Clinical factors predicting return emergency department visits in chemotherapy-induced febrile neutropenia patients.

BACKGROUND: Although chemotherapy-induced febrile neutropenia (FN) is the most common and life-threatening oncologic emergency, the characteristics and outcomes associated with return visits to the emergency department (ED) in these patients are uncertain. Hence, we aimed to investigate the predictive factors and clinical outcomes of chemotherapy-induced FN patients returning to the ED. METHOD: This single-center, retrospective observational study spanning 14 years included chemotherapy-induced FN patients who visited the ED and were discharged. The primary outcome was a return visit to the ED within five days. We conducted logistic regression analyses to evaluate the factors influencing ED return visit. RESULTS: This study included 1318 FN patients, 154 (12.1%) of whom revisited the ED within five days. Patients (53.3%) revisited the ED owing to persistent fever (56.5%), with no intensive care unit admission and only one mortality case who was discharged hopelessly. Multivariable analysis revealed that shock index >0.9 (odds ratio [OR]: 1.45, 95% confidence interval [CI], 1.01-2.10), thrombocytopenia (<100 × 103/uL) (OR: 1.64, 95% CI, 1.11-2.42), and lactic acid level > 2 mmol/L (OR: 1.51, 95% CI, 0.99-2.25) were associated with an increased risk of a return visit to the ED, whereas being transferred into the ED from other hospitals (OR: 0.08; 95% CI, 0.005-0.38) was associated with a decreased risk of a return visit to the ED. CONCLUSION: High shock index, lactic acid, thrombocytopenia, and ED arrival type can predict return visits to the ED in chemotherapy-induced FN patients.

Can Risk Stratification Tools Be Utilized to Safely Discharge Low-Risk Febrile Neutropenic Patients from the Emergency Department?

BACKGROUND: Chemotherapy-induced febrile neutropenia (FN) is one of the more common oncological emergencies. Despite evidence in the oncology literature suggesting that low-risk cases of FN can be managed safely at home, most patients with FN who present to the emergency department (ED) are admitted. FN risk stratification methods, such as Multinational Association for Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores, may be useful when considering patient disposition. We sought to address whether the existing body of literature is adequate to support the use of these methods when treating patients with FN in the ED. METHODS: A PubMed search from January 1, 2016 to March 19, 2021 was performed using the following search strategy: "febrile neutropenia" OR (fever AND neutropenia)) AND (emerg* OR outpatient) AND (admit OR admission OR hospitalization). General review articles and case reports were omitted. Each of the articles selected underwent a structured review. RESULTS: The search yielded 371 articles, which were independently screened for relevance by two authors, and 23 articles were selected for inclusion. MASCC score was used in 10 of the identified studies and each of these studies concluded that the score was useful in the ED. Most of the identified studies found that CISNE score had a higher sensitivity than MASCC score (96.7% vs. 32.9%, respectively), but a lower specificity (22.2% vs. 89.5%). CONCLUSIONS: FN risk stratifications tools, such as MASCC and CISNE scores, are supported by the existing literature and may be included as part of the decision-making process when considering patient disposition.

CISNE versus MASCC: Identifying low risk febrile neutropenic patients.

OBJECTIVE: Febrile neutropenia though a dreaded complication of chemotherapy, not all patients need inpatient treatment. Risk score indices like MASCC and CISNE have been developed to identify low risk patients eligible for outpatient management. We undertook this study to compare the performances of MASCC and CISNE. METHODS: This was a prospective observational study conducted in a tertiary care centre from August 2017 to April 2019 where patients with chemotherapy induced febrile neutropenia were included. Basic demographic data and primary site of cancer were collected with characteristics required to calculate both MASCC and CISNE scores. The primary outcome measure was 30-day mortality. Apart from the 3 group risk stratification of CISNE, apriori it was decided that two-tier CISNE score will be calculated with 0 or 1 score as low risk and ≥2 as high risk. Descriptive statistics are reported and predictive performance of each score was analysed. RESULTS: Total of 129 patients were recruited. The performance of three-tier CISNE score was more specific (90.6%, 95% CI 76.9-96.9) but sensitivity (25.1%, 95% CI 17.0-36.3) was low compared to that of MASCC score (sensitivity 58.1%, 95% CI 47.0-68.5; specificity 65.1, 95% CI 49.0-78.5%). However, analysis with two-tier CISNE score demonstrated a better sensitivity (56.9%, 95%CI 45.8-67.4). Kappa for agreement between the two scores was 0.520 (95% CI 0.373-0.667, p < 0.001). CONCLUSION: CISNE and MASCC have fair discriminatory power in identifying low risk febrile neutropenia cases. Two group stratification on CISNE scoring will help in better decision making in emergency department.

Comparison of the MASCC and CISNE scores for identifying low-risk neutropenic fever patients: analysis of data from three emergency departments of cancer centers in three continents.

PURPOSE: Patients with febrile neutropenia are a heterogeneous group with a minority developing serious medical complications. Outpatient management of low-risk febrile neutropenia has been shown to be safe and cost-effective. Scoring systems, such as the Multinational Association for Supportive Care in Cancer (MASCC) score and Clinical Index of Stable Febrile Neutropenia (CISNE), have been developed and validated to identify low-risk patients. We aimed to compare the performance of these two scores in identifying low-risk febrile neutropenic patients. METHODS: We performed a pooled analysis of patients presenting with febrile neutropenia to three tertiary cancer emergency centers in the USA, UK, and South Korea in 2015. The primary outcome measures were the occurrence of serious complications. Admission to an intensive care unit (ICU) and 30-day mortality were secondary outcomes. The predictive performance of each score was analyzed. RESULTS: Five hundred seventy-one patients presented with febrile neutropenia. With MASCC risk index, 508 (89.1%) were classified as low-risk febrile neutropenia, compared to 60 (10.5%) with CISNE classification. Overall, the MASCC score had a greater discriminatory power in the detection of low-risk patients than the CISNE score (AUC 0.772, 95% CI 0.726-0.819 vs. 0.681, 95% CI 0.626-0.737, p = 0.0024). CONCLUSION: Both MASCC and CISNE scores have reasonable discriminatory value in predicting patients with low-risk febrile neutropenia. Risk scores should be used in conjunction with clinical judgment for the identification of patients suitable for outpatient management of neutropenic fever. Developing more accurate scores, validated in prospective settings, will be useful in facilitating more patients being managed in an outpatient setting.

Accuracy of the Multinational Association of Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores for predicting serious complications in adult patients with febrile neutropenia: A systematic review and meta-analysis.

We compared the Multinational Association of Supportive Care in Cancer (MASCC) and Clinical Index of Stable Febrile Neutropenia (CISNE) scores for identifying serious complications in febrile neutropenia patients. We searched MEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews from inception to March 19, 2019. Two reviewers independently screened citations, extracted data, and assessed quality. We included 26 studies, totalling 6617 patients. Pooled sensitivity and specificity for MASCC < 21 was 55.6 % (95 % CI: 46.2 %-64.5%) and 86.0 % (95 % CI: 81.3 %-89.7 %), respectively. Pooled sensitivity and specificity for CISNE ≥ 3 was 78.9 % (95 % CI: 65.3 %-88.1 %) and 64.9 % (95 % CI: 49.6 %-77.7 %), respectively. Pooled sensitivity and specificity for CISNE ≥ 1 was 96.7 % (95 % CI: 93.6 %-98.3 %) and 22.2 % (95 % CI: 15.6 %-30.4 %), respectively. The CISNE score had higher sensitivity and may be more useful than the MASCC score in the acute setting.

SEOM clinical practice guideline: management and prevention of febrile neutropenia in adults with solid tumors (2018).

Febrile neutropenia (FN) is a common dose-limiting toxicity of chemotherapy, with a profound impact on the evolution of patients with cancer, due to the potential development of serious complications, mortality, delays, and decrease in treatment intensity. This article seeks to present an updated clinical guideline, with recommendations regarding the diagnosis, prevention, and treatment of febrile neutropenia in adults with solid tumors. The aspects covered include how to properly approach the risk of microbial resistances, epidemiological aspects, considerations about the initial empirical approach adapted to the risk, special situations, and prevention of complications. A decision-making algorithm is included for use in the emergency department based on a new, validated tool, the Clinical Index of Stable Febrile Neutropenia, which can be used in patients with solid tumors who appear stable in the initial phase of neutropenic infections, and can help detect those at high risk for complications in whom early discharge must be avoided.

The time has come for new models in febrile neutropenia: a practical demonstration of the inadequacy of the MASCC score.

Since its publication more than 15 years ago, the MASCC score has been internationally validated any number of times and recommended by most clinical practice guidelines for the management of febrile neutropenia (FN) around the world. We have used an empirical data-supported simulated scenario to demonstrate that, despite everything, the MASCC score is impractical as a basis for decision-making. A detailed analysis of reasons supporting the clinical irrelevance of this model is performed. First, seven of its eight variables are "innocent bystanders" that contribute little to selecting low-risk candidates for ambulatory management. Secondly, the training series was hardly representative of outpatients with solid tumors and low-risk FN. Finally, the simultaneous inclusion of key variables both in the model and in the outcome explains its successful validation in various series of patients. Alternative methods of prognostic classification, such as the Clinical Index of Stable Febrile Neutropenia, have been specifically validated for patients with solid tumors and should replace the MASCC model in situations of clinical uncertainty.

Performance of the clinical index of stable febrile neutropenia (CISNE) in different types of infections and tumors.

PURPOSE: The clinical index of stable febrile neutropenia (CISNE) can contribute to patient safety without increasing the complexity of decision-making. However, febrile neutropenia (FN) is a diverse syndrome. The aim of this analysis is to assess the performance of CISNE according to the type of tumor and infection and to characterize these patients. METHODS: We prospectively recruited 1383 FN episodes in situations of apparent clinical stability. Bonferroni-adjusted z tests of proportions were used to assess the association between the infections suspected at the time of onset and the type of tumor with the risk of serious complications and mortality. The performance of CISNE was appraised in each category using the Breslow-Day test for homogeneity of odds ratios and Forest Plots. RESULTS: 171 patients had a serious complication (12.3 %, 95 % confidence interval 10.7-14.2 %). The most common initial assumptive diagnoses were: fever without focus (34.5 %), upper respiratory infection (14.9 %), enteritis (12.7 %), stomatitis (11.8 %), and acute bronchitis (10.7 %). Lung and breast were the most common tumors, accounting for approximately 56 % of the series. The distribution of complications, mortality, and bacteremia varies for each of these categories. However, Breslow-Day tests indicate homogeneity of the odds ratio of the dichotomized CISNE score to predict complications in all infection and tumor subtypes. CONCLUSION: Despite FN's clinical and microbiological heterogeneity, the CISNE score was seen to be consistent and robust in spite of these variations. Hence, it appears to be a safe tool in seemingly stable FN.

Tratamiento quirúrgico de las deformidades en Boutonniere y cuello de cisne del pulgar en la artritis reumatoidea / Traitement chirurgical des déformations du pouce en boutonnière et en col de cygne dans l'arthrite rhumatoïde / Surgical Treatment of Boutonniere and Swan-Neck Deformities in Rheumatoid Arthritis Thumb

Introducción: la artritis reumatoidea es una enfermedad sistémica, en la que son comunes las deformidades articulares, estas se pueden observar en el pulgar donde las de mayor frecuencia son las de Boutonniere y en cuello de cisne. Objetivo: el objetivo principal fue evaluar los resultados de la aplicación de las técnicas quirúrgicas en estas deformidades. Método: se realizó un estudio longitudinal prospectivo de intervención. Se trataron un total de 20 pacientes con este diagnóstico, atendidos en el Servicio de Miembro Superior Minifijación Externa y Microcirugía del Complejo Científico Ortopédico Internacional Frank País en el período comprendido desde enero 2011 a diciembre 2012. La evaluación de los pacientes se realizó según la escala confeccionada para este grupo particular en estudio. Resultados: se obtuvieron resultados excelentes en el 10 por ciento, buenos en el 75 por ciento y regulares en el 15 por ciento de los casos. Conclusiones: las técnicas quirúrgicas empleadas en el tratamiento de esta afección mostraron resultados alentadores(AU)

Introduction: Rheumatoid arthritis is a systemic disease, in which joint deformities are common; these deformities are observed in the thumb where the most frequent are Boutonniere and swan-neck deformities. Objective: Assess the results of the application of surgical techniques in these deformities. Method: A longitudinal prospective intervention study was conducted at Frank País International Orthopedic Scientific Complex from January 2011 to December 2012. Twenty patients with this diagnosis were treated in the Upper Limb Service for External Miniaturization and Microsurgery. The evaluation of the patients was performed according to the scale prepared for this particular study group. Results: 10 of the cases obtained excellent results, 75 percent obtained good results and 15 percent had moderate results. Conclusions: The surgical techniques used in the treatment of this condition showed encouraging results(AU)

Introduction: L'arthrite rhumatoïde est une maladie systémique caractérisée par des atteintes articulaires, surtout au niveau du pouce, telles que les déformations en boutonnière et en col de cygne. Objectif: Évaluer les résultats de l'application des techniques chirurgicales dans le traitement de ces déformations. Méthodes: Une étude longitudinale prospective interventionnelle a été réalisée. Un total de vingt patients, diagnostiqués d'arthrite rhumatoïde, ont été traités au Service d'orthopédie de membres supérieurs, mini-fixation externe et microchirurgie, au Complexe scientifique international d'orthopédie Frank Pais, dans la période comprise entre janvier 2011 et décembre 2012. Les patients de ce groupe ont été évalués selon une échelle élaborée pour cette étude. Résultats: On a obtenu des résultats excellents (10 pourcent), bons (75 pourcent), et passables (15 pourcent). Conclusions: Les techniques chirurgicales utilisées dans le traitement de cette affection ont montré des résultats encourageants(AU)

Encontros sinistros: uma análise do filme Cisne negro / Uncanny Encounters: An Analysis of the film Black Swan / Encuentros siniestros: un análisis de la película Cisne negro

O artigo propõe-se a pensar o que torna sinistros os encontros com o duplo, no filme Cisne negro. Com esse fim em vista, realiza uma revisão na teoria psicanalítica sobre o caráter unheimlich do doppelgänger. No que concerne à película analisada, o trabalho promove uma leitura intertextual das obras que a inspiram e expõe algumas possibilidades de interpretação psicanalítica desse filme. A partir dessas reflexões, procedemos à decomposição plano a plano de duas cenas de Cisne negro. De tal intervenção metodológica, decorre nossa hipótese de que, nas cenas analisadas, a unidade imaginária do espectador é ameaçada pela irrupção de uma das pulsões parciais constitutivas do estádio do espelho: olhar ou voz. Ademais, nessas cenas o real do olhar materno invade o olhar narrativo da câmera, tornando-as profundamente perturbadoras(AU)

The purpose of this article is to reflect upon what makes the encounters with doubles so uncanny in the film Black Swan. With that in mind, we revise psychoanalytic theory regarding the unheimlich character of doppelgängers. The study performs an intertextual reading of the works that inspired the film and exposes some possibilities of psychoanalytical interpretation. Considering these reflections, we proceed to a shot-by-shot breakdown of two scenes of Black Swan. Starting from this methodological intervention follows our hypothesis that, in the analyzed scenes, the irruption of one of the partial drives of Lacan's mirror stage - gaze or voice - threatens the imaginary unit of the viewer. Additionally, in such scenes the reality of the maternal gaze invades the narrative look of the camera, making them deeply disturbing(AU)

El artículo se propone pensar lo que torna siniestros los encuentros con el doble, en la película Cisne negro. Con este fin, realiza una revisión en la teoría psicoanalítica respecto al carácter unheimlich del doppelgänger. En cuanto a la película analizada, el trabajo promueve una lectura intertextual de las obras que la inspiran y expone algunas posibilidades de su interpretación psicoanalítica. A partir de estas reflexiones, procedemos a la descomposición plan a plan de dos escenas de Cisne negro. De tal intervención metodológica, sucede nuestra hipótesis de que, en las escenas analizadas, la unidad imaginaria del espectador se ve amenazada por una explosión de impulsos parciales constitutivos del estadio del espejo: mirada y voz. Además, en estas escenas lo real de la mirada materna invade la mirada narrativa de la cámara, tornándolas sumamente perturbadoras(AU)

Encontros sinistros: uma análise do filme Cisne negro / Uncanny Encounters: an Analysis of the film Black Swan / Encuentros siniestros: un análisis de la película Cisne negro

O artigo propõe-se a pensar o que torna sinistros os encontros com o duplo, no filme Cisne negro. Com esse fim em vista, realiza uma revisão na teoria psicanalítica sobre o caráter unheimlich do doppelgãnger. No que concerne à película analisada, o trabalho promove uma leitura intertextual das obras que a inspiram e expõe algumas possibilidades de interpretação psicanalítica desse filme. A partir dessas reflexões, procedemos à decomposição plano a plano de duas cenas de Cisne negro. De tal intervenção metodológica, decorre nossa hipótese de que, nas cenas analisadas, a unidade imaginária do espectador é ameaçada pela irrupção de uma das pulsões parciais constitutivas do estádio do espelho: olhar ou voz. Ademais, nessas cenas o real do olhar materno invade o olhar narrativo da câmera, tornando-as profundamente perturbadoras.

The purpose of this article is to reflect upon what makes the encounters with doubles so uncanny in the film Black Swan. With that in mind, we revise psychoanalytic theory regarding the unheimlich character of doppelgãngers. The study performs an intertextual reading of the works that inspired the film and exposes some possibilities of psychoanalytical interpretation. Considering these reflections, we proceed to a shot-by-shot breakdown of two scenes of Black Swan. Starting from this methodological intervention follows our hypothesis that, in the analyzed scenes, the irruption of one of the partial drives of Lacan's mirror stage - gaze or voice - threatens the imaginary unit of the viewer. Additionally, in such scenes the reality of the maternal gaze invades the narrative look of the camera, making them deeply disturbing.

El artículo se propone pensar lo que torna siniestros los encuentros con el doble, en la película Cisne negro. Con este fin, realiza una revisión en la teoría psicoanalítica respecto al carácter unheimlich del doppelgãnger. En cuanto a la película analizada, el trabajo promueve una lectura intertextual de las obras que la inspiran y expone algunas posibilidades de su interpretación psicoanalítica. A partir de estas reflexiones, procedemos a la descomposición plan a plan de dos escenas de Cisne negro. De tal intervención metodológica, sucede nuestra hipótesis de que, en las escenas analizadas, la unidad imaginaria del espectador se ve amenazada por una explosión de impulsos parciales constitutivos del estadio del espejo: mirada y voz. Además, en estas escenas lo real de la mirada materna invade la mirada narrativa de la cámara, tornándolas sumamente perturbadoras.

A bumblefoot outbreak and fatal septicemia in captive aquatic birds in Brazil / Surto de esparavão e septicemia fatal em aves aquáticas cativas no Brasil

A bumblefoot outbreak with different prognosis according to host species was studied in captive aquatic avian species. Six wood ducks (Aix sponsa), three scarlet-ibis (Eudocimus ruber), two black-swans (Cygnus atratus), five white-faced ducks (Dendrocygna viduata) and two roseate spoonbills (Platalea ajaja) were kept in a common pen with abrasive pavement pond margin, predisposing to podal skin wear. Incoordination and mortality occurred in the two roseate spoonbils and one black swan. Coagulase-positive penicillin-resistant Staphylococcus aureus was isolated from the synovial fluid and from the liver. All birds sharing the pen presented active or cicatricial foot lesions, indicating a possible challenge to the environmental Staphylococci. However, except for the roseate spoonbill and the black swan, which had fatal disease, for all other species the case did not evolve to a clinically debilitating or fatal disease. The different susceptibility to a fatal Staphylococcus aureus coagulase positive infection is discussed.

Este trabalho relata um surto de esparavão em aves aquáticas cativas com prognóstico variado conforme a espécie de ave. Foram examinados um marreco carolina (Aix sponsa), três guarás (íbis vermelha) (Eudocimus ruber), dois cisnes negros (Cygnus atratus), cinco marrecas piadeiras (Dendrocygna viduata) e dois colhereiros (Platalea ajaja) mantidos em recinto comunitário, em cativeiro e em criatório. No recinto, a piscina é margeada por borda de cimento abrasivo que possibilita a abrasão da pele podal. Todas as aves apresentaram erosões da pele na face de apoio dos pés, indicando fator predisponente (erosão) similar e possível semelhante desafio infeccioso. Entretanto, incoordenação e mortalidade ocorreram em colhereiros e no cisne negro, mas não nas outras espécies. Staphylococcus aureus coagulase positivo e resistente à penicilina foi isolado do líquido sinovial e do fígado das aves recém-mortas e conservadas em geladeira. A susceptibilidade diferenciada das espécies aquáticas estudadas à infecção por S. aureus coagulase positivo é discutida.