ABSTRACT
Febrile neutropenia (FN) is a common dose-limiting toxicity of chemotherapy, with a profound impact on the evolution of patients with cancer, due to the potential development of serious complications, mortality, delays, and decrease in treatment intensity. This article seeks to present an updated clinical guideline, with recommendations regarding the diagnosis, prevention, and treatment of febrile neutropenia in adults with solid tumors. The aspects covered include how to properly approach the risk of microbial resistances, epidemiological aspects, considerations about the initial empirical approach adapted to the risk, special situations, and prevention of complications. A decision-making algorithm is included for use in the emergency department based on a new, validated tool, the Clinical Index of Stable Febrile Neutropenia, which can be used in patients with solid tumors who appear stable in the initial phase of neutropenic infections, and can help detect those at high risk for complications in whom early discharge must be avoided.
Subject(s)
Antineoplastic Agents/adverse effects , Febrile Neutropenia/prevention & control , Granulocyte Colony-Stimulating Factor/therapeutic use , Neoplasms/drug therapy , Practice Guidelines as Topic/standards , Severity of Illness Index , Adult , Clinical Trials as Topic , Disease Management , Febrile Neutropenia/chemically induced , Febrile Neutropenia/diagnosis , Humans , Prognosis , Risk Assessment , Societies, MedicalABSTRACT
The objective of this study was to analyze the clinical, immunitary and virological implications of an elevated erythrocyte sedimentation rate (ESR) in HIV-positive patients. A retrospective crossover study of 350 HIV-positive patients undergoing periodic evaluations (942 follow-ups) at the outpatient service of the Division of Infectious Diseases of the Fundación Jiménez Díaz in Madrid was carried out from January 1993 to July 1998. The relationship between the ESR (cut-off point: 20 mm/h), the clinical status (symptomatic or asymptomatic), the immune status (CD4, cut-off point: 200 cells/microl), and viral status (viral load, cut-off point: 3 log) of the patients was analyzed. Information on other possible confounding factors was also collected. It was found that in 667 cases (71%), the ESR was normal and in 275 (29%) it was >20 mm/h. In the univariate analysis, a statistically significant relation was found between the ESR and the clinical, immune and viral status of the patients: a normal ESR was associated with a CD4 >200 cells/ml, viral load <3 log, and an asymptomatic clinical status (p <0.05). A significant inverse relation was found between ESR and hematocrit (p <0.05, CI 95%: 3.87-5.1) and between ESR and gammaglobulin (p <0.05). The multivariate analysis did not show a significant relation between ESR and clinical status (OR: 1.98, IC95%: 1-3.9), nor between ESR and the CD4 level (in the case of hematocrit 42-43%, OR: 0.755, p >0.005). However, in patients with low hematocrit the risk of having CD4 < or = 200 cells/microl when the ESR was >20 mm/h was significant (OR: 9.34, IC95%: 4.56-11.35). When adjusting for clinical factors such as age, sex, gammaglobulin, hematocrit and co-infection with hepatitis C or B virus, we did not find a relation between the ESR and the clinical, immune or viral status of the seropositive patients. We believe that it is not necessary to determine the ESR when monitoring HIV-positive patients, since it does not appear to be a good marker for a deterioration in clinical, immune or viral status.
Subject(s)
HIV Infections/blood , HIV Infections/virology , Viral Load , Adult , Aged , Analysis of Variance , Blood Sedimentation , Cross-Sectional Studies , Female , HIV Infections/immunology , HIV Seropositivity , Humans , Logistic Models , Male , Middle Aged , Retrospective StudiesABSTRACT
BACKGROUND: The main question in the mind of a physician about to treat a Hispanic patient for facial cosmetic improvement using laser resurfacing is: How safely can I predict an even pigmentation after the procedure? Specific studies in Hispanic patients to establish the safety of laser skin resurfacing with the UltraPulse carbon dioxide laser do not exist. OBJECTIVE: To establish the degree of safety for this procedure in this patient population. METHODS: Thirty-six volunteer patients were treated for facial rhytides and acne scars. A Coherent UltraPulse 5000c carbon dioxide laser was used. The guidelines for the minimal mechanical trauma technique were followed. Monthly follow-up for 6 months was done, except in three patients. RESULTS: Cosmetic improvement was achieved in the vast majority of patients. No cases of persisting erythema, hyperpigmentation, or hypopigmentation were seen at 90 days or at the completion of the study. CONCLUSION: This appears to be a safe procedure for this patient group following the criteria of minimizing mechanical trans-operative trauma and close follow-up as described in this paper.
