A review of 76 patients with myelodysplastic syndromes treated with danazol

BACKGROUND

Treatment of myelodysplastic syndromes (MDSs) remains unsatisfactory. A limited number of reports provide contradictory information on whether danazol, a synthetic androgen, may be useful in patients with MDS.

METHODS

Between 1984 and 1992, 76 patients were treated with danazol (Danatrol, Winthrop) in an open nonrandomized study. Clinical status, blood counts, differential marrow cell counts, transfusion requirements, and liver enzymes were monitored at 3-month intervals during and 6 months after discontinuation of therapy. The authors present the retrospective analysis of this cohort of patients.

RESULTS

This study shows a limited usefulness of danazol in patients with MDS. Blood counts were not significantly changed during danazol administration; neither were transfusion requirements. Overall survival and the rate of leukemic transformation were not affected when compared with 50 untreated patients or with data available in the literature. An increase in platelet numbers in four patients and in hemoglobin level in one patient was observed; these patients were unremarkable and were not transfused before initial danazol therapy; therefore, changes in blood counts were of limited clinical significance. The search for subgroups of patients likely to have a favorable response was unsuccessful. Side effects of danazol were limited. In addition, this study provides information on the frequency of antiplatelet antibodies and other autoantibodies in patients with MDS.

CONCLUSIONS

This study does not support a positive effect of danazol in patients with MDS during long term follow-up. Anecdotal positive evolution in a few patients cannot be formally ascribed to danazol. These results should be interpreted by comparison with previous publications that report on small numbers of patients with limited follow-up. Based on these data, the authors cannot recommend the systematic use of danazol in MDS.

Validation of the Minnesota Leisure Time Physical Activity Questionnaire in Spanish men. The MARATHOM Investigators

Questionnaires are frequently used for measuring physical activity. The aim of this study was to validate the Spanish version of the Minnesota Leisure Time Physical Activity Questionnaire (MLTPAQ) in Spanish men. Healthy men (n = 187) aged 20-60 years were recruited. The MLTPAQ was administered to assess the quantity (total activity metabolic index) and quality (heavy, moderate, and light) of physical activity performed in the last year, quarter, month, and week. Fitness was assessed with an exercise test. Spearman's correlation coefficients between the total activity metabolic index and exercise test duration, time to maximal theoretical heart rate, and caloric intake were 0.57, 0.46, and 0.40, respectively. The intraclass correlation coefficients between the total activity metabolic indexes in the last year and in the last quarter, month, and week were 0.62, 0.46, and 0.35, respectively. In multiple linear regression, the heavy, moderate, and light activity metabolic index, age, body mass index, and basal heart rate explained 40% of the variability of time to the maximum theoretical heart rate. The Spanish version of the MLTPAQ is a valid instrument to measure the quantity and quality of physical activity performed in the last year (also in periods shorter than 1 year) by Spanish men aged 20-60 years. Only heavy physical activity is related to cardiorespiratory fitness.

[The diagnostic confirmation of mild arterial hypertension via ambulatory monitoring]

OBJECTIVE

To compare the clinical diagnosis of light arterial hypertension with a system of out-patient monitoring of arterial pressure (OMAP).

DESIGN

Observational study.

SETTING

An urban health centre.

PATIENTS

People diagnosed as suffering from light hypertension (diastolic pressure > 90 and < or = 104 mmHg).

MEASUREMENTS AND MAIN RESULTS

The recordings obtained on a Spacelabs 90202 model over 24 hours for 42 patients diagnosed with light Arterial Hypertension were analysed. The arterial pressure load or average deviation index (the average percentage of the systolic and diastolic measurements above the established criteria: 140/90 mmHg) as well as the systolic and diastolic arterial pressures (the arithmetical mean of the valid recordings) were calculated.

MEASUREMENTS AND MAIN RESULTS

At least 35.7% of the patients showed normal tension in the OMAP, presenting an arterial pressure load < or = 15% and mean systolic and diastolic arterial pressures of 117.6 +/- 7.5 and 72.7 +/- 5.6 mmHg, respectively. Out of 42 patients, 29 were male (69%) and 13 women (31%). 57% presented some degree of obesity or hypercholesterolemia and 24% were smokers.

CONCLUSIONS

The high percentage of "white gown" hypertensive patients should be noted. It is important to unify OMAP analysis criteria.

[The protection of an internal mammary artery graft with a tubular prosthesis made of polytetrafluoroethylene]

A polytetrafluoroethylene tubular prosthesis was used to protect an internal mammary artery graft in a patient with high risk of reoperation. This technique was used to avoid the risk of damage of the graft and to reduce the difficulties of the injection of cardioplegia during the reoperation procedure. The usefulness of this technique is discussed in the article.

[Exhaustion syndromes in a popular marathon]

The clinical characteristics of seven healthy subjects who required hospital care for an exhaustion syndrome due to extenuated physical exercise during participation in a public marathon are presented. All the patients were used to practising sports activities and in all the cases the symptoms of exhaustion appeared in the last few kilometers of the race. The most frequent symptom found in all the patients was lipothymia with falling to the ground followed by gastrointestinal manifestations, muscle cramping and fever. Upon analysis the signs of rhabdomyolysis and others suggestive of dehydration were observed in all the cases. Leukocytosis was observed in four and hypopotassemia in two. Evolution was good in all the cases with rest and hydroelectrolytic reposition. Finally, the preventive measures to avoid heat stroke and exhaustion syndromes in public marathons are reported.

[Ambulatory monitoring of arterial pressure in mild hypertensives without pharmacologic treatment]

OBJECTIVE

To evaluate, using a scheme to monitor arterial pressure in out-patients (MAPOP), how well patients were able to control their light arterial hypertension after hygienic-dietary measures had been found insufficient.

DESIGN

Observational study. SITE. Urban health centre.

PATIENTS

18 people suffering from light arterial hypertension and undergoing treatment with hygienic-dietary measures only.

MAIN MEASUREMENTS AND RESULTS

Out-patient monitoring of arterial pressure over 24 hours with an oscillometric model Spacelabs 90202. The arterial pressure load or index of average deviation (APL/IAD) was analysed. Two of the 18 (11%) presented APL values corresponding to normal tension and 11 (61%) had values of circadian curve type 1 (APL/IAD < or = 30%).

CONCLUSIONS

A high percentage (61%) of those patients with light arterial hypertension, whose doctors had considered exhausted the possibilities of treatment without drugs, showed they could control to an acceptable degree their arterial tension with MAPOP: The perfecting and lowering in price of MAPOP systems, along with their increasing use in the diagnosis and treatment of patients with hypertension, could also provide important savings on pharmaceuticals.

Anxiety disorders in the joint hypermobility syndrome

A case-control study was designed to test the association between joint hypermobility syndrome (JHS), an inherited disorder of collagen synthesis, and anxiety and phobic disorders. One hundred fourteen cases of JHS diagnosed at the rheumatology outpatient clinic of the Hospital del Mar (Barcelona) were compared to 59 control subjects randomly selected from patients seen at the same clinic. Both cases and controls were examined by a psychologist who used the Structured Clinical Interview for DSM-III-R and who was unaware of their medical diagnoses. DSM-III-R diagnoses of panic disorder, agoraphobia, and simple phobia, but not generalized anxiety disorder, dysthymic disorder, or major depression were found to be highly associated with JHS (age- and sex-adjusted odds ratio = 10.7). Mitral valve prolapse (MVP) was present only among JHS cases. Among cases of JHS, subjects with MVP were almost three times more likely to suffer from anxiety than subjects without MVP (odds ratio = 2.95), although the association was not statistically significant. The strong association between panic anxiety and JHS appears to occur at a higher level than the association between panic and MVP, and provides a new basis for further studies on the genetic background of panic-anxiety.

[The radiofrequency ablation of accessory pathways. The initial experience in Mexico]

Thirteen patients with paroxysmal supraventricular tachycardia (SVT) due to an accessory pathway were submitted to an electrophysiological study and radiofrequency ablation of the Kent bundle. There were 9 males and 4 females. The mean age was 22 years. Other than their SVT, none had any structural heart disease. Ten of them had Wolff-Parkinson-White syndrome, and three had concealed accessory pathways. Two different types of radiofrequency devices were used: one generating damped sinusoid waves, and two other generators producing pure continuous sinusoid waves. With the first type, two attempts were made: one patient with a concealed pathway and one with overt preexcitation. The successful ablation was not achieved because this wave type is 100 times more powerful, it desiccates the tissue, and thus does not produce the right kind of lesion. The other eleven patients were divided in three groups: I) With left overt preexcitation (7 pts) II) Concealed left Kent bundles (2 pts) III) Right Kent bundles. Ablation was 100% successful in group I, while in the other two groups, only one patient of each was successfully ablated. The overall successful rate of these 3 groups was 81.8%. Of the two patients that could not be treated, one had an anterior septal Kent bundle and the other had a concealed left Kent bundle. We believe that catheter ablation is a very promising therapeutic procedure for patients with SVT, besides being a extraordinary instrument that will enable us to be able to understand further clinical electrophysiology.

The influence of morphological variation on Candida albicans adhesion to denture acrylic in vitro

Using denture acrylic pieces coated with either whole human stimulated saliva or oral streptococci, the binding ability of three different Candida albicans strains was investigated. The C. albicans strains include a clinical isolate with the commonly observed, smooth, round colonial morphology (strain 613p), a morphological variant spontaneously derived from the clinical isolate strain 613p (strain 613m1BK) and a clinical isolate from an oral lesion that was also a morphological variant upon primary isolation (strain 228). Levels of adhesion to the acrylic pieces were determined radiometrically using C. albicans cells metabolically labelled with [35S]-methionine. Whole stimulated saliva significantly increased the binding of all strains compared to uncoated acrylic. However, the level of binding of strain 613p to saliva-coated acrylic was significantly greater than the levels observed for the morphological variant strain 613m1BK. Coating acrylic pieces with either Streptococcus sanguis NCTC 10904, Strep. mutans GS-5 or Strep. sobrinus ATCC 27352 instead of saliva resulted in significantly greater binding by strain 613p compared to uncoated acrylic. Pre-coating the acrylic with the oral streptococci did not significantly increase the binding of morphological variant strains 613m1BK and 228 compared to uncoated acrylic. In general, preincubation of adherent streptococci with sucrose to induce the synthesis of extracellular carbohydrate polymers did not significantly increase the binding levels of the C. albicans strains above those observed using streptococci in buffer alone. Compared to its parental strain 613p, morphological variant strain 613m1BK adhered poorly to denture acrylic coated with either salivary constituents or oral streptococci, while strain 228 adhered to the same substrates at an intermediate level. Furthermore, physical disaggregation of clusters of the morphological variant strain 613m1BK did not appear to increase its binding capacity to saliva-coated denture acrylic. The effect of whole stimulated saliva on the adherence of C. albicans 613p to a variety of plastic substrates in addition to denture acrylic was examined. Overall, saliva pre-coating of the various plastics promoted C. albicans 613p adhesion. The adhesion of strain 613p to denture acrylic coated with whole stimulated saliva from each of five different donors or with parotid and submandibular/sublingual saliva from each of two donors was also examined. Regardless of donor, a coating of whole stimulated saliva significantly increased the binding of strain 613p to denture acrylic compared to uncoated acrylic. In addition, a coating of parotid saliva significantly increased the binding of strain 613p to denture acrylic compared to submandibular/sublingual saliva.

[Coronary heart disease and lipoprotein (a): relationship with other lipid cardiovascular risk factors]

BACKGROUND

Lipoprotein (Lp) (a) is considered a risk factor for early coronary heart disease (CHD), and a discriminant cutoff of Lp(a) concentration has been suggested.

METHODS

Serum Lp(a) concentrations have been determined by enzymoimmunoassay in 66 men with CHD and in 100 healthy control men. Serum cholesterol, serum triglycerides, high density lipoprotein (HDL)-cholesterol, and apoprotein (apo) A-I were also determined.

RESULTS

Serum Lp(a) concentration was 21.7 +/- 16.9 mg/dl (mean +/- SD) in patients and 12.5 +/- 12.5 mg/dl in controls (p less than 0.001). Serum cholesterol was 5.63 +/- 1.22 mmol/l and 5.29 +/- 1.00 mmol/l (p less than 0.05) respectively; serum triglycerides were 1.99 +/- 1.23 mmol/l and 1.29 +/- 0.61 mmol/l (p less than 0.001) respectively; HDL-cholesterol was 0.97 +/- 0.27 mmol/l and 1.07 +/- 0.30 mmol/l (p less than 0.05) respectively; and apo A-I was 94 +/- 15 mg/dl and 144 +/- 41 mg/dl (p less than 0.001) respectively. Lp(a) concentrations were not correlated with other well-recognized cardiovascular risk lipidic factors, nor influenced by age either body mass index. Using 20 mg/dl as discriminant Lp(a) concentration between patients and controls, a ratio 2:1 in patients with respect to controls has been observed and exceeded some more when the threshold level was put on 30 mg/dl. A subset of normocholesterolemic and normotriglyceridemic patients (n = 17) and controls (n = 49) had serum Lp(a) concentration of 22.7 +/- 16.3 mg/dl and 9.1 +/- 8.2 mg/dl (p less than 0.001) respectively.

CONCLUSIONS

Increased concentration of Lp(a) constitutes an independent risk factor for CHD. On the other hand, Lp(a) concentrations of 20 mg/dl or 30 mg/dl as risk threshold levels are well-defined.

Role of splenectomy in incidence and severity of acute graft-versus-host disease: a multicenter study of 157 patients

Allogeneic bone marrow transplantation is a therapeutic option for many hematological malignancies. Graft-versus-host disease (GVHD) remains one of the major complications and has a high mortality rate. The pathophysiological mechanisms involved are poorly understood and GVHD prevention regimens still give disappointing results. This study concerned 157 patients with diverse diagnoses from Bordeaux, Grenoble and Marseille who had undergone an HLA-matched transplantation without T cell depletion. Thirty-one patients (20%) had been splenectomized before transplantation. The role of splenectomy in the incidence and severity of acute GVHD was investigated using a univariate and multivariate analysis of 11 risk factors including splenectomy. Univariate analysis found three significant risk factors linked with GVHD incidence: splenectomy, age of recipient and GVHD prevention by monotherapy versus a combination of methotrexate plus cyclosporin. Multivariate analysis retained only the effects of age and GVHD prevention on GVHD incidence and showed that splenectomy was the most important factor in GVHD severity. One explanation for the role of splenectomy could be the spleen's possible function as a filter of activated T lymphocytes from the transplant. We therefore concluded that it would be preferable to abstain from splenectomizing patients before transplantation although splenectomy is still advisable in certain malignancies after transplantation.

Study of megakaryocytic progenitors (CFU-MK) in human long-term bone marrow cultures (LTBMC): adjuvant effect of plasma from aplastic patients

Human long-term bone marrow cultures (LTBMC) provide a very interesting tool for studying the events that are involved in stem cell commitment. At the present time, megakaryocyte (MK) progenitor cells have never been demonstrated in this system. In an effort to detect this cell lineage, we modified the culture medium by substituting fetal calf serum (FCS) and horse serum (HS) mix with human plasma obtained from treated aplastic leukemic patients. This plasma was harvested between days 15 and 21 following induction chemotherapy or conditioning regimen for autograft or allogeneic bone marrow transplantation. Using LTBMC, 17 normal marrows were cultivated for 11 weeks in Iscove's modified Dulbecco's medium containing either 20% human aplastic plasma or control FCS/HS mixture. In this plasma medium we observed the development of an adherent layer morphologically comparable to that observed with standard medium. We demonstrated presence of MK cells at all stages of maturation for 10 weeks and MK colony-forming cells (CFU-MK) for 11 weeks in the culture supernatants. An increased production of nonadherent cells and granulocyte-macrophage progenitors (CFU-GM) was also observed. LTBMC in aplastic plasma medium provide a new method for studying megakaryocytopoiesis, especially in human hematological diseases.

A prospective study of atrial fibrillation and stroke

In a prospective study of 72 patients with stroke and atrial fibrillation, we classified strokes as cardioembolic or noncardioembolic based on arterial assessment using Doppler sonography and angiography. We analyzed and cross-tabulated 18 clinical characteristics and found four to be significantly associated with a cardioembolic mechanism: stroke with onset during activity and peak deficit at onset (p less than 0.008), previous infarct in a different vascular territory (p less than 0.01), previous transient ischemic attack in a different vascular territory (p less than 0.01), and transient ischemic attack lasting greater than 1 hour (p less than 0.02). Starting with these four characteristics, we used a step-down procedure to select variables for a logistic regression model. Only previous infarct in a different vascular territory (odds ratio = 7.38) and transient ischemic attack lasting greater than 1 hour (odds ratio = 7.89) were selected by the model. Using M-mode and two-dimensional echocardiography, we compared left atrial size in 46 patients with that in 78 controls who had atrial fibrillation without stroke. Left atrial size in patients and controls with mitral valvulopathy was significantly larger than that in patients and controls without mitral valve disease. There was, however, no difference in left atrial size between patients with nonvalvular atrial fibrillation and cardioembolic stroke and controls or patients with nonvalvular atrial fibrillation and noncardioembolic stroke. We concluded that some clinical characteristics are closely related to cardioembolic stroke and that left atrial enlargement reflects underlying cardiopathy rather than atrial emboli-forming capability.

Diluted epinephrine solution for the treatment of priapism

We report our experience with 18 consecutive cases of priapism treated with intracorporeal irrigations of dilute epinephrine solution. Of the 18 patients 16 were treated successfully. The 2 failures had priapism 36 hours and 5 days in duration, respectively.

[Autoimmunity in thyroid disease secondary to amiodarone: heredofamilial aspects]

Spontaneous autoimmune thyroid disease (SATD) shows familial aggregation. Some patients receiving amiodarone treatment have been found to develop thyroid dysfunction. Previously, we reported genetic predisposition among this group of patients, now we inform a prospective study which includes the search for autoantibodies and family history to identify risk factors in amiodarone treated patients, 40 of them with amiodarone related thyroid disfunction, and 100 without it; for comparison, 30 patients with SATD and a control group of healthy subjects were also studied. We looked for the presence of autoantibodies against thyroglobulin, smooth muscle, gastric mucosa, myocardium, mitochondria, epithelial intercellular substance, and basal membrane as well as antinuclear antibodies and rheumatoid factors; in addition the history of thyroid disease in first degree relatives was investigated. Organ-specific antibodies anti-thyroglobulin, gastric mucosa and myocardium were found with increased frequency in the three groups of patients compared with controls (p less than 0.05). The frequency of antihydroglobulin antibodies was similar in patients receiving amiodarone with or without thyroid dysfunction. Prognostic stratification revealed that this finding is independent of sex, age, dosage or duration of treatment. A family history of thyroid dysfunction was found more frequently among patients with SATD and amiodarone related dysthyroidism in comparison with patients receiving amiodarone without altered thyroid function (p less than 0.005). The appearance of clinical thyroid disease depends on individual genetical predisposition. In patients with a positive family history, the risk of developing clinical, thyroid disease is 7.6 when treated with amiodarone.

[Use of the subclavian vein for permanent cardiac stimulation]

The experience on 101 cases of permanent cardiac stimulation is reported; in all of them, the access was via the subclavian vein. Punction of the subclavian artery, transient injury of the brachial plexus and pneumothorax, were seen in 4.3 and 3% respectively. Early electrode luxation was observed in 5% of the patients. As late complications there where two cases of destruction of the electrode protecting sheet and one electrode rupture. In spite of the potential risks directly related to the vein puncture, the subclavian puncture offers an excellent alternative for placing definitive pacing electrodes.

[Clinical electrophysiological evaluation of mexiletine]

We studied sixteen patients (pts), seven men and nine women (mean age 35 years) with sustained tachyarrhythmias, for acute therapeutic trial with mexiletine (3 mg/kg IV). The arrhythmias were: ventricular tachyarrhythmia in eight pts supra-ventricular tachycardia (SVT) in eight pts, seven due to abnormal tracts (43%) and one to nodal reentry. After mexiletine administration, the sinusal cycle length was reduced in 12.7% (P less than 0.05) and the H-V interval decreased 6.1% (P less than 0.05). The nodal conduction (A-H) didn't show any substantial change, neither the atrial nor the ventricular refractory periods (RP). In two pts with complex premature ventricular beats it was not possible to induce the ventricular tachycardia(VT) six had sustained VT. After mexiletine administration, three of them (37.5%) showed self limited VT with a greater R-R cycle. Another case was complicated by ventricular fibrillation, In the pts with SVT, the retrograde RP of the abnormal tracts shortened in 27% (P less than 0.05), while the antegrade was not modified. Mexiletine showed to be efficient for the VT treatment. Its efficacy was very limited in pts with SVT. There was no evidence of any deleterious effect over the His-Purkinje conduction.

[Thyroid dysfunction induced by amiodarone]

Amiodarone (2-n-butyl-3,4-diethylaminoethoxy-3',-diiodobenzoyl-benzofurone ) is a drug widely used for the treatment of cardiac arrhythmias. Due to its high iodine content and structural similarity to thyroxine it produces abnormalities in thyroid hormone metabolism and, in some cases, clinical thyroid dysfunction as well. We report 18 patients, 11 females and 7 males, whose thyroid disease developed during treatment with amiodarone (A). Age ranged from 13 to 64 years. A history of thyroid disease in a first-degree relative was present in five, and three patients had goiter prior to A therapy. Fifteen patients had atrial arrhythmias, and 3 had ventricular arrhythmias. Amiodarone was being given in doses of 200 to 800 mg daily. Thyroid function abnormalities appeared between 1 and 29 months after starting A therapy. Nine patients became clinically and chemically thyrotoxic; three patients developed diffuse thyroid enlargement and had total T4 concentration and FI4I increased with normal T3 and no signs of hyperthyroidism; and the six remaining patients became clinically hypothyroid with low values of total T4 and FTI and raised basal TSH. No relationship between dosages of A or duration of treatment and the appearance or severity of thyroid dysfunction was found. Regression of symptoms occurred in all but two patients with simple goiter between 1 and 8 months after amiodarone was discontinued and appropriate treatment was given. Our observations confirm the potential of A to induce thyroid abnormalities in patients with and without preexistent thyroid disease.(ABSTRACT TRUNCATED AT 250 WORDS)