A retrospective study of intravenous pentamidine for Pneumocystis jirovecii pneumonia prophylaxis in adult patients with hematologic malignancies-its utility during respiratory virus pandemics

OBJECTIVES

In hematology, prophylaxis for Pneumocystis jirovecii pneumonia (PCP) is recommended for patients undergoing hematopoietic stem cell transplantation and in selected categories of intensive chemotherapy for hematologic malignancies. Trimethoprim-sulfamethoxazole (TMP-SMX) is the recommended first-line agent; however, its use is not straightforward. Inhaled pentamidine is the recommended second-line agent; however, aerosolized medications were discouraged during respiratory virus outbreaks, especially during the COVID-19 pandemic, in view of potential contamination risks. Intravenous (IV) pentamidine is a potential alternative agent. We evaluated the effectiveness and tolerability of IV pentamidine use for PCP prophylaxis in adult allogeneic hematopoietic stem cell transplantation recipients and patients with hematologic malignancies during COVID-19.

RESULTS

A total of 202 unique patients who received 239 courses of IV pentamidine, with a median of three doses received (1-29). The largest group of the patients (49.5%) who received IV pentamidine were undergoing or had received a hematopoietic stem cell transplant. The most common reason for not using TMP-SMX prophylaxis was cytopenia (34.7%). We have no patients who had breakthrough PCP infection while on IV pentamidine. None of the patients developed an infusion reaction or experienced adverse effects from IV pentamidine.

CONCLUSIONS

Pentamidine administered IV monthly is safe and effective.

A novel network pharmacology approach for leukaemia differentiation therapy using Mogrify®

Acute myeloid leukaemia (AML) is a rapidly fatal blood cancer that is characterised by the accumulation of immature myeloid cells in the blood and bone marrow as a result of blocked differentiation. Methods which identify master transcriptional regulators of AML subtype-specific leukaemia cell states and their combinations could be critical for discovering novel differentiation-inducing therapies. In this proof-of-concept study, we demonstrate a novel utility of the Mogrify® algorithm in identifying combinations of transcription factors (TFs) and drugs, which recapitulate granulocytic differentiation of the NB4 acute promyelocytic leukaemia (APL) cell line, using two different approaches. In the first approach, Connectivity Map (CMAP) analysis of these TFs and their target networks outperformed standard approaches, retrieving ATRA as the top hit. We identify dimaprit and mebendazole as a drug combination which induces myeloid differentiation. In the second approach, we show that genetic manipulation of specific Mogrify®-identified TFs (MYC and IRF1) leads to co-operative induction of APL differentiation, as does pharmacological targeting of these TFs using currently available compounds. We also show that loss of IRF1 blunts ATRA-mediated differentiation, and that MYC represses IRF1 expression through recruitment of PML-RARα, the driver fusion oncoprotein in APL, to the IRF1 promoter. Finally, we demonstrate that these drug combinations can also induce differentiation of primary patient-derived APL cells, and highlight the potential of targeting MYC and IRF1 in high-risk APL. Thus, these results suggest that Mogrify® could be used for drug discovery or repositioning in leukaemia differentiation therapy for other subtypes of leukaemia or cancers.

The utility of voriconazole therapeutic drug monitoring in a multi-racial cohort in Southeast Asia

OBJECTIVES

Voriconazole serum concentration, which is affected by several factors, is associated with treatment response and toxicity. There is paucity of data on voriconazole therapeutic drug monitoring (TDM) among Southeast Asians, who exhibit a higher prevalence of CYP2C19-poor metabolisers compared with Caucasians and East Asians. Hence, there are concerns for higher risk of voriconazole accumulation and toxicity. We aim to determine the utility of voriconazole TDM through establishing: (1) proportion of patients achieving therapeutic troughs without dose adjustments; (2) characterisation of patients with sub-therapeutic, therapeutic and supra-therapeutic levels; (3) appropriate dose titrations/dose required for therapeutic troughs; (4) correlation between troughs and adverse events, treatment response/fungal breakthrough.

PATIENTS AND METHODS

A single-centre retrospective analysis of data from adults (≥21 years old) with ≥1 voriconazole trough measured at Singapore General Hospital from 2015 to 2017 was performed.

RESULTS

Thirty-two patients (45.7%) among 70 patients achieved therapeutic troughs (defined as 2.0-5.5 mg/L) without dose adjustments. Eleven patients (15.7%) experienced hepatotoxicity (troughs 0.5 to >7.5 mg/L). Neurotoxicity occurred in three patients (4.3%) (troughs ≥6.7 mg/L) and all patients had symptom resolution upon dose reduction. Treatment failure of invasive fungal infection appeared less in patients with therapeutic troughs compared with sub-therapeutic troughs (11.4% vs. 14.2%). Two patients experienced treatment failure despite supra-therapeutic voriconazole troughs.

CONCLUSIONS

TDM should be implemented due to significant unpredictability in dose exposure. TDM can reduce unnecessary switches to alternatives due to intolerability and rule in the possibility of resistant organisms in the event of treatment failure despite therapeutic troughs, alerting clinicians to switch to alternatives promptly.

2107. Azole Therapeutic Drug Monitoring (TDM) in a Multiracial Cohort with Varied Pharmacogenetics

Background

Voriconazole (VOR) and posaconazole (POS) exhibit wide pharmacokinetic variability. Various factors including race and genetic polymorphisms are at play and this may affect treatment response. We aim to evaluate the utility of VOR/POS TDM among Southeast Asians that are predominantly intermediate/poor VOR metabolizers.

Methods

All adults with VOR/POS TDM performed at our institution from 2015 to 2018 were included. We determined proportion of patients and doses required to achieve TDM targets [(2 – 5.5 mg/L (VOR) or ≥ 0.7 and ≥ 1.0 mg/L (POS prophylaxis and treatment respectively)], and correlate levels with treatment efficacy and safety.

Results

VOR/POS TDM was performed mostly among patients with hematological malignancy or solid-organ transplant (146/174, 83.9%). Less than half (32/70, 45.7%) of patients on VOR achieved target—18 (25.7%) were < 2 mg/L while 20 (28.5%) had levels > 5.5 mg/L. Doses required to achieve TDM target ranged from 1.9–11.4 mg/kg/day. Drug interactions, critically ill state and change in drug formulation were major causes of intra-patient variability. One-fifth (n = 14) experienced transaminitis; corresponding VOR trough levels were 0.5–> 7.5 mg/L. Neurotoxicity was also seen in 3 (4.3%) patients—all 3 had VOR trough ≥ 6.7 mg/L and saw symptom resolution upon dose reduction. There appears to be no association between the achievement of TDM targets and response rates. Majority (81/104, 77.9%) of patients on POS achieved TDM targets. Patients prescribed POS tablet were significantly more likely to attain targets compared with suspension 600 mg/day [19/26 (73.0%) vs. 27/62 (43.5%), P < 0.05] and 800 mg/day [17/26 (65.3%) vs. 4/16 (25.0%), P < 0.05)]. Of 23 with sub-therapeutic levels, 19 (82.6%) responded to dose increase and/or change in acid-reducing agents. Breakthrough infection occurred despite troughs ≥ 0.7 mg/L [5/42 (11.9%) vs. 2/40 (5.0%) when < 0.7 mg/L (P = 0.3)]. Treatment failure was observed in 2 patients (troughs > 1.0 mg/L).

Conclusion

VOR/POS TDM should be implemented in Southeast Asians due to significant unpredictability in dose exposure and potential to avoid need for switch to alternative anti-fungals due to intolerability. Higher POS trough cutoff may be required for effective anti-fungal prophylaxis.

Disclosures

All authors: No reported disclosures.

Chromosomal microarray analysis is superior in identifying cryptic aberrations in patients with acute lymphoblastic leukemia at diagnosis/relapse as a single assay

INTRODUCTION

Conventional cytogenetics (CC) is important in diagnosis, therapy, monitoring of post-transplant bone marrow, and prognosis assessment of acute lymphoblastic leukemia (ALL). However, due to the nature of ALL, CC often encounters difficulties of complex karyotype, poor chromosome morphology, low mitotic index, or normal cells dividing only. In contrast, chromosomal microarray analysis (CMA) showed a specificity >99% and a sensitivity of 100% in chronic lymphocytic leukemia (CLL) patients. Here, we report our experience with CMA on adult ALL patients.

METHODS

Thirty-three bone marrow/blood samples from ALL patients (aged 18-79 years, median 44) at diagnosis/relapse, analyzed by CC and/or fluorescence in situ hybridization (FISH), were recruited. Chromosomal microarray analysis results were compared with CC. Fluorescence in situ hybridization analysis, if available, was applied when there was a discrepancy.

RESULTS

Copy-neutral loss-of-heterozygosity (CN-LOH) was found in 8 cases (24.2%). Only CN-LOH at 9p was recurrent (3 cases, 9.1%). Copy number alterations (CNAs) were detected in 6 of 9 cases (66.7%) with normal karyotypes, in 3 of 5 cases (60.0%) with sole "balanced" translocations, and in 18 of 19 cases (94.7%) with complex karyotypes. Common CNAs involved CDKN2A/2B (30.3%), IKZF1 (27.3%), PAX5 (9.1%), RB1 (9.1%), BTG1 (6.7%), and ETV6 (6.7%), which regulate cell cycle, B lymphopoiesis, or act as tumor suppressors in ALL. Copy number alteration detection rate by CMA was 81.8% (27 of 33 cases) as compared to 57.6% (19 of 33 cases) by CC.

CONCLUSION

Incorporation of CMA as a routine clinical test at the time of diagnosis/relapse, in conjunction with CC and/or FISH, is highly recommended.

Impact of an alternating first-line antibiotics strategy in febrile neutropenia

Background

Rising antibiotic resistance poses a challenge to the management of febrile neutropenia in patients with haematological malignancies receiving chemotherapy.

Aim

We studied an alternating first-line antibiotic strategy to determine its impact on all-cause mortality and bacteremia rates in patients with febrile neutropenia.

Methods

An alternating first-line antibiotic strategy was established in mid-2013. Data for 2012 (before strategy implementation) and 2014 (post-strategy implementation) were compared. Antibiotic Heterogeneity Index (AHI) for each of the two time-periods was also calculated.

Findings

There were 2012 admissions (26082 patient-days) in 2012 and 1843 admissions (24331 patient-days) in 2014. There was no significant difference in the baseline characteristics of patients in the two groups. The defined daily doses (DDD) of cefepime (CEF) fell while the DDD of piperacillin-tazobactam (PTZ) rose in 2014 compared with 2012. Vancomycin DDD fell in 2014. The AHI was 0.466 in 2012 and 0.582 in 2014. The difference in all-cause mortality was not statistically significant. There was no difference in rates of bacteremia with CEF-resistant, PTZ-resistant and carbapenem-resistant gram-negative organisms in the two groups. Rates of new cases of Methicillin-resistant Staphylococcus aureus (MRSA) were 2.38/1000 and 2.59/1000 patient-days in 2012 and 2014 respectively. Rates of new cases of Vancomycin-resistant Enterococcus (VRE) were 1.84/1000 and 1.81/1000 patient-days in 2012 and 2014 respectively. There was no Carbapenem-resistant Enterobacteriaceae (CRE) bacteremia in 2012 and 1 in 2014.

Conclusion

An alternating first-line antibiotic strategy resulted in an increase in antibiotic heterogeneity, without increasing mortality. There was also no significant increase in bacteremia rates.

Treatment of elderly patients with acute myeloid leukemia with azacitidine results in fewer hospitalization days and infective complications but similar survival compared with intensive chemotherapy

AIMS

Azacitidine has been shown to prolong overall survival (OS) compared with best supportive care in elderly patients with acute myeloid leukemia (AML) with low blast counts but it is unknown if azacitidine has a similar efficacy in patients with blast counts of >30%. It is also unknown if azacitidine is comparable to intensive chemotherapy in terms of survival and morbidity.

METHODS

Differences between the outcomes of elderly AML patients who received intensive chemotherapy, azacitidine-based therapy or best supportive care are studied in this retrospective review. Patients 60 years or older diagnosed with AML between January 2009 and June 2011 were included. Those who passed away within less than 2 weeks of diagnosis were excluded.

RESULTS

At a median follow-up of 7.2 months (range: 0.5-26.4 months), estimated median OS for patients who received azacitidine-based therapy was 9.8 months (range: 2.4-22.5 months) compared with 8.9 months (range: 0.9-26.4 months) for patients who received intensive chemotherapy (P=0.89). Compared with azacitidine-based therapy, intensive chemotherapy is associated with more inpatient days and episodes of febrile illness requiring inpatient stay or intravenous antibiotics.

CONCLUSIONS

Compared with intensive chemotherapy in elderly patients with AML, azacitidine-based therapy is associated with similar median survival but lower number of hospitalization days and infective episodes.

Leukaemic transformation of Philadelphia chromosome-negative myeloproliferative neoplasms: are Asian patients different?

BACKGROUND

Leukaemic transformation (LT) is rare in the natural history of Philadelphia(Ph) chromosome-negative myeloproliferative disorders (MPD), and has a dismal prognosis. Little literature is available on Asian patients.

AIMS

The aim of this study is to report a single institution experience of Asian patients who developed acute leukaemia after being diagnosed and treated for Ph chromosome-negative MPDs, and to compare the findings of this series with similar studies from the literature.

METHODS

Patients were recruited from the MPD registry of Singapore General Hospital, Department of Hematology. Clinical data including treatment modalities and duration of use in myeloproliferative phase, latency to LT, characteristics of leukaemia, chemotherapy administered and survival after LT were examined.

RESULTS

Over a 29-year period from 1980 to 2009, there were 22 Asian patients with LT of Ph chromosome-negative MPD of which four had polycythaemia vera (PV), nine had essential thrombocythaemia (ET), seven had myelofibrosis (MF) and two had unspecified MPD at diagnosis. Primary treatment modality was Hydroxyurea (HU) during MPD phase. Median latency to LT was 14 years for PV, 10 years for ET and 1 year for MF. Median age at LT diagnosis was 67.5 years. Nine patients had complex cytogenetics, with abnormalities of chromosomes 5 and 7 being common. Overall, median survival was 2 months after LT. Eight patients who received induction chemotherapy had a median survival of 2.5 months. Survival was independent of MPD type and treatment administered. None received stem cell transplantation.

CONCLUSIONS

LT of Ph chromosome-negative MPD is rare and uniformly fatal. Despite chemotherapy, survival was poor, and patients succumbed to refractory disease and infections. Asian patients did not have a more favourable outcome. It remains to be investigated whether upfront stem cell transplant may be a treatment option.

Should Chemotherapy Be Administered for Essential Thrombocythemia (ET) Patients with Leukemic Transformation?

Introduction:

Essential Thrombocythemia (ET) is a clonal myeloproliferative disease presenting predominantly with thrombocytosis. One of its rare complications is leukemic transformation (LT). Once leukemic transformation occurs, prognosis is dismal. We aim to determine the disease profile of LT in our ET patients and evaluate if chemotherapy can alter prognosis.

Methods:

Clinical data of all patients diagnosed and treated with ET from 1999 to 2008 in the Department of Hematology, Singapore General Hospital, were captured in the Myeloproliferative Disease(MPD) Registry. ET patients with LT were selected. Patient characteristics, disease profile, including ET treatment, duration from ET diagnosis to LT, prior myelofibrosis (MF) history, type of chemotherapy, response and eventual survival were recorded.

Results:

Two hundred and thirty ET patients were diagnosed and treated from 1999 to 2008. Six patients had LT (2.6%). All were Chinese. Four were females. Age range was 47–70 years (mean 61.2 years). Transformation to acute myeloid leukemia (AML) was seen in 5 patients, after a latency period of 3–28 years. Acute biphenotypic leukemia was diagnosed in 1 patient 4 years after ET diagnosis. All patients had received hydroxyurea. There was no prior evolution to MF. Complex cytogenetics were seen in all cases. Three patients treated conservatively died within 1 month. The other 3 patients did not go into durable complete remission despite chemotherapy and succumbed within 9 months.

Conclusions:

Leukemic transformation in ET, though rare, is associated with grave prognosis. Outcome with chemotherapy is dismal. More studies are needed to evaluate if alternative treatment can improve survival.

A patient with extramedullary acute myeloid leukaemia involving the brachial plexus: Case report and review of the literature

Extramedullary leukaemic involvement is not uncommon as part of the presentation in acute myeloid leukaemia (AML). However, infiltrative peripheral neuropathy due to AML was rarely reported. We report a case of extramedullary leukaemic infiltration of the brachial plexus in a patient with relapsed AML.

Use of Antibiotics in a Haematology Ward – An Audit

Introduction: Rising rates of antibiotic resistance prompted a review of antibiotic use policies hospitalwide. The Department of Haematology established a new set of consensus guidelines in 2002 for antibiotic use in febrile neutropenia. The aim of our study was to audit adherence to the guidelines established for febrile neutropenia in patients treated for haematologic malignancies. Materials and Methods: An antibiotic escalation pathway was developed by haematologists and infectious disease physicians. Adherence to the guidelines was audited. Patients with acute myeloid leukaemia (AML) or acute lymphocytic leukaemia (ALL) who had febrile neutropenia after chemotherapy were reviewed. The audit was performed by a retrospective review of casenotes. Results: Forty patients with 100 episodes of febrile neutropenia were surveyed. Thirty-two had AML, 7 had ALL and 1 had undifferentiated leukaemia. In 76% of episodes, fever developed within the first 14 days of neutropenia. In 31 episodes, cefepime was started as the first-line agent; hence, compliance with the first-line agent was 31%. Fever defervesced in 13 episodes. The most common reason for switching antibiotics was persistent fever. There were clinical indications for non-compliance with the use of the first-line agent in all cases. There were 3 deaths – none related to non-complianc e with or strict adherence to the guidelines. Four patients had proven fungal infections. Conclusions: Given the complex nature of the cases, compliance was reasonable, as there were valid reasons in all cases where the guidelines were not adhered to. Based on our findings, the guidelines could be simplified. Key words: Adherence, Chemotherapy, Febrile neutropenia, Leukaemia, Resistance

Use of antibiotics in a haematology ward--an audit

INTRODUCTION

Rising rates of antibiotic resistance prompted a review of antibiotic use policies hospitalwide. The Department of Haematology established a new set of consensus guidelines in 2002 for antibiotic use in febrile neutropenia. The aim of our study was to audit adherence to the guidelines established for febrile neutropenia in patients treated for haematologic malignancies.

MATERIALS AND METHODS

An antibiotic escalation pathway was developed by haematologists and infectious disease physicians. Adherence to the guidelines was audited. Patients with acute myeloid leukaemia (AML) or acute lymphocytic leukaemia (ALL) who had febrile neutropenia after chemotherapy were reviewed. The audit was performed by a retrospective review of casenotes.

RESULTS

Forty patients with 100 episodes of febrile neutropenia were surveyed. Thirty-two had AML, 7 had ALL and 1 had undifferentiated leukaemia. In 76% of episodes, fever developed within the first 14 days of neutropenia. In 31 episodes, cefepime was started as the first-line agent; hence, compliance with the first-line agent was 31%. Fever defervesced in 13 episodes. The most common reason for switching antibiotics was persistent fever. There were clinical indications for non-compliance with the use of the first-line agent in all cases. There were 3 deaths - none related to non-compliance with or strict adherence to the guidelines. Four patients had proven fungal infections.

CONCLUSIONS

Given the complex nature of the cases, compliance was reasonable, as there were valid reasons in all cases where the guidelines were not adhered to. Based on our findings, the guidelines could be simplified.

Acute biphenotypic leukemia arising in a patient with essential thrombocythemia

Acute leukemia is an uncommon complication of patients with essential thrombocythemia (ET). We describe a patient with ET, who transformed to acute biphenotypic leukemia 4 and 1/2 years after initial ET diagnosis. She had received hydroxyurea, anagrelide, and interferon, in different combinations and varying doses, before leukemic transformation. Acute biphenotypic leukemia was confirmed on bone marrow studies and immunophenotyping. Complete remission (CR) was achieved with induction chemotherapy for acute leukemia. This was followed with consolidation chemotherapy and the patient has remained in CR 9 months after initial induction chemotherapy. To our knowledge, this is a rare event of acute biphenotypic leukemic transformation of a patient with ET.

Successful treatment of primary granulocytic sarcoma by non-myeloablative stem cell transplant

Pre-leukemic granulocytic sarcoma (GS) may pose an initial diagnostic problem and its therapeutic approach has never been formally established. To our knowledge, non-myeloablative stem cell transplantation has been reported in cases of leukemic GS, but not in primary GS. We report a case of primary GS with extensive and aggressive presenting features and successfully treated with intensive chemotherapy followed by non-myeloablative allogeneic stem cell transplant. This resulted in complete remission with minimal complications. Our case demonstrates the potential of graft-vs.-tumour effect in the treatment of GS and suggests that non-myeloablative allogeneic stem cell transplant may be a feasible therapeutic approach for primary GS.

MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report

BACKGROUND/METHODS

Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died.

RESULTS

Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation.

CONCLUSIONS

MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.

Management of haematologic malignancies in pregnancy

INTRODUCTION

Malignancy complicates about 1 in 1000 pregnancies and is the second leading cause of death in women of reproductive age. Commonly diagnosed malignancies during pregnancy include breast cancer, cervical carcinoma, melanoma and lymphoma. Chemotherapy is usually necessary for optimal treatment, especially in patients with leukaemia and lymphoma. Concerns arise regarding the effects of imaging modalities in the pregnant cancer patients and the effects of chemotherapeutic agents on the developing fetus.

METHODS

A Medline search of articles describing haematologic malignancies in pregnant patients was performed. Particular attention was paid to the kind of malignancy, stage of pregnancy, the types and side effects of chemotherapeutic agents used and the outcome of the pregnancy.

RESULTS

There is no entirely safe cytotoxic drug or timing of exposure for the developing fetus. The administration of chemotherapy during pregnancy will not always produce a poor outcome. A pregnant cancer patient can also be safely and reasonably staged with imaging. Magnetic resonance imaging will most often be the procedure of choice as it does not use ionising radiation.

CONCLUSIONS

The management of each pregnant patient diagnosed with a malignancy has to be highly individualized and involves a multidisciplinary team of medical personnel. The patient and her family need counselling regarding the diagnosis, long-term prognosis, options of termination of pregnancy, choice of chemotherapeutic agents and their effects on the fetus and pregnancy.

Capacity building to improve women's health in rural China

The Women's Reproductive Health and Development Program (WRDHP) is an ambitious attempt to operationalize two important tenets of health development thinking within a rural reproductive health context. First, it is important for communities to participate in decisions about the services and programs that affect them. Secondly, the complex nature of healthcare is best addressed by intervention processes which call for a multi-functional approach to planning and coordination. In both planning and intervention approach, the WRHDP recognizes the social, cultural and economic realities that affect women's efforts to secure the health and well-being of themselves and their families. The focus of the WRHDP is on capacity-building within a rural reproductive health environment, in this case Yunnan Province in rural China. Rather than using international donor funding to provide a specific intervention, the WRDHP used Ford Foundation funding as a lever to encourage community investment in environmental resources that affect health, to improve the technical skills of individuals within the existing health bureaucracies, and to promote structural changes within existing health and development bureaucracies to support interagency collaboration and community empowerment within the region's health and development agencies. This article describes how the WRHDP created new methods for provincial and local agencies to overcome obstacles and work with one another to improve women's health. It also describes the processes used in the rural areas of Chengjiang and Luliang counties to assess local conditions and needs, and the supported and expanded local efforts in improving woman's reproductive and family health that resulted from the processes.

CT findings after uterine artery embolization

Asymptomatic uterine leiomyoma can be detected on routine computed tomography (CT) of the pelvis. Leiomyomas have been described as low attenuation masses that can disrupt the smooth contour of a normal uterus. Four women underwent uterine artery embolization for the treatment of uterine leiomyoma. CT findings include initial retention of contrast in fibroids the day of the procedure and central necrosis of the fibroid with subsequent cavitation as early as 1 month postprocedure.

Retrieval of a Greenfield IVC filter displaced to the right brachiocephalic vein

During insertion of a central venous sheath an inferior vena cava stainless steel Greenfield filter was dislodged to the right brachiocephalic vein without a free end. Successful retrieval was achieved by using a combination of a guidewire and a snare. Percutaneous retrieval of this vena cava filter is feasible with minimal risk using this method.

Percutaneous delivery of a heparin-impregnated collagen stent-graft in a porcine model of atherosclerotic disease

RATIONALE AND OBJECTIVES

To develop collagen stent-grafts impregnated with heparin to improve the biocompatibility of endovascular stents and to design a percutaneous delivery system for graft deployment in a swine model.

METHODS

Heparin-impregnated collagen stent-grafts were deployed, and follow-up angiograms were obtained every 15 minutes for 90 minutes to assess acute thromboses and again at 2 and 4 weeks afterward to assess patency. If stenosis or occlusion was detected at the 2-week evaluation, guidewire passage across the lesion was attempted and angioplasty was performed. If stenosis or occlusion was present at the 4-week evaluation, only guidewire passage was attempted; thereafter, the animals were killed and the stent-grafts were harvested and reviewed by a vascular pathologist.

RESULTS

Group A represents a feasibility study to optimize the deployment method applied in groups B and C. Fifteen of 17 stent-grafts were successfully deployed using this method. In group B, 89% of grafts were successfully deployed; 12% were patent at 2 weeks and none at 4 weeks. In group C, a 10-minute inflation time was added to the deployment procedure; 88% of grafts were successfully deployed and 28% were patent at 2 weeks and 14% at 4 weeks. Extensive luminal thrombosis and myointimal hyperplasia were present in every case.

CONCLUSIONS

A method was developed for percutaneous implantation of collagen stent-grafts into peripheral vessels. The heparin-impregnated grafts did not prevent vessel restenosis. Modification of the graft-processing technique may improve patency.

Hierarchical self-assembly of F-actin and cationic lipid complexes: stacked three-layer tubule networks

We describe a distinct type of spontaneous hierarchical self-assembly of cytoskeletal filamentous actin (F-actin), a highly charged polyelectrolyte, and cationic lipid membranes. On the mesoscopic length scale, confocal microscopy reveals ribbonlike tubule structures that connect to form a network of tubules on the macroscopic scale (more than 100 micrometers). Within the tubules, on the 0.5- to 50-nanometer length scale, x-ray diffraction reveals an unusual structure consisting of osmotically swollen stacks of composite membranes with no direct analog in simple amphiphilic systems. The composite membrane is composed of three layers, a lipid bilayer sandwiched between two layers of actin, and is reminiscent of multilayered bacterial cell walls that exist far from equilibrium. Electron microscopy reveals that the actin layer consists of laterally locked F-actin filaments forming an anisotropic two-dimensional tethered crystal that appears to be the origin of the tubule formation.

Uterine artery embolization: a minimally invasive technique for the treatment of uterine fibroids

Uterine artery embolization (UAE) as a primary therapy for symptomatic fibroids was first used in France in 1991. Currently, there are at least 250 centers in the United States, as well as centers in Canada and England, with experience in this technique. Initial published results worldwide indicate that after UAE, uterine fibroids shrink at least 50% in volume on average and symptoms of refractory vaginal bleeding and chronic pelvic pain are controlled in approximately 85% of patients. Major complications are rare. Overall, this technique is minimally invasive, preserves the uterus, and requires a shorter hospitalization than hysterectomy or myomectomy.

Oral idarubicin in patients with late chronic phase chronic myelogenous leukemia or chronic myelomonocytic leukemia

Patients with chronic myelogenous leukemia (CML) who have failed or cannot receive interferon alpha (IFN-alpha) based regimens or patients with advanced chronic myelomonocytic leukemia (CMML) have very limited current therapeutic options. Hence, there is a need to develop new strategies for these patients. This study was undertaken to determine the efficacy and toxicity of a chronic low-dose oral idarubicin regimen in these patients as positive data has been generated on this agent in shorter schedules given to patients with other hematological malignancies. Eighteen patients were treated on study. The starting dose of oral idarubicin was 2 to 5 mg/m2 daily depending in initial WBC count. This dose was escalated in the absence of Grade 4 myelosuppression or Grade 3 or 4 extramedullary toxicity. Oral idarubicin was given daily for 28 days followed by a 21 day break off treatment in repeated cycles until there was evidence of disease progression or intolerable toxicity. The dose of idarubicin was adjusted, at 2-week intervals, by 25% to maintain a white blood cell (WBC) count between 2 and 4x10(9)/L and a platelet count of >75x10(9)/L. The dose was reduced by 25% for grade 2 extramedullary toxicity and held until toxicity resolved to grade 2 or better for grade 3 toxicity. Oral idarubicin was then restarted at 75% of the initial dose. Five out of 14 CML patients achieved a complete hematologic remission. No CMML patient responded (median survival 3 months). The overall median survival was 24 months. CML patients had a median survival of 28 months. Major toxicities (myelosuppression, gastrointestinal, cardiac) were infrequent with a median cumulative dose of 1110 mg/m2 (range 54-9750). Five patients have received oral idarubicin for > 1 year with no overt cardiotoxicity, reaching median cumulative dose of 2756 mg/m2 (range 2550-9750) which is higher than those documented in prior studies. We conclude that oral idarubicin is sufficiently safe and active to warrant phase II studies investigating it as part of interferon-based regimens in patients with advanced CML.

Hypergammaglobulinaemic purpura presenting as reticulate purpura

Hypergammaglobulinaemic purpura, first described by Waldenstrom, is a rare skin disease. The essential features are the presence of purpura with polyclonal hypergammaglobulinaemia. We describe a case of hypergammaglobulinaemic purpura occurring in a Chinese man with reticulate purpura and haemorrhagic blisters.

Topotecan and cytarabine is an active combination regimen in myelodysplastic syndromes and chronic myelomonocytic leukemia

PURPOSE

To evaluate the efficacy and safety of the combination of topotecan and cytarabine in patients with myelodysplastic syndromes (MDSs) and chronic myelomonocytic leukemia (CMML).

PATIENTS AND METHODS

Fifty-nine patients with MDSs and 27 with CMML were enrolled. They were either previously untreated (66%) or had received only biologic agents (14%) or chemotherapy with or without biologic agents (20%). Treatment consisted of topotecan 1.25 mg/m(2) by continuous intravenous infusion daily for 5 days and cytarabine 1. 0 g/m(2) by infusion over 2 hours daily for 5 days. Prophylaxis included antibacterial, antifungal, and antiviral agents. At a median follow-up of 7 months, all 86 patients were assessable for response and toxicity.

RESULTS

Complete remission (CR) was observed in 48 patients (56%; 61% with MDSs, 44% with CMML; P =.15). Similar CR rates were observed for patients with good-risk and poor-risk MDS (70% and 56%, respectively). The treatment effectively induced CR in patients with a poor-prognosis karyotype involving chromosomes 5 and 7 (CR, 71%) and secondary MDSs (CR, 72%). Fifty-four patients received one induction course, 25 patients received two, and the rest received more than two. The median number of continuation courses was two. The median overall duration of CR was 34 weeks (50 weeks for MDSs and 33 weeks for CMML). The median survival was 60 weeks for MDS and 44 weeks for CMML patients. CR and survival durations were longer in patients with refractory anemia with excess blasts (RAEB). Grade 3 or 4 mucositis or diarrhea was observed in three patients each. Fever was observed in 63%, and infections in 49% of patients. Six patients (7%) died during induction therapy.

CONCLUSION

Topotecan and cytarabine induced high CR rates in unselected patients with MDSs and CMML, particularly among patients with poor-prognosis cytogenetics and secondary MDSs. Topotecan-cytarabine is an active induction regimen in MDS and CMML patients, is well tolerated, and is associated with a low mortality rate.

A case report of neutrophilic eccrine hidradenitis in a patient receiving chemotherapy for acute myeloid leukaemia

Neutrophilic eccrine hidradenitis (NEH) is a neutrophilic dermatosis primarily affecting the eccrine glands and occurs in patients undergoing chemotherapy. It must be distinguished from infections, drug eruptions, leukaemia cutis or other forms of skin diseases. As it is self-limiting, establishing the diagnosis will avoid unnecessary treatment for infections or changes in drug therapy.

A study of idiopathic thrombocytopenic purpura (ITP) patients over a ten-year period

Adult idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder caused by antiplatelet autoantibodies that cause platelet destruction by the reticuloendothelial system. The disease has been well-documented in the West. We studied 78 ITP patients diagnosed and followed up in a tertiary hospital, over a 10-year period, to give a profile of our local patients and their response to treatment. The majority of patients were females and fall in the 20 to 39 years age group. 21.8% were asymptomatic at presentation. The mean presenting platelet count was 31 x 10(9)/L. Complete response rate to steroid treatment was 46.7%. Thirty-seven patients (47.4%) underwent splenectomy with a success rate of 64.9%. 6.4% required multiple drugs to maintain a stable platelet count. There was no spontaneous, long-term remission in this series. 10.3% of our patients eventually developed an autoimmune disease. ITP has a variable clinical course and treatment has to be highly individualised.

Arterial embolism complicating implantable cardioverter defibrillator shocks with normal ventricular function

A 69-year-old man developed an embolus to his right femoral artery 24 h following the insertion of an implantable cardioverter defibrillator (ICD), with multiple shocks administered in the early postoperative period. He had nonobstructive hypertrophic cardiomyopathy with normal left ventricular function and no evidence of left atrial or ventricular thrombus seen on pre- or postoperative transthoracic echocardiography. There was no evidence of atrial fibrillation documented before or after implantation of the device. He had no other known risk factors for thromboembolic disease. Thromboembolic phenomena as a complication of ICD use have been described but arterial emboli believed related to ICD shocks have not been reported in patients without impaired systolic function.

Acute promyelocytic leukemia with a dicentric chromosome involving chromosomes 11, 17, and 18

We report a case of acute promyelocytic leukemia with dicentric chromosome resulting from translocation of chromosomes 11, 17, and 18.

Vaginal misoprostol compared with oral misoprostol in termination of second-trimester pregnancy

OBJECTIVE

To compare the efficacy of vaginal with oral misoprostol in termination of second-trimester pregnancy after pretreatment with mifepristone.

METHODS

Women requesting termination of second-trimester pregnancy were randomized into two groups. Thirty-six to 48 hours after oral administration of 200 mg of mifepristone, women were given either oral or vaginal misoprostol 200 microg every 3 hours for a maximum of five doses in the first 24 hours. Women receiving oral misoprostol also were given a vaginal placebo (vitamin B6), whereas those receiving vaginal misoprostol were given an oral placebo. If they failed to abort, a second course was given by the same route.

RESULTS

The median induction-abortion interval in the vaginal group (9 hours) was significantly shorter than that in the oral group (13 hours). The percentage of women aborting within 24 hours in the vaginal group (90%) was significantly higher than that in the oral group (69%). The median amount of misoprostol used in the vaginal group (600 microg) also was significantly less than that in the oral group (1000 microg). There was no significant difference in the incidence of side effects between the two groups except for fatigue and breast tenderness, which were more common in the oral group. Seventy-six percent of the women preferred the oral route, and 24.5% of the women preferred the vaginal route.

CONCLUSION

Vaginal misoprostol is more effective than oral misoprostol in termination of second-trimester pregnancy after pretreatment with mifepristone, but more women preferred the oral route.

Clinical characteristics and natural history of human immunodeficiency virus infected patients seen at a general hospital in Singapore

The number of patients with human immunodeficiency virus (HIV) infection in Singapore has risen over the years. A considerable proportion of them present with acquired immunodeficiency syndrome (AIDS). In this study, we document the clinical characteristics and natural history of a consecutive series of 50 patients who were found to have HIV infection when they were seen at a tertiary care hospital. The majority were in the 30 to 49 age group and the most common mode of acquisition was heterosexual contact. The patients presented with a variety of symptoms to 11 different clinical departments. Fifty-eight per cent of the patients had AIDS-defining illnesses at presentation, with Pneumocystis carinii pneumonia being the most common. On follow-up, the most frequently occurring opportunistic infection that developed was Cytomegalovirus retinitis. Most patients had multiple subsequent admissions--for both AIDS-defining and non AIDS-defining conditions. The median CD4 count of the cohort at presentation was 72/mm3. The median survival was 399 and 822 days in those who had and those who did not have an AIDS-defining illness at presentation, respectively. Mortality was most commonly attributed to pneumonia. HIV infection has protean manifestations and patients may present to various specialty departments; hence, doctors need to be aware of the spectrum of disease in order to make a diagnosis.

Exacerbation of hepatitis in hepatitis B carriers following chemotherapy for haematological malignancies

We describe nine asymptomatic chronic carriers of hepatitis B virus, four males and five females, with a mean age of forty-six years and all were Chinese, who developed exacerbation of hepatitis following chemotherapy for haematological malignancies. Seven patients had non-Hodgkin's lymphoma of whom three were treated with MACOP-B, two with BCEPP, one with PROMACE-CYTABOM and one with CHOP. Two patients had acute myeloid leukaemia and were treated with daunorubicin and cytosine arabinoside. Exacerbation of hepatitis occurred between one to four weeks following the last course of chemotherapy in eight patients. Two patients developed exacerbation of hepatitis when the dosage of prednisolone was reduced after they had ten weeks of high dose prednisolone. The outcome was fatal in six patients; all of whom developed hepatic encephalopathy. In four of these patients, alanine transaminase levels exceeded 1000 iu/l. Cytotoxic and immunosuppressive therapy permit enhanced viral replication. Withdrawal of the drugs results in partial restoration of immunocompetence and leads to rapid destruction of hepatocytes with consequent hepatic necrosis. Hence, patients who are hepatitis B virus carriers undergoing chemotherapy should be closely monitored. The fatal outcome of reactivation of chronic hepatitis B virus warrants prospective trials addressing preventive measures.

Seeking women's voices: setting the context for women's health interventions in two rural counties in Yunnan, China

If interventions to improve health are truly to benefit women, they must be developed from the start with a critical understanding of women's own perceptions of their health problems and needs, and how these concerns are linked to other facets of women's lives. To obtain such understanding, it is crucial for health planners to seek out women in the communities where they live, to encourage them to speak in their own voices about their health and lives, and to be genuinely committed to listening to what the women have to say. This paper presents results of focus group discussions with village women in two rural counties in Yunnan, China. The data are derived from 28 focus group discussions conducted by the Women's Reproductive Health and Development Program in Yunnan as part of a comprehensive assessment of reproductive health needs in poorer, more remote areas of the two counties. The discussions were held to ascertain what village women themselves feel to be their most pressing health problems, and how these relate to work, family, social status and their use of health services. Results show how women's health and their use of health services are rightly intertwined with their labor roles, harsh environmental conditions and oppressive poverty. Widespread breakdowns in the village-level primary health care network lead village women to express a profound lack of confidence in local health services. The findings have several implications for planning and implementation. Demands on women's scarce time need to be explicitly considered when designing health education activities and health service delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

Characteristics of women having abortion in China

A pre-coded, closed response questionnaire was administered to women at abortion clinic sites in August 1985. The convenience sample was comprised of 1200 women, 200 samples in both Chengdu and the Lianshan Yi Autonomous Region in Sichuan Province, 400 in Nanjing and Jiangsu Province, and 400 in the municipality of Shanghai. The women were interviewed by physicians as part of the women's intake medical history. The sample yielded 574 respondents who were urban and 624 who were rural. The number of previous abortions reported ranged from 0 to 5. Nearly half of the abortion recipients had had at least one prior abortion and 18% had had two or more prior abortions. Education, age, marriage duration and residence have apparent effect on abortion order. The urban respondents reported an average of 1.08 children vs 1.60 children for the rural respondents. Approximately 72% of the respondents claimed to have been using a contraceptive method at the time they became pregnant. The most commonly used method was the IUD (41.6%), followed by the pill (21.3%) and the condom only (16.5%). Residence appeared to be the greatest factor determining the type of contraceptive methods. The data presented here are limited and cannot be generalized to the larger population. However, they do shed some light on the contraception characteristics of a group of women who undergo abortion procedures in China. Their response to questions to contracepting behavior prior to abortion suggests that the problem, in part, is behavioral. For example after the expulsion of the IUD, no other method was substituted to avert pregnancy. In order to alleviate the problem of contraceptive failure, and subsequent abortion, there are policy as well as training and education implications for the state.