Remarkable Response of Hairy Cell Leukemia Variant to Single-Agent Cladribine

Classical hairy cell leukemia (cHCL) and related mature lymphoid B-cell neoplasms including hairy cell leukemia variant (HCLv) and splenic diffuse red pulp lymphoma (SDRPL) are a rare subset of lymphoid neoplasms. cHCL accounts for around 2% of all leukemias and is characterized by a peripheral smear with large lymphoid cells with cytoplasmic projections giving the cells a hairy appearance, splenomegaly, and cytopenias. Majority of cHCL cases harbor a BRAFV600E mutation. cHCL usually responds well to single-agent purine analogs. HCLv is even rarer and constitutes around 0.4% of lymphoid malignancies. Unlike cHCL, HCLv is less responsive to standard single-agent purine analogs and typically does not harbor the BRAFV600E mutation. The “hairy cells,” splenomegaly, and cytopenias are common in both. We report a case of a patient with HCLv who was treated with a single purine analog and achieved a near-complete response.

Managing Massive Splenic Hematoma: Exploratory Laparotomy or Active Surveillance?

Splenic hematoma is a known complication of blunt force abdominal trauma. Traditional management of splenic hematomas has been primarily surgical. However, more recently, spleen-sparing management has been favored over surgical management for cases that meet certain criteria, with surgery now reserved for patients with complications. In this report, we present a case of a massive splenic hematoma that was managed conservatively and analyze the challenges faced in clinical decision making.

Tackling Diversity in Prostate Cancer Clinical Trials: A Report From the Diversity Working Group of the IRONMAN Registry

Prostate cancer disproportionately affects racial and ethnic minority populations. Reasons for disparate outcomes among minority patients are multifaceted and complex, involving factors at the patient, provider, and system levels. Although advancements in our understanding of disease biology have led to novel therapeutics for men with advanced prostate cancer, including the introduction of biomarker-driven therapeutics, pivotal translational studies and clinical trials are underrepresented by minority populations. Despite attempts to bridge the disparities gap, there remains an unmet need to expand minority engagement and participation in clinical trials to better define the impact of therapy on efficacy outcomes, quality of life, and role of biomarkers in diverse patient populations. The IRONMAN registry (ClinicalTrials.gov identifier: NCT03151629), a global, prospective, population-based study, was borne from this unmet medical need to address persistent gaps in our knowledge of advanced prostate cancer. Through integrated collection of clinical outcomes, patient-reported outcomes, epidemiologic data, and biospecimens, IRONMAN has the goal of expanding our understanding of how and why prostate cancer outcomes differ by race and ethnicity. To this end, the Diversity Working Group of the IRONMAN registry has developed informed strategies for site selection, recruitment, engagement and retention, and trial design and eligibility criteria to ensure broad inclusion and needs awareness of minority participants. In concert with systematic strategies to tackle the complex levels of disparate care, our ultimate goal is to expand minority engagement in clinical research and bridge the disparities gap in prostate cancer care.

The Pulmonary Complications of Paraneoplastic Autoimmune Vasculitis in a Patient With Myelodysplastic Syndrome

Paraneoplastic autoimmune phenomena may occur in up to 30% of patients with myelodysplastic syndrome (MDS). We present the case of a patient with MDS who developed diffuse alveolar hemorrhage due to paraneoplastic autoimmune vasculitis.

The patient was a 55-year-old male who had been referred for outpatient hematology/oncology evaluation by his primary care physician for incidentally discovered thrombocytopenia. When he presented to the clinic, he reported new-onset chills, weakness, and night sweats. He endorsed a 20-pound weight loss over two months as well as two weeks of fatigue, exertional dyspnea, and epistaxis. He was noted to be ill-appearing and had bilateral pitting edema to the knees. Vital signs revealed a temperature of 102.3 °F, oxygen saturation of 84% on room air, and tachycardia to the 90s. Labs showed hemoglobin of 5.7 g/dL, hematocrit of 17.2 g/dL, and platelet count of 27 kµL. He was admitted to the hospital for blood and platelet transfusions, empiric antibiotics, and further diagnostic studies. The peripheral blood smear showed 4% blasts and frequent dyspoietic granulocytes. Bone marrow biopsy (BMB) was performed to differentiate between acute leukemia and myelodysplasia. BMB revealed myelodysplasia with excess blasts and erythroid predominance.During hospitalization, the patient developed acute hypoxemic respiratory failure due to bronchoscopy-confirmed diffuse alveolar hemorrhage from thrombocytopenia. His platelet count was 12 kµL. High-dose corticosteroids (2 mg/kg prednisone) were initiated for suspected paraneoplastic autoimmune vasculitis, pending BMB results. The patient steadily improved, was extubated, and had reduced oxygen and transfusion requirements.High-dose steroids were stopped, and the patient was started on decitabine chemotherapy with the ultimate goal of bone marrow transplantation. On day five of decitabine, the patient developed acute hypoxic respiratory failure requiring intubation as well as hypotension requiring vasopressors. Given that recurrent diffuse alveolar hemorrhage was again suspected, high-dose steroids were resumed upon transfer to the ICU. He continued to decompensate and ultimately experienced ventricular tachycardia requiring three separate episodes of cardiopulmonary resuscitation. Per the family’s wishes, he was palliatively extubated, and he expired an hour later.

Diffuse alveolar hemorrhage is a rare but potentially deadly pulmonary complication of MDS, stemming from a paraneoplastic autoimmune vasculitis. Patients who initially present with atypical autoimmune phenomena should raise suspicion for an underlying MDS, the presence of which can guide the promptness, extent, and duration of immunosuppressive therapy. Failure to expeditiously treat these patients with corticosteroids can lead to serious complications and death.

Treatment preference discussion in oncology outpatient clinic

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Background: Often end of life discussions are either not held in a timely manner or remain poorly communicated when outpatients are transferred to hospital care. This leads to unwarranted and costly interventions. Methods: In an academic oncology clinic we developed an electronic medical record (EMR) template that listed important information for management decisions, including life expectancy, goals of management and specific patient treatment preferences (ventilator support, tube feedings, transfusions, do-not-resuscitate (DNR) wishes, etc.). The completed note was placed in an easily retrievable location in patients’ electronic charts. Clinic charts were reviewed one week ahead of visits to identify patients who were within the last year of life and a pop up reminder for the treating physician was placed in the EMR. The physicians who admitted our patients to the hospital were educated on utilization of the template notice. We compared the percentage of patients with advanced directives or treatment preference notes before the intervention with the percentage 1½ years after the intervention was begun. We utilized a cross-sectional, self-administered survey to compare in-patient physician responses before and after implementation of the intervention to evaluate the in-hospital utility of the intervention. Results: Easily accessible treatment preference or advanced directive discussions with patients in their last year of life increased from 32% to 55% (p =0.004) with the intervention. Results of the survey also showed improved understanding of patient’s wishes for DNR status (26.9% vs 52.6%, p = 0.08) among admitting physicians. Conclusions: The development of an easily utilized EMR template to record the treatment preferences of patients near the end of life, with an EMR accountability instrument, improved both documentation of discussion and physician understanding of patient treatment preferences when patients were transferred from outpatient to inpatient care. We hypothesize that this intervention will lead to a decline in costly and unwanted interventions for patients near the end of life, and plan to test this hypothesis with further outcomes measures.

Hand-assisted laparoscopic vs open colectomy in a rural healthcare center

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Background: Complete surgical resection is a key component of curative therapy for colon cancer. Accurate pathologic staging requires examination of a sufficient number of lymph nodes in the resection specimen. Open colectomy (OC) is the traditional surgical technique, newer minimally-invasive laparoscopic techniques allow equivalent-quality cancer resection while reducing post-operative morbidity, but require longer operating time. Hand-assisted laparoscopic colectomy (HALC) may yield the benefits of laparoscopic colectomy while reducing operating time. The benefits of laparoscopic surgery reported in tertiary healthcare centers may not be achievable in non-tertiary care centers. We compared the operative experience of patients undergoing HALC to those who had OC at a rural veterans Hospital. Methods: Study design: Retrospective case-control study of consecutive patients undergoing HALC for colon cancer from April 2000 to September 2004 compared to patients who had OC. Patients with rectal and stage IV colon cancer were excluded. Reported variables were compared by the non-parametric Mann-Whitney U-test, all p-values are two-tailed. Results: Data is reported as HALC vs. OC. N= 39 in HALC cohort vs. 55 in OC. Median age: 72.1 vs 70.3 yrs (p 0.46). Location of tumors: right colon 62% vs 56%, left colon 2.5 vs 11%, sigmoid colon 36% vs 33. Stage: 0, 23% vs 11%; I 23% vs 23%; II 31% vs 36%; III 23% vs 31%. Median operating room time was 139 vs 137 minutes (p 0.94). 4 of 39 (10%) HALC procedures were converted to OC. Number of lymph nodes in resection specimen 12 vs 9 (p=0.043). Duration of hospitalization: 6 days vs 10 days (p=0.007). 5% of HALC patients were transfused vs 13% of OC patients. There were 3 cases of serious post-operative infection in the HALC group vs 9 in the OC cohort, 0 cases of wound dehiscence vs 3, 0 perioperative deaths vs 3. Overall, 8% of HALC patients developed severe post-operative surgical complications vs 22% of OC patients (p<0.05). Conclusions: HALC is technically feasible in the non-tertiary care setting, with equivalent duration of surgery to OC, but significantly shorter duration of hospitalization. The quality of surgical resection, pathologic staging and rates of peri-operative morbidity and mortality are similar or slightly better with HALC.

No significant financial relationships to disclose.

Job satisfaction and psychological health of doctors at the University of Benin Teaching Hospital

BACKGROUND

Studies on job satisfaction and health have mainly been carried out among Caucasian populations. Similar studies are lacking in Nigeria.

AIM

To investigate the level of job satisfaction and its relationship to psychological disorder amongst Nigerian doctors.

METHODS

All 190 doctors at the University of Benin Teaching Hospital were invited to participate in a cross-sectional study. The respondents completed two self-administered questionnaires, a specifically designed (25-item) questionnaire and a standard instrument--the General Health Questionnaire (GHQ 28).

RESULTS

One hundred and fifty-two doctors responded, giving a response rate of 80%. Twenty-one (14%) doctors had a GHQ score of 4 and above, and were at increased likelihood of having a psychological disorder. Fifty-four per cent were either very dissatisfied or dissatisfied with their jobs, while 30% were very satisfied or satisfied with their jobs. The proportion of doctors with GHQ scores of 4 or above increased with the level of dissatisfaction although this was not statistically significant. The crude odds ratio of psychological disorder (GHQ score 4 and above) in dissatisfied respondents compared to satisfied respondents was 2.2 (95% confidence interval = 0.6-8.4). The odds ratio remained non-significant after controlling for the presence of adolescent children, stress outside work and length of service.

CONCLUSION

This study showed a high rate of job dissatisfaction among Nigerian doctors compared to their European and North American counterparts. The reason for this is not altogether obvious. Further research is needed to determine the causes of job dissatisfaction amongst Nigerian doctors.

Towards malaria control: the knowledge of health care providers about mosquito and malaria transmission

OBJECTIVE

To find out how much health care providers know about the transmission of malaria and the vector.

DESIGN

A cross sectional study was carried out using a predesigned questionnaire which was self administered by the student to collect the necessary information for analysis. Live samples of mosquito larvae, drawn larva and adults were provided for the subjects to identify to assess their knowledge.

SETTING

The University of Benin Teaching Hospital and the School of Health Technology.

SUBJECTS

254 randomly selected Community Health Officers in training at the University of Benin Teaching Hospital and the School of Health Technology in Benin City, Edo State, Nigeria.

MAIN OUTCOME MEASURES

Many of the students had no knowledge of the subject. The School's authorities were encouraged to include field practicals in their curriculum to improve the students' knowledge on mosquitoes and malaria transmission.

RESULTS

Only (26.8%) and (18.1%) of the subjects could identify both drawn and live larvae respectively while (25.2%) identified the adult mosquito correctly. All the respondents knew that the mosquito transmits diseases but quite a few knew the diseases transmitted included malaria (55.3%), yellow fever (16.0%) and elephantiasis (10.7%) respectively.

CONCLUSION

The knowledge of the students on the biology of mosquitoes and their role as the malaria vector was poor. The education of the subject on this important endemic disease is advocated to improve the quality of life of citizens and promote the primary Health Care Programme in Nigeria.

Towards malaria control in Nigeria: a qualitative study on the population of mosquitoes

Malaria is still highly prevalent in many tropical countries and this disease can only survive in areas where mosquitoes and infected human populations are high. Relevant information on the species of mosquitoes, their habitats and their population are important in planning preventative strategies in the control of malaria, hence this study. Mosquito species and their habitats were investigated in both high and low density areas of Benin City, Edo State, Nigeria. The results showed that Culex pipiens fatigans, Aedes aegypti, Aedes albopictus, Anopheles gambiae and Culex trigripes were the commonest mosquitoes found in Benin City. Among the habitats studied, containers and gutters had the highest population of mosquitoes. The serious public health implications of these various species of mosquitoes is the possibility of outbreaks of infectious diseases like yellow fever, dengue, which some of these mosquitoes are known to transmit. Malaria, though endemic, is also important because of its associated high morbidity and mortality rates. This study provides some useful information on the habitats and species of mosquitoes found in Benin City. Follow-up studies are being carried out by the authors on quantitative studies on the population of these species of mosquitoes, the dissolved elements present in the different habitats that could promote or inhibit the breeding of mosquitoes, and KAP surveys on mosquitoes and malaria among the Benin populace. It is hoped that such comprehensive data would be very useful in planning effective preventative strategies in the control of malaria in Benin City.

Knowledge, attitude and practice towards AIDS among civil servants in Nigeria

A study about knowledge, attitude and practice (KAP) towards AIDS was carried out amongst 340 randomly selected workers in Benin City in Nigeria using self-administered questionnaires. Three hundred and thirty (97.1%) of the workers were aware of the existence of AIDS but only 50 (14.7%) had the correct knowledge of the aetiology of AIDS, and of these 29 (8.5%) had tertiary education. Generally there was a good knowledge of the different routes of transmission except for the erroneous belief by a high number, 125 (36.8%) and 129 (37.9%) that it could be transmitted through sharing of utensils and causal kissing respectively. The attitude to AIDS sufferers is poor and 156 (45.9%) actually think they should be ostracized. Twenty-one (6.2%) of the respondents still keep multiple sexual partners while 142 (41.8%) would willingly use the condom for safer sex. There is therefore the need for an intensive and effective health education campaign to combat this deadly disease in the country.

Anaemia in pregnancy

Four hundred and thirty-five pregnant women attending the antenatal clinic at the University of Benin Teaching Hospital (UBTH) were investigated. The ages of the women ranged from 16-42 years with an average haemoglobin level of 10.52 gms%. The prevalence rate of anaemia among these antenatals was 20.7% and 2.8% had severe anaemia. This shows that anaemia is still a problem in Nigeria. Mothers in the age groups 10-19 years and 30-39 years constituted higher percentages of anaemic cases compared to the other age groups. The percentages of the pregnant women who were anaemic were also higher in social-classes IV and V contributing 27.6% and 21.9% respectively. One hundred and eight (49.4%) of the pregnant women booked for antenatal care during the 3rd trimester and the percentage of anaemia was highest in this group 54 (28.4%). About half of the mothers who were para 5+ were anaemic. Nutrition education components of the antenatal care should be intensified. In this regard, mothers should be encouraged to participate actively in income generating activities to improve their economic and nutritional status. Also, during the health education activities in the clinics, the importance of family planning and early bookings for antenatal care need to be stressed.

Schistosoma haematobium in rural school children in Nigeria

A survey of Schistosoma haematobium infection was carried out in 722 rural school children in Emu, Edo State of Nigeria. The ages of the children ranged from 5-19 years with those between the age-group 10-14 years constituting the highest percentage 317 (43.9%). There were more males 383 (53.0%) than females 339 (47.0%) in the study population. Urine analysis of these children showed that 254 (35.2%) of them were excreting Schistosoma haematobium ova and of these 196 (27.2%) had haematuria. The prevalence of the disease was highest in the younger children with 43.1% for haematuria and 55.3% for S. haematobium ova among the age-group 5-9 years. The corresponding figures were 21.4% and 24.7% for age-group 10-14 years and 14.9% and 27.7% for 15-19 years old children. The sex-specific prevalences of haematuria and Schistosoma haematobium ova were higher for females than for the males.

Morbidity and mortality patterns among malnourished children in Benin City, Nigeria

A morbidity and mortality survey was carried out amongst 196 malnourished children attending the Nutrition Unit, Ministry of Health, Owina Street, Benin City, Nigeria, between January 1971 and December 1973 (morbidity) and also between October 1974 and March 1975 (mortality). Gastrointestinal disorders (77, 39.3%) and measles (67, 34.2%) predominated in both morbidity and mortality patterns. In all, 30 (15.3%) of these children died, and kwashiorkor contributed 14 (46.7%) of this total. The age group of the majority of the sick and dead children was 1-2 years, which is within the traditional weaning age of Nigerian children. Immunization of children and their mothers at appropriate times, coupled with sound nutrition and health education to their mothers, will go a long way towards ensuring the good health and welfare of our children.

Pregnancy among schoolgirls in Nigeria

A study was made of 127 cases of schoolgirls with pregnancy-related problems who were admitted into three of the major hospitals in Benin City, Nigeria, over a 10-month period. The findings suggest that schoolgirl pregnancy in Benin City is found chiefly among teenage girls during the early years of secondary school. Lack of experience in family life and knowledge about contraceptive methods, coupled with poor parental control, are the major factors that put the young adolescent at risk of unwanted pregnancy. School drop-out and complications of illegally induced abortion are the most frequent and worst consequences of schoolgirl pregnancies. The provision of formal education on family life and effective and easily accessible family planning methods for the adolescent population are suggested as a means to reduce the rate of schoolgirl pregnancy.