Unusual Listeria monocytogenes peritonitis in peritoneal dialysis patient with liver cirrhosis: a case report and review of literature.

Spontaneous Listeria peritonitis is well described in liver failure, but is uncommon in peritoneal dialysis patients. Atypical cases where peritonitis symptoms develop after systemic manifestations are rare and challenging for diagnostic. A 57-year-old peritoneal dialysis patient with history of ethylic cirrhosis was admitted after epileptic seizure. On admission, patient was soporous without signs of peritonitis and meningitis. Patient's peritoneal effluent was clear, with normal leukocytes. Cranial CT scan showed no abnormalities. Laboratory exams revealed positive inflammatory syndrome. Despite antibiotic therapy, next day, symptoms aggravated with coma development. Peritoneal effluent became cloudy and its leukocyte count rose up. Effluent microscopy revealed Gram-positive bacilli. Patient was started with intraperitoneal Vancomycin and Amikacin. Patient's clinical condition deteriorated with lethal outcome. Post-mortem analysis of effluent and blood culture showed growth of L. monocytogenes. Apart from idiopathic etiology, goat-milk curd, that patient had started consuming 10 days before admission, could theoretically be considered as possible infection vehicle. L. monocytogenes peritonitis in peritoneal dialysis patients is rare, but must be considered in immunocompromised or patients with concomitant liver failure, especially after Gram-positive bacilli identification in peritoneal effluent. In case of suspiscion of Listeria peritonitis, Ampicillin should be initiated, because bacteria often poorly respond to currently recommended empiric regimens.

Relative risk for cardiovascular morbidity in hemodialysis patients regarding gene polymorphism for IL-10, IL-6, and TNF.

Uremia-related inflammation is prone to be a key factor to explain high cardiovascular morbidity in hemodialysis patients. Genetic susceptibility may be of importance, including IL-10, IL-6, and TNF. The aim was to analyze IL-10, IL-6, and TNF gene polymorphisms in a group of hemodialysis patients and to correlate the findings with cardiovascular morbidity. This study included 169 patients on regular hemodialysis at Zvezdara University Medical Center. Gene polymorphisms for IL-10, IL-6 and TNF were determined using PCR. These findings were correlated with the cardiovascular morbidity data from patient histories. Heterozygots for IL-10 gene showed significantly lower incidence of cardiovascular events (p = 0.05) and twice lower risk for development of myocardial infarction, but experienced twice higher risk for left ventricular hypertrophy. Regarding TNF gene polymorphism, patients with A allele had 1.5-fold higher risk for cerebrovascular accident and cardiovascular events and 2-fold higher risk for hypertension and peripheral vascular disease. Patients with G allele of IL-6 gene experienced 1.5-fold higher risks for cerebrovascular accident. We need studies with larger number of patients for definitive conclusion about the influence of gene polymorphisms on cardiovascular morbidity in hemodialysis patients and its importance in everyday clinical practice.

SU-E-T-197: A Comprehensive Variance Reporting System and an Analysis of Variances Reported at Our Institution.

PURPOSE: It is essential for radiation oncology departments to have comprehensive patient safety and quality programs. Two years ago we undertook a systematic review of our safety/QA program. Existing policies were updated and new policies created where necessary. One crucial component of any safety/QA program is continually updating it based on current information, the 'check' and 'act' portions of the Deming Cycle. We accomplished this with a transparent variance reporting system and a safety/QA committee reviewing and acting on reported variances. METHODS: With 5 radiation oncology centers in our institution, we needed to devise a system that would allow anyone to report a variance and provide our QA committee the ability to review variances system-wide. We developed the system using web-based tools. The system allows individuals to report variances, anonymously or named, specify the nature of the variance and indicate the tools used to identify the variance. RESULTS: In 2011, 285 variances were reported, 102 were reported by physicists, 86 anonymously, 71 by therapists and 26 by dosimetrists. We realized the need to develop clear classifications for variances. We added a high priority category, defined as variances which resulted in or had the potential to result in harm to a patient or when a policy is purposely overridden. Of the 285 variances reported, 5 were high priority. We created a process variance category, defined as variances where a specific clinical process is not followed. Of the 285 reported variances 155 were process variances. CONCLUSIONS: Reporting of variances through a centralized database is central toward developing a robust patient safety/quality assurance program. Anonymous reporting fosters a non-punitive environment, and promotes the 'safety culture'. The goal of such a system is to review trends in clinical processes and ultimately to improve safety/quality by reducing variances associated with these processes.

Transplantation in patients with multiple myeloma: a multicenter comparative analysis of peripheral blood stem cell and allogeneic transplant.

We performed a multicenter comparative analysis of autologous peripheral blood stem cell transplantation (PBSCT) and allogeneic bone marrow transplantation (alloBMT) in multiple myeloma. Forty-eight consecutive patients received either PBSCT (24 patients) or alloBMT (24 patients) at one of three institutions in the study group. Preparatory regimens consisted of melphalan and total body irradiation (TBI) or melphalan alone in the PBSCT group. The alloBMT group received one of four regimens: cyclophosphamide and TBI; cyclophosphamide, VP-16 and 1,3-bis(2-chloroethyl)-1-nitrosourea (CVB); busulfan and cyclophosphamide (BU/CY) and total marrow irradiation (TMI); or melphalan and TBI. Procedure-related mortality was 12.5% for the PBSCT group and 25% for the alloBMT group. With a median follow-up for survivors in the PBSCT and alloBMT groups of 11 months (range, 4-46) and 15 months (range, 2-84 months), respectively, there was no significant difference in median overall survival (33.5 versus 38.6 months, p = 0.7637) or event-free survival (16.7 versus 31 months, p = 0.8450). There was, however, a plateau in survival at 40% in the alloBMT group. No plateau in survival was seen in the PBSCT group. Clinical relapses occurred as late as 39 months posttransplant. Patients have survived up to 28 months postrelapse.

Accelerated fractionation radiotherapy and concomitant chemotherapy in patients with stage IV inoperable head and neck cancer.

BACKGROUND: Stage IV inoperable head and neck cancer has a 2-year mortality rate of greater than 70% when treated with conventional radiotherapy. A Phase II study was undertaken to evaluate the effects of concomitant chemotherapy and accelerated, interrupted, twice-a-day radiotherapy on tumor response, locoregional control, survival, and morbidity. METHODS: Thirty-four patients with Stage IV inoperable squamous cell carcinoma of the head and neck and a minimum follow-up of 36 months were evaluated. Concomitant chemoradiotherapy was administered during weeks 1, 3, and 5 (with planned breaks during weeks 2 and 4), consisting of cisplatin 60 mg/m2 on day 1, continuous 5-day infusion of 5-fluorouracil, 750 mg/m2 per day, and radiotherapy, 2 Gy twice a day, more than 6 hours apart, followed by 3 days of radiation therapy alone (final "boost") in week 6, for a total dose of 70 Gy and treatment duration of 5 1/2 weeks (38 days). RESULTS: Twenty-seven patients achieved a clinical complete response (82%). Actuarial locoregional control at 3 years was 73% and the actuarial 3-year survival probability, including all deaths, was 38%. All locoregional recurrences were manifested within 12 months. Of the 20 deaths, 12 were tumor related (locoregional and/or metastatic), 3 were treatment related, and 5 were due to other causes. Acute toxicity consisted of grade 3 mucositis and dysphagia and grade 2-3 leukopenia, not requiring treatment interruption or cessation. CONCLUSION: Concomitant accelerated radiation therapy and chemotherapy is a feasible treatment approach in this prognostically poor patient population, yielding dramatic tumor responses and impressive locoregional control at the cost of somewhat increased acute toxicity. Although serious late complications have not been observed, caution should be exercised in view of the relatively short follow up.

Nicotinamide pharmacokinetics in patients.

Pharmacokinetic analyses were performed on blood samples of 12 patients undergoing treatment with nicotinamide, hyperthermia and radiation therapy for a variety of recurrent/metastatic cancers. Escalating oral doses of 3, 4, 5, 6 and 10 g of nicotinamide showed a linear relationship between maximum recorded plasma concentrations and the dose in grams (correlation coefficient, r = 0.91). Maximum plasma levels were observed by 30 min in most patients ingesting up to 6 g of nicotinamide. In marked contrast, five out of six patients ingesting 10 g of nicotinamide demonstrated increasing plasma levels at least up to 3 h post-ingestion. Doses up to 6 g were well tolerated and resulted in average maximum recorded plasma levels (mean +/- 1 SEM) of 156.4 +/- 33.6 micrograms/ml. Doses of 10 g were generally not well tolerated, but a high plasma level was maintained on average for at least 4 h. Plasma concentrations of the above order have been previously associated with maximal enhancement of radiation damage in mouse tumor models. This suggests that radiosensitization can be expected to occur in human tumors following oral administration of a safe and well tolerated dose of 6 g. However, at higher doses (i.e., 10 g), the pharmacokinetics, and perhaps radiosensitization, may differ markedly.

Local superficial hyperthermia in combination with low-dose radiation therapy for palliation of locally recurrent breast carcinoma.

From September 1984 through March 1987, 30 patients with locally recurrent breast carcinoma who had been heavily pretreated with conventional modes of therapy (radiation, chemotherapy, and hormonal therapy) were entered into a phase II study of hyperthermia and low-dose irradiation. The purpose of the study was to determine the feasibility, effectiveness, and morbidity of this treatment combination. Radiation therapy was administered twice weekly, 4 Gy per fraction, to a total dose of 32 Gy, with 6 or 9 MeV electrons depending on the thickness of the lesions. Hyperthermia generated by microwave frequencies of 200 to 700 MHz was administered immediately after radiation therapy, with a time and temperature aim of 60 minutes at 43 degrees C. Complete response (CR) was achieved in 17 patients (57%), and partial response (PR) in 11 patients (36%). Response was positively correlated with tumor size; lesions less than 5 cm in diameter achieved CR significantly more frequently than lesions greater than or equal to 5 cm (P less than .001). Eighty percent of the complete responders continued to experience sustained control of the treated site from 6 to 32 months but showed evidence of progressive systemic disease or locoregional progression to the adjacent untreated sites, reflecting the natural history of this disease and extensive dermal lymphatic permeation. True recurrence within the treated volume occurred in three patients. Nonhealing ulceration developed in nine patients and seven of those were associated with persistent tumor. This study confirms the palliative value of hyperthermia in combination with radiotherapy for previously irradiated recurrent chest wall tumors and sets the scene for its comparative clinical evaluation against radiation therapy alone as first line therapy for locally recurrent breast carcinoma.

Diagnosis of the unstable detrusor: comparison of an incremental and continuous infusion technique.

Incremental infusion cystometry and continuous infusion urethrocystometry were performed on sequential days in 52 patients with an unstable detrusor. Bladder compliance was the same in both techniques. However, continuous infusion urethrocystometry demonstrated involuntary detrusor contractions in three times as many patients as incremental infusion cystometry. It is concluded that in the supine position, medium rate continuous infusion urethrocystometry is more discriminating than rapid rate incremental infusion cystometry with a Lewis recording cystometer in the demonstration of involuntary detrusor contractions.