Immunotransplantation for multiple myeloma using allogeneic peripheral blood stem cell transplantation

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Background: Despite the improvement seen in patients with multiple myeloma (MM) treated with autologous hematopoietic cell transplantation (auto-HCT), most of the patients relapse or die of their disease. The objective of the study was to decrease toxicity of allogeneic HCT for MM patients while allowing the benefit of graft-versus-myeloma effect by using a non-myeloablative HCT (NM- HCT) approach. Methods: Newly diagnosed or previously treated myeloma patients of any stage were enrolled. All patients but one received VAD regimen prior to conditioning regimen which consisted of Fludarabine at 30 mg/m2/day on days -5, -4, -3 and Melphalan at 80 mg/m2 x 2 on days -2 and -1. Graft-versus-host disease (GVHD) prophylaxis included cyclosporine 3 mg/kg intravenously on day -2 and methotrexate at 10 mg/m2 intravenously on days 3, 6, and 11. Results: A total of 8 MM patients (4 IgG, 1 IgA, 1 light chain restriction, 2 non-secretory MM) with a median age of 46 years old (range, 35 to 57 years) have been enrolled. Only one patient received 3 regimens prior to NM-HCT. The initial responses to therapy prior to NM-HCT were: 2 CR, 1 nCR, and 5 PR. All patients received identical 6/6 HLA sibling donor stem cells. All patients but one attained CR (88%) after NM-HCT. The median time for ANC engraftment (≥ 500/mm3) was 12.5 days (range, 10–22 days). Four patients developed acute GVHD grade I-II (3 skin, 1 gastrointestinal); all of them responded well to methylprednisolone treatment. Four patients developed chronic GVHD (grade I-II). The 100-day mortality rate was 12% (1 patient died at day + 96 without evidence of MM). Post-transplant, all patients have reported a Karnofsky’s scale performance status between 80%-100%. Two patients relapsed after 31 months post-transplantation. After a median follow-up of 46 months, median survival has not been reached. Only 1 patient who relapsed has received treatment including auto-HCT. Conclusions: NM-HCT is a feasible treatment option in MM patients with a manageable toxicity profile and acceptable treatment-related mortality. Longer follow-up is needed to evaluate for graft-vs- myeloma effect using this approach.

No significant financial relationships to disclose.

Results of BFM 90 protocol at a single institute in a developing country: Three years experience

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Background: In a developing country the affordability status of a patient is the main factor in deciding the type of treatment a patient will receive. Majority of patients [>95%] at our institute have received MCP 841 protocol for acute lymphoblastic lymphoma .We have reviewed the treatment results of patients who had received chemotherapy as per the BFM 90 protocol over last 3 years. Methods: 18 patients (15 males and 3 females) with ALL who had received BFM 90 protocol as therapy during the period between January 2003 to January 2006 were analysed. 15 were of the pediatric age group (2–13 years) and 3 were adult patients (31 & 42 years). Median follow up period was 1 year 9 months. 5 patients were considered as high risk, 4 medium risk and the rest as standard risk. All patients were ph chromosome negative. Results: All paediatric patients are in CR. One patient had CNS relapse but he responded well to reinduction and is in CR. Three patients developed grade 4 toxicity after high dose methotrexate. The rest tolerated it well, however, leucoverin rescue had to be given empirically as methotrxeate level measurement was not available at that time. Two patients turned HCV positive during the course of treatment and had altered liver enzymes due to which maintenance treatment was interrupted. There were three instances of catheter removal and one port had to be removed due to infection. Both the adult patients had bone marrow relapse during treatment [one during maintenance and the other during reinduction] and could not be salvaged. Conclusions: BFM 90 protocol is a viable alternative to MCP 841 in developing countries where high dose methotrexate is given with empirical leucoverin rescue. High rates of catheter infection is of concern. Better patient education and improved techniques will probably improve the situation.

No significant financial relationships to disclose.

Improving outcomes from acute kidney injury (AKI): Report on an initiative

Acute Kidney Injury (AKI) is a complex disorder for which currently there is no accepted definition. We describe an initiative to develop uniform standards for defining and classifying AKI and 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 2-day conference in Amsterdam in September 2005 to draft consensus recommendations for diagnosing and staging AKI. This report describes the proposed diagnostic and staging criteria for AKI and the formation of a multidisciplinary collaborative network.

[Appendicitis necessitatis: appendicitis perforating the abdominal wall]

Perforation of the appendix through the anterior abdominal wall is a rare complication of a frequent disorder. We report on a 37-year old patient presenting with purulent secretion from the right lower abdomen. The CT scan of the abdomen revealed a perityphlitic abscess with perforation of the anterior abdominal wall. The patient underwent laparotomy with appendectomy and subsequent revision of the abdominal wall. Appendicocutaneous fistula due to perforation through the abdominal wall is a rarity. In analogy to empyema necessitatis, which would require the pleural empyema to penetrate the thoracic wall, the entity was denoted appendicitis necessitatis.

Robotic assisted laparoscopic radical prostatectomy: a review of the current state of affairs

Open retropubic radical prostatectomy is the gold standard treatment for localised prostate cancer. However, the procedure has inherent morbidity associated to it. Therefore, less invasive surgical techniques have been sought, one such alternative is robotic-assisted laparoscopic radical prostatectomy. The advantages provided by robotic technology have the potential to minimise patient morbidity while improving both functional and oncological outcomes. Although it is a recent technological advancement, robotic surgery has shown an increasing rate of adoption worldwide. Currently more than 30,000 patients have undergone this procedure worldwide. We present a review of the available literature on robotic-assisted laparoscopic radical prostatectomy.

Rationale for the administration of acellular pertussis vaccine to parents of infants in the neonatal intensive care unit

Pertussis infections in the United States are increasing as a consequence of waning immunity and increased surveillance. Those most at-risk of mortality include infants less than 6 months of age and premature infants. The 2006 immunization schedule emphasizes an adolescent pertussis booster at 12 years of age. However, of concern is the current generation of parents and grandparents who will still be un-immunized and therefore, available vectors of pertussis to vulnerable neonates. Given the proximity of parents to medical care in the Neonatal Intensive Care Unit (NICU), and the potential for severe disease in their children, NICU personnel should consider administration of acellular pertussis vaccine to parents of hospitalized infants.

Haemoglobin and albumin as markers of HIV disease progression in the highly active antiretrovial therapy era: relationships with gender

OBJECTIVES

The aims of the study were to describe gender differences in haemoglobin and albumin and to investigate the prognostic value of these measurements in relation to highly active antiretroviral therapy (HAART).

METHODS

Anaemia was defined as haemoglobin <13.5 g/dL for men and <11.5 g/dL for women. Albumin <35 g/L was defined as hypoalbuminaemia. Proportional hazards models were used to describe relationships between these markers and HIV progression and death.

RESULTS

A total of 291 patients had pre-HAART and 1-year measurements. Mean haemoglobin and albumin levels pre-HAART were lower in women than in men (haemoglobin: 11.2 vs 13.2 g/dL, respectively, P<0.0001; albumin: 37.4 vs 40.2 g/L, respectively, P<0.0001), and a higher proportion of women were anaemic and hypoalbuminaemic compared with men. Despite a rise in both markers in the first year on HAART, mean haemoglobin levels remained lower by 2.08 g/dL (P<0.0001) and albumin by 2.88 g/L (P<0.0001) in women. In the 495 patients included in this analysis, haemoglobin and albumin levels were both significantly related to short-term risk of AIDS and death independently of CD4 count [hazards ratio (HR)=0.73/g/dL higher haemoglobin, 95% confidence interval (CI) 0.55-0.82, P<0.0001 and HR=0.87/g/L higher albumin, 95% CI 0.83-0.91, P<0.0001]. The prognostic value did not differ by gender.

CONCLUSIONS

Women were more likely to be anaemic and/or hypoalbuminaemic pre-HAART, but post-HAART increases were similar to those in men. Both haemoglobin and albumin were strong independent prognostic factors for risk of AIDS and death, regardless of gender.

Hepatic veno-occlusive disease due to tacrolimus in a single-lung transplant patient

Hepatic veno-occlusive disease is defined as nonthrombotic fibrous obliterative endophlebitis of small centrilobular hepatic venules. Clinically, patients present with elevated liver enzymes and a triad of jaundice, hepatomegaly and ascites. Although reported as a complication of other solid organ and stem cell transplantation, there have been no reported cases to date of veno-occlusive disease following lung transplantation. The present authors report a case of veno-occlusive disease following single-lung transplantation in a patient on a triple-drug immunosuppressive regimen composed of tacrolimus, mycophenolate mofetil and prednisone. The diagnosis was established by transjugular liver biopsy and by discontinuing tacrolimus; there was clinical regression of symptoms and serological return to baseline.

Cervical screening in HIV-positive women: characteristics of those who default and attitudes towards screening

OBJECTIVES

To determine the characteristics of HIV-positive women who undergo cervical screening and to identify negative attitudes and experiences of these women to screening and the factors associated with these.

METHODS

We compared the Royal Free Cohort data from 59 newly diagnosed HIV-infected women, 31 of whom did and 28 of whom did not attend for cervical screening in 2001, and from 227 women under active cervical screening follow-up (at least one cervical screen since June 2001) and 88 HIV-infected women lost to follow-up (not screened since January 2001). Attitudes to screening were investigated with the aid of a questionnaire given to all women attending clinic who had had a previous colposcopy.

RESULTS

Of the 59 newly HIV diagnosed women, 31 (53%) underwent cervical screening. These 31 women were more likely to be heterosexual (100 vs 89%, P=0.05), to have lower median viral loads (< 50 vs 3210 HIV-1 RNA copies/mL) and to be receiving antiretrovirals (ARVs) (74 vs 54%, P=0.1) than those not screened. Of the 315 women who had at least one screen, 72% returned for further follow-up. There were no differences in age or ethnicity between these groups. Those under active follow-up had a higher CD4 count (P=0.04) and lower viral load (P=0.0001) at their last visit. They were also more likely to be on highly active antiretroviral therapy (HAART) (68 vs 52%, P=0.006). A total of 78 of 104 questionnaires (75%) were returned. Women participating in the questionnaire study were mainly of back ethnicity (68%), did not speak English as their first language (59%) and were taking ARVs (76%). Most agreed that regular smears and colposcopy were valuable. Women of white ethnicity, and those speaking English as a first language, were more likely to dislike colposcopy compared with those of nonwhite ethnicity (87 vs 25%, respectively, P=0.0007) and not speaking English as a first language (74 vs 26%, respectively, P=0.002). Those of white ethnicity were more likely to find smears and colposcopy painful (60 and 73%) compared with those of black ethnicity (46 and 51%, P=0.47 and 0.28, respectively).

CONCLUSIONS

Our results suggest that women on HAART with better disease control, older women, and those of black African ethnicity are more likely to take up cervical screening. Cervical screening experience varies by ethnicity and language.

Poly TLR agonist polyantigenic vaccine (Mycobacterium w) in palliative therapy of head and neck cancer

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Background: Poly TLR poly-antigenic vaccine containing Mycobacterium w (Mw) is found useful in the management of lung cancer and bladder cancer when used along with standard therapy1,2 but not in Head and Neck cancer3–4. This study was carried out to evaluate its efficacy as a single agent in advanced head & neck cancer. Methods: In a prospective study consecutive 75 symptomatic patients with advanced head & neck cancer (squamous cell) attending hospital for palliative care following failure of standard therapy were administered Mw once a week for 8 weeks. Results: Of 75 patients 43 were male & 32 females with 76% between the ages of 31 to 60). 18 had buccal mucosa tumor, 12 alveolar and 11 at base of the tongue. Partial response was seen in 27. It was associated with Pain relief (27/27), Healing of ulcer/fistula (4/5), improvement in dysphagia (7/15), improvement in voice(5/19). All 27 showed improvement in constitutional symptoms also. No systemic side effects were seen. Conclusions: Mw vaccine is useful in palliative care of head & neck cancer. Reference 1Sur PK, Dastidar AG. Role of mycobacterium w as adjuvant treatment of lung cancer. J Indian Med Assoc. 2003;101:118, 120. 2Chaudhuri P, Mukhopadhyay S. Bladder preserving approach for muscle invasive bladder cancer–role of mycobacterium w. J Indian Med Assoc. 2003;101:559–60 3M. C. Pant, R. Hadi, R. Prasad, D. Dalela, et al. Role of immuno-therapy as a adjuvant treatment in advance head & neck cancer, patient receiving chemo radiotherapy. Journal of Clinical Oncology 2005; 23, (16S Part 1): 190S 4S. K. Sarkar, C. Dasgupta. Role of Mycobacterium W as an adjuvant treatment of Head & Neck Cancer_A Randomised trial. Journal of Clinical Oncology 2005; 23, (16S Part 1): 521 s.

No significant financial relationships to disclose.

Parachute tricuspid valve

Parachute abnormality of mitral valve frequently occurs with left sided obstructive lesions though occasionally may occur as an isolated lesion. Symptoms depend upon the severity of stenosis and associated lesions. Parachute abnormality of the tricuspid valve has rarely been reported and its association with left to right shunts has not been described so far.