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The goalless point spread betting rules on blackjack with Chelsea on the road last time out granted at bayern vs arsenal betting preview a point for Wolverhampton second time within their recent five winless games in the PL schedule. Even though making surprising wins were a thing for the host last season, defeating Arsenal is easier said than done in their current form. They are seven points behind the Gunners on the table this term as it stands. Apart from the FA Cup loss on the road to Southampton, Arsenal has lost none of their last eight clashes in their schedule. Their previous defeat in PL was in December to Everton away from home. The Gunners are on a six-game unbeaten run in the league, following a win on the road against Southampton last time out in their schedule. Wolves have secured the mid-table position along with the visitor and are just 7 points behind the latter on the table as it stands this season.

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This study showed that in younger and older adults, IIV4 had a similar safety profile as the licensed IIV3 and that including a second B strain lineage in IIV4 provided superior immunogenicity for the added B strain without affecting the immunogenicity of the three IIV3 strains. Current trivalent influenza vaccines contain a single B strain, but since the s, two distinct genetic lineages of influenza B virus, Victoria and Yamagata, have been co-circulating worldwide, both of which are responsible for influenza illnesses.

For example, in the US, in half of the Northern Hemisphere influenza seasons between — and —, the B-strain lineage included in the trivalent vaccine was not the same as the predominant circulating B lineage. Influenza B disproportionately affects children and older adults, although it can cause illness as severe as influenza A in all age groups.

Here, we present the results of a study designed to confirm these observations in younger and older adults and to demonstrate lot-to-lot consistency of three commercial batches of the — Northern Hemisphere formulation of IIV4. We also describe antibody persistence up to one year post-vaccination and how vaccination the previous year and high-risk conditions affect the vaccine's immunogenicity.

A total of participants completed up to month 12, and the study ended on October 23, The main reason for early discontinuation was voluntary withdrawal unrelated to an adverse event AE. Disposition of participants in the study. All but three participants were vaccinated. Reasons for discontinuation included a severe adverse event SAE , voluntary withdrawal not for an adverse event AE , noncompliance with the study procedures, and loss to follow-up LFU.

Also, in each of the previous three influenza seasons —, —, and — , roughly one-third of participants in each group had received the seasonal influenza vaccine and 0. Although vaccination rates were balanced between the study groups, the rates were consistently lower in younger participants approx.

Values are for all participants vaccinated. Values are for all participants vaccinated with available pre- and post-vaccination HAI titers. Values are for all subjects vaccinated and with data available. Non-inferiority and superiority of post-vaccination day 21 HAI antibody responses for pooled quadrivalent vs. Values are for all participants completing the study according to protocol. The SN antibody response was examined in a randomly selected subset of participants as part of an exploratory analysis.

Values are for all participants with pre- and post-vaccination seroneutralization titers available. Within each age group, proportions with solicited reactions or grade 3 solicited reactions were similar between IIV3 and IIV4. No SAEs considered related to vaccination were reported up to the end of the safety follow-up at month 6.

One participant left the study before the end of the safety follow-up period due to an unrelated SAE. The participant had a history of convulsive seizure before enrollment in the study, and the event was not considered to be related to vaccination. This study confirmed that for younger and older adults, adding a second B strain lineage to IIV3 to produce IIV4 provides a superior response to the added B strain lineage without affecting the antibody response induced by the original three vaccine strains.

Despite relatively high seroprotection rates at baseline, vaccination with IIV4 increased GMTs from baseline for all four vaccine strains by at least 4-fold in older adults and by at least 7-fold in younger adults. As found in previous studies and concluded in a recent meta-analysis of clinical trials.

As found in other studies of inactivated influenza vaccines, 18,19 reactogenicity was lower in older adults than in younger adults. Consistent with other studies, antibody responses were also lower in older adults. Very similar results were found in a study of younger adults vaccinated with the — formulation in France and Germany. Also, as in the current study, a study performed in Australia and the Philippines found robust, equivalent antibody responses to three lots of the — Northern Hemisphere formulation of IIV4 in children, adolescents, and younger adults.

Rates of serious influenza illness are known to be higher and vaccine immune responses lower in older adults because of immunosenescence, the age-related decline of the immune system. This study showed that HAI antibody titers to each strain were lower in participants vaccinated with the previous season's influenza vaccine. Some authors have suggested, however, that serologic results overestimate protection by IIVs, and they argue that fixed HAI titer cut-offs, at least alone, are not appropriate for estimating protection.

This strengthens the conclusion that, in most participants, IIV4 induced protective antibodies against all four vaccine strains of influenza. Because a correlate of protection based on SN titer has not been established, these results cannot be used to estimate or compare efficacy between vaccines. Quadrivalent influenza vaccines are gradually replacing trivalent vaccines.

The current study confirmed the immunogenicity, safety profile, and lot-to-lot consistency of the — Northern Hemisphere formulation of IIV4. It also showed that the vaccine should provide good protection against all four included strains of influenza, even in individuals with high-risk conditions and individuals vaccinated the previous year for seasonal influenza.

By providing broader coverage and a better match to circulating B strains, IIV4 should help reduce the public health impact of influenza. The study was approved by each institution's ethics committee or review board. The conduct of this trial was consistent with the standards established by the Declaration of Helsinki and complied with the International Conference on Harmonization Guidelines for Good Clinical Practice as well as all local and national regulations and directives.

All participants provided written informed consent to be included in this trial. Women were excluded if they were pregnant, lactating, or of childbearing potential and not using an effective method of birth control. Prior to enrollment, all participants were assessed for preexisting conditions and illnesses. Participants were considered to be at risk for influenza-related complications if they had at least one past or current high-risk condition as defined by the US Centers for Disease Control and Prevention.

All vaccines were thimerosal-free, inactivated, split-virion, and each 0. The randomization list was generated by computer using the permuted block method with stratification by site and age group. Participants were assigned via an interactive voice or web response system. The IIV group was single-blinded because it was delivered in different packaging than the investigational products, although it was presented to participants in an identical 0.

For all participants, immunogenicity was assessed in a blinded manner. HAI titers were also assessed at baseline day 0 , at the end of the safety follow-up period month 6 , and at month HAI titers were measured as described previously. Briefly, the highest serum dilution resulting in complete inhibition of hemagglutination was determined for duplicates of each sample.

The HAI antibody titer for each sample was calculated as the geometric mean of the reciprocal of the duplicate values. The lower limit of quantitation was set at the reciprocal of the lowest dilution used in the assay 10 , and the upper limit of quantitation as the highest dilution used in the assay 10, GMTs, geometric means of individual titer ratio of post-vaccination vs.

SN titers were measured using the World Health Organization procedure 35 in 50 randomly selected participants in each age and vaccine group. Briefly, serially diluted, heat-inactivated human serum samples were mixed with a fixed amount of challenge virus prior to the addition of Madin-Darby canine kidney cells. Challenge virus strains were the same as those in IIV4.

After overnight incubation, the viral nucleoprotein production in infected cells was measured by enzyme linked immunosorbent assay using a monoclonal antibody specific to influenza A or influenza B nucleoprotein. The lower limit of detection was the reciprocal of the lowest dilution used in the assay , and the upper limit of detection was the reciprocal of the highest dilution used in the assay , All other reactions and AEs were considered grade 1 for not interfering with activity, grade 2 for some interference with activity, and grade 3 for significant, preventing daily activity.

For each age group, approximately participants were to be enrolled in each IIV4 lot group and participants in each IIV3 group participants in total. This produced an overall power i. Missing or incomplete data were not replaced, with the exception that all HAI titers under the lower limit of quantitation 10 were assigned a value of 5 and all HAI titers above the upper limit of quantitation 10, were assigned a value of 10, IIV3 were assessed in all participants who completed the study according to protocol.

IIV3 was assessed primarily in all vaccinated participants. Immunogenicity measures were reported for all randomized participants who received the study vaccine with available pre- and post-vaccination HAI titers. Non-inferiority and superiority were assessed as previously described. Safety is presented using descriptive statistics and assessed in all participants who received a study vaccine according to the vaccine actually received.

Vandermeulen acts as investigator of vaccine trials for which the KU Leuven obtains research grants to conduct the vaccine trials. Van Damme acts as investigator of vaccine trials for which the University of Antwerp obtains research grants to conduct the vaccine trials. Sesay, C. Salamand, and S. Pepin are employees of Sanofi Pasteur. All other authors declare no conflict of interest.

Medical writing was provided by Dr. National Center for Biotechnology Information , U. Memory loss is cited as the most common feature; this can develop to confusion and then finally to unconsciousness. On magnetic resonance imaging MRI of the head, there are hyperintense lesions noted, and these are referred to as post-transplant acute limbic encephalitis PALE.

For a confirmed diagnosis to be made, the gold standard would be tissue biopsy. Foscarnet and ganciclovir are the recommended treatments and should be started as soon as possible following symptoms suggestive of HHV6 Ogata et al. Pneumocystis jirovecii PCP is an atypical fungus that causes severe pneumonia in immunocompromised patients. Recognized as a protozoan initially and reclassified in as a fungus, pneumocystis cannot be propagated in culture, and few treatment options exist for those with PCP pneumonia.

The accepted belief for contracting PCP was as a reactivation of a latent virus. However, evidence suggests that PCP may occur following recent infection and may also be transmitted person to person. Many hospital policies do not mandate isolation, but a pragmatic approach is often taken, and HSCT recipients should avoid exposure to those with proven PCP Gea-Banacloch et al. The most effective first-line prophylaxis is a combination of trimethoprim-sulfamethoxazole given in a variety of doses dependent upon your local policy.

If the patient develops any sensitivity to these drugs, then alternatives are pentamidine nebulizer, atovaquone and oral dapsone. If dapsone is to be used, then glucose 6-phosphate dehydrogenase G6PD deficiency should be ruled out.

Nebulized pentamidine can cause bronchospasm, and patients need to be informed of this prior to inhalation. Atovaquone is generally well tolerated but poorly absorbed unless taken with a high fat diet. Those with PCP present with symptoms of subtle onset dyspnoea, a low-grade temperature and a non-productive cough, and when examined, the chest is clear on auscultation.

However, this may rapidly change with the onset of hypoxia requiring admission to a critical care unit. Imaging of the chest with X-ray reveals bilateral perihilar interstitial infiltrates that become increasingly homogenous and diffuse as the disease progresses. Computed tomography CT scans show extensive ground-glass attenuation or cystic lesions Thomas and Limper Due to the difficulties of culturing samples, the diagnosis of PCP is made through microscopic examination of sputum or bronchoalveolar fluid or by polymerase chain reaction PCR.

If PCP pneumonia is suspected, treatment is with trimethoprim-sulfamethoxazole and the addition of systemic steroids to reduce the inflammatory lung processes. For those that are intolerant to trimethoprim-sulfamethoxazole, then atovaquone or a combination of clindamycin with primaquine is licenced for use Chen et al.

Varicella zoster virus VZV infection or chickenpox is usually a childhood disease, and transmission is either by inhalation of respiratory secretions or direct physical contact. Herpes zoster is grouped painful vesicular lesions that can affect several dermatomes in immunocompetent people.

Complications such as post-herpetic neuralgia, skin scarring and bacterial superadded infection are factors in morbidity Steer et al. If the immunocompromised patient is in contact with an individual with VZV infection varicella or HZ , they are at significant risk of developing varicella themselves and will require prompt action from the transplant team Styczynski et al. Immunization of family contacts especially children is advised to reduce risk.

Risk factors include unrelated donors, myeloablative conditioning, graft versus host disease GvHD and the use of systemic corticosteroids. Pain in the back or abdomen with distension and a rise in ALT are seen in approx. The rash may spread to more than 1—3 dermatomes in patients with visceral dissemination and is more difficult to treat. The best method for diagnosing VZV is by polymerase chain reaction PCR testing of blood or a glass slide touched to a vesicle as the DNA is highly specific and sensitive.

Treatment for those who have been exposed to a healthy individual with VZV infection is advised depending upon the serostatus of the recipient and availability of drug. If this passive immunization medication is unavailable, then high-dose aciclovir, valaciclovir or famciclovir nucleoside analogues that interfere with viral thymidine kinase activity can be employed. Post treatment for VZV, it is advisable to restart prophylactic aciclovir if this was previously discontinued.

It currently has more than 50 serotypes and is divided into six subgroups A—F La Rosa et al. Adenovirus is more prevalent in children but is becoming more prevalent in adults in the transplant population. Adenovirus is spread by aerosolization or the faecal-oral route with approx. Risk factors include mismatched or unrelated donor, acute graft versus host disease aGvHD and isolation of ADV from multiple sites Ljungman et al.

In healthy individuals, infection is self-limiting causing conjunctivitis and upper respiratory tract, urinary tract or gastrointestinal infections and remains latent in lymphocytes post exposure. Chakrabarti et al. Those with viral-like symptoms usually have a full screen of virology requested that will include ADV. Samples taken from nasopharyngeal, rectal and corneal secretions, urine and unfixed biopsy tissue can be examined with PCR to assess viral load.

Cidofovir is first-line treatment and is a monophosphate nucleotide analogue of cytosine. Patients require hyper-hydration and oral probenecid pre, during and post cidofovir to protect nephrons. An active immunization of donors and early post-transplant vaccination of recipients have been suggested to avoid HBV reactivation. Donors should optimally receive more than one immunization, a rather high Ag dose and a highly immunogenic vaccine Lindemann et al. The use of chemotherapy and immunosuppression can reactivate latent hepatitis B.

Transplantation of HBV-negative patients with stem cells from an infected donor HBsAg positive is associated with a high risk of transmission; some patients develop chronic hepatitis B. Post-transplant HBV infection can arise in different ways. Infection may also occur during the transplantation process, from an infected HSC donor or rarely from infected blood products. At the time of immune reconstitution or during reduction of immunosuppressive drugs, a flare is given by a rise in serum aspartate aminotransferase AST and alanine aminotransferase ALT levels.

Another clinical symptom is jaundice and fulminant liver failure as a result of HBV liver-related mortality Lau et al. Several studies in the literature describe prevention of HBV reactivation in the setting of immunosuppression. HBV reactivation has been variably reported as ALT elevation above upper limit of normal or by increases from baseline. The nucleoside analogue antiviral drugs lamivudine, adefovir, telbivudine, entecavir and tenofovir may all be of potential use in the prevention of HBV reactivation in such patients.

The majority of reports describe the use of lamivudine or entecavir, and both drugs appear to reduce the incidence of HBV reactivation. However, entecavir and potentially tenofovir may be superior to lamivudine because of more potent viral suppression and lower risk of antiviral resistance.

Prophylaxis for HBV reactivation with antiviral nucleoside analogues should be commenced in susceptible individuals before the initiation of chemotherapy, in order to lessen the risk of HBV reactivation and the associated adverse clinical outcomes Pattullo It can be responsible for several systemic complications. The extrahepatic manifestations include vasculitis, fatigue, cryoglobulinemia and autoimmune disorders. HCV replication is significantly increased by immunosuppression and may cause a direct cytopathic effect in infected cells.

The identification of pre-transplant HCV infection appears clinically relevant. Being infected with HCV has been indicated as an independent risk factor for post-transplant veno-occlusive disease VOD of the liver. Reactivation of chronic HCV infection after tapering immunosuppressive therapy can sometimes lead to fulminant hepatic failure Locasciulli et al. HCV infection is responsible for hepatic and extrahepatic manifestations. The symptom of liver decompensation among patients who had cirrhosis at the time of transplant has been described in the literature, and rarely, fatal fibrosing cholestatic HCV can occur before day in recipients receiving mycophenolate mofetil Torres et al.

HCV infection is associated with high risk for several complications, which include accelerated liver disease progression, acute HCV exacerbation and viral reactivation. The last two are common, but not associated with increased liver-related mortality rates or changes in HSCT care Kyvernitakis et al. Liver biopsy revealed chronic portal inflammation, bile duct injury and moderate cholestasis Oliver et al. HCV adversely impacts on platelet recovery, non-relapse mortality and overall survival.

Pre-transplant HCV infection is associated with a lower rate of platelet recovery. An excess of bacterial infections in HCT recipients with HCV infection has been reported, and these findings suggest that the defence mechanisms against bacterial infections are impaired in recipients with HCV Nakasone et al. If there is an oncologic imperative for moving quickly to transplant, a therapy with direct-acting antiviral agents DAAs should be able to clear extrahepatic HCV from donors more quickly than interferon and ribavirin.

Treatment of post-transplant HCV infection must be an urgent consideration for patients with fibrosing cholestatic HCV, patients with cirrhosis whose condition is deteriorating and patients who underwent HSCT for HCV-related lymphoproliferative disorders. Once HCV therapy is initiated, treatment interruption is not recommended because it is associated with increased risk of treatment failure.

Commonly used DAAs include daclatasvir, sofosbuvir, ledipasvir, ombitasvir, paritaprevir, ritonavir, dasabuvir, simeprivir and ribavirin. The choice of regimen should be individualized on the basis of patient-specific data, and take into consideration potential drug interactions with tacrolimus, sirolimus and ciclosporin Torres et al. A vaccination against HCV does not exist.

However, to prevent the complication of co-infection, people with hepatitis C should be vaccinated against hepatitis A and B. Standard precautions are recommended for the care and treatment of all patients, regardless of their perceived or confirmed infectious status and in handling of blood, all other body fluids, secretions and excretions, non-intact skin and mucous membranes ASHM It was discovered in by investigators of an outbreak of unexplained hepatitis in Russian soldiers in Afghanistan.

In areas with poor sanitation, HEV 1 and 2 are spread orofaecally between humans, usually via contaminated water. HEV antibodies were found in pig farmers, slaughterhouse workers, veterinarians, and farm labourers. In Western Europe the food chain is the main source of infection, where HEV is transmitted through the consumption of contaminated animal meat undercooked pig liver.

Person-to-person transmission is uncommon, although nosocomial and parenteral transmission in haemophiliac and in haemodialysis patients has been reported Marano et al. The source of infection is human, mostly by faecal-oral route via infected water. Symptoms of HEV progress with fever, nausea, abdominal pain, vomiting, anorexia, malaise and hepatomegaly. Pregnant females and individuals with underlying chronic liver disease present a high mortality. Large outbreaks do not occur, most cases are sporadic and the source of infection remains uncertain in most cases.

In the developed countries, we can distinguish between acute and chronic hepatitis E. Acute HEV is mostly caused by genotypes 3 and 4. HEV infection may be misdiagnosed as drug-induced liver injury DILI and is responsible for extrahepatic disorders: neurological disorders, kidney injury, acute pancreatitis associated with HEV 1 and haematological disorders as thrombocytopenia and aplastic anaemia.

No studies have assessed the prevalence or incidence of HEV infection among haematological patients receiving chemotherapy. A small number have been found to have a chronic HEV infection and include a patient with untreated hairy cell leukaemia, a patient with idiopathic CD4 T lymphopenia and patients treated for lymphoma, chronic myelomonocytic leukaemia and B-cell chronic lymphocytic leukaemia.

One case of chronic HEV infection following allogeneic haematopoietic stem cell transplantation was reported in as differential diagnosis for graft versus host disease Bettinger et al. Immunocompromised patients should be screened for HEV antibodies and RNA not only prior transplantation but also post-transplantation and during episodes of liver enzyme abnormalities. Multidrug-resistant organisms MDRO have emerged as significant pathogens in haematology and haematopoietic stem cell transplant recipients.

Neutropenia and malignancy are independent risk factors for MDRO-invasive infections. Resistant Escherichia coli and Klebsiella pneumoniae bacteraemia and carbapenemase-producing K. Infection prevention, antimicrobial stewardship and antimicrobial prophylaxis are essential for control and management of MDRO. In the World Health Organization declared antimicrobial resistance a worldwide threat that requires urgent action. CP may include single-room isolation, an entire isolation ward or cohorting of a group of patients with or without designated staff.

Current controversies remain whether patients only colonized, rather than infected, with MDROs should be subjected to isolation. Healthcare workers who care for patients in contact isolation enter their rooms less frequently and have significantly less direct contact with them. Patients express greater dissatisfaction with their treatment and have less documented care Landelle et al. A review by Cohen et al.

Vancomycin-resistant Enterococci VRE. Coagulase-negative Staphylococcus CNS. Enterococci are gram-positive aerobes and facultative anaerobes which are seen microscopically as single, pairs and short chains and are part or the normal flora of the gastrointestinal tract. In transplant recipients, enterococcal infections are usually nosocomial and occur generally as invasive infections in the immediate post-transplant period, mostly as a consequence of endogenous gram-positive translocation.

VRE, also known as glycopeptide-resistant Enterococci , are increasingly causing outbreaks in haematology units. The evidence for an association between acting contact precautions and surveillance testing or not and the incidence of VRE bacteraemia starts to stagger. Infection control efforts should include contact precautions, and the need for active surveillance testing should be guided by local epidemiology Kamboj and Sepkowitz However, Almyroudis et al.

In this study, the incidence of VRE bacteraemia remained stable after discontinuation of surveillance and contact precautions. Furthermore, contact isolation can be associated with medication errors, reduced visits of physicians and nurses, safety concerns such as increased falls and bedsores, anxiety and depression among patients and a significant increase in the cost of care Almyroudis et al. CNS are members of the Micrococcaceae family, produce catalase and divide in irregular clusters to produce packets of cells.

CNS cause surgical wound infections and infections associated with lines, including CVC bacteraemia, CVC local infections and drain-associated peritonitis. Staphylococcus aureus occurs microscopically as single, pairs and short chains and has a strong tendency to form clusters. Staphylococcus aureus is mainly found in the nasopharynx and on the skin. The prevalence of vancomycin-intermediate S. According to the Center for Disease Control and Prevention guidelines ref website?

MRSA is indeed transmitted via an infected or colonized patient or by a colonized healthcare worker. Streptococcus viridans are facultative anaerobic, gram-positive cocci and are part of the normal microflora, found mainly in the oral cavity but also in the upper respiratory, gastrointestinal and female genital tract. Septicaemia is the most common manifestation in bone marrow transplant BMT recipients Ihendyane et al. Streptococcus pneumoniae is a gram-positive diplococcus causing significant morbidity and mortality in all age groups, wherein children, the elderly and immunocompromised patients are especially vulnerable.

Pneumococcal infection may occur during hospitalization for the transplant procedure but more commonly occurs as a community-acquired infection, months or years following the transplantation as meningitis or fulminant sepsis. Over the last decade, multidrug-resistant MDR gram-negative gram- pathogens have been implicated in severe healthcare-associated infections, and their occurrence has increased steadily.

The emerging problem of carbapenemase-producing Enterobacteriaceae has become a major healthcare threat with associated mortality also in haematology populations. The recommended strategies to prevent healthcare-associated transmission of gram-negative bacteria are prompt laboratory-based identification, adherence to contact precautions and strict hand hygiene. Further, more expensive approaches include dedicated equipment and staff, especially for patients with MDR in the respiratory tract.

Cohorting patients in a specific hospital area can be effective but also very disruptive. Finally, integration of antimicrobial stewardship efforts based on dominant MDR organisms may help prevent future problems Kamboj and Sepkowitz The ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug-resistant gram-negative bacteria in hospitalized patients by Tacconelli et al.

Enterobacteriaceae are facultative anaerobes and are intestinal colonizers. Enterobacteriaceae encompass a large heterogeneous family of gram-negative bacteria, which are divided into lactose fermenters as Escherichia coli , Citrobacter , Klebsiella spp. In the past it has been seen as an important causative agent of community-acquired infections, including a severe form of pneumonia. In the early s, infections caused by K. Carbapenemase-producing Enterobacteriaceae CPE cause serious infections in immunocompromised patients, in association with prolonged hospital stay and increased mortality rates, because of panresistance to antimicrobials Tzouvelekis et al.

Carbapenemase-producing Klebsiella pneumoniae CP-Kp are emerging in immunosuppressed patients, and their expansion represents a challenging problem in terms of outcome and management. A retrospective study by Girmenia et al. An analysis of 50 cases of KPC bloodstream infections BSI in neutropenic patients with haematological malignancies or aplastic anaemia, conducted by Tofas et al. Pseudomonas aeruginosa is a glucose non-fermenting gram-negative rod.

It is a strict aerobe pathogen, cosmopolitan in distribution, with a particular predilection for moist environments. Pseudomonas aeruginosa has shown the ability to acquire resistance to all traditionally effective agents, such as anti-pseudomonal penicillins, third- and fourth-generation cephalosporins, aminoglycosides, fluoroquinolones and carbapenems. Patient gastrointestinal colonization serves as an important reservoir for endogenous infection, as well as the source of horizontal transmission to other patients.

In patients with haematological malignancies, enteric colonization by Pseudomonas aeruginosa occurs typically after chemotherapy. Acinetobacter baumannii is a nonfermentative gram-negative pathogen. Its ability to survive on dry, inanimate surfaces for long periods of time suggests that the hospital environment serves as a reservoir for MDR strains. Acinetobacter baumannii can be resistant to many or all available antibiotics. Commonly employed strategies to avoid the spread of Acinetobacter baumannii include identifying and eliminating common sources of contamination, optimizing contact isolation and hand hygiene to minimize cross-transmission, enhancing environmental cleaning to reduce contamination and reducing broad-spectrum antibiotic use Lin et al.

Clostridium difficile is an anaerobic, gram-positive spore-forming bacterium and increasingly identified as the cause of nosocomial diarrhoea in growing numbers of patients. Risk factors for CDI include exposure to broad-spectrum antibiotics, which can cause changes to the microbiota of the gut, total body irradiation, long hospitalization, immunocompromised state, older age and irritation of the intestinal mucosa by chemotherapy drugs Gu et al.

In the event of confirmation of a Clostridium difficile CD toxin-positive result in a patient with diarrhoea, who is not already isolated, the patient must be moved to a single room with en suite bathroom or dedicated night commode. The nurse looking after the patient should inform the infection prevention control team.

Dedicated patient equipment must be used, including disposable blood pressure cuffs and tourniquet. Floors, night commodes, toilets and bedframes are subject to the heaviest faecal contamination; it is important that the ward environment should not be cluttered in order to facilitate thorough and effective ward cleaning.

The patient should be assisted with hand hygiene after using the toilet or night commode and before eating if unable to wash his or her hands independently. Alcohol hand rubs or gels are not effective against Clostridium difficile spores.

Hands must be decontaminated before putting on and after removing gloves. Ensure that all healthcare workers and visitors wear and dispose of PPE appropriately. Any clinical waste and linen, including bedding and, if present, curtains, should be considered contaminated and managed properly. Patients with CD should not be transferred to other wards in the hospital, except for isolation purposes or if they require specialist care on another ward.

CD spores are known to contaminate the environment, are resistant to standard disinfectants and are capable of surviving for long periods on dry surfaces. The combination of strict hand hygiene and contact precautions gloves and apron significantly reduces the incidence of CD Dubberke and Riddle Gu et al. Additional studies are needed to demonstrate whether berberine could be a new useful therapeutic agent to alleviate clinical symptoms of CDI Gu et al.

Further treatments of recurrent CDI are fidaxomicin, probiotics, intravenous immunoglobulin and faecal transplants. The treatment with faecal microbiota therapy consists in a technique that involves transfer of fresh stool from a healthy donor to the gastrointestinal tract of the patient suffering from severe or recalcitrant Clostridium difficile infection CDI.

In the case report by Neemann et al. After a brief liquefaction procedure, 30 ml of fresh stool suspended in non-bacteriostatic saline was slowly injected via nasojejunal tube into upper jejunum, followed by non-bacteriostatic saline flush. Another case reported by Castro et al. The patient had an allergic response to oral vancomycin and was subsequently treated with oral metronidazole and i.

Haematopoietic stem cell transplantation HSCT is a major procedure, which needs the use of chemotherapy. Some patients who are undergoing allogeneic transplantation for haemato-oncological malignancies will require radiotherapy. The administration of immunosuppressant to prevent graft rejection contributes also to the high risk of infections in this patient group Brown In recent years, improvement in HSCT supportive care measures, better understanding of the mechanism of immunosuppression, the introduction of reduced intensity conditioning RIC regimens and new anti-infectious agents and prophylactic strategies have decreased infectious morbidity and mortality.

However, there is still scope for improvement since infection remains a leading cause of morbidity and mortality in patients undergoing HSCT Gratwohl et al. Source of progenitor cells bone marrow, peripheral blood or cord blood. Degree of histocompatibility between the donor and the recipient sibling, unrelated or mismatch.

Depending on these factors, the patient can be rendered immunodeficient for months or even years after HSCT Rovira et al. Thus, in the autologous setting, bacterial infections are less frequent and severe, and the other infections are exceptional Rovira et al. However, autologous candidates who receive immunosuppressive agents steroids, purine analogues or monoclonal antibodies such as rituximab or alemtuzumab or with severe hypogammaglobulinaemia prior to the auto-HSCT run the same risk of developing infections as those patients undergoing allogeneic SCT.

However, viral and fungal infections occurring in the intermediate and late period are comparable because the incidence and severity of GvHD are similar to that observed in myeloablative HSCT. Additionally, RIC-HSCT is usually used in older patients, who are usually in poorer general condition with or without the presence of comorbidities; for all these reasons, the infection-related mortality has not decreased in this setting Rovira et al.

Infections are a major cause of morbidity and mortality in allogeneic transplantation Parody et al. Therefore, it is crucial to have a skilled nursing team to assess, prevent, detect and treat infections. Delays in diagnosing an infection that results from a depressed inflammatory response may lead to increased susceptibility to a broad range of potentially life-threatening organisms.

For this reason, in addition to antimicrobial prophylaxis, there are other important strategies to prevent infections, for example, building a multi-professional network team specialized in infection control measures Masszi and Mank The large number of patients considered at risk requires an evaluation of all proposals of protective systems, in relation to the effectiveness, applicability and cost benefit Pizzo The Centres for Disease Control and Prevention CDC has published in very specific recommendations regarding precautions to be taken in haematopoietic stem cell transplant.

The indications are the use of single room and the use of filtered air entering through a central or portable high-efficiency filter HEPA , capable of removing Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin including rashes and mucous membranes.

These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic. Hand hygiene refers to both washing with plain or antibacterial soap and water and to the use of alcohol gel to decontaminate hands. When hands are not visibly soiled, alcohol gel is the preferred method of hand hygiene when providing healthcare to clients. PPE includes items such as gloves, gowns, masks, respirators and eyewear protectors used to create barriers that protect the skin, clothing, mucous membranes and the respiratory tract from infectious agents.

PPE is used as a last resort when work practices and engineering controls alone cannot eliminate worker exposure. The items selected for use depend on the type of interaction a public health worker will have with a client and the likely modes of disease transmission. Wear gloves when touching blood, body fluids, non-intact skin, mucous membranes and contaminated items. Gloves must always be worn during activities involving vascular access, such as performing phlebotomies.

Wear a surgical mask and goggles or face shield if there is a reasonable chance that a splash or spray of blood or body fluids may occur to the eyes, mouth or nose. Wear a gown if skin or clothing is likely to be exposed to blood or body fluids remove PPE immediately after use and wash hands.

It is important to remove PPE in the proper order to prevent contamination of skin or clothing. Safe handling of needles and other sharp devices is a component of standard precautions that are implemented to prevent healthcare worker exposure to blood-borne pathogens. The Needlestick Safety and Prevention Act link is external mandates the use of sharps with engineered safety devices when suitable devices exit.

Clients in waiting rooms or other common areas can spread infections to others in the same area or to local public health agency staff. Measures to avoid spread of respiratory secretions should be promoted to help prevent respiratory disease transmission. Elements of respiratory hygiene and cough etiquette include:. Using tissues to contain respiratory secretions and discarding in the nearest waste receptacle after use.

Asking clients with signs and symptoms of respiratory illness to wear a surgical mask whilst waiting in common areas or placing them immediately in examination rooms or areas away from others. Provide tissues and no-touch receptacles for used tissue disposal. Spacing seating in waiting areas at least three feet apart to minimize close contact among persons in those areas. Supplies such as tissues, wastebaskets, alcohol gel and surgical masks should be provided in waiting and other common areas in local public health agencies.

Place cough etiquette signs link is external where the general public can see them. Outbreaks of hepatitis B and hepatitis C infections in US ambulatory care facilities have prompted the need to re-emphasize safe injection practices. All healthcare personnel who give injections should strictly adhere to the CDC recommendations.

Some centres use additional protection in an effort to reduce the risk of infection, but there are insufficient data to recommend such behaviours Tomblyn et al. Consistent with the organization of the department, it would be advisable to hospitalize the patient in a single room with attached bathroom, in order to give them greater comfort.

The ventilation system should ensure at least 12 air changes per hour; a direct flow area of the room must have the way out on the opposite side with respect to that of entry. The optimum ambient air quality can be obtained without using the expensive laminar flow.

The rooms, housing highly immunocompromised patients, need to be placed under positive pressure to prevent the entry into the room of airborne pathogens in the hallway or in adjacent spaces. Although it is unlikely that exposure to plants causes invasive fungal infections in patients undergoing HSCT, it is recommended that plants and dried or fresh flowers do not enter the room during hospitalization conditioning phase included because of the Aspergillus sp.

In addition it was found a high proportion of gram-negative bacteria in the water of the cut flower vase Pseudomonas Tomblyn et al. For the patient hospitalized in a protective environment, exits from the room should be restricted just for the execution of diagnostic tests and for a short period. If a construction site is present nearby the hospital, it is indicated to use a filter mask N95 to prevent inhalation of spores. There are no recommendations regarding use of the mask with filter in the absence of the construction work Tomblyn et al.

The most important point in the prevention of infections in hospitalized patients, being in protective isolation, remains handwashing. Hand hygiene is a key element of the standard precautions for all types of patients Tomblyn et al.

It is also advisable not to wear false nails or extensions during direct contact with the patient and maintain the natural nails short. Even if there is still an unsolved problem, many studies have shown that the skin below the rings is more colonized than that without; rings and dirty jewelry can host microorganisms. Furthermore hand hygiene cannot be done in a perfect way if you wear bulky rings. Nurses have an important role in educating the family, patient and visitors to an effective handwashing as shown in Fig.

Some transplant centres display cartoons near the sinks at the entrance of the hospital room, where they describe the handwashing procedure step by step and how it needs to be performed WHO guidelines The environmental cleaning plays an important role in the prevention of nosocomial infections, particularly in patients with haematological cancers and diseases undergoing transplantation of haematopoietic stem cells.

The cleaning staff must be well prepared and needs to be informed and trained, with particular attention to the problems of immunosuppressed patients. It is preferable to assign stable staff to the division, in order to ensure a continuity of service. The light fixtures and outdoor grills of ventilation vents and all horizontal surfaces should be cleaned with pre-moistened disposable cloths with a disinfectant FDA and Environmental Protection Agency approved.

The design and selection of the furniture of a transplant program should be focused in creating and maintaining an environment: free of dust and the floors and finishes should be brushable, waterproof, easy to disinfect and antistatic Tomblyn et al. To verify that hospital rooms are at effective reduced environmental load, periodic monitoring of the environments must be guaranteed. All linen should be changed daily and pillows and mattresses should have protective coatings.

During the hospital stay for the patient undergoing HSCT, it is enough to wash clothes and linens at high temperatures in a washing machine Tomblyn et al. Each centre has its own policy on the number of visitors allowed and the frequency of visits. Personal hygiene is a key aspect for the patient undergoing HSCT.

It represents the most effective way to reduce infections caused by endogenous organisms. The interview with the patient and his family is a very important moment and must be programmed before HSCT. The nurse must be able to define when, how and which are the major needs for the patient.

It is important to explain the importance of personal hygiene and its role in preventing infections. Several centres are supported by audio-visual media and information booklets to reinforce the provided information. Recommendations for personal hygiene, Carreras , CDC Thorough intimate hygiene must be performed after each evacuation, especially in case of diarrhoea. Patients are advised to gently rub the skin and dry it accurately especially at the level of the armpits and groin, where the body microorganisms can proliferate if they find a moist environment.

For teeth cleaning, it is recommended to use synthetic brushes with soft bristles. Soaps, perfumes, deodorants and aftershave containing alcohol, cotton sticks for ear cleaning patient should clean the external pinna with soap and water only , lipsticks. Patients should be advised to cut the nails of the hands and feet before admission, as, during aplasia, they are more susceptible to infections and bleeding. Also keeping short nails facilitates good hand hygiene. Enamel or false nails should be removed.

For men an electric razor is recommended; razor blades and scissors are forbidden due to their increased bleeding risk. Management of oral and gastrointestinal mucositis is one of the main challenges during the period of aplasia, with risk of sepsis related to degree of mucosal barrier breakdown and depth of marrow suppression Peterson et al. Oral care is an important aspect in the control of infections in transplant patients Quinn et al.

All treatment strategies aimed to improve mouth care are dependent on four key principles: accurate assessment of the oral cavity, individualized plan of care, timely preventive measures and correct treatment initiation Quinn et al.

The use of central venous catheters CVC is linked to the need to infuse complex therapies for a long time, having available a valid and secure access. The goals of care, for the CVC management, must aim to ensure prevention of infections and maintenance of the patency. This is feasible if the device is managed by competent healthcare workers and if the process is based on continuous improvement of performance RCN ; INS ; CDC Plan an echo-guided insertion when possible, for both centrally and peripherally inserted central lines.

Use of sutureless devices StatLock for fixing the catheter, wherever possible. Education of the patients on the need to inform the nurse if changes at the level of the CVC are noticed. The low bacterial diet LBD , also known as neutropenic diet or low microbial diet, is a diet aimed at reducing the ingestion of bacterial and fungal contaminants excluding it from foods such as fresh fruits and vegetables, raw eggs, raw meat and fish, unpasteurized dairy products, ice and yogurt that will be excluded from any type of diet or raw food containing probiotics.

The consumption of fruits with thick skin, if peeled and washed, in accordance with good hygienic practices has low probability to be contaminated Todd et al. For decades, the concept of a neutropenic diet or diet containing food with low levels of bacteria LBD has implied a strict limitation of foods allowed for consumption, as a presumptive means of reducing the risk of infection in cancer patients.

The rationale was to limit the introduction of potentially harmful bacteria into the gastrointestinal tract by the restriction of certain foods that might harbour those organisms Fox and Freifeld However, there is no clear evidence that the use of a low bacterial diet LBD actually decreases the number of infections.

It is clear from numerous surveys of current practice that the majority of hospitals place neutropenic patients on a restricted diet Mank et al. Many studies have limitations and conclude that there are no differences in terms of infectious episodes and survival when comparing a normal to a neutropenic diet Van Tiel et al. In a randomized study of patients with acute myeloid leukaemia undergoing induction therapy, no difference in terms of infectious episodes and survival was reported between patients prescribed with a LBD and those put on a normal diet.

The conclusion was that the LBD has not prevented major infections or death Gardner et al. Notably, a study on the use of a non-neutropenic diet showed an increase in satisfaction for the meal from a The feedback of the team was positive Tarr and Allen Patients who are prescribed a neutropenic diet may have a poor nutritional status and often need counselling and nutritional support Murray and Pindoria A study conducted in Brazil shows how dietary restrictions can lead to a deficiency of vitamin C Galati et al.

Nutritional support guidelines for patients with GI GvHD, which are also on common sense, include a low microbial diet Trifilio et al. The study results are in line with preclinical experiments conducted on mice where the presence of a mixed intestinal flora e. Lactobacillus rhamnosus GG would be able to decrease the proliferation of the most virulent bacterial species and of the system that immunomodulate what is in their intestine Docampo et al.

A more liberal diet could bring benefits in terms of palatability, cholesterol reducing, use of parenteral nutrition and an improvement in quality of life. The LBD, usually poorer from a nutritional point of view and less attractive compared to a normal diet, may be an unnecessary burden on patients who already have difficulties with eating. The studies reviewed do not support significant results on the effectiveness or ineffectiveness of the LDB, and many useful results still do not encourage the use of LBD.

Protective isolation can have significant psychological effects on the patient. Patients are encouraged to personalize their rooms with family pictures. Some may have computer access and are able to maintain communication with family members and friends in this way.

However, the length of time spent in isolation does lead to many patients having feelings of anxiety, fear for the future, concerns about the family and worry about whether engraftment will occur Brown Loss of body image as a result of weight loss or scars, sexuality issues and concerns about employment may preoccupy a patient Gruber et al.

Nurses should be aware of the potential effect that both, the transplant and the isolation, can have on patients. Spending time with the patient and offering him or her an opportunity to talk about concerns can be helpful. Providing information, education and advice may reduce the negative psychological effects of isolation Brown However it should be considered for selected categories of patients the possibility of an early discharge after transplantation to provide a more comfortable environment for patients and their family.

Increasing implementation of ambulatory treatment has the potential to decrease patient exposure to multidrug-resistant organisms in the hospital and to provide patients with the possibility to spend the neutropenic phase at home and to facilitate more admissions to the haematology ward Mank et al.

Patient and family will have to face everyday life far from a safe hospital environment. In fact, in the hospital, the continued support of the multidisciplinary team makes them feel protected; in hospital, doctors, nurses and other professionals are always present to clarify doubts, give advice and also try to reduce anxiety and fears. Being aware of the risks of infection means that going home can be stressful Brown Nurses should spend time with the patient, identify and explore any concerns before discharge.

In some cases, the patient may become overdependent on nursing staff, and this may need to be addressed. Allogeneic transplant patients have a high risk of readmission as a result of infection, and it is critical that discharge planning provides patients with the understanding and information on how best to minimize the risk of infection Grant et al. Discharge checklist for patients following allogeneic stem cell transplantation Brown modified. Discharge checklist for patients following allogeneic stem cell transplantation.

Care should be taken when around schoolchildren, as there is a risk of exposure to sick children. Patients should be advised to stop smoking and avoid smoky areas for the first few months following transplantation. When considering travel, patients should seek advice regarding travel vaccinations, particularly if they would need live vaccines. It is essential that patients continue to take their medication and attend all follow-up outpatient appointments.

Patients should be advised to continue their oral care routine. It is very important. The patient will require a great deal of information before and at discharge, and this would include information on follow-up treatment.

As recent research suggests, pulmonary complications are a leading cause of post-transplant complications and death in HSCT recipients Alsharif ; Roychowdhury et al. Post-transplant pulmonary complications are classified as either infectious or noninfectious. The rate of complications is significantly lower for autologous transplant recipients than for allogeneic transplant recipients.

This is because of the absent risk of GvHD in autologous transplants, the infrequent use of immunosuppressive medications such as ciclosporin or tacrolimus and the absence of radiation therapy in the preconditioning regimen Ho et al. Methods that healthcare professionals can use to improve patient outcomes in autologous and allogeneic recipients include raising clinical awareness, improving diagnostics, shortening time to medical intervention and continuing multidisciplinary research Stephens et al.

The spectrum of pulmonary complications for transplant recipients will continue to change, due in part to rapid advances in supportive care, the increasing age of transplant recipients, new antiviral and antifungal agents and an increasing use of prophylactic broad-spectrum antibiotics post-transplant Sharma et al. The real key, however, to decreasing morbidity and mortality in adult and paediatric HSCT patient populations remains in effective diagnostic techniques Stephens et al.

The principal cause of infection is the severe immunocompromised status of the patients from the disease process malignant or non-malignant , conditioning regimens non-myeloablative and myeloablative and immunosuppressive prophylaxis to prevent and treat GvHD. A CT study by Escuissato et al. Typical onset of pulmonary complications following stem cell transplantation divided into three stages based on information from Antin and Raley Camus and Costabel , Coomes et al.

Candidaemia Candida sepsis and candidiasis general Candida infections. Diagnostic techniques for pulmonary disease in HSCT patients are similar to that for non-transplant patients. Chest radiograph X-ray and thoracic computed tomography CT scan remain the most popular and less invasive options. CT scans are particularly useful when compared with two-dimensional X-rays because they can expose acute and chronic changes in the lung parenchyma. Respiratory CT scans involve taking pictures of cross-sections of lung tissue using high special-frequency reconstruction during inhalation and exhalation Stephens et al.

This could include collecting sputum samples, bronchoscopy with or without bronchoalveolar lavage BAL , open lung biopsy and needle biopsy Kaplan et al. Sputum samples can be collected by nurses, physicians or respiratory therapists according to transplant program protocols. Respiratory virus detection is highly dependent on the type of sample collected, the time of collection after the onset of clinical symptoms, the age of the patient and the transport and storage of the sample prior to testing.

Several different upper respiratory tract specimens are applicable for testing, including nasopharyngeal NP washes, NP aspirates and NP swabs placed in virus transport media Specter ; Storch Expectorations in the early morning or after a respiratory procedure can be the easiest for the patient to produce because of the natural accumulation of secretions at these times. About 15 ml of sputum is usually required for adequate laboratory analysis, and a recent study suggested that the sputum must reach the laboratory within a few hours from expectoration Murray et al.

Sputum can also be collected during a bronchoscopy. In some cases, broncholveolar lavage BAL will be performed during the bronchoscopy. BAL involves the flushing of fluid usually a sterile normal saline solution into a localized area of the lower respiratory tract and then immediately suctioning the fluid up the bronchoscope and into a sterile specimen container.

In patients with focal pulmonary lesions, aspergillosis or pulmonary GvHD, fine-needle aspiration biopsy is considered the first-line diagnostic method Gupta et al. These most commonly occur in the first month but can occur at any time. Both gram-negative and gram-positive organisms can cause pneumonia, the most common being Escherichia coli , Klebsiella , Pseudomonas , Enterobacter , Acinetobacter , Staphylococcus aureus , coagulase-negative Staphylococcus , Streptococcus pneumoniae , Streptococcus viridans and Enterococcus.

One also needs to recognize the risk of Mycoplasma and Chlamydia infections, although the common use of fluoroquinolones will empirically treat these organisms. Other causes of late pneumonia that should not be missed include Nocardia , Listeria and Actinomyces. Galactomannan and beta-glucan testing may be helpful but are not always informative. A history of noncompliance with prophylaxis medication should be elicited. All patients undergoing HSCT are at risk for pulmonary complications. Prompt reporting of symptoms can ensure proper and timely medical intervention and facilitate improved patient outcomes.

This has been found particularly true in identifying GvHD, with clinical nurses at the forefront of identifying and reporting suspicious symptoms to the healthcare team Mattson Nurses take a central role in patient and family education regarding the course of treatment, complications and other key pieces of the HSCT process, including caring for a central line Stephens et al.

By educating patients on what to expect after transplant with regard to troubling symptoms, nurses ensure patient participation in identifying developing complications early and improving HSCT outcomes. A thorough assessment can assist the nursing staff in detecting changes indicative of developing complications.

Nurses are crucial in assessing patients for symptoms of bacterial infection and should perform routine laboratory tests as necessary. Regarding pulmonary infections, nurses should closely monitor patients for symptoms of progressing respiratory disease, such as decreased auscultation of air sounds in the lungs, increasing fevers and appearance of a productive cough with coloured sputum.

Antibiotics should start as soon as possible in these patients. The recent addition of monoclonal antibodies MoAbs to GvHD prophylaxis protocols has been met with mixed results. For example, a study using infliximab did not lead to lower rates of GvHD but did suggest higher rates of bacterial or fungal pulmonary infection in patients who participated in the study Hamadani et al. It is important that patients in the post-transplant period are encouraged to pace their activity with their level of ability.

Coughing and deep breathing exercises accompanying the regular use of an incentive spirometer constitute critical ways to open deep alveolar tissue and encourage pulmonary toileting on patients prone to fatigue and malaise and whose blood counts are very low Stephens et al. Immunization with live viral or bacterial vaccines is a known hazard to patients with serious immunodeficiencies Shearer et al. They have no protective immune response and therefore are at risk of developing the disease itself Marciano et al.

Avoid immunization with live Bacillus Calmette-Guerin BCG , rotavirus vaccine or live poliovirus since they can cause persistent and disseminated infection Shearer et al. Patients who received BCG vaccine prior to diagnosis will need to start anti-tuberculosis treatment. It is characterized by local erythema and purulent regional lymph node enlargement.

It involves distant lymph nodes, bone, liver and spleen. Shrot et al. The images or other third party material in this book are included in the work's Creative Commons license, unless indicated otherwise in the credit line; if such material is not included in the work's Creative Commons license and the respective action is not permitted by statutory regulation, users will need to obtain permission from the license holder to duplicate, adapt or reproduce the material.

Skip to main content Skip to sections. This service is more advanced with JavaScript available. Advertisement Hide. Open Access. First Online: 22 November Download chapter PDF. Mackall et al. Open image in new window. Campath 1-H Systemic immunosuppression particularly corticosteroids, antibodies directed against T-cells, e. Toxicity Teratogenicity has been shown in animal models and therefore care should be used in handling the drug. Toxicity Renal dysfunction is the major dose-limiting toxicity and may be irreversible.

Early lesions Are those that show features when biopsied of infectious mononucleosis and plasmacytic hyperplasia. Monomorphic PTLD Comprises large lymphocytes and plasma cells that are uniform in appearance with most being B cells with a clonal abnormality. In practice, a clear separation between the different subtypes is not always possible; early lesions, polymorphic PTLD and monomorphic PTLD probably represent a spectrum of diseases Parker et al. More recently Styczynski et al.

Extrahepatic manifestations of acute and chronic hepatitis E involve the following systems and organs Dalton et al. Table 7. Acute Acute HEV is mostly caused by genotypes 3 and 4. Chronic No studies have assessed the prevalence or incidence of HEV infection among haematological patients receiving chemotherapy. This is a list of the more common virus that patients develop during transplantation. Isolation In the event of confirmation of a Clostridium difficile CD toxin-positive result in a patient with diarrhoea, who is not already isolated, the patient must be moved to a single room with en suite bathroom or dedicated night commode.

An isolation notice must be displayed on the door. Equipment and Cleaning Dedicated patient equipment must be used, including disposable blood pressure cuffs and tourniquet. Hand Hygiene The patient should be assisted with hand hygiene after using the toilet or night commode and before eating if unable to wash his or her hands independently. Waste and Linen Any clinical waste and linen, including bedding and, if present, curtains, should be considered contaminated and managed properly.

Movement of Patients Patients with CD should not be transferred to other wards in the hospital, except for isolation purposes or if they require specialist care on another ward. Principal risk factors for infections after HSCT are: Status of the haematological disease at HSCT Comorbidities of the patient Degree and duration of neutropenia Disruption of anatomical barriers mucositis and indwelling catheters Depressed T- and B-cell function and immunosuppressive therapy.

Reconstitution of immune status after HSCT depends on: Type of transplantation autologous or allogeneic Source of progenitor cells bone marrow, peripheral blood or cord blood Conditioning regimen myeloablative, RIC or non-myeloablative Degree of histocompatibility between the donor and the recipient sibling, unrelated or mismatch Type of GvHD prophylaxis calcineurin or mTOR inhibitors, mono or polyclonal antibodies or T-cell depletion Presence and grade of GvHD and its treatment.

There is a clear relationship between the type of immunodeficiency after HSCT and the incidence of certain infections. According to this, three different periods can be distinguished, with a predominance of specific pathogens in each phase Fig.

Protection with lab coat, gloves and mask is not indicated in the absence of suspected or confirmed infection of patients Tomblyn et al. The effectiveness of specific precautions in preventing infections in patients undergoing autologous HSCT has not been evaluated but must follow the standard precautions for every patient contact. Standard precautions Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin including rashes and mucous membranes.

These measures are to be used when providing care to all individuals, whether or not they appear infectious or symptomatic Hand hygiene Hand hygiene refers to both washing with plain or antibacterial soap and water and to the use of alcohol gel to decontaminate hands.

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Double chance betting bet365 italia Dairy farmers Steve Schalla and Jay Binversie along with seasoned commodity broker Carl Babler will discuss positive and negative experiences linked to. It is a strict aerobe pathogen, cosmopolitan in distribution, with a particular predilection for moist environments. A reaction to rituximab is thought to be mediated by a cytokine release from both normal and malignant B cells. During the transplant process, HHV6 has been cited by Zerr et al. Am J Roentgenol. Are those that show features when biopsied of infectious mononucleosis and plasmacytic hyperplasia.
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This session is designed to uncover solutions and opportunities not just in food production but also human medicine. Producers also need to protect and care for their families, their employees and themselves. This session explores mental and physical awareness regarding personal and business health.

Kelley Donham, veterinarian, will cover topics ranging from musculoskeletal health to veterinary pharmaceutical risks and other seemingly unrelated subjects. This is a session that will equip producers with the resources they need to be healthy on all fronts. What can we do to make a buck? Lowering costs, addressing marginal milk and marginal dry-matter intake will also be discussed. Prior to joining the farm, he was a licensed comSteve Schalla modity broker.

He works in the futures industry as a broker, educator and hedger. Nicole Bettinger is a consultant for The Family Business Consulting Group, specializing in communication, conflict resolution and training next-generation family-business owners. Barbara Dartt, veterinarian, is a senior consultant for The Family Business Consulting Group, assisting businesses with succession strategies, long-term planning, management transitions and family-governance implementation.

Heather White is an assistant professor of dairy science at UW-Madison. Randy Singer, veterinarian, is a professor of epidemiology at the University of Randy Singer Minnesota. Kelley J. He practiced veterinary medicine before returning to the University of Iowa, where he was a professor until Mike Hutjens is a world-renowned University of Illin o i s - E x te n s i o n dairy specialist who spent most of his career at the Mike Hutjens University of Illinois.

Producers once again start off with a choice of one minute session. Abby Augarten. H e Zhijun Cao founded the Elite Cattlemen Program, a program that builds alliances between college and university dairy-science departments worldwide. In this session producers will hear the facts directly from two Chinese experts. Dairy farmer and processor Zhu Li Ke is also a retail expert with more than 1, stores to his name. Together with Shanghai dairy-science profe sso r Z h i j u n C a o, t h e dynamic duo will talk about dairying in China, the future with the United States and what expanded relations with the United States may look like in the future.

Rising labor costs: strategies and approaches: Many factors are contributing to the rise in labor cost. How management teams respond will determine the financial. Hear insights on the five most critical managem e n t a re a s that impact labor cost, from analyst Jason Karszes.

Honor your family; do the business right: It takes effort and know-how for a family business to work. Consultant Jolene Brown will discuss the necessities of successful family-business man agement and t ra n s i t i o n. Gleaned from Jolene kitchen-taBrown ble consultations of farm families, the farm-raised speaking pro will share invaluable tips to help dairy farmers build and transition their businesses.

Kick bottlenecks aside to find margin: To help producers control how much is spent on feed, Bill Weiss will share ways to maximize income over feed costs in a d d i t i o n to Bill Weiss minimizing feed costs. Producers in this session will work through market situations and scenarios, and dive deeper into the economic-agricultural landscape. Glean insights on how to manage margins until the next upturn arrives.

Learn how to more effectively describe the technologies that promote the sustainability of dairy production and their synergy with consumer demands. Science report: well water: Mark Borchardt, the lead scientist studying private wells in northeast Wisconsin, recently completed a study to identify the sources of fecal contamiMark nation. It also Borchardt looked at risk factors such as land use, well construction and weather patterns that lead to groundwater contamination.

It takes a village: successful calf management: Dr. Theresa Fro m t h e Ollivett management of people and facilities to rations and procedures, this session covers the critical details commonly overlooked by even the best calf raisers. Business analysis: measuring costs to improve performance: Dairy prod u c e r Ky l e Getty and analyst Jason Karszes will explore some of the different activities Kyle Getty that can be measured on a farm.

There are costs to load, mix and deliver feed, and to run a milking center, impregnate a cow and spread manure. He founded the Elite Cattlemen Program, a program that builds alliances between dairy-science departments worldwide. Jennifer Lu is an international economic-development consultant for the Wisconsin Department of Agriculture, Trade and Consumer Protection.

With a wealth of experience in international marketing, distribution, retailing and joint-venture management, she has significant expertise in the China and Asia markets. Daniel Basse is president of Ag Re so u rce Co m pa ny, a domestic and international agricultural research firm in Chicago that forecasts agricultural-price trends. Jolene Brown of West Branch, Iowa, is a farmer, family-business consultant and professional speaker. Participants will gain a clearer understanding of what happens when infection arrives.

They will see the udder from a new perspective during a dynamic hands-on dissection. His main research areas are factors affecting digestibility in dairy cows, and relationships between minerals and vitamins. Alison Van Eenennaam is a University of California-Davis-Extension specialist in animal genomics and biotechnology, focusing on animal genomics and biotechnology as well as genome editing.

M a rk B o rc h a rd t i s a research microbiologist for the U. He grew up on a dairy farm in Calumet County, Wisconsin, operated by his father and uncles. Woolums, veterinarian, will combine hands-on calf diagnostics with a healthy dose of immunology to show attendees what researchers are learning about the developing immune system. Raising healthy calves is not limited to colostrum.

Theresa Ollivett, veterinarian, is an assistant professor at the University of Wisconsin-Madison-School of Veterinary Medicine, where her most recent research focuses on dairy-calf respiratory disease and fresh-cow health. Getty serves as the chief financial officer, and manages the crop and feed programs for the 3,acre dairy. Matt Akins is a dairy-management specialist at UW-Madison, working with producers and industry professionals.

His main focus is on heifer nutrition, including genetics, reproduction and environmental impacts. Act now: Attendees will walk through real-life fire drills. Ron Naab and Jerry Minor will school attendees on the use of fire extinguishers and the steps to save equipment, buildings and lives. Participants will walk away with an action plan to complete with their families and on-farm teams.

Make it, Shake it, Feed it: As important as ration formulation is, Tom Oelberg and Bob Myers will show that just as vital are the way rations are mixed and presented to the cow. Attendees will evaluate each mix by focusing on ration structure, consistency and other critical properties. Laura Hernandez is an associate professor of dairy science at the University of W i s c o n sin-Madison. Her research focuses on how Laura serotonin controls the mam- Hernandez mary gland and various aspects of lactation.

Ron Naab has been active in the fire service for more than 50 years, serving as an emergency Ron Naab medical service captain, fire captain and as assistant chief. He has taught farm-rescue and safety in four states. He created in the farm-rescue program for Wisconsin. Her r e s e a r c h Ameilia focuses on Woolums i m m u n i ty i n cattle and calves, including the host response in bovine respiratory disease and vaccinating to prevent it.

To m O e l berg is a ruminant field technical specialist with Diamond V, p rov i d i n g technical and research assis- Tom Oelberg tance, and sales support. He has developed a number of technical advances for dairy, including the TMR Audit resource. Bob Myers s e r ve s d a i r y producers, nutritionists, veterinarians and feed manufa c t u re rs i n Bob Myers Wisconsin as a regional sales manager for Diamond V. This continuing education tool for tracking and reporting offers more training and support from trusted educational providers than ever.

Learn more here: www. Learning Lounges add to energy Throughout day one and two, minute Learning Lounge Sessions will be presented. The sessions are held in the green, blue or red lounge areas in the Hall of Ideas. Producers can Tom fine-tune Thibodeau actions to develop cultures of true caring within their organizations.

Blue Lounge: Your ace to managing cost Mike Hutjens discusses ways to build on key manage ment s t re n g t h s to increase margins. He offers tips for assess- Mike Hutjens ing where cuts can be made without jeopardizing animal health and quality. Red Lounge: Sharpen your mind D r. K e l l e y Donham, veterinarian, teaches the signs of compassion-fatigue and other Kelley Donham physiological risks that rob energy, focus and effectiveness.

He shares his take on the ongoing transformation. Red Lounge: Basics of businesssuccession planning Family-business consultant Nicole Nicole Bettinger Bettinger helps make business-transition decisions and conversations easier; she shares a checklist among other tips and strategies. Green Lounge: Grooming the leader within Tom Thibodeau knows how to coach others to grow as leaders who others will follow and respect.

Blue Lounge: Make your move against feed-borne pathogens John Goeser discusses how molds, mycotoxins and other feed-borne bacteria form and how prod u c e r s c a n John Goeser manage them. Learn the Abby latest on nitroAugarten gen-use efficiency.

Green Lounge: Group housing for calves? Blue Lounge: Excess heifers, take action Matt Akins, U W- M a d i so n dairy-management specialist, prompts producers to consider if their heifers are eating Matt Akins at profits. Red Lounge: Legal ins and outs of hiring and firing Agricultural attorney Blake Knickelbein helps attendees rise above the jargon of hiring and firing to Blake understand the legal rights of an Knickelbein employer. Green Lounge: Mind the gap A l i so n Va n Eenennaam shares that dairy producers are the difference Alison Van between trust and mistrust in Eenennaam the food system.

Learn from this well-known scientist how to humanize and connect the science of what dairy producers do. The public needs to know the truth. Blue Lounge: Fatten up your milk check Bill Weiss will give attendees the skinny on the effects of milk composition on a milk check. Learn how to Bill Weiss impact the milk check without adding to cost, time or labor.

Red Lounge: Thinking about farmstead marketing? Agricultural program specialist Lois Federman discusses what it takes to provide and sell homestead Lois products. Contact AMPI today to learn why we are the best choice out there. Thrive: keynotes will In the midst of learning and networking, Business Conference attendees will be treated to a handful of opportunities to hear from others who have overcome the odds to lead lives of thriving. He learned at a young age success. He faced one of his first obstacles as he fell behind fellow classmates in reading.

With a lot of hard work, determination and a fantastic third-grade teacher, the young Tauscher charged past his first block to become an independent reader and honor student. He went on to play for the Wisconsin Badgers as a walk-on. Tauscher was drafted by the Green Bay Packers in the seventh round; he found himself the starting right tackle his rookie year. Attendees will learn about the farm kid whose sense of self, fortitude and unique brand of humor helped him defeat unlikely opponents and build a life that thrives far beyond the green turf.

He defeated the odds despite burns to percent of his body and a less than 1 percent chance of survival that first night. For more information about the farm dividend program and how you may qualify, contact your local Rural Mutual agent or visit us on the web at www. With an anticipated bottoming of Dan U. Closing keynote speaker Liz Murray will highlight how continuous learning and sheer determination is central to rising above difficult circumstances.

Mocked in school for her lice-infested hair and dirty clothes, she skipped so Liz many classes she was put Murray into a girls home. At age 15 she landed on the streets as her family life unraveled. She learned to scrape by, foraging for food from dumpsters and riding subways all night to have a warm place to sleep.

Determined to escape her situation, she recognized education was key to a new beginning. She earned a scholarship to Harvard University, graduating in This session is sure to inspire and will provide perspective, hope and a new way of viewing would-be obstacles. In addition to staying current on industry news and events, board members are involved in PDPW programs and committees. They proactively seek leadership opportunities and mentor opportunities on non-PDPW committees in the agricultural industry.

Ultimately board members help facilitate the development of programs that bring cutting-edge research, elite training, peer-networking events and hands-on educational opportunities to the dairy industry. Her parents,. Roger and Sandy Grade, are currently transitioning ownership to their son, David Grade, and the Clark couple. The dairy consists of registered milking Holsteins and 1, acres of Janet owned and rented land. Clark Janet Clark manages the financials and calves.

Along with his parents, two older brothers, three nephews and several employees, he manages the daily responsibilities of the dairy and most of the field work. He also served on the District 4 Holstein Animal Breeders sale committee. The dairy has 1, Holstein cows, raises all its heifers, crops 2, acres of corn and alfalfa, and Jay employs 21 full-time workHeeg ers.

Incumbent Dan Scheider is a fifth-generation dairy farmer on both sides of his family. He farms with his parents, Doug and Trish Scheider, and a dedicated team of employees. The team at Scheidairy Farms milks cows and farms 1, acres. He worked for three years in agribusiness banking in central Wisconsin before returning to the family farm. March Consistent with other studies, antibody responses were also lower in older adults. Very similar results were found in a study of younger adults vaccinated with the — formulation in France and Germany.

Also, as in the current study, a study performed in Australia and the Philippines found robust, equivalent antibody responses to three lots of the — Northern Hemisphere formulation of IIV4 in children, adolescents, and younger adults.

Rates of serious influenza illness are known to be higher and vaccine immune responses lower in older adults because of immunosenescence, the age-related decline of the immune system. This study showed that HAI antibody titers to each strain were lower in participants vaccinated with the previous season's influenza vaccine.

Some authors have suggested, however, that serologic results overestimate protection by IIVs, and they argue that fixed HAI titer cut-offs, at least alone, are not appropriate for estimating protection. This strengthens the conclusion that, in most participants, IIV4 induced protective antibodies against all four vaccine strains of influenza. Because a correlate of protection based on SN titer has not been established, these results cannot be used to estimate or compare efficacy between vaccines.

Quadrivalent influenza vaccines are gradually replacing trivalent vaccines. The current study confirmed the immunogenicity, safety profile, and lot-to-lot consistency of the — Northern Hemisphere formulation of IIV4. It also showed that the vaccine should provide good protection against all four included strains of influenza, even in individuals with high-risk conditions and individuals vaccinated the previous year for seasonal influenza.

By providing broader coverage and a better match to circulating B strains, IIV4 should help reduce the public health impact of influenza. The study was approved by each institution's ethics committee or review board. The conduct of this trial was consistent with the standards established by the Declaration of Helsinki and complied with the International Conference on Harmonization Guidelines for Good Clinical Practice as well as all local and national regulations and directives.

All participants provided written informed consent to be included in this trial. Women were excluded if they were pregnant, lactating, or of childbearing potential and not using an effective method of birth control. Prior to enrollment, all participants were assessed for preexisting conditions and illnesses. Participants were considered to be at risk for influenza-related complications if they had at least one past or current high-risk condition as defined by the US Centers for Disease Control and Prevention.

All vaccines were thimerosal-free, inactivated, split-virion, and each 0. The randomization list was generated by computer using the permuted block method with stratification by site and age group. Participants were assigned via an interactive voice or web response system. The IIV group was single-blinded because it was delivered in different packaging than the investigational products, although it was presented to participants in an identical 0.

For all participants, immunogenicity was assessed in a blinded manner. HAI titers were also assessed at baseline day 0 , at the end of the safety follow-up period month 6 , and at month HAI titers were measured as described previously. Briefly, the highest serum dilution resulting in complete inhibition of hemagglutination was determined for duplicates of each sample.

The HAI antibody titer for each sample was calculated as the geometric mean of the reciprocal of the duplicate values. The lower limit of quantitation was set at the reciprocal of the lowest dilution used in the assay 10 , and the upper limit of quantitation as the highest dilution used in the assay 10, GMTs, geometric means of individual titer ratio of post-vaccination vs.

SN titers were measured using the World Health Organization procedure 35 in 50 randomly selected participants in each age and vaccine group. Briefly, serially diluted, heat-inactivated human serum samples were mixed with a fixed amount of challenge virus prior to the addition of Madin-Darby canine kidney cells. Challenge virus strains were the same as those in IIV4. After overnight incubation, the viral nucleoprotein production in infected cells was measured by enzyme linked immunosorbent assay using a monoclonal antibody specific to influenza A or influenza B nucleoprotein.

The lower limit of detection was the reciprocal of the lowest dilution used in the assay , and the upper limit of detection was the reciprocal of the highest dilution used in the assay , All other reactions and AEs were considered grade 1 for not interfering with activity, grade 2 for some interference with activity, and grade 3 for significant, preventing daily activity.

For each age group, approximately participants were to be enrolled in each IIV4 lot group and participants in each IIV3 group participants in total. This produced an overall power i. Missing or incomplete data were not replaced, with the exception that all HAI titers under the lower limit of quantitation 10 were assigned a value of 5 and all HAI titers above the upper limit of quantitation 10, were assigned a value of 10, IIV3 were assessed in all participants who completed the study according to protocol.

IIV3 was assessed primarily in all vaccinated participants. Immunogenicity measures were reported for all randomized participants who received the study vaccine with available pre- and post-vaccination HAI titers. Non-inferiority and superiority were assessed as previously described.

Safety is presented using descriptive statistics and assessed in all participants who received a study vaccine according to the vaccine actually received. Vandermeulen acts as investigator of vaccine trials for which the KU Leuven obtains research grants to conduct the vaccine trials. Van Damme acts as investigator of vaccine trials for which the University of Antwerp obtains research grants to conduct the vaccine trials.

Sesay, C. Salamand, and S. Pepin are employees of Sanofi Pasteur. All other authors declare no conflict of interest. Medical writing was provided by Dr. National Center for Biotechnology Information , U. Journal List Hum Vaccin Immunother v. Hum Vaccin Immunother. Published online Nov Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC.

KEYWORDS: adult, elderly, immunogenicity, inactivated influenza vaccine, randomized controlled trial, safety, quadrivalent influenza vaccine. Introduction Current trivalent influenza vaccines contain a single B strain, but since the s, two distinct genetic lineages of influenza B virus, Victoria and Yamagata, have been co-circulating worldwide, both of which are responsible for influenza illnesses.

Open in a separate window. Figure 1. Table 1. Participant baseline characteristics. HAI antibody responses. Figure 2. Table 3. Table 4. IIV4 lot equivalence. Table 5. Table 6. Post-vaccination day 21 seroprotection rates by previous year's vaccination.

Seroneutralizing SN antibody response to vaccination with IIV4 The SN antibody response was examined in a randomly selected subset of participants as part of an exploratory analysis. Table 7. SN antibody responses. Safety and tolerability. Discussion This study confirmed that for younger and older adults, adding a second B strain lineage to IIV3 to produce IIV4 provides a superior response to the added B strain lineage without affecting the antibody response induced by the original three vaccine strains.

Ethics The study was approved by each institution's ethics committee or review board. SN assay SN titers were measured using the World Health Organization procedure 35 in 50 randomly selected participants in each age and vaccine group. Estimation of study size For each age group, approximately participants were to be enrolled in each IIV4 lot group and participants in each IIV3 group participants in total.

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