Allogeneic bone marrow tranplantation for young adult patients with newly diagnosed acute myeloid leukemia: HLA-Matched sibling donor availability does not improve treatment ouctome

In order to assess the place of HLA-identical allogeneic bone marrow transplantation (BMT) and to compare it to other post-induction therapies, we analyzed patient outcome in intention-to-treat based on the presence or not of an HLA-identical familial donor in young adults with de novo acute myeloid leukemia (AML) in first complete remission (CR). Between 1985 and 1998, 152 consecutive AML patients aged less than 41 years old, seen in our institution, were treated according to 3 different successive protocols (LYLAM85, LAM90, AML10). 144/152 patients entered our prospective study in which they were registered at time of diagnosis for presence or absence of HLA-identical donor and analyzed in intention-to-treat. In this study, 52 patients (36%), who had at least one identical sibling donor (group 1), were offered allogeneic BMT after CR achievement. The 92 patients without donor were allocated to group 2 and were assigned to receive chemotherapy or autologous transplantation as post-remission according to the protocol they were initially included in. Patients from both groups had similar disease characteristics at diagnosis. Karyotypes at diagnosis were defined as low risk (t(8;21) or t(15;17) or chromosome 16 abnormalities(, intermediate risk (normal karyotypes), or high risk (other abnormalities). Overall, 114/152 patients (75%) achieved a CR. Of the 144 eligible patients, 46/52 (88%) with a donor and 68/92 (74%) without a donor achieved a CR. The median follow-up duration of the 144 patients was 21.2 months. The relapse rate was higher in group 2 (56%) than in group 1 (31%). However, the overall survival was not different between patients with and without donor (median survival respectively at 16.7 months and 26.6 months with estimated survival at 5 years respectively at 32% and 34%). Thirty-four patients from group 1 (65%) were actually transplanted in first CR. The probability of 5-year survival for patients receiving effectively allogeneic BMT was 44% and was not significantly better than that of patients who did not. In univariate as in multivariate analysis, karyotypic status was the main prognostic factor for CR achievement (p = 0.002), CR duration (p < 0.0001), and overall survival (p < 0.0001). There were no significant differences between group 1 and group 2 when survivals were compared with adjustment for karyotypes.We conclude that the availability of an HLA-identical sibling donor did not confer any prognostic advantage in terms of outcome for young adults with AML in first CR. These results make allogeneic BMT process questionable as systemic post-remission therapy in patients with an HLA-identical familial donor.     

Informed Consent

There have been significant changes in the doctor patient relationship with the impact of technology in day-to-day practice. More and more patients are aware of their rights and are keen to make free choice and decision on their treatment. This helps them to choose the treatment of their choice from the options available and to select a physician of their choice. Doctor's decisions are being questioned regarding their correctness and there is a need to educate the patient, on what one offers by way of treatment. In some procedures and types of treatment, patient needs to be educated and informed of the merits and demerits of the treatment available. This will help the patient to make appropriate choice and also to accept some adverse outcome of treatment. Towards this end, all countries are looking afresh at the necessity of Informed Consent. Methods adopted by some countries are highlighted to help our physicians practice them in an appropriate way. A lot of remedial work needs to be done to minimize future litigation, as many doctors misunderstand their legal obligations and haven't caught up with the change in judge's thinking.     

Significance of subcentimetre 18F-FDG PET/CT pulmonary abnormality in patients with known extrapulmonary malignancy

The significance of a subcentimetre ¹⁸F-FDG PET/CT pulmonary abnormality in a patient with known extrapulmonary primary malignancy can have a major impact on the clinical management of the patient. The clinician’s reliance on the semi-quantitative and qualitative PET/CT analysis of the abnormality has, at times, led to untoward diagnostic problems, given the limited spatial resolution of PET for a small volume lesion performed as part of the standard PET/CT study. This paper highlights a case each of an FDG-positive and an FDG-negative focal pulmonary abnormality in a combined PET/CT study of patients with known extrapulmonary malignancy. © 2010 Biomedical Imaging and Intervention Journal. All rights reserved.     

Assessment of stool colour in community management of prolonged jaundice in infancy

Jaundice persisting beyond the first 2 wk of life is often regarded as an indication for investigation to exclude cholestatic liver disease. Most babies with prolonged jaundice have breast milk-related jaundice, which is a benign condition. Cholestatic liver disease is usually accompanied by pale stools and yellow or orange urine. A community programme was established to ascertain the incidence of prolonged jaundice and determine whether abnormal stool and urine colour could be used to assist primary care staff in referral decisions. Data were collected on normal stool and urine colour and used to devise a colour chart and information sheet for parents. Babies with prolonged jaundice were identified and referred for investigation. In all, 3661 babies were recruited into the study, of which 127 were jaundiced at 28 d of age. Of these, 125 were breastfed. The incidence of jaundice in breastfed babies at 28 d was 9.2% (95% CI 7.8%-11.0%) Abnormal liver function tests (LFTs) were common, but no baby had abnormal stool or urine colour and none was found to have liver disease. Jaundiced breastfed babies who are well are unlikely to have serious disease. Elevated LFTs are compatible with a diagnosis of breast milk-related jaundice. Prolonged jaundice in bottle-fed babies, and persistent pallor of stools or yellow/orange urine, are rare and merit immediate referral. Parents and professionals can be advised to report pale stools without generating a large number of unnecessary referrals. Further work is needed to determine whether a colour chart reduces the mean age of referral and treatment of infants with cholestatic liver disease.     

The prevalence of headache with emphasis on tension-type headache in rural Tanzania: a community-based study

The aim of the study was to assess the prevalence of headache with special attention to tension-type headache (TTH) in a rural area in northern Tanzania. A door-to-door study was performed using a standardized and validated questionnaire. A total of 7412 participants were screened. The total headache prevalence during the past year was 12.1%; the overall 1-year prevalence of TTH was 7%; 5% reported episodic TTH and 0.4% chronic TTH. Borderline cases (International Headache Society code 2.3) were described in 1.6%. The prevalence of headache was highest in the 41–50-year-old group in women and in the 61+ age group in men. This is the first account of the prevalence of TTH in a rural Tanzanian population, and shows that headache in general and, more specifically, TTH are prevalent disorders that deserve attention. However, the prevalence of primary headache seems to be lower than in Western countries.     

Ossicular erosions in the dry ear: CT diagnosis

Erosions of the ossicular chain that occurred as a complication of noncholesteatomatous chronic otitis media were studied with computed tomography (CT) in 55 patients. The incus (particularly the long and lenticular processes) was the ossicle most commonly involved (50 cases). Coronal and axial CT sections were complementary in the diagnosis of these erosions. Fibrous replacement of the incudostapedial articulation was diagnosed in four cases on axial CT scans when an unusually wide joint was present.     

Congenital abnormalities of the aortic arch: MR imaging

Thirty-four patients, 1 month to 63 years old, with known or suspected congenital abnormalities of the aortic arch underwent magnetic resonance (MR) imaging. Sixteen patients were studied retrospectively, 18 prospectively. In all retrospective studies, the aortic arch abnormality was seen with MR imaging. In the prospective studies, MR imaging enabled diagnosis in 15 of 18 (83%) patients. Twenty-nine of 34 patients underwent two-dimensional echocardiography; nine were studied retrospectively, 20 prospectively. In the prospective studies, echocardiography enabled diagnosis in 13 of 20 (65%) patients. Although two-dimensional echocardiography has a high sensitivity in the detection of aortic arch abnormalities in the neonate, arch abnormalities in the neonate, its sensitivity is lower in older children, adults, and postoperative patients. The authors' experience shows that MR imaging is an important, noninvasive modality in the evaluation of older children, adults, and postoperative patients with congenital aortic arch abnormalities.     

The effects of manual therapy and exercise directed at the cervical spine on pain and pressure pain sensitivity in patients with myofascial temporomandibular disorders

Summary No studies have investigated the effects of the treatments directed at the cervical spine in patients with temporomandibular disorders (TMD). Our aim was to investigate the effects of joint mobilization and exercise directed at the cervical spine on pain intensity and pressure pain sensitivity in the muscles of mastication in patients with TMD. Nineteen patients (14 females), aged 19–57 years, with myofascial TMD were included. All patients received a total of 10 treatment session over a 5‐week period (twice per week). Treatment included manual therapy techniques and exercise directed at the cervical spine. Outcome measures included bilateral pressure pain threshold (PPT) levels over the masseter and temporalis muscles, active pain‐free mouth opening (mm) and pain (Visual Analogue Scale) and were all assessed pre‐intervention, 48 h after the last treatment (post‐intervention) and at 12‐week follow‐up period. Mixed‐model anovas were used to examine the effects of the intervention on each outcome measure. Within‐group effect sizes were calculated in order to assess clinical effect. The 2 × 3 mixed model anova revealed significant effect for time (F = 77·8; P < 0·001) but not for side (F = 0·2; P = 0·7) for changes in PPT over the masseter muscle and over the temporalis muscle (time: F = 66·8; P < 0·001; side: F = 0·07; P = 0·8). Post hoc revealed significant differences between pre‐intervention and both post‐intervention and follow‐up periods (P < 0·001) but not between post‐intervention and follow‐up period (P = 0·9) for both muscles. Within‐group effect sizes were large (d > 1·0) for both follow‐up periods in both muscles. The anova found a significant effect for time (F = 78·6; P < 0·001) for changes in pain intensity and active pain‐free mouth opening (F = 17·1; P < 0·001). Significant differences were found between pre‐intervention and both post‐intervention and follow‐up periods (P < 0·001) but not between the post‐intervention and follow‐up period (P > 0·7). Within‐group effect sizes were large (d > 0·8) for both post‐intervention and follow‐up periods. The application of treatment directed at the cervical spine may be beneficial in decreasing pain intensity, increasing PPTs over the masticatory muscles and an increasing pain‐free mouth opening in patients with myofascial TMD.