Cycle threshold predicted mortality in a cohort of patients with hematologic malignancies infected with SARS-CoV-2.

When a SARS-CoV-2 RT-qPCR test is performed, it may determine an indirect measure of viral load called cycle threshold (Ct). Respiratory samples with Ct <25.0 cycles are considered to contain a high viral load. We aimed to determine whether SARS-CoV-2 Ct at diagnosis could predict mortality in patients with hematologic malignancies (lymphomas, leukemias, multiple myeloma) who contracted COVID-19. We included 35 adults with COVID-19 confirmed by RT-qPCR performed at diagnosis. We evaluated mortality due to COVID-19 rather than mortality due to the hematologic neoplasm or all-cause mortality. Twenty-seven (27) patients survived and 8 died. The global mean Ct was 22.8 cycles with a median of 21.7. Among the survivors, the mean Ct was 24.2, and the median Ct value was 22.9 cycles. In the deceased patients, the mean Ct was 18.0 and the median Ct value was 17.0 cycles. Using the Wilcoxon Rank Sum test, we found a significant difference (p=0.035). SARS-CoV-2 Ct measured in nasal swabs obtained at diagnosis from patients with hematologic malignancies may be used to predict mortality.

[Hepatitis B virus reactivation in rituximab-treated patients: incidence and risk factors]. / Reactivación del virus de la hepatitis B en pacientes tratados con rituximab: incidencia y factores de riesgo.

Hepatitis B virus (HBV) reactivation after chemotherapy regimens is a well-known complication. The incidence and risk factors for HBV reactivation remain to be elucidated. We aimed to determine the incidence and risk factors for HBV reactivation in patients receiving rituximab, and the potential role of the cumulative rituximab dose in HBV reactivation. We retrospectively reviewed 320 patients receiving rituximab in our hospital. Of these, 42 (13.12%) had serological markers of hepatitis B. During follow-up, 21% (9/42) had HBV reactivation. Risk factors for reactivation were HBsAg positivity (p < 0.05), isolated anti-HBc positivity (p < 0.05), marginal zone lymphoma, and Mantle cell lymphoma (p < 0.05). The median rituximab dose tended to be higher in patients with reactivation (p = 0.06).

Hematologic neoplasms: interpreting lung findings in chest computed tomography.

Lung disease is very common in patients with hematologic neoplasms and varies in function of the underlying disease and its treatment. Lung involvement is associated with high morbidity and mortality, so it requires early appropriate treatment. Chest computed tomography (CT) and the analysis of biologic specimens are the first line diagnostic tools in these patients, and sometimes invasive methods are necessary. Interpreting the images requires an analysis of the clinical context, which is often complex. Starting from the knowledge about the differential diagnosis of lung findings that radiologists acquire during training, this article aims to explain the key clinical and radiological aspects that make it possible to orient the diagnosis correctly and to understand the current role of CT in the treatment strategy for this group of patients.

Incidental detection of raised serum levels of vitamin B12 and its association with neoplasms.

BACKGROUND AND OBJECTIVES: Elevated serum levels of vitamin B12 have been associated with oncohematological diseases. However, the relevance of its incidental detection in subjects without a previous diagnosis of cancer is unknown. The aim of this study was to evaluate the relationship between incidental hypercobalaminemia (vitamin B12 > 1000 pg/mL) and the diagnosis of a tumor process in patients without a diagnosis and to establish the risk factors. MATERIAL AND METHODS: Retrospective observational study of a cohort of patients with hypercobalaminemia. The incidence of neoplasms was compared with a cohort of patients with vitamin B12 levels <1000 pg/mL. RESULTS: Vitamin B12 determinations of 4800 subjects were selected. Of them, 345 (7.1%) had levels >1000 pg/mL. 68 (28.4%) were excluded due to exogenous administration, 12 (5%) due to insufficient data and 15 (3%) due to having an active neoplasia, selecting 250 patients, with a median follow-up of 22 (IQR 12-39) months. Structural liver disease was detected in 59 (23.6%). 18.2% (44 patients) had solid organ cancer and 17 (7.1%) had malignant hemopathy. The average time from the detection of hypercobalaminemia to the diagnosis of cancer was about 10 months. The median until the diagnosis of neoplasia was higher in the high vitamin B12 group (13 vs. 51 months p < 0.001). Hypercobalaminemia (HR 11.8; 95% CI 2.8-49.6; p = 0.001) and smoking (HR 4.0; 95% CI, 2.15-7.59; p < 0.001) were independent predictors of neoplasia in the multivariate analysis. CONCLUSIONS: Incidental detection of serum vitamin B12 levels >1000 pg/mL is high in the population. The diagnosis of solid organ and hematological neoplasia is frequent during the following year of follow-up, with hypercobalaminemia and smoking being predictors of a higher risk of cancer.

Secondary hypogammaglobulinemia in adults-A large retrospective cohort study.

BACKGROUND AND OBJECTIVE: IgG replacement therapy (IgG-RT) has radically changed the clinical evolution of primary immunodeficiencies, yet the information regarding secondary hypogammaglobulinemia (SHG) is insufficient or conflicting. We aim to describe clinical features, evolution and treatment of SHG patients in our center. METHODS: Dynamic retrospective cohort between January 2001 and July 2021 of adults with gamma globulin fraction <0.6g/dL in a serum protein electrophoresis and a coincident decrease of IgG levels - with a disease-related SHG or treatment that reduces serum immunoglobulins. RESULTS: We included 1012 patients with SHG with a median follow-up of 5 years (IQR 2-8). Hematological diseases were identified in 95% of the patients and 61% received drugs related to SHG. Sixty five percent had more than one etiological factor associated with SHG. Infectious diseases were present in 69% of the patients, 48% had respiratory infections and 17% had severe infections. There was statistical association between respiratory and severe infections with multiple myeloma (MM), lymphoma and rituximab. MGUS had less infections and death compared with other etiologies. IgG-RT was indicated in 18.7% of the patients and 4.6% received it for more than 6 months with variable intervals. Among the latter group, there was a significant reduction of all-type infections and respiratory infections with IgG-RT (p<0.001), and it was consistent with similar findings in lymphoma, MM and all IgG levels subgroups. CONCLUSION: SHG was associated with more than one etiological factor and a high frequency of infections. IgG-RT indication was irregular yet still effective. It is relevant to consider IgG levels screening, monitoring and accurate indication of IgG-RT.

Risk stratification model for the pharmaceutical care of oncology patients with solid or hematologic neoplasms. / [Artículo traducido] Modelo de estratificación de riesgo de atención farmacéutica para pacientes oncológicos con neoplasias sólidas o hematológicas.

OBJECTIVE: We aimed to develop of a risk stratification model for the pharmaceutical care (PC) of patients with solid or hematologic neoplasms who required antineoplastic agents or supportive treatments. METHOD: The risk stratification model was collaboratively developed by oncology pharmacists from the Spanish Society of Hospital Pharmacy (SEFH). It underwent refinement through three workshops and a pilot study. Variables were defined, grouped into four dimensions, and assigned relative weights. The pilot study collected and analyzed data from participating centers to determine priority levels and evaluate variable contributions. The study followed the Kaiser Permanente pyramid model, categorizing patients into three priority levels: Priority 1 (intensive PC, 90th percentile), Priority 2 (60th-90th percentiles), and Priority 3 (60th percentile). Cut-off points were determined based on this stratification. Participating centers recorded variables in an Excel sheet, calculating mean weight scores for each priority level and the total risk score. RESULTS: The participants agreed to complete a questionnaire that comprised 22 variables grouped into 4 dimensions: demographic (maximum score =11); social and health variables and cognitive and functional status (maximum = 19); clinical and health services utilization (maximum = 25); and treatment-related (maximum = 41). From the results of applying the model to the 199 patients enrolled, the cutoff points for categorization were 28 or more points for priority 1, 16 to 27 points for priority 2 and less than 16 for priority 3; more than 80% of the total score was based on the dimensions of 'clinical and health services utilization' and 'treatment-related'. Interventions based on the pharmaceutical care model were recommended for patients with solid or hematological neoplasms, according to their prioritization level. CONCLUSION: This stratification model enables the identification of cancer patients requiring a higher level of pharmaceutical care and facilitates the adjustment of care capacity. Validation of the model in a representative population is necessary to establish its effectiveness.

Medication reconciliation in hospitalized hematological patient. / Conciliación de la medicación en el paciente hematológico ingresado.

OBJECTIVE: The main objective was to analyze unjustified discrepancies during the medication reconciliation process in patients admitted to the Hematology Service of our hospital and the pharmaceutical interventions. As a secondary objective, to detect possible points of the procedure to be perfected with a view to protocolizing the medication reconciliation process in hematological patients that adapts to the conditions of our center. METHODS: Cross-sectional observational pilot study carried out in a reference hospital in hematology for a population of 800,000 inhabitants. Adult inpatients admitted to the Hematology Service between August and October 2022 whose medication had been reconciled were included. The main variables were: number and type of unjustified discrepancy, proposed pharmaceutical intervention, and acceptance rate. RESULTS: 36 conciliation processes were analyzed, 34 admissions and 2 intrahospital transfer. 58.3% of the patients presented at least one unjustified discrepancy. 38 unjustified discrepancies were detected, with an acceptance of pharmaceutical interventions of 97.4%. The most common types of discrepancy were medication omission (56.8%) and drug interaction (24.3%). The most frequent pharmaceutical interventions were reintroducing medication (48.6%) and treatment discontinuation (16.2%). Polypharmacy and chemotherapy multiplied by 4 the probability of presenting drug interactions. CONCLUSIONS: The most common unjustified discrepancies in the medication reconciliation process in hospitalized hematology patients are: Medication omission and drug interactions. The reintroduction of medication and suspension of the prescription are the most frequent accepted pharmaceutical interventions. Polypharmacy is related to an increase in unjustified discrepancies. The factors that promote the appearance of interactions are admissions to receive chemotherapy treatment and polypharmacy. The main point of improvement detected is the need to create a circuit that allows conciliation to be carried out on discharge. Medication reconciliation contribute to improving patient safety by reducing medication errors.

Risk stratification model for the pharmaceutical care of oncology patients with solid or hematologic neoplasms.

OBJECTIVE: We aimed to develop of a risk stratification model for the pharmaceutical care of patients with solid or hematologic neoplasms who required antineoplastic agents or supportive treatments. METHOD: The risk stratification model was collaboratively developed by oncology pharmacists from the Spanish Society of Hospital Pharmacy (SEFH). It underwent refinement through 3 workshops and a pilot study. Variables were defined, grouped into 4 dimensions, and assigned relative weights. The pilot study collected and analyzed data from participating centers to determine priority levels and evaluate variable contributions. The study followed the Kaiser Permanente pyramid model, categorizing patients into 3 priority levels: Priority 1 (intensive PC, 90th percentile), Priority 2 (60th-90th percentiles), and Priority 3 (60th percentile). Cut-off points were determined based on this stratification. Participating centers recorded variables in an Excel sheet, calculating mean weight scores for each priority level and the total risk score. RESULTS: The participants agreed to complete a questionnaire that comprised 22 variables grouped into 4 dimensions: demographic (maximum score=11); social and health variables and cognitive and functional status (maximum=19); clinical and health services utilization (maximum=25); and treatment-related (maximum=41). From the results of applying the model to the 199 patients enrolled, the cut-off points for categorization were 28 or more points for priority 1, 16-27 points for priority 2, and less than 16 for priority 3; more than 80% of the total score was based on the dimensions of "clinical and health services utilization" and "treatment-related." Interventions based on the pharmaceutical care model were recommended for patients with solid or hematological neoplasms, according to their prioritization level. CONCLUSION: This stratification model enables the identification of cancer patients requiring a higher level of pharmaceutical care and facilitates the adjustment of care capacity. Validation of the model in a representative population is necessary to establish its effectiveness.

Evaluation of the diagnostic accuracy of galactomannan from the bronchoalveolar lavage fluid of patients with suspected invasive pulmonary aspergillosis.

BACKGROUND: Several studies to evaluate the accuracy of galactomannan (GM) in bronchoalveolar lavage fluid (BALF) as a diagnostic tool have been carried out; however, there are still controversies about the optimal cut-off point of BALF GM. AIMS: The objective of this study was to determine the diagnostic accuracy and the optimal cut-off point on BALF GM from patients with suspected invasive pulmonary aspergillosis (IPA) in a tertiary care hospital. METHODS: A cross-sectional study with 188 patients (≥18 years) that had undergone a bronchoscopy with BAL due to suspected IPA was carried out. IPA was diagnosed according to the EORTC/MSG guidelines. RESULTS: The optimal optical density cut-off point for BALF GM was 0.67, with sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 70%, 32.3%, and 100%, respectively. CONCLUSIONS: BALF GM detection proved to be a useful supplementary technique in the early diagnosis of IPA in both neutropenic and non-neutropenic patients.

[Relevance of liposomal amphotericin B in the treatment of invasive fungal infections in patients with hematologic malignancies]. / Relevancia de la anfotericina B liposomal en el tratamiento de las infecciones fúngicas invasoras en pacientes oncohematológicos.

Liposomal amphotericin B (L-AmB) has been a key cornerstone for the management of invasive fungal infections (IFI) caused by a wide array of molds and yeasts during the last three decades. Multiple studies performed over this period have generated a large body of evidence on its efficacy and safety, becoming the main antifungal agent in the management of IFI in patients with hematologic malignancies in several not mutually exclusive clinical settings. First, L-AmB is the most commonly used antifungal agent in patients undergoing intensive chemotherapy for acute leukemia and high-risk myelodysplastic syndrome, as well as in hematopoietic stem cell transplant recipients. Additionally, due to the administration of newer targeted therapies (such as monoclonal antibodies or small molecule inhibitors), opportunistic mold infections are increasingly being reported in patients with hematologic malignancies usually considered low-risk for IFI. These agents usually have a high drug-drug interaction potential, being triazoles, commonly used for antifungal prophylaxis, included. Finally, patients developing breakthrough IFI because of either subtherapeutic concentrations of antifungal prophylactic drugs in blood or selection of resistant strains, require broad spectrum antifungal therapy, usually with an antifungal of a different class. In both situations, L-AmB remains as the best option for early antifungal therapy.

The appearance of malnutrition in hematological inpatients prolongs hospital stay: the need for nutritional surveillance during hospitalization.

INTRODUCTION: Introduction: oncohematological diseases are associated with a high prevalence of malnutrition during hospitalization. Our aim was to analyze the appearance and repercussions of malnutrition in well-nourished hematological inpatients at admission. Method: a prospective one-year study conducted in hematology inpatients. The Malnutrition Screening Tool (MST) was used at admission and repeated weekly. Patients with a negative screening at admission who developed malnutrition during hospitalization constituted our study sample. A nutritional evaluation and intervention was performed. We also analyzed the effect of newly diagnosed malnutrition on patients' outcomes in comparison with the outcomes of patients that remained well-nourished during hospitalization. Results: twenty-one percent of hematological inpatients who were well nourished at admission developed malnutrition during hospitalization. Of the patients, 62.4% needed a nutritional intervention (100% oral supplements, 21.4% diet changes, 5.2% parenteral nutrition). After intervention, an increase in real intake was achieved (623 kcal and 27.3 g of protein/day). Weight loss was slowed and visceral protein was stabilized. Length of stay was 8.5 days longer for our sample than for well-nourished patients. Conclusions: newly diagnosed malnutrition appeared in one in five hematological well-nourished inpatients, leading to a longer length of stay. Nutritional intervention improved intake and nutritional status. Nutritional surveillance should be mandatory.

INTRODUCCIÓN: Introducción: las enfermedades oncohematológicas asocian una elevada prevalencia de malnutrición, especialmente durante la hospitalización. Objetivo: analizar la aparición de malnutrición y su repercusión en pacientes normonutridos al ingreso. Métodos: estudio prospectivo de un año en una cohorte de ingresados hematológicos. El Malnutrition Screening Tool (MST) se realizó al ingreso, repitiéndose semanalmente. Los pacientes con cribado negativo al ingreso que desarrollaron malnutrición durante la hospitalización constituyeron nuestra muestra. Se realizó evaluación e intervención nutricional, analizando el efecto de la aparición de malnutrición en el pronóstico, comparado con los pacientes que permanecieron normonutridos. Resultados: el 21% de los pacientes normonutridos al ingreso desarrolló malnutrición en la hospitalización. El 62.4% precisó intervención nutricional (100% suplementos orales, 21,4% cambios dietéticos, 5.2% nutrición parenteral). La intervención logró un aumento de ingesta real de 623 kcal y 27,3 g proteína/día, frenando la pérdida de peso y estabilizando las proteínas viscerales. La estancia fue 8,5 días mayor en nuestra muestra que en los pacientes que permanecieron normonutridos. Conclusiones: uno de cada cinco ingresados normonutridos al ingreso desarrolló malnutrición en la hospitalización, asociando mayor estancia. La intervención nutricional puede mejorar la ingesta y el estado nutricional, por tanto, la vigilancia nutricional debería ser obligatoria.

Estado nutricional, força muscular e capacidade funcional em portadores de mieloma múltiplo / Nutritional status, muscle strength and functional capacity in patients with multiple myeloma

O mieloma múltiplo é uma neoplasia maligna caracterizada pela proliferação clonal de plasmócitos na medula óssea. O objetivo deste trabalho foi avaliar as possíveis associações entre o estado nutricional, força muscular e capacidade funcional de pacientes ambulatoriais portadores de mieloma múltiplo. Trata-se de estudo transversal realizado em amostra não probabilística de pacientes com mieloma múltiplo atendidos no Hospital das Clínicas, em Goiânia. Os dados foram coletados entre agosto e dezembro de 2015, utilizando-se de entrevistas e informações dos prontuários. O estado nutricional foi avaliado aplicando-se a Avaliação Subjetiva Global Produzida pelo Próprio Paciente; a força muscular medida por meio da Força do Aperto de Mão e a capacidade funcional, pela Escala de Performance de Karnofsky. O estudo foi aprovado pelo Comitê de Ética e Pesquisa do referido hospital. Foram avaliados 52 pacientes, em que 48,1% estavam desnutridos, 30,8% apresentavam baixa força muscular e 73,1%, comprometimento da capacidade funcional. A força muscular e a capacidade funcional foram menores nos desnutridos. Observou-se que aqueles que utilizavam corticoides apresentaram 18% menos chance de se tornarem desnutridos (OR=0,18; IC=0,05-0,62; p=0,011) porém, é importante considerar as possíveis causas de viés; por outro lado, os pacientes com baixa força muscular ou faziam quimioterapia apresentaram, aproximadamente, quatro vezes mais chances de desnutrição, respectivamente (OR=3,46; IC=0,99-12,08; p=0,047) (OR=3,64; IC=1,13-11,69; p=0,027). Concluiu-se que a desnutrição é comum nos pacientes portadores de mieloma múltiplo, indicando a necessidade premente de intervenção nutricional apropriada e precoce.

Multiple myeloma is a malignant neoplasm characterized by the clonal proliferation of plasma cells in the bone marrow. The objective of this study was to evaluate possible associations between nutritional status, muscle strength and functional capacity of outpatients with multiple myeloma. This is a cross-sectional study carried out on a non-probabilistic sample of patients with multiple myeloma treated at Hospital das Clínicas, in Goiânia. Data were collected between August and December 2015, using interviews and information from medical records. Nutritional status was assessed using the Patient Generated Subjective Global Assessment; muscular strength measured using Hand Grip Strength and functional capacity, using the Karnofsky Performance Scale. The study was approved by the Ethics and Research Committee of that hospital. 52 patients were evaluated, of which 48.1% were malnourished, 30.8% had low muscle strength and 73.1% had impaired functional capacity. Muscle strength and functional capacity were lower in malnourished individuals. It was observed that those who used corticosteroids were 18% less likely to become malnourished (OR=0.18; CI=0.05-0.62; p=0.011), however, it is important to consider the possible causes of bias; on the other hand, patients with low muscle strength or undergoing chemotherapy were approximately four times more likely to be malnourished, respectively (OR=3.46; CI=0.99-12.08; p=0.047) (OR=3.64; CI=1.13-11.69; p=0.027). It was concluded that malnutrition is common in patients with multiple myeloma, indicating the pressing need for appropriate and early nutritional intervention.

Estudio del líquido cefalorraquídeo en pacientes con neoplasias hematológicas malignas / Study of cerebrospinal fluid in patients with hematologic malignancies

Introducción: La infiltración del sistema nervioso central por células malignas constituye una complicación grave de algunas neoplasias hematológicas, principalmente leucemias agudas y linfomas agresivos. Objetivo: Resumir la base científica y la significación clínica de los métodos de estudio del líquido cefalorraquídeo para el diagnóstico y el seguimiento de la infiltración neuromeníngea en pacientes con neoplasias hematológicas. Métodos: Se buscó información durante abril de 2021 en las bases de datos PubMed, ScienceDirect y SciELO. Se seleccionaron las publicaciones en base a su tipología, actualidad, alcance y las limitaciones de los estudios. Conclusiones: El estudio citomorfológico del líquido cefalorraquídeo se considera el método estándar para el diagnóstico y el seguimiento de la infiltración neuromeníngea. La citometría de flujo resulta más sensible para la detección de infiltración oculta que la citología convencional; pero aún existen reservas sobre su significación clínica. Se investiga también la sensibilidad de otros estudios moleculares como el uso de la reacción en cadena de la polimerasa y la detección de biomarcadores(AU)

Introduction: Infiltration of the central nervous system by malignant cells constitutes a serious complication of some hematological malignancies, mainly acute leukemias and aggressive lymphomas. Objective: To summarize the scientific basis and clinical significance of cerebrospinal fluid study methods for the diagnosis and follow-up of neuromeningeal infiltration in patients with hematologic malignancies. Methods: Information was searched during April 2021 in PubMed, ScienceDirect and SciELO databases. Publications were selected based on their typology, timeliness, scope, and study limitations. Conclusions: The cytomorphological study of cerebrospinal fluid is considered the standard method for the diagnosis and follow-up of neuromeningeal infiltration. Flow cytometry is more sensitive for the detection of occult infiltration than conventional cytology, but there are still reservations about its clinical significance. The sensitivity of other molecular studies such as the use of PCR and biomarker detection is also investigated(AU)

Respuesta inmunológica a la vacunación y riesgo de COVID-19 en adultos con neoplasias hematológicas / Immunological response to vaccination and risk of COVID-19 in adults with hematological malignancies

Los pacientes con malignidades hematológicas tienen un riesgo más alto de hospitalización, admisión a cuidado crítico y muerte cuando contraen COVID-19. En este grupo se ha propuesto la vacunación y los refuerzos para disminuir el riesgo de complicaciones. Sin embargo, es posible ver una pobre respuesta humoral y celular a las vacunas. En esta revisión se presenta la evidencia sobre la respuesta a la vacunación, poniendo de presente algunas patologías y tratamientos que pueden disminuirla de forma significativa. Los pacientes con neoplasias hematológicas se deben considerar en riesgo de complicaciones, incluso después de haber sido vacunados de forma completa y haber recibido los refuerzos. Se debe mantener la vigilancia de forma estrecha después de haber sido vacunados y evaluar la posibilidad de otras estrategias (medicamentos, anticuerpos monoclonales) para la prevención o el manejo de COVID-19.

Patients with hematological malignancies have a higher risk of hospital admission, critical care and death when they suffer from COVID-19. In this group of patients, vaccination and boosters have been proposed to mitigate the risk of complications. However, it is possible to observe a diminished rate of humoral and cellular response. In this review, evidence is shown about the response to COVID-19 vaccination, considering some specific pathologies and treatments that can affect such response in a significant account. Patients with malignant neoplasm must be considered at risk of COVID-19 complications, even after a complete vaccine schedule and boosters. Surveillance must be maintained after vaccination over these patients and other strategies must be considered (drugs, monoclonal antibodies) for prevention and management of COVID-19.

Etiología, clínica y evolución de infecciones fúngicas invasoras en pacientes con neoplasias hematológicas en un hospital universitario de Argentina / Etiology, clinical characteristics and outcomes of invasive fungal infection in patients with hematological malignancies in a university hospital in Argentina

INTRODUCCIÓN: Las infecciones fúngicas invasoras (IFI) en pacientes con neoplasias hematológicas (NH) representan un desafío diagnóstico y terapéutico. OBJETIVOS: Describir la etiología, características clínicas, diagnóstico y evolución de los episodios de IFI probadas y probables en pacientes con NH y trasplante de progenitores hematopoyéticos (TPH). PACIENTES Y MÉTODOS: Estudio descriptivo, retrospectivo y de cohorte que incluyó IFI probadas y probables en pacientes adultos con NH y TPH. Se realizó seguimiento hasta el día 90. RESULTADOS: Se incluyeron 80 episodios de IFI: 49% probadas y 51% probables, 67,5% por hongos filamentosos (HF), 30% por hongos levaduriformes (HL) y 2,5% por hongos dimorfos. Los tipos de IFI más frecuentes fueron aspergilosis invasoras pulmonares (AP) y candidiasis invasoras (CI), en su mayoría por Candida spp. no albicans. Todos los casos de AP se diagnosticaron por detección de galactomanano en sangre y/o lavado broncoalveolar, y solamente 22,2% presentaban nódulos con halo en la tomografía computada (TC) de tórax, siendo los infiltrados inespecíficos los hallazgos más frecuentes. Tuvieron coinfección bacteriana y viral el 30 y 17,5%, respectivamente. El 50% fueron IFI de brecha, y la mortalidad global y mortalidad relacionada a la IFI fue 51 y 24%, respectivamente. CONCLUSIÓN: Los HF fueron la principal causa de IFI, con una gran proporción de IFI de brecha, y presentaron elevada mortalidad. Para el diagnóstico, resulta importante la utilización de biomarcadores y jerarquizar cualquier imagen patológica en la TC.

BACKGROUND: Invasive fungal infections (IFI) in patients with hematological malignancies (HM) represent a diagnostic and therapeutic challenge. AIM: To describe the etiology, clinical characteristics, diagnosis and evolution of proven and probable IFI episodes in patients with HM and hematopoietic stem cell transplantation (HSCT). METHODS: Retrospective, descriptive, cohort study performed in adult patients with HM and HSCT, who developed proven and probable IFI. Follow-up was carried out until day 90. RESULTS: A total of 80 IFI episodes were included: 49% proven and 51% probable, 67,5% due to mold (M), 30% to yeast-like fungi (Y) and 2,5% to dimorphic fungi. The most frequent causes were probable pulmonary aspergillosis (PA) and invasive candidiasis (IC), mainly due to non-albicans Candida species. PA were all diagnosed by detection of galactomannan (GM) in blood and bronchoalveolar lavage, and only 22,2% presented halo sign on chest CT. Bacterial and viral coinfections were reported in 30% and 17,5% respectively. Breakthrough IFI occurred in 50%, and global and IFI-related mortality were 51% and 24% respectively. CONCLUSION: Mold was the main cause of IFI, with a large proportion of breakthrough IFI, presenting high mortality. The use of biomarkers and the classification of any pathological image on CT contribute to the diagnosis.

Differences in the economic valuation and determining factors of informal care over time: the case of blood cancer.

OBJECTIVE: To estimate differences in the economic valuation and sociodemographic and clinical factors associated with informal care between phases of the treatment in the case of blood cancer patients. METHODS: 139 haematological cancer patients who underwent a stem cell transplantation completed a longitudinal questionnaire according to 3 phases of the treatment: short-term (pre-transplant), medium-term (1st year post-transplant) and long-term (2nd-6th year post-transplant). Economic value of informal care was estimated using proxy good and opportunity cost methods. Ordered and binary logistic models were performed to identify factors associated with informal care. RESULTS: 123 patients reported having received informal care. A progressive reduction of the number of hours of care was observed between phases. Monetary value per patient ranged from 1,288 to 3,409; 1,045 to 2,786; and 336 to 854 €/month in the short, medium and long term, respectively. Patients with acute leukaemia and those who received an unrelated allogeneic transplantation were 22% (short-term) and 33.5% (medium-term) more likely to receive more than 8hours/day of care respect to patients diagnosed with lymphoma and autologous transplantation. In the long term, patients with multiple myeloma were more likely to receive more care. Better health status and higher educational level were associated with fewer daily hours of care. CONCLUSIONS: Informal care varies greatly between stages of the treatment depending on the clinical and sociodemographic factors. Significant caring time and societal costs are associated with such care in blood cancer patients.

Elements for assistance to patients with hematological malignancies to propose care lines: a scoping review / Elementos de asistencia a pacientes con neoplasias hematológicas para proponer líneas de atención: revisión de alcance / Elementos para assistência a pacientes com neoplasias hematológicas para propor linhas de cuidado: scoping review

ABSTRACT Objectives: to identify the elements for assistance to patients with hematological malignancies to propose a care line. Methods: this is a scoping review, anchored in the JBI theoretical framework, with searches carried out in April 2021, in eight electronic databases and 10 repositories of theses and dissertations. Results: the final sample consisted of 93 studies, and the main forms of assistance provided that can support a care line for this public were imaging tests, immunophenotyping, chemotherapy regimens, radiotherapy, infection management, assessment of nutritional status, maintenance of oral function, symptom management and screening for second malignancies. Conclusions: the elaboration of a care line for onco-hematologic patients is necessary, considering the complexity surrounding the diagnosis and treatment of hematologic malignancies, in addition to the difficulties that are imposed in relation to access and continuity of care in the network.

RESUMEN Objetivos: identificar los elementos para la asistencia a pacientes con neoplasias hematológicas para proponer una línea de atención. Métodos: se trata de una revisión de alcance, anclada en el marco teórico del JBI, con búsquedas realizadas en abril de 2021 en ocho bases de datos electrónicas y 10 repositorios de tesis y disertaciones. Resultados: la muestra final estuvo compuesta por 93 estudios, y las principales formas de asistencia brindadas que pueden sustentar una línea de atención a este público fueron pruebas de imagen, inmunofenotipificación, regímenes de quimioterapia, radioterapia, manejo de infecciones, evaluación del estado nutricional, mantenimiento de la función oral, manejo de síntomas y detección de segundas neoplasias malignas. Conclusiones: es necesario el desarrollo de una línea de atención al paciente oncohematológico, dada la complejidad que rodea al diagnóstico y tratamiento de las neoplasias hematológicas, además de las dificultades que se imponen en relación al acceso y continuidad de la atención en una red.

RESUMO Objetivos: identificar os elementos para assistência a pacientes com neoplasias hematológicas para propor uma linha de cuidado. Métodos: trata-se de uma scoping review, ancorada no referencial teórico do JBI, com buscas realizadas em abril de 2021 em oito bases de dados eletrônicas e 10 repositórios de teses e dissertações. Resultados: a amostra final foi composta por 93 estudos, e as principais formas de assistências prestadas que podem embasar uma linha de cuidado para esse público foram exames de imagem, imunofenotipagem, regimes quimioterápicos, radioterapia, gestão de infecções, avaliação do estado nutricional, manutenção da função oral, gerenciamento de sintomas e rastreio para segundas neoplasias. Conclusões: a elaboração de uma linha de cuidados para pacientes onco-hematológicos se faz necessária, tendo em vista a complexidade que cerca o diagnóstico e tratamento das neoplasias hematológicas, além das dificuldades que se impõem em relação ao acesso e continuidade do cuidado em rede.

Second neoplasms in adult patients submitted to haematopoietic stem cell transplantation. / Segundas neoplasias en pacientes adultos receptores de un trasplante de progenitores hematopoyéticos.

BACKGROUND AND OBJECTIVE: Patients submitted to haematopoietic stem cell transplantation (HSCT) are at increased risk of late complications, such as second neoplasm (SN). The incidence and risk factors of SN in patients receiving HSCT at a single centre were analysed. PATIENTS AND METHODS: The follow-up of adult patients who received a first HSCT (autologous [auto-HSCT] or allogeneic [allo-HSCT]) between January 2000 and December 2015 was reviewed. We collected their demographic characteristics, the primary disease and type of HSCT, and analysed the cumulative incidence of SN and their risk factors. RESULTS: Of 699 transplanted patients (auto-HSCT, n=451; allo-HSCT, n=248), 42 (6%) developed SN (17 haematological and 25 solid), 31 post-auto-HSCT and 11 post-allo-HSCT. Haematologic SN were more frequent after auto-HSCT than after allo-HSCT. The median time between HSCT and SN was 4.09 years [range 0.07-13.15], with no differences between auto-HSCT and allo-HSCT. The cumulative incidence of SN was 5% (95% CI 3-6) at 5 years, 7% (95% CI 5-10) at 10 years and 11% (95% CI 8-15) at 15 years, without differences according to the type of HSCT. Only the age over 40 years correlated with an increased risk of SN. CONCLUSIONS: In this series, the incidence of post-HSCT SN was similar to that previously described. Patients submitted to an auto-HSCT showed a higher frequency of haematologic SN. A higher incidence of SN was detected in patients older than 40 at the time of HSCT.

Cycle threshold predicted mortality in a cohort of patients with hematologic malignancies infected with SARS-CoV-2 / El umbral de ciclado predijo la mortalidad en una cohorte de pacientes conneoplasias hematológicas infectados con SARS-CoV-2 / Microbiología clinica y enfermedades infecciosas

Abstract When a SARS-CoV-2 RT-qPCR test is performed, it may determine an indirect measureof viral load called cycle threshold (Ct). Respiratory samples with Ct <25.0 cycles are consideredto contain a high viral load. We aimed to determine whether SARS-CoV-2 Ct at diagnosis couldpredict mortality in patients with hematologic malignancies (lymphomas, leukemias, multiplemyeloma) who contracted COVID-19. We included 35 adults with COVID-19 confirmed by RT-qPCR performed at diagnosis. We evaluated mortality due to COVID-19 rather than mortalitydue to the hematologic neoplasm or all-cause mortality. Twenty-seven (27) patients survivedand 8 died. The global mean Ct was 22.8 cycles with a median of 21.7. Among the survivors,the mean Ct was 24.2, and the median Ct value was 22.9 cycles. In the deceased patients, themean Ct was 18.0 and the median Ct value was 17.0 cycles. Using the Wilcoxon Rank Sum test,we found a significant difference (p = 0.035). SARS-CoV-2 Ct measured in nasal swabs obtainedat diagnosis from patients with hematologic malignancies may be used to predict mortality.

Resumen Cuando se realiza una RT-qPCR para SARS-CoV-2, es posible determinar una medidaindirecta de la carga viral llamada umbral de ciclado (Ct). Las muestras respiratorias con Ct<25,0 ciclos se consideran de alta carga viral. Nos propusimos determinar si el Ct para SARS-CoV-2 al diagnóstico predice la mortalidad en pacientes con neoplasias hematológicas (linfomas,leucemias, mielomas) que contrajeron COVID-19. Incluimos 35 adultos con COVID-19 confirmadopor RT-qPCR al diagnóstico. Evaluamos la mortalidad por COVID-19, no la mortalidad por la neo-plasia hematológica o la mortalidad por cualquier causa. De los 35 pacientes, 27 sobrevivierony 8 fallecieron. El Ct global medio fue 22,8 ciclos con una mediana de 21,7 ciclos. Entre lossobrevivientes, el Ct medio fue 24,2 ciclos con una mediana de 22,9 ciclos. Entre los fallecidos,el Ct medio fue 18,0 y el Ct mediano fue 17,0 ciclos. Empleando la prueba de suma de rangosde Wilcoxon, encontramos una diferencia significative (p = 0,035). En pacientes con neoplasiashematológicas infectados con coronavirus, el Ct de SARS-CoV-2 medido en hisopados nasales almomento del diagnóstico podría ser utilizado para predecir la mortalidad.

Debut y manejo de leucemia mieloblástica aguda durante la gestación: a propósito de un caso / Debut and management of acute myeloblastic leukaemia during pregnancy: a case report

La leucemia mieloide aguda (LMA) es una de las neoplasias hematológicas más mortales. Durante el embarazo es una complicación rara, que puede dar resultados adversos, como la muerte, sin tratamiento adecuado. El manejo de la LMA durante el embarazo sigue siendo un desafío. Presentamos el caso de una mujer primigesta de 34 años con 18 semanas de gestación que acudió a Urgencias por cuadro de dolor e hipertrofia de mucosa oral, acompañado de astenia intensa. Se diagnóstico leucemia mieloblástica aguda (LAM-M4). Se ofertó posibilidad de interrumpir la gestación, dada la poca evidencia referente a la evolución materno-fetal, que la paciente rechazó, por lo que se inició tratamiento quimioterápico. En los controles ecográficos no se evidenciaron alteraciones teratogénicas; el crecimiento fetal tuvo parámetros normales, sin alteraciones en los valores del flujo Doppler. Se decidió finalizar gestación a las 32 semanas y tres días. Nació un varón pretérmino mediante parto eutócico con test de Apgar y pH de cordón umbilical normales, sin precisar reanimación. El puerperio fue favorable y a los 15 días del alta ingresó para un trasplante de médula ósea de su hermana, HLA idéntica. La paciente finalmente falleció por rechazo del trasplante y las complicaciones derivadas de este suceso.

Acute myeloid leukaemia (AML) is one of the deadliest haematological malignancies. During pregnancy it is a rare comorbidity and can lead to adverse outcomes, such as death, without adequate treatment. The management of AML during pregnancy remains a challenge. We report the case of a primigravida 34-year-old, with 18 weeks of amenorrhoea, who attended the emergency department presenting with pain and hypertrophy of the oral mucosa, accompanied by intense asthenia. Acute myeloblastic leukaemia was diagnosed. The possibility of terminating the pregnancy was offered given the lack of evidence regarding the maternal-foetal outcome, but the patient rejected it, so chemotherapy treatment was started. In the ultrasound controls there was no evidence of teratogenic alterations nor foetal growth restriction, and there were no alterations in Doppler flow values. It was decided to end the pregnancy at 32+3 GW. A preterm male was born through eutocic delivery with a normal Apgar test and umbilical cord pH, and did not require resuscitation. The puerperium was favourable and 15 days following discharge she was admitted for a bone marrow transplant from her HLA identical sister. The patient died due to rejection of the transplant and the complications derived from this event.