Diana F Florescu

University of Nebraska Medical Center, Omaha, Nebraska, United States

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Publications (63)202.12 Total impact

  • Diana F Florescu · Uriel Sandkovsky
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    ABSTRACT: Patients who undergo intestinal and multivisceral transplantation are at increased risk for infectious complications. Fungal infections are major causes of morbidity and mortality in these patients. The current review highlights key diagnostic and management issues in this population. Invasive infections caused by Candida spp. remain the most common invasive fungal infections in intestinal and multivisceral transplant recipients. Aspergillus is an emerging pathogen but data are limited to case reports or case series. Other fungi including the mucorales, Cryptococcus and endemic mycoses are emerging pathogens but data regarding incidence and timing of disease in intestinal and multivisceral transplant recipients are lacking. Invasive candidiasis is the most common fungal infection in patients with intestinal and multivisceral transplants. Experience for diagnosis and management comes from case series and single centers. Diagnosis and management of infections caused by other pathogens such as Aspergillus, Cryptococcus, Mucor, and endemic mycoses is usually extrapolated from other solid organ transplant recipients.
    Current opinion in organ transplantation 06/2015; 20(3):295-302. DOI:10.1097/MOT.0000000000000188 · 2.38 Impact Factor
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    ABSTRACT: From 2014 to early May 2015, >26,000 Ebola virus disease (EVD) cases were reported from West Africa. We present an EVD patient who received brincidofovir and convalescent plasma treatment. The relative contributions of supportive care, investigational therapies, or the patient's immune response upon the patient's survival could not be determined. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.
    Clinical Infectious Diseases 05/2015; DOI:10.1093/cid/civ395 · 9.42 Impact Factor
  • Uriel Sandkovsky · Andre C. Kalil · Diana F. Florescu
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    ABSTRACT: Procalcitonin has been increasingly used as a biomarker of bacterial infection and as a tool to guide antimicrobial therapy, especially in lower respiratory tract and bloodstream infections. Despite its increased use, data in patients with solid organ transplants is limited. Even without the presence of infection, procalcitonin increases as a result of surgical procedures during transplantation, implantation of devices and use of induction immunosuppressive therapy. The risk of infection is also higher in solid organ transplant recipients when compared to the general population. Monitoring PCT in the early post-transplant period seems to be promising method for early detection of infectious complications. It has been shown that elevated PCT levels after 1 week of transplantation are correlated with infectious complications. PCT may be a useful adjunctive biomarker that may improve early identification and guide appropriate treatment of infection or rejection, with the potential to further improve clinical outcomes. The use of serial PCT measurements may be more reliable than single values. It is important to recognize which factors may lead to procalcitonin increases in the post-transplantation period, which in turn will help understand the kinetics of this useful biomarker in this important patient population. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
    Clinical Transplantation 05/2015; 29(8). DOI:10.1111/ctr.12568 · 1.49 Impact Factor
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    Andre C Kalil · Mark E Rupp · Diana F Florescu
  • D F Florescu
    Clinical & Experimental Immunology 12/2014; 178 Suppl 1:54-6. DOI:10.1111/cei.12510 · 3.28 Impact Factor
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    ABSTRACT: Background: The experience with cidofovir in pediatric SOT is limited. The study aimed to assess the impact of cidofovir use on the renal function. Methods: Summary statistics were presented for demographics and outcomes, Wilcoxon signed-rank tests to compare changes in renal function and Wilcoxon rank-sum tests to test association with potential confounding factors. Results: We included 25 patients (mean age 4.2years; SD 4.6): liver-small bowel (15), small bowel (4), liver (3) and kidney (3) transplant recipients. Viral infections: adenovirus (20), BKv (2), HHV6 (1), and EBV (1). 24% of patients while on cidofovir compared with 4% at baseline (p=0.03) were on renal replacement therapy (RRT). For patients not on RRT, there was no difference: 1) in the median creatinine clearance between baseline and one month after (p=0.32) or end of cidofovir treatment (p=0.23); 2) in the creatinine from baseline to end of cidofovir therapy (p=0.2); there was marginal decrease in the median creatinine from baseline to one month post-cidofovir treatment (p=0.06). Less patients had proteinuria (72.2% vs. 27.8%;p=0.02) and hematuria (22.2% vs. 0%) at the end than at the beginning of cidofovir treatment. No evidences of associations were found between changes in creatinine clearance (by univariate analysis) with: exposure to vancomycin (p=0.44), amikacin (p=0.13), dopamine (p=0.66), epinephrine (p=0.99), norepinephrine (p=0.48), intravenous contrast (p=0.41) and surgery (p=0.59). Conclusion: Cidofovir was mainly used to treat adenovirus infections. In our study, cidofovir did not have nephrotoxic effects during the treatment and 1 month after treatment in pediatric transplant recipients, although they required RRT while on cidofovir because of fluid overload.
    IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
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    ABSTRACT: Background. Sepsis is a serious complication of solid organ transplant (SOT). Evidence on survival differences between SOT recipients and non-SOT patients with sepsis is lacking. Methods. This was a matched, case-control propensity-adjusted study. Conditional logistic regression was performed for risk factor analysis, and Cox proportional hazards regression for survival analysis. Results. Three hundred sixty-nine patients (123 cases; 246 controls) diagnosed with blood culture-proven sepsis were matched 1: 2 by age, sex, and hospital location. The distribution of allografts was 36.6% kidney, 34.1% liver, 13% kidney-pancreas, 7.3% small bowel/liver, 5.7% heart/lung, and 3.3% multivisceral. The conditional logistic regression showed that the following factors were significantly more frequently associated with SOT compared to non-SOT: higher number of comorbidities (odds ratio [OR] = 8.2 [95% confidence interval {CI}, 1.48-45.44], P = .016); higher Sepsis-related Organ Failure Assessment score (OR = 1.2 [95% CI, 1.07-1.32], P = .001); presence of nosocomial infection (OR = 36.3 [95% CI, 9.71-135.96], P < .0001); appropriate initial antibiotics (OR = 0.04 [95% CI,.006-.23], P < .0001); and lower white blood cell count (OR = 0.93 [95% CI,.89-.97], P < .0001). Cox proportional hazards regression showed that after all adjustments for clinical presentation, severity of illness, and types of infection, SOT recipients with sepsis had a significantly lower risk of death at 28 days (hazard ratio [HR] = 0.22 [95% CI,.09-.54], P = .001) and at 90 days (HR = 0.43 [95% CI,.20-.89], P = .025). Conclusions. The 28-day and 90-day mortality were significantly decreased for transplant recipients compared with nontransplant patients. These findings suggest that the immunosuppression associated with transplantation may provide a survival advantage to transplant recipients with sepsis through modulation of the inflammatory response.
    Clinical Infectious Diseases 10/2014; 60(2). DOI:10.1093/cid/ciu789 · 9.42 Impact Factor
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    ABSTRACT: Background Severe hypogammaglobulinemia (IgG<400 mg/dL) has adverse impact on mortality during the first year post-transplantation. The aim of the study was to determine whether increasing IgG levels to >400mg/dl improved outcomes.Methods Kaplan-Meier analyses were performed to estimate survival, log-rank test to compare survival distributions between groups and Fisher's exact test to determine the association between hypogammaglobulinemia and rejection or graft loss.Results37 solid organ transplant (SOT) recipients were included. Hypogammaglobulinemia was diagnosed at median of 5.6months (range:0-291.8months) post-transplantation. Types of transplants: liver-small bowel (17); liver-small bowel-kidney (2); liver (5); small bowel (4); liver-kidney (1); kidney/kidney-pancreas (3); heart (3); heart-kidney (1); heart-lung (1). The 3-year survival after the diagnosis of hypogammaglobulinemia was 49.5% (95%CI:32.2-64.6%). Patients were dichotomized based upon IgG level at last follow-up: IgG>400mg/dL (23patients) and IgG<400mg/dL (14patients). There was no evidence of a difference in survival (p=0.44), rejection rate (p=0.44) and graft loss censored for death (p=0.99) at one year between these 2 groups. There was no difference in survival between patients receiving or not immunoglobulin (p=0.99) or cytomegalovirus hyperimmunoglobulin (p=0.14).Conclusion Severe hypogammaglobulinemia after SOT is associated with high mortality rates, but increasing IgG levels to >400mg/dL did not seem to translate in better patient or graft survival in this cohort.This article is protected by copyright. All rights reserved.
    Clinical Transplantation 09/2014; 28(11). DOI:10.1111/ctr.12458 · 1.49 Impact Factor
  • Diana F Florescu · Megan A Keck
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    ABSTRACT: CMX001 (hexadecyloxypropyl-cidofovir, Brincidofovir) is a broad spectrum, lipid conjugate of cidofovir that is converted intracellularly into the active antiviral, cidofovir diphosphate. The lipid conjugation results in oral bioavailability, higher intracellular concentrations of active drug, lower plasma concentrations of cidofovir and increased antiviral potency against dsDNA viruses.
    Expert Review of Anti-infective Therapy 08/2014; 12(10). DOI:10.1586/14787210.2014.948847 · 2.28 Impact Factor
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    Uriel Sandkovsky · Luciano Vargas · Diana F Florescu
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    ABSTRACT: Infections caused by adenoviruses are associated with significant morbidity and mortality in both hematopoietic stem cell and solid organ transplant recipients. The risk seems to be highest in allogeneic hematopoietic stem cell transplant recipients as well as heart, lung and small-bowel transplant recipients. Management of these infections may be difficult and includes reduction of immunosuppression whenever possible combined sometimes with antiviral therapy (mainly cidofovir). The currently available antiviral therapy is limited by the need for intravenous administration, potentially significant renal and hematologic toxicities. New emerging therapies such as brincidofovir and transfusion of adenovirus-specific T-lymphocytes may increase the available armamentarium for these potentially life-threatening infections.
    Current Infectious Disease Reports 08/2014; 16(8):416. DOI:10.1007/s11908-014-0416-y
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    ABSTRACT: Background We conducted a randomized and unblinded 2×2 sequential-factorial trial, composed of an induction arm (part 1) comparing single-dose (SD) versus divided-dose rabbit antithymocyte globulin (rATG), and a maintenance arm (part 2) comparing tacrolimus minimization versus withdrawal. We report the long-term safety and efficacy of SD-rATG induction in the context of early steroid withdrawal and tacrolimus minimization or withdrawal. Methods Patients (n=180) received 6 mg/kg rATG, SD or four alternate-day doses (1.5 mg/kg/dose), with early steroid withdrawal and tacrolimus or sirolimus maintenance. After 6 months targeted maintenance levels were tacrolimus, 2 to 4 ng/mL and sirolimus, 4 to 6 ng/mL or, if calcineurin inhibitor–withdrawn, sirolimus 8 to 12 ng/mL with mycophenolate mofetil 2 g two times per day. Primary endpoints were renal function (abbreviated modification of diet in renal disease) and chronic graft histopathology (Banff). Secondary endpoints included patient survival, graft survival, biopsy-proven rejection, and infectious or noninfectious complications. Results Follow-up averaged longer than 4 years. Tacrolimus or sirolimus and mycophenolate mofetil exposure was identical between groups. The SD-rATG associated with improved renal function (2-36 months; P<0.001) in deceased donor recipients. The SD-rATG associated with quicker lymphocyte, CD4 T cell, and CD4-CD8 recovery and fewer infections. Cox multivariate hazard modeling showed divided-dose–rATG (P=0.019), deceased donor (P=0.003), serious infection (P=0.0.018), and lower lymphocyte count (P=0.001) associated with increased mortality. Patients with all four covariates showed a 27-fold increased likelihood of death (P=0.00002). Chronic graft histopathology, rejection rates, and death-censored graft survival were not significantly different between groups. Conclusion The SD-rATG induction improves the 3-year renal function in recipients of deceased donor kidneys. This benefit, along with possibly improved patient survival and fewer infections suggest that how rATG is administered may impact its efficacy and safety.
    Transplantation 07/2014; 99(1). DOI:10.1097/TP.0000000000000250 · 3.78 Impact Factor
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    ABSTRACT: Background: Clinical experience with cidofovir in pediatric solid organ transplantation is limited. We assessed the effect of cidofovir use on renal function in pediatric solid organ transplant recipients. Methods: Wilcoxon signed-rank tests were used to determine if changes in renal function were significant, Wilcoxon rank-sum tests to test the association between changes in glomerular filtration rate and potential confounding factors, and MacNemar tests to compare the proportions of patients at different time points. Results: We included 25 patients with a mean age of 4.2 years (SD 4.6). More patients were receiving renal replacement therapy while being treated with cidofovir compared with baseline (24% vs. 4%; P = 0.03). For patients not receiving renal replacement therapy, there was no evidence of a significant median change in glomerular filtration rate from baseline to 1 month after cidofovir treatment (P = 0.32) or to the end of cidofovir treatment (P = 0.23) or in creatinine from baseline to the end of cidofovir therapy (P = 0.2). There was a marginal decreased median change in creatinine from baseline to 1 month after cidofovir treatment (P = 0.06). Fewer patients had proteinuria (72.2% vs. 27.8%; P = 0.02) and hematuria (22.2% vs. 0%) after cidofovir treatment. Conclusion: In our pediatric transplant cohort, cidofovir did not significantly change renal function reflected by creatinine, glomerular filtration rate, hematuria or proteinuria, but a significant number of patients required renal replacement therapy because of fluid overload.
    The Pediatric Infectious Disease Journal 07/2014; 34(1). DOI:10.1097/INF.0000000000000487 · 3.14 Impact Factor
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    ABSTRACT: Background: We aimed to evaluate and quantify the risk of serious opportunistic infections after induction with polyclonal antibodies versus IL-2 receptor antagonists (IL-2RAs) in randomized clinical trials. Methods: PRISMA guidelines were followed and random-effects models were performed. Results: 70 randomized clinical trials (10,106 patients) were selected: 36 polyclonal antibodies (n = 3377), and 34 IL-2RAs (n = 6729). Compared to controls, polyclonal antibodies showed higher risk of serious opportunistic infections (OR: 1.93, 95% CI: 1.34-2.80; p < 0.0001); IL-2RAs were associated with lower risk of serious opportunistic infections (OR: 0.80, 95% CI: 0.68-0.94; p = 0.009). Polyclonal antibodies were associated with higher risk of bacterial (OR: 1.58, 95% CI: 1.00-2.50; p = 0.049) and viral infections (OR: 2.37, 95% CI: 1.60-3.49; p < 0.0001), while IL-2RAs were associated with lower risk of cytomegalovirus (CMV) disease (OR: 0.73, 95% CI: 0.56-0.97; p = 0.032). Adjusted indirect comparison: compared to polyclonal antibodies, IL-2RAs were associated with lower risk of serious opportunistic infections (OR: 0.41, 95% CI: 0.34-0.49; p < 0.0001), bacterial infections (OR: 0.51, 95% CI: 0.39-0.67; p < 0.0001) and CMV disease (OR: 0.58, 95% CI: 0.34-0.98; p = 0.043). Results remained consistent across allografts.Conclusion The risk of serious opportunistic infections, bacterial infections and CMV disease were all significantly decreased with IL-2RAs compared to polyclonal antibodies.
    Expert Review of Anti-infective Therapy 05/2014; DOI:10.1586/14787210.2014.917046 · 2.28 Impact Factor
  • Biology of Blood and Marrow Transplantation 02/2014; 20(2):S93. DOI:10.1016/j.bbmt.2013.12.121 · 3.35 Impact Factor
  • Diana F Florescu · Fang Qiu · Cynthia M Schmidt · Andre C Kalil
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    ABSTRACT: Background. Prophylactic and preemptive strategies are used to prevent cytomegalovirus infections after solid organ transplantation. We assessed the safety and efficacy of both strategies for CMV prevention. Methods. DerSimonian and Laird random-effects model was used for pooling the data and Q statistic and I-squared methods were used to assess statistical heterogeneity. Results. Twenty studies (2744 patients) were selected for the direct analysis and 20 studies (2544 patients) for the indirect analysis. The odds of CMV syndrome (OR=1.10;95%CI:0.60-2.03;p=0.757;Q=18.55;I(2)=51.49%) and disease (OR=0.77;95%CI:0.41-1.47;p=0.432;Q=32.71;I(2)=44.97%.) were not significantly different between strategies. The odds of developing late-onset CMV infections were higher for the prophylactic compared to the preemptive strategy (OR=6.21;95%CI:2.55-15.20;p<0.0001;Q=9.66;I(2)=37.9%). The odds of CMV viremia were lower for prophylaxis (OR=0.42;95%CI:0.24-0.74;p=0.003;Q=48.10;I(2)=75.1%) than preemptive therapy. No differences between strategies were noted for: graft loss (OR=0.88;95%CI:0.37-2.13;p=0.779;Q=13.03,I(2)=38.62%), graft loss censored for death (OR=0.73;95%CI:0.17-3.21;p=0.679;Q=4.48;I(2)=55.32%), acute rejection (OR=0.93;95%CI:0.70-1.24;p=0.637;Q=12.99;I(2)=7.61%) and mortality (OR=0.80;95%CI:0.56-1.14;p=0.220;Q=8.76;I(2)=0%). Other infections (HSV, VZV, bacterial and fungal infections) were not significantly different between strategies. Leukopenia (OR=1.97;95%CI:1.39-2.79;p=0.0001;Q=7.10;I(2)=0%) and neutropenia (OR=2.07;95%CI:1.13-3.78;p=0.018;Q=6.77;I(2)=11.40%) were more frequent with prophylaxis than preemptive strategy. The results of direct and indirect comparisons were consistent. Conclusions. Prophylaxis was associated with less early post-transplant viremia, but with significantly more late-onset CMV infections and side effects - leukopenia and neutropenia, than the preemptive strategy. Both preventive strategies showed similar efficacy in preventing CMV syndrome and disease, with no differences regarding rejection, graft loss, death and opportunistic infections.
    Clinical Infectious Diseases 01/2014; 58(6). DOI:10.1093/cid/cit945 · 9.42 Impact Factor
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    Diana F Florescu · Andre C Kalil
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    ABSTRACT: Severe sepsis is traditionally associated with bacterial diseases. While fungi and parasites can also cause sepsis, they are significantly less common than bacterial causes. However, viruses are becoming a growing cause of severe sepsis worldwide. Among these viruses, influenza is crossing all geographic boundaries and is causing larger epidemics and pandemics. As a consequence, more critically ill patients with severe sepsis caused directly by influenza viruses, or indirectly by influenza-induced secondary bacterial infections are being admitted to hospitals worldwide. This manuscript aims to provide a pathophysiological and clinical update on the link between influenza and severe sepsis.
    Virulence 11/2013; 5(1). DOI:10.4161/viru.27103 · 3.32 Impact Factor
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    ABSTRACT: Practice variation regarding cytomegalovirus (CMV) prevention and treatment across intestinal transplantation (IT) programs is unknown. An electronic survey was sent to IT programs registered with the Intestinal Transplant Association. Proportions were analyzed for categorical variables; means and SDs were analyzed for continuous variables. Seventy-seven percent of IT programs responded to the survey. For CMV D+/R- recipients, 39.1% programs used universal prophylaxis (UP), 8.7% preemptive strategy (PE), and 52.2% hybrid strategy. For CMV R+ recipients, 45.8% programs used UP, 12.5% PE, 37.1% hybrid strategy, and 4.2% none. For CMV D-/R- recipients, 39.1% programs used UP, 21.7% PE, 26.1% hybrid strategy, and 13% none. Frequency of monitoring for PE was weekly 71.4% of programs, every 2 weeks 21.4%, and monthly 7.1%. For CMV viremia, syndrome and disease, the most common first-line agents used were ganciclovir (100% and 96.2%) and valganciclovir (23.1%) and the second-line agent was foscarnet (73.1% and 84.6%). Immunoglobulins were administered in 65.4% of the programs for pneumonia (69.2%), meningoencephalitis (50%), enteritis (46.2%), colitis (38.5%), syndrome (42.3%), viremia (30.8%), and resistant/refractory infections (11.5%). Prophylaxis and hybrid strategy were the most commonly used. Treatment practices were consistent and mainly involved ganciclovir as first-line agent and foscarnet as second-line agent. The use of immunoglobulins appeared to be more common than in other allografts.
    Transplantation 10/2013; 97(1). DOI:10.1097/TP.0b013e3182a6baa2 · 3.78 Impact Factor
  • D F Florescu · A C Kalil · F Qiu · C M Schmidt · U Sandkovsky
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    ABSTRACT: Hypogammaglobulinemia has been described after solid organ transplantation and has been associated with increased risk of infections. The aim of the study was to evaluate the rate of severe hypogammaglobulinemia and its relationship with the risk of infections during the first year posttransplantation. Eighteen studies (1756 patients) that evaluated hypogammaglobulinemia and posttransplant infections were included. The data were pooled using the DerSimonian and Laird random-effects model. Q statistic method was used to assess statistical heterogeneity. Within the first year posttransplantation, the rate of hypogammaglobulinemia (IgG < 700 mg/dL) was 45% (95% CI: 0.34-0.55; Q = 330.1, p < 0.0001), the rate of mild hypogammaglobulinemia (IgG = 400-700 mg/dL) was 39% (95% CI: 0.22-0.56; Q = 210.09, p < 0.0001) and the rate of severe hypogammaglobulinemia (IgG < 400 mg/dL) was 15% (95% CI: 0.08-0.22; Q = 50.15, p < 0.0001). The rate of hypogammaglobulinemia by allograft type: heart 49% (21%-78%; Q = 131.16, p < 0.0001); kidney 40% (30%-49%; Q = 24.55, p = 0.0002); liver 16% (0.001%-35%; Q = 14.31, p = 0.0002) and lung 63% (53%-74%; Q = 6.85, p = 0.08). The odds of respiratory infection (OR = 4.83; 95% CI: 1.66-14.05; p = 0.004; I(2) = 0%), CMV (OR = 2.40; 95% CI: 1.16-4.96; p = 0.02; I(2) = 26.66%), Aspergillus (OR = 8.19; 95% CI: 2.38-28.21; p = 0.0009; I(2) = 17.02%) and other fungal infections (OR = 3.69; 95% CI: 1.11-12.33; p = 0.03; I(2) = 0%) for patients with IgG <400 mg/dL were higher than the odds for patients with IgG >400 mg/dL. The odds for 1-year all-cause mortality for severe hypogammaglobulinemia group was 21.91 times higher than those for IgG >400 mg/dL group (95% CI: 2.49-192.55; p = 0.005; I(2) = 0%). Severe hypogammaglobulinemia during the first year posttransplantation significantly increased the risk of CMV, fungal and respiratory infections, and was associated with higher 1-year all-cause mortality.
    American Journal of Transplantation 08/2013; 13(10). DOI:10.1111/ajt.12401 · 6.19 Impact Factor
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    Andre C Kalil · Diana F Florescu
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    ABSTRACT: Despite the same manufacturer, the same drotrecogin alfa activated dose, and the same placebo-controlled design, the negative result from the PROWESS-SHOCK trial contradicted the survival benefit observed in the PROWESS trial. We hypothesize that the different results were due to factors other than the experimental therapy and performed an analysis of the clinical heterogeneity (differences related to the trials' clinical aspects) and the statistical heterogeneity (differences related to the trials' statistical aspects) between these trials. Baseline characteristics and co-interventions were analyzed by chi-square testing and mortality was analyzed by random-effects modeling and I2. Our findings show that clinical variables presented significant heterogeneity, and that up to 90% of the mortality differences between both trials were not due to chance. These results demonstrate that PROWESS and PROWESS-SHOCK are not comparable trials due to the highly significant clinical and statistical heterogeneity. We propose a new and pragmatic solution.
    Critical care (London, England) 07/2013; 17(4):167. DOI:10.1186/cc12752
  • Diana F Florescu · Alan N Langnas · Uriel Sandkovsky
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    ABSTRACT: Intestinal transplantation (IT) has become a standard treatment for patients with intestinal failure and complications of parenteral nutrition. The pool of intestinal transplant recipients has been slowly growing over the last two decades. Of the 2191 ITs performed between 1 January 1990 and 31 March 2012, 50.5% were children less than 10 years of age. Survival rates at 1, 5 and 10 years have been reported to be 78.5, 58.2 and 47%, respectively. IT restores organ functions, but it is associated with complications, with infections representing the major cause of morbidity and mortality in this population.
    Expert Review of Anticancer Therapy 04/2013; 11(4):367-81. DOI:10.1586/eri.13.25 · 3.06 Impact Factor

Publication Stats

488 Citations
202.12 Total Impact Points

Institutions

  • 2008–2015
    • University of Nebraska Medical Center
      • Division of Infectious Diseases
      Omaha, Nebraska, United States
  • 2013
    • Cleveland Clinic
      Cleveland, Ohio, United States
  • 2011–2013
    • University of Nebraska at Omaha
      Omaha, Nebraska, United States
  • 2011–2012
    • The Nebraska Medical Center
      Omaha, Nebraska, United States