The Utility of Early Broncholaveolar Lavage in Prolonged Neutropenic Patients with Pulmonary Nodules
Notice bibliographique
Résumé
Abstract Introduction Management of patients with hematologic malignancies (HM) post induction chemotherapy or allogeneic hematopoietic cell transplant (Allo HSCT) is often complicated by neutropenic fever associated with nodular pulmonary infiltrates, and may result in acute respiratory failure and death. The presence of a halo sign in a neutropenic patient with nodular infiltrates is highly suggestive of invasive pulmonary aspergillosis (IPA). Fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) is the preferred procedure for identifying the infectious aetiology of pulmonary infiltrates in post Allo-HSCT or post chemotherapy in HM patients with neutropenic fever. The diagnostic value of FOB with BAL in such patients is controversial, however, it has been suggested that the microbiologic yield from FOB and BAL is higher when bronchoscopy is performed within 24 hours of presentation, allowing subsequent BAL-guided therapeutic adjustment. With a view towards improving health care resource utilization, we re-evaluated this diagnostic strategy. Methods We conducted a prospective observational study of 100 participants with the following diagnoses: acute myeloid leukemia (AML), 76%; myelodysplastic syndrome (MDS), 9%; acute lymphoblastic leukemia (ALL), 6%; and acute promyelocytic leukemia (APL), 6%. One hundred sequential patients who underwent FOB after August 2016 and provided informed consent, were enrolled and followed for 30 days. Sixty six percent were admitted for induction chemotherapy; 17% for re-induction chemotherapy; 10% for conditioning pre- Allo- HSCT; 4% for consolidation chemotherapy; and 3% for other therapy. Data collected included patients' demographics, dates of onset of fever and of baseline chest CT scan, findings on CT scan, dates of initiation of empirical antibiotic and antifungal therapy, BAL results, and the impact on antimicrobial choices. Other outcomes included transfer to ICU and death. We assessed the utility of performing early FOB (within 48 hours of performing a low dose chest CT scan) vs Late FOB (after 48 hours from low dose chest CT scan) in post-chemotherapy HM and Allo-HSCT patients. Results Of the 100 enrolled participants, 61 and 39 underwent early and late FOB, respectively (Figure-1: Table of results) . A positive BAL Galactomannan was observed in 7 (11.5%) early FOB cases, compared to only 1 (2.6 %) in late FOB case (p=0.15), with a subsequent impact on the choice of antifungal in 6 cases (9.8 %) and 1 case (2.6 %), respectively (p=0.042). BAL culture was positive in 2 cases (3.3%) in the early FOB group, compared to only 1 case (2.6%) in the late FOB group (p=0.99). The choice of antibiotic was influenced by BAL results in 1 of the 2 early FOB cases. Eight (13.3%) and 7 (17.9%) of early and late FOB patients, respectively, were transferred to the ICU (p=0.57); and 6 (9.8%) of the early FOB and 3 (7.7 %) of late FOB patients died (p=0.99). Conclusion The diagnostic yield of early FOB was greater than that of late FOB, as assessed by GM positivity, and more frequently permitted targeted antifungal therapy. There was no difference in the rate of antibiotic use between the two groups. Download : Download high-res image (119KB) Download : Download full-size image Disclosures Gupta: Incyte: Consultancy, Research Funding; Novartis: Consultancy, Honoraria, Research Funding. Schuh: Amgen: Consultancy, Honoraria. Yee: Astex: Research Funding; Oncoethix: Research Funding; Karyopharm: Research Funding; Novartis Canada: Honoraria; Celgene Canada: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,003 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
| Bibliométrie | 0,001 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,000 |
| Communication savante | 0,001 | 0,001 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,001 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».