Successful matched sibling donor marrow transplantation following reduced intensity conditioning in children with hemoglobinopathies

Fifty-two children with symptomatic sickle cell disease sickle cell disease (SCD) (N = 43) or transfusion-dependent thalassemia (N = 9) received matched sibling donor marrow (46), marrow and cord product (5), or cord blood (1) allografts following reduced intensity conditioning (RIC) with alemtuzumab, fludarabine, and melphalan between March 2003 and May 2014*. The Kaplan-Meier probabilities of overall and event-free survival at a median of 3.42 (range, 0.75-11.83) years were 94.2% and 92.3% for the group, 93% and 90.7% for SCD, and 100% and 100% for thalassemia, respectively. Treatment-related mortality (all related to graft versus host disease, GVHD) was noted in three (5.7%) recipients, all 17-18 years of age. Acute and chronic GVHD was noted in 23% and 13%, respectively, with 81% of recipients off immunosuppression by 1 year. Graft rejection was limited to the single umbilical cord blood recipient who had prompt autologous hematopoietic recovery. Fourteen (27%) had mixed chimerism at 1 year and beyond; all had discontinued immunosuppression between 4 and 12 months from transplant with no subsequent consequence on GVHD or rejection. Infectious complications included predominantly bacteremia (48% were staphylococcus) and CMV reactivation (43%) necessitating preemptive therapy. Lymphocyte recovery beyond 6 months was associated with subsidence of infectious complications. All patients who engrafted were transfusion independent; no strokes or pulmonary complications of SCD were noted, and pain symptoms subsided within 6 months posttransplant. These findings support using RIC for patients with hemoglobinopathy undergoing matched sibling marrow transplantation (*www.Clinical Trials.gov: NCT00920972, NCT01050855, NCT02435901).

Psychiatric Morbidity in Chinese Adults with Type 1 Diabetes in Hong Kong

OBJECTIVES

To determine the prevalence of psychiatric morbidity and identify the correlates, as well as to evaluate the effectiveness of the Hospital Anxiety and Depression Scale and the 12-item General Health Questionnaire to screen for psychiatric morbidity in Chinese adults with type 1 diabetes.

METHODS

Subjects were recruited from a local public diabetes specialist outpatient clinic from August 2013 to January 2014. Demographic and clinical factors were recorded. Psychiatric diagnosis was established using the Chinese-bilingual version of the Structured Clinical Interview for the DSM-IV Axis I disorders. Scores for the Hospital Anxiety and Depression Scale and the 12-item General Health Questionnaire were compared with the psychiatric diagnosis.

RESULTS

Of the 136 patients, the point prevalence of overall psychiatric, depressive, and anxiety disorders was 39.7%, 23.5%, and 25.7%, respectively. Family history of mental illness, smoking status, history of mental illness, presence of social problems, perceived absence of confidant, presence of neuropathy and hyperlipidaemia, as well as higher level of glycosylated haemoglobin were found to be the associated factors.

CONCLUSION

Psychiatric disorders were common in Chinese adults with type 1 diabetes. Finding out associated factors and using the Hospital Anxiety and Depression Scale and the 12-item General Health Questionnaire as a screening tool helped to identify patients in a diabetes clinic with psychiatric disorders.

Transplant Outcomes for Children with T Cell Acute Lymphoblastic Leukemia in Second Remission: A Report from the Center for International Blood and Marrow Transplant Research

Survival for children with relapsed T cell acute lymphoblastic leukemia (T-ALL) is poor when treated with chemotherapy alone, and outcomes after allogeneic hematopoietic cell transplantation (HCT) is not well described. Two hundred twenty-nine children with T-ALL in second complete remission (CR2) received an HCT after myeloablative conditioning between 2000 and 2011 and were reported to the Center for International Blood and Marrow Transplant Research. Median age was 10 years (range, 2 to 18). Donor source was umbilical cord blood (26%), matched sibling bone marrow (38%), or unrelated bone marrow/peripheral blood (36%). Acute (grades II to IV) and chronic graft-versus-host disease occurred in, respectively, 35% (95% confidence interval [CI], 27% to 45%) and 26% (95% CI, 20% to 33%) of patients. Transplant-related mortality at day 100 and 3-year relapse rates were 13% (95% CI, 9% to 18%) and 30% (95% CI, 24% to 37%), respectively. Three-year overall survival and disease-free survival rates were 48% (95% CI, 41% to 55%) and 46% (95% CI, 39% to 52%), respectively. In multivariate analysis, patients with bone marrow relapse, with or without concurrent extramedullary relapse before HCT, were most likely to relapse (hazard ratio, 3.94; P = .005) as compared with isolated extramedullary disease. In conclusion, HCT for pediatric T-ALL in CR2 demonstrates reasonable and durable outcomes, and consideration for HCT is warranted.

Transplantation outcomes for severe combined immunodeficiency, 2000-2009

BACKGROUND

The Primary Immune Deficiency Treatment Consortium was formed to analyze the results of hematopoietic-cell transplantation in children with severe combined immunodeficiency (SCID) and other primary immunodeficiencies. Factors associated with a good transplantation outcome need to be identified in order to design safer and more effective curative therapy, particularly for children with SCID diagnosed at birth.

METHODS

We collected data retrospectively from 240 infants with SCID who had received transplants at 25 centers during a 10-year period (2000 through 2009).

RESULTS

Survival at 5 years, freedom from immunoglobulin substitution, and CD3+ T-cell and IgA recovery were more likely among recipients of grafts from matched sibling donors than among recipients of grafts from alternative donors. However, the survival rate was high regardless of donor type among infants who received transplants at 3.5 months of age or younger (94%) and among older infants without prior infection (90%) or with infection that had resolved (82%). Among actively infected infants without a matched sibling donor, survival was best among recipients of haploidentical T-cell-depleted transplants in the absence of any pretransplantation conditioning. Among survivors, reduced-intensity or myeloablative pretransplantation conditioning was associated with an increased likelihood of a CD3+ T-cell count of more than 1000 per cubic millimeter, freedom from immunoglobulin substitution, and IgA recovery but did not significantly affect CD4+ T-cell recovery or recovery of phytohemagglutinin-induced T-cell proliferation. The genetic subtype of SCID affected the quality of CD3+ T-cell recovery but not survival.

CONCLUSIONS

Transplants from donors other than matched siblings were associated with excellent survival among infants with SCID identified before the onset of infection. All available graft sources are expected to lead to excellent survival among asymptomatic infants. (Funded by the National Institute of Allergy and Infectious Diseases and others.).

Reconstructive surgery for females with congenital adrenal hyperplasia due to 21-hydroxylase deficiency: a review from the Prince of Wales Hospital

OBJECTIVES

To present the results of feminising genitoplasty done in female patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

DESIGN

Case series.

SETTING

A tertiary referral centre in Hong Kong.

PATIENTS

Female patients with congenital adrenal hyperplasia undergoing corrective surgery for virilisation between 1993 and 2012.

MAIN OUTCOME MEASURES

The operative result was judged with a scoring system (1-3) for four areas: appearance of clitoris, labia and vagina, plus requirement for revision surgery.

RESULTS

A total of 23 female patients with congenital adrenal hyperplasia with a median age of 17.5 (range, 1.5-33.8) years were identified. Of these individuals, 17 presented in the neonatal period and early infancy, of which four had an additional salt-losing crisis. Six patients-including four migrants from mainland China-were late presenters at a median age of 2 (range, 0.5-14) years. Twenty-two patients had corrective surgery at a median age of 2 (range, 1-14) years. Clitoral reduction was performed in all, and further surgery in 21 patients. The additional surgery was flap vaginoplasty in 10 patients, a modified Passerini procedure in six, and a labial reconstruction in five; one patient with prominent clitoris was for observation only. Minor revision surgery (eg mucosal trimming) was required in three patients; a revision vaginoplasty was done in one individual. Of the 23 patients, 18 (78%) with a median age of 20 (range, 9.3-33.8) years participated in the outcome evaluation: a 'good' outcome (4 points) was seen in 12 patients and a 'satisfactory' (5-9 points) result in five patients.

CONCLUSIONS

Nearly three quarters of our cohort (n=17) presented with classic virilising form of 21-hydroxylase deficiency. Only four (25%) patients experienced a salt-losing crisis. Female gender assignment at birth was maintained for all individuals in this group. 'Good' and 'satisfactory' outcomes of surgery were reported in nearly all participants.

Does K-wire position in tension band wiring of olecranon fractures affect its complications and removal of metal rate?

BACKGROUND

Despite the recognised complications of migration of wires and soft tissue irritation, tension band wiring (TBW) remains the gold standard for fixation of displaced, minimally comminuted olecranon fractures. There is much variation in placement of the K-wires with current AO guidance stating that each wire should be drilled through the anterior cortex and then backed up by 1 cm. The aim of this study was to examine the effect of K-wire position (intramedullary vs. transcortical) on stability of the construct and significant local complications.

METHODS

All patients who underwent TBW for an isolated olecranon fracture in our trauma unit between 1/1/2009 and 31/12/2011 were included in this retrospective study. Mean follow-up was 14 months (range 5-29 months). Data was gathered from medical records and radiographs. The outcome measured was removal of metal due to complications such as wound problems or proximal migration of wires as standard practice within out trauma unit.

RESULTS

Sixty-three patients met the inclusion criteria. Forty-seven had an intramedullary compared with 16 with transcortical configuration (ratio 3:1). Nine patients (19%) with intramedullary K-wires required removal of metalwork - seven due to prominent metalwork and two with wound infection. Four patients (25%) with transcortical K-wires required removal of metalwork - three due to prominent metalwork and one with failure of metalwork. There was no significant statistical difference between transcortical and intramedullary K-wire placement with regards to complication rates following tension band wiring of an isolated olecranon fracture requiring removal of metal (Chi squared test with Yates' correction p = 0.89).

CONCLUSION

We concluded that we found no difference in complications or metalwork removal rate in the placement of K-wire in tension band wiring for isolated olecranon fracture. We recognise our study was limited by small numbers and is based on the experience of one trauma unit.

Outcome of transplantation for acute lymphoblastic leukemia in children with Down syndrome

We report on 27 patients with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) who received allogeneic hematopoietic cell transplantation (HCT) between 2000 and 2009. Seventy-eight percent of patients received myeloablative conditioning and 52% underwent transplantation in second remission. Disease-free survival (DFS) was 24% at a median of 3 years. Post-transplant leukemic relapse was more frequent than expected for children with DS-ALL (54%) than for non-DS ALL. These data suggest leukemic relapse rather than transplant toxicity is the most important cause of treatment failure. Advancements in leukemia control are especially needed for improvement in HCT outcomes for DS-ALL.

Silencing of Jagged1 inhibits cell growth and invasion in colorectal cancer

Dysregulated Notch signaling has a critical role in the tumorigenesis. Jagged1, a Notch ligand, is overexpressed in various human cancers. Recent studies revealed the involvement of Jagged1 in colorectal cancer (CRC) development. These basic studies provide a promising potential for inhibition of the Notch pathway for the treatment of CRC. Herein, we aimed to investigate the consequences of targeting Jagged1 using shRNA on CRC both in vitro and in vivo to test their potential to inhibit this key element for CRC treatment. We found that downregulation of Jagged1 with lentiviral Jagged1-shRNA resulted in decreased colon cancer cell viability in vitro, most likely mediated through reduced cell proliferation. Importantly, Jagged1 knockdown induced G₀/G₁ phase cell cycle arrest, with reduced Cyclin D1, Cyclin E and c-Myc expression. Silencing of Jagged1 reduced the migration and invasive capacity of the colon cancer cells in vitro. Furthermore, colon cancer cells with knockdown of Jagged1 had much slower growth rate than control cells in a xenograft mouse model in vivo, with a marked downregulation of cell proliferation markers (PCNA, Ki-67, and c-Myc) and metastasis markers (MMP-2 and MMP-9). These findings rationalize a mechanistic approach to CRC treatment based on Jagged1-targeted therapeutic development.

Under pressure: a contribution to the pathogenesis of acquired ileal atresia

An acquired ileal atresia is a rare occurrence. A 3-week-old neonate is presented, who developed postnatally a type 2 ileal atresia and an ileal stenosis within a pre-existing internal hernia secondary to an adhesion band. The literature reports a total of eight cases (4 females) with acquired ileal atresia in babies ranging in age from 3 weeks to 2 years (median 4 months). Mechanical forces (eg, adhesion band, intussusception and volvulus) onto the intestine are most frequently (75%) implicated as the primary event. The distal ileum is most often affected and a type 3A atresia is identified in six of eight (75%) cases.

Allogeneic human mesenchymal stem cell therapy (remestemcel-L, Prochymal) as a rescue agent for severe refractory acute graft-versus-host disease in pediatric patients

Severe steroid-refractory acute graft-versus-host disease (aGVHD) is related to significant mortality and morbidity after allogeneic stem cell transplantation. Early clinical trials of therapy with human mesenchymal stem cells (hMSCs) in pediatric patients with severe aGVHD resistant to multiple immunosuppressive agents showed promising results. In this study, we evaluated the risk/benefit profile of remestemcel-L (Prochymal), a third-party, off-the-shelf source of hMSCs, as a rescue agent for treatment-resistant aGVHD in pediatric patients. Children with grade B-D aGVHD failing steroids and, in most cases, other immunosuppressive agents were eligible for enrollment. Patients received 8 biweekly i.v. infusions of 2 × 10(6) hMSCs/kg for 4 weeks, with an additional 4 weekly infusions after day +28 for patients who achieved either a partial or mixed response. The enrolled patients compose a very challenging population with severe disease that was nonresponsive to the standard of care, with 88% of the patients experiencing severe aGVHD (grade C or D). Seventy-five patients (median age, 8 yr; 58.7% male; and 61.3% Caucasian) were treated in this study. Sixty-four patients (85.3%) had received an unrelated hematopoietic stem cell graft, and 28 patients (37.3%) had received a cord blood graft. At baseline, the distribution of aGVHD grades B, C, and D was 12.0%, 28.0%, and 60.0%, respectively. The median duration of aGVHD before enrollment was 30 d (range, 2 to 1639 d), and patients failed a median of 3 immunosuppressive agents. Organ involvement at baseline was 86.7% gastrointestinal, 54.7% skin, and 36.0% liver. Thirty-six patients (48.0%) had 2 organs involved, and 11 patients (14.7%) had all 3 organs involved. When stratified by aGVHD grade at baseline, the rate of overall response (complete and partial response) at day +28 was 66.7% for aGVHD grade B, 76.2% for grade C, and 53.3% for grade D. Overall response for individual organs at day +28 was 58.5% for the gastrointestinal system, 75.6% for skin, and 44.4% for liver. Collectively, overall response at day +28 for patients treated for severe refractory aGVHD was 61.3%, and this response was correlated with statistically significant improved survival at day +100 after hMSC infusion. Patients who responded to therapy by day +28 had a higher Kaplan-Meier estimated probability of 100-d survival compared with patients who did not respond (78.1% versus 31.0%; P < .001). Prochymal infusions were generally well tolerated, with no evidence of ectopic tissue formation.

Positive influence of L-carnitine on the different muscle fibres types of racing pigeons

Succinate dehydrogenase (SDH), Ca(2+) ATPase, Lactate dehydrogenase (LDH), are involved in energy metabolism. These enzymes can be used as indicators of the energy capacity of aerobic cells. The study investigated the effects of L-carnitine supplementation on M. pectoralis superficialis, M. pectoralis profundus, M. extensor carpi radialis muscle and M. flexor carpi ulnaris. Twenty-eight racing pigeons hatched at the same time were divided randomly into three groups. Eight pigeons, which were used as the control group, were sacrificed at 92-day old. The remaining twenty pigeons continued training until they reached 157-day old, with half the pigeons getting 25 mg/head/day of L-carnitine, while the other half given the same amount of water. The pigeons were assessed by histochemical methods and reverse transcription polymerase chain reaction (RT-PCR). To assess influence of L-carnitine on muscle fibre composition and the performance of three genes' mRNA, this study applied SDH localization, SDH, Ca(2+) ATPase and LDH mRNA expression to examine the results after oral administration of L-carnitine in vivo in racing pigeons. The results showed that L-carnitine significantly elevated the amount of white muscle fibre type IIa (p < 0.05). The mRNA expression quantities of SDH and LDH gene was higher via RT-PCR method. However, the expression of Ca(2+) ATPase remains similar. In conclusion, appropriate oral administration of L-carnitine of 25 mg/pigeon/day will result in an improvement of muscles related to flying.

Hitching the gallbladder in laparoscopic-assisted cholecysto-cholangiography: a simple technique

Neonatal cholestatic disorder in the late neonatal period requires often cholangiography to differentiate between biliary atresia and other causes of prolonged neonatal jaundice. A simplified method of a laparoscopic-assisted cholecysto-cholangiography is presented. Retrospective chart review was conducted of all patients who from May 2002 to April 2012 underwent a laparoscopic-assisted cholecysto-cholangiography with routine fixation of the fundus of the gallbladder to the lateral aspect of the abdominal wall. A total of 18 infants (8 boys) aged 41-104 (median 64) days underwent laparoscopic-assisted cholecysto-cholangiography for prolonged jaundice. The technique identified ten cases of a patent bile duct system and eight biliary atresias. (Thirty-two cases of suspected biliary atresia were confirmed by laparoscopy alone.) Two cases required suturing of a bile leak at the puncture site. Hitching the gallbladder to the lateral abdominal wall is a simple method allowing an optimal radiographic assessment of the extra- and intra-hepatic bile duct anatomy.

Prevalence of abnormal Papanicolaou smears in female sex workers in Hong Kong

OBJECTIVE. To investigate the prevalence of pre-cancerous uterine cervix lesions as detected in Papanicolaou (Pap) smears from female sex workers in Hong Kong. DESIGN. Retrospective analysis of laboratory records. SETTING. Private anatomical pathology laboratory, Hong Kong. PATIENTS. Female sex workers undergoing Pap smear examinations at two non-governmental organisations between 2006 and 2012. MAIN OUTCOME MEASURES. Detection of pre-cancerous uterine cervical conditions and their management. RESULTS. A total of 2697 satisfactory Pap smears from female sex workers were performed during the study period from 2006 to 2012. In these subjects, the point prevalence of low-grade squamous intraepithelial lesion and atypical squamous cells of unknown significance was 10.12% (compared with 3.92% for the general population during the same period), whereas that of high-grade squamous intraepithelial lesions and atypical squamous cells of unknown significance with or without high-grade intraepithelial lesions was 2.22% (compared with 0.54% in the general population). For both categories of lesions, the higher prevalence among female sex workers than in the general population was statistically significant. Most patients who had abnormal Pap smears received proper referrals and follow-up management according to recommended guidelines. CONCLUSIONS. Female sex workers in Hong Kong as a group had a significantly higher prevalence of abnormal Pap smears than the general population. Non-governmental organisations providing free-of-charge screening services to these women helped early detection and proper follow-up for those who had abnormal Pap smears, whilst also increasing their awareness of women's health issues.

Outcome of transplantation for acute myelogenous leukemia in children with Down syndrome

Data on outcomes of allogeneic transplantation in children with Down syndrome and acute myelogenous leukemia (DS-AML) are scarce and conflicting. Early reports stress treatment-related mortality as the main barrier; a recent case series points to posttransplantation relapse. We reviewed outcome data for 28 patients with DS-AML reported to the Center for International Blood and Marrow Transplant Research between 2000 and 2009 and performed a first matched-pair analysis of 21 patients with DS-AML and 80 non-DS AML controls. The median age at transplantation for DS-AML was 3 years, and almost half of the cohort was in second remission. The 3-year probability of overall survival was only 19%. In multivariate analysis, adjusting for interval from diagnosis to transplantation, risks of relapse (hazard ratio [HR], 2.84; P < .001; 62% versus 37%) and transplant-related mortality (HR, 2.52; P = .04; 24% versus 15%) were significantly higher for DS-AML compared to non-DS AML. Overall mortality risk (HR, 2.86; P < .001; 21% versus 52%) was significantly higher for DS-AML. Both transplant-related mortality and relapse contribute to higher mortality. Excess mortality in DS-AML patients can only effectively be addressed through an international multicenter effort to pilot strategies aimed at lowering both transplant-related mortality and relapse risks.

Clinicopathological study of renal biopsies after liver transplantation

OBJECTIVE

To perform a clinicopathological study of patients having renal biopsies after liver transplantation.

DESIGN

Case series. SETTING; Queen Mary Hospital, Hong Kong.

PATIENTS

All post-liver transplantation patients who had a renal biopsy in the period from January 2000 to December 2010.

RESULTS

Eleven renal biopsies were retrieved for review from 10 patients with liver transplantation. The male-to-female ratio was 9:1 (age range, 47-63 years). The median liver transplant-to-renal biopsy interval was 1590 (range, 102-3699) days. The predominant histological changes were interstitial fibrosis and tubular atrophy. Diabetic nephropathy (n=6) and immunoglobulin A nephropathy (n=4) were the commonest glomerulopathies. Only one patient had chronic calcineurin inhibitor nephrotoxicity. With a mean follow-up of 53 months, three patients died 2 to 53 months post-renal biopsy. All surviving patients had chronic renal impairment. Five patients developed end-stage renal failure and four had significant persistent proteinuria.

CONCLUSION

Renal pathology was variable after liver transplantation; most biopsies showed complex renal lesions, whilst calcineurin inhibitor nephrotoxicity was rare. The recognition of kidney histology attributable to metabolic derangements after liver transplantation is potentially important in the interpretation of renal biopsy specimens and patient management. The renal outlook of this group of patients is guarded.

Reliability of acute illness dihydrorhodamine-123 testing for chronic granulomatous disease

BACKGROUND

Dihydrorhodamine (DHR) flow cytometric analysis is used to evaluate granulocyte oxidative bursts and is the test of choice for the diagnosis of chronic granulomatous disease (CGD). We present the clinical and DHR test profiles of five subjects assessed during and after acute illness.

METHODS

This was a retrospective report of the findings of five out of a total of one hundred and seventeen patients, whose blood was sent to the laboratory for dihydrorhodamine-123 flow cytometry testing between January 2005 and December 2010. Using whole blood technique and stimulation using phorbol myristate acetate, the results of DHR were expressed as stimulation index and coefficient of variation of histograms of stimulated cells and compared with healthy controls. DHR tests were repeated when the patients had recovered and were clinically well.

RESULTS

These five patients showed abnormal DHR test results during their acute illness, with a stimulation index (SI) lower (p = 0.009) and coefficient of variation (CV) higher (p = 0.009) than controls. The DHR profiles repeated when patients had recovered showed normalization of tests with no significant difference for SI (p = 0.602) and CV (p = 0.917) compared to controls. Wilcoxon Signed Rank tests showed a significant improvement in SI (p = 0.043) and CV (p = 0.043) upon recovery. On follow up, all five patients were well, with no further severe or atypical infections.

CONCLUSIONS

DHR may be transiently abnormal during acute illness, and may therefore not be reliable when assessed during an acute illness. If these subjects had CGD, it would be of a hypomorphic variant that has not previously been described.

Clinical practice implications of immunizations after pediatric bone marrow transplant: a literature review

The number of pediatric bone marrow transplants is increasing for malignant and nonmalignant diseases. The number of survivors is also increasing, and their long-term health and protection from infection is increasingly important. To prevent infections, it is standard practice to re-immunize pediatric patients after bone marrow transplant (BMT) using the Centers for Disease Control and Prevention immunization guidelines; however, surveys in the United States and other parts of the world indicate that many BMT patients do not receive all the recommended immunizations. A literature review was conducted to identify research based on evidence for immunization following BMT and to recognize barriers to the process. Also, the immunization clinical guidelines from 2000 and 2011 for patients following BMT were compared and an updated clinical protocol and immunization schedule was developed to reflect the current evidence, encourage a change in practice, and discourage fragmented care.

Clonal cytogenetic abnormalities after tyrosine kinase inhibitor therapy in Ph+ ALL resolution after decitabine therapy

Mixed chimerism and presence of minimal residual disease after stem cell transplantation (SCT) usually predict leukemia recurrence. In Philadelphia chromosome positive (Ph+) leukemia tyrosine kinase inhibitors can restore remission. These agents can induce clonal cytogenetic abnormalities in the Philadelphia negative cell population (CCA/Ph-), which may rarely progress to acute myeloid leukemia. A child with Ph+ acute lymphoblastic leukemia showed mixed donor chimerism and persistent bcr-abl transcripts after a matched sibling SCT. There was no response to tyrosine kinase inhibitor (TKI) therapy, but she has remained hematologically normal for more than 5 years. CCA/Ph- was detected but resolved with hypomethylating therapy.

Giant urethral diverticulum calculus presenting as scrotal abscess

We report herein a patient with a urethral calculus associated with urethral diverticulum. A 39-year-old man presented with scrotal swelling and acute retention of urine. Computed tomography of the pelvis and cystoscopy demonstrated a giant calculus in the proximal penile urethra. Emergency in-situ lithotripsy was performed. Complete stone clearance was achieved and a large urethral diverticulum was encountered. The rare occurrence of urethral diverticulum and associated stone disease were discussed.

Fludarabine, melphalan, thiotepa and anti-thymocyte globulin conditioning for unrelated cord blood transplant

Unrelated cord blood transplant (CBT) is an alternative treatment option for patients who lack a matched donor. However, the optimal type and intensity of the preparative regimen remains unclear. We evaluated the toxicity and outcomes of a conditioning regimen consisting of melphalan 140 mg/m(2) (day - 8), thiotepa 10 mg/kg (day - 7), fludarabine 160 mg/m(2) over 4 days (days - 6 to - 3) and rabbit antithymocyte globulin (ATG) 1.25 mg/kg (day - 4) and 1.75 mg/kg (day - 3) (FMT). Forty-seven patients with advanced hematologic malignancies with a median age of 23 years (30 adults and 17 children) were treated. Sixty percent of patients were in remission at transplant. Ninety-one percent of the patients engrafted neutrophils after a median of 22 days, and all but one of the patients achieving donor engraftment had hematopoietic recovery with 100% cord blood-derived cells. Grade 3 gastrointestinal toxicity was the major non-hematopoietic toxicity, occurring in 32% of patients. Cumulative incidence of day-100 grade II-IV acute graft-versus-host disease (aGVHD) and chronic graft-versus-host disease (cGVHD) was 53% and 34%, respectively, and non-relapse mortality at day 100 and 2 years was 11% and 40%. Two-year disease-free and overall survival rates were 31% and 44%, respectively. These results suggest that FMT is a feasible conditioning regimen for patients undergoing CBT.

Single-incision laparoscopic cholecystectomy: from four wounds to one

OBJECTIVE

To review the initial results and surgical outcomes of single-incision laparoscopic cholecystectomy.

DESIGN

Prospective case series.

SETTING

A university teaching hospital and a regional hospital in Hong Kong.

PATIENTS

All patients undergoing single-incision laparoscopic cholecystectomy from August 2009 to March 2011.

RESULTS

Fifty patients underwent single-incision laparoscopic cholecystectomy during the study period. The indications for surgery included symptomatic gallstones (n=43) and gallbladder polyps (n=7). The mean operating time was 78 (standard deviation, 24) minutes. Forty-five of the patients successfully underwent single-incision laparoscopic cholecystectomy, giving a success rate of 90%. In the remaining five patients, additional working ports were constructed to obtain better exposure and dissection around Calot's triangle. On comparing the results of the initial 25 cases to the subsequent 25 cases, in the latter group the operating time was significantly shorter (86 vs 71 minutes; P=0.02), and the success rate was higher (80% vs 100%; P=0.05). During the median follow-up period of 6.8 months, four patients had complications, which included: postoperative urinary retention (n=2), one each with a haematoma and an incisional hernia. No patient endured bile duct injury, postoperative bile leakage, or haemorrhage in our series.

CONCLUSION

Single-incision laparoscopic cholecystectomy is feasible and safe for treatment of uncomplicated gallbladder diseases. There was a reduction in the operating time and increase in success rate with accumulation of experience. Nevertheless, surgeons should be cautious about the potential risks of this new technique.