Nasolacrimal polyurethane stent placement for epiphora: technical long-term results

PURPOSE

To assess technical problems related to implantation of a polyurethane stent to treat obstructive epiphora, and to assess the long-term patency of the nasolacrimal system.

MATERIALS AND METHODS

Fluoroscopically guided placement of a polyurethane nasolacrimal stent was performed in 70 obstructed lacrimal systems of 62 patients with grade 3-4 obstructive epiphora. Follow-up was conducted for 1-20 months (average, 11.3 months). The obstruction was at the lacrimal sac in six systems, at the junction between the lacrimal sac and the nasolacrimal duct in 60 systems, and at the nasolacrimal duct in four systems. The cause of the obstruction was idiopathic in all cases but was probably residual to dacryocystitis.

RESULTS

Of these 70 procedures, stent placement was technically successful in 61 systems (87%). On long-term follow-up, 41 (67.2%) stents remained in place, with resolution or clinical improvement, and 18 (29.5%) stents were removed (because of occlusion in 17 systems), with stent malpositioning in the duct in six cases. There were seven cases of malpositioning in all. Statistical analysis was performed to evaluate patency, compare patency in properly positioned stents and malpositioned stents, and establish the relationship between malpositioning and the need for irrigation to maintain stent patency. Of the total 70 stents originally placed, 41 (58.6%) were still in place and functional at long-term follow-up. At 1 year, 73% of properly positioned stents remained patent versus 0% of improperly positioned stents. Median stent patency in the former group was 20 months and was 1 month in the latter group (P = .00002). Eleven percent of properly positioned stents required irrigation versus 57% of incorrectly positioned stents (P = .01).

CONCLUSION

After follow-up for 1 year, recurrence of epiphora brought on by stent obstruction was 28%. Early stent blockage and the need for periodic irrigation may be indicative of malpositioning of the stent.

Activation of MHC class I, II, and CD40 gene expression by histone deacetylase inhibitors

Epigenetic mechanisms are involved in regulating chromatin structure and gene expression through repression. In this study, we show that histone deacetylase inhibitors (DAIs) that alter the acetylation of histones in chromatin enhance the expression of several genes on tumor cells including: MHC class I, II, and the costimulatory molecule CD40. Enhanced transcription results in a significant increase in protein expression on the tumor cell surface, and expression can be elicited on some tumors that are unresponsive to IFN-gamma. The magnitude of induction of these genes cannot be explained by the effect of DAIs on the cell cycle or enhanced apoptosis. Induction of class II genes by DAIs was accompanied by activation of a repressed class II transactivator gene in a plasma cell tumor but, in several other tumor cell lines, class II was induced in the apparent absence of class II transactivator transcripts. These findings also suggest that the abnormalities observed in some tumors in the expression of genes critical to tumor immunity may result from epigenetic alterations in chromatin and gene regulation in addition to well-established mutational mechanisms.

[Varicella pneumonia in the adult: study of 22 cases]

BACKGROUND

Retrospective study of the varicella pneumonia in adults with clinical, therapeutic and evolutive features in 22 patients in the last 5 years.

MATERIAL AND METHODS

The diagnosis was established by clinical and radiologic criteria in the course of varicella infection. The antecedents of pregnancy, smoking habit, previous contact with patients with varicella and underlying disease were evaluated.

RESULTS

Twenty-two patients (14 males and 8 women: mean age 31 years. range: 22-40) were included in the study. None of them were immunocompromised, 16 (72.7%) have had previous contact with varicella patients. 19 (86.3%) were heavy smokers and none of the female patients was pregnant. All patients had fever and exanthem, cough had 20 (90.9%) dyspnea 16 (72.7%), chest pain 9 (40.9%) and hemoptysis 5 (22.7%). Only two patients showed pO2 < 60 mmHg. Chest X-ray revealed an interstitial pattern in 14 cases (63.3%), and micronodular in 8 (36.3%). All patients received treatment with intravenous acyclovir. Three patients (13.6%) were admitted to the Intensive Care Unit due to respiratory insufficiency, needing mechanical ventilation one of them (4.5%). Another three developed failure renal reversible associated with acyclovir. All patients had a favourable clinical course.

CONCLUSIONS

We believe, that early, aggressive use of intravenous acyclovir in adult varicella pneumonia may be lifesaving, preventing progressive respiratory failure and reducing the high mortality rate of the disease. Therapy with corticosteroids should be considered in addition to antiviral therapy in patients with severe varicella pneumonia. While oral acyclovir chemoprophylaxis is probably beneficial in populations with chicken pox.

[Advantages of primary rhinoplasty in the treatment of lip fissure]

Congenital cleft lip is always associated to nasal deformity. The classical approach has been not to treat the severe nose defects during childhood, in the fear that early surgery would interfere with nasal growth. However, long term follow-up in patients with early conservative rhinoplasty has shown the nose to hold its new shape and its growth to be normal. During the period between november 1996 and november 1998, 22 infants affected with cleft lip underwent early rhinoplasty according to McComb's technique. During the follow-up period (6 months to 30 months) the children had a good nasal growth. The nose tip is in the medial position in all cases, and only the inferior view of the nose shows a discrete nosetril assimetry in some patients.

[Progressive bone elongation of the maxillo-facial area: mandibular distraction]

Thanks to the distraction osteogenesis technique, it is nowadays possible to create new bone in the facial area. Between january 1997 and march 1999 we have performed 20 such procedures, from which 15 were mandibular. We present our experience in 10 patients with this new technique, 5 unilateral and 5 bilateral. Those were 7 boys and 3 girls, aged 2 to 14 years, affected with hemifacial microsomia, Goldenhar syndrome: 3; retrognatism with severe malocclusion: 4; facial assimetry due temporomandibular joint abnormalities: 2; and facial assimetry: 1. The proposed elongation was achieved in all cases. There was not only a skeletal improvement, but also growth and remodeling of the facial soft tissues. Distraction osteogenesis is the early treatment of the mandibulofacial deformities and offers a great deal of advantages to the growing patient.

"Recommendations for uniform reporting of data following major trauma--the Utstein style" (as of July 17, 1999). An International Trauma Anaesthesia and Critical Care Society (ITACCS)

Basic and advanced care of trauma patients has always been an important aspect of prehospital and immediate in-hospital emergency medicine, involving a broad spectrum of disciplines, specialties and skills delivered through Emergency Medical Services Systems which, however, may differ significantly in structure, resources and operation. This complex background has, at least in part, hindered the development of a uniform pattern or set of criteria and definitions. This in turn has hitherto rendered data incompatible, with the consequence that such differing systems or protocols of care cannot be readily evaluated or compared with acceptable validity. Guided by previous consensus processes evolved by the ERC, the AHA and other International Organizations--represented in ILCOR--on 'Uniform reporting of data following out-of-hospital and in-hospital cardiac arrest--the Utstein style' an international working group of ITACCS has drafted a document, 'Recommendations for uniform reporting of data following major trauma--the Utstein style'. The reporting system is based on the following considerations: A structured reporting system based on an "Utstein style template" which would permit the compilation of data and statistics on major trauma care, facilitating and validating independent or comparative audit of performance and quality of care (and enable groups to challenge performance statistics which did not take account of all relevant information). The recommendations and template should encompass both out-of-hospital and in-hospital trauma care. The recommendations and template should further permit intra- and inter-system evaluation to improve the quality of delivered care and identification of the relative benefits of different systems and innovative initiatives. The template should facilitate studies setting out to improve epidemiological understanding of trauma; for example such studies might focus on the factors that determine survival. The document is structured along the lines of the original Utstein Style Guidelines publication on 'prehospital cardiac arrest'. It includes a glossary of terms used in the prehospital and early hospital phase and definitions, time points and intervals. The document uses an almost identical scheme for illustrating the different process time clocks--one for the patient, one for the dispatch centre, one for the ambulance and, finally, one for the hospital. For clarity, data should be reported as core data (i.e. always obtained) and optional data (obtained under specific circumstances). In contrast to the graphic approach used for the Utstein template for pre- or in-hospital cardiac arrest, respectively, the present template introduces, for the time being, at least, a number of terms and definitions and a semantic rather than a graphic report form. The document includes the following sections: The Section Introduction and background The Section on Trauma Data Structure Development: presents a general outline of the development of structured data using object-orientated modelling (which will be discussed in due course) and includes a set of explanatory illustrations. The Section on Terms and Definitions: outlines terms and definitions in trauma care, describing different types of trauma (blunt, penetrating, long bone, major/combined, multiple/polytrauma and predominant trauma). The Section on Factors relating to the circumstances of the injury describes the following items: cause of injury (e.g. type of injury (blunt or penetrating), burns, cold, crush, laceration, amputation, radiation, multiple, etc. Severity of Injury e.g. prehospital basic abbreviated injury score developed by the working group. The score contains anatomical and physiological disability data, with the anatomical scale ranging ordinally from 1. Head to 9. External; the physiological disability scale ranging ordinally from 0--unsurvivable. Mechanism of injury recording for transportation incidents etc. e.g. the type of impact, po

Remission status defined by immunofixation vs. electrophoresis after autologous transplantation has a major impact on the outcome of multiple myeloma patients

We have retrospectively analysed 344 multiple myeloma (MM) patients (202 de novo patients) treated in a non-uniform way in whom high-dose therapy and autologous stem cell transplantation (ASCT) response was simultaneously measured by both electrophoresis (EP) and immunofixation (IF). Patients in complete remission (CR) by EP were further subclassified as CR1 when IF was negative and CR2 when it remained positive. Partial responders (PR) were also subclassified as PR1 (very good PR, > 90% reduction in M-component) or PR2 (50-90% reduction). CR1 patients showed a significantly better event-free survival (EFS) [35% at 5 years, 95% confidence interval (CI) 17-53, median 46 months] and overall survival (OS) (72% at 5 years, CI 57-86, median not reached) compared with any other response group (univariate comparison P < 0.00000 to P = 0. 004). In contrast, comparison of CR2 with PR1 and with PR2 did not define different prognostic subgroups (median EFS 30, 30 and 26 months respectively, P = 0.6; median survival 56, 44 and 42 months respectively, P = 0.5). The non-responding patients had the worst outcome (5-year OS 8%, median 7 months). Multivariate analysis confirmed both the absence of differences among CR2, PR1 and PR2 and the highly discriminatory prognostic capacity of a three-category classification: (i) CR1 (ii) CR2 + PR1 + PR2, and (iii) non-response (EFS P < 0.00000; OS P < 0.00000; both Cox models P < 0.00000). In the logistic regression analysis, the factors significantly associated with failure to achieve CR1 were the use of two or more up-front chemotherapy lines, status of non-response pre-ASCT and inclusion of total body irradiation (TBI) in the preparative regimen. Tandem transplants or the use of multiple agents (busulphan and melphalan) in the preparative regimen resulted in a higher CR1 level; none of the biological factors explored influenced the possibility of achieving CR1. These results confirm that, in MM patients undergoing ASCT, achieving a negative IF identifies the patient subset with the best prognosis; accordingly, therapeutic strategies should be specifically designed to achieve negative IF.

Conditioning regimens in autologous stem cell transplantation for multiple myeloma: a comparative study of efficacy and toxicity from the Spanish Registry for Transplantation in Multiple Myeloma

High-dose chemoradiotherapy conditioning regimens for autologous stem cell transplantation (ASCT) are generally held to give similar results in multiple myeloma (MM), but no specific comparative study has been published. We addressed this issue by comparing the main high-dose chemoradiotherapy regimens used in the Spanish Registry. Patient cohorts included 315 cases treated with 200 mg/m2 melphalan (MEL200), 127 patients with 140 mg/m2 melphalan plus total body irradiation (MEL140 + TBI) and 121 cases with 12 mg/kg busulphan plus 140 mg/m2 melphalan (BUMEL). After ASCT, granulocyte and platelet recovery time was similar in all conditioning groups. There were no differences in transplant-related mortality. All regimens yielded a similar response in reference to pre-ASCT MM status, although BUMEL produced a slightly better overall response when compared with the other regimens (97% vs. 89% and 92%, P = 0.003). The 5-year overall survival (OS) with BUMEL was 47% [95% confidence interval (CI) 26-68] compared with 43% (CI 31-54) for MEL140 + TBI and 37% (CI: 18-56) for MEL200. The median survival for the BUMEL group was 64 months compared with 45 and 37 months for the MEL200 and MEL140 + TBI groups respectively. These differences were non-significant (P = 0.2). The median event-free survival (EFS) was better for BUMEL (32 months) than for MEL200 (22 months) or for MEL140 + TBI (20 months). The differences in EFS between BUMEL and the other conditioning regimens reached statistical significance (P = 0.01). Nevertheless, the adjusted multivariate analysis for OS and EFS revealed that the conditioning regimens had no independent prognostic value. We concluded that three different conditioning regimens, commonly used for ASCT in MM, have a similar antimyeloma effect. However, the trend for better results observed in our series with BUMEL requires a prospective trial.

Secondary metabolites from Senecio minutus and Senecio boissieri: a new jacaranone derivative

Jacaranone (1), the related new dimethoxy derivative 2, and known triterpenoids were isolated from the aerial parts of Senecio minutus. The aerial parts and the rhizomes of Senecio boissieri afforded the furanoeremophilanes 3 and 4 and known triterpenoids.

Management and outcome of liver recipients with post-transplant lymphoproliferative disease

BACKGROUND/AIMS

The possibility of development of post-transplant lymphoproliferative disease by patients receiving immunosuppressive therapy is well known. However, elective treatment and outcome remain controversial. We reviewed the management and outcome of our patients with post-transplant lymphoproliferative disease.

METHODOLOGY

Records of 457 patients who underwent orthotopic liver transplantation from 1986 to 1997 were analyzed. Patients who developed post-transplant lymphoproliferative disease were reviewed retrospectively. Incidence, clinical presentation, risk factors and outcomes were examined with special emphasis on ductopenic rejection and hilum involvement.

RESULTS

Eleven patients developed a post-transplant lymphoproliferative disease (2.4%). These were B-cell non-Hodgkins lymphoma, Epstein-Barr virus-associated in all cases. Five patients (45.5%) received monoclonal antibodies or antithymocyte globulin. Seven patients (63.6%) developed a lymphoproliferative disease before 9 months post-transplant and 4 recipients (36.4%) after 20 months. No late lymphomas regressed after withdrawal from immunosuppression. Six patients (54.5%) were treated with chemotherapy. Eight patients (72.7%) had a tumoral remission. Five patients (45.5%) developed chronic rejection after immunosuppressant discontinuation. Four of them died as a consequence of ductopenic rejection and retransplantation was required in another; 2 died due to graft hilum infiltration. Five patients (45.5%) are alive after a follow-up of 36.5 +/- 32 months (range: 4-77 months).

CONCLUSIONS

Patients with post-transplant lymphoproliferative disease require a close follow-up in order to promptly treat conditions that could lead to death. In our series, these were more closely associated with a failing transplanted organ than with the lymphoma itself.

[Treatment of severe scrotal hypospadias with onlay-type urethroplasty using mouth mucosa]

Failure in repairing severe hypospadias complicated with fistula and cutaneous retraction is often associated with lack of subcutaneous tissue and skin providing protection to the neourethra. We report the results of treatment in 6 patients with scrotal hypospadias with severe deviation and scarce dorsal prepuce. A neourethra was created by the onlay technique applying an oral mucosa graft and preserving in all cases the dorsal preputial skin for the island cutaneous flap. All patients had hypospadias without previous repairs excepting one of them, who had had one first time hypospadias repair in other hospital. Patients age ranged between 2 years and 3 months, and 4 years (mean: 2 years and 9 months). In all cases, hypospadias was scrotal type with severe deviation and scarce dorsal prepuce. All patients had prior hormone stimulation with dehydrotestosterone 3%. Surgical repair was performed in one-stage. Urethroplasty included preservation of the urethral plate, oral mucosa graft to provide ventral coverage, and island cutaneous flap with the dorsal preputial skin. In all cases, the chord was dissected behind the urethral plate. In 3 patients a dorsal Nesbit plication was necessary to obtain a complete straighten penis. Results in all 6 cases were satisfactory. Only one patient had a small leakage at the previous neomeatus. The other five patients are asymptomatic. Follow-up ranges from 6 months to 2 years. We conclude that urethroplasty in association with a well vascularized island flap of dorsal preputial skin decrease the incidence of fistulae. In patients with severe hypospadias with scarce dorsal prepuce urethroplasty should be completed with oral mucosa grafts preserving dorsal preputial skin for the ventral cutaneous plasty.

Early postpartum metabolic assessment in women with prior gestational diabetes

OBJECTIVE

To present the results of early postpartum metabolic assessment in women with gestational diabetes mellitus (GDM), to determine predictive factors for subsequent diabetes, and to investigate the association of postpartum glucose tolerance with other components of the metabolic syndrome.

RESEARCH DESIGN AND METHODS

A total of 788 women were evaluated 3-6 months after a GDM pregnancy. A 75-g oral glucose tolerance test (OGTT) was performed. Cholesterol, HDL cholesterol, triglycerides, blood pressure, BMI, and body fat distribution were assessed. Clinical and obstetric history, baseline variables at the diagnosis of GDM, metabolic control during pregnancy, and index pregnancy outcome were compared in women with diabetes and women without diabetes (American Diabetes Association [ADA] criteria) after pregnancy. Multivariate logistic regression analysis was used to ascertain independent predictors of subsequent diabetes. Correlation coefficients were assessed between postpartum glucose tolerance and lipid levels, blood pressure, BMI, and body fat distribution.

RESULTS

According to ADA criteria, 588 (74.6%) women were normal, 46 (5.8%) had impaired fasting glucose, 82 (10.4%) had impaired glucose tolerance, 29 (3.7%) had both impaired fasting glucose and impaired glucose tolerance, and 43 (5.4%) had diabetes. Prepregnancy obesity, recurrence of GDM, gestational age at diagnosis of GDM, glucose values in the 100-g OGTT, number of abnormal values in the 100-g OGTT, fasting C-peptide levels in pregnancy, C-peptide/glucose score in pregnancy, insulin requirement in pregnancy, 3rd trimester HbA1c levels, and macrosomia differed significantly in women with subsequent diabetes. Independent predictors of postpartum diabetes were prepregnancy obesity, C-peptide/glucose score during pregnancy, and the number of abnormal values in the 100-g diagnostic OGTT. The area under the postpartum glucose curve was positively associated with BMI, waist circumference, waist-to-hip ratio, triglycerides, and systolic and diastolic blood pressures.

CONCLUSIONS

Low C-peptide/glucose score during pregnancy together with prepregnancy obesity and severity of GDM (number of abnormal values in the 100-g diagnostic OGTT) are independent predictors of subsequent diabetes. Our data suggest that regardless of obesity and severity of GDM, a beta-cell defect increases the risk of postpartum diabetes. The association of postpartum glucose tolerance with triglyceride levels, blood pressure, obesity, and regional distribution of body fat suggests that postpartum glucose intolerance anticipates a high-risk cardiovascular profile that comprises other risk factors besides diabetes.

Oxygen consumption, lactate metabolism, and gastric intramucosal pH in an experimental liver transplantation model

OBJECTIVE

To assess the usefulness of measuring whole-body oxygen consumption (VO2), arterial lactate concentration, and gastric intramucosal pH (pHi) as parameters for evaluating hepatic graft viability in a model of experimental liver transplantation.

DESIGN

Experimental, prospective study.

SETTING

Hospital laboratory for experimental surgery.

SUBJECTS

Twenty-eight Landrace-Largewhite pigs: 14 donors and 14 recipients.

INTERVENTIONS

Orthotopic liver transplantation. Two groups were differentiated by graft preservation status: an optimal-graft group (group 1), which received donor livers that had been preserved in Collins solution at 4 degrees C for <4 hrs (n = 7), and an injured-graft group (group 2), which received donor livers that had been preserved in Collins solution at 4 degrees C for >24 hrs (n = 7).

MEASUREMENTS AND MAIN RESULTS

Hemodynamic parameters, variables related with systemic and hepatic oxygen and lactate metabolism, gastric pHi, and arterial pH were measured at two stages: a) preanhepatic stage; and b) neohepatic stage (60 mins after reperfusion). There were no differences in VO2 between graft groups or stages. In the neohepatic stage, hepatic oxygen extraction and lactate turnover were significantly higher in the optimal-graft group than in the injured-graft group. In the neohepatic stage, gastric pHi decreased significantly and arterial lactate concentrations increased significantly in both groups.

CONCLUSIONS

Changes in hepatic VO2 cannot be detected by VO2 measurements. Optimal-state grafts increased their lactate turnover as a result of substrate overload, but injured grafts did not. Therefore, the evolution of arterial lactate concentrations in the immediate postoperative period may be useful for the early evaluation of transplanted livers. Gastric pHi can be a useful measurement in the immediate posttransplantation period for differentiating between hyperlactacidemia produced by liver dysfunction (normal pHi) and hyperlactacidemia produced by lactate generation as a consequence of inadequate tissue oxygenation or of a mixed origin (abnormal pHi).

Nasolacrimal polyurethane stent: complications with CT correlation

PURPOSE

To evaluate initial results in patients with epiphora secondary to obstruction of the nasolacrimal duct treated by placement of a polyurethane stent, and to discuss the technical problems and complications arising during the procedure, with visualization of the anatomy of the drainage apparatus using computed tomography (CT).

METHODS

We inserted 20 polyurethane Song stents under fluoroscopic guidance after dacryocystography in 19 patients with grade 3-4 epiphora caused by idiopathic obstruction of the nasolacrimal duct. CT scans were obtained following stent placement in all patients.

RESULTS

We focus on the technical problems and complications that arose during these procedures. During negotiation of the guidewire past the obstruction at the level of the junction of the duct with the lacrimal sac, the guidewire created a false passage in a posterior suborbital direction in two cases and towards the posterior midline in another. In all cases the guidewire was withdrawn and reinserted through the proper anatomic route without further difficulty or complications. In two cases the stent was improperly positioned wholly or partially outside the nasolacrimal system (one medially, one posteriorly). In one case the stent was removed and reinserted; in the other it remains in place and functional. CT was performed in all these cases to ensure proper anatomic alignment and determine what had gone wrong. The epiphora was completely resolved in 13 cases and partially relieved in four; there were three cases of stent obstruction. Epistaxis of short duration (1 hr) occurred in seven patients and headache in one.

CONCLUSIONS

Treatment of epiphora with polyurethane stents is a technique that is well tolerated by patients and achieves a high success rate, yet problems in placement may be encountered. Though no major consequences for patients are involved, cognizance of such difficulties is important to avoid incorrect positioning of stents.

Postprandial cholecystokinin response in patients with chronic pancreatitis in treatment with oral substitutive pancreatic enzymes

Cholecystokinin (CCK) response to a test meal should be increased in patients with pancreatic insufficiency, as trypsin is absent from the duodenum. If pancreatic enzymes are added, a restoration of the inhibitory feedback should result in lower levels of CCK. Ten patients with chronic pancreatitis and steatorrhea were studied. CCK basal and postprandial levels were evaluated the day before and 45 and 90 days after treatment with oral pancreatin. Twelve healthy volunteers were included as reference group. CCK basal levels did not vary. CCK response to a test meal was increased in patients before treatment and diminished when oral enzymes were maintained for months even after three days of therapy withdrawal. We conclude that long-term therapy with oral enzymes induces changes in CCK response that do not regress after three days of treatment suspension.

Body fat distribution, insulin mediated suppression of non-esterified fatty acids and plasma triglycerides in obese subjects

Triglyceride levels and free fatty acid metabolism are influenced by body fat distribution. To test whether the pattern of fat distribution in obese subjects results in distinct insulin mediated suppression of non-esterified fatty acids which could account for differences in plasma triglycerides, we studied 59 obese subjects who were classified according to waist-to-hip ratio. Non-esterified fatty acids and insulin response to a 75 g oral glucose tolerance test were higher in abdominal obesity. Total non-esterified fatty acids response, after adjustment for sex, showed a positive association with waist-to hip ratio (r = 0.292; p < 0.05). The abdominal obese group had higher fasting triglycerides (1.74+/-0.83 versus 1.11+/-0.71 mmol/L; p = 0.003) and lower glucose/insulin ratio (5.2+/-2.3 versus 7.1+/-2.4; p = 0.003). Stepwise multiple regression analysis showed that triglyceride levels are explained by fasting and 120 min non-esterified fatty acids and by glucose/insulin ratio. We conclude that abdominal obesity is associated with a higher resistance to insulin mediated suppression of non-esterified fatty acids in obese subjects. Variation of triglyceride concentrations in obesity is dependent on both fasting and 120 min non-esterified fatty acids as well as on insulin sensitivity to glucose utilization.

Idarubicin and intermediate dose ARA-C followed by consolidation chemotherapy or bone marrow transplantation in relapsed or refractory acute myeloid leukemia

Sixty-one adult patients with relapsed or refractory acute myelogenous leukemia (AML) were treated in a cooperative study with Idarubicin 12 mg/m2/day on days 1 to 3 and AraC 1 g/m2/12h on days 1 to 4. Responding patients were scheduled for consolidation with Ida-IDAraC and bone marrow transplantation (BMT) when feasible. Twelve of 23 refractory patients (52%) and 21 of 38 relapsed patients (55%) achieved complete remission (CR). Refractory patients treated very early with Ida-IDAraC (CR 63%) and relapsed patients with initial CR > 6 months (CR 68%) were the subgroups with better CR rate. The only factor influencing the disease free survival (DFS) was the intensity of postremission therapy: Nine patients had severe toxicity with the salvage regimen and were excluded for consolidation, fourteen patients received Ida-IDAraC and ten patients proceeded to myelo-ablative therapy supported with autologous or allogeneic BMT. The three groups had different median DFS of 6 months, 9 months and 15 months respectively (P = 0.017). In summary, Ida-AraC is an efficient salvage regimen for AML. The CR rate seems to be improved in refractory patients if used promptly, but the long term outcome appears to depend on the intensity of treatment given once remission is achieved and on the ability to perform BMT.