Immunogenicity of High-Dose Versus MF59-Adjuvanted Versus Standard Influenza Vaccine in Solid Organ Transplant Recipients: The Swiss/Spanish Trial in Solid Organ Transplantation on Prevention of Influenza (STOP-FLU Trial).

BACKGROUND: The immunogenicity of the standard influenza vaccine is reduced in solid-organ transplant (SOT) recipients, so new vaccination strategies are needed in this population. METHODS: Adult SOT recipients from 9 transplant clinics in Switzerland and Spain were enrolled if they were >3 months after transplantation. Patients were randomized (1:1:1) to a MF59-adjuvanted or a high-dose vaccine (intervention), or a standard vaccine (control), with stratification by organ and time from transplant. The primary outcome was vaccine response rate, defined as a ≥4-fold increase of hemagglutination-inhibition titers to at least 1 vaccine strain at 28 days postvaccination. Secondary outcomes included polymerase chain reaction-confirmed influenza and vaccine reactogenicity. RESULTS: A total of 619 patients were randomized, 616 received the assigned vaccines, and 598 had serum available for analysis of the primary endpoint (standard, n = 198; MF59-adjuvanted, n = 205; high-dose, n = 195 patients). Vaccine response rates were 42% (84/198) in the standard vaccine group, 60% (122/205) in the MF59-adjuvanted vaccine group, and 66% (129/195) in the high-dose vaccine group (difference in intervention vaccines vs standard vaccine, 0.20; 97.5% confidence interval [CI], .12-1); P < .001; difference in high-dose vs standard vaccine, 0.24 [95% CI, .16-1]; P < .001; difference in MF59-adjuvanted vs standard vaccine, 0.17 [97.5% CI, .08-1]; P < .001). Influenza occurred in 6% of the standard, 5% in the MF59-adjuvanted, and 7% in the high-dose vaccine groups. Vaccine-related adverse events occurred more frequently in the intervention vaccine groups, but most of the events were mild. CONCLUSIONS: In SOT recipients, use of an MF59-adjuvanted or a high-dose influenza vaccine was safe and resulted in a higher vaccine response rate. CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov NCT03699839.

[Opioids in patients with renal impairment]. / Opioide bei Patienten mit Niereninsuffizienz.

Opioids in patients with renal impairment Abstract. Renal impairment can reduce the elimination of certain opioids and their metabolites. Accumulation and toxicity may occur. Due to their pharmacokinetic properties, fentanyl, alfentanil and buprenorphine can be used safely in patients with renal impairment. Codeine and pethidine should be avoided entirely. Morphine should also be avoided if the creatinine clearance is below 30 ml / min. Reduced dose hydromorphone is an alternative here. Methadone, oxycodone and tramadol should be used with caution and in reduced doses. In this article we briefly explain the renal elimination processes, certain pharmacokinetic properties of the different opioids and the recommendations for clinical practice.

Carbon monoxide poisoning following use of a water pipe/hookah.

BACKGROUND: Water pipe (hookah) smoking has become a common activity in Germany, particularly among adolescents and young adults; in 2011, its lifetime prevalence was as high as 68.8%. Similar trends can be seen in other European countries. Water-pipe smokers are exposed to the same health-endangering substances as cigarette smokers, and the inhaled amount of carbon monoxide (CO) can be as much as ten times as high. In CO intoxication, carboxyhemoglobin is formed and causes direct injury at the cellular level, leading to hypoxia and nonspecific neuro logical manifestations. There have only been ten reported cases around the world of CO intoxication due to the use of a water pipe, and none of these were fatal. It should be recalled, however, that accidental CO intoxication is common and is associated with high morbidity and mortality. CASE PRESENTATION AND COURSE: We present a series of four young adults, aged 16 to 21, three of whom were hospitalized because of transient unconsciousness. The carboxyhemoglobin (CO-Hb) content of the blood in the symptomatic patients ranged from 20.1% to 29.6%, while the asymptomatic patient had a CO-Hb content of 16.7%. Water-pipe smoking was the cause of CO intoxication in all four cases. The CO-Hb values were successfully brought down by the administration of highly concentrated oxygen and all patients were discharged in asymptomatic condition. CONCLUSION: This case series reveals that CO intoxication due to water-pipe smoking is probably more common than is generally realized. Emergency room staff should be aware of this problem and inquire specifically about water-pipe smoking in patients with nonspecific neurological manifestations.

Catheter related blood stream infections in critically ill patients with continuous haemo(dia)filtration and temporary non-tunnelled vascular access.

UNLABELLED: This prospective, single centre, observational study analysed the rate of catheter related blood stream infections in critically ill patients in intensive care units treated with haemo(dia)filtration. The infection rate was 3.8 per 1000 patient days. All infections were caused by coagulase negative staphylococci. BACKGROUND: Temporary central venous catheters in patients undergoing continuous veno-venous haemo(dia)filtration contribute to serious infectious complications. The goal of this study was to assess the incidence of catheter related blood stream infections in critically ill patients treated with continuous veno-venous haemo(dia)filtration. METHODS: Prospective observational study of all intensive care unit patients treated with continuous veno-venous haemo(dia)filtration by a central venous catheter at the University Hospital Basel. All patients underwent a standardised anti-infective protocol including screening for nasal colonisation with S. aureus on the day of catheter insertion, antiseptic catheter placement technique and daily disinfection of the insertion site followed by local mupirocin application. Catheter related blood stream infection was diagnosed according to standard guidelines of the Center of Disease Control and Prevention. Primary end point was the incidence of catheter related blood stream infection in all intensive care unit patients treated with continuous veno-venous haemo(dia)filtration. RESULTS: From 2003 to 2007 a total of 194 consecutive critically ill patients treated with continuous veno-venous haemo(dia)filtration were investigated. 173 patients (63% men) were suitable for final analysis. Median age was 68.6 years (18.9-87.8). Eight patients (4.6%) had positive blood cultures, six of them had a catheter related blood stream infection (incidence 3.8/1000 catheter days). All infections were caused by coagulase negative staphylococci. The duration of catheter use (p = 0.02) and pre-existing chronic skin disease (p = 0.042) were identified as potential risk factors for catheter related blood stream infection. CONCLUSIONS: The incidence of catheter related blood stream infection in critically ill patients on intensive care units treated with continuous veno-venous haemo(dia)filtration was 3.8 per 1000 catheter days. All catheter related blood stream infections were caused by coagulase negative staphylococci.