Single-Point Mutations in Qβ Virus-like Particles Change Binding to Cells

Virus-like particles (VLPs) constitute large, polyvalent platforms onto which a wide variety of functional units can be grafted. Their use in biological settings often depends on their specific binding to cells or receptors of interest; this can be compromised by excessive nonspecific association with other cells. We found that lysine residues mediate such nonspecific interactions, presumably by virtue of protonation and interaction with anionic membrane lipid headgroups and/or complementary residues of cell surface proteins and polysaccharides. Chemical acylation of surface-exposed amines of the Qβ VLP led to a significant reduction in the association of particles with mammalian cells. Single-point mutations of particular lysine residues to either glutamine, glutamic acid, tryptophan, or phenylalanine were mostly well-tolerated and formed intact capsids, but the introduction of double and triple mutants was far less forgiving. Introduction of glutamic acid at position 13 (K13E) led to a dramatic increase in cellular binding, whereas removal of the lysine at position 46 (K46Q) led to an equally striking reduction. Several plasma membrane components were found to specifically interact with the Qβ capsid irrespective of surface charge. These results suggest that specific cellular interactions are engaged or obviated by such mutations and provide us with more "benign" particles to which can be added binding functionality for targeted delivery applications.

Probing the Open Global Health Chemical Diversity Library for Multistage-Active Starting Points for Next-Generation Antimalarials

Most phenotypic screens aiming to discover new antimalarial chemotypes begin with low cost, high-throughput tests against the asexual blood stage (ABS) of the malaria parasite life cycle. Compounds active against the ABS are then sequentially tested in more difficult assays that predict whether a compound has other beneficial attributes. Although applying this strategy to new chemical libraries may yield new leads, repeated iterations may lead to diminishing returns and the rediscovery of chemotypes hitting well-known targets. Here, we adopted a different strategy to find starting points, testing ∼70,000 open source small molecules from the Global Health Chemical Diversity Library for activity against the liver stage, mature sexual stage, and asexual blood stage malaria parasites in parallel. In addition, instead of using an asexual assay that measures accumulated parasite DNA in the presence of compound (SYBR green), a real time luciferase-dependent parasite viability assay was used that distinguishes slow-acting (delayed death) from fast-acting compounds. Among 382 scaffolds with the activity confirmed by dose response (<10 μM), we discovered 68 novel delayed-death, 84 liver stage, and 68 stage V gametocyte inhibitors as well. Although 89% of the evaluated compounds had activity in only a single life cycle stage, we discovered six potent (half-maximal inhibitory concentration of <1 μM) multistage scaffolds, including a novel cytochrome bc1 chemotype. Our data further show the luciferase-based assays have higher sensitivity. Chemoinformatic analysis of positive and negative compounds identified scaffold families with a strong enrichment for activity against specific or multiple stages.

Improvement over the years of long-term survival in high-risk lymphoma patients treated with hematopoietic stem cell transplantation as consolidation or salvage therapy

The role of hemopoietic stem cell transplantation (HSCT) is not well established in certain types of lymphoma, such as those with a high relapse risk or relapsing after initial therapy. New chemotherapeutic schemes and immunotherapy have improved survival of these patients. Nevertheless, there is not enough evidence regarding whether transplantation is the best therapeutic approach. Moreover, published data on long-term follow-up of high-risk lymphoma patients treated with HSCT are scarce. We analyzed 177 consecutive patients diagnosed with a high risk of relapse or with relapsed lymphoma who underwent HSCT after induction with standard chemotherapy in a tertiary academic center from 1989 to 2013. The median age was 40 years. Diagnoses were Hodgkin disease (n = 56), diffuse large B-cell lymphoma (n = 44), follicular lymphoma (n = 29), mantle cell lymphoma (n = 15), T-cell lymphoma (n = 18), and others (n = 15). Patients received either an autologous graft (n = 154) in first complete remission (1CR; n = 59) or more advanced stages (AS; n = 95), or an allogeneic graft (n = 23) in 1CR (n = 4) or AS (n = 19). In the autologous group, overall survival (OS) at 5 years was 57% and 75% in the periods 1989-2001 and 2002-2013, respectively (P = .05). Patients receiving an allogeneic graft presented an OS of 25% and 43% in the 2 periods. With a mean follow-up of 5 years (95% confidence interval 3.5-6.6), for patients receiving a transplant in 1CR, OS at 5 years was 80%, and for those receiving a transplant in AS it was 59% (P = .003). Nonrelapse mortality (NRM) at 5 years was 3.1% in the autologous group and 27.9% in the allogeneic group (P < .001). The main cause of NRM was infection (44%) in the whole cohort. All this leads to the conclusion that transplantation, as a therapeutic strategy, has shown a high long-term OS in this subgroup of patients with such a poor prognosis. OS improved over the years and reaching 1CR was a good prognostic feature. Infections were the main cause of NRM.

Invented fairy tales in groups with onco-haematological children

BACKGROUND

The impact of an onco-haematological illness for children is a traumatic event that opens to pain, hospitalizations and interrupts the continuity of daily life. It is difficult for the child to make meaning, to share the pain or ask a question related to the illness because, often, the parents or doctors cannot find a way to communicate in a suitable way for the child who remains in a situation of 'unspoken', where, fear, anxiety and pain cannot find a space to express.

METHODS

The present research-intervention uses the methodology of invented fairy tales in groups with onco-haematological children, in the hospital, in order to explore the organization of the meanings at the base of the tales co-constructed by the participants underlying weaknesses and strengths of the invented fairy tales in groups intervention. The invented fairy tales in groups is used as a tool, such as a play, to express, share and support the experience of the illness of children. Forty-nine children participated to the invented fairy tales in groups in an onco-haematological hospital. Within a quali-quantitative framework we performed a thematic analysis of elementary context, cluster analysis, on the fairy tales considered as a unique narrative corpus of the thought of the group.

RESULTS

The analysis shows four thematic clusters: fantasy as search for a meaning, 29.71%, the group as a space for illusions, 27.90%, the illness as a family problem, 25.72%, anchoring reality, 16.67%. The results highlighted three main carriers of sense: the representation of illness/the relational world/the representation of the institution.

CONCLUSIONS

The use of invented-fairy-tales groups allowed the onco-haematological children to tell and share the experience of illness through a different way, which let them express symbolically their pain. The invented fairy tale in groups becomes a mediator of psychic processes which offer new solutions while improving interpersonal relationships/communication between the participants in group.

Hemopoietic stem cell transplantation in childhood: reduction in mortality and improvement of survival over the years

Stem cell transplantation (SCT) is an effective treatment for life-threatening hematologic and nonhematologic pediatric diseases. Reducing transplant-related mortality (TRM), a major complication of SCT, to improve long-term survival, therefore, is one of the main objectives of transplantation teams. We analyzed TRM and overall survival (OS) over the years in children undergoing SCT in our center. From June 1998 to October 2002, 156 consecutive children, 105 boys and 51 girls, median age 10 years (range, 2-18), with different diagnoses underwent SCT (100 autologous and 56 allogeneic). OS and TRM were analyzed in 2 different periods (June 1989-December 1998 and January 1999-October 2002) and grouped according to the different SCT modalities. The median follow-up was 18 months (range, 1-160). Autologous TRM showed a statistically significant improvement within 1999-2002 (0%) compared with 1989-1998 (12.2%) (P < .05). There were no statistical differences for allogeneic SCT. OS was 34% in the first period and 80.4% in the second period (P < .01), the improvement being for both autologous and allogeneic SCT. In our study, TRM decreased significantly for those children receiving autologous SCT in recent years. OS was significantly better in the latter period (1999-2002), both globally and for each SCT modality.

Safety of the concomitant use of caspofungin and cyclosporin A in patients with invasive fungal infections

Caspofungin, an echinocandin antifungal agent, is active against invasive Aspergillus and Candida infections. In a phase I study in healthy volunteers, mild transient increases in serum aminotransferases were observed with the concomitant administration of caspofungin and cyclosporin A (CsA). As a result, it is recommended that the concomitant use of the two drugs be limited to those settings with appropriate risk-benefit balance. We retrospectively assessed safety data in 14 patients with refractory invasive mycoses who were treated concomitantly with CsA and caspofungin before the drug was licensed in Spain. In all, 13 patients were adults (median age, 31.5 years; range, 14-67 years). The average duration of concomitant therapy was 15 days (range, 2-43 days). No clinically significant elevations of serum aminotransferases were observed, and no patient had concomitant therapy discontinued or interrupted due to a drug-related adverse event. In this study of a limited number of patients, the coadministration of caspofungin and CsA was generally well tolerated.

[Information and worry among patients with non-oncohematological pathologies upon arrival at the hematology clinic]

PURPOSE

Patients are frequently referred to the haematologist to be studied due to the presence of processes that are not properly haematological. We have studied the group of outpatients with non-oncohaematological pathologies referred to our external haematology clinic to evaluate their knowledge about the reason for consultation, the existence or not of worry upation and its degree at the arrival.

PATIENTS AND METHODS

We have made a prospective study including all patients with non-oncohaematological processes (n = 204) who were referred for the first time to our external consultation between April and October 1997. We evaluated in each patient, using an inquest, the following data: age, sex, origin (hospital consultations or urban or rural health centres), reason for consultation, knowledge of the reason for consultation (yes/partially/no), existence or not of worry (yes/no) and when present, its degree (low, moderate, high). The inquiry was made to the parents in those patients aged under 12 years. We have analyzed all adults, each group of adult patients (rural, urban, hospital) separately and compared one group to each other, all pediatric patients and we have compared as well the overall results obtained with adult patients with those from the parents of pediatric patients.

RESULTS

1) Adult patients (n = 169; 78 referred from hospital, 59 from urban and 32 from rural health centres): with respect to the knowledge of the reason for consultation 49.7% of them knew it perfectly, 20.1% partially, and 30.2% did not know about it. 48.5% of patients arrived worried to the clinic, 16.6% of them with a high degree, 17.8% moderate and 14.2% low. 2) Adults referred from primary health care (urban versus rural health centres): We have found neither significant differences in the knowledge of the reason for consultation, worry or its degree with respect to age, sex or origin (urban or rural), nor in the worry or its degree with respect to the patient knowledge of the reason for consultation. 3) Adults referred from other hospital units: The mean age of patients who knew the reason for consultation was significatively lower than that observed in the group who did not (respectively 43.3 and 57 years) (p = 0.003). These differences did not exist with respect to sex. Differences in the existence or not of worry with respect to sex were almost significant, women arrive more worried than men (57.1% and 31.8% respectively, p = 0.07). No significant differences were found in the existence or not of worry and its degree with respect to age or knowledge of the reason for consultation. 4) Comparison between both groups of adults patients (hospital consultation and health centres): No significant differences in the knowledge of the reason for consultation, existence or not of worry and its degree have been found with respect to the other parameters studied. 5) Paediatric patients (n = 35; 8 referred from hospital, 14 from urban and 13 rural health centres): With respect to the knowledge of the reason for consultation 62.9% of them knew it perfectly, 17.1% partially and 20% did not know about it. 80% of patients' parents arrived worried at consultation, 45.7% with a high degree, 20% moderate and 14.3% low. 6) Comparison between paediatrics and adult patients: we have only found significative differences in the existence or not of worry (80% and 48.5% respectively, p = 0.001) and its degree (65.7% of parents with moderate or high worry and 34.4% of adults, p = 0.0004). Parents of paediatric patients arrive at our consultation more worried and with a higher worry degree than the other adults.

CONCLUSION

We consider that patients referred to our external consultation of haematology for the first time arrive with a poor knowledge of their reason for consultation. This observation does not seem to have any relation with age, sex or origin (hospital consultations, urban or rural health centres). (ABSTRACT TRUNCATED)

rHuEpo for the treatment of anemia in myelofibrosis with myeloid metaplasia. Experience in 6 patients and meta-analytical approach

BACKGROUND AND OBJECTIVE

Experience with recombinant human erythropoietin (rHuEPO) in the treatment of the anemia secondary to myelofibrosis with myeloid metaplasia (MMM) is slight up to now. We present our results of the treatment of 6 patients and a review of the literature in search of possible parameters predicting response to this treatment.

DESIGN AND METHODS

From January 1994 to June 1996 all transfusion-dependent patients with MMM diagnosed in our hospital were included in this study. We established a minimum period of 4 weeks of treatment and a maximum of 12 if no response was observed. Initial dosages used were 100 U/kg s.c. 3 times weekly, increasing by 50 U/kg every 4 weeks where no response was observed. Response was defined as a reduction > or = 30% of the previous transfusional needs. The review of the literature was made using a MEDLINE search (January 1990-December 1996) on the keywords erythropoietin, myelofibrosis, and agnogenic myeloid metaplasia. A statistical study was made in search of possible parameters to predict response. The parameters studied include age, sex, hemoglobin, serum erythropoietin (sEPO) levels, transfusional dependency, transfusional requirements per month prior to treatment, maximum dosages used and dosage at which response was obtained.

RESULTS

Only 2 of our 6 patients responded, both at a dosage of 600 U/kg/week (200 U/kg 3 times weekly s.c.). In addition to our 6 patients we have found only 28 other patients in the literature. For statistical calculation 2 of our patients were not considered as they did not complete the period of study. The overall rate of response was 17/32 (53.1%). In the univariate analysis comparing responders and non-responders we found a tendency to significance with respect to sex (p = 0.07), sEPO (p = 0.07) and transfusional needs in units of packed red blood cells per month (PRBC/m) (p = 0.13). In this way patients with low sEPO, females and those with low transfusional needs (< 3 PRBC/m) respond better. This better response in females could be explained by the fact that their disease situation was more stable (with both lower sEPO levels and transfusional dependency). The best cut-off point in the sEPO to predict response was 123 mU/mL. No important side-effects have been observed except three cases of aggravation of splenomegaly. In two cases this condition improved when the rHuEPO was discontinued. The association of rHuEPO with hydroxyurea or interferon does not seem to affect the response.

INTERPRETATION AND CONCLUSIONS

Though the number of patients is low, our data suggest that some MMM patients, in particular females and individuals with low sEPO levels and with low transfusional needs, might benefit from rHuEPO in terms of elevation of hemoglobin levels. Unfortunately, transfusion dependent-patients, i.e. those in whom a beneficial effect of rHuEPO would be most welcome, are unlikely to respond, and more generally, treatment is not cost effective in medically responsive patients.

[Acute myeloid leukemia in those over 70 years of age. Experience using low-dose ara-C treatment]

PURPOSE

The treatment of elderly patients with acute myeloid leukaemia (AML) remains controversial. We present the results of the treatment of a group of patients aged above 70 years with AML diagnosed in our Hospital since 1990.

PATIENTS AND METHODS

We have studied retrospectively the cases of AML in patients older than 70 years diagnosed in our Service since January 1990 to June 1996. Induction treatment was performed, in all cases but one, with two cycles of Ara-C 10 mg/m2/12 h s.c. for 21 days and after haematological recuperation, if complete remission had been achieved, monthly maintenance treatment with Ara-C (25 mg/m2/12 h oral x 5 days), prednisone (40 mg/m2/day x 5 days) y vincristine (1 mg/m2 i.v. x 1 day) was begun.

RESULTS

During the period of study 48 patients with AML have been diagnosed in our Service, among them 22 (45.8%) were older than 70 years. One of them could not be considered for the study as not all data from him could be compiled. Among the other 21 patients 5 presented previous haematological processes (4 myelodysplastic syndrome and 1 Waldenström's macroglobulinemia). Initial diagnosis according to FAB classification for AML was as follows: 7 M1, 6 M2, 4 M4, 2 M5 and 2 M6. From these 21 patients 2 received no treatment due to rapid progression and death, among the other 19, one was directly treated with a modification of the maintenance treatment with vincristine and prednisone without response (survival 2 months). The other 18 patients were treated with low-dose Ara-C (described above), among them 3 (16.7%) were not evaluable as they did not finish the first cycle of induction treatment; 8 (44.4%) showed no response; 2 (11.1%) achieved partial remission and 5 (27.8%) complete remission. One patient did not show any response after two cycles of low-dose Ara-C but she obtained complete remission when treated with Ara-C and idaurubicin. Overall mean survival was 5.7 months (median 2; 95% confidence interval 1.6-9.8 months). In the group of patients treated with low-dose Ara-C mean survival was 6.6 months (median 3.5; 95% confidence interval 1.9-11.2 months).

CONCLUSION

We consider that the treatment with low-dose Ara-C is a valid option in the treatment of elderly patients (aged 70 or above) with AML because 28% complete remissions can be achieved, specially in those ones in which other more aggressive treatments are not possible.

Waldenström's macroglobulinemia complicated with acute myeloid leukemia. Report of a case and review of the literature

The evolution of Waldenström's macroglobulinemia (WM) into chronic or acute myeloid leukemia (AML) is a rare event. Most of these cases have occurred after treatment with alkylating agents. We herein report a case of WM terminating in an acute myelomonocytic leukemia after treatment with prednimustine and chlorambucil and present a review of the literature.

[T-cell-rich B-cell lymphoma. Presentation of 3 cases]

T-cell-rich B-cell lymphoma (TBL) is a rare entity not included in the classical classifications of non-Hodgkin's lymphomas (NHL), presenting usually at diagnosis in advanced stages and with extranodal involvement. Its differential diagnosis, based on immunophenotyping technics, include other entities with different treatment and prognosis, mainly lymphocytic-predominance Hodgkin disease and peripheral T-cell lymphoma; this differential diagnosis has importance in patient's survival. We present 3 patients, two males (one of them with HIV infection) and one female, aged 38, 60 and 64 respectively, diagnosed as having TBL. The two former patients presented advanced stages at diagnosis. None of them was initially diagnosed as having TBL, the diagnosis were immunoblastic NHL in the first patient, peripheral T-cell lymphoma in the second and mixed cellularity Hodgkin's disease in the third one. The first patient was not treated due to rapid worsening and early death of septic shock; the other two cases were treated with COP-BLAM/IMVP-16 protocol achieving partial and complete remission respectively after 6 cycles of treatment. Comments about clinical, pathological and differential diagnostic aspects are made.

[Kikuchi-Fujimoto disease associated with acute infection by herpesvirus 6]

The histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto disease is a very rare entity in Spain. We present a 34-year-old arabic male admitted to hospital because one-month story of asthenia, anorexia, weight loss, fever and lymphadenopathies in all palpable sites. Analytic studies were all within normal limits except LDH levels and globular sedimentation rate, both raised. After cervical lymph node biopsy performance high grade Non-Hodgkin lymphoma was initially diagnosed. During admission he complained from pain in both shoulders and an erythematous desquamative eruption in trunk appeared. Some days later, a second lymph node biopsy was performed and Kikuchi-Fujimoto disease was diagnosed. Serologic tests for human herpes virus 6 were positive demonstrating active associated infection. He begun treatment with indomethicin, fever and general symptoms disappeared one week later discontinuing treatment. Two months after discharge, all lymphadenopathies had disappeared. A review on epidemiological, clinical, pathological and differential diagnosis issues is made.

[Comparative study of the stability of oral anticoagulant treatments (warfarin vs acenocoumarol)]

PURPOSE

To compare the stability of the effect of two oral anticoagulants, one of them (acenocoumarol) with a short half life and the other one with a long half life (warfarin) in patients in the stable phase of treatment (at least 2 months with treatment before entering the study).

PATIENTS AND METHODS

During a year period (January-December 1993) a comparative study of two groups of 53 patients each was performed: group 1 patients were treated with warfarin and group 2 with acenocoumarol. Both groups were paired with respect to age, sex, diagnosis for anticoagulant therapy and desired therapeutic range (INR 3-4.5). The mean value of controls per patient, the dosage changes, the evolutive controls and the incidence of haemorrhagic and thromboembolic episodes were studied.

RESULTS

The controls performed in group 1 were 728 in total with a mean value of 13.74 per patient and 800 in group 2 with a mean value of 15.09 per patient. A change in the dosage was performed in 214 controls in patients of group 1 and in 269 of group 2. Seventeen patients had 38 haemorrhagic episodes (2 major and 36 minor) in group 1, and 6 of group 2 had 20 episodes (2 major and 18 minor). Significant differences were observed in the mean value of controls (p = 0.04), the evolutive controls (p < 0.001), the global incidence of haemorrhages (p = 0.008) and incidence of minor ones (p = 0.006). No significant differences in dosage were observed. In both groups no thromboembolic episodes during the period of study were reported.

CONCLUSIONS

Anticoagulant treatment with warfarin is more stable than with acenocoumarol. The total controls and the mean value of controls per patient are decreased. Nevertheless with warfarin we have observed a greater incidence of haemorrhagic episodes.

[Primary testicular lymphoma. Report of two cases]

Primary testicular lymphoma (PTL) is the most frequently diagnosed testicular tumor in men over 60 years, in spite of this circumstance it is a rare process. Two cases of PTL are reported, the first one in a child and the second in an adult. Both cases were intermediate grade lymphoma and had low stage (IEA), presenting initially as an enlargement of the testicle as the only symptom, the second case presented involvement by contiguity of the abdominal muscles. Immunohistological markers showed T nature in the first case, and B in the second. The treatment applied in both cases was orchiectomy and systemic chemotherapy using COP-BLAM/IMVP-16, in the child prophylaxis of the central nervous system using methotrexate was made. Response to treatment was good, the first patient achieved complete remission and his survival at present is 24 months, the second patient died 5 month after diagnosis due to stroke without having completed chemotherapy but with an important reduction of the tumoral mass. A review of the literature on clinical, diagnostic and therapeutic issues is made.

[Human recombinant erythropoietin in the treatment of myelodysplastic syndromes anemia. Meta-analytic study]

PURPOSE

To study the usefulness of different published epidemiological and analytic parameters to decide the treatment with human recombinant erythropoietin (rHuEPO) of anaemic patients with myelodysplastic syndromes (MDS).

PATIENTS AND METHODS

We have revised 10 published series compiling 115 patients, studying age, sex, initial diagnosis, route of administration and posology, criteria of response, duration of the study, dosis with the response was obtained, response according to initial diagnosis, duration of responses, and effect of the treatment on other hematopoietic series. We have made a comparison between responders and non-responders based on epidemiological and analytical parameters.

RESULTS

We have compiled 115 patients with a rate of global response of 23.5%. We have not found significative differences between the route (s.c. or i.v.) or frequency of administration, however the number of responses was higher when rHuEPO was administered three times weekly. A great variability in the criteria of response was observed among the different studies. Most of studies have a duration of three months but we have observed significative differences in the number of responses when the study is longer. We have not found significative differences between responders and non-responders with respect to age, sex, used dosis, transfusional dependency and degree of transfusional dependency, basal serum erythropoietin, time since diagnosis, transfusional period, haemoglobin level among non-transfusion dependent patients and haemoglobin level among transfusion dependent patients. We have found significative differences with respect to initial diagnosis, a higher rate of responses was observed in the refractory anaemia with excess of blasts (RAEB) group. We have not found a higher rate of transformations into acute myeloid leukaemia (AML) among these patients. The effects of the treatment on other haematopoietic series can be considered as anecdotical.

CONCLUSION

The different epidemiological and analytic parameters published up to now are not useful in the decision of including an anaemic patient with MDS in the treatment with rHuEPO. Those patients with RAEB can be benefited with the treatment with rHuEPO. The concomitant use of other cytokines could improve these results.

[Treatment with oral anticoagulants (acenocoumarol): influence of the initial doses in the incidence of hemorrhagic and thromboembolic episodes]

PURPOSE

To compare two initial doses of oral anticoagulant (acenocoumarin) studying the haemorrhagic and thromboembolic episodes occurred during the first month of treatment, the mean time and necessary controls until achievement of the desired level of anticoagulation.

PATIENTS AND METHODS

From january 1992 to december 1993; a comparative study of two groups of patients was performed: group 1, compiling 129 patients chosen at random and retrospectively, who begun oral anticoagulant treatment with 4 daily mg of acenocoumarin; and group 2, compiling 129 patients chosen prospectively, who begun with 2 mg daily. In both groups the mean time and the number of controls performed until achieving the desired level of anticoagulation were analyzed, as well as the haemorrhagic episodes occurred during the first month of treatment, their severity (classified into major and minor ones), the level of anticoagulation when they occurred and their possible causes. In the same way the thromboembolic processes occurred during that period in both groups were studied.

RESULTS

The mean time necessary to achieve the desired level of anticoagulation was 3.8 days in group 1 and 6.3 in group 2; the mean number of controls performed in group 1 was 1.2 and in group 2 it was 1.8. We have observed 19 haemorrhagic episodes, 15 in group 1 (4 minor and 11 major); and 4 in group 2 (2 minor and 2 major). We have found significant differences with respect to the mean time (p < 0.01), number of controls (p < 0.01) and incidence of hemorrhages (p = 0.017) between groups 1 and 2. One thromboembolic episode was registered in each group: in group 1 a deep venous thrombosis and in group 2 a stroke.

CONCLUSION

The initial daily doses of acenocoumarin of 2 mg is as effective as the 4 mg one in the prevention of thromboembolic episodes, with a significant reduction in the number of haemorrhages observed during the first month of treatment. However this produces a prolongation in the necessary mean time and more number of controls performed until the achievement of the desired level of anticoagulation.

[Hemorrhagic complications in patients treated with oral anticoagulants]

PURPOSE

We have studied the haemorrhagic episodes occurred in patients treated with oral anticoagulants, with special reference to their type, frequency and severity and analyzing the risk factors that could influence in their production.

PATIENTS AND METHODS

We carried out a retrospective study in 435 patients of the haemorrhagic episodes occurred since January 1989 to December 1991, determining in each one the prothrombin time expressed as INR, the time from the beginning of treatment, the patient's age and the known or underlying pathologies that could predispose to haemorrhage; depending on their severity these episodes were classified as moderate and major.

RESULTS

We observed 50 haemorrhagic episodes in 50 patients (11.5%) which represents 7 x 100 patient/years, 30 (6.8% of the total patients or 4.2 x 100 patient-years) were moderate and 20 (4.5% of the total patients or 2.8 x 100 patient/years) were major. The mean age in patients with haemorrhage was 50.5 years. The incidence of hemorrhages in the first month of treatment was 60.8 x 100 patient/years; 9.4 x 100 patient/years in the period from the first month to the first year of treatment; and 3.6 x 100 patient/years in the period from the first year of treatment. The most frequent type of haemorrhage among the moderate ones was haematuria (46%) and among major ones digestive haemorrhages (26%). Depending on the coagulation level, 37 patients (66%) were within therapeutical range. Depending on patients' sex, the incidence was 23 (46%) males and 27 (54%) females. We observed at risk predisposing factors hypertension (18%), stroke (12%), hepatic disease (8%) and myocardial infarction (8%).

CONCLUSION

We have found no relationship between haemorrhagic episodes and patients' age or sex. The risk of haemorrhage is higher at the beginning of the treatment and increases with the level of anticoagulation, which makes the beginning of treatment with lower doses more desirable, increasing them progressively until the desired level is achieved. Previous hypertension, stroke, hepatic disease and myocardial infarction are factors predisposing to haemorrhage.

[Chronic neutrophilic leukemia associated with myeloma. Simultaneous presentation]

A case of chronic neutrophilic leukaemia associated with multiple myeloma is reported. The patient had a 6 months history of bruising and weight loss, and showed mature neutrophilic leukocytosis, hepatosplenomegaly, high neutrophil alkaline phosphatase score, hyperuricaemia, neutrophils with pseudotoxic granulation and scarce Döhle bodies; moreover, a monoclonal IgG lambda was detected amounting 57.3 g/L. The bone marrow was grossly hypercellular with marked myeloid hyperplasia and aggregates of immature plasma cells. After treatment during 1 year with melphalan and prednisone she is well, although persisting with neutrophilic leukocytosis, slight splenomegaly, and the monoclonal IgG decreased to 25.8 g/L.