How could improvement in the management of T-cell acute lymphoblastic leukemia be achieved? Experience of Princess Nourah Oncology Center, National Guard Hospital, Jeddah, Saudi Arabia

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Background: T-cell acute lymphoblastic leukemia (T-ALL) is representing 10–15% of pediatric ALL. The use of more intensive treatments and risk adapted therapy have significantly improved the outcome of patients with T-ALL and event-free survival rate of 60–70% are now reported in children. Our published data showed that T-ALL phenotype patients fared poorly with 5 year survival of 27% versus 83% for precursor B-ALL (Recent Advances Research Update: 2006, 7; 1, P 51–56). Objectives: We reviewed all patients diagnosed with T-ALL to assess risk classification according to NCI criteria, type of therapy received, overall survival and causes of mortality. Methods: Retrospective review of all patients files diagnosed with T-ALL from 1989 until now with data collection including; sex, age, white cell count (WBCs), CNS disease, type of protocol used, length of survival, overall survival, cause of death (toxic, disease). Results: Over the last 20 years, T-ALL cases registered were 52/460 (11%) of all ALL cases, Male:Female ratio 42:10 (4.2:1), median age 7 year (range: 1.5–12 yrs). Median WBCs 50,000/Cmm (range: 1.500–619,000/Cmm) and positive CNS at diagnosis 10/52 (20%). NCI risk classification criteria showed SR 24/52 (46%) and HR 28/52 (54%). Protocols used were UKALL ( n = 21; 3 UKALL X-B, 4 UKALL X-D, 10 UKALL XI and 4 MRC-97 ). BFM (n = 8); and CCG 1961 (n = 23). Overall survival 27/52 (52%) and 25 pts. died (48%); 15 secondary to disease recurrence (9 on UKALL, 4 BFM, 2 CCG 1961); 4 during induction, 1 fulminant hepatic failure, 1 tumor lysis syndrome, and 4 due to toxicities (mucormycosis, staphylococcal toxic shock syndrome, CMV pneumonia, pseudomonas sepsis). Survival for different regimen; UKALL: 5/21=31%, BFM: 4/8=50%, CCG: 18/23=78%, while overall cohort survival 52%. Mean length of survivors 4 year (range 4–140 month) and mean length for non-survivors 1 year (range 0.1–40 months). Conclusions: This review showed the improvement of T-ALL survival from 27% to 56%. Using augmented therapy based on CCG1961 was associated with better outcome. Further risk and response stratification in addition to intensification of therapy for T-cell ALL in our center may prove to be beneficial. Therapy remains an important prognostic factor.

No significant financial relationships to disclose.

The Impact of Diabetes on Pregnancy in Qatar

Objectives: To investigate maternal and neonatal outcomes of pregnancies in women with different types of diabetes in Qatar. To identify factors such as age, family history of diabetes and obesity contributing to the increased risk of GD.

Design: The design of this study is retrospective.

Materials and Methods: il4 pregnant women with different types of diabetes including 143(28%) Impaired Glucose Tolerance Test (IGTT), 334(65%) Gestational Diabetes (GD), 26(5%) Insulin Dependent Diabetes Mellitus (IDDM) and 11(2%) Non Insulin Dependent Diabetes Mellitus (NIDDM) who delivered between Jan - June 2004formed the subject of this study.Data extracted from the files included maternal characteristics, fetal and maternal complications.

Result: Eight women had abortions and two had stillbirths, leaving a final dataset comprising 504 women (141 IGTT, 332 GDM, 21 IDDM and 10 NIDDM). Two hundred and eighty three (56.2%) were Qatari.53 %(n = 267) aged >30 years, 57.5 %(n = 290) had family history of diabetes, only 16.1 %(n = 81) treated by insulin.Polyhydramnios was the most common antenatal complication occurred in 15 %(n = 76). No maternal mortality.The overall Cesarean section was 6.2 %(n = 31),.Preterm delivery 5.8 %(n = 29). Macrosomia appeared in 7.3 %(n = 37) infants and congenital malformations in 2 %(n = 10) infants.

Conclusions: We observed that the risk factors for GDM found in other studies are generally valid for our population. Also we found that IDDM has a poorer outcome than NIDDM. However a future prospective study is need it to draw firm conclusions regarding the relative magnitudes of the adverse effects between the different diabetic groups

Vaginal Misoprostol in the Management of First Trimester Non-viable Pregnancy

To study the effectiveness of a regimen of repeated doses of vaginal misoprostol in the management of first trimester missed abortion, one hundred andfour pregnant women with first trimester non-viable pregnancies were treated with an initial dose of800 g of vaginal misoprostol followed after four hours by further doses of400 ! g fourhourly for a maximum of three doses. The complete expulsion rate was 85.6%. Fifty of the 104 (48.1%) women underwent surgical evacuation. In 14 (135%) women, gestational products were obtained and confirmed by histopathological examination. In 36 (34.6%) there were minimal or no products obtained and these were considered to be complete miscarriages. The cervical os was found open in all (135%) the incomplete miscarriages. Severe abdominal pain was experienced by 10.6% of the patients and excessive vaginal bleeding occurred in 135% of them. A fall in hemoglobin of more than one gramldl occurred in 5.8% of the women and another 5.8% of them had fever > 38°C. The stay in hospital was two days for 87 (83.7%) women and three days for 15 (14.4%) women. One (1%) woman stayed four days and another stayed less than one day. None of the women had any complications. This study demonstrated the efficacy and safety of vaginal misoprostol as a medical treatment for first trimester non-viable pregnancies using an initial dose of 800 g, followed after four hours by further doses of 400 ! g four-hourly for a maximum of three doses. This management also provided adequate cervical dilatation for surgical evacuation when complete expulsion did not occur.

Poverty and Health of Unborn

It is clear that poverty cannot be defined solely in terms of lack of income. A person, a family, even a nation is not deemed poor only because of low economic resources. Little or no access to health services, lack of access to safe water and adequate nutrition, illiteracy or low educational level and a distorted perception of rights and needs are also essential components of poverty

A Cautionary Case of Female Genital Mutilation

We report a case of a tightly circumcised woman who bled irregularly throughout her first year of marriage but failed to conceive. The detection and management of a large but hidden cervical polyp solved her problems. We suggest that such cases, especially in immigrant women, require deeper investigation than might at first appear to be needed.

The Outcome of Pregnancies Associated with Intrauterine Contraceptive Devices

In this retrospective study we sought to determine the outcome of pregnancies associated with intrauterine contraceptive devices. Medical records of2000 women, who used IUCD, were reviewed in detail. All IUCDs were inserted either post menstrual, post delivery or post miscarriage. 1196 (60%) IUCDs were inserted by doctors and the remaining 804 (40%) by midwives. The cohort was divided to four groups on the basis of their age. There were 300, 950, 300 and 450 women in 18-22,23-27,28-32 and 33-37 years groups respectively. They were also divided to three groups on the basis of their parity with 300 Para 1 women, 1100 Para 2-4 women and 600 Para 5 or more. 37 (1.85%) unintended pregnancies occurred, including 35 intrauterine pregnancy and 2 ectopic pregnancies. 9 (3%) of these pregnancies occurred in 18-22 year group, 16 (1.68%) in 23-27 age group, 8 (2.67%) in 28-32 age group and 4 (0.89%) in 33-37 age group (Fig. 1). 19 (1.59%) of the pregnancies occurred in women whose IUCDs were inserted by medical staff and 18 (1.51%) in those whose IUCDs were inserted by midwives. The outcome of intrauterine pregnancies included 19 (51%) term pregnancies, 9 (24%) miscarriages, no septic abortions, 7 (19%) Preterm labour including 2, 26-28 weeks and 5 29-32 weeks. No puerperal sepsis or congenital abnormalities were reported (Fig. 2).

Fetal Echocardiography Service in Qatar: Establishment, Challenges and Outcome

A prospective observational study at the newly estab-lished Fetal Medicine Unit, Hamad Hospital, Qatar; evalu-ated the impact of the service on the detection rate of criti-cal congenital heart defects, patterns of referral and sub-sequent yield for structural congenital heart disease in a population with a significant proportion of high risk fac-tors.

Of 391 pregnant females examined between January 2003 and December 2004, 58 (14.8%) had fetal cardiac abnormalities of which 23 (5.8% of total referrals) had major structural malformations of the heart. Cases of fetal congenital heart disease had further evaluation us-ing real time three-dimensional echocardiography (RT3DE) which is new equipment in the paediatric cardi-ology department. All cases with cardiac defects whether minor or major had follow up fetal echocardiography. Neonatal echocardiography confirmed the diagnosis in all cases with major defects (100% specificity). False positive cases that were found to be normal post natal were 1% of the total cases referred (12% of cases with congenital mal-formation). False negative cases were 1% and all had a small ventricular septal defect (VSD) except for one Down's syndrome with a very large VSD.

Three patients needed urgent Caesarean section (CS) deliveries, one with complete heart block (HB) and two with supraventricular tachycardia (SVT). One patient traveled abroad as the fetus had left isomerism and major cardiac defects and complete HB. Fifteen newborns had to receive prostaglandin based on the fetal diagnosis before being seen by paediatric cardiologists. There was no termination of pregnancy due to major cardiac defects even in cases of HLHS.

The preliminary results of this clinic are very satisfac-tory and have affected favorably the outcome of the new-borns with congenital heart defects. It is hoped that the results of this study will encourage more referrals to the FMU.

In vivo antitumour effect of combretastatin A-4 phosphate added to fractionated irradiation

BACKGROUND

The study aimed at evaluating the potential benefit from a combination of fractionated ionising radiation with the vascular-targeting compound combretastatin A-4 phosphate (CA-4-P).

MATERIALS AND METHODS

Syngenic rat rhabdomyosarcoma (R1), growing subcutaneously, was treated at 2 different sizes: either small (2 +/- 0.5 cm3) or large (10.94 +/- 0.6 cm3). Localised fractionated irradiation of the tumours (5 x 3 Gy) in 5 days was followed 1 day later by an intraperitoneal CA-4-P treatment (25 mglkg).

RESULTS

The combined treatment of only large tumours resulted in a small additional growth delay when compared with radiotherapy only.

CONCLUSION

The present data indicate a size-dependent increase in tumour growth delay from combining fractionated irradiation with CA-4-P.

Safety of vaginal birth after cesarean delivery

OBJECTIVE

To compare the outcomes of labor induction in women with a history of 1 cesarean section (CS) who undergo trial of labor.

METHODS

A prospective observational study of 702 pregnant women who had 1 previous CS was conducted at Women's Hospital, Hamad Medical Corporation, Doha, Qatar, between April 2003 and April 2004. Those with no history of vaginal delivery were assigned to one group and those with a history of vaginal delivery were assigned to another group, and the latter group was then divided into 2 subgroups according to the results of trial of labor.

RESULTS

Of these 702 women with a history of 1 CS, 62.4% also had a history of vaginal delivery. After trial of labor, vaginal delivery occurred more often among women with no history of vaginal delivery (64.8%). Moreover, trial of labor resulted in a vaginal delivery more often in women who were delivered only once and by CS (87.7%) than in women who also had a history of vaginal delivery (79.2%).

CONCLUSION

These findings indicate that women who have had a CS should strongly consider natural delivery for subsequent pregnancies.

Combretastatin A-4 phosphate enhances CPT-11 activity independently of the administration sequence

We evaluated the effect of different intervals and sequences of the vascular targeting agent combretastatin A-4 disodium phosphate (CA4DP) and CPT-11 administration on tumour growth delay and intratumoral uptake of CPT-11 using a syngeneic rhabdomyosarcoma tumour model. Irrespective of the administration sequence, the combination of CA4DP and CPT-11 significantly increases tumour growth delay in comparison with both drugs alone (P<0.001). Intratumoral CPT-11 concentration generally decreased (up to 5-fold) in the combination groups, while SN-38, the active metabolite of CPT-11, increased up to 9-fold. However, the increased amount of intratumoral SN-38 trapping after CA4DP injection did not correlate with the observed tumour growth delay. In conclusion, CA4DP significantly enhances the antitumour effect of CPT-11, which is not greatly influenced by the administration sequence, and which lacks a correlation with the intratumoral trapping of CPT-11 or SN-38. Mechanisms other than trapping are likely to be involved in the chemosensitising capacity of CA4DP.

Synthesis and antihepatotoxic activity of some heterocyclic compounds containing the 1,4-dioxane ring system

Silymarin isolated from Silybum marianum is a mixture of three isomers, silybin (1), silydianin (2) and silychristin (3). Silybin is the most active antihepatotoxic agent, and contains a 1,4-dioxane ring in addition to a flavonoid moiety. Based on the skeleton of silybin, we prepared some flavones and coumarins containing the 1,4-dioxane ring system and evaluated them for antihepatotoxic activity against carbon tetrachloride induced hepatotoxicity in albino rats. The degree of protection was determined by measuring biochemical parameters such as serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), alkaline phosphatase (ALKP), total protein (TP) and total albumin (TA). The compounds namely 3',4'(1",4"-dioxino) flavone (4f), and 3',4'(2-hydroxy methyl, 1",4"-dioxino) flavone (4g) were found to exhibit a significant activity comparable to standard drug silymarin (silybon-70). Other compounds also exhibited good activity. The structure activity relationship (SAR) was also studied, and where the flavonoid analogues containing a hydroxy methyl group at position-2" in the dioxane ring exhibited superior antihepatotoxic activity in comparison to coumarin derivatives.

Antihepatotoxic activity of Phyllanthus fraternus

Different fractions of alcoholic extracts of aerial parts and roots of Phyllanthus fraternus Webster (Euphorbiaceae) were screened for antihepatotoxic activity on carbon tetrachloride induced liver damage in albino rats. The degree of protection was measured using biochemical parameters like serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), total protein (TP) and total albumin (TA). The methanol fraction was found to be the most active, which was further supported by a significant recovery of hepatocytes in the histopathological study of the liver showing almost complete normalization of the tissues as neither the fatty accumulation nor the necrosis was observed.

Triumfettoside, a new alkaloidal steroid glycoside and triumfettosterol, a new sterol from Triumfetta flavescens

The aerial parts of Triumfetta flavescens H. (N. O. Tiliaceae) afforded a new alkaloidal steroid glycoside, characterized as stigma 5(6)-ene-7,22-dione-25-methylamino-3 beta,23 beta-diol-3-O-beta-D- glucoside and designated as triumfettoside (1); and a new sterol identified as stigma 5(6)-ene-7,22-dione-3 beta,23 beta-diol, designated as triumfettosterol (2). Their structures were elucidated on the basis of chemical and spectral analysis.

Necrosectomy followed by closed cavity lavage for necrotising pancreatitis--report of three cases

Necrotizing Pancreatitis is a life threatening condition involving pancreas, peripancreatic and retroperitoneal tissues. It's serious regional and systemic involvement causes multiple organ or system failure. Planned and carefully performed necresectomy followed by closed cavity lavage can significantly reduce the mortality and morbidity of this catastrophic condition. Meticulous preoperative resuscitation, preparation and operative necrosectomy followed by continuos irrigation in the postoperative period were done in three consecutive patients. The operative procedure including postoperative management and follow up is reported and analyzed.

Percutaneous transhepatic biliary stenting

OBJECTIVE

Bilary stenting with endoprosthesis is a palliative procedure to relieve malignant biliary obstruction. Percutaneous transhepatic technique has been employed whenever endoscopic technique was not possible or had failed.

SETTING

Angiography/intervention suite, department of radiology, Aga Khan University hospital, Karachi.

METHODS

We present retrospective analysis of 17 patients with malignant jaundice who were treated with percutaneous techniques after the endoscopic route had failed.

RESULTS

The success rate was 94% with placement of single plastic stent in 14 patients, double stents in 3 patients and self-expandable stent in one patient. The overall complication rate was 41% including sepsis, liver abscess, biloma formation, biliary leakage and stent occlusion. There was one procedure related death due to severe sepsis.

CONCLUSION

Percutaneous transhepatic biliary stenting is an alternative procedure to relieve malignant biliary obstruction with high complication rate and should be reserved for selected patients in whom endoscopic route has failed.

Hepatoprotective activity of Luffa echinata fruits

The different extracts of the fruits of Luffa echinata Roxb. (Cucurbitaceae) were tested for their hepatoprotective activity against CCl(4) induced hepatotoxicity in albino rats. The degree of protection was measured by using biochemical parameters like serum glutamic oxalacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), alkaline phosphatase (ALKP), total protein (TP) and total albumin (TA). The petroleum ether, acetone and methanolic extracts showed a significant hepatoprotective activity comparable with those of Silymarin.