Prospective Cohort Study

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

CA : A Cancer Journal for Clinicians

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

ABS T RA C T During the last decades, a better understanding of the biology of multiple myeloma (MM) has led to the application of novel treatment strategies for MM patients. The new antimyeloma regimens produce higher incidence of durable and of better quality responses and they improve overall survival, challenging the dogma of incurable disease, outside the context of allogeneic transplantation. This review presents all these strategies that aim to cure MM, including continuous treatment i.e. induction, consolidation and maintenance, treatment of asymptomatic MM and monitoring minimal residual disease using modern techniques, such as multi-parameter flow cytometry, molecular assays and advanced imaging.

Transfusion and Apheresis Science

Bone disease

Guise, T.A. (2006) Bone loss and fracture risk associated with cancertherapy. The Oncologist, 11, 1121–1131.Holick, M.F. (2007) Vitamin D deﬁciency. New England Journal ofMedicine, 357, 266–281.Kyle, R.A., Yee, G.C., Somerﬁeld, M.R., Flynn, P.J., Halabi, S., Jagan-nath, S., Orlowski, R.Z., Roodman, D.G., Twilde, P. & Anderson, K.(2007) American Society of Clinical Oncology 2007 Clinical PracticeGuideline update on the role of bisphosphonates in multiplemyeloma. Journal of Clinical Oncology, 25, 2464–2472.Roodman, G.D. (2005) Myeloma bone disease: pathogenesis andtreatment. Oncology (Williston Park), 19, 983–984.Terpos, E., Politou, M. & Rahemtulla, A. (2005) The role of markersofboneremodelinginmultiplemyeloma.Blood Reviews,19,125–142.

Platelet activation and apoptosis are different phenomena: evidence from the sequential dynamics and the magnitude of responses during platelet storage

712 www.thelancet.com/oncology Vol 12 August 2011 new drugs (ie, bortezomib or lenalidomide) were given as part of the initial treatment? Is zoledronic acid superior to pamidronic acid in the era of new drugs? Is zoledronic acid recommended for all patients with symptomatic myeloma or only those with abnormal fi ndings on PET, CT, or MRI? What should be the duration of treatment with zoledronic acid? Can we administer treatment for more than 2 years and in which patients? All these issues have to be addressed in future studies. Until then, based on the results of the MRC Myeloma IX study, we suggest that all patients with newly diagnosed, symptomatic multiple myeloma should be treated with zoledronic acid.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(11)70185-1.pdf

Dignity therapy for patients who are terminally ill

Introduction: Skeletal related events (SREs) remain a devastating consequence of multiple myeloma bone disease (MMBD). The presence of osteolytic disease increases the risk of SREs, which include pathologic fractures, spinal cord compression (SCC) and need for surgery or radiotherapy to bone. Methods: In this context, we conducted this single-center, prospective, observational study to determine the incidence of SREs among MM patients who received treatment with novel agents during first-line therapy (NDMM) and explore possible correlations with disease characteristics, imaging finding and patient prognosis. Results: Overall, data from 370 patients with NDMM according to the International Myeloma Working Group criteria are included in the present analysis. 200 (54%) were males, whereas 99% were Caucasian. The median age at diagnosis was 65 (range 31-92). One third (n=120) had an ECOG performance status (PS) of 0, 27% (n=100) a PS of 1, 8% (n=30) a PS of 2 and 32% (n=120) a PS of 3-4. One third were ISS stage 1 (34%), one third were ISS stage 2 (35%) and another third were ISS stage 3 (31%). 214 patients (58%) had IgG myeloma subtype, 90 patients had IgA (24%) and 62 patients had light-chain myeloma (17%). At diagnosis, the patients were evaluated for the presence of MMBD with at least one of the following imaging modalities: whole body X-rays (WBXR), whole body low dose computed tomography (WBLDCT) and magnetic resonance imaging (MRI). Based on the WBXR, 73 patients (20%) had no osteolytic lesions, 48 patients (13%) had 1 to 3 lytic lesions and 223 patients (60%) had more than 3 lytic lesions at diagnosis. According to WBLDCT, only 12 (3%) patients had no osteolytic lesions, whereas 7 (2%) patients had 1 to 3 lytic lesions and 76 (20%) had more than 3 lytic lesions (data available for 95 patients). Based on MRI findings, 58 patients (16%) had normal MRI pattern, 151 (40%) had focal MRI pattern, 139 (38%) patients had diffuse MRI pattern and 22 (6%) had variegated MRI pattern at diagnosis. Regarding treatment regimens at first line, 161 patients received IMiD– based regimens, 152 patients received PI-based treatments, 24 patients received PI and IMiD-based regimens, whereas 33 patients received therapy based on alkylating agents. SREs were observed in 183 patients at diagnosis: 154 (154/370 42%) patients presented with pathological fractures (110 with vertebral fractures, 29 with rib fractures and 15 with fractures of the long bones; 6 patients had both vertebral and 14 long bone or rib fractures), while 11 (11/370 3%) needed radiotherapy, 9 (9/370 2%) surgery to bone and 9 (9/370 2%) patients presented with spinal cord compression. The incidence of SREs at diagnosis was higher in patients with osteolytic lesions. Among patients with SREs at Diagnosis, 92.4% showed new SREs during the disease course with WBLDCT. Among those without SREs at diagnosis, 72.2% showed new SREs with WBLDCT. Importantly, patients with normal MRI pattern, who did not present with SREs at diagnosis, had statistically significant improved median overall survival in comparison with patients who had abnormal MRI pattern or presence of SREs at diagnosis (9.2 vs 6.5 years, p=0.048). Conclusion: Approximately one half of NDMM patients presented with SREs at diagnosis. The presence of SRE or abnormal MRI pattern was associated with inferior survival. SREs lead to functional impairment and increased mortality rates; therefore early detection and prompt management is essential. 

https://doi.org/10.1097/01.hs9.0000829552.03067.2b

B03: skeletal-related events and abnormal mri pattern at diagnosis are associated with inferior overall survival in patients with newly diagnosed multiple myeloma

Evangelos Terpos

Papers

Transfusion and Apheresis Science

Bone disease

Platelet activation and apoptosis are different phenomena: evidence from the sequential dynamics and the magnitude of responses during platelet storage

Dignity therapy for patients who are terminally ill

B03: skeletal-related events and abnormal mri pattern at diagnosis are associated with inferior overall survival in patients with newly diagnosed multiple myeloma