Environmental SARS-CoV-2 contamination in hospital rooms of patients with acute COVID-19.

OBJECTIVE: Data on the transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) remain conflicting. Airborne transmission is still debated. However, hospital risk control requires better understanding of the different modes of transmission. This study aimed to evaluate the frequency of, and factors associated with, environmental air and surface contamination in the rooms of patients with coronavirus disease 2019 in the acute phase of the disease. METHODS: Sixty-five consecutive patients were included in this study. For each patient, seven room surfaces, air 1 m and 3 m from the patient's head, the inner surface of the patient's mask, and the outer surface of healthcare workers' (HCW) masks were sampled. Environmental contamination was assessed by quantitative reverse transcription polymerase chain reaction (RT-qPCR) for SARS-CoV-2 RNA on surfaces, air and masks. A viral isolation test was performed on Vero cells for samples with an RT-qPCR cycle threshold (Ct) ≤37. RESULTS: SARS-CoV-2 RNA was detected by RT-qPCR in 34%, 12%, 50% and 10% of surface, air, patient mask and HCW mask samples, respectively. Infectious virus was isolated in culture from two samples among the 85 positive samples with Ct ≤37. On multi-variate analysis, only a positive result for SARS-CoV-2 RT-qPCR for patients' face masks was found to be significantly associated with surface contamination (odds ratio 5.79, 95% confidence interval 1.31-25.67; P=0.025). CONCLUSION: This study found that surface contamination by SARS-CoV-2 was more common than air and mask contamination. However, viable virus was rare. The inner surface of a patient's mask could be used as a marker to identify those at higher risk of contamination.

Two-year follow-up of 196 interstitial lung disease patients after ICU stay.

OBJECTIVE: Interstitial lung diseases (ILDs) are associated with poor prognosis in the intensive care unit (ICU). We aimed to assess factors associated with hospital mortality in ILD patients admitted to the ICU and to investigate long-term outcome.MATERIAL AND METHODS: This was a retrospective study in a teaching hospital specialised in ILD management. Patients with ILD who were hospitalised in the ICU between 2000 and 2014 were included. Independent predictors of hospital mortality were identified using logistic regression.RESULTS: A total of 196 ILD patients were admitted to the ICU during the study period. Overall hospital mortality was 55%. Two years after ICU admission, 70 (36%) patients were still alive. Of the 196 patients, 108 (55%) required invasive mechanical ventilation, of whom 21 (20%) were discharged alive from hospital. Acute exacerbation of ILD and multi-organ failure were highly associated with hospital mortality (OR 5.4, 95% CI 1.9-15.5 and OR 12.6, 95% CI 4.9-32.5, respectively).CONCLUSION: Hospital mortality among ILD patients hospitalised in the ICU was high, but even where invasive mechanical ventilation was required, a substantial number of patients were discharged alive from hospital. Multi-organ failure could lead to major ethical concerns.

Incidence and risk factors of hypoxaemia after preoxygenation at induction of anaesthesia.

BACKGROUND: The incidence of hypoxaemia related to airway management is still a matter of concern. Our aim was to determine the factors that contribute to hypoxaemia during induction of anaesthesia after a standardised preoxygenation procedure. METHODS: The study was a multicentre and prospective observational trial. It evaluated the incidence of hypoxaemia at induction of anaesthesia in adult patients. The primary endpoint was the incidence of hypoxaemia defined as pulse oximetry of arterial oxyhaemoglobin saturation (SpO2) <95%. RESULTS: Of 2398 patients, hypoxaemia was observed in 158 (6.6%). We identified five preoperative independent risk factors: chronic obstructive pulmonary disease, hypertension, anticipated difficult mask ventilation and difficult tracheal intubation, and emergency surgery. There were also three pre-induction independent risk factors: difficult preoxygenation, difficult mask ventilation, and difficult tracheal intubation. We found a high negative predictive value of preoperative risk factors for difficult mask ventilation of 0.96 (0.95-0.96), and for difficult tracheal intubation (0.95 [0.94-0.96]). A total of 723 patients (30%) experienced difficult preoxygenation (FeO2 <90% at the end of preoxygenation). Male sex, chronic obstructive pulmonary disease, hypertension, emergency surgery, and predictable difficult mask ventilation were independent patient risk factors for difficult preoxygenation. CONCLUSIONS: Difficult mask ventilation and difficult tracheal intubation are risk factors for hypoxaemia at induction of general anaesthesia. Difficult preoxygenation was observed in 30% of patients and was also identified as a risk factor for hypoxaemia. This suggests that techniques improving preoxygenation should be implemented in daily practice.

Slow Gait Speed Is an Independent Predictor of Early Death in Older Cancer Outpatients: Results from a Prospective Cohort Study.

OBJECTIVE: To assess the predictive value of gait speed for early death in older outpatients with cancer. DESIGN: Prospective bicentric observational cohort study. SETTING: The Physical Frailty in Elder Cancer patients (PF-EC) study (France). PARTICIPANTS: One hundred and ninety outpatients with cancer during the first 6 months of follow up in the PF-EC study. MEASUREMENTS: The association between usual gait speed over 4 m alone (GS) or included in the short physical performance battery (SPPB) and overall survival within 6 months following a comprehensive geriatric assessment (CGA). A Cox proportional-hazard regression model was performed in non-survivors for clinical factors from the CGA, along with c reactive protein (CRP). Two models were created to assess GS alone and from inclusion in the SPPB. RESULTS: The mean age was 80.6 years, and 50.5% of the participants were men. Death occurred in 11% (n=22) of the participants within the 6 month follow up period. Of these participants, 98% had solid cancers, and 33% had a metastatic disease. A GS < 0.8 m/s (HR=5.6, 95%CI=1.6-19.7, p=0.007), a SPPB < 9 (HR=5.8, 95%CI=1.6-20.9, p=0.007) and a CRP of 50 mg/l or greater (p<0.0001) were significantly associated with early death in the two multivariate analyses. Cancer site and extension were not significantly associated with early death. CONCLUSION: Walking tests are associated with early death within the 6 month follow up period after a CGA independent of cancer site and cancer extension. GS alone < 0.8 m/s is at least as efficacious as the SPPB in predicting this outcome. GS alone could be used routinely as a marker of early death to adapt oncologic therapeutics. Further studies are needed to validate these preliminary data.

New parameters on the hematology analyzer XN-10 (SysmexTM) allow to distinguish childhood bacterial and viral infections.

INTRODUCTION: Complete blood counts (CBC) performed for infected children admitted for fever mostly disclose leukocytosis. Yet, the recently developed XN-10® provides novel CBC parameters which could be useful to ascertain infection and discriminate between bacterial and viral etiologies. These were the main objectives of the study presented here. METHODS: Blood samples from 90 children, 1 month to 5 years old, admitted to an emergency unit for fever benefited from a CBC, C-reactive protein, and procalcitonin assays. For 58, a bacterial infection was documented while a viral cause was disclosed for 32. Concomitantly, 30 healthy children of the same age range were selected as a control group. RESULTS: Complete blood counts parameters and leukocyte differentials allowed to statistically significantly disclose infection, compared to reference children, in the age group of 1-5 years old. Among the eight novel discriminant parameters, a particular interest appeared for Neutr-RI and Delta-He. They both were successfully incorporated in a score together with age and immature granulocytes (IG). ROC curves and AUCs were calibrated using a Hosmer-Lemeshow test. Moreover, novel lymphocyte parameters allowed to segregate bacterial and viral infections in the whole group of 90 febrile children. CONCLUSION: Complete blood counts is the most broadly performed rapid laboratory investigation. Here, we show that XN-10® provides complementary information allowing to confirm infection in febrile children, moreover discriminating between bacterial or viral origin.

Increased mean corpuscular haemoglobin concentration: artefact or pathological condition?

INTRODUCTION: In daily practice in haematology laboratories, spurious increased MCHC induces an analytical alarm and needs prompt corrective action to ensure delivery of the right results to the clinicians. The aim of this study was to establish a 'decision tree' using the new parameters red blood cells (RBC-O) and haemoglobin (HGB-O) from the Sysmex XN-10 RET obtained by flow cytometry to deliver appropriate results. METHODS: From 128 unknown patients with MCHC > 365 g/L, all erythrocyte parameters including reticulocyte parameters were measured and analysed in parallel with blood smears, chemistry index and osmolarity. Differences between optical parameters (RBC-O, HGB-O) and usual parameters (RBC, HGB) obtained by impedance and photometry were reported also. RESULTS: Four groups were defined from observations: -RBC agglutination (n = 22); -optical interference (n = 17); -RBC disease (n = 18); and -others (n = 71). The use of RBC-O and HGB-O permitted efficient correction of the abnormalities when RBC agglutination and/or optical interference were present in 36 of 39 patients. Reticulocyte parameters permitted to elaborate an RBC score that allowed a highly sensitive detection of RBC disease patients (17/18). CONCLUSION: Based on new parameters, we propose a 'decision tree' that delivers time savings and supports biological interpretation in case of elevated MCHC.

What threshold values of antral follicle count and serum AMH levels should be considered for oocyte cryopreservation after in vitro maturation?

STUDY QUESTION: What threshold values of ultrasonographic antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) levels should be considered for ensuring the cryopreservation of sufficient number of in vitro matured (IVM) oocytes, in cancer patients seeking fertility preservation (FP)? SUMMARY ANSWER: AFC and serum AMH values >20 follicles and 3.7 ng/ml, respectively, are required for obtaining at least 10 IVM oocytes for cryopreservation. WHAT IS KNOWN ALREADY: IVM of cumulus oocyte complexes (COCs) followed by oocyte cryopreservation has emerged recently as an option for urgent FP. Recent data have reported that, in healthy patients, 8-20 cryopreserved oocytes after ovarian stimulation would maximize the chance of obtaining a live birth. Although both AFC and AMH have been reported as predictive factors of IVM success in infertile patients with polycystic ovary syndrome (PCOS), there is a dramatic lack of data regarding the values of these parameters in oncological patients as candidates for FP. STUDY DESIGN, SIZE, DURATION: From January 2009 to April 2015, we prospectively studied 340 cancer patients, aged 18-41 years, as candidates for oocyte cryopreservation following IVM. PARTICIPANTS/MATERIALS, SETTING, METHODS: All patients had AFC and AMH measurements, 48-72 h before oocyte retrieval, regardless of the phase of the cycle. COCs were recovered under ultrasound guidance 36 h after hCG priming. Logistic regression allowed the determination of threshold values of AFC and AMH, for obtaining at least 8, 10 or 15 matures oocytes frozen after the IVM procedure. Similar analyses were performed for a final number of mature oocytes ≤2. MAIN RESULTS AND THE ROLE OF CHANCE: Among the 340 cancer patients included, 300 were diagnosed with breast cancers, 14 had hematological malignancies and 26 underwent the procedure for others indications. Overall, the mean age of the population was 31.8 ± 4.5 years. Mean AFC and serum AMH levels were 21.7 ± 13.3 follicles and 4.4 ± 3.8 ng/ml, respectively. IVM was performed in equal proportions during the follicular or luteal phase of the cycle (49 and 51%, respectively). Statistical analysis showed that AFC and AMH values above 28 follicles and 3.9 ng/ml, 20 follicles and 3.7 ng/ml and 19 follicles and 3.5 ng/ml are required, respectively, for obtaining at least 15, 10 or 8 frozen IVM oocytes with a sensitivity ranging from 0.82 to 0.90. On the contrary, ≤2 IVM oocytes were cryopreserved when AFC and AMH were <19 follicles and 3.0 ng/ml, respectively. LIMITATIONS, REASONS FOR CAUTION: Although the potential of cryopreserved IVM oocytes from cancer patients remains unknown, data obtained from infertile PCOS women have shown a dramatically reduced competence of these oocytes when compared with that of oocytes recovered after ovarian stimulation. As a consequence, the optimal number of IVM oocytes frozen in candidates for FP is currently unpredictable. WIDER IMPLICATIONS OF THE FINDINGS: Cryopreservation of oocytes after IVM should be considered in the FP strategy when ovarian stimulation is unfeasible, in particular when markers of the follicular ovarian status are at a relatively high range. Further investigation is needed to objectively assess the real potential of these IVM oocytes after cryopreservation. Therefore, even when a good COCs yield is expected, we should systematically encourage IVM in combination with ovarian tissue cryopreservation. STUDY FUNDING/COMPETING INTERESTS: No external funding was obtained for the present study. The authors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER: Not applicable.

Effect of immune modulation in relapsed peripheral T-cell lymphomas after post-allogeneic stem cell transplantation: a study by the Société Française de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC).

Peripheral T-cell lymphoma carries a poor prognosis. To document a possible graft-versus-lymphoma effect in this setting, we evaluated the impact of immunomodulation in 63 patients with peripheral T-cell lymphoma who relapsed after allogeneic transplant in 27 SFGM-TC centers. Relapse occurred after a median of 2.8 months. Patients were then treated with non-immunologic strategies (chemotherapy, radiotherapy) and/or immune modulation (donor lymphocyte infusions (DLI) and/or discontinuation of immunosuppressive therapy). Median overall survival (OS) after relapse was 6.1 months (DLI group: 23.6 months, non-DLI group: 3.6 months). Among the 14 patients who received DLI, 9 responded and 2 had stable disease. Among the remaining 49 patients, a complete response accompanied by extensive chronic GvHD was achieved in two patients after tapering of immunosuppressive drugs. Thirty patients received radio-chemotherapy, with an overall response rate of 50%. In multivariate analysis, chronic GvHD (odds ratio: 11.25 (2.68-48.21), P=0.0009) and skin relapse (odds ratio: 4.15 (1.04-16.50), P=0.043) were associated with a better response to treatment at relapse. In a time-dependent analysis, the only factor predictive of OS was the time from transplantation to relapse (hazards ratio: 0.33 (0.17-0.640), P=0.0009). This large series provides encouraging evidence of a true GvL effect in this disease.

Incidence and prediction of inadequate preoxygenation before induction of anaesthesia.

BACKGROUND: Preoxygenation aims to obtain an expired oxygen fraction (FEO2)≥90%. Little is known about the incidence and predictors of inadequate preoxygenation in the clinical setting. PATIENTS AND METHODS: Over a 12-month period, 1050 consecutive preoperative patients were prospectively included. Preoxygenation was performed for 3minutes with a facial mask using a machine circuit and 12-L/min oxygen flow. Inadequate preoxygenation was defined as an FEO2<90%. A logistic regression was performed to identify incidence and independent predictors. RESULTS: The patient characteristics were: age 51±20years, 47% male, BMI of 26±5kg/m(2), and ASA score (median [extremes]) of 2 [1-4]. Inadequate preoxygenation was observed in 589 patients (56%). The effective FiO2 delivered was lower in the patients with inadequate preoxygenation than in those with adequate preoxygenation, 95±3% vs. 98±2%, P<0.001. The difference between the FiO2 and the FEO2 was higher (12±6% vs. 6±3%, P<0.0001) in patients with inadequate preoxygenation compared with those with adequate preoxygenation. The independent risk factors for inadequate preoxygenation were: firstly, bearded male (odds ratio [OR] of 9.1 [2.7-31.4] P<0.001); secondly, beardless male (OR 2.4 [1.6-3.4] P<0.001), thirdly, ASA score of 4 (OR 9.1 [2.6-31.2] P<0.015); fourthly, ASA score of 2-3 (OR 2.4 [1.6-3.4] P<0.015); fifthly, lack of teeth (OR 2.4 [1.2-4.5] P<0.006), and lastly age>55 years (OR 1.8 [1.2-2.7] P<0.005). CONCLUSION: Inadequate preoxygenation, defined as an FEO2 <90% despite 3-min tidal volume breathing, was a common occurrence. The predictive factors share an overlap with those previously identified for difficult mask ventilation.