Fetal head position and perineal distension associated with the use of the BD Odon Device™ in operative vaginal birth: a simulation study

Objective

To investigate (i) the placement of the BD Odon Device on the model fetal head, and (ii) perineal distention during simulated operative vaginal births conducted with the BD Odon Device

Design

Observational simulation study

Setting

North Bristol NHS Trust, UK

Population or Sample

440 simulated operative vaginal births

Methods

Three bespoke fetal mannequins were developed to represent (i) bi-parietal diameter of the 50^th centile at term (ii) bi-parietal diameter at the 5^th centile at term and (iii) 50^th centile head with 2 cm of caput. Siting of the BD Odon Device on model heads was determined before and after 400 simulated operative vaginal births. Variables were analysed to determine their effect on device siting and movement during birth.

The fetal mannequins were placed inside a maternal mannequin (PROMPT Flex, Limbs & Things, Bristol, UK) and the BD Odon Device was placed around the fetal head as per the instructions for use. The location of the air cuff was determined before and after the head was delivered. Perineal distension was determined by recording maximum perineal distention during a simulated operative vaginal birth using the same procedure, as well as scenarios employing an inappropriately non-deflated air cuff (for the BD Odon Device), the Kiwi ventouse and non-rotational forceps.

Main Outcome Measures

Site and displacement during birth of the BD Odon Device on a model head. Maximal perineal distension during birth.

Results

The BD Odon Device was reliably sited in a standard over the fetal head position (approximately 40mm above the fetal chin) for all stations, head sizes and positions with no significant displacement. In occipito-posterior births, compared to occipito-anterior or transverse, the BD Odon Device routinely sited further down the fetal head (toward the chin).

The BD Odon Device was not associated with more perineal distension than forceps or Kiwi ventouse (21mm vs 26mm vs 21mm at posterior fourchette).

Conclusions

The BD Odon Device reliably sited over a safe area of the fetal head in 400 simulated births representative of clinical practice. The BD Odon Device generates similar levels of perineal distension compared to Kiwi ventouse when used correctly.

Pressure and traction on a model fetal head and neck associated with the use of forceps, Kiwi™ ventouse and the BD Odon Device™ in operative vaginal birth: a simulation study

Objective

To determine the pressure and traction forces exerted on a model fetal head by the BD Odon Device, forceps and Kiwi ventouse during simulated births.

Design

Simulation study.

Setting

Simulated operative vaginal birth.

Population or Sample

84 simulated operative vaginal births.

Methods

A bespoke fetal mannequin with pressure sensors around the head and strain gauge across the neck was used to investigate pressure applied over the head, and traction across the neck during 84 simulated births using the BD Odon Device, non-rotational forceps and Kiwi ventouse.

Main Outcome Measures

Peak pressure on the fetal face and lateral aspects of the head during correct use of the BD Odon Device and forceps. Peak pressure on orbits and neck during misplacement of the BD Odon Device and forceps. Peak traction force generated until instrument failure using the BD Odon Device, forceps and Kiwi ventouse.

Results

When correctly sited and using 80kPa inflation pressure on the cuff, the BD Odon Device generated a lower peak pressure on the fetal head than forceps (83kPa vs 146kPa). When instruments were purposefully misplaced over the orbits the BD Odon Device generated a lower peak pressure on the orbits than forceps (70kPa vs 123kPa). When purposefully misplaced over the neck the BD Odon Device, compared to forceps, generated a greater peak pressure on the anterio-lateral aspect of the neck (56kPa vs 17kPa) and a lower peak pressure on the posterior aspect of the neck (76kPa vs 93kPa) than forceps. In cases of true cephalic disproportion the BD Odon Device ‘popped-off’ at a lower traction force than forceps (208N vs 270N).

Conclusions

In simulated assisted vaginal birth with correctly placed instruments the peak pressure exerted on the fetal head by a BD Odon Device is lower than pressure exerted by non-rotational forceps. In cases in which delivery of the fetal head is not possible due to cephalo-pelvic disproportion lower traction forces could be applied using the BD Odon Device than with forceps before the procedure was abandoned due to device failure.

Design and development of the BD Odon DeviceTM : a human factors evaluation process

OBJECTIVE

To (1) determine how intended users interact with and use the BD Odon Device in simulation, (2) use these findings to alter progressively the design of the BD Odon Device and (3) validate that these changes have improved the ability of practitioners to use the BD Odon Device.

DESIGN

Human factors evaluation study.

SETTING

Simulation suite designed to mimic delivery room.

POPULATION OR SAMPLE

Three hundred and ninety simulated operative births, performed by 100 practising clinicians.

METHODS

Simulated operative vaginal births performed using the BD Odon Device and the device Instructions for use were subjected to three formative human factors evaluations and one human factors validation test. Following each evaluation, findings were reviewed and the design of the BD Odon Device and Instructions for use were modified.

MAIN OUTCOME MEASURES

Successful performance of an operative vaginal birth using the BD Odon Device in accordance with provided training and Instructions for use.

RESULTS

Using version two of the BD Odon Device, and following exposure to face-to-face training and written instructions, 25% of accouchers were able successfully to perform a simulated operative vaginal birth. In the final evaluation, following device design and training material alterations, all accouchers were able successfully to perform a simulated operative vaginal birth using version four of the BD Odon Device.

CONCLUSIONS

Human factors evaluations have enabled a multi-professional device and training materials design team to alter the design of the BD Odon Device and the Instructions for use in an evidence-based fashion. This process has resulted in a device which has a predictable and likely safe pattern of use.

TWEETABLE ABSTRACT

Human Factors evaluations help make the BD Odon Device safe and usable for clinical practice.

Inotuzumab ozogamicin for the treatment of patients with acute lymphocytic leukemia

Inotuzumab ozogamicin is an antibody-drug conjugate comprised of a humanized anti-CD22 monoclonal antibody conjugated to calicheamicin, a cytotoxic antibiotic agent. Inotuzumab ozogamicin binds to CD22-expressing tumor cells, resulting in apoptotic cell death. Based on the results of the pivotal, phase III INO-VATE trial in acute lymphoblastic leukemia (ALL), approval of inotuzumab ozogamicin was recently granted for the treatment of patients with relapsed or refractory ALL, a group that otherwise has a poor prognosis with standard chemotherapy. Several ongoing clinical trials are now testing whether outcomes can be further improved by combining inotuzumab ozogamicin with low-dose chemotherapy or by including inotuzumab ozogamicin in the front-line setting. In this article we discuss the preclinical, clinical and safety data of inotuzumab ozogamicin.

Phase I study of pemetrexed in patients with relapsed or refractory acute leukemia or lymphoid blast phase chronic myelogenous leukemia

7068

Background: Pemetrexed is a folate antimetabolite that is clinically active in a number of different cancers. The purpose of this phase I trial was to define the dose-limiting toxicity (DLT), maximum tolerated dose (MTD), and recommended phase II dose (RP2D) of pemetrexed given with vitamin supplementation to patients with relapsed or refractory leukemia. Secondary objectives were pharmacokinetic (PK) and pharmacodynamic (PD) analyses of pemetrexed. Methods: Patients ≥15 years of age were enrolled with relapsed or refractory leukemia, Eastern Cooperative Oncology Group performance status ≤2, adequate renal and hepatic function, and life expectancy of ≥6 weeks. Enrollment was planned using a 3+3 dose escalation design. Intravenous pemetrexed was given at a starting dose of 900 mg/m2 over 1 hour every 3–4 weeks. Doses were escalated to 1,200, 1,500, 2,000, 2,700, and 3,600 mg/m2. Folic acid and Vitamin B12 were given with pemetrexed. Response was assessed by standard blood and bone marrow criteria. Toxicities were assessed using Common Terminology Criteria for Adverse Events, version 3.0. Results: Twenty-two patients entered the trial; median age was 50 years (range: 18–75); 15 patients had acute myeloid leukemia and 7 patients had acute lymphocytic leukemia (ALL). Two patients were ineligible and did not receive study drug. At the 1,200 and 1,500 mg/m2 dose levels, 1 patient per level developed grade (G) 3–4 liver enzyme and bilirubin elevations attributed to sepsis. At the 3,600 mg/m2 dose level, 1 patient had a G3 liver enzyme elevation and 2 added patients also had G3 liver toxicity. In addition, 2 patients in the 3,600 mg/m2 cohort developed G2 liver abnormalities. Based on liver toxicities, the DLT dose level was established at 3,600 mg/m2. Two patients died during the study due to disease progression and 1 patient discontinued due to a subdural hematoma of unknown cause. One patient with ALL achieved a partial response. There were no other objective responses. PK and PD data were not available for this report. Conclusions: The MTD and RP2D of pemetrexed were determined to be 2,700 mg/m2. Due to limited observed efficacy, a planned phase II trial was canceled.

[Table: see text]

Comorbidity description using the hematopoietic cell transplantation-specific comorbidity index (HCT-CI) in elderly de novo poor-risk AML patients (pts) treated with laromustine

7050

Background: Treatment of older pts with AML is often complicated by comorbidities and pts with comorbidities are often underrepresented in clinical trials. The HCT-CI, which was developed in pts receiving allogeneic SCT, has been applied to pts receiving induction therapy for AML in an effort to assist in therapeutic and investigational decisions (Kantarjian 2006; Etienne 2007; Giles 2007). HCT-CI scores have been shown to be predictive of early death and survival in pts ≥ 60 years receiving induction therapy for AML, with early death rates of 3%, 11%, and 29% for pts with HCT-CI scores of 0, 1–2, and ≥ 3, respectively (Giles 2007). Methods: 140 pts age ≥ 60 with poor risk de novo AML from two phase II studies were scored for comorbidity by HCT-CI. In these studies, poor risk was defined by the presence of at least one risk factor: age ≥ 70, ECOG PS = 2, unfavorable cytogenetics, or cardiac, pulmonary, or hepatic dysfunction. All pts received induction therapy with 600 mg/m2 laromustine as a single 30–60 min infusion. A second induction cycle could be administered to pts with PR or hematologic improvement. Pts with CR or CRp were able to receive consolidation with laromustine 400 mg/m2 (Study CLI-033) or araC 400 mg/m2/day CIV for 5 days (Study CLI-043). Results: HCT-CI score was 0 in 7 (5%) pts, 1–2 in 19 (14%), and ≥ 3 in 114 (81%). The median HCT-CI score was 5 (range 0–13). The most common comorbidities were cardiac (42%), severe pulmonary (39%), infection (35%), and arrhythmia (31%). 52 (37%) of all pts achieved a CR/CRp; 39/114 (34%) of pts with HCT-CI score ≥ 3 achieved a CR/CRp. Deaths within 30 days of first induction were observed in 0/7 pts with HCT-CI score 0, 4/19 (21%) with score 1–2, and 16/114 (14%) with score ≥ 3. Overall survival at 12 months was 43%, 14%, and 21% for pts with HCT-CI scores of 0, 1–2, and ≥ 3, respectively. Conclusions: The majority (81%) of these older poor risk AML pts treated with laromustine had a HCT-CI score ≥ 3, confirming the poor risk nature of this patient group. The induction death rate for pts treated with laromustine and with HCT-CI score ≥ 3 was lower than that reported for a group of pts with HCT-CI score ≥ 3 treated with standard induction chemotherapy (14% vs 29%; Giles 2007).

[Table: see text]

Soluble syndecan-1 (sCD138) as a prognostic factor independent of mutation status in patients with chronic lymphocytic leukemia

Syndecan-1 (sCD138) is a transmembrane heparan sulfate-bearing proteoglycan expressed in epithelial cells as well as hematopoietic cells that demonstrate plasmacytoid differentiation. Higher levels of sCD138 correlate with poor outcome in myeloma. We examined the association of circulating sCD138 levels in plasma with clinical behavior in 104 patients with chronic lymphocytic leukemia. sCD138 levels were significantly higher in patients (median, 52.8 ng/ml; range, 13.4-252.7 ng/ml) than in healthy control subjects (median, 19.86; range, 14.49-33.14 ng/ml) (P < 0.01). Elevated sCD138 (>median, 52.8 ng/ml) was associated with significantly shorter survival (P = 0.0004); this association was independent of IgVH mutation status, beta2-microglobulin (beta2-M) level, and treatment history. Patients with mutated IgVH but high sCD138 levels (>52.8 ng/ml) had significantly shorter survival than those with mutated IgVH and lower levels of sCD138. Similarly, patients with unmutated IgVH but high sCD138 levels had significantly shorter survival than those with lower sCD138 levels and unmutated IgVH (P = 0.007). In a multivariate Cox regression model, only Rai stage, beta2-M, and sCD138 remained predictors of survival. These data suggest that sCD138 when combined with beta2-M and Rai stage, may replace the need for testing IgVH mutation status.

Action learning in partnership with Landcare and catchment management groups to support increased pasture sowings in southern inland Queensland

The incorporation of sown pastures as short-term rotations into the cropping systems of northern Australia has been slow. The inherent chemical fertility and physical stability of the predominant vertisol soils across the region enabled farmers to grow crops for decades without nitrogen fertiliser, and precluded the evolution of a crop–pasture rotation culture. However, as less fertile and less physically stable soils were cropped for extended periods, farmers began to use contemporary farming and sown pasture technologies to rebuild and maintain their soils. This has typically involved sowing long-term grass and grass–legume pastures on the more marginal cropping soils of the region. In partnership with the catchment management authority, the Queensland Murray–Darling Committee (QMDC) and Landcare, a pasture extension process using the LeyGrain™ package was implemented in 2006 within two Grain & Graze projects in the Maranoa-Balonne and Border Rivers catchments in southern inland Queensland. The specific objectives were to increase the area sown to high quality pasture and to gain production and environmental benefits (particularly groundcover) through improving the skills of producers in pasture species selection, their understanding and management of risk during pasture establishment, and in managing pastures and the feed base better. The catalyst for increasing pasture sowings was a QMDC subsidy scheme for increasing groundcover on old cropping land. In recognising a need to enhance pasture knowledge and skills to implement this scheme, the QMDC and Landcare producer groups sought the involvement of, and set specific targets for, the LeyGrain workshop process. This is a highly interactive action learning process that built on the existing knowledge and skills of the producers. Thirty-four workshops were held with more than 200 producers in 26 existing groups and with private agronomists. An evaluation process assessed the impact of the workshops on the learning and skill development by participants, their commitment to practice change, and their future intent to sow pastures. The results across both project catchments were highly correlated. There was strong agreement by producers (>90%) that the workshops had improved knowledge and skills regarding the adaptation of pasture species to soils and climates, enabling a better selection at the paddock level. Additional strong impacts were in changing the attitudes of producers to all aspects of pasture establishment, and the relative species composition of mixtures. Producers made a strong commitment to practice change, particularly in managing pasture as a specialist crop at establishment to minimise risk, and in the better selection and management of improved pasture species (particularly legumes and the use of fertiliser). Producers have made a commitment to increase pasture sowings by 80% in the next 5 years, with fourteen producers in one group alone having committed to sow an additional 4893 ha of pasture in 2007–08 under the QMDC subsidy scheme. The success of the project was attributed to the partnership between QMDC and Landcare groups who set individual workshop targets with LeyGrain presenters, the interactive engagement processes within the workshops themselves, and the follow-up provided by the LeyGrain team for on-farm activities.

The role of prognostic factors in assessing ‘high-risk’ subgroups of patients with chronic lymphocytic leukemia

The management of chronic lymphocytic leukemia (CLL) has historically relied on 'watchful waiting' and palliative approaches to therapy. However, the course of disease is highly variable and a substantial proportion of patients with early-stage CLL develop rapidly progressive disease requiring therapy. In recent decades, numerous clinical and biological prognostic markers that are predictive of decreased survival outcomes, disease progression and/or resistance to therapy, and that may play a role in defining the subgroups of patients with 'high-risk' CLL have been identified. At the same time, highly effective treatment modalities have become available with the advent of chemoimmunotherapy combinations and allogeneic stem cell transplantation. Thus, we are approaching an era when patients with CLL may potentially benefit from individualized risk assessments based on prognostic markers and when specific therapies may be offered to the subgroup of patients with high-risk disease. This review provides a brief overview of newer biological prognostic markers, discusses the challenges associated with identifying the subgroup of patients with high-risk CLL and further aims to provide recommendations on how prognostic markers may be used to assess high-risk subgroups in different clinical situations in CLL.

Having a higher blast percentage in circulation than bone marrow: clinical implications in myelodysplastic syndrome and acute lymphoid and myeloid leukemias

Determining the percentage of peripheral blood (PB) and bone marrow (BM) blasts is important for diagnosing and classifying acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). Although most patients with acute leukemia or MDS have a higher percentage of BM blasts than PB blasts, the relative proportion is reversed in some patients. We explored the clinical relevance of this phenomenon in MDS (n = 446), AML (n = 1314), and acute lymphoblastic leukemia (ALL) (n = 385). Among patients with MDS or ALL, but not AML, having a higher blast percentage in PB than in BM was associated with significantly shorter survival. In multivariate analyses, these associations were independent of other relevant predictors, including cytogenetic status. Our findings suggest that MDS and ALL patients who have a higher percentage of PB blasts than BM blasts have more aggressive disease. These data also suggest that MDS classification schemes should take into account the percentage of blasts in PB differently from the percentage of blasts in BM.

Can dietary treatment of non-anemic iron deficiency improve iron status?

OBJECTIVE

To investigate the efficacy of, first, a dietary regimen involving increased consumption of iron-rich foods and enhancers of iron absorption and decreased consumption of inhibitors of iron absorption and, second, a low dose iron chelate iron supplement, for increasing iron stores in young adult New Zealand women with mild iron deficiency (MID).

METHODS

The study was a 16 week randomized placebo-controlled intervention. Seventy-five women aged 18 to 40 years with MID (serum ferritin < 20 microg/L and hemoglobin > or = 120 g/L) were assigned to one of three groups: Placebo, Supplement (50 mg iron/day as amino acid chelate) or Diet. Participants in the Diet Group were given individual dietary counseling to increase the intake and bioavailability of dietary iron. Dietary changes were monitored by a previously validated computer-administered iron food frequency questionnaire.

RESULTS

Diet Group members significantly increased their intake of flesh foods, heme iron, vitamin C and foods cooked using cast-iron cookware and significantly decreased their phytate and calcium intakes. Serum ferritin increased in the Supplement and Diet Groups by 59% (p=0.001) and 26% (p=0.068), respectively, in comparison to the Placebo Group. The serum transferrin receptor:serum ferritin ratio decreased by 51% in the Supplement Group (p=0.001), and there was a non-significant decrease of 22% (p=0.1232) in the Diet Group.

CONCLUSIONS

This study is the first, to our knowledge, to demonstrate that an intensive dietary program has the potential to improve the iron status of women with iron deficiency.

Homoharringtonine: history, current research, and future direction

BACKGROUND

Cephalotoxine esters, including homoharringtonine (HHT), have shown encouraging activity in leukemia in initial studies in China and in later studies in the U.S.

METHODS

The authors conducted a review of the literature to examine the studies pertinent to HHT in relation to preclinical studies and Phase I-II trials in patients with hematologic malignancies and solid tumors.

RESULTS

HHT and analogues appear to induce differentiation and apoptosis. Studies from China reported high response rates in patients with leukemia. Trials in the U.S. using short HHT infusions (3-4 mg/m(2) daily for 5 days) resulted in a high incidence of cardiovascular complications that were reduced using continuous infusion schedules of 3-7 mg/m(2) daily for 5-7 days initially, and later lower dose schedules of 2.5 mg/m(2) daily for 7-14 days. Results in solid tumors were negative. However encouraging results were reported in patients with acute myeloid leukemia, myelodysplastic syndrome, acute promyelocytic leukemia, and, most important, chronic myeloid leukemia (CML). In CML patients, HHT has been investigated alone and in combination with interferon-alpha and low-dose cytarabine in late and early chronic phases, with positive results. Additional areas of interest include the potential use of HHT for the treatment of central nervous system leukemia, polycythemia vera, and other nonmalignant conditions such as malaria. New semisynthetic preparations and HHT derivatives that bypass multidrug resistance may improve the efficacy and toxicity profiles, and broaden the range of antitumor efficacy.

CONCLUSIONS

HHT and its derivatives appear to have promising activity in hematologic malignancies, a finding that needs to be pursued.

Fractionated cyclophosphamide, vincristine, liposomal daunorubicin (daunoXome), and dexamethasone (hyperCVXD) regimen in Richter's syndrome

Approximately 3 to 5% of patients with chronic lymphocytic leukemia (CLL) develop an aggressive large cell non Hodgkin's lymphoma (NHL) known as Richter's syndrome (RS). RS has a poor prognosis and a response rate of < 10% with fludarabine-based or other cytotoxic combination regimens. The aim of this study was to evaluate the efficacy and toxicity of the hyperCVXD regimen in RS. Twenty-nine patients, median age 61 years (36-75) 23 males, were treated. Prior diagnosis was CLL in 26 patients, NHL in 2, and Prolymphocytic leukemia in 1. Treatment consisted of fractionated cyclophosphamide, vincristine, daunoXome and dexamethasone. Six patients (20%) died while receiving study therapy, 4 (14%) during the first cycle of whom 2 had started therapy with overt pneumonia. Grade 4 granulocytopenia occurred in all 95 cycles of therapy with a median time to recovery of 14 days. Twenty three (24%) cycles were complicated by fever, and 15 (15%) by pneumonia. Sepsis was documented in 8 (8%) cycles, and neuropathy in 5 (5%) of cycles. Twenty three patients had a platelet count < 100 x 10(9)/l prior to therapy: a greater than 50% decrease in platelet count over pre-therapy level occurred in 79% of first cycles, overt bleeding occurred in 4 (4%) of all cycles. Eleven of 29 (38%) patients achieved complete remission (CR), 4 of whom have relapsed after 5, 6, 9, and 12 months of remission. Two of 11 CR patients presented with RS without any prior CLL therapy. One patient had a partial remission. Thus the overall response rate was 12/29 (41%). Overall median survival was 10 months, 19 months in patients who achieved CR, 3 months in those who did not (p = 0.0008). A landmark analysis performed at 2 months from start of therapy comparing patients alive in CR versus patients alive but not in CR showed a median survival of 19 months versus 6 months, respectively (p 0.0017). In conclusion the hyper CVXD regimen has a relatively high response rate, significant toxicity and a moderate impact on survival in RS.

Blunt tracheobronchial injuries: treatment and outcomes

BACKGROUND

Tracheobronchial injury is a recognized, yet uncommon, result of blunt trauma to the thorax. Often the diagnosis and treatment are delayed, resulting in attempted surgical repair months or even years after the injury. This report is an extensive review of the literature on tracheobronchial ruptures that examines outcomes and their association with the time from injury to diagnosis.

METHODS

We reviewed all patients with blunt tracheobronchial injuries published in the literature to determine the anatomic location of the injury, mechanism of the injury, time until diagnosis and treatment, and outcome. Only patients with blunt intrathoracic tracheobronchial traumas were included.

RESULTS

We identified 265 patients reported between 1873 and 1996. Motor vehicle accidents were the most frequent mechanism of injury (59%). The overall mortality among reported patients has declined from 36% before 1950 to 9% since 1970. The injury occurred within 2 cm of the carina in 76% of patients, and 43% occurred within the first 2 cm of the right main bronchus. The proximity of the injury to the carina had no detectable effect on mortality. Injuries on the right side were treated sooner but were associated with a higher mortality than left-sided injuries. No association was detected between delay in treatment and successful repair of the injury; ninety percent of patients undergoing treatment more than 1 year after injury were repaired successfully.

CONCLUSIONS

This review of patients with blunt tracheobronchial injuries represents the largest cohort studied to date. These data suggest an ability to repair tracheobronchial injuries successfully many months after they occur. We are also able to assess the mortality associated with the location and side of injury, examine the time from injury until diagnosis and treatment, and evaluate treatment outcome.

Rituximab dose-escalation trial in chronic lymphocytic leukemia

PURPOSE

To conduct a dose-escalation trial of rituximab in patients with chronic lymphocytic leukemia (CLL) to define the maximum-tolerated dose (MTD), to evaluate first-dose reactions in patients with high circulating lymphocyte counts, and to assess the efficacy at higher versus lower doses.

PATIENTS AND METHODS

Fifty patients with CLL (n = 40) or other mature B-cell lymphoid leukemias (n = 10) were treated with four weekly infusions of rituximab. The first dose was 375 mg/m(2) for all patients; dose- escalation began with dose 2 but was held constant for each patient. Escalated doses were from 500 to 2,250 mg/m(2).

RESULTS

Toxicity with the first dose (375 mg/m(2)) was noted in 94% of patients but was grade 1 or 2 in most, predominantly fever and chills. Six patients (12%) experienced severe toxicity with the first dose, including fever, chills, dyspnea, and hypoxia in all six patients, hypotension in five, and hypertension in one. Toxicity on subsequent doses was minimal until a dose of 2,250 mg/m(2) was achieved. Eight (67%) of 12 patients had grade 2 toxicity, including fever, chills, nausea, and malaise, although no patient had grade 3 or 4 toxicity. Severe toxicity with the first dose was significantly more common in patients with other B-cell leukemias, occurring in five (50%) of 10 patients versus one (2%) of 40 patients with CLL (P <.001). The overall response rate was 40%; all responses in patients with CLL were partial remissions. Response rates were 36% in CLL and 60% in other B-cell lymphoid leukemias. Response was correlated with dose: 22% for patients treated at 500 to 825 mg/m(2), 43% for those treated at 1,000 to 1,500 mg/m(2), and 75% for those treated at the highest dose of 2,250 mg/m(2) (P =.007). The median time to disease progression was 8 months. Myelosuppression and infections were uncommon.

CONCLUSION

Rituximab has significant activity in patients with CLL at the higher dose levels. Severe first-dose reactions were uncommon in patients with CLL, even with high circulating lymphocyte counts, but were frequent in patients with other mature B-cell leukemias in which CD20 surface expression is increased. Efficacy of rituximab was also significant in this group of patients.

Results of the fludarabine and cyclophosphamide combination regimen in chronic lymphocytic leukemia

PURPOSE

To assess the efficacy of combination therapy with fludarabine and cyclophosphamide in patients with chronic lymphocytic leukemia (CLL) based on data suggesting in vitro synergistic activity of the two agents.

PATIENTS AND METHODS

A total of 128 patients with CLL were treated with fludarabine 30 mg/m(2) intravenously daily for 3 days and cyclophosphamide at either 500 mg/m(2) daily for 3 days (n = 11), 350 mg/m(2)/d for 3 days (n = 26), or 300 mg/m(2) daily for 3 days (n = 91). The cyclophosphamide dose was decreased because of myelosuppression in the early part of the study. Patients were divided into four groups based on the expectation for response to single-agent fludarabine, including previously untreated patients, patients previously treated with alkylating agents, patients successfully treated with alkylating agents and fludarabine but relapsing, and patients refractory to fludarabine with or without alkylating agents.

RESULTS

Fludarabine and cyclophosphamide produced > or = 80% response rates in all patients not refractory to fludarabine at the start of therapy as well as a 38% response rate in patients who were refractory to fludarabine. The complete remission (CR) rate was 35% in previously untreated patients, which was not significantly different from the CR rate in historical control patients treated with single-agent fludarabine. However, residual disease assessed by flow cytometry occurred in only 8% of previously untreated patients achieving CR, and median time to progression has not been reached after a median follow-up of 41 months. The main complication of therapy was related to myelosuppression and infection. Neutropenia to less than 500 x 10(9)/L was noted in 48% of patients who received cyclophosphamide 300 mg/m(2). Pneumonia or sepsis occurred in 25% of patients, and fever of unknown origin occurred in another 25%. Pneumonia or sepsis were significantly more frequent in patients who were refractory to fludarabine at the start of combination chemotherapy.

CONCLUSION

Fludarabine and cyclophosphamide seem to have a significant advantage over single-agent fludarabine in the salvage setting. Although the CR rate was not increased in previously untreated patients, residual disease detected by flow cytometry was rare and remission durations seemed to be prolonged in this subset. Myelosuppression and infection remain the most significant complications of therapy in CLL.

Utility of obtaining blood cultures in febrile neutropenic patients undergoing bone marrow transplantation

Infection remains an important cause of morbidity and mortality after bone marrow or stem cell transplantation. To evaluate the role of obtaining blood cultures for intermittent or persistent fever in neutropenic patients on antibiotic therapy, we performed a retrospective chart review of 196 consecutive patients admitted to the Bone Marrow Transplant Unit at the University of North Carolina Hospitals from 1995 to 1998. From the cohort of 196 patients, 154 patients developed neutropenic fever. The initial blood culture was positive in 16 of 145 patients during the first fever episode giving a prevalence of 11%. From the total of 109 patients that had blood cultures drawn after day 1 of fever, five patients had blood cultures positive for a pathogen, a prevalence of 4.6%. In only one patient, did blood cultures drawn after day 1 identify an organism not present on day 1 (prevalence 0.9%). After reviewing the results in the first 105 patients, we changed our timing of collection of blood cultures. Forty-nine patients were treated in this manner and we found that the mean number of blood cultures decreased from 9.2 to 4.7 per patient without a change in the frequency of infectious complications or length of hospitalization.

Acute myeloid leukemia, inversion 16, occurring in a patient with chronic lymphocytic leukemia

The occurrence of acute myeloid leukemia (AML) in patients previously diagnosed with chronic lymphocytic leukemia (CLL) is rare. In most cases, AML develops after treatment of CLL and is thought to be therapy related; unfavorable karyotypes are often evident. Herein, we report a patient with a long-standing history of CLL who developed AML with cytogenetic analysis revealing inversion 16. In keeping with the favorable prognosis of this abnormality, the patient has achieved a complete remission, which has been maintained for 13 months.

Informing patients of diagnostic mammography results: mammographer's opinions

PURPOSE

The authors' purpose was to determine mammographers' practices and attitudes regarding disclosing results of diagnostic mammograms to patients.

MATERIALS AND METHODS

In 1995, the authors mailed a questionnaire to 500 members of the Society of Breast Imaging; 399 (80%) responded to the survey.

RESULTS

Three-quarters of respondents stated that mammographers should disclose results to their patients, and approximately half were already doing so (52% for normal results, 51% for abnormal results). A sizable minority (25%) said that not telling patients was the best practice and identified several barriers to direct disclosure, including lack of time. Although bivariate analysis showed direct disclosure to be more common among female mammographers, the sex difference did not persist in multivariate analysis. In both bivariate and multivariate analyses, reading more than 100 mammograms per week and having a radiology practice in a university or academic setting were each strongly associated with direct disclosure.

CONCLUSION

Implementation of the Mammography Quality Standards Reauthorization Act of 1998 may not require a major change in mammographers' current practice. It remains critical to establish systems that help radiologists disclose results and communicate with referring physicians efficiently and effectively.