Upper and/or Lower Respiratory Tract Infection Caused by Human Metapneumovirus After Allogeneic Hematopoietic Stem Cell Transplantation.

BACKGROUND: Human metapneumovirus (hMPV) epidemiology, clinical characteristics and risk factors for poor outcome after allogeneic stem cell transplantation (allo-HCT) remain a poorly investigated area. METHODS: This retrospective multicenter cohort study examined the epidemiology, clinical characteristics, and risk factors for poor outcomes associated with human metapneumovirus (hMPV) infections in recipients of allo-HCT. RESULTS: We included 428 allo-HCT recipients who developed 438 hMPV infection episodes between January 2012 and January 2019. Most recipients were adults (93%). hMPV infections were diagnosed at a median of 373 days after allo-HCT. The infections were categorized as upper respiratory tract disease (URTD) or lower respiratory tract disease (LRTD), with 60% and 40% of cases, respectively. Patients with hMPV LRTD experienced the infection earlier in the transplant course and had higher rates of lymphopenia, neutropenia, corticosteroid use, and ribavirin therapy. Multivariate analysis identified lymphopenia and corticosteroid use (>30 mg/d) as independent risk factors for LRTD occurrence. The overall mortality at day 30 after hMPV detection was 2% for URTD, 12% for possible LRTD, and 21% for proven LRTD. Lymphopenia was the only independent risk factor associated with day 30 mortality in LRTD cases. CONCLUSIONS: These findings highlight the significance of lymphopenia and corticosteroid use in the development and severity of hMPV infections after allo-HCT, with lymphopenia being a predictor of higher mortality in LRTD cases.

Impact of early candidemia on the long-term outcome of allogeneic hematopoietic stem cell transplant in non-leukemic patients: an outcome analysis on behalf of IDWP-EBMT.

We assessed the incidence and outcome of early candidemia after hematopoietic stem cell transplant (HSCT). The analysis included all first HSCTs performed from 2000 to 2015 in adult and pediatric patients with a non-leukemic disease and recorded in the EBMT registry. Overall survival (OS), non-relapse mortality (NRM), and relapse mortality (RM) were evaluated. Candidemia was diagnosed in 420 of 49,852 patients at a median time of 17 days post HSCT (range 0-100), the cumulative incidence being 0.85%. In 65.5% of episodes, candidemia occurred by day 30 after HSCT. The mortality rate by day 7 was 6.2%, whereas 100-day NRM was higher (HR 3.47, p < 0.0001), and 100-day OS was lower (HR 3.22, p < 0.0001) than that of patients without candidemia. After a median follow-up of 4.3 years, 5-year OS, NRM, and RM for patients with and without candidemia were 50.5% vs. 60.8%, p < 0.0001, 28.2% vs.18.8%, p < 0.0001, and 25.3% vs. 27.2%, p = 0.4, respectively. In conclusion, in non-leukemic transplant patients, the occurrence of an early episode of candidemia is rare but it is still associated with a negative effect on the outcome.

Upfront stem cell transplantation for newly diagnosed multiple myeloma with del(17p) and t(4;14): a study from the CMWP-EBMT.

We analyzed newly diagnosed multiple myeloma patients with del(17p) and/or t(4;14) undergoing either upfront single autologous (auto), tandem autologous (auto-auto) or tandem autologous/reduced-intensity allogeneic (auto-allo) stem cell transplantation. 623 patients underwent either auto (n = 446), auto-auto (n = 105), or auto-allo (n = 72) between 2000 and 2015. 46% of patients had t(4;14), 45% had del(17p) while 9% were reported having both abnormalities. Five-year overall survival (OS) was 51% (95% confidence interval [CI], 45-58%) for single auto, 60% (95% CI, 49-72%) for auto-auto, and 67% (95% CI, 53-80%) for auto-allo (p = 0.187). Five-year progression-free survival (PFS) was 17% (95% CI, 12-22%), 33% (95% CI, 22-43%), and 34% (95% CI, 21-38%; p = 0.048). Five-year relapse rate was 82, 63, and 56%, while non-relapse mortality was 1, 4, and 10%. In multivariable analysis, in t(4;14) with single auto as reference, auto-auto (hazard ratio [HR], 0.44; p = 0.007) and auto-allo (HR, 0.45; p = 0.018) were associated with better PFS. In terms of t(4;14) and OS, auto-auto appeared to improve outcome compared with single auto (HR, 0.49; p = 0.096). In del(17p), outcome in PFS was similar between single auto and auto-auto, while auto-allo appeared to improve PFS (HR, 0.65; p = 0.097). No significant difference in OS was identified between the groups in patients with del(17p).

The times they are a-changing: what worked and what we learned in deploying Ontario's Wait Time Information System.

How many days would you be comfortable waiting if you needed cancer surgery? What would you do if someone, not as medically urgent, was able to receive an MRI or CT scan before you? Would you want to know if you could wait less time for treatment at another location or with another clinician? These are some of the dilemmas facing patients and our health system when dealing with the issue of wait times. To address these pressing concerns, in the fall of 2004, Ontario launched its Wait Time Strategy. Two years later, Collins-Nakai et al. (2006) reported that Ontario had moved "from being a laggard to a leader" with respect to wait times. This article summarizes Ontario's work to date to improve access to care, including reviewing the need, action taken and the emerging results. Much can be learned and leveraged from the experiences described in this article and throughout this issue. They can serve as an important starting point for further discussion, improvement and action, for initiatives big and small, by all types of organizations and jurisdictions.

A visit down under: our journey to improve Canada's healthcare system.

Good health is a journey. It cannot be achieved overnight, in a month or even a year. Good health is perhaps best viewed as a quest - an evolution that takes ongoing commitment and often requires compromise, sacrifice and a lot of simple hard work. Indeed, the creation of a reliable and accessible healthcare system is no different. Few countries have adopted the same approach to delivering healthcare and each approach comes with its own unique rationale and lengthy list of pros and cons. In the end, the perfect system is elusive; however, for those of us who work within these systems, the quest for perfection is ongoing. There is a constant need and drive to make improvements and innovations to design a system that meets the needs of patients and providers without leaving behind a wake of frustration and financial burden.

Medical errors: understanding the parent's perspective.

Health care practitioners who advocate for full and open disclosure of medical errors often are met with opposition from legal advisors, insurance providers, hospital leadership, and colleagues. Although some progress has been made, a culture of fear around blame and retribution persists and continues to stymie the progression toward open discussion and disclosure of adverse events. The following case discussion addresses some common obstacles to disclosure of medical errors and reversals the potential for positive outcomes for patients and their families, hospital staff, and the health care system when those challenges are overcome.

Integration of cancer services in Ontario: the story of getting it done.

Leaders in healthcare have known for years that integrating service delivery makes sense, yet paradoxically across Canada, despite major system restructuring, cancer care has remained the exception. In Ontario it was recognized that this was an area both ripe for and in need of change. The economic impact associated with the growing burden of cancer in Ontario has been well documented. Also well documented are the potential solutions for how cancer services could be better integrated and organized to improve efficiency and quality of care. Until recently, however, little action was taken. Traditional biases, turf protection, political minefields and perhaps even restructuring fatigue have been excuses to stand still.