Engraftment syndrome (ES) is increasingly observed in patients who receive auto-SCT. To investigate this fact, validate the clinical criteria for ES diagnosis and analyze the risk factors for this complication, we reviewed 328 consecutive peripheral blood auto-SCT performed during the past 7 years. A total of 43 patients presented with clinical or biological data suggestive of ES. Of the total, 41 (95%) and 22 (51%) could be diagnosed with ES using the Maiolino criteria (MC) and the Spitzer criteria (SC), respectively. The SC were less sensitive as they do not consider some relevant clinical data and limit the observation time after engraftment. All ES cases had high C-reactive protein (CRP) values not observed in the remaining patients at engraftment (median ± s.d.: 17.5 ± 7.3 vs 2.4 ± 3.4 mg per 100 ml; P ¼ 0.0001). Multivariate analysis showed a higher risk of ES in SCT performed in recent years (relative risk (RR) 2.3, 95% confidence interval (CI 1.0-4.7), female patients (RR 2.5, 95% CI 1.2-5.2), and absence of intensive chemotherapy before SCT (RR 8.8,). All patients except one improved after treatment with corticosteroids. The MC seem to be the best tool to establish a diagnosis of ES. In doubtful cases, the diagnosis could be confirmed by evaluating CRP. Auto-SCT in patients not receiving previous chemotherapy could explain the increasing incidence of ES in the past years.

Mupirocin is a topically applied drug that is very active in the eradication of nasal carriage of methicillinresistant Staphylococcus aureus (MRSA). However, studies designed to compare mupirocin treatment with other antimicrobial regimens are lacking. We therefore conducted an open, prospective, randomized, controlled trial to compare the efficacy and safety of mupirocin versus those of oral co-trimoxazole plus topical fusidic acid (both regimens with a clorhexidine scrub bath) for the eradication of MRSA from nasal and extranasal carriers of MRSA. The eradication rates with mupirocin and co-trimoxazole plus fusidic acid at 2, 7, 14, 21, 28, and 90 days were 93 and of 93, 100 and 100, 97 and 94, 100 and 92, 96 and 95, and 78 and 71%, respectively, for nasal carriage. At 7, 14, and 28 days the eradication rates for extranasal carriage by the two regimens were 23 and 74, 83 and 76, and 45 and 69%, respectively. The efficacies and safety of both regimens were similar. The MRSA isolates were not resistant to the study drugs either at the baseline or at follow-up. These results suggest that mupirocin and co-trimoxazole plus fusidic acid, both used in conjunction with a chlorhexidine soap bath, are equally effective and safe for the eradication of MRSA from nasal and extranasal MRSA carriers. Mupirocin was easier to use but was more expensive.Nasal and extranasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) plays a decisive role as a reservoir of and in the dissemination of MRSA infections (1).Eradication of MRSA from these reservoirs can be accomplished with only a few topical or systemic antimicrobial agents. Topical mupirocin (pseudomonic acid) is effective against both methicillin-susceptible S. aureus and MRSA carriage (3,22,24). Oral co-trimoxazole (13) and topical fusidic acid are antimicrobial agents commonly used either individually or in association to eradicate MRSA (8, 10, 15). We conducted an open, randomized, controlled trial in order to compare the efficacies and safety of two different regimens (mupirocin versus co-trimoxazole plus topical fusidic acid) to eradicate MRSA from nasal and extranasal carriers of MRSA during an extensive outbreak of MRSA in our hospital.(This study was presented in part at the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy, Anaheim, Calif., 11 to 14 October 1992.) MATERIALS AND METHODSHospital setting. Gregorio Marañón Hospital is a 2,200-bed university institution with an ongoing outbreak of MRSA representing 25% of all S. aureus isolated during 1991 (15). All of our MRSA strains are susceptible in vitro to co-trimoxazole, fusidic acid, and mupirocin (15).Study sample. From September 1991 to July 1992 we carried out a prospective, open, randomized, comparative trial in order to compare the efficacy and safety of topical mupirocin versus those of the combination of oral co-trimoxazole plus topical fusidic acid in the eradication of MRSA from nasal carriers. Patients and health care workers from areas with high incidences of MRSA (tw...

Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Background and ObjectiveTwenty per cent of chronic obstructive pulmonary disease (COPD) patients are readmitted for acute exacerbation (AECOPD) within 30 days of discharge. The prognostic significance of early readmission is not fully understood. The objective of our study was to estimate the mortality risk associated with readmission for acute exacerbation within 30 days of discharge in COPD patients.MethodsThe cohort (n = 378) was divided into patients readmitted (n = 68) and not readmitted (n = 310) within 30 days of discharge. Clinical, laboratory, microbiological, and severity data were evaluated at admission and during hospital stay, and mortality data were recorded at four time points during follow-up: 30 days, 6 months, 1 year and 3 years.ResultsPatients readmitted within 30 days had poorer lung function, worse dyspnea perception and higher clinical severity. Two or more prior AECOPD (HR, 2.47; 95% CI, 1.51–4.05) was the only variable independently associated with 30-day readmission. The mortality risk during the follow-up period showed a progressive increase in patients readmitted within 30 days in comparison to patients not readmitted; moreover, 30-day readmission was an independent risk factor for mortality at 1 year (HR, 2.48; 95% CI, 1.10–5.59). In patients readmitted within 30 days, the estimated absolute increase in the mortality risk was 4% at 30 days (number needed to harm NNH, 25), 17% at 6-months (NNH, 6), 19% at 1-year (NNH, 6) and 24% at 3 years (NNH, 5).ConclusionIn conclusion a readmission for AECOPD within 30 days is associated with a progressive increased long-term risk of death.