Association of hematopoietic cell transplantation-specific comorbidity index with resource utilization after allogeneic transplantation.

Comorbidities affect clinical outcomes and costs in medicine. The hematopoietic cell transplantation (HCT)-specific comorbidity index (HCT-CI) predicts mortality risk after HCT. Its association with resource utilization (RU) is unknown. In this single-center, retrospective study, we examined the association of HCT-CI with RU (readmissions, length of hospital stay (LOS) and days out of hospital alive (DOHA)) in first 100 days (n=328) and 1 year (n=226) in allogeneic HCT patients from January 2010 to June 2014. Age, disease risk, conditioning and use of antithymocyte globulin were significantly different in the four groups with HCT-CI 0 to1 (n=138), 2 (n=56), 3 (n=55) or ⩾4 (n=79). Although the readmissions were higher in the first 100 days for patients with HCT-CI >0-1 (P=0.03), they were not significantly different in patients over 1 year (P=0.13). In the multivariable analysis, patients with HCT-CI score of >0 to 1 had increased LOS and fewer DOHA in both 100 days and 1 year after HCT. In this exploratory analysis, we found that HCT-CI >0 to 1 is associated with increased RU after allogeneic HCT. Recognizing predictors of RU can identify patients at risk of high utilization and help understand what drives health-care costs.

Comparison of donor chimerism following myeloablative and nonmyeloablative allogeneic hematopoietic SCT.

Surveillance of hematopoietic chimerism following hematopoietic SCT (HSCT) with nonmyeloablative (NMA) preparative regimens is standard to assess the need for clinical intervention. Monitoring of donor chimerism following HSCT with myeloablative (MA) preparative regimens is, however, not considered useful because engraftment is thought to occur rapidly and consistently. This study compares the timing of donor hematopoietic cell engraftment in patients undergoing NMA conditioning with fludarabine and TBI with those receiving MA conditioning with BU- or TBI-based regimens. Achievement of ≥ 90% donor leukocyte chimerism occurred rapidly and consistently in all three groups and time to achievement of ≥ 90% donor T cells was similar among the three groups (P = 0.57). Achievement of ≥ 90% donor leukocyte chimerism was not associated with risk of acute or chronic GVHD, graft rejection, relapse or all cause mortality in multivariate analyses. Donor T-cell chimerism of ≥ 90% was significantly associated with development of extensive chronic GVHD. The value of routine surveillance of chimerism following any of the preparative regimens used in this study should be reevaluated.

Increased hepatic endothelin-1 levels and endothelin receptor density in cirrhotic rats.

Endothelin-1 (ET-1), the most powerful agent to cause constriction of the hepatic vasculature, is synthesized in the liver by sinusoidal endothelial cells. Circulating ET-1 levels have been shown to increase in liver cirrhosis. As liver could be a major source of increased plasma ET-1 as well as a target for its pathologic actions, this study was designed to determine hepatic ET-1 and ET receptor(s) in experimental liver cirrhosis. Cirrhosis was induced in rats by intraperitoneal administration of carbon tetrachloride for 8 weeks. Hepatic ET-1 was measured by radioimmunoassay and ET receptors were determined by radioligand competition binding procedure. A four fold increase in ET-1 concentration accompanied by a 65% increase in ET-receptor density was observed in the cirrhotic liver. There was no change in the ET receptor affinity. The capacity of the liver to metabolize ET-1 was reduced significantly in cirrhosis. Interestingly, transforming growth factor-beta, hepatic levels of which increase in cirrhosis, stimulated ET-1 synthesis in cultured Ito cells. It has been shown that ET-1 is a potent constrictor of Ito cells that proliferate and transform into highly contractile myofibroblasts in liver cirrhosis. Thus, interactions between ET-1 and Ito cells may have significant implications in the pathogenesis and complications of liver cirrhosis.

A multicentre survey of hand hygiene practice in intensive care units.

A detailed survey of hand hygiene in 16 intensive care units (ICUs) in Yorkshire was undertaken with the aim of following up the results of a national survey of infection control policies and practices which had been conducted in 1990 (Inglis et al., Br J Anaesthesia 1992; 68, 216-220). The main problems associated with infection control were identified as: the limited relevance of some infection control policies to the specialist nature of intensive care, poor compliance by nurses to local infection control policies, sub-optimal hand hygiene by all healthcare professionals and a need for more effective communication of research-based infection control recommendations in the ICU. Our results suggest that hand hygiene practice in the ICU is sub-optimal as a consequence of ineffective communication of infection control recommendations, insufficient promotion and enforcement of agreed research-based infection control practices, and a deficiency in infection control education. The current methods of communicating infection control recommendations have a limited effect on compliance rates in the ICU and are not evaluated adequately. Recommendations for further development in this field are to prioritise surveillance of infection rates in ICUs and to feedback infection rates to intensive care staff, to identify local priorities for infection control and to introduce continuous infection control education for all healthcare professionals. Further research is required to investigate and understand why educated health professionals are not complying with recommended research-based infection control practices.

Staphylococcal pneumonia in ventilated patients: a twelve-month review of cases in an intensive care unit.

We reviewed staphylococcal lower respiratory tract infections in our intensive care unit over a 12-month period. Staphylococcus aureus was isolated from tracheal aspirates more commonly in patients with intracranial trauma (P < 0.001), between one and six days (mean = 3) after admission to the intensive care unit. Bacteriophage typing of all S. aureus lower respiratory tract isolates from the 17 patients with head injury did not provide evidence for a common external source of infection or patient-to-patient transmission.

Gastroduodenal dysfunction and bacterial colonisation of the ventilated lung.

The source of ventilator-associated pneumonia (gastric or oropharyngeal flora) remains controversial. We investigated the source of bacterial colonisation of the ventilated lung in 100 consecutive intensive-care patients. Gram-negative bacilli were isolated from the lower respiratory tract in 19 patients. Bacteria isolated from the stomach contents either previously or at the same time were identical to lower respiratory isolates in 11 patients. No gram-negative oropharyngeal isolate was identical to a lower respiratory tract isolate. Gastric bacterial overgrowth with gram-negative bacilli was associated with the presence of bilirubin in the stomach contents. Detectable bilirubin was also associated with subsequent acquisition of gram-negative bacilli in the lower respiratory tract. Only 5 gastric aspirate specimens with pH < 3.5 contained gram-negative bacilli. These results establish a relation between duodenal reflux and subsequent bacterial colonisation of the lower respiratory tract. Restoration of normal gastroduodenal motility might help prevent pneumonia in intensive-care patients.

Gastroduodenal dysfunction as a cause of gastric bacterial overgrowth in patients undergoing mechanical ventilation of the lungs.

We have studied 15 patients undergoing mechanical ventilation of the lungs for evidence of a relationship between gastroduodenal dysfunction and gastric bacterial overgrowth. Duodenal reflux was detected by quantitative measurement of conjugated bilirubin in gastric aspirate specimens. The pH and bacterial content of these specimens were analysed. A minority of specimens with pH less than 3.5 contained measurable numbers of viable bacteria. The total bacterial count and the count of Gram negative bacteria correlated significantly with specimen pH in both cases (P less than 0.001, in both). In the 72 specimens of gastric aspirate with pH greater than 3.5, the presence of Gram negative bacteria was associated significantly with detectable bilirubin (P less than 0.001). The total bacterial count was greater also in specimens containing bilirubin (P = 0.009). These results suggest that gastroduodenal dysfunction may promote gastric bacterial overgrowth, contributing to the development of ventilator-associated pneumonia.

Infection control in intensive care units: U.K. national survey.

A completed questionnaire was returned by 246 (85%) intensive care units participating in a national survey of infection control practice in intensive care. Thirty-three units had no provision for isolating patients in single side wards. Sixty percent of responding ICU had fewer than one washbasin per bedspace. Several units reported using ventilator filters or tubing more frequently than is currently recommended. Excessive numbers of catheter urine specimens were sent for laboratory examination by some units. A small number of units used open urinary drainage systems. A significant proportion of ICU had no formally recognized policy on the management of intravascular cannulae. Only 8% of ICU in the U.K. were using a selective decontamination regimen, and nine of these (50%) had no full time consultant microbiologist available to supervise the recommended microbiological management. The majority of ICU received a regular visit (greater than or equal to one per week) from a microbiologist. Proposals are made on the development of a specialized infection control service in order to reduce the risk of nosocomial infection in intensive care, and to improve on existing resource management.