considered "off-label" use. Few studies, however, have determined the outcomes of rhBMP-2 when used in patients with numerous risk factors for a pseudarthrosis. One hundred ninety-five patients were divided into 4 groups depending on fusion material and the presence/absence of fusion-related risk factors for nonunions; group A was defined as rhBMP-2 used in the presence of high-risk factors (FRRF), group B was defined as rhBMP-2 used in the absence of FRRF, group C was defined as autograft used in the presence of FRRF, and group D was defined as autograft used in the absence of FRRF. The time to fusion, fusion rate were compared between each group. The time to fusion was significantly faster in group B than in group D in patients with no history of smoking (P<0.05), hypertension (P<0.01), or other significant comorbidity (P<0.05). The time to complete fusion was also significantly faster in group B than in group D in patients under the age of 65 (P<0.05), patients undergoing primary surgery (P<0.05), single-level surgery (P<0.01), no smoking history (P<0.05), no diabetes mellitus (P<0.01), no hypertension (P=0.001), no osteoporosis (P<0.01), and no significant comorbidity (P<0.01). Although the fusion rate was higher in group B than in group D, with the exception of sex and single-level surgery, there were no significant differences between groups B and D. Although initial fusion mass and time to solid fusion was faster in group A than in group C, there were no significant differences between groups A and C. In addition, fusion rates were higher in group C than in group A, looking at all factors except revision surgery, but the differences were not statistically significant. With relative low dosage of rhBMP-2 compared with the dose used in Food and Drug Administration trial, in patients without fusion-related risk factors, rhBMP-2 may lead to acceptable fusion rates and faster fusion time when compared with autograft. Therefore, rhBMP-2 may serve as an acceptable alternative to autogenous bone graft in patients without fusion-related risk factors undergoing instrumented posterolateral lumbar fusions. When compared with patients with fusion-related risk factors, the use of rhBMP-2 was comparable with autograft but was not sufficient to overcome all aspects of the weakened osteoinductive capacity encountered in patients with these risk factors.

Neutrophil toxicity and primary prophylaxis in diffuse large B cell lymphoma treated with R-CHOP

e19548 Background: Three weekly R-CHOP therapy is regarded as standard treatment in advanced stage Diffuse Large B Cell Lymphoma (DLBCL) patients with low to intermediate-risk International prognostic index (IPI). This regimen is associated with intermediate risk (10–20%) of febrile neutropenia. Primary prophylaxis with colony-stimulating factor (CSFs) is therefore not recommended except in the presence of high risk factors as defined in the National Comprehensive Cancer Center Network guidelines for use of myeloid growth factors v.1.2008. It is however well realized that a significant number of good risk patients will still develop significant neutrophil toxicity. Methods: This observational study was conducted at Oncology department Combined Military Hospital, Rawalpindi, on fifty good risk patients of advanced stage DLBCL, treated with R-CHOP regimen without primary CSFs prophylaxis. NCI Common Toxicity Criteria version 3.0 was used for grading toxicity and significant neutrophil toxicity was defined as Grade 4 neutropenia between day 7 and 10 post therapy, febrile neutropenia and Grade 2 or more neutrophil toxicity persisting on day 1 of next cycle. Good risk patients were recruited by the following exclusion criteria: WHO Performance status scale 4, concurrent immunosuppressive drug therapy, abnormal hepatic or renal functions and inadequate hematological values. Results: 10(20%) patients, developed significant neutrophil toxicity. In this group 7(70%) had grade 4 neutropenia and 3(30%) patients developed febrile neutropenia. 8(80%) of these patients developing significant toxicity had WHO Performance scale ≥ 2. 2(20%) patients developing Grade 4 toxicity between days 7 and 10 post therapy had good performance status (0 or 1) and toxicity resolved by next cycle without getting complicated to febrile neutropenia. Conclusions: Performance status in terms of scale has not been defined in the high risk factors for developing febrile neutropenia in the NCCN guidelines on myeloid growth factors use. We observed that DLBCL patients with WHO performance status scale ≥ 2 treated with R-CHOP therapy at 3 weekly intervals are at greatest risk for developing significant neutrophil toxicity and febrile neutropenia. No significant financial relationships to disclose.

Klinischer Verlauf bei Cumarin-Nekrose*

In three patients painful reddening of a well-circumscribed area of the skin occurred within five days of starting anticoagulant treatment with phenprocoumon (Marcumar), and within a short time it developed into a full-blown picture of coumarin necrosis. The indication for phenprocoumon was, in the first patient (a 29-year-old mother lying-in after her second child had been born) an increased platelet count and the presence of high risk factors for thromboembolism. In the second patient (25-year-old man) and the third one (45-year-old woman) it was secondary prophylaxis after pulmonary embolus and deep-vein thrombosis, respectively. All three patients were very obese and had a drug allergy, as well as other allergies (bronchial asthma in Cases 1 and 2; allergic rhinitis in Case 3). Phenprocoumon was at once discontinued in all three patients and low-dose heparin administration (Cases 1 and 3) or dextran infusion (Case 2: heparin intolerance) started. All three needed excision of the necrotic tissue with grafting to the skin defect. The coexistence of obesity and allergic diathesis may thus present an especially high risk for coumarin necrosis.

Surveillance biologique après chirurgie orthopédique. Quel apport au diagnostic des complications infectieuses et thromboemboliques ?: Première partie : évolution de la CRP et des leucocytes. Place dans la strategie diagnostique des infections postopératoires

Objectives. – To evaluate the usefulness of monitoring C-reactive protein (CRP) level and leukocyte count for early diagnosis of infection following orthopedic surgery. Method. – A cohort of 179 patients was followed: group 1 comprised 128 patients undergoing lower limb arthroplasty, group 2 comprised 29 patients undergoing lower limb surgery without implant, and group 3 comprised 22 patients undergoing spinal or upper limb surgery. CRP level and leukocyte count were systematically measured on admission and then once a week for 4 weeks. Wound infections, other infections, wound disconnection without infection and hematoma were noted. CRP level and leukocyte count were monitored postoperatively in patients with and without complications. Results. – CRP level was 4- to 8-fold above the normal range at the first postoperative measurement but normalized within the next 3 weeks (reaching normal levels by the 30th postoperative day, on average). In the 7 cases of wound infection (WI), the CRP level rose to 28-fold above normal and was significantly different from that in without infection or with intercurrent infection ( P < 0.01). A receiver operating characteristic (ROC) curve was established for CRP level, and for a value of 60 (12-fold above the normal range) the sensitivity was 100%, the specificity 83.6% and the negative predictive value 100%. The variation in leukocyte count was minor, with a significant difference noted between only patients not infected or those with WI ( P < 0.05). Discussion and conclusions. – Measurement of CRP level can be used for early diagnosis of wound infection. In the case of strong clinical suspicion or in the presence of high risk factors, when the level is at 12-fold or more above the normal range, the diagnosis of infection is highly probable.

Antimicrobial Prophylaxis for Cholecystectomy in Diabetes

Two schedules of antimicrobial agents were compared in this prospective study of antimicrobial prophylaxis in diabetes mellitus patients undergoing cholecystectomy for symptomatic cholelithiasis. One hundred women grouped into two matched groups of 50 women each were studied. The results suggest that apart from a population of patients with identifiable risks of complications, a 24 hour, four dose antimicrobial prophylaxis is adequate and more cost effective than the five day schedule for most patients.

Poor compliance with universal precautions

An anonymous survey was conducted in order to examine compliance with universal precautions in the Department of Pediatrics at Loyola University Medical Center in Maywood, Illinois. Completed questionnaires were returned by 23 faculty members, 29 residents, and 22 medical students. Gloves were worn consistently during venipuncture or intravenous catheterization by 13, 7, and 18% of attending physicians, residents, and students, respectively. Most physicians wear gloves only occasionally and cite presence of high-risk factors as their selection criterion. Interference with the performance of procedures is the most common cause of noncompliance. In view of poor compliance with universal precautions, further efforts are needed in order to decrease the incidence of preventable exposure to blood-borne infections.