Predicting the complicated neutropenic fever in the emergency department

Plasma Profiling of Acute Myeloid Leukemia With Fever- and Infection-Related Complications During Chemotherapy-Induced Neutropenia

BACKGROUND

Acute myeloid leukemia (AML) is a heterogenous and complex blood cancer requiring aggressive treatment. Early identification and prediction of the complications following treatment is vital for effective disease management.

AIMS

We explored associations between plasma protein levels and fever- and infection-related complications in 26 AML patients during chemotherapy-induced neutropenia.

MATERIAL AND METHODS

Longitudinal plasma profiling was conducted using data-dependent mass spectrometry analysis.

RESULTS

Mass spectrometry-based plasma profiling data correlated well with laboratory parameters, including C-reactive protein, and revealed a broader inflammation protein network associated with fever- and infection-related complications.

DISCUSSION AND CONCLUSION

These data indicate the potential of longitudinal plasma profiling in AML patients for identifying and predicting complications that may aid in improved disease monitoring and treatment.

Acute Oncologic Complications: Clinical-Therapeutic Management in Critical Care and Emergency Departments

Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient's admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981-April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.

Phase I/II study to assess the clinical pharmacology and safety of single ascending and multiple subcutaneous doses of PF-06881894 in women with non-distantly metastatic breast cancer

PURPOSE

To evaluate the pharmacodynamics (PD), pharmacokinetics (PK), and safety of single and multiple doses of PF-06881894 (pegfilgrastim-apgf; Nyvepria™), a biosimilar to reference pegfilgrastim (Neulasta®), in women with non-distantly metastatic breast cancer.

METHODS

In Phase I (Cycle 0) of this Phase I/II study, the PD response (absolute neutrophil count [ANC]; CD34 + count), PK profile, and safety of a single 3- or 6-mg subcutaneous dose of PF-06881894 were assessed in chemotherapy-naïve patients before definitive breast surgery. In Phase II (Cycles 1-4), the PD response (duration of severe neutropenia [DSN, Cycle 1], ANC [Cycles 1 and 4]) and PK profile (Cycles 1 and 4) of single and multiple 6-mg doses of PF-06881894 concomitant with chemotherapy and after definitive breast surgery were assessed.

RESULTS

Twenty-five patients (mean age 59 years) were enrolled (Cycle 0, n = 12; Cycles 1-4, n = 13). In Cycle 0, PD responses and PK values were lower with 3-mg versus 6-mg PF-06881894. In Cycles 1 and 4, mean DSN was 0.667 days after single or multiple 6-mg doses of PF-06881894, respectively. In Cycle 4 versus Cycle 1, PD responses were more robust; PK values (mean area under the curve, maximum concentration) were lower; and clearance values were higher. The safety profile of PF-06881894 was similar to that for reference pegfilgrastim.

CONCLUSION

PF-06881894 as a single 3- or 6-mg dose prior to definitive surgery, or multiple 6-mg/cycle doses postoperatively, with/without myelosuppressive chemotherapy, was consistent with the clinical pharmacology and safety profile of reference pegfilgrastim.

TRIAL REGISTRATION

October 2017. ClinicalTrials.gov Identifier: NCT02650193. EudraCT Number: 2015-002057-35.

Machine Learning for Early Warning of Septic Shock in Children With Hematological Malignancies Accompanied by Fever or Neutropenia: A Single Center Retrospective Study

OBJECTIVES

The purpose of this article was to establish and validate clinically applicable septic shock early warning model (SSEW model) that can identify septic shock in hospitalized children with onco-hematological malignancies accompanied with fever or neutropenia.

METHODS

Data from EMRs were collected from hospitalized pediatric patients with hematological and oncological disease at Shanghai Children's Medical Center. Medical records of patients (>30 days and <19 years old) with fever (≥38°C) or absolute neutrophil count (ANC) below 1.0 × 109/L hospitalized with hematological or oncological disease between January 1, 2017 and August 1, 2019 were considered. Patients in whom septic shock was diagnosed during the observation period formed the septic shock group, whereas non-septic-shock group was the control group. In the septic shock group, the time points at 4, 8, 12, and 24 hours prior to septic shock were taken as observation points, and corresponding observation points were obtained in the control group after matching. We employed machine learning artificial intelligence (AI) to filter features and used XGBoost algorithm to build SSEW model. Area under the ROC curve (AU-ROC) was used to compare the effectiveness among the SSEW Model, logistic regression model, and pediatric sequential organ failure score (pSOFA) for early warning of septic shock.

MAIN RESULTS

A total of 64 observation periods in the septic shock group and 2191 in the control group were included. AU-ROC of the SSEW model had higher predictive value for septic shock compared with the pSOFA score (0.93 vs. 0.76, Z = -2.73, P = 0.006). Further analysis showed that the AU-ROC of the SSEW model was superior to the pSOFA score at the observation points 4, 8, 12, and 24 h before septic shock. At the 24 h observation point, the SSEW model incorporated 14 module root features and 23 derived features.

CONCLUSION

The SSEW model for hematological or oncological pediatric patients could help clinicians to predict the risk of septic shock in patients with fever or neutropenia 24 h in advance. Further prospective studies on clinical application scenarios are needed to determine the clinical utility of this AI model.

Neutropénie fébrile aux urgences, stratification du risque et conditions du retour à domicile

La neutropénie fébrile (NF) est une situation fréquemment rencontrée aux urgences avec un taux de mortalité non négligeable variant de 5 à 40 %. Cette variabilité importante met en avant l’importance de stratifier le risque afin de permettre un traitement ambulatoire per os de certains patients à faible risque. En plus du MASCC (The Multinational Association for Supportive Care in Cancer) score, d’autres outils permettent d’évaluer ce risque ou sont à l’étude dans ce but, tels que le dosage de la CRP, la procalcitonine ou encore le score CISNE. Après une prise en charge rapide aux urgences incluant l’administration sans délai d’un traitement adéquat, la poursuite de l’antibiothérapie per os à domicile est envisageable chez les patients à faible risque. La combinaison amoxicilline–acide clavulanique et ciprofloxacine est le plus souvent recommandée, mais la moxifloxacine ou la lévofloxacine en monothérapie peuvent également être utilisées pour les patients traités à domicile. Le retour à domicile permet de réduire fortement les coûts engendrés par l’hospitalisation, de diminuer le risque d’infection nosocomiale et d’améliorer la qualité de vie des patients avec NF à faible risque. Dans cette optique, plusieurs critères doivent être remplis, et une discussion avec le patient reste primordiale à la prise de décision. Parmi ceux-ci, nous retiendrons notamment un score MASCC supérieur à 21, une durée attendue de neutropénie inférieure à sept jours, l’accord du patient et de son entourage ainsi que la proximité entre le domicile et un service de soin adapté.

Diagnosis and Management of Oncologic Emergencies

Oncologic emergencies may be seen in any emergency department and will become more frequent as our population ages and more patients receive chemotherapy. Life-saving interventions are available for certain oncologic emergencies if the diagnosis is made in a timely fashion. In this article we will cover neutropenic fever, tumor lysis syndrome, hypercalcemia of malignancy, and hyperviscosity syndrome. After reading this article the reader should be much more confident in the diagnosis, evaluation, and management of these oncologic emergencies.

Critical review of emergency department management of chemotherapy complications in cancer patients

INTRODUCTION

Recent worldwide advances in cancer therapies have resulted in an increased number of people receiving chemotherapy in ambulatory care settings. In Spain, emergency departments are the single point of entry to acute inpatient services and they play a pivotal role in the management of chemotherapy complications. Little research exists in patterns of emergency department utilisation by oncology patients with chemotherapy-related complications. However, it is important for the oncology patients and the healthcare system to gain understanding in the disease pathway and the organisational factors influencing the quality of care.

METHODS

This critical review's main aims were to describe the clinical characteristics of patients who presented to an emergency department after chemotherapy treatment as reported in international literature; to map reported patterns of care in emergency department access; and quality of care exploring the management of febrile neutropenic patients described in the literature, against best practice guidelines.

RESULTS

The search strategy yield 701 articles from MEDLINE, TROVE and SCOPUS and 26 were included. The review combines systematic reviews, observational, cross-sectional case-control studies and randomised control trials.

CONCLUSION

All articles showed areas and opportunities for improvement in the management of this population, especially with regard to time from triage to antibiotic administration in febrile neutropenic patients.

Prognostic Factors Predicting Poor Outcome in Cancer Patients with Febrile Neutropenia in the Emergency Department: Usefulness of qSOFA

Background/Aims

Febrile neutropenia is considered as one of the most important and potentially life-threatening oncologic emergencies, which requires prompt medical assessment and treatment with antibiotics. This was a single-center retrospective study that investigated the prognostic factors predicting poor outcome in patients with cancer who presented with febrile neutropenia at the emergency department (ED).

Methods

The medical records of patients diagnosed with febrile neutropenia in the ED from January 2014 to December 2017 were reviewed. Patients aged >18 years who were diagnosed with a malignancy were included in the analysis. Febrile neutropenia was defined as an absolute neutrophil count < 1,000/mm³ with a temperature greater than 38°C. Patients were divided into two groups: those who were admitted at the intensive care unit (ICU) or those who died in the hospital (case group) and those who were admitted at general wards and were discharged (control group). The two groups were compared to determine the factors associated with poor prognosis.

Results

We identified 104 patients (25 and 79 from the case and control groups, respectively) with cancer who presented with febrile neutropenia at the ED during the study period. Lower blood pressure, platelet count, and HCO₃⁻ level, higher CRP and creatinine level, and the presence of bacteremia were more commonly observed in the case group than in the control group. In the multiple logistic regression analysis, the following independent predictors significantly correlated with ICU admission and in-hospital mortality: quick sequential (sepsis-related) organ failure assessment (qSOFA) score (odds ratio [OR]: 4.62; 95% confidence interval [CI]: 1.17–18.22; p=0.285), hemoglobin level (OR: 0.51; 95% CI: 0.33–0.78; p=0.002), total bilirubin level (OR: 7.69; 95% CI: 1.29–45.8; p=0.025), and respiratory tract infection (OR: 29.65; 95% CI: 3.81–230.7; p=0.0012).

Conclusions

The qSOFA can be a useful bedside tool for patients with cancer who present with febrile neutropenia at the ED. Moreover, it can help emergency physicians in identifying patients at risk of poor prognosis and in initiating prompt empirical antimicrobial therapy. Further studies must be conducted to validate the efficacy of the qSOFA in these patients in the ED.

Making Improvements in the ED: Does ED Busyness Affect Time to Antibiotics in Febrile Pediatric Oncology Patients Presenting to the Emergency Department?

OBJECTIVES

Febrile neutropenic pediatric patients are at heightened risk for serious bacterial infections, and rapid antibiotic administration (in <60 minutes) improves survival. Our objectives were to reduce the time-to-antibiotic (TTA) administration and to evaluate the effect of overall emergency department (ED) busyness on TTA.

METHODS

This study was a quality improvement initiative with retrospective chart review to reduce TTA in febrile children with underlying diagnosis of cancer or hematologic immunodeficiency who visited the pediatric ED. A multidisciplinary clinical practice guideline (CPG) was implemented to improve TTA. The CPG's main focus was delivery of antibiotics before availability of laboratory data. We collected data on TTA during baseline and intervention periods. Concurrent patient arrivals to the ED per hour served as a proxy of busyness. Time to antibiotic was compared with the number of concurrent arrivals per hour. Analyses included scatter plot and regression analysis.

RESULTS

There were 253 visits from October 1, 2010 to March 30, 2012. Median TTA administration dropped from 207 to 89 minutes (P < 0.001). Eight months after completing all intervention periods, the median had dropped again to 44 minutes with 70% of patients receiving antibiotics within 60 minutes of ED arrival. There was no correlation between concurrent patient arrivals and TTA administration during the historical or intervention periods.

CONCLUSIONS

Implementation of a CPG and process improvements significantly reduced median TTA administration. Total patient arrivals per hour as a proxy of ED crowding did not affect TTA administration. Our data suggest that positive improvements in clinical care can be successful despite fluctuations in ED patient volume.

Diagnostic performance of procalcitonin, presepsin, and C-reactive protein in patients with hematological malignancies

INTRODUCTION

Infections represent a major complication of hematological malignancies. C-reactive protein (CRP) and procalcitonin (PCT) have been used as diagnostic biomarkers of infections, but do not produce definitive findings. Recently, a new biomarker, presepsin, has been used as a diagnostic tool for detecting infections in the fields of emergency and neonatal medicine. However, the usefulness of presepsin for identifying infections in patients with hematological malignancies, including those who develop febrile neutropenia, remains unclear.

METHODS

In this study, we retrospectively analyzed the utility of PCT, presepsin, and CRP as biomarkers of infections during 49 febrile episodes that occurred in 28 patients with hematological malignancies.

RESULTS

The levels of PCT, but not those of CRP or presepsin, were significantly higher in the infection group than in the uninfected group (P<.03), indicating that PCT might be a more sensitive biomarker of infections. No differences in presepsin levels were detected between the patients with and without neutropenia, or between the infected and uninfected patients with neutropenia, indicating that presepsin might have less diagnostic value in patients with neutropenia.

CONCLUSIONS

We conclude that PCT might provide additional information and could be used in combination with other biomarkers to detect infections in patients with hematological malignancies.

Independent factors for prediction of poor outcomes in patients with febrile neutropenia

Background

Febrile neutropenia (FN) is a life-threatening condition that requires urgent management in the emergency department (ED). Recent progress in the treatment of neutropenic fever has underscored the importance of risk stratification. In this study, we aimed to determine independent factors for prediction of poor outcomes in patients with FN.

Material/Methods

We retrospectively evaluated 200 chemotherapy-induced febrile neutropenic patients who visited the ED. Upon arrival at the ED, clinical data, including sex, age, vital signs, underlying systemic diseases, laboratory test results, estimated GFR, blood cultures, CRP, radiologic examinations, and Multinational Association of Supportive Care in Cancer (MASCC) score of all febrile neutropenic patients were obtained. Outcomes were categorized as “poor” if serious complications during hospitalization, including death, occurred.

Results

The platelet count <50 000 cells/mm³ (OR 3.90, 95% CI 1.62–9.43), pulmonary infiltration (OR 3.45, 95% CI 1.48–8.07), hypoproteinemia <6 g/dl (OR 3.30, 95% CI 1.27–8.56), respiratory rate >24/min (OR 8.75, 95% CI 2.18–35.13), and MASCC score <21 (OR 9.20, 95% CI 3.98–21.26) were determined as independent risk factors for the prediction of death. The platelet count <50 000 cells/mm3 (OR 3.93, 95% CI 1.42–10.92), serum CRP >50 mg/dl (OR 3.80, 95% CI 1.68–8.61), hypoproteinemia (OR 7.81, 95% CI 3.43–17.78), eGFR ≤90 ML/min/1.73 m² (OR 3.06, 95% CI 1.13–8.26), and MASCC score <21 (OR 3.45, 95% CI 1.53–7.79) were determined as independent risk factors for the prediction of poor clinical outcomes of FN patients. Platelet count, protein level, respiratory rate, pulmonary infiltration, CRP, MASCC score, and eGFR were shown to have a significant association with outcome.

Conclusions

The results of our study may help emergency medicine physicians to prevent serious complications with proper use of simple independent risk factors besides MASCC score.

Prognostic factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia: a systematic review and meta-analysis

Chemotherapy-induced febrile neutropenia patients are heterogeneous in their risk of adverse outcomes. Management strategies are tailored according to level of risk. Many emerging predictors for risk stratification remain controversial being based on single studies only. A systematic review was conducted to determine the strength of association of all identified predictors. Studies were obtained from electronic databases, grey literatures and reference lists. Methodological quality of studies was assessed for internal validity and representativeness. Seven studies (four prospective and three retrospective cohorts) investigating 22 factors were reported. Fixed effects meta-analysis showed: hypotension and thrombocytopenia were significant predictors for high-risk. Additional predictors that might enhance performance of current models include: tachypnoea, presence of central venous catheter, duration and severity of neutropenia. Further research to investigate new factors/markers is needed to develop a robust prognostic model, which is the key to enhance patient safety.

Significance of interleukin-6 (IL-6) and C-reactive protein (CRP) in children and young adults with febrile neutropenia during chemotherapy for cancer: a prospective study

OBJECTIVES

We evaluated the usefulness of interleukin-6 (IL-6) and C-reactive protein (CRP) at the onset of febrile neutropenia and 72 hours later, in identifying risk groups and assessing response to antibiotic therapy.

METHODS

All episodes of febrile neutropenia were divided in 3 study groups-microbiologically documented infection (MDI), clinically documented infection (CDI), and fever of unknown origin (FUO). Three outcome groups were defined as those responding to first-line antibiotics (R1), those responding to second-line antibiotics (R2), and those requiring antifungal therapy (RAF). Median values of IL-6 and CRP were compared between the groups.

RESULTS

There were 57 episodes of febrile neutropenia among 26 patients younger than 25 years during 1 year of study period. On day 1, median IL-6 level was significantly lower in FUO group compared with CDI+MDI groups combined (P < 0.001). Rise in CRP on day 3 was highly significant to differentiate MDI group from other 2 groups (P < 0.001). The CRP also increased significantly on day 3 in RAF (P < 0.001) and R2 (P = 0.002) groups than in R1 group.

CONCLUSIONS

Low level of IL-6 may help differentiate patients with FUO from those with documented infections. A rising CRP is indicative of serious infection.

Point-of-care urine albumin:creatinine ratio is associated with outcome in emergency department patients with sepsis: a pilot study

OBJECTIVES

Sepsis is characterized by an initial systemic proinflammatory response leading to endothelial damage and increased capillary permeability. The authors conducted a pilot study to determine if microalbuminuria, measured by the urine albumin:creatinine ratio (ACR), was associated with outcome in emergency department (ED) sepsis patients.

METHODS

This was an observational cohort study of a convenience sample of adult patients presenting to two EDs over 10 months with sepsis (two or more systemic inflammatory response syndrome [SIRS] criteria and suspected infection). Those who received a urinalysis were prospectively enrolled. Patients with anuria, grossly contaminated specimens, or concurrent noninfectious diagnoses were excluded. Urine ACR was measured on a point-of-care (POC) device. The primary study outcome was ED disposition (three groups): treated and discharged, admitted to the floor, or admitted to the intensive care unit (ICU). Kruskal-Wallis testing was used to compare ACR based on disposition. Variables associated with ACR were identified by Spearman rank correlation or Mann-Whitney rank-sum testing. A post hoc subgroup analysis of patients with and without a genitourinary (GU) source of infection was also performed.

RESULTS

A total of 121 patients were screened, and 29 (24%) were excluded; 92 patients met criteria (mean ± SD age, 51.2 ± 17.0 years; 51 [55%] had severe sepsis, three [3%] had septic shock). There were three in-hospital deaths. Median ACR for patients treated and discharged (n = 22), admitted to floor (n = 50), and admitted to ICU (n = 20) was 2.54 (interquartile range [IQR] = 0.89 to 6.16) versus 2.8 (IQR = 1.69 to 8.8) versus 12.15 (IQR = 4.76 to 20.95), respectively (p = 0.0049). Age, serum creatinine, and GU source of infection were associated with ACR. ACR was significantly associated with disposition among patients without a GU source of infection (p = 0.003), but not among patients with a GU source (p = 0.3744).

CONCLUSIONS

In this pilot study, microalbuminuria measured by POC ACR was associated with disposition in ED patients with sepsis or severe sepsis. Larger studies using more robust outcomes comparing ACR with validated sepsis biomarkers are needed to elaborate on these results.

Prognostic factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia: a systematic review and meta-analysis

BACKGROUND

Increasing numbers of studies identify new prognostic factors for categorising chemotherapy-induced febrile neutropenia adult cancer patients into high- or low-risk groups for adverse outcomes. These groupings are used to tailor therapy according to level of risk. However many emerging factors with prognostic significance remain controversial, being based on single studies only.

OBJECTIVES

A systematic review was conducted to determine the strength of association of all identified factors associated with the outcomes of chemotherapy-induced febrile neutropenia patients.

INCLUSION CRITERIA

The participants included were adults of 15 years old and above, with a cancer diagnosis and who underwent cancer treatment.The review focused on clinical factors and their association with the outcomes of cancer patients with chemotherapy-induced febrile neutropenia at presentation of fever.All quantitative studies published in English which investigated clinical factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia were considered.The primary outcome of interest was to identify the clinical factors for risk stratification of adult cancer patients with chemotherapy-induced febrile neutropenia.

SEARCH STRATEGY

Electronic databases searched from their respective inception date up to December 2011 include MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Science-Direct, Scopus and Mednar.

METHODOLOGICAL QUALITY

The quality of the included studies was subjected to assessment by two independent reviewers. The standardised critical appraisal tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used to assess the following criteria: representativeness of study population; clearly defined prognostic factors and outcomes; whether potential confounders were addressed and appropriate statistical analysis was undertaken for the study design.

DATA COLLECTION

Data extraction was performed using a modified version of the standardised extraction tool from the JBI-MAStARI. Prognostic factors and the accompanying odds ratio reported for the significance of these factors that were identified by multivariate regression, were extracted from each included study.

DATA SYNTHESIS

Studies results were pooled in statistical meta-analysis using Review Manager 5.1. Where statistical pooling was not possible, the findings were presented in narrative form.

RESULTS

Seven studies (four prospective cohort and three retrospective cohort) investigating 22 factors in total were included. Fixed effects meta-analysis showed: hypotension [OR=1.66, 95%CI, 1.14-2.41, p=0.008] and thrombocytopenia [OR=3.92, 95%CI, 2.19-7.01, p<0.00001)] were associated with high-risk of adverse outcomes for febrile neutropenia. Other factors that were statistically significant from single studies included: age of patients, clinical presentation at fever onset, presence or absence of co-morbidities, infections, duration and severity of neutropenia state. Five prognostic factors failed to demonstrate an association between the variables and the outcomes measured and they include: presence of pneumonia, total febrile days, median days to fever, recovery from neutropenia and presence of moderate clinical symptoms in association with Gram-negative bacteraemia.

CONCLUSIONS

Despite the overall limitations identified in the included studies, this review has provided a synthesis of the best available evidence for the prognostic factors used in risk stratification of febrile neutropenia patients. However, the dynamic aspects of prognostic model development, validation and utilisation have not been addressed adequately thus far. Given the findings of this review, it is timely to address these issues and improve the utilisation of prognostic models in the management of febrile neutropenia patients.

IMPLICATIONS FOR PRACTICE

The identified factors are similar to the factors in current prognostic models. However, additional factors that were reported to be statistically significant in this review (thrombocytopenia, presence of central venous catheter, and duration and severity of neutropenia) have not previously been included in prognostic models. This review has found these factors may improve the performance of current models by adding or replacing some of the factors.

IMPLICATIONS FOR RESEARCH

The role of risk stratification of chemotherapy-induced febrile neutropenia patients continues to evolve as the practice of risk-based therapy has been demonstrated to be beneficial to patients, clinicians and health care organisations. Further research to identify new factors /markers is needed to develop a new model which is reliable and accurate for these patients, regardless of cancer types. A robust and well-validated prognostic model is the key to enhance patient safety in the risk-based management of cancer patients with chemotherapy-induced febrile neutropenia.

Prognostic evaluation of febrile neutropenia in apparently stable adult cancer patients

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BACKGROUND

Predictive models to identify low-risk febrile neutropenia (FN) have been developed with heterogeneous samples, which included stable and unstable patients, solid tumours, acute leukaemia and bone marrow transplantation. These models fail to recognise 5-15% of cases with unexpected complications, and literature specifically addressing apparently stable patients (ASPs) is scarce.

METHODS

We reviewed 861 episodes of FN in outpatients with solid tumours, including 692 (80%) episodes with apparent clinical stability. We aimed to investigate the prognosis of this latter group and explore the possibility of stratifying it according to the presenting features. A case-control study was performed and the MASCC index was evaluated.

RESULTS

The rates of complications and bacteraemia in ASPs were 7.3% and 6.2%, respectively. The MASCC index yielded a low sensitivity to detect complications (36%). Prognostic factors were identified: ECOG performance status ≥2, chronic bronchitis, chronic heart failure, stomatitis NCI grade ≥2, monocytes <200 mm(-3) and stress hyperglycaemia.

CONCLUSION

A very simple assessment is useful to classify the patients with FN according to the risk of complications. A few additional variables may predict the clinical course of the patients. We additionally show that the MASCC index applied to this specific group has a low sensitivity to predict complications.

C-reactive protein in critically ill cancer patients with sepsis: influence of neutropenia

INTRODUCTION

Several biomarkers have been studied in febrile neutropenia. Our aim was to assess C-reactive protein (CRP) concentration in septic critically ill cancer patients and to compare those with and without neutropenia.

METHODS

A secondary analysis of a matched case-control study conducted at an oncologic medical-surgical intensive care unit (ICU) was performed, segregating patients with severe sepsis/septic shock. The impact of neutropenia on CRP concentrations at admission and during the first week of ICU stay was assessed.

RESULTS

A total of 154 critically ill septic cancer patients, 86 with neutropenia and 68 without, were included in the present study. At ICU admission, the CRP concentration of neutropenic patients was significantly higher than in non-neutropenic patients, 25.9 ± 11.2 mg/dL vs. 19.7 ± 11.4 mg/dL (P = 0.009). Among neutropenic patients, CRP concentrations at ICU admission were not influenced by the severity of neutropenia (< 100/mm3 vs. ≥ 100/mm3 neutrophils), 25.1 ± 11.6 mg/dL vs. 26.9 ± 10.9 mg/dL (P = 0.527). Time dependent analysis of CRP from Day 1 to Day 7 of antibiotic therapy showed an almost parallel decrease in both groups (P = 0.335), though CRP of neutropenic patients was, on average, always higher in comparison to that of non-neutropenic patients.

CONCLUSIONS

In septic critically ill cancer patients CRP concentrations are more elevated in those with neutropenia. However, the CRP course seems to be independent from the presence or absence of neutropenia.

A genetic association study of serum acute-phase C-reactive protein levels in rheumatoid arthritis: implications for clinical interpretation

BACKGROUND

The acute-phase increase in serum C-reactive protein (CRP) is used to diagnose and monitor infectious and inflammatory diseases. Little is known about the influence of genetics on acute-phase CRP, particularly in patients with chronic inflammation.

METHODS AND FINDINGS

We studied two independent sets of patients with chronic inflammation due to rheumatoid arthritis (total 695 patients). A tagSNP approach captured common variation at the CRP locus and the relationship between genotype and serum CRP was explored by linear modelling. Erythrocyte sedimentation rate (ESR) was incorporated as an independent marker of inflammation to adjust for the varying levels of inflammatory disease activity between patients. Common genetic variants at the CRP locus were associated with acute-phase serum CRP (for the most associated haplotype: p = 0.002, p<0.0005, p<0.0005 in patient sets 1, 2, and the combined sets, respectively), translating into an approximately 3.5-fold change in expected serum CRP concentrations between carriers of two common CRP haplotypes. For example, when ESR = 50 mm/h the expected geometric mean CRP (95% confidence interval) concentration was 43.1 mg/l (32.1-50.0) for haplotype 1 and 14.2 mg/l (9.5-23.2) for haplotype 4.

CONCLUSIONS

Our findings raise questions about the interpretation of acute-phase serum CRP. In particular, failure to take into account the potential for genetic effects may result in the inappropriate reassurance or suboptimal treatment of patients simply because they carry low-CRP-associated genetic variants. CRP is increasingly being incorporated into clinical algorithms to compare disease activity between patients and to predict future clinical events: our findings impact on the use of these algorithms. For example, where access to effective, but expensive, biological therapies in rheumatoid arthritis is rationed on the basis of a DAS28-CRP clinical activity score, then two patients with identical underlying disease severity could be given, or denied, treatment on the basis of CRP genotype alone. The accuracy and utility of these algorithms might be improved by using a genetically adjusted CRP measurement.