Trey Spencer

Pathogenic Aspergillus Species Recovered from a Hospital Water System: A 3-Year Prospective Study

Nosocomial aspergillosis, a life-threatening infection in immunocompromised patients, is thought to be caused primarily by Aspergillus organisms in the air. A 3-year prospective study of the air, environmental surfaces, and water distribution system of a hospital in which there were known cases of aspergillosis was conducted to determine other possible sources of infection. Aspergillus species were found in the hospital water system. Significantly higher concentrations of airborne aspergillus propagules were found in bathrooms, where water use was highest (2.95 colony-forming units [cfu]/m(3)) than in patient rooms (0.78 cfu/m(3); P=.05) and in hallways (0.61 cfu/m(3); P=.03). A correlation was found between the rank orders of Aspergillus species recovered from hospital water and air. Water from tanks yielded higher counts of colony-forming units than did municipal water. An isolate of Aspergillus fumigatus recovered from a patient with aspergillosis was genotypically identical to an isolate recovered from the shower wall in the patients room. In addition to the air, hospital water systems may be a source of nosocomial aspergillosis.

Thalidomide in the management of multiple myeloma.

A phase II trial of thalidomide in refractory multiple myeloma was initiated using a dose schedule that escalated from 200 mg/d to 800 mg/d. More than two thirds of patients had cytogenetic abnormalities and more than half had received at least two cycles of high-dose therapy. A paraprotein reduction of at least 25% was noted in 37% of patients and 14% had either a complete remission (CR) or a near CR. No treatment-related mortality was observed. With a median follow-up of almost 2 years, the 2-year event-free survival (EFS) and overall survival (OS) estimates were 15% and 60%, respectively. A reduction of paraprotein levels by greater than 50% was associated with a significant reduction in bone marrow plasmacytosis and beta(2)-microglobulin levels (beta2M), and greater recovery of hemoglobin and IgM levels compared to patients whose paraprotein was reduced by a lesser degree. Responses occurred more frequently among patients with a lower plasma cell labeling index (PCLI) and normal cytogenetics. Comparing response and survival by thalidomide dose for low- and high-risk groups revealed a thalidomide dose-response effect in the high-risk group of patients. The virtual absence of myelosuppressive toxicity, except in heavily pretreated patients with compromised bone marrow function, suggests that thalidomide is an ideal agent to be used in combination with cytotoxic agents and dexamethasone. Several trials are currently underway at the Arkansas Myeloma and Transplantation Research Center to determine the clinical benefit of adding thalidomide to post-transplant salvage therapy and in the upfront management of patients.

Predicting long-term (≥ 5 years) event-free survival in multiple myeloma patients following planned tandem autotransplants

Summary. Although outcome in multiple myeloma (MM) patients has improved significantly with the introduction of autotransplants (AT), the curability of this approach remained to be demonstrated. Therefore, we analysed outcome and prognostic factors using a logistic regression model in 515 consecutive newly diagnosed and previously treated patients intended to receive melphalan‐based tandem transplants with follow up of ≥ 5 years. One quarter ofpatients had event‐free survivals (EFS) ≥ 5 years with no further relapses seen after 7 years (46 patients on plateau). On multivariate analysis, factors associated with EFS ≥ 5 years were absence of chromosome 11 and 13 abnormalities (odds ratio: 6·1), ≤ 12 months of preceding standard‐dose therapy (SDT) (OR: 2·6) and β‐2 microglobulin (B2M) level ≤ 2·5 mg/l at time of first AT (OR: 1·7). Patients with only favourable variables (25%) had a 7‐year EFS in excess of 35%, compared with 15% and 10%, respectively, with one (43%) or two unfavourable variables (27%), and 0% for 5% of patients with three unfavourable variables (P < 0·0001). Using a 1‐year landmark analysis to allow for guaranteed time and thereby excluding early treatment failures, attaining a complete remission (CR) had no significant effect on long‐term survival. Our data are consistent with cure in MM patients with a CR duration ≥ 7 years and re‐establishment of a monoclonal gammopathy of undetermined significance (MGUS) phase in those with persistent evidence of disease post transplantation, but without disease progression ≥ 7 years.

Changes in Ultrasonographic Echogenicity and Visibility of Needles with Changes in Angles of Insonation

PURPOSE To objectively compare the echogenicity of several types of needles at clinically important angles of insonation. MATERIALS AND METHODS Four commercial needles (Echotip, Mini-Stick, Echo-Coat, Surflo) and a prototype dimpled needle were tested in a liver phantom at angles of insonation ranging from 90 degrees to 15 degrees. Photodensity measurement determined echogenicity levels in arbitrary echogenicity units (EU). RESULTS At 90 degrees angles of insonation all needles were easily seen (60-76 EU) and echogenic levels were similar (P =.264). All values decreased with angulation. From the 35 degrees to 15 degrees angles, the prototype and Echotip needles were superior (P <.05). At 15 degrees the values were 43 EU for the prototype needle, 40 EU for the Echotip needle, 9.0 EU for the Echo-Coat needle, and 5.0 EU for the Surflo needle. CONCLUSION With angulation, all needles drop in echogenicity, with prototype dimpled and Echotip best maintaining visibility at clinically important angles.

Cytotoxic chemotherapy following tandem autotransplants in multiple myeloma patients.

Summary. High‐dose treatment (HDT) with autologous stem cell transplant (ASCT) is superior to conventional chemotherapy in multiple myeloma. However, relapses eventually occur, especially in the presence of unfavourable cytogenetic abnormalities, high β‐2 microglobulin levels prior to transplant and extensive prior treatment. Cytotoxic consolidation chemotherapy, following tandem transplants (TT), was given to 75 myeloma patients with at least one poor prognostic factor. When their outcome was compared with that of 75 matched controls who received dexamethasone ± interferon post TT, no event‐free or overall survival advantage was observed. Other approaches may be required to improve survival in multiple myeloma.