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C-reactive protein (CRP) is a useful marker in suspected infection in children with cancer, severe neutropenia and fever
HEMATOLOGY AND ONCOLOGY ‘‘POSTOPERATIVE INTRA-ABDOMINAL INFECTION RISK IN THE ONCOLOGIC PATIENT SUBMITTED TO LAPAROTOMY.’’ Olivares A. Castellanos, F. Valdes de la Torre, L. Krause Senties, and N. Wacher Rodarte. CEU, Hospital de Especialidades, Instituto Mexicano del Seguro Social, Mexico City, Mexico. Introduction: Cancer patients are at higher risk of postoperative morbidity because host-tumor interaction, chemotherapy and radiotherapy before radical surgery contribute to deterioration of the immunological and nutritional status of the patient and cause dysfunction of organs and systems. Objective: To investigate the risk factors for postoperative intra-abdominal infection in cancer patients submitted to laparotomy. Design: Case-control study. Cases were patients with postoperative intraabdominal infection. Controls were matched patients without postoperative infection. Participants: There were 28 case-control pairs, 17 men and 11 women, average (SD) age 53.8 6 14.6 and 53.2 6 13.2 years, respectively; 3 pairs with cancer of the gastroesophagic junction, 7 pairs stomach cancer, 3 pairs uterine-cervical cancer, 7 pairs colon cancer, 3 pairs rectum cancer and 4 at other locations. Main Outcomes Measure(s): The records of cancer patients submitted to laparotomy from January 1st, 1991 to March 31st, 1995, were reviewed an the following variables were recorded: age, sex, weight, diagnosis, clinical stage, type of surgery, preoperative hospital stay, previous surgeries and reoperations, surgical team, presence of infection (fever, abscess, pus and/or a positive culture of abdominal), previous and postoperative treatments, complete white blood cell count with differential, serum albumin and chemistries, surgical time, trans- and postoperative hemorrhage, other diseases and APACHE II score at 24 h postoperatively. Cases were matched with controls of the same age, sex, diagnosis, clinical stage, type of surgery and surgical team. Results: In the univariate analysis significant differences were noted on the following variables (p , 0.05): serum albumin, lymphopenia, weight lost, preoperative hospital stay, postoperative hemorrhage and transoperative hypotension. A conditional log regression analysis showed that weight lost and lymphopenia were the most potent predictors of postoperative infections. Conclusions: Weight lost and lymphopenia are the most potent predictors of post-operative intra-abdominal infection even after controlling for confounding variables. They are easy to measure and inexpensive and may be modified before surgery.
‘‘ROLE OF SERUM FERRITIN IN THE DIAGNOSIS OF IRON DEFICIENCY ANEMIA IN PATIENTS WITH LIVER CIRRHOSIS.’’ T. Intragumtornchai, P. Rojnukkarin, D. Swasdikul, and S. Israsena. CEU, Chulalongkorn University, Bangkok, Thailand. Objective: To determine the diagnostic values of serum ferritin and other conventional tests in the diagnosis of iron deficiency anemia in patients with liver cirrhosis. Design: Cross-sectional study for diagnostic tests. Setting: University hospital. Participants: Seventy-two consecutive patients with liver cirrhosis in whom the hemoglobin level was less than 13.0 g/dl for men and 12.0 g/dl for women. The diagnosis of liver cirrhosis was based on characteristic clinical and hepatic ultrasonographic findings. Main Outcome Measure(s): By using absence of bone marrow iron as the standard criterion, the diagnostic powers of mean corpuscular volume, transferrin saturation, serum ferritin and the presence of hypochromic red cells in the diagnosis of iron deficiency were compared by analyzing the likelihood ratios, the area under the receiver operating curves (ROC) and the stepwise logistic regression associated with each test. Results: The likelihood ratios, the area under the ROC and the stepwise logistic regression indicated that serum ferritin was the most powerful test predictive of iron deficiency. Other tests added little further diagnostic value. The likelihood ratios associated with the serum ferritin levels were as follows: , 50 µg/l, 22.3; 51–200 µg/l, 1.5–1.8; 201–400 µg/l, 1.0; . 400 µg/l, , 1. Conclusion: Serum ferritin is the most powerful non-invasive test for the diagnosis of iron deficiency anemia in patients with liver cirrhosis. It should be the primary test of choice in patients suspected of having the disease. When the level was less than 50 µg/l, iron supplement may be prescribed without necessitating bone marrow aspiration.
‘‘C-REACTIVE PROTEIN (CRP) IS A USEFUL MARKER IN SUSPECTED INFECTION IN CHILDREN WITH CANCER, SEVERE NEUTROPENIA AND FEVER.’’ M. Penagos-Paniagua, M. A. Villasis-Keever, and F. Solorzano-Santos. Hospital de Pediatria, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico. Objective: Because the identification of infection in pediatric patients with severe neutropenia and fever is difficult and levels of CRP in these patients remain unknown, this study was performed to determine sensitivity (Sn), specificity (Sp), and positive and negative predictive values (PPV, NPV) of CRP to establish the diagnosis of systemic bacterial infection in these patients. Design: Analysis of a diagnostic test; positive blood culture and clinical documented infection were the gold standards. Setting: Tertiary care pediatric hospital. Participants: Patients less than 16 years old, with cancer, neutropenia (,500 cell/mm3) and fever (.39°C). Interventions: At the time of first clinical evaluation a sample of blood was taken for blood cultures and CRP. All patients received empirical antibiotic therapy and were followed every day until discharge from hospital. CRP was determined by rate nephelometry. Patients were classified in four groups: bacteriologically documented infection (GI), clinical infection (GII), fever related to cancer (GIII) and neutropenic patients without fever (GIV). Statistics: Sn, Sp, PPV, NPV were performed according to ROC curves. Results: 111 events of neutropenia and fever occurred in 89 subjects. Acute lymphoblastic leukemia was the most frequent underlying disease (50%). The distribution in each group was as follows: GI, 19 events; GII, 33; GIII, 15 and GIV, 44. Median of CRP for the different groups were: 96 mg/l (47–525) for Gl; 145 mg/l (69–460) for GII; 35 mg/l (5–203) GIII and 6.9 mg/l (0-59) for GIV. With a cutoff of 70 mg/l for CRP, the Sn was 92%, Sp 86%, PPV 96% and PNV 76%. Post-test odds for the target disorder was 6.5 and 0.09 for a negative result. Patients with leukemia had a Sn of 89%, Sp 83%, PPV 94% and NPV 71%; the four values for patients with solid tumors were 100%. Conclusions: CRP is a useful, fast and low cost diagnostic test that can identify neutropenic patients with a bacterial infection.
‘‘THE DIFFERENCE IN COMPLETE REMISSION RATE OF ACUTE LEUKEMIA BETWEEN SECONDARY AND TERTIARY HOSPITALS IN SHANGHAI, CHINA.’’ Wang Qian, Lin Guowei, Wang Xiaoqing and Lin Peidi. CEU, Shanghai Medical University, Shanghai, China. Objective: To describe and compare the complete remission (CR) rates of acute leukemia in secondary and tertiary hospitals. Design: Retrospective study. Setting and Participants: All 2867 patients with acute leukemia admitted to hospitals in Shanghai during 1984 to 1993 were eligible for this study. Three hundred and thirty-two patients who died before first induction course or without treatment were excluded. Finally, 2535 patients, 1495 males and 1040 females, were included in this study. There were 1714 patients in tertiary and 821 in secondary hospitals. Main Outcome Measure(s): Complete remission during first hospitalization. Results: The CR rates were 52% in secondary hospitals and 64% in tertiary hospitals (χ2 5 31.0, p , 0.01). The proportions of children and older leukemia patients in secondary hospitals were higher than in tertiary hospitals (25% vs. 28% and 10% vs. 19%, χ2 5 50.6 with df 5 2, p , 0.01). The time interval between onset and admission in secondary hospitals was shorter than in tertiary hospitals (median 30 vs. 34 days). There were no significant differences in the distributions of types of acute leukemia (ALL or AML), sex or hospital stay between secondary and tertiary hospitals. Using logistic regression modeling to adjust age, sex, and time interval from onset to admission, types of leukemia and severity on admission, the level of hospital still related to the CR of patients. The odds ratio for CR comparing the tertiary hospitals with secondary hospitals was 1.9 (95% CI of OR was 1.5 to 2.3, p , 0.05). Conclusion: In Shanghai, the patients with acute leukemia treated in tertiary hospitals were more likely to get a complete remission than those treated in secondary hospitals.
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‘‘ROLE OF SERUM FERRITIN IN THE DIAGNOSIS OF IRON DEFICIENCY ANEMIA IN PATIENTS WITH LIVER CIRRHOSIS.’’ T. Intragumtornchai, P. Rojnukkarin, D. Swasdikul, and S. Israsena. CEU, Chulalongkorn University, Bangkok, Thailand. Objective: To determine the diagnostic values of serum ferritin and other conventional tests in the diagnosis of iron deficiency anemia in patients with liver cirrhosis. Design: Cross-sectional study for diagnostic tests. Setting: University hospital. Participants: Seventy-two consecutive patients with liver cirrhosis in whom the hemoglobin level was less than 13.0 g/dl for men and 12.0 g/dl for women. The diagnosis of liver cirrhosis was based on characteristic clinical and hepatic ultrasonographic findings. Main Outcome Measure(s): By using absence of bone marrow iron as the standard criterion, the diagnostic powers of mean corpuscular volume, transferrin saturation, serum ferritin and the presence of hypochromic red cells in the diagnosis of iron deficiency were compared by analyzing the likelihood ratios, the area under the receiver operating curves (ROC) and the stepwise logistic regression associated with each test. Results: The likelihood ratios, the area under the ROC and the stepwise logistic regression indicated that serum ferritin was the most powerful test predictive of iron deficiency. Other tests added little further diagnostic value. The likelihood ratios associated with the serum ferritin levels were as follows: , 50 µg/l, 22.3; 51–200 µg/l, 1.5–1.8; 201–400 µg/l, 1.0; . 400 µg/l, , 1. Conclusion: Serum ferritin is the most powerful non-invasive test for the diagnosis of iron deficiency anemia in patients with liver cirrhosis. It should be the primary test of choice in patients suspected of having the disease. When the level was less than 50 µg/l, iron supplement may be prescribed without necessitating bone marrow aspiration.
‘‘C-REACTIVE PROTEIN (CRP) IS A USEFUL MARKER IN SUSPECTED INFECTION IN CHILDREN WITH CANCER, SEVERE NEUTROPENIA AND FEVER.’’ M. Penagos-Paniagua, M. A. Villasis-Keever, and F. Solorzano-Santos. Hospital de Pediatria, Centro Medico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico. Objective: Because the identification of infection in pediatric patients with severe neutropenia and fever is difficult and levels of CRP in these patients remain unknown, this study was performed to determine sensitivity (Sn), specificity (Sp), and positive and negative predictive values (PPV, NPV) of CRP to establish the diagnosis of systemic bacterial infection in these patients. Design: Analysis of a diagnostic test; positive blood culture and clinical documented infection were the gold standards. Setting: Tertiary care pediatric hospital. Participants: Patients less than 16 years old, with cancer, neutropenia (,500 cell/mm3) and fever (.39°C). Interventions: At the time of first clinical evaluation a sample of blood was taken for blood cultures and CRP. All patients received empirical antibiotic therapy and were followed every day until discharge from hospital. CRP was determined by rate nephelometry. Patients were classified in four groups: bacteriologically documented infection (GI), clinical infection (GII), fever related to cancer (GIII) and neutropenic patients without fever (GIV). Statistics: Sn, Sp, PPV, NPV were performed according to ROC curves. Results: 111 events of neutropenia and fever occurred in 89 subjects. Acute lymphoblastic leukemia was the most frequent underlying disease (50%). The distribution in each group was as follows: GI, 19 events; GII, 33; GIII, 15 and GIV, 44. Median of CRP for the different groups were: 96 mg/l (47–525) for Gl; 145 mg/l (69–460) for GII; 35 mg/l (5–203) GIII and 6.9 mg/l (0-59) for GIV. With a cutoff of 70 mg/l for CRP, the Sn was 92%, Sp 86%, PPV 96% and PNV 76%. Post-test odds for the target disorder was 6.5 and 0.09 for a negative result. Patients with leukemia had a Sn of 89%, Sp 83%, PPV 94% and NPV 71%; the four values for patients with solid tumors were 100%. Conclusions: CRP is a useful, fast and low cost diagnostic test that can identify neutropenic patients with a bacterial infection.
‘‘THE DIFFERENCE IN COMPLETE REMISSION RATE OF ACUTE LEUKEMIA BETWEEN SECONDARY AND TERTIARY HOSPITALS IN SHANGHAI, CHINA.’’ Wang Qian, Lin Guowei, Wang Xiaoqing and Lin Peidi. CEU, Shanghai Medical University, Shanghai, China. Objective: To describe and compare the complete remission (CR) rates of acute leukemia in secondary and tertiary hospitals. Design: Retrospective study. Setting and Participants: All 2867 patients with acute leukemia admitted to hospitals in Shanghai during 1984 to 1993 were eligible for this study. Three hundred and thirty-two patients who died before first induction course or without treatment were excluded. Finally, 2535 patients, 1495 males and 1040 females, were included in this study. There were 1714 patients in tertiary and 821 in secondary hospitals. Main Outcome Measure(s): Complete remission during first hospitalization. Results: The CR rates were 52% in secondary hospitals and 64% in tertiary hospitals (χ2 5 31.0, p , 0.01). The proportions of children and older leukemia patients in secondary hospitals were higher than in tertiary hospitals (25% vs. 28% and 10% vs. 19%, χ2 5 50.6 with df 5 2, p , 0.01). The time interval between onset and admission in secondary hospitals was shorter than in tertiary hospitals (median 30 vs. 34 days). There were no significant differences in the distributions of types of acute leukemia (ALL or AML), sex or hospital stay between secondary and tertiary hospitals. Using logistic regression modeling to adjust age, sex, and time interval from onset to admission, types of leukemia and severity on admission, the level of hospital still related to the CR of patients. The odds ratio for CR comparing the tertiary hospitals with secondary hospitals was 1.9 (95% CI of OR was 1.5 to 2.3, p , 0.05). Conclusion: In Shanghai, the patients with acute leukemia treated in tertiary hospitals were more likely to get a complete remission than those treated in secondary hospitals.
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