Recommendations for the Use of Etoposide-Based Therapy and Bone Marrow Transplantation for the Treatment of HLH: Consensus Statements by the HLH Steering Committee of the Histiocyte Society

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome requiring aggressive immunosuppressive therapy. Following 2 large international studies mainly targeting pediatric patients with familial disease and patients without underlying chronic or malignant disease, the HLH-94 protocol is recommended as the standard of care when using etoposide-based therapy by the Histiocyte Society. However, in clinical practice, etoposide-based therapy has been widely used beyond the study inclusion criteria, including older patients and patients with underlying diseases (secondary HLH). Many questions remain around these extended indications and published reports do not address several practical issues. To tackle these concerns, the HLH Steering Committee of the Histiocyte Society decided to issue guidance for use of the HLH-94 protocol. The group convened in a structured consensus finding process to define recommendations that are based largely on expert opinion backed up by available data from the literature. The recommendations address all main elements of HLH-94 including corticosteroids, cyclosporin, etoposide, intrathecal therapy, and hematopoietic stem cell transplantation (HSCT) and consider various forms of HLH and all age groups. Aspects covered include indications, applications, dosing, side effects, duration of therapy, salvage therapy, and HSCT. These recommendations aim to provide a framework to guide treatment decisions in this severe disease.

Medical students' aptitude toward smoking in Warsaw, Strasbourg and Teheran

Cigarette smoking is a leading cause of preventable death in the world. Medical students play a role in smoking prevention especially as future physicians, but also as role models in society. Their approach, although influenced by medical education, is based on cultural and socio-economic background. The aim of this study was to analyze smoking habits, prevalence and attitudes towards smoking cessation in medical students from three different countries: Poland, France and Iran. A questionnaire on tobacco smoking was distributed among medical students from three Medical Universities: in Warsaw, Strasbourg and Teheran. The study population consisted of 1,036 students: 499 from Poland, 367 from France and 170 from Iran. The percentage of smokers among medical students was 14% in Warsaw, 14.4% in Strasbourg and 3.5% in Teheran. The prevalence of ex-smokers was 13.6%, 18%, and 1.2% respectively. The use of nicotine replacement therapy or pharmacological aid in smoking cessation was 9% in Warsaw, 7% in Strasbourg, and none in Teheran. In Strasbourg students willing to choose surgical specialization were more likely to be smoking with OR 2.6 (95% CI 1.4-5.0). Never-smokers were more likely than actual smokers to discourage their friends and family from smoking. In Warsaw OR was 3.8 (95% CI 2.0-7.2), in Strasbourg 6.2 (2.6-14.4) and 7.2 (1.0-82.6) in Teheran. In conclusion, similarities in smoking prevalence and attitudes between medical students in Warsaw and Strasbourg were observed, while in Teheran the percentage of smokers reported was much lower. Pharmacological aid or nicotine replacement therapy in smoking cessation was rarely used among medical students.

Knowledge, attitudes, and influenza vaccination of medical students in Warsaw, Strasbourg, and Teheran

OBJECTIVE

Influenza vaccinations are recommended for health professionals by the WHO and the CDC. Medical students are important health professionals not only as future physicians, but also due to their frequent contact with patients during their education. The aim of this study was to compare the knowledge, attitudes, motivations and influenza vaccinations of medicine students in three different countries: Poland, France, and Iran.

MATERIAL AND METHODS

1045 self-reported questionnaires were given to medical students of Warsaw Medical University (n = 502), the Faculty of Medicine of Strasbourg University (n = 371) and Teheran University of Medical Sciences (n = 172). In France, students working in a hospital can be vaccinated free of charge. In Poland and Iran students are required to pay for the vaccine and have to arrange the administration of the vaccine on their own.

RESULTS

Vaccination of students during the year of the study time was generally infrequent: the highest was in Strasbourg 29.7%; it was lower in Warsaw 15.2%, and lowest in Teheran at 4.7%. Similarly, 60% of medical students in Strasbourg, 65% of students in Warsaw and 86% of students in Teheran have never been vaccinated. The percentage of students knowing that they belong to the group of people that have strong indications for being vaccinated was 78% in Strasbourg, 48% in Warsaw and 40% in Teheran. The main reasons for obtaining a shot, cited by students, were to protect from influenza and the fear of disease sequelae. The most important reasons for not being vaccinated were laziness, lack of time, and also lack of knowledge of the indications in favor of being vaccinated. Being vaccinated at least once in the past is the most important predictor of the vaccination in the current season.

CONCLUSIONS

Few medical students in all of the examined countries are immunized against influenza. Data indicate that providing access to free vaccinations, although very important, cannot alone solve the problem. Strengthening educational efforts seems crucial, although no immediate effects should be expected due to remarkable inertia. Influencing attitudes at an earlier stage can be more advantageous.