Ophthalmic manifestations of haematological disorders

Five case histories are presented. Waldenstrom's macroglobulinaemia caused bilateral central retinal vein occlusion, proptosis was the presenting feature of retro-orbital plasmacytoma in relapsed multiple myeloma, a red painful eye was due to neovascular glaucoma in primary polycythaemia, bilateral VIth nerve palsy caused convergent squint and diplopia in meningeal relapse of acute lymphoblastic leukaemia and lymphoma of the eyelid caused complete ptosis. Interdisciplinary management is described. Ophthalmological lesions in haematological disease should be promptly recognized and managed. Collaboration between ophthalmology and haematology departments may be effective for palliative management.

Five-year follow-up of patients treated with imatinib mesylate for chronic myeloid leukaemia in Trinidad and Tobago

OBJECTIVE

Data on the use of Imatinib (IM) in developing countries remain limited. A retrospective study was done to assess the efficacy and toxicity of IM in treating chronic myeloid leukaemia (CML) in Trinidad and Tobago.

METHODS

Patients in all phases of CML who started IM therapy between February 2001 and February 2004 were included. All had received other previous therapy. They were assessed for haematological, cytogenetic and molecular response, overall survival (OS), event free survival (EFS) and adverse effects (AE).

RESULTS

Twenty-five patients were followed-up for a median 61 months. At initiation of IM, 18 were in the chronic phase (CP), 3 in accelerated phase (AP), 3 in blast crisis (BC) and one in myelofibrotic transformation (MF). Overall, 96% of patients achieved complete haematological remission (CHR). Among CP patients, 67% attained a major cytogenetic response (MCR) and 44% a complete cytogenetic response (CCR). Overall survival and event free survival in the CP group were 82% and 76% respectively. Overall survival for advanced phase patients was 14% at 61 months. The adverse effects of IM were the same as previously described and generally tolerable. No patient opted to discontinue IM because of side effects.

CONCLUSION

After 5 years of follow-up, IM was found to induce favourable and durable survival responses with an acceptable side effect profile in CP-CML patients who had received prior treatment with alternative agents.

Evaluation of blood donor deferral causes in the Trinidad and Tobago National Blood Transfusion Service

The majority of blood donations in Trinidad and Tobago are made as replacement by family members or friends. National Blood Transfusion Policy was drafted in 2007 to promote voluntary, repeated donation. The objective of this study is to assess the current rate and reasons for donor deferral, and the aim is to guide the proposed donor education and recruitment programme. A retrospective study of pre-donation deferral of prospective blood donors at the National Blood Transfusion Centre, Port of Spain, Trinidad and Tobago, was conducted. Records of all pre-donation deferrals over a 12-month period were studied. As many as 11,346 pre-donation screening interviews were conducted. There were 4043 (35.6%) deferrals. The most common reasons for donor deferral were exposure to high-risk sexual activity (27.6%), low haemoglobin 22.2% and hypertension 17.5%. Other reasons such as medication, chronic medical illness, tattoos, travel history, recent pregnancy, surgery or presentation outside the accepted age limit caused 33.8% of all deferrals and the majority (34.7%) of male deferrals. Low haemoglobin (44.5%) was the most common reason among females. The rate of deferral of voluntary donors was not significantly different from that for replacement donors (31.7 vs. 35.4%, P = 0.25). This study exposed a lack of public awareness as the principal reason for an unacceptably high rate of donor deferral. Donor education about selection criteria needs to be urgently addressed as an objective of the National Policy. Monitoring and evaluation of deferral rates and reasons could be used as one indicator of the effectiveness of the Policy.

Establishing an oral anticoagulant monitoring service in a multiethnic developing country

We describe the establishment of an International Normalized Ratio (INR)-based system for monitoring oral anticoagulant therapy in a multiethnic developing country. There was significant variation in geometric mean normal prothrombin time among ethnic groups: 12.7 s for Indians, 13.4 s for Africans and 13.7 s for subjects of mixed ancestry. About 4129 INR measurements were performed in the first 2 years. The majority (55.2%) of achieved INRs were subtherapeutic. We found 31 (0.8%) instances of severe overanticoagulation (INR > 8.0). There were no bleeding manifestations in 24 (77%) of them. Only two experienced life-threatening haemorrhage. The management of bleeding and excessive anticoagulation was not always in accordance with international recommendations. The high incidence of underanticoagulation in Trinidad and Tobago may be due to genetically determined warfarin resistance or underdosing. Oral anticoagulant monitoring in Trinidad and Tobago could benefit from the centralization of such services to designated clinics with specialized staff and computer-assisted dosing which adopt internationally accepted guidelines for practice.

Attitudes towards blood donation in Trinidad and Tobago

The aims of this study were to determine the factors that influence blood donation in different demographic groups in a multi-ethnic, multicultural community, and to devise a strategy for a national campaign to increase voluntary non-remunerated blood donations. The majority (87%) of blood donations in Trinidad and Tobago are replacement donations. Seventy per cent of the country's transfusion needs are not met. In 1998, the World Health Assembly recommended that reliance on replacement donations should be phased out due to their association with an increased risk of transfusion-transmitted infections. An observer-administered questionnaire was completed by 1423 respondents in a multi-ethnic borough in central Trinidad. Respondents were classified as donors or non-donors and grouped by age, race, religion, employment status and highest level of education. The prevalence of a history of blood donation and the factors that encouraged donation or conversely discouraged donation in each demographic group were recorded. A total of 1146 (81.2%) respondents had never donated blood. Of the 277 (18.8%) who had previously donated, replacement for a family member or friend was the most common reason (86.9%). The prevalence of donation was low in all racial, religious, gender, educational and age groups. However, there were significant demographic variations. The majority (71.3%) of non-donors cited a lack of information as a major reason for non-donation and expressed a willingness to donate if access to information and donation facilities were improved. Voluntary blood donation in Trinidad and Tobago could be greatly increased by a national education campaign and increased accessibility to donation centres. This would ensure a safer and more reliable blood supply.

Hospital admissions for acute painful crisis in Trinidad and Tobago. Are the British Committee for Standards in Haematology (BCSH) guidelines applicable?

We observed consecutive hospital admissions for acute painful crisis (APC) among adults with Sickle Cell Disease (SCD) over a 6-month period in Trinidad and Tobago. Episodes (111) of APC resulted in 82 admissions of 59 patients. The most common site for pain was the trunk. Patients ranged in age from 17 to 53 years (median: 25). Median length of hospital stay was 4 days. Total dose of Pethidine given per admission ranged from 100 to 1650 mg (median: 525). The mean dose of morphine was 70 mg. Six (7%) of patients were readmitted within 10 days of discharge. Twenty-five (30%) of patients had chest pain at presentation of whom 10 (12%) had consolidation on chest X-ray, defining the acute chest syndrome (ACS). There was one death caused by biliary sepsis. The study revealed seemingly low opiate usage for in-hospital treatment of APC with acceptable rates of readmission. The BCSH 2003 guidelines seemed applicable apart for the choice and route of fluid for rehydration and opiate analgesia.

Audit of bone marrow aspirates and trephine biopsies in multiple myeloma - a single centre study

We compared 79 simultaneous marrow aspirates and trephine biopsies from multiple myeloma patients for sensitivity, concordance, quality and clinical relevance. A total of 60 examinations had been performed for initial diagnosis, i.e. in cases of suspected myeloma and 19 at follow-up. Of which, 45 (57%) of trephine biopsies were less than 1.6 cm before processing and 33 (42%) were crushed and/or fragmented. Overall, only 19/79 (24%) of trephine biopsy specimens were of at least 1.6 cm length prior to processing and not disrupted. On the other hand, 75% of aspirates were particulate and satisfactory. Mean time between receipt of a trephine biopsy specimen and issuance of a histopathological report was 9 days. Although 40% of trephine biopsies yielded information that could not be reliably obtained from a bone marrow aspirate such information was in all cases clinically irrelevant or obtainable by non-invasive means. In all cases where myeloma was detected in a trephine biopsy it was also detected in a simultaneous bone marrow aspirate, if particulate. However, there were four (5%) cases in which myeloma was detected in such aspirates but not in simultaneously taken trephine biopsies. In cases (n=19) where repeat aspirates/trephine biopsies were taken for surveillance, concordance was found between reported changes in plasma cell ratio. Our data failed to demonstrate any added benefit from routinely performing trephine biopsies after a particulate specimen had been aspirated for the diagnosis or surveillance of myeloma. Furthermore, they suggest that particulate aspirates may be at least as sensitive as trephine biopsies for detecting myeloma.

Scrotal ulceration during all-trans retinoic (ATRA) therapy for acute promyelocytic leukaemia

We report the development of painful scrotal ulceration in two patients during treatment with all-trans-retinoic acid (ATRA) for acute promyelocytic leukaemia (APL). ATRA 45 mg/m2 was administered orally for 8 days prior to the addition of standard induction chemotherapy. Painful scrotal ulceration developed in both cases within 2 weeks of therapy (9 and 13 days) and responded slowly to drug withdrawal and systemic, or topical, corticosteroids. A total of 17 APL patients have been treated with ATRA at our institution during the last 10 years, giving an incidence of approximately 12%. The present report, together with a review of literature, suggests that scrotal ulceration is a specific adverse effect of ATRA therapy and that this complication may be more common than previously documented.