Infectious complications in patients with Hodgkin's lymphoma of unfavourable prognosis]

Analysis of the infectious complications in 48 primary patients with Hodgkin's lymphoma of infavourable prognosis recorded within 1998-2006 is presented. Respiratory tract infections, mucositis and Herpes infection were stated in 43, 24 and 22% of the patients respectively. Bacterial infections predominated (61% of the patients), then followed viral and fungal infections (26 and 43% of the patients respectively). Associations of bacterial and fungal infections were most frequent (50% of the patients). Associations of bacterial and viral infections were less frequent (30%) and fungal and viral infection associations were revealed in 20% of the patients. The structure of the bacterial, viral and fungal infections and the dynamics of the pathogen spectra are presented. The results of the analysis showed that the infections were frequent complications in such patients and could be due not only to obligate but also to opportunistic pathogens, that requires design of the diagnostic algorithm for prediction of the complication process and outcome, thus improving the remote results of the treatment.     

Bleeding complications after pacemaker or cardioverter-defibrillator implantation in patients receiving dual antiplatelet therapy

Introduction. The aim of the study was to define the prevalence of bleeding events in patients treated with dual antiplatelet therapy (DAT) in comparison with patients receiving only acetylsalicylic acid (ASA). Methods. Prospective two-centre registry of all first implantations of pacemakers, cardioverter-defibrillators and cardiac resynchronisation therapy units in patients receiving ASA (n=194) or DAT (n=53). Results. Bleeding complications were detected in 27 (16.2%) patients in the ASA group and in 13 (24.5%) in the DAT group. There was no significant difference in the overall number of complications between the patients receiving ASA or DAT, although there was a trend towards a higher incidence of overall complication rates in the DAT group (p=0.0637). The incidence of major complications (requiring blood transfusion or surgical intervention or prolonging hospital stay) was low (3.6%), and similar in both groups (3.6 and 3.8% respectively, ns). The rate of minor complications (subcutaneous haematomas) was greater in the DAT group (p=0.015). Conclusions. Treatment with DAT does not increase the risk of major bleeding complications as a result of device implantation; however, minor complications are significantly more frequent. Our results suggest that DAT could be continued in patients undergoing device implantation with a moderate risk of bleeding complications. (Neth Heart J 2010;18:230-5.)     

Acute drug poisoning in the adult

In a prospective study of 349 patients with acute poisoning treated at The Montreal General Hospital in 1972 benzodiazepines and non-barbiturate hypnotics were found to be the most frequent putative drugs. Of the 108 patients admitted to hospital 37% had taken an overdose of a drug prescribed for them by their psychiatrist or other physician; 48% had formerly taken an overdose of drugs and 44% had had previous psychiatric treatment. Unconsciousness, respiratory depression, metabolic acidosis and acidemia, and hypokalemia were the most frequent clinical abnormalities observed. Treatment was supportive. There were six deaths. The average duration of coma was short; only five surviving patients remained unconscious for more than 24 hours. Respiratory complications were frequent.It is recommended that more attention be paid to recognizing patients whose behaviour pattern might include such an impulsive gesture, and that alternatives be found for barbiturate and non-barbiturate hypnotics.     

Expression and distribution of aphidicolin-induced fragile sites in chronic myeloid leukaemia, acute lymphocytic leukaemia and acute myeloid leukaemia

New information is revealed concerning the frequency of expression and distribution of aphidicolin-induced fragile sites in eight leukaemic patients, namely, four chronic myeloid leukaemic patients (CML), three acute lymphocytic leukaemic (ALL) patients, and one acute myeloid leukaemic (AML) patient. The cytogenetic data demonstrate a statistically significant (p less than 10(-6] increase in the frequency of aphidicolin-induced fragile sites in seven of the eight leukaemic patients compared with healthy age-matched and sex-matched controls. The chromosomal band locations of the aphidicolin-induced fragile sites from 400 metaphase spreads of these leukaemic patients reveal a nonrandom distribution in the karyotype. Some aphidicolin-induced fragile sites in these leukaemic patients were located at chromosome bands known to be induced specifically by folic acid, distamycin A, bromodeoxyuridine or azacytidine. The cross-induction of fragile sites in the leukaemic patients may be indicative of shared molecular homology in the sequence composition of nonrandom chromosomal DNA.     

Correlation of clinical and anatomical findings in childhood meningitis]

Clinical and anatomical findings of 76 prophylactically not irradiated children with acute leukaemia were compared. In the group of 17 children (22%) with clinically manifest symptoms of CNS involvement in the course of the illness leukaemic infiltrates were identified in the CNS at the autopsy and during histopathological examinations even in 70% in spite of clinical healing and normalization of the cerebrospinal fluid finding. In children who had either no clinical symptoms of CNS leukaemia (42 children) or only terminal symptoms in the last 24 hours of their life (17 children) leukaemic infiltrations were found in 25.4% of the cases. Non-myeloid types showed 44.5% of histopathological changes, myeloid types 22.7%. Clinical main symptoms and anatomical findings were correlated to the corresponding groups of patients and typical illustrations were added.     

Acute lymphoblastic leukemia: a study of 25 cases by scanning electron microscopy.

Cells from 25 cases of acute lymphoblastic leukemia (ALL) were studied under the scanning electron microscope (SEM). In 24 of the cases, the vast majority of circulating leukaemic cells had few microvilli. Villous cells were rarely encountered and prominent ridge-like profiles and ruffled membranes were not seen. Only six cases were studied by immunological techniques and four of the cases were of the null type while in two the cells bore detectable T-markers. It seems that ALL is almost always associated with the presence of cells with few microvilli in the peripheral circulation, differing in this respect from most cases of CLL. Although circulating leukaemic lymphocytes with few microvilli are sometimes seen in CLL, the most frequent cell type encountered is a more villous lymphocyte. Differences between leukaemic cells from patients with ALL, CLL and non-lymphoblastic leukaemias are discussed. It appears that SEM may help to distinguish lymphoblastic and nonlymphoblastic leukaemic cells in many instances and can be used as a useful adjunct to other modes of microscopy in the diagnosis of acute leukaemia.     

Stem cell and kinase activity-independent pathway in resistance of leukaemia to BCR-ABL kinase inhibitors

BCR-ABL tyrosine kinase inhibitors, such as imatinib (Gleevec) are highly effective in treating human Philadelphia chromosome-positive (Ph+) chronic myeloid leukaemia (CML) in chronic phase but not in terminal acute phase; acquired drug resistance caused mainly by the development of BCR-ABL kinase domain mutations prevents cure of the leukaemia. In addition, imatinib is ineffective in treating Ph+ B-cell acute lymphoblastic leukaemia (B-ALL) and CML blast crisis, even in the absence of the kinase domain mutations. This type of drug resistance that is unrelated to BCR-ABL kinase domain mutations is caused by the insensitivity of leukaemic stem cells to kinase inhibitors such as imatinib and dasatinib, and by activation of a newly-identified signalling pathway involving SRC kinases that are independent of BCR-ABL kinase activity for activation. This SRC pathway is essential for leukaemic cells to survive imatinib treatment and for CML transition to lymphoid blast crisis. Apart from BCR-ABL and SRC kinases, stem cell pathways must also be targeted for curative therapy of Ph+ leukaemia.     

Blast Cells with Monoclonal Surface Immunoglobulin in Two Cases of Acute Blast Crisis Supervening on Chronic Lymphocytic Leukaemia

Acute blast crisis occurred in two patients with previously well-confirmed chronic lymphocytic leukaemia. The finding by direct immunofluorescence of membrane-bound monoclonal immunoglobulins on the surface of the blast cells showed that they were related to B cells in the same way as the proliferating lymphocytes in most patients with chronic lymphocytic leukaemia. In one patient the surface monoclonal IgM detected on both the lymphocytes and the blast cells had the same rheumatoid antibody activity, supporting the concept that the leukaemic cells found during the acute and chronic phases of the disease originated from the same clone.     

Haematological complications in polycythaemia vera and thrombocythaemia patients treated with radiophosphorus (32P).

We have evaluated 230 patients with myeloproliferative disorders treated in the last 15 years with 32P. None of the patients affected by essential thrombocythaemia developed haematological complications. In the larger group of polycythaemia patients (214 subjects) only 38 patients (17 males and 21 females) developed complications. 60.5% of these subjects had a minor complications: 1.8% showed a thrombocytopenia lower than 100.10e9/lt, 2.3% anaemia with Hb lower than 10 g%, 2.6% leukopenia lower than 40.10e9/lt and 2.3% a pancytopenia. All these complications were transient and eventually treated with limited blood transfusions. We could not identify a correlation between the dose used and the development of such complications. We noted only that the occurrence of anaemia, given a similar dose, was more frequent in females. Only 7% of all patients presented a major complication after 32P administration. In this case too, there was no correlation with the dose administered. Myelofibrosis and chronic myeloid leukaemia resulted to be the more frequent complication (9 out of 15) but we could not clarify if they represented a natural evolution of polycythaemia vera or were due to the treatment with 32P. Acute leukaemia developed only in 5 patients and again we could not recognized a correlation with the dose administered. Moreover, the time from the diagnosis of polycythaemia vera the onset of acute leukaemia ranged widely. 32P has a definite effect on the prevention of thrombotic and haemorrhagic complications in polycythaemia patients since it prolongs their life but it also increases the incidence of acute leukaemia.     

Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator for Ischemic Stroke Patients over 80 Years Old: The Fukuoka Stroke Registry

Objectives

The benefit of intravenous recombinant tissue plasminogen activator (rt-PA) therapy for very old patients with acute ischemic stroke remains unclear. The aim of this study was to elucidate the efficacy and safety of intravenous rt-PA therapy for patients over 80 years old.

Methods

Of 13,521 stroke patients registered in the Fukuoka Stroke Registry in Japan from June 1999 to February 2013, 953 ischemic stroke patients who were over 80 years old, hospitalized within 3 h of onset, and not treated with endovascular therapy were included in this study. Among them, 153 patients were treated with intravenous rt-PA (0.6 mg/kg). For propensity score (PS)-matched case-control analysis, 148 patients treated with rt-PA and 148 PS-matched patients without rt-PA therapy were selected by 1∶1 matching with propensity for using rt-PA. Clinical outcomes were neurological improvement, good functional outcome at discharge, in-hospital mortality, and hemorrhagic complications (any intracranial hemorrhage [ICH], symptomatic ICH, and gastrointestinal bleeding).

Results

In the full cohort of 953 patients, rt-PA use was associated positively with neurological improvement and good functional outcome, and negatively with in-hospital mortality after adjustment for multiple confounding factors. In PS-matched case-control analysis, patients treated with rt-PA were still at lower risk for unfavorable clinical outcomes than non-treated patients (neurological improvement, odds ratio 2.67, 95% confidence interval 1.61–4.40; good functional outcome, odds ratio 2.23, 95% confidence interval 1.16–4.29; in-hospital mortality, odds ratio 0.30, 95% confidence interval 0.13–0.65). There was no significant association between rt-PA use and risk of hemorrhagic complications in the full and PS-matched cohorts.

Conclusions

Intravenous rt-PA therapy was associated with improved clinical outcomes without significant increase in risk of hemorrhagic complications in very old patients (aged>80 years) with acute ischemic stroke.     

Influence of cryopreservation on human leukaemic clonogenic cells (CFU-L).

The biological and clinical significance of growth characteristics of leukaemic clonogenic cells (CFU-L) cultured from patients has been the subject of many studies. While some investigators collect leukaemic cells in large numbers from blood of untreated patients and store them in a frozen state before use in experiment, others study fresh cells. Since cryopreservation may alter the proliferation and differentiation of CFU-L, we have followed its influence and that of DMSO, used as protective agent and known to be an inducer of differentiation in leukaemic blasts, on the clonogenicity of peripheral blast cells from patients with AML and CML in blast crisis. Our data show that a short incubation with 7.5% DMSO (with or without cryopreservation) induced increase in the clonogenicity and proliferation rate of CFU-L (without morphological changes). The possible causes of these effects as well as the question of aggressivity of leukaemic blasts after the short incubation with 7.5% DMSO are discussed.     

Perioperative cardiovascular complications versus perioperative bleeding in consecutive patients with known cardiac disease undergoing non-cardiac surgery. Focus on antithrombotic medication. The PRAGUE-14 registry

Background

Interruption of antithrombotic treatment before surgery may prevent bleeding, but at the price of increasing cardiovascular complications. This prospective study analysed the impact of antithrombotic therapy interruption on outcomes in non-selected surgical patients with known cardiovascular disease (CVD).

Methods

All 1200 consecutive patients (age 74.2 ± 10.2 years) undergoing major non-cardiac surgery (37.4 % acute, 61.4 % elective) during a period of 2.5 years while having at least one CVD were enrolled. Details on medication, bleeding, cardiovascular complications and cause of death were registered.

Results

In-hospital mortality was 3.9 % (versus 0.9 % mortality among 17,740 patients without CVD). Cardiovascular complications occurred in 91 (7.6 %) patients (with 37.4 % case fatality). Perioperative bleeding occurred in 160 (13.3 %) patients and was fatal in 2 (1.2 % case fatality). Multivariate analysis revealed age, preoperative anaemia, history of chronic heart failure, acute surgery and general anaesthesia predictive of cardiovascular complications. For bleeding complications multivariate analysis found warfarin use in the last 3 days, history of hypertension and general anaesthesia as independent predictive factors. Aspirin interruption before surgery was not predictive for either cardiovascular or for bleeding complications.

Conclusions

Perioperative cardiovascular complications in these high-risk elderly all-comer surgical patients with known cardiovascular disease are relatively rare, but once they occur, the case fatality is high. Perioperative bleeding complications are more frequent, but their case fatality is extremely low. Patterns of interruption of chronic aspirin therapy before major non-cardiac surgery are not predictive for perioperative complications (neither cardiovascular, nor bleeding). Simple baseline clinical factors are better predictors of outcomes than antithrombotic drug interruption patterns.     

Phacoemulsification, vitrectomy and the implantation of an intraocular lens in diabetic patients

The purpose of this study was to evaluate results of combined phacoemulsification, intraocular lens implantation and pars plana vitrectomy in patients with advanced diabetic retinopathy. We retrospectively evaluated postoperative outcomes and complications in 102 eyes of 102 patients who underwent a combined procedure. All patients had a visually significant cataract. Forty two patients had vitreous hemorrhage and mild proliferative diabetic retinopathy. Sixty patients had a mild tractional retinal detachment. The median follow up was 14 months (range 6-36 months). 80% of patients had an increase of visual acuity of at least 2 Snellen lines. The most frequent early postoperative complication was elevated intraocular pressure, followed by mild fibrinous reaction. The most frequent late postoperative complication was the presence of posterior synechia, followed by glaucoma. Eleven patients required a repeated pars plana vitrectomy. Combined phacoemulsification, posterior chamber intraocular lens implantation and pars plana vitrectomy can be successfully performed in selected diabetic patients with favorable postoperative outcome.     

Bacterial urinary infections in acute leukemia

Hundred thirty patients with the acute leukemia were examined. Bacterial urinary infections were detected in 34% of the examined patients, statistically more frequently in women. Decreased response to the inflammatory process is noted in leukemic patients with the urinary infections. Non-stable clinical symptoms, multiple changes in the normal laboratory findings in both the urine and blood serum may suggest urinary infection which should be confirmed by the urinary cultures. The most frequent causes of the urinary infections are various species of gram-negative bacteria of Enterobacteriaceae similarly to non-leukemic patients with urinary infections. Reinfections and superinfections were seen in some patients but the latter were more frequent in the acute lymphoblastic leukemia.     

Humoral indices of the inflammatory process in psoriasis]

Immune complexes were determined in 104 patients with psoriasis, aged between 19 and 55 years. Duration of the disease, extension of lesions, and effects of infections preceding skin eruptions were considered. The studies showed the activation of immunological mechanism in psoriasis manifested by the increase in IgG and IgA levels, unchanged IgM levels, significantly more frequent negative values of IgD, significant increase in complement C4 component levels in all forms of the disease, and C3 activation in the acute and generalized chronic form. A significant increase in alpha 2 Mg was noted independently of the evolution and extension of skin lesions. An increase in alpha 1 AT was noted only in the initial phase of skin eruptions. An increase in Hp, Cr, CRP, and CIC was noted only during exacerbations. CIC were noted most frequently in postinfection psoriasis.     

TdT expression in acute myeloid leukaemia. Haemopoietic immaturity or maturational asynchrony?

A total of 412 cases of acute leukaemia were examined for the presence of nuclear terminal deoxynucleotidyl transferase (TdT) by indirect immunofluorescence. Of the 129 cases of acute myeloblastic leukaemia (AML FAB groups M1/M2) examined, 18% (n = 23) had significant proportions (greater than 10%) of TdT-positive blasts. Although most of these AML cases (n = 18) were of poorly differentiated (M1) type; 5 cases of AML showing features of granulocytic differentiation (M2) were also found to be TdT-positive. Even though TdT was generally more strongly expressed in the M1 group and associated with other markers of myeloid immaturity (Ia positive and lack of chloroacetate esterase), there was no inverse relationship with Sudan black or myeloperoxidase activity. In addition, although the proportion of AML-M1 cases with increased TdT-positive cells was slightly higher (18/95, 19%) than for the AML-M2 group (5/34, 15%) the results suggest that the presence of nuclear TdT in leukaemic myeloblasts may not only reflect cellular immaturity but may also be due to maturational asynchrony in otherwise well-differentiated blasts.     

Value of anti-infective chemoprophylaxis in primary systemic vasculitis: what is the evidence?

Although infections are a major concern in patients with primary systemic vasculitis, actual knowledge about risk factors and evidence concerning the use of anti-infective prophylaxis from clinical trials are scarce. The use of high dose glucocorticoids and cyclophosphamide pose a definite risk for infections. Bacterial infections are among the most frequent causes of death, with Staphylococcus aureus being the most common isolate. Concerning viral infections, cytomegalovirus and varicella-zoster virus reactivation represent the most frequent complications. The only prophylactic measure that is widely accepted is trimethoprim/sulfamethoxazole to avoid Pneumocystis jiroveci pneumonia in small vessel vasculitis patients with generalised disease receiving therapy for induction of remission.     

Allogeneic bone marrow transplantation for leukaemia and aplastic anaemia. Results of the Leipzig BMT Group

In acute leukaemias there was a stable plateau in the survival curve at 45% after two years if grafted in first complete remission (n = 20) but only 13% of the patients are disease-free alive if grafted in a more advanced stage of the disease (n = 8). In 16 patients transplanted for chronic myeloid leukaemia the overall survival is 40%, in cases with graft-versus-host disease (GVHD) prevention by cyclosporine survival rate could be improved. Only 8 patients with severe aplastic anaemia, partially in low performance status were able to be transplanted; three died of infections, another by acute GVHD. The fatal complications in our study characterize the international well-known major problems in BMT: GVHD, interstitial pneumonitis, infections, graft failure in aplastic anaemia and recurrence of leukaemia, especially in more advanced leukaemia stage.     

Arterial chemoembolization in the combined treatment of malignant tumors of the tongue and maxilla: preliminary results

The authors made a clinical evaluation of the efficiency of regional bolus chemotherapy and embolization as a stage of combined therapy in patients with inoperable cancer of the tongue and maxilla complicated by bleeding episodes. Carotid angiography by attempting to make chemoembolization was performed in 15 patients. The procedure could not be done in full in 2 (13%) patients due to transient vascular and neurological disorders. The remaining 13 (87%) patients had successful chemoembolization of tumor-supplying arteries with 5-fluorouracil (700 mg/m2) and methotrexate (40 mg/m2) in combination with finely cut hemostatic sponge and fragments of metallic spirals (n = 12) or regional bolus injection of a cytostatic (n = 1) without arterial occlusion. After embolization, bleeding episodes ceased in all the patients. Full (n = 1) and partial (n = 6) responses to treatment or stabilization of the process (n = 5) were noted in 12 (92%) cases, progression was only in 1 (8%) case. The study suggests that chemoembolization of the branches of the external carotid artery in patients with cancer of the tongue and maxilla contributes to the arrest of chronic tumorous bleeding and to the reduction in the risk for acute A combination of systemic multidrug therapy, radiation therapy, and chemoembolization stabilizes a tumorous process in most patients.     

Leucostasis, an underestimated cause of death in leukaemia

Massive sludging of leukaemic cells in blood vessels is a frequent and often lethal complication of leukaemia. In a retrospective clinicopathological study on the causes of death in 52 patients with acute myeloid leukaemia and myeloproliferative disease, pulmonary leucostasis was found in 40% of the patients. In many of these patients the vessels of the heart, brain and testes were also involved. In search for signs and symptoms specific for leucostasis, the clinical records of the 21 patients with leucostasis (the study group) were compared to those of 20 patients without leucostasis (the control group). Dysfunction of the organs most affected by leucostasis, namely lungs, heart and brain, was found more often in the study group than in the controls, but the combination of unexplained fever with cardiopulmonary and/or central nervous system failure occurred almost exclusively and in half of the patients with leucostasis. Leucostasis occurs predominantly, but not exclusively, in patients with high leucocyte counts, and especially, but again not exclusively, when the leucocyte counts rise sharply.