Maintenance Treatment With Low‐Dose Mercaptopurine in Combination With Allopurinol in Children With Acute Lymphoblastic Leukemia and Mercaptopurine‐Induced Pancreatitis

Mercaptopurine (6‐mercaptopurine, 6MP) is a mainstay of curative therapy in childhood acute lymphoblastic leukemia (ALL), and contributes to its 90% overall survival rate. We present two patients with ALL who suffered with severe pancreatitis secondary to 6MP. Through the use of allopurinol in conjunction with reduced dose 6MP, we were able to continue 6MP without further pancreatitis. This report contributes to the small body of literature on 6MP associated pancreatitis in childhood ALL and describes a novel approach to continued use of 6MP during therapy.     

Management of Primary Gastrointestinal Non-Hodgkin Lymphomas: a Population-Based Survival Analysis

Introduction

Primary gastrointestinal non-Hodgkin lymphomas (PGINHL) are a heterogeneous group of rare GI malignancies with limited data to guide management. This study describes management of PGINHL in a population-based registry and aims to determine the association between receipt of surgery and long-term survival.

Methods

All adults diagnosed with PGINHL over 27 years in the Surveillance, Epidemiology, and End Results were identified (excluding mucosa-associated lymphoid tissue lymphomas). Demographic and clinical characteristics were assessed. Survival was compared using the log-rank method. Cox hazard modeling was used to determine independent prognostic factors.

Results

We identified 16,129 patients. The majority were of gastric origin and had diffuse large B cell histology. Surgery was performed in 46.9 % of patients, not recommended in 41.8 % and recommended but not performed in 10.1 %. Overall 1-year and 5-year survival rates were 65.6 and 35.6 %, respectively. Patients undergoing surgery had a 5-year survival of 43.6 % compared to 34.8 % for whom surgery was recommended but not performed (p?<?.0001), (receipt of chemotherapy not available). Female gender, gastric location, follicular or mantle cell histology, and radiation therapy were associated with improved survival.

Conclusions

Nearly 50 % of PGINHL patients underwent surgery. Surgery was not associated with improved survival. More prospective, case-matched studies are needed to guide management.

     

Translocation (4;11)(p12;q23) with rearrangement of FRYL and MLL in therapy-related acute myeloid leukemia

Reciprocal chromosomal translocations involving the MLL gene at chromosome region 11q23 are recurring cytogenetic abnormalities in both de novo and therapy-related acute myeloid leukemia (AML) and in acute lymphoblastic leukemia. We report a t(4;11)(p12;q23) with rearrangement of MLL and FRYL (also known as AF4p12), a human homolog to the furry gene of Drosophila, in an adult patient with therapy-related AML after fludarabine and rituximab therapy for small lymphocytic lymphoma and radiation therapy for breast carcinoma. To our knowledge, t(4;11)(p12;q23) has been reported in two previous patients, and MLL and FRYL rearrangement was demonstrated in one of them. Both of the previous patients had therapy-related leukemias after exposure to topoisomerase II inhibitors, whereas our patient had received cytotoxic therapy that did not include a topoisomerase II inhibitor. Thus, t(4;11)(p12;q23) with MLL and FRYL involvement represents a new recurring 11q23 translocation, to date seen only in therapy-related acute leukemias.     

Access to postacute rehabilitation

Buntin MB. Access to postacute rehabilitation.Each year, more than 10 million Medicare beneficiaries are discharged from acute care hospitals into postacute care (PAC) settings, including inpatient rehabilitation facilities, skilled nursing facilities, and homes with services from home health agencies. These beneficiaries include very frail and vulnerable elders, many of whom have suffered from an acute event such as a stroke or a fall resulting in hip fracture, all of whom are judged unable to return to their homes without further care. Whether beneficiaries receive PAC and the type and intensity of care they receive is influenced not only by clinical factors, but by nonclinical factors including provider supply and financing, especially Medicare’s methods of payment. This article provides a definition of PAC and discusses the wide cross-sectional variation in the use of postacute rehabilitation. It then discusses recent changes to PAC provider payment that have raised concerns about access to postacute rehabilitation, trends in the use of PAC, and what these trends imply about the appropriateness of PAC as it is now delivered. It concludes by identifying issues about the policy and research implications of recent developments and the PAC literature reviewed.     

The relationship between moral distress and perception of futile care in the critical care unit.

PURPOSE: Study the relationship between moral distress (MD) and futile care in the critical care unit (CCU). SUBJECTS AND METHODS: A cross-sectional survey consisting of 38 clinical situations associated with MD related to 6 categories: physician practice, nursing practice, institutional factors, futile care, deception and euthanasia was distributed to 100 nurses at a single CCU. The intensity and frequency of MD were scored with Likert scale: 0-lowest and 6-highest. RESULTS: The survey was completed by 44 (44%) nurses. Median age was 33 years, 80% females. Median intensity of MD was high for the six categories and had no relationship with age, time in CCU or nursing practice. The encounter frequency of MD for futile care was the highest and was significantly related to age >33 years (p=0.03), time in CCU >4 years (p=0.04) and nursing practice >7 years (p=0.01). CONCLUSION: MD associated with clinical situations representing futile care increased with time in CCU. Future interventions are required to minimize the exposure to futile care situations and develop mechanisms to mitigate the effects of MD in the CCU.