Role of continuous subcutaneous insulin infusion in patients with recalcitrant diabetes in South India

BACKGROUND

We aimed to assess the effect of continuous subcutaneous insulin infusion (CSII) therapy in patients with "recalcitrant diabetes" whose glycemia had not been controlled adequately with multiple daily injections of insulin or insulin plus oral hypoglycemic agents.

PATIENTS AND METHODS

We retrospectively analyzed the medical records of patients with diabetes who were initiated on insulin pump therapy at our center in India between 2002 and 2007. Data analysis included fasting and postprandial blood glucose and glycated hemoglobin (HbA1c) values, insulin requirement, body weight, and the occurrence of hypoglycemia and diabetic ketoacidosis.

RESULTS

We studied 33 patients with diabetes (type 1 [n = 17] and type 2 [n = 16]) who were on CSII therapy for a mean duration of 3.4 years. A statistically significant reduction in HbA1c was found after initiating CSII (prepump 10.7% vs. postpump 8.3%, P < 0.001). The reduction was greater in type 1 patients (10.6 +/- 2.1 vs. 8.0 +/- 1.6%) than in type 2 patients (11.0 +/- 2.1 vs. 8.8 +/- 1.4%). There was a reduction in frequency of severe hypoglycemia after starting the CSII pump, and there were no instances of diabetic ketoacidosis.

CONCLUSIONS

Although HbA1c levels did not reach optimal targets, our data indicate that CSII is an effective therapy for patients with diabetes having recalcitrant diabetes who can afford this treatment and whose glycemia is poorly controlled with conventional therapies.

The use of reduced-intensity stem cell transplantation in haemophagocytic lymphohistiocytosis and Langerhans cell histiocytosis

Allogeneic stem cell transplant is curative for haemophagocytic lymphohistiocytosis (HLH) and refractory Langerhans cell histiocytosis (LCH). However, patients frequently have significant pre-transplant morbidity and there is high TRM. Because HLH is caused by immune dysregulation, we surmised that a reduced-intensity conditioned (RIC) regimen might be sufficient for cure, while decreasing the TRM. In 2006, we reported the outcome of 12 patients treated with RIC SCT from a matched family/unrelated or haploidentical donor. Here we discuss the update of these patients, including a total of 25 patients treated with RIC SCT for HLH and three for LCH. Twenty-one of the twenty-five patients with HLH (84%) are alive and well with remission at a median of 36 months from SCT. Mortality included pneumonitis (n=3) and hepatic rupture (n=1). All three patients treated with RIC SCT for LCH remain alive and in remission at a median of 5.1 years from SCT. Seven of twenty-four survivors (one with LCH) have mixed chimerism but remain disease-free. These data are supported by other groups including 100% survival in seven patients with HLH and 78% survival of nine patients with LCH. In summary, RIC compares favourably with conventional SCT with long-term disease control in surviving patients with both HLH and LCL, despite a significant incidence of mixed chimerism.

An assessment of post-tsunami psychosocial training programmes in Tamilnadu, India

BACKGROUND

After the Tsunami struck Tamilnadu in India in 2004, a spate of psychosocial training programmes were held by a host of agencies, both government and non-government.

AIM

This study is an empirical approach to the assessment of the psychosocial training programmes held after tsunami. The nature and quality of training received by the community level workers (CLWs) and the interventions carried out by them are described.

METHODS

CLWs were interviewed using a questionnaire to assess details about training and interventions carried out by them. Qualitative information was also gathered both from CLWs and the community. A comparison was made between CLWs of government, non-governmental organizations (NGOs) and those belonging to self-help groups.

RESULTS

While most CLWs seemed to have benefited greatly from the training programmes, they had several suggestions to make about refining its quality. Multiple programmes, not well coordinated, resulted in a lot of overlap. The community was generally happy with the interventions provided and felt that they were necessary for about six months at least. One-to-one interventions are preferred to group activities, except in the case of children.

CONCLUSIONS

Psychosocial support (PSS) training programmes after a disaster situation will need to be coordinated by a nodal agency. Too many players on the field with their own agenda do not benefit the community and can well be a waste of resources.

Reduced intensity conditioning and allogeneic stem cell transplantation in childhood malignant and nonmalignant diseases

Allogeneic hematopoietic SCT is well established as a potentially curative therapy for children and adults with both malignant and nonmalignant diseases. However, myeloablative SCT is associated with significant short- and long-term complications. The goals of a reduced intensity-conditioning (RIC) regimen are to prevent graft rejection and establish stable donor-derived hematopoiesis at a level sufficient for cure of the underlying disease and, in patients with hematologic malignancy, to provide a GVL effect, while decreasing the short- and long-term complications associated with myeloablative conditioning therapy. RIC regimens have enabled SCT to be performed in children with preexisting comorbidities that preclude conventional conditioning. RIC-SCT has been most extensively studied in patients with nonmalignant disorders and for some of these, including primary immunodeficiencies and hemophagocytic lymphohistiocytosis, sufficient data now exist to support its routine use even in patients without comorbidity. Less data exist on RIC-SCT for children with hematologic malignancies and at present this should be restricted to children who are not candidates for, or have relapsed after, myeloablative SCT. Here we review available data on the use of RIC-SCT in pediatric patients, highlighting important clinical lessons and areas that require further study.

Cotyledonoid leiomyoma in pregnancy

BACKGROUND

Benign smooth-muscle tumors (leiomyomata) are the most frequent tumors found in the female genital tract. They are easy to diagnose in pregnancy and usually managed conservatively. Some variant forms with unusual infiltrative growth pattern have been known, but they are rare in pregnancy. The variant forms pose diagnostic and management difficulties.

CASE

An unusual type of leiomyoma (cotyledonoid), adhering to the bowels and occupying the whole left broad ligament, was excised completely at 14 weeks of gestation, and the pregnancy continued to term.

CONCLUSION

Familiarity with benign uterine smooth-muscle tumors with unusual growth patterns by gynecologists and pathologists is essential in avoiding over-treatment.

Aetiology and outcome of burns in the elderly

INTRODUCTION

This retrospective study, analyses aetiology and factors affecting the outcome of burns in patients over 65 years of age.

METHODS

Sixty-three consecutive patients, over 65 years of age, were admitted to a Burns Unit over a period of 3 years. Retrospective data was analyzed, taking into account aetiology, burn thickness and area, co-morbid factors. Also, surgery as a factor-affecting outcome was examined.

RESULTS

There was a significant difference of total body surface area burn (TBSA), Abbreviated Burn Severity Index (ABSI), Baux score and the number of pre-existing co-morbid factors between survivors and non-survivors. Age and surgery were not significant to the outcome. Patients undergoing surgery had increased hospital stay without any difference in mortality. The timing of surgery did not have any impact on hospital stay or survival.

CONCLUSION

This study shows a positive correlation between the number of co-morbid conditions and mortality. Early surgery after careful patient selection does not have any negative impact on patient survival.

Phase I study utilizing an intravenous busulfan test dose to prospectively target and determine the maximum tolerated systemic exposure (MTSE) of a continuous intravenous infusion

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Background: Busulfan systemic concentration has correlated with toxicity and efficacy. We previously demonstrated that administration of intravenous high-dose busulfan (HD-Bu) as a 90 hour continuous infusion (CIV) has efficacy, safety, and mean daily area under the concentration curves (AUC) comparable to intermittent dosing regimens and that it is possible to use a test dose of busulfan to predict the systemic exposure with less than 10% variability. The objective of this study is to identify the MTSE of CIV HD-Bu utilizing a test dose for AUC targeting. Methods: Prior to HD-Bu, patients received a single test dose of Bu (0.8 mg/kg) by two hour infusion with blood concentrations obtained at 0, 2.5, 4, 5, and 6 hours. Serum concentrations were analyzed using GC-MS. Non-compartmental PK analysis was used to determine clearance using WIN-NONLIN software. The systemic clearance (dose/AUC) of the test dose was used to predict the 90 hour CIV dose of Bu needed to achieve the desired AUC. On days -7 to -3, the treatment dose was administered and blood samples were collected at 0, 12, 16, 18, 48, 60, 72, and 89.5 hours to verify that the desired AUC was reached. Dose adjustments were made after 18 hours if necessary. A blood sample was obtained for evaluation of polymorphisms in genes associated with busulfan metabolism and transport. Results: Five patients (4 MUD, 1 matched-sibling donor) were enrolled at the 24 hour Bu target AUC of 4800 uM*min ± 15%. One patient was not able to be evaluated due to errors in PK acquisition. 3 of the 4 patients required CIV doses different than that based on weight alone (i.e. 12.8 mg/kg). All 4 patients had AUCs within the desired range (mean 24 hour busulfan AUC of 4708 uM*min) with a mean bias and precision of −1.9% and 8.7%, respectively. No adjustments were required after 18 hours. No grade 3 or greater chemotherapy related toxicity has been identified. Conclusions: The systemic clearance determined by a busulfan test dose may be used to prospectively target the desired AUC of a 90 hour CIV. Enrollment on this Phase I study will continue beyond the first dose level which is at the upper limit of the normal range (4800 uM*min).

No significant financial relationships to disclose.

Self-inflicted burns, outcome and cost

INTRODUCTION

Self-inflicted burns represent a small number of total admissions to a burns unit, yet they constitute a major workload.

METHODS

A retrospective analysis of self-inflicted burns admitted between 1998 and 2002.

RESULTS

One thousand six hundred and fifty six patients were admitted with acute burn injuries, of these 56 were self-inflicted. 24 patients had a previous history of self-harming and 22 were unemployed. History of a psychiatric illness was found in 46 patients. Flames caused 46 out of 56 injuries. Mean total body surface area (TBSA) was 27%. Approximately 39% needed admission to intensive care unit (ICU). The mortality rate was 25%. On discharge, 29% of the patients re-self harmed.

CONCLUSION

Self-inflicted burns have a poorer outcome. Improving the psychiatric and social support can reduce the incidence of self-harming behaviour, its repetitiveness and subsequently the cost of burn care.