Dec 192014
 
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Chronic lymphocytic leukemia: a clinical review.

JAMA. 2014 Dec 3;312(21):2265-76

Authors: Nabhan C, Rosen ST

Abstract
IMPORTANCE: The most common leukemia is chronic lymphocytic leukemia (CLL). Every year, there are 15 000 new diagnoses and 5000 CLL deaths in the United States. Although therapeutic choices were once limited, treatment of this disease has vastly improved in the last decade.
OBJECTIVE: Evidence-based review of the diagnosis, staging, and treatment of CLL.
EVIDENCE REVIEW: PubMed, Cochrane Library, Scopus, and Google Scholar databases were searched through August 28, 2014. English-language peer-reviewed articles published between 2000-2014 were found using the keywords chronic lymphocytic leukemia, upfront therapy, upfront therapies, upfront therapeutic, upfront therapeutics, upfront treatment, front-line treatment, first-line treatment, front-line treatments, first-line treatments, front-line therapy, front-line therapies, randomized, randomized studies, randomized study, clinical trial, clinical trials, phase 3, and phase 3 clinical trial. Abstracts and presentations at scientific meetings were excluded. A total of 277 articles were retrieved, of which 24 met our predefined selection criteria; treatment recommendations were based on subsequent analysis of these 24 articles.
FINDINGS: The Rai and Binet systems for staging CLL were established in 1975 and 1977, respectively. However, they do not account for new disease categories such as monoclonal B-cell lymphocytosis (peripheral blood clonal lymphocytosis that does not meet other criteria for CLL). Two subsets of CLL are now recognized based on risk stratification involving molecular and cytogenetic analyses. Outcomes are improved by the addition of immunotherapy to combination chemotherapy for initial treatment in all subsets of treated patients. Overall response rates between 75% and 90% and complete responses between 22% and 45% are expected in the current era, with more than 80% of treated patients alive at 3 years. Overall, 5-year survival has increased to 66% from 60% (P < .001) in the past 10 years.
CONCLUSIONS AND RELEVANCE: Chemoimmunotherapy is the standard first-line option approach for CLL, the most common leukemia observed in adults. Treatment is initiated when the disease becomes symptomatic, and survival is high following treatment.

PMID: 25461996 [PubMed - indexed for MEDLINE]

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Dec 042014
 

Missed diagnosis of Clostridium difficile infection; a prospective evaluation of unselected stool samples.

J Infect. 2014 Nov 5;

Authors: Reigadas E, Alcalá A, Marín M, Burillo A, Muñoz P, Bouza E

Abstract
BACKGROUND: Clostridium difficile infection (CDI) is the leading cause of hospital-acquired diarrhoea in developed countries, however a high proportion of CDI episodes go undiagnosed, either because physicians do not request identification of toxigenic C. difficile or microbiologists do not perform the appropriate tests.
OBJECTIVE: To investigate the clinical characteristics of patients with CDI within a non-selected population and to determine risk factors for clinical underdiagnosis.
METHODS: We conducted a prospective study in which systematic testing for toxigenic C. difficile on all diarrhoeic stool samples was performed regardless of the clinician's request. Patients aged >2 years positive for toxigenic C. difficile and diarrhoea were enrolled (Jan-June 2013) and monitored at least 2 months after their last episode.
RESULTS: We identified 204 cases of CDI, of which three-quarters were healthcare-associated. Most cases were mild to moderate (83.8%), the recurrence rate was 16.2%, and CDI-related mortality was low (2.5%). A significant proportion (12.7%) of CDI cases would have been missed owing to lack of clinical suspicion. Community-acquired cases and young age were risk factors for clinical underdiagnosis.
CONCLUSION: Our data support the introduction of a systematic search for toxigenic C. difficile in all diarrhoeic stools from inpatients and outpatients older than 2 years.

PMID: 25452039 [PubMed - as supplied by publisher]

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Dec 042014
 
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Underdiagnosis of Clostridium difficile across Europe: the European, multicentre, prospective, biannual, point-prevalence study of Clostridium difficile infection in hospitalised patients with diarrhoea (EUCLID).

Lancet Infect Dis. 2014 Dec;14(12):1208-1219

Authors: Davies KA, Longshaw CM, Davis GL, Bouza E, Barbut F, Barna Z, Delmée M, Fitzpatrick F, Ivanova K, Kuijper E, Macovei IS, Mentula S, Mastrantonio P, von Müller L, Oleastro M, Petinaki E, Pituch H, Norén T, Nováková E, Nyč O, Rupnik M, Schmid D, Wilcox MH

Abstract
BACKGROUND: Variations in testing for Clostridium difficile infection can hinder patients' care, increase the risk of transmission, and skew epidemiological data. We aimed to measure the underdiagnosis of C difficile infection across Europe.
METHODS: We did a questionnaire-based study at 482 participating hospitals across 20 European countries. Hospitals were questioned about their methods and testing policy for C difficile infection during the periods September, 2011, to August, 2012, and September, 2012, to August, 2013. On one day in winter, 2012-13 (December, 2012, or January, 2013), and summer, 2013 (July or August), every hospital sent all diarrhoeal samples submitted to their microbiology laboratory to a national coordinating laboratory for standardised testing of C difficile infection. Our primary outcome measures were the rates of testing for and cases of C difficile infection per 10 000 patient bed-days. Results of local and national C difficile infection testing were compared with each other. If the result was positive at the national laboratory but negative at the local hospital, the result was classified as undiagnosed C difficile infection. We compared differences in proportions with the Mann-Whitney test, or McNemar's test if data were matched.
FINDINGS: During the study period, participating hospitals reported a mean of 65·8 tests (country range 4·6-223·3) for C difficile infection per 10 000 patient-bed days and a mean of 7·0 cases (country range 0·7-28·7) of C difficile infection per 10 000 patient-bed days. Only two-fifths of hospitals reported using optimum methods for testing of C difficile infection (defined by European guidelines), although the number of participating hospitals using optimum methods increased during the study period, from 152 (32%) of 468 in 2011-12 to 205 (48%) of 428 in 2012-13. Across all 482 European hospitals on the two sampling days, 148 (23%) of 641 samples positive for C difficile infection (as determined by the national laboratory) were not diagnosed by participating hospitals because of an absence of clinical suspicion, equating to about 74 missed diagnoses per day.
INTERPRETATION: A wide variety of testing strategies for C difficile infection are used across Europe. Absence of clinical suspicion and suboptimum laboratory diagnostic methods mean that an estimated 40 000 inpatients with C difficile infection are potentially undiagnosed every year in 482 European hospitals.
FUNDING: Astellas Pharmaceuticals Europe.

PMID: 25455988 [PubMed - as supplied by publisher]

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Dec 032014
 

Effectiveness of stringent decontamination of computer input devices in the era of electronic medical records and bedside computing: A randomized controlled trial.

Am J Infect Control. 2014 Nov 1;

Authors: Codish S, Toledano R, Novack V, Sherf M, Borer A

Abstract
Bedside computing may lead to increased hospital-acquired infections mediated by computer input devices handled immediately after patient contact. We compared 2 decontamination methods in 2 types of wards. We found high baseline contamination rates, which decreased following decontamination, but the rates remained unacceptably high. Decontamination was more effective in intensive care units compared with medical wards and when using alcohol-based impregnated wipes compared with quaternary ammonium-based impregnated wipes.

PMID: 25442396 [PubMed - as supplied by publisher]

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Dec 032014
 

Detection of hospital outbreaks of influenza-like illness based on excess of incidence rates compared to the community.

Am J Infect Control. 2014 Oct 16;42(12):1325-1327

Authors: Vanhems P, Voirin N, Bénet T, Roche S, Escuret V, Régis C, Giard M, Lina B, Comte B, Coppéré B, Ecochard R

Abstract
The risk of nosocomial influenza-like illness (noso-ILI) compared with that of community-acquired ILI was calculated during 3 influenza seasons (2004-2007) at a 1100-bed university hospital with a total of 21,519 hospitalized patients. Outbreaks of noso-ILI occurred in each season, although a protective effect against noso-ILI was also identified for other wards.

PMID: 25444307 [PubMed - as supplied by publisher]

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Dec 032014
 

Colonization of stickers used for the identification of intravenous lines: Results from an in vitro study.

Am J Infect Control. 2014 Nov;42(11):1161-4

Authors: Pérez Granda MJ, Guembe M, Cruces R, Martín-Rabadán P, Bouza E

Abstract
BACKGROUND: Clear differentiation of arterial and intravenous (IV) lines is a safety strategy recommended by the World Health Organization, and signaling stickers attached to IV lines are implemented in many institutions. However, the risk of colonization of the stickers' surface has not been evaluated. Our objective was to assess the colonization rate of stickers used for IV lines identification in an in vitro model using 3 different contamination degrees.
METHODS: A set of 30 stickers used for IV lines identification were exposed to low, medium, and high contamination degrees for up to 15 days. Twice a day, a single manipulator vigorously touched the surface of the stickers simulating the daily handling. Surface cultures of all stickers were performed daily. The microorganisms recovered were counted and identified by phenotypic characteristics.
RESULTS: Colonization occurred after 5 days in low and medium manipulation models and after 3 days in the high manipulation model. Nonadhesive sticker sides were associated with greater significant numbers of colony forming units when manipulation was performed without gloves.
CONCLUSION: Stickers used for the identification of IV lines may become potential reservoirs of catheter colonization. Clinical studies to validate these data and design policies of stickers' changes are required.

PMID: 25444263 [PubMed - in process]

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