Severe cytomegalovirus enterocolitis developing following daratumumab exposure in three patients with multiple myeloma.

OBJECTIVES: The risk of cytomegalovirus (CMV) reactivation in multiple myeloma (MM) patients treated with bortezomib-based induction regimens is increased following autologous stem cell transplantation (ASCT). There is paucity of data regarding the risk of CMV infections in MM patients who did not receive bortezomib and ASCT. METHODS: We herein report three cases of heavily pretreated MM patients, receiving daratumumab-containing combination regimens, in whom ASCT had been performed long ago and who recently developed severe CMV-related gastrointestinal disease. RESULTS: All the three patients had a prolonged CMV disease course requiring a long-term antiviral treatment. All the patients suffered from CMV colitis. One patient had concurrent CMV duodenitis and another patient had a concurrent CMV retinitis. CONCLUSION: Novel myeloma treatments prolong patient survival and more patients with profound immunosuppression following multiple lines of therapies are seen in clinical practice. These patients may present with opportunistic infections that were rare in the past. Our findings suggest a possible association between daratumumab therapy (in combination with other immunosuppressive therapies) and severe CMV gastrointestinal disease. A longer follow-up is needed to explore long-term side effects of novel agents like daratumumab in newly diagnosed as well as heavily pretreated MM patients.

Adult Nephrotic Syndrome after Hematopoietic Stem Cell Transplantation: Renal Pathology is the Best Predictor of Response to Therapy.

Nephrotic syndrome (NS) after allogeneic hematopoietic stem cell transplantation (HSCT) is a rare phenomenon usually associated with graft-versus-host disease (GVHD). This systematic review of post-HSCT NS cases reported in the literature aimed to identify risk factors and unique features of the disease in this clinical setting. One hundred sixteen cases of post-HSCT NS published in the English literature between 1988 and 2015 were revealed and analyzed. The median onset of NS was 20.5 months (range, 3 to 174) post-HSCT. NS development was associated with acute or chronic GVHD in 87.2% of cases. Membranous nephropathy (MGN) was the most frequent pathology (65.5%), followed by minimal change disease (MCD) (19%). Complete remission of the NS was achieved in 63.5% of patients (59.1% of MGN cases and 81.3% of MCD cases; P = .15). Patients presenting with MCD recovered at a median of 1.75 months (range, 1 to 12) and with MGN a median of 7 months (range, 1 to 53) (P = .001). NS was treated with corticosteroids alone in 16.8% of patients and with a combination of corticosteroids and other immunosuppressive agents in 73.5% of patients. Univariate analysis failed to identify a single predictive factor of response to therapy. In conclusion, post-HSCT NS usually develops concomitant to GVHD and is associated with high rates of response to therapy. Although most patients were treated with a combination of immunosuppressive drugs, single-agent therapy with steroids may be sufficient in some cases.

MDS-Related Anemia Is Associated with Impaired Quality of Life but Improvement Is Not Always Achieved by Increased Hemoglobin Level.

Quality of life is impaired in MDS, but the role of hemoglobin level is unclear. To study the Hb-QoL correlation at diagnosis and 1 year later, patients filled out the EQ-5D questionnaire, assessing their mobility, self care, daily activities, pain/discomfort, and anxiety/depression, using scores of 0 (normal), 1 (mild/moderate), or 2 (poor). They also evaluated their health using a visual analogue scale, scoring from 0 (poor) to 100 (excellent). The anemia subgroups were: none/normal (Hb ≥ 12.5 g/dL), mild (10 ≤ Hb < 12.5), moderate (9 ≤ Hb < 10), severe (8 ≤ Hb < 9), or very severe (Hb < 8). LR-MDS patients (n = 127) and inpatient controls (n = 141) participated. The anemic patients had a poor QoL and the MDS patients had a lower QoL with a lower Hb. The controls had no QoL difference among the various anemia subgroups. In addition, the MDS QoL sharply decreased with an Hb of < 9. The MDS patients showed a wide QoL variability, i.e., different QoL scores in the same Hb subgroup, suggesting that other factors affect QoL (e.g., age and comorbidities). After 1 year (n = 61), the QoL was still poor for most MDS patients (including 27 patients with an increased Hb). In summary: (1) a poor QoL in MDS-anemia is non-linear, suggesting other influencing factors on QoL. (2) The sharp QoL drop with Hb < 9 g/dL challenges the transfusion Hb threshold. (3) The QoL in anemic MDS patients might differ from that in non-MDS patients. (4) Raising Hb, while recommended, does not guarantee an improved QoL.

Appropriate antibiotic prescribing pattern in hospitalized children.

This study analyzes prospectively the antibiotic prescription habits in terms of appropriateness of use and cost pattern effects in the paediatric wards of two different university hospital patient set-ups. Data on demographics, discharge diagnosis, antibiotic utilization and costs were collected prospectively from the children's individual electronic charts at Rambam Health Care Campus (R) and Kaplan Medical Centre (K) in Israel. A total of 505 and 497 children from R and K units, respectively, were screened. Of the surveyed population, 239 and 330 children in the R and K units were hospitalized due to infectious diseases. The antibiotic appropriateness for the R and K units were 84% and 91%, respectively (p>0.5). Total antibiotics Defined Daily Dose (DDD) and Drug Utilization 90% (DU90%) index were 241.7 and 217.5 for the R unit and 388 and 349.2 for the K unit, (p<0.001). Drug Cost 90% indices (DC90%) for the two units were NIS 6,023.5 and NIS 5,955.8; respectively. This study generates up-to-date information on the antimicrobial prescription habits in two different hospitals and suggests that antibiotic treatment in both hospitals appears to be appropriate. Significant lower median antibiotic cost was depicted in the K admission unit in comparison to the R admission unit (11.3 NIS - 40.0 NIS; p<0.01), respectively. Drug use evaluations are useful indicators for following trends of drug prescription, optimizing antibiotic usage and controlling expenditure.

General medications utilization and cost patterns in hospitalized children.

UNLABELLED: Drug utilization in the in-patient setting can provide mechanisms to assess drug prescribing trends, efficiency and cost-effectiveness of hospital formularies and examine sub-populations such as children for which prescribing habits are different from adults. OBJECTIVES: The aim of this descriptive study was to analyze general medication utilization patterns and costs excluding antimicrobials prescriptions and to compare two pediatric admission units in a tertiary care university hospital. METHODS: The total number of admitted children was 1,521 and 1,467 for the A and B admission units, respectively. The electronic data from 252 and 253 hospitalized children in the A and B admission unit were prospectively screened for general medication prescriptions, children on antimicrobials were excluded from the analysis. Their electronic charts were viewed once weekly from October 15, 2007 up to April 7, 2008 using the prescription-point prevalence method. One medication was considered to be one prescription. RESULTS: The general medications prescription number was 790 for 94 children (8.4 prescription/patient) in A and 959 for 88 children (10.9 prescription/patient) in B (p=0.02). The general medications defined daily dose (DDD) and drug utilization 90% (DU90%) index were 2,509.63, 2,259 for A; and 6,110.35, 5,499 for B, respectively. The DU90% index placed salbutamol inhalation with 835 DDD and sodium heparin with 2,102 DDD in the first place for the A and B admission units, respectively. A net increment in medication cost was registered according to the calculated cost from the depicted DU90% when the A (20,263 NIS) and B (6,269 NIS) admission units were compared (p=0.04). CONCLUSIONS: A significant difference in the prescription utilization of general medications was shown between the A and B admission units. The A admission unit had lower prescriptions measured by the DU90% index with higher medication cost. Potential drug-drug interactions were depicted in 18 (19%) and 17 (19%) subjects in the A and B admission unit, respectively.

General medications utilization and cost patternsin hospitalized children / Utilización general de medicamentos y patrones de costes en niños hospitalizados

Drug utilization in the in-patient setting can provide mechanisms to assess drug prescribing trends, efficiency and cost-effectiveness of hospital formularies and examine sub-populations such as children for which prescribing habits are different from adults. Objectives: The aim of this descriptive study was to analyze general medication utilization patterns and costs excluding antimicrobials prescriptions and to compare two pediatric admission units in a tertiary care university hospital. Methods: The total number of admitted children was 1,521 and 1,467 for the A and B admission units, respectively. The electronic data from 252 and 253 hospitalized children in the A and B admission unit were prospectively screened for general medication prescriptions, children on antimicrobials were excluded from the analysis. Their electronic charts were viewed once weekly from October 15, 2007 up to April 7, 2008 using the prescription-point prevalence method. One medication was considered to be one prescription. Results: The general medications prescription number was 790 for 94 children (8.4 prescription/patient) in A and 959 for 88 children (10.9 prescription/patient) in B (p=0.02). The general medications defined daily dose (DDD) and drug utilization 90% (DU90%) index were 2,509.63, 2,259 for A; and 6,110.35, 5,499 for B, respectively. The DU90% index placed salbutamol inhalation with 835 DDD and sodium heparin with 2,102 DDD in the first place for the A and B admission units, respectively. A net increment in medication cost was registered according to the calculated cost from the depicted DU90% when the A (20,263 NIS) and B (6,269 NIS) admission units were compared (p=0.04). Conclusions: A significant difference in the prescription utilization of general medications was shown between the A and B admission units. The A admission unit had lower prescriptions measured by the DU90% index with higher medication cost. Potential drug-drug interactions were depicted in 18 (19%) and 17 (19%) subjects in the A and B admission unit, respectively (AU)

La utilización de medicamentos en el entorno hospitalario puede proporcionar mecanismos para evaluar las tendencias de prescripción de medicamentos, la eficiencia y coste-efectividad de los formularios hospitalarios y examinar sub-poblaciones tales como los niños para los que los hábitos de prescripción son diferentes de los adultos. Objetivos: El objetivo de este estudio descriptivo fue analizar los patrones y costes de la utilización de la medicación general excluyendo los antibióticos, y comparar dos unidades de ingreso pediátricas en un hospital universitario terciario. Métodos: El número total de niños admitidos fue de 1.521 y de 1.467 para las unidades de ingreso A y B, respectivamente. Se escrutaron los datos electrónicos de 252 y 253 niños hospitalizados en las unidades de ingreso A y B, a la búsqueda de la medicación general, excluyendo antibióticos. Sus historiales electrónicos se revisaban una vez a la semana desde el 15 de octubre de 2007 al 7 de abril de 2008 usando el método de prevalencia de prescripción. Se consideró que una medicación era una prescripción. Resultados: el número de medicaciones generales prescritas fue de 790 para 94 niños (8,4 prescripciones/paciente) en A y 959 para 88 niños (10,9 prescripciones/paciente) en B (p=0,02). Las dosis diarias definidas (DDD) y utilización de medicamento90% (DU90%) para la medicación general fueron 2.509.63 y 2.259 para A; and 6.110,35 y 5.499 para B, respectivamente. El índice DU90% situó las inhalaciones con salbutamol con 835 DDD y la heparina sódica con 2.102 DDD en el primer lugar para las unidades A y B de ingreso, respectivamente. Se registró un incremento neto del coste de medicación de acuerdo con el coste calculado de lo dibujado por el DU90% cuando se comparaban las unidades A (20.263 NIS) y B (6.269 NIS) (p=0,04). Conclusiones: Se vio una diferencia significativa en la utilización de prescripciones de medicación general entre las unidades de ingreso A y B. La unidad A tenía menores prescripciones medidas con el índice DU90% de mayor coste. Se identificaron 18 (19%) y 17 (19%) interacciones medicamentosas potenciales en los individuos de las unidades A y B, respectivamente (AU)