Risk Of Severe Infectious Complications Research Articles

The association between renal pelvis urine density and the risk of severe infectious complications in patient with symptom-free hydronephrosis after shock wave lithotripsy: a multi-center prospective study.

Finding reliable and easy-to-obtain predictors of severe infectious complications after shock wave lithotripsy (SWL) is a major clinical need, particular in symptom-free hydronephrosis. Therefore, we aim to prospectively investigate the predictive value of Hounsfield units (HU) in renal pelvis urine for the risk of severe infectious complications in patients with ureteral stones and symptom-free hydronephrosis after SWL. This multi-center prospective study was conducted from June 2020 to December 2023. The HU of renal pelvis urine was measured by non-enhanced computed tomography. The severe infectious complications included systemic inflammatory response syndrome, sepsis, and septic shock. Binary logistic regression models assessed the odds ratios (ORs) and 95% confidence intervals (CIs). Finally, 1,436 patients with ureteral stones were enrolled in this study. 8.9% (128/1,436) of patients experienced severe infectious complications after SWL treatment. After adjusting confounding variables, compared with the patients in the lowest renal pelvis urine density quartile, the OR (95% CI) for the highest quartile was 32.36 (13.32, 78.60). There was a positive linear association between the HU value of renal pelvis urine and the risk of severe infectious complications after SWL (P for trend < 0.001). Furthermore, this association was also observed stratified by age, gender, BMI, stone size, stone location and hydronephrosis grade (all P for interaction > 0.05). Additionally, the nonlinear association employed by restricted cubic splines is not statistically significant (nonlinear P = 0.256). The AUROC and 95%CI of renal pelvis urine density were 0.895 (0.862 to 0.927, P value < 0.001). The cut-off value was 12.0 HU with 78.59% sensitivity and 85.94% specificity. This multi-center prospective study demonstrated a positive linear association between HU in renal pelvis urine and the risk of severe infectious complications in patients with ureteral stones and symptom-free hydronephrosis after SWL, regardless of age, gender, BMI, stone size, stone location, and hydronephrosis grade. These findings might be helpful in the SWL treatment decision-making process.

Динамика выявления РНК вируса SARS-CoV-2 у пациентов и сотрудников ФГБУ «НМИЦ гематологии» Минздрава России в первые 2 года пандемии новой коронавирусной инфекции COVID-19

Background. COVID-19 required fundamental changes in healthcare management, also in medical care for oncological and hematological patients. Visits to healthcare organizations were minimized, 75 % of doctor appointments were converted to telemedicine consultations. The solutions aimed at preventing further spread of COVID-19 included establishing of observational units, distinguishing between patient and employee flows, regular SARS-CoV-2 RNA testing, reducing hospital stays and transferring patients with positive COVID-19 tests to the remodeled hospitals specializing in the novel coronavirus infection, as well as providing only emergency medical treatment and, as far as feasible, converting systemic chemotherapy to per os treatment, etc.&#x0D; Aim. To assess SARS-CoV-2 RNA detection dynamics at the National Research Center for Hematology from April 2020 to January 2022 during the implementation of epidemic control measures.&#x0D; Materials &amp; Methods. The study was based on SARS-CoV-2 RNA testing of naso- and oropharyngeal samples obtained from patients and employees of the National Research Center for Hematology (hereafter referred to as Center). Besides, bronchoalveolar lavage fluid, lung tissue biopsies, and sputum were examined for SARS-CoV-2 RNA. The study was performed at the Center’s Virusology Department with the use of Sintol reagent kit “ПЦР-РВ-2019-nCov”.&#x0D; Results. The study was based on 107,470 tests: 58,141 (54 %) of employees and 45,126 (46 %) of patients; 35,508 (33 %) of men and 71,962 (67 %) of women. In 1318 cases SARS-CoV-2 RNA was detected which accounted for 1.15 % of total test number. In the groups of employees/patients, virus detection rate was 1.42 %/1.09 % (p &lt; 0.001), and in male/female groups it was 1.3 %/1.2 %, respectively (p = 0.154). The rate of infection in the groups of tumor and non-tumor hematological patients, as proved by SARS-CoV-2 RNA testing, was 1.24 % and 0.92 %, respectively (p = 0.147). In employees and patients of the Center, a wave-like virus detection rate was observed. The largest number of infections was registered in April-June 2020 (79 patients and 170 employees), October-December 2020 (126 patients and 190 employees), and January 2022 (59 patients and 203 employees), which corresponded to the first, second, and fifth COVID-19 waves in Russia.&#x0D; Conclusion. The analysis of data obtained at the National Research Center for Hematology demonstrated a wave-like SARS-CoV-2 RNA detection rate in employees and patients of the Center, which corresponded to the general trend in Russia. The SARS-CoV-2 RNA detection rate did not depend on sex of subjects under study and was not significantly different in the groups of tumor and non-tumor hematological patients. Although the patients in hematological hospital are more exposed to the risk of severe infectious complications, they showed laboratory markers for COVID-19 less frequently than the Center employees.

Impact of graft-versus-host disease prophylaxis on immune reconstitution in patients after allogeneic hematopoietic stem cell transplantation

The graft-versus-host disease (GVHD) is among the most common complications after hematopoietic stem cell transplantation (allo-HSCT). The main tools for GVHD prevention remain calcineurin inhibitors (cyclosporin A, tacrolimus), methotrexate, mycophenolate mofetil. Upon implementation of reduced-intensity conditioning regimens, antithymocyte globulin was widely introduced. However, negative effects upon reconstitution of T-cell immunity have been noted, thus increasing risk of severe infectious complications and disease relapse. With extended practice of HSCT from alternative (partially matched or haploidentical) donors, cyclophosphamide was increasingly used. Our aim was to study reconstitution of immune cell subpopulations in the patients undergoing bone marrow transplantation (BMT), when using different GVHD prophylaxis regimens, including the schedules with post-transplant CP usage. The study concerned 44 cases classified into 2 groups. The first one included patients with standard immunosuppressive therapy, antithymocyte therapy, cyclosporine A, methotrexate, mycophenolate mofetil. The second group included the patients who received CP as immunosuppressive drug combined with other treatments (cyclosporine A, methotrexate, mycophenolate mofetil). At specified control terms, (D+14, +30, +60, +90) the blood leukocyte subpopulations were assayed by means of multicolor flow cytometry. Absolute counts of CD4+ cells in HSCT recipients treated with CP post-BMT proved to be sufficiently lower at D+14 and +30, than in those treated with classical immunosuppressive therapy. However, at later terms, (D+60, +90), these differences were not observed. Moreover, in CP-treated bone marrow recipients, absolute numbers of CD8+cells was significantly higher, compared to the patients who received conventional GVHD prophylaxis. Reconstitution of the studied lymphocyte populations in hematopoietic cell recipients did not depend on the GVHD prophylaxis regimen. Usage of CP combined with bone marrow as a source of stem cells, brings about sufficient decrease of some cell populations (CD4+; CD8+; NK cells) at early terms post-transplant. Administration of CP combined with hematopoietic stem cells as the source of hematopoietic graft seems to be more reasonable.

A novel laparoscopic assisted mediastinal dissection with gastric tube inversion technique for gastric tube cancer reconstructed through a retrosternal route.

A median sternotomy is often performed in patients with gastric tube cancer reconstructed through the retrosternal route; however, this procedure is invasive and has the risk of severe infectious complications. To overcome these problems, we created a novel method to perform the reconstructed gastric tube resection using a gastric tube inversion technique combined with a laparoscopic mediastinal approach. After the duodenum was divided, the oral side of the cut end was sutured with silken threads for traction. The gastric tube was dissected from the caudal side under a laparoscopic mediastinal approach, whereas the cervical esophagus was taped. After the adhesion between the middle side of the posterior sternum and the reconstructed gastric tube was dissected to the cervix, the gastric tube was inverted by guiding and pulling the thread toward the cervical side. Sharp dissection was facilitated between the inverted gastric tube and the surrounding organs under moderate traction and a favorable surgical view. We have performed this procedure and evaluated the short‐term outcomes in six cases. The laparoscopic mediastinal approach was completed without a median sternotomy in all six cases. Restorable intraoperative lung injury was observed in one case and no major vessel injuries were observed. The postoperative course was satisfactory with a 29.5‐day median length of hospital stay (range, 16‐60 days). The gastric tube inversion technique combined with the laparoscopic mediastinal approach for patients with retrosternal‐reconstructed gastric tube cancer was shown to be safe and less invasive and should be considered in resection of the reconstructed gastric tube.

The contamination of hospital water supply systems by &lt;i&gt;Legionella pneumophila&lt;/i&gt;

The risk of severe infectious complications associated with provision of medical care continues to be a pressing issue in modern surgery. Legionella pneumophila, characterized by its wide distribution in water supply systems and is highly active in film formation, represents a dangerous/important cause of hospital-acquired pneumonia. Patients requiring immunosuppression, including organ transplant recipients, are in the special risk group. Prevention of hospital-acquired legionellosis in patients at risk is essential due to severe clinical manifestations and high mortality. Objective: to summarize the practical experience in detecting contamination of water supply systems by Legionella pneumophila strains in multidisciplinary hospitals in Moscow. Materials and methods. Isolation of Legionella pneumophila strains from water and biofilms of water supply systems in multidisciplinary hospitals in Moscow and serotyping of this pathogen using bacteriological, molecular genetic and enzyme immunoassay methods. Results. Legionella pneumophila content in water reached high levels. The peculiarities of Legionella pneumophila contamination of hot water supply systems included formation of stable biofilms, in which other hospital-acquired pathogens were also identified. The share of Legionella pneumophila «SG 1», which causes up to 80% legionellosis cases in the world, was 13% in the water of the hospitals surveyed. The most effective measures for prevention of legionellosis are actions aimed at ensuring water biosecurity. Conclusion. There are potential risks of disease in the surgical wards of hospitals providing medical care, including in immunocompromised patients. Due to potential risks, prevention of hospital-acquired legionellosis is a necessary component of ensuring the safety of treatment for immunosuppressed patients.

The problem of global development of antibiotic resistant nosocomial pathogens

The problem of global expansion of multidrug-resistant nosocomial infections pathogens is under special attention at the moment. Antibiotic resistance increasing give us the limited treatment options. This problem is particularly acute for transplant clinics, because of patients need lifelong immunosuppressive therapy. From the one hand this ensures stable allograft functioning, but from the other increases the risk of severe infectious complications in the postoperative period. The purpose of this article is analysis carbapenem resistance dynamics of Klebsiella spp., Acinetobacter spp., Pseudomonas spp. and Staphylococcus spp. isolated from the blood of recipients of donor organs from 2009 to 2019 in the Shumakov National Medical Research Center of Transplantology and Artificial Organs. A significant annual decrease of carbapenem-sensitive strains of Klebsiella spp. and Acinetobacter spp. are shown. The study of a distinctive pathogen resistance profile specific to each institution can help one in selecting an adequate antimicrobial strategy and is an effective predictive tool for controlling the growth of multidrug-resistant microorganisms.

Non-molecular Methods to Detect Bacteriuria Prior to Urological Interventions: A Diagnostic Accuracy Systematic Review

Urine culture still has to be considered as the gold standard to rule out bacteriuria and should, therefore, be obtained prior to invasive endoscopic or open urological procedures to minimize the risk of severe infectious complications.

Granulomatous inflammation in cartilage-hair hypoplasia: Risks and benefits of anti–TNF-α mAbs

Cartilage-hair hypoplasia (CHH) is a rare autosomal recessive disorder characterized by short-limbed skeletal dysplasia. Some patients also have defects in cell-mediated immunity and antibody production. Granulomatous inflammation has been described in patients with various forms of primary immunodeficiencies but has not been reported in patients with CHH. We sought to describe granulomatous inflammation as a novel feature in patients with CHH, assess associated immunodeficiency, and evaluate treatment options. In a retrospective observational study we collected clinical data on 21 patients with CHH to identify and further characterize patients with granulomatous inflammation. Four unrelated patients with CHH (with variable degrees of combined immunodeficiency) had epithelioid cell granulomatous inflammation in the skin and visceral organs. Anti-TNF-α mAb therapy in 3 of these patients led to significant regression of granulomas. However, 1 treated patient had fatal progressive multifocal leukoencephalopathy caused by the JC polyomavirus. In 2 patients immune reconstitution after allogeneic hematopoietic stem cell transplantation led to the complete disappearance of granulomas. To the best of our knowledge, this is the first report of granulomatous inflammation in patients with CHH. Although TNF-α antagonists can effectively suppress granulomas, the risk of severe infectious complications limits their use in immunodeficient patients.

Thymic peptides for treatment of cancer patients.

Purified thymus extracts (pTE) and synthetic thymic peptides (sTP) are thought to enhance the immune system of cancer patients in order to fight the growth of tumour cells and to resist infections due to immunosuppression induced by the disease and antineoplastic therapy. To evaluate the effectiveness of pTE and sTP for the management of cancer. We searched CENTRAL (The Cochrane Library 2010, Issue 3), MEDLINE, EMBASE, AMED, BIOETHICSLINE, BIOSIS, CATLINE, CISCOM, HEALTHSTAR, HTA, SOMED and LILACS (to February 2010). Randomised trials of pTE or sTP in addition to chemotherapy or radiotherapy, or both, compared to the same regimen with placebo or no additional treatment in adult cancer patients. Two authors independently extracted data from published trials. We derived odds ratios (OR) from overall survival (OS) and disease-free survival (DFS) rates, tumour response (TR) rates, and rates of adverse effects (AE) related to antineoplastic treatments. We used a random-effects model for meta-analysis. We identified 26 trials (2736 patients). Twenty trials investigated pTE (thymostimulin or thymosin fraction 5) and six trials investigated sTP (thymopentin or thymosin α(1)). Twenty-one trials reported results for OS, six for DFS, 14 for TR, nine for AE and 10 for safety of pTE and sTP. Addition of pTE conferred no benefit on OS (RR 1.00, 95% CI 0.79 to 1.25); DFS (RR 0.97, 95% CI 0.82 to 1.16); or TR (RR 1.07, 95% CI 0.92 to 1.25). Heterogeneity was moderate to high for all these outcomes. For thymosin α(1) the pooled RR for OS was 1.21 (95% CI 0.94 to 1.56, P = 0.14), with low heterogeneity; and 3.37 (95% CI 0.66 to 17.30, P = 0.15) for DFS, with moderate heterogeneity. The pTE reduced the risk of severe infectious complications (RR 0.54, 95% CI 0.38 to 0.78, P = 0.0008; I² = 0%). The RR for severe neutropenia in patients treated with thymostimulin was 0.55 (95% CI 0.25 to 1.23, P = 0.15). Tolerability of pTE and sTP was good. Most of the trials had at least a moderate risk of bias. Overall, we found neither evidence that the addition of pTE to antineoplastic treatment reduced the risk of death or disease progression nor that it improved the rate of tumour responses to antineoplastic treatment. For thymosin α(1), there was a trend for a reduced risk of dying and of improved DFS. There was preliminary evidence that pTE lowered the risk of severe infectious complications in patients undergoing chemotherapy or radiotherapy.

Diffuse Large B-Cell Lymphoma in Hyperimmunoglobulinemia E Syndrome

We report a case of diffuse large B-cell lymphoma occurring in a patient with the hyperimmunoglobulinemia E syndrome, a rare immune disorder defined by elevated immunoglobulin E levels and recurrent bacterial and fungal infections often manifesting as cold abscesses. This case further supports the notion that patients with hyperimmunoglobulinemia E have an increased risk of lymphoid malignancies and should be closely monitored. Despite a theoretic risk of severe infectious complications, chemotherapy was well tolerated and resulted in a sustained complete remission.

Low Incidence of CMV Reactivation and Infection after Allogeneic Bone Marrow Transplantation (BMT) Incorporating Post-Transplantation Cyclophosphamide (Cy).

Cytomegalovirus (CMV) disease remains an important complication of allogeneic stem cell transplantation (SCT). A major goal has been to develop bone marrow transplant (BMT) preparative regimens that minimize the duration of post-transplantation immunosuppression, and thus the risk of severe infectious complications. Previously, we reported a low rate of CMV reactivation (17.6%, 6/34 eligible patient-donor pairs) among hematologic malignancies patients receiving partially HLA-mismatched (haploidentical) BMT after non-myeloablative conditioning including high dose, post-transplantation Cy (50 mg/kg IV on days 3 and 4). Here, we have retrospectively analyzed an additional 99 recipients of post-transplantation Cy after fludarabine/200 cGy TBI-based nonmyeloablative conditioning and haploidentical BMT (n=44) or busulfan/Cy-based myeloablative conditioning and HLA-matched BMT (n=55). After high-dose Cy, patients undergoing haploidentical BMT received mycophenolate mofetil and tacrolimus, while recipients of HLA-matched grafts received no further graft-versus-host disease (GVHD) prophylaxis. Patients did not receive CMV prophylaxis. CMV reactivation, measured weekly by quantitative PCR, occurred in 38.7% (12/31 eligible donor-patient pairs) in the mini-haploBMT trial and 31% (13/42 eligible patient donor pairs) in the myeloablative trial. CMV reactivation occurred twice in two patients in each trial. CMV disease occurred in two patients in the haploidentical BMT trial (1 retinitis, 1 pneumonia) but in no recipients of HLA-matched grafts. No deaths have been attributed to CMV infection on either trial. In the mini-haplo BMT patients, 58.3% (7/12) of those with CMV reactivation were considered high-risk (recipient CMV IgG positive, donor CMV IgG positive or negative) and 25% (3/12) were considered to be at intermediate risk (recipient CMV IgG negative and donor CMV IgG positive). Of the myeloablative BMT patients, 100% (13/13) of patients with CMV reactivation were part of the high-risk group. In addition to recipient CMV positivity, the presence of graft-versus-host disease (GVHD) was a risk factor for CMV reactivation on the myeloablative trial as 77% (10/13) of patients who reactivated their CMV had GVHD, but not on the “mini-haploBMT” trial where only 41.7% (5/12) had GVHD. The median number of days post-transplant to CMV reactivation was 49 (range 19–197) in the “mini-haploBMT” patients and 56 (range 19–140) in the myeloablative group. The median number of weeks to clear detectable CMV was 1 (range 1–11 in the mini-haploBMT group and 1–4 in the myeloablative group). These rates of CMV reactivation and infection compare favorably to the rates seen in patients receiving haploidentical and HLA-matched grafts following myeloablative conditioning without post-transplantation Cy. The low rates of CMV reactivation may be secondary to low rates of Grade 3–4 GVHD (9.1%, 4/44 “mini-haploBMT patients”; 7.3%, 4/55 myeloablative patients) and rapid immunologic recovery facilitated by the absence of prolonged pharmacologic immunosuppression, especially among recipients of HLA-matched grafts.

Impaired T-Lymphocyte Proliferation Function in Biliary Atresia Patients With Chronic Cholestatic Jaundice After a Kasai Operation

To investigate the association between chronic cholestatic jaundice, systemic immunity, and various infectious complications in patients with biliary atresia (BA), we performed a survey of the systemic immune function in 30 children with BA. Patients were divided into a jaundice group (total serum bilirubin > or = 2 mg/dL for >6 mo) and control group (total serum bilirubin <2 mg/dL for >6 mo) with comparable age. Patients were tested for serum immunoglobulin and complement levels, mitogen response, interleukin (IL)-4, IL-5, and interferon-gamma production after phytohemagglutinin (PHA) stimulation, blood cell and lymphocyte subpopulation counts, phagocytic function, and leukocyte adhesion complex. They were then followed prospectively for 6 mo, and severe infectious complications requiring hospitalization were recorded. Compared with jaundice-free patients, T-lymphocyte proliferation function, determined by PHA mitogen test was significantly lower (p = 0.02) in BA patients with chronic cholestatic jaundice after a Kasai operation. During the study period, patients with chronic cholestatic jaundice had a higher risk of severe infectious complications than their jaundice-free counterparts (risk ratio = 5.87; p = 0.001). In conclusion, BA patients with chronic cholestatic jaundice are associated with impairment of T-lymphocyte proliferation and increased incidence of severe infectious complications.

Disease activity and pretreatment, rather than hypogammaglobulinaemia, are major risk factors for infectious complications in patients with chronic lymphocytic leukaemia

To identify patients at high risk of life-threatening infections, we retrospectively analysed the prevalence of infectious complications in 187 chronic lymphocytic leukaemia patients treated in our institution since 1999 and correlated them with clinical features. A questionnaire with detailed questions regarding infectious complications was mailed to patients and their general practitioners. Major infections (requiring intravenous antibiotics or inpatient treatment) were reported in 37 patients (19.8%) and minor infections (requiring oral antibiotics and outpatient treatment) in 113 patients (60.4%). Univariate analysis identified advanced disease (P = 0.02), gender (P = 0.01), duration of disease (P = 0.007), number of previous chemotherapy regimens (P < 0.001), previous therapy with purine analogues and monoclonal antibodies (P < 0.001; P = 0.019), massive splenomegaly (P = 0.03), low granulocyte count (P < 0.001), low serum immunoglobulin concentration (P = 0.005), low haemoglobin concentration (P < 0.001) and high serum lactate dehydrogenase (LDH) concentration (P < 0.001) as risk factors for major infections. In multivariable logistic regression analysis, only the number of previous chemotherapy regimens (risk ratio [RR] = 1.8; 95% confidence interval [CI] 1.2-8.0) and haemoglobin concentration (RR = 0.6; CI 0.5-0.8) remained significant for major infections. The number of previous chemotherapy regimens was the only independent risk factor for minor (RR = 7.6; CI 2.2-25.7) and varicella-zoster virus infections (RR = 2.1; CI 1.3-3.4). In untreated patients, the only risk factor for major infections was LDH concentration. Patients treated with purine analogues or autologous stem cell transplantation had a higher risk of developing viral infections. In conclusion, disease activity and pretreatment extent have a stronger impact on the risk of severe infectious complications than hypogammaglobulinaemia. Preferably, prophylactic strategies should be evaluated in patients defined by these parameters.

Treatment considerations in acute renal failure.

Acute renal failure (ARF) is characterised by progressive azotaemia, and for therapeutic purposes consideration of prerenal, intrinsic renal and postrenal types still holds good. Prerenal azotaemia is generally caused by loss of body fluids or blood, whereas postrenal azotaemia is effected by acute or chronic urinary tract obstruction. Provided these conditions are recognised on time and treated, they are reversible. However, delay in recognition or treatment could result in renal parenchymal damage and sustained ARF. Therefore utmost attention should be focused on identifying reversible factor(s) in the setting of ARF. Once reversible factors have been excluded, and ARF becomes sustained, a diagnosis of acute intrinsic renal failure is almost certain. Lack of natriuretic and diuretic responses to fluid challenge or infusion of furosemide (frusemide) and dopamine are further indications of this possibility. Management of acute intrinsic renal failure essentially consists of dietary control and dialysis therapy. The latter facilitates fluid and electrolyte management, but does not reduce the overall mortality. The potential benefit of parenteral hyperalimentation to promote renal function recovery must be carefully weighed against the risk of severe infectious complications.