Increased LL37 in psoriasis and other inflammatory disorders promotes LDL uptake and atherosclerosis

Patients with chronic inflammatory disorders such as psoriasis have an increased risk of cardiovascular disease and elevated levels of LL37, a cathelicidin host defense peptide that has both antimicrobial and proinflammatory properties. To explore whether LL37 could contribute to the risk of heart disease, we examined its effects on lipoprotein metabolism and show that LL37 enhanced LDL uptake in macrophages through the LDL receptor (LDLR), scavenger receptor class B member 1 (SR-B1), and CD36. This interaction led to increased cytosolic cholesterol in macrophages and changes in expression of lipid metabolism genes consistent with increased cholesterol uptake. Structure-function analysis and synchrotron small-angle x-ray scattering showed structural determinants of the LL37-LDL complex that underlie its ability to bind its receptors and promote uptake. This function of LDL uptake is unique to cathelicidins from humans and some primates and was not observed with cathelicidins from mice or rabbits. Notably, Apoe-/- mice expressing LL37 developed larger atheroma plaques than did control mice, and a positive correlation between plasma LL37 and oxidized phospholipid on apolipoprotein B (OxPL-apoB) levels was observed in individuals with cardiovascular disease. These findings provide evidence that LDL uptake can be increased via interaction with LL37 and may explain the increased risk of cardiovascular disease associated with chronic inflammatory disorders.

CXCL4 assembles DNA into liquid crystalline complexes to amplify TLR9-mediated interferon-α production in systemic sclerosis

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by fibrosis and vasculopathy. CXCL4 represents an early serum biomarker of severe SSc and likely contributes to inflammation via chemokine signaling pathways, but the exact role of CXCL4 in SSc pathogenesis is unclear. Here, we elucidate an unanticipated mechanism for CXCL4-mediated immune amplification in SSc, in which CXCL4 organizes "self" and microbial DNA into liquid crystalline immune complexes that amplify TLR9-mediated plasmacytoid dendritic cell (pDC)-hyperactivation and interferon-α production. Surprisingly, this activity does not require CXCR3, the CXCL4 receptor. Importantly, we find that CXCL4-DNA complexes are present in vivo and correlate with type I interferon (IFN-I) in SSc blood, and that CXCL4-positive skin pDCs coexpress IFN-I-related genes. Thus, we establish a direct link between CXCL4 overexpression and the IFN-I-gene signature in SSc and outline a paradigm in which chemokines can drastically modulate innate immune receptors without being direct agonists.

A review of immune amplification via ligand clustering by self-assembled liquid-crystalline DNA complexes

We examine how the interferon production of plasmacytoid dendritic cells is amplified by the self-assembly of liquid-crystalline antimicrobial peptide/DNA complexes. These specialized dendritic cells are important for host defense because they quickly release large quantities of type I interferons in response to infection. However, their aberrant activation is also correlated with autoimmune diseases such as psoriasis and lupus. In this review, we will describe how polyelectrolyte self-assembly and the statistical mechanics of multivalent interactions contribute to this process. In a more general compass, we provide an interesting conceptual corrective to the common notion in molecular biology of a dichotomy between specific interactions and non-specific interactions, and show examples where one can construct exquisitely specific interactions using non-specific interactions.

Leukaemic transformation of Philadelphia chromosome-negative myeloproliferative neoplasms: are Asian patients different?

BACKGROUND

Leukaemic transformation (LT) is rare in the natural history of Philadelphia(Ph) chromosome-negative myeloproliferative disorders (MPD), and has a dismal prognosis. Little literature is available on Asian patients.

AIMS

The aim of this study is to report a single institution experience of Asian patients who developed acute leukaemia after being diagnosed and treated for Ph chromosome-negative MPDs, and to compare the findings of this series with similar studies from the literature.

METHODS

Patients were recruited from the MPD registry of Singapore General Hospital, Department of Hematology. Clinical data including treatment modalities and duration of use in myeloproliferative phase, latency to LT, characteristics of leukaemia, chemotherapy administered and survival after LT were examined.

RESULTS

Over a 29-year period from 1980 to 2009, there were 22 Asian patients with LT of Ph chromosome-negative MPD of which four had polycythaemia vera (PV), nine had essential thrombocythaemia (ET), seven had myelofibrosis (MF) and two had unspecified MPD at diagnosis. Primary treatment modality was Hydroxyurea (HU) during MPD phase. Median latency to LT was 14 years for PV, 10 years for ET and 1 year for MF. Median age at LT diagnosis was 67.5 years. Nine patients had complex cytogenetics, with abnormalities of chromosomes 5 and 7 being common. Overall, median survival was 2 months after LT. Eight patients who received induction chemotherapy had a median survival of 2.5 months. Survival was independent of MPD type and treatment administered. None received stem cell transplantation.

CONCLUSIONS

LT of Ph chromosome-negative MPD is rare and uniformly fatal. Despite chemotherapy, survival was poor, and patients succumbed to refractory disease and infections. Asian patients did not have a more favourable outcome. It remains to be investigated whether upfront stem cell transplant may be a treatment option.

Successful treatment of primary granulocytic sarcoma by non-myeloablative stem cell transplant

Pre-leukemic granulocytic sarcoma (GS) may pose an initial diagnostic problem and its therapeutic approach has never been formally established. To our knowledge, non-myeloablative stem cell transplantation has been reported in cases of leukemic GS, but not in primary GS. We report a case of primary GS with extensive and aggressive presenting features and successfully treated with intensive chemotherapy followed by non-myeloablative allogeneic stem cell transplant. This resulted in complete remission with minimal complications. Our case demonstrates the potential of graft-vs.-tumour effect in the treatment of GS and suggests that non-myeloablative allogeneic stem cell transplant may be a feasible therapeutic approach for primary GS.

MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report

BACKGROUND/METHODS

Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died.

RESULTS

Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation.

CONCLUSIONS

MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.

Management of haematologic malignancies in pregnancy

INTRODUCTION

Malignancy complicates about 1 in 1000 pregnancies and is the second leading cause of death in women of reproductive age. Commonly diagnosed malignancies during pregnancy include breast cancer, cervical carcinoma, melanoma and lymphoma. Chemotherapy is usually necessary for optimal treatment, especially in patients with leukaemia and lymphoma. Concerns arise regarding the effects of imaging modalities in the pregnant cancer patients and the effects of chemotherapeutic agents on the developing fetus.

METHODS

A Medline search of articles describing haematologic malignancies in pregnant patients was performed. Particular attention was paid to the kind of malignancy, stage of pregnancy, the types and side effects of chemotherapeutic agents used and the outcome of the pregnancy.

RESULTS

There is no entirely safe cytotoxic drug or timing of exposure for the developing fetus. The administration of chemotherapy during pregnancy will not always produce a poor outcome. A pregnant cancer patient can also be safely and reasonably staged with imaging. Magnetic resonance imaging will most often be the procedure of choice as it does not use ionising radiation.

CONCLUSIONS

The management of each pregnant patient diagnosed with a malignancy has to be highly individualized and involves a multidisciplinary team of medical personnel. The patient and her family need counselling regarding the diagnosis, long-term prognosis, options of termination of pregnancy, choice of chemotherapeutic agents and their effects on the fetus and pregnancy.

Capacity building to improve women's health in rural China

The Women's Reproductive Health and Development Program (WRDHP) is an ambitious attempt to operationalize two important tenets of health development thinking within a rural reproductive health context. First, it is important for communities to participate in decisions about the services and programs that affect them. Secondly, the complex nature of healthcare is best addressed by intervention processes which call for a multi-functional approach to planning and coordination. In both planning and intervention approach, the WRHDP recognizes the social, cultural and economic realities that affect women's efforts to secure the health and well-being of themselves and their families. The focus of the WRHDP is on capacity-building within a rural reproductive health environment, in this case Yunnan Province in rural China. Rather than using international donor funding to provide a specific intervention, the WRDHP used Ford Foundation funding as a lever to encourage community investment in environmental resources that affect health, to improve the technical skills of individuals within the existing health bureaucracies, and to promote structural changes within existing health and development bureaucracies to support interagency collaboration and community empowerment within the region's health and development agencies. This article describes how the WRHDP created new methods for provincial and local agencies to overcome obstacles and work with one another to improve women's health. It also describes the processes used in the rural areas of Chengjiang and Luliang counties to assess local conditions and needs, and the supported and expanded local efforts in improving woman's reproductive and family health that resulted from the processes.

CT findings after uterine artery embolization

Asymptomatic uterine leiomyoma can be detected on routine computed tomography (CT) of the pelvis. Leiomyomas have been described as low attenuation masses that can disrupt the smooth contour of a normal uterus. Four women underwent uterine artery embolization for the treatment of uterine leiomyoma. CT findings include initial retention of contrast in fibroids the day of the procedure and central necrosis of the fibroid with subsequent cavitation as early as 1 month postprocedure.

Retrieval of a Greenfield IVC filter displaced to the right brachiocephalic vein

During insertion of a central venous sheath an inferior vena cava stainless steel Greenfield filter was dislodged to the right brachiocephalic vein without a free end. Successful retrieval was achieved by using a combination of a guidewire and a snare. Percutaneous retrieval of this vena cava filter is feasible with minimal risk using this method.

Percutaneous delivery of a heparin-impregnated collagen stent-graft in a porcine model of atherosclerotic disease

RATIONALE AND OBJECTIVES

To develop collagen stent-grafts impregnated with heparin to improve the biocompatibility of endovascular stents and to design a percutaneous delivery system for graft deployment in a swine model.

METHODS

Heparin-impregnated collagen stent-grafts were deployed, and follow-up angiograms were obtained every 15 minutes for 90 minutes to assess acute thromboses and again at 2 and 4 weeks afterward to assess patency. If stenosis or occlusion was detected at the 2-week evaluation, guidewire passage across the lesion was attempted and angioplasty was performed. If stenosis or occlusion was present at the 4-week evaluation, only guidewire passage was attempted; thereafter, the animals were killed and the stent-grafts were harvested and reviewed by a vascular pathologist.

RESULTS

Group A represents a feasibility study to optimize the deployment method applied in groups B and C. Fifteen of 17 stent-grafts were successfully deployed using this method. In group B, 89% of grafts were successfully deployed; 12% were patent at 2 weeks and none at 4 weeks. In group C, a 10-minute inflation time was added to the deployment procedure; 88% of grafts were successfully deployed and 28% were patent at 2 weeks and 14% at 4 weeks. Extensive luminal thrombosis and myointimal hyperplasia were present in every case.

CONCLUSIONS

A method was developed for percutaneous implantation of collagen stent-grafts into peripheral vessels. The heparin-impregnated grafts did not prevent vessel restenosis. Modification of the graft-processing technique may improve patency.

Hierarchical self-assembly of F-actin and cationic lipid complexes: stacked three-layer tubule networks

We describe a distinct type of spontaneous hierarchical self-assembly of cytoskeletal filamentous actin (F-actin), a highly charged polyelectrolyte, and cationic lipid membranes. On the mesoscopic length scale, confocal microscopy reveals ribbonlike tubule structures that connect to form a network of tubules on the macroscopic scale (more than 100 micrometers). Within the tubules, on the 0.5- to 50-nanometer length scale, x-ray diffraction reveals an unusual structure consisting of osmotically swollen stacks of composite membranes with no direct analog in simple amphiphilic systems. The composite membrane is composed of three layers, a lipid bilayer sandwiched between two layers of actin, and is reminiscent of multilayered bacterial cell walls that exist far from equilibrium. Electron microscopy reveals that the actin layer consists of laterally locked F-actin filaments forming an anisotropic two-dimensional tethered crystal that appears to be the origin of the tubule formation.

Uterine artery embolization: a minimally invasive technique for the treatment of uterine fibroids

Uterine artery embolization (UAE) as a primary therapy for symptomatic fibroids was first used in France in 1991. Currently, there are at least 250 centers in the United States, as well as centers in Canada and England, with experience in this technique. Initial published results worldwide indicate that after UAE, uterine fibroids shrink at least 50% in volume on average and symptoms of refractory vaginal bleeding and chronic pelvic pain are controlled in approximately 85% of patients. Major complications are rare. Overall, this technique is minimally invasive, preserves the uterus, and requires a shorter hospitalization than hysterectomy or myomectomy.

Oral idarubicin in patients with late chronic phase chronic myelogenous leukemia or chronic myelomonocytic leukemia

Patients with chronic myelogenous leukemia (CML) who have failed or cannot receive interferon alpha (IFN-alpha) based regimens or patients with advanced chronic myelomonocytic leukemia (CMML) have very limited current therapeutic options. Hence, there is a need to develop new strategies for these patients. This study was undertaken to determine the efficacy and toxicity of a chronic low-dose oral idarubicin regimen in these patients as positive data has been generated on this agent in shorter schedules given to patients with other hematological malignancies. Eighteen patients were treated on study. The starting dose of oral idarubicin was 2 to 5 mg/m2 daily depending in initial WBC count. This dose was escalated in the absence of Grade 4 myelosuppression or Grade 3 or 4 extramedullary toxicity. Oral idarubicin was given daily for 28 days followed by a 21 day break off treatment in repeated cycles until there was evidence of disease progression or intolerable toxicity. The dose of idarubicin was adjusted, at 2-week intervals, by 25% to maintain a white blood cell (WBC) count between 2 and 4x10(9)/L and a platelet count of >75x10(9)/L. The dose was reduced by 25% for grade 2 extramedullary toxicity and held until toxicity resolved to grade 2 or better for grade 3 toxicity. Oral idarubicin was then restarted at 75% of the initial dose. Five out of 14 CML patients achieved a complete hematologic remission. No CMML patient responded (median survival 3 months). The overall median survival was 24 months. CML patients had a median survival of 28 months. Major toxicities (myelosuppression, gastrointestinal, cardiac) were infrequent with a median cumulative dose of 1110 mg/m2 (range 54-9750). Five patients have received oral idarubicin for > 1 year with no overt cardiotoxicity, reaching median cumulative dose of 2756 mg/m2 (range 2550-9750) which is higher than those documented in prior studies. We conclude that oral idarubicin is sufficiently safe and active to warrant phase II studies investigating it as part of interferon-based regimens in patients with advanced CML.

Hypergammaglobulinaemic purpura presenting as reticulate purpura

Hypergammaglobulinaemic purpura, first described by Waldenstrom, is a rare skin disease. The essential features are the presence of purpura with polyclonal hypergammaglobulinaemia. We describe a case of hypergammaglobulinaemic purpura occurring in a Chinese man with reticulate purpura and haemorrhagic blisters.

Topotecan and cytarabine is an active combination regimen in myelodysplastic syndromes and chronic myelomonocytic leukemia

PURPOSE

To evaluate the efficacy and safety of the combination of topotecan and cytarabine in patients with myelodysplastic syndromes (MDSs) and chronic myelomonocytic leukemia (CMML).

PATIENTS AND METHODS

Fifty-nine patients with MDSs and 27 with CMML were enrolled. They were either previously untreated (66%) or had received only biologic agents (14%) or chemotherapy with or without biologic agents (20%). Treatment consisted of topotecan 1.25 mg/m(2) by continuous intravenous infusion daily for 5 days and cytarabine 1. 0 g/m(2) by infusion over 2 hours daily for 5 days. Prophylaxis included antibacterial, antifungal, and antiviral agents. At a median follow-up of 7 months, all 86 patients were assessable for response and toxicity.

RESULTS

Complete remission (CR) was observed in 48 patients (56%; 61% with MDSs, 44% with CMML; P =.15). Similar CR rates were observed for patients with good-risk and poor-risk MDS (70% and 56%, respectively). The treatment effectively induced CR in patients with a poor-prognosis karyotype involving chromosomes 5 and 7 (CR, 71%) and secondary MDSs (CR, 72%). Fifty-four patients received one induction course, 25 patients received two, and the rest received more than two. The median number of continuation courses was two. The median overall duration of CR was 34 weeks (50 weeks for MDSs and 33 weeks for CMML). The median survival was 60 weeks for MDS and 44 weeks for CMML patients. CR and survival durations were longer in patients with refractory anemia with excess blasts (RAEB). Grade 3 or 4 mucositis or diarrhea was observed in three patients each. Fever was observed in 63%, and infections in 49% of patients. Six patients (7%) died during induction therapy.

CONCLUSION

Topotecan and cytarabine induced high CR rates in unselected patients with MDSs and CMML, particularly among patients with poor-prognosis cytogenetics and secondary MDSs. Topotecan-cytarabine is an active induction regimen in MDS and CMML patients, is well tolerated, and is associated with a low mortality rate.

A case report of neutrophilic eccrine hidradenitis in a patient receiving chemotherapy for acute myeloid leukaemia

Neutrophilic eccrine hidradenitis (NEH) is a neutrophilic dermatosis primarily affecting the eccrine glands and occurs in patients undergoing chemotherapy. It must be distinguished from infections, drug eruptions, leukaemia cutis or other forms of skin diseases. As it is self-limiting, establishing the diagnosis will avoid unnecessary treatment for infections or changes in drug therapy.

A study of idiopathic thrombocytopenic purpura (ITP) patients over a ten-year period

Adult idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder caused by antiplatelet autoantibodies that cause platelet destruction by the reticuloendothelial system. The disease has been well-documented in the West. We studied 78 ITP patients diagnosed and followed up in a tertiary hospital, over a 10-year period, to give a profile of our local patients and their response to treatment. The majority of patients were females and fall in the 20 to 39 years age group. 21.8% were asymptomatic at presentation. The mean presenting platelet count was 31 x 10(9)/L. Complete response rate to steroid treatment was 46.7%. Thirty-seven patients (47.4%) underwent splenectomy with a success rate of 64.9%. 6.4% required multiple drugs to maintain a stable platelet count. There was no spontaneous, long-term remission in this series. 10.3% of our patients eventually developed an autoimmune disease. ITP has a variable clinical course and treatment has to be highly individualised.

Arterial embolism complicating implantable cardioverter defibrillator shocks with normal ventricular function

A 69-year-old man developed an embolus to his right femoral artery 24 h following the insertion of an implantable cardioverter defibrillator (ICD), with multiple shocks administered in the early postoperative period. He had nonobstructive hypertrophic cardiomyopathy with normal left ventricular function and no evidence of left atrial or ventricular thrombus seen on pre- or postoperative transthoracic echocardiography. There was no evidence of atrial fibrillation documented before or after implantation of the device. He had no other known risk factors for thromboembolic disease. Thromboembolic phenomena as a complication of ICD use have been described but arterial emboli believed related to ICD shocks have not been reported in patients without impaired systolic function.

Acute promyelocytic leukemia with a dicentric chromosome involving chromosomes 11, 17, and 18

We report a case of acute promyelocytic leukemia with dicentric chromosome resulting from translocation of chromosomes 11, 17, and 18.

Vaginal misoprostol compared with oral misoprostol in termination of second-trimester pregnancy

OBJECTIVE

To compare the efficacy of vaginal with oral misoprostol in termination of second-trimester pregnancy after pretreatment with mifepristone.

METHODS

Women requesting termination of second-trimester pregnancy were randomized into two groups. Thirty-six to 48 hours after oral administration of 200 mg of mifepristone, women were given either oral or vaginal misoprostol 200 microg every 3 hours for a maximum of five doses in the first 24 hours. Women receiving oral misoprostol also were given a vaginal placebo (vitamin B6), whereas those receiving vaginal misoprostol were given an oral placebo. If they failed to abort, a second course was given by the same route.

RESULTS

The median induction-abortion interval in the vaginal group (9 hours) was significantly shorter than that in the oral group (13 hours). The percentage of women aborting within 24 hours in the vaginal group (90%) was significantly higher than that in the oral group (69%). The median amount of misoprostol used in the vaginal group (600 microg) also was significantly less than that in the oral group (1000 microg). There was no significant difference in the incidence of side effects between the two groups except for fatigue and breast tenderness, which were more common in the oral group. Seventy-six percent of the women preferred the oral route, and 24.5% of the women preferred the vaginal route.

CONCLUSION

Vaginal misoprostol is more effective than oral misoprostol in termination of second-trimester pregnancy after pretreatment with mifepristone, but more women preferred the oral route.

Clinical characteristics and natural history of human immunodeficiency virus infected patients seen at a general hospital in Singapore

The number of patients with human immunodeficiency virus (HIV) infection in Singapore has risen over the years. A considerable proportion of them present with acquired immunodeficiency syndrome (AIDS). In this study, we document the clinical characteristics and natural history of a consecutive series of 50 patients who were found to have HIV infection when they were seen at a tertiary care hospital. The majority were in the 30 to 49 age group and the most common mode of acquisition was heterosexual contact. The patients presented with a variety of symptoms to 11 different clinical departments. Fifty-eight per cent of the patients had AIDS-defining illnesses at presentation, with Pneumocystis carinii pneumonia being the most common. On follow-up, the most frequently occurring opportunistic infection that developed was Cytomegalovirus retinitis. Most patients had multiple subsequent admissions--for both AIDS-defining and non AIDS-defining conditions. The median CD4 count of the cohort at presentation was 72/mm3. The median survival was 399 and 822 days in those who had and those who did not have an AIDS-defining illness at presentation, respectively. Mortality was most commonly attributed to pneumonia. HIV infection has protean manifestations and patients may present to various specialty departments; hence, doctors need to be aware of the spectrum of disease in order to make a diagnosis.

Exacerbation of hepatitis in hepatitis B carriers following chemotherapy for haematological malignancies

We describe nine asymptomatic chronic carriers of hepatitis B virus, four males and five females, with a mean age of forty-six years and all were Chinese, who developed exacerbation of hepatitis following chemotherapy for haematological malignancies. Seven patients had non-Hodgkin's lymphoma of whom three were treated with MACOP-B, two with BCEPP, one with PROMACE-CYTABOM and one with CHOP. Two patients had acute myeloid leukaemia and were treated with daunorubicin and cytosine arabinoside. Exacerbation of hepatitis occurred between one to four weeks following the last course of chemotherapy in eight patients. Two patients developed exacerbation of hepatitis when the dosage of prednisolone was reduced after they had ten weeks of high dose prednisolone. The outcome was fatal in six patients; all of whom developed hepatic encephalopathy. In four of these patients, alanine transaminase levels exceeded 1000 iu/l. Cytotoxic and immunosuppressive therapy permit enhanced viral replication. Withdrawal of the drugs results in partial restoration of immunocompetence and leads to rapid destruction of hepatocytes with consequent hepatic necrosis. Hence, patients who are hepatitis B virus carriers undergoing chemotherapy should be closely monitored. The fatal outcome of reactivation of chronic hepatitis B virus warrants prospective trials addressing preventive measures.

Seeking women's voices: setting the context for women's health interventions in two rural counties in Yunnan, China

If interventions to improve health are truly to benefit women, they must be developed from the start with a critical understanding of women's own perceptions of their health problems and needs, and how these concerns are linked to other facets of women's lives. To obtain such understanding, it is crucial for health planners to seek out women in the communities where they live, to encourage them to speak in their own voices about their health and lives, and to be genuinely committed to listening to what the women have to say. This paper presents results of focus group discussions with village women in two rural counties in Yunnan, China. The data are derived from 28 focus group discussions conducted by the Women's Reproductive Health and Development Program in Yunnan as part of a comprehensive assessment of reproductive health needs in poorer, more remote areas of the two counties. The discussions were held to ascertain what village women themselves feel to be their most pressing health problems, and how these relate to work, family, social status and their use of health services. Results show how women's health and their use of health services are rightly intertwined with their labor roles, harsh environmental conditions and oppressive poverty. Widespread breakdowns in the village-level primary health care network lead village women to express a profound lack of confidence in local health services. The findings have several implications for planning and implementation. Demands on women's scarce time need to be explicitly considered when designing health education activities and health service delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of women having abortion in China

A pre-coded, closed response questionnaire was administered to women at abortion clinic sites in August 1985. The convenience sample was comprised of 1200 women, 200 samples in both Chengdu and the Lianshan Yi Autonomous Region in Sichuan Province, 400 in Nanjing and Jiangsu Province, and 400 in the municipality of Shanghai. The women were interviewed by physicians as part of the women's intake medical history. The sample yielded 574 respondents who were urban and 624 who were rural. The number of previous abortions reported ranged from 0 to 5. Nearly half of the abortion recipients had had at least one prior abortion and 18% had had two or more prior abortions. Education, age, marriage duration and residence have apparent effect on abortion order. The urban respondents reported an average of 1.08 children vs 1.60 children for the rural respondents. Approximately 72% of the respondents claimed to have been using a contraceptive method at the time they became pregnant. The most commonly used method was the IUD (41.6%), followed by the pill (21.3%) and the condom only (16.5%). Residence appeared to be the greatest factor determining the type of contraceptive methods. The data presented here are limited and cannot be generalized to the larger population. However, they do shed some light on the contraception characteristics of a group of women who undergo abortion procedures in China. Their response to questions to contracepting behavior prior to abortion suggests that the problem, in part, is behavioral. For example after the expulsion of the IUD, no other method was substituted to avert pregnancy. In order to alleviate the problem of contraceptive failure, and subsequent abortion, there are policy as well as training and education implications for the state.