Respiratory syncytial virus infection in hematopoietic stem cell transplant patients

Respiratory Syncytial Virus (RSV) is a major cause of respiratory tract infections in immunocompromised patients such as children less than 2 years, premature infants with congenital heart disease and chronic lung disease, elderly patients and patients who have undergone hematopoietic stem cell transplant (HSCT). HSCT patients are at high risk of RSV infection, at increased risk of developing pneumonia, and RSV-related mortality. Immunodeficiency can be a major risk factor for severe infection & mortality. Therapy of RSV infection with Ribavirin, Palivizumab and Immunoglobulin has shown to reduce the risk of progression to LRI and mortality, especially if initiated early in the disease. Data on RSV infection in HSCT patients is limited, especially at various levels of immunodeficiency. 323 RSV infections in HSCT patients have been identified between 1/1995 and 8/2009 at University of Texas M D Anderson Cancer Center (UTMDACC). In this proposed study, we attempted to analyze a de-identified database of these cases and describe the epidemiologic characteristics of RSV infection in HSCT patients, the course of the infection, rate of development of pneumonia and RSV-related mortality in HSCT patients at UTMDACC. Key words: RSV infections, HSCT patient

Does Antithrombotic Drug Use Mandate Trauma Team Activation in Awake Geriatric Patients with Intracranial Hemorrhage?

Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P \u3c 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P \u3c 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit

Does Antithrombotic Drug Use Mandate Trauma Team Activation in Awake Geriatric Patients with Intracranial Hemorrhage?

Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P \u3c 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P \u3c 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit

Does Antithrombotic Drug Use Mandate Trauma Team Activation in Awake Geriatric Patients with Intracranial Hemorrhage?

Antithrombotic (anticoagulant [AC] and antiplatelet [AP]) drugs have been associated with mortality in geriatric patients with intracranial hemorrhage (ICH). It is unclear whether trauma team activation (TTA) in this cohort impacts outcome. Patients ≥65 years with a Glasgow Coma Scale of ≥13 and ICH over four years were included and were divided into three groups according to type of drug: group 1, AC with or without AP; group 2, AP only and; group 3, no AC or AP. The Rotterdam score was used to characterize the severity of CT findings. The primary outcome was inhospital mortality or transition to comfort measures. The secondary outcome was need for neurosurgical intervention within 48 hours. Logistic regression analysis was performed to evaluate for predictors of each outcome. Of 419 patients, 20.5, 50.4, and 29.1 per cent belonged to groups 1, 2, and 3, respectively, with TTA occurring in 39.5, 18.0, and 32.0 per cent of the respective groups. Within each group, there were no differences for the primary and secondary outcomes whether or not TTA was triggered. TTA patients had shorter times to CT (median, 20 minutes versus 80 minutes, P \u3c 0.0001) and to administration of reversal agents (median, 105 minutes versus 255 minutes, P \u3c 0.0001). Age, head-Abbreviated Injury Score, and the Rotterdam score were predictors for both outcomes by multivariable analysis, whereas antithrombotic drug use and TTA were not. In awake elderly patients on antithrombotic drugs found to have ICH, TTA expedited evaluation and treatment but was not associated with mortality benefit

Shannon’s information transmission model adapted to scoring of a patient on the 7 point modified Rankin Scale.

<p>A noise or error source is assumed to be in the channel between the sender represented by the ‘True Rankin’ score and the receiver represented by the ‘Observed Rankin’ score.</p

Box plots of error rates for the full ordinal scale of mRS (mRS 0.6), considering mRS 0 to 3 as individual grades and collapsing mRS grades 4 to 6 (mRS 0.3,4–6), dichotomizing at various cut-points of mRS 1 (mRS 0–1, 2–6), mRS 2 (mRS 0–2, 3–6), mRS 3 (mRS 0–3, 4–6) and mRS 4 (mRS 0–4, 5–6).

<p>van Swieten’s inter-rater reliability matrix used as confusion matrix. (p<.001 ANOVA; post-hoc testing shows that all dichotomization errors are lower than either full scale errors with mRS 0–4 dichotomization the lowest; p<.05).</p

Error percentages for 38 studies for the full ordinal scale (mRS 0.6), partially collapsed ordinal scale (mRS 0.3, 4–6) and dichotomization (mRS 0–1, 2–6; mRS 0–2, 3–6; mRS 0–3, 4–6; mRS 0–4, 5–6) and trichotomization (mRS 0–1, 2–4, 5–6; mRS 0–2, 3–4, 5–6) cut-points.

<p>Error percentages for 38 studies for the full ordinal scale (mRS 0.6), partially collapsed ordinal scale (mRS 0.3, 4–6) and dichotomization (mRS 0–1, 2–6; mRS 0–2, 3–6; mRS 0–3, 4–6; mRS 0–4, 5–6) and trichotomization (mRS 0–1, 2–4, 5–6; mRS 0–2, 3–4, 5–6) cut-points.</p

Inter-rater reliability matrix for mRS from Wilson et al [26] used as confusion matrix.

<p>Box plots of error rates for the full ordinal scale of mRS (mRS 0.6), considering mRS 0 to 3 as individual grades and collapsing mRS grades 4 to 6 (mRS 0.3,4–6), dichotomizing at a cut-point of mRS 1 (mRS 0–1, 2–6), dichotomizing at a cut-point of mRS 2 (mRS 0–2, 3–6), mRS 3 (mRS 0–3, 4–6) and mRS 4 (mRS 0–4, 5–6). Post-hoc testing shows that each error rate with this matrix is higher than the corresponding error using van Swieten’s confusion matrix except the error rates for mRS 4.</p

Box plots of error rates for dichotomizing at cut-point of mRS 1 (mRS 0–1, 2–6), trichotomizing at cut-points 1 and 4 (mRS 0–1, 2–4, 5–6), dichotomizing at mRS 2 (mRS 0–2, 3–6), and trichotomizing at cut-points 2 and 4 (mRS 0–2, 3–4, 5–6).

<p>van Swieten’s inter-rater reliability matrix used as confusion matrix. Post-hoc testing shows that both trichotomization errors are higher than dichotomization (p<.05).</p