Variables influencing the timing of marrow transplantation in patients with chronic myelogenous leukemia

The prognosis for patients with chronic myelogenous leukemia (CML) has improved only for patients who can receive marrow transplantation from a histocompatible sibling. The timing of the marrow transplant is made difficult by the high peritransplant mortality of 20% to 35% and a group of patients with a prolonged chronic phase of CML, which can be identified on the basis of prognostic indexes (age, percent blood myeloblasts, spleen size, and platelet count). We have developed a mathematic model and computer program that consider age, prognostic index, and projected survival rate by transplantation to balance the risk of peritransplant mortality against the risk of delaying the transplantation of patients with Philadelphia chromosome-positive CML. The computation assesses the risk of delaying transplantation; it does not offer the option of avoiding transplantation, since long-term survival ultimately requires transplantation. Three prognostic groups were considered as described by Sokal and co-workers (Blood 63:789, 1984) (I, best; II, intermediate; III, worst prognosis). The computation used the projected survival rates of transplantation from the Seattle experience and from the International Bone Marrow Transplant Registry. As an example of the model's utility, we have determined the ratio of the calculated life expectancy to the normal life expectancy for hypothetical patients up to 50 years of age in each of the three prognostic categories. A value of 20% is used for patients who successfully receive transplants after the onset of the accelerated phase. The analysis allows assessment of the risk of delaying transplantation for a finite time in patients with CML. The importance of the method rests in its consideration of multiple variables, including the peritransplant mortality, transplant projected survival before and upon entering the accelerated phase, age, prognostic group, and other risk factors. The program permits a change in these parameters as new information or advances in treatment occur. This analysis does not replace the diagnostic deliberations of the clinician. Rather, it provides a numeric framework for prognosis based on the currently available data. The physician in conjunction with the patient, not the algorithm, makes the decisions of whether and when to transplant.     

Handwriting,visuomotor integration,and neurological condition at school age

Aim The study investigated the relationships between handwriting, visuomotor integration, and neurological condition. We paid particular attention to the presence of minor neurological dysfunction (MND). Method Participants were 200 children (131 males, 69 females; age range 8–13y) of whom 118 received mainstream education (mean age 10y 5mo, SD 1y 4mo) and 82 special education (mean age 10y 8mo, SD 1y 2mo). Each child had four assessments: a neurological examination, which paid attention to the type and severity of MND, a test to measure motor performance, a handwriting test, and the Developmental Test of Visual Motor Integration. Results Dysgraphic handwriting and slow writing speed were closely related to the severity of neurological dysfunction (both p<0.001); impaired visuomotor integration was related to the presence of MND (p<0.001) but somewhat less to its severity. Impaired handwriting and visuomotor integration were strongly related to two specific dysfunctions: fine manipulative disability and coordination problems (both p<0.001). Impaired visuomotor integration was weakly related to dysfunctional muscle tone regulation (p=0.009) and sensory dysfunction (p=0.042). Interpretation Poor handwriting and impaired visuomotor integration are related to MND, but in a differential way. Poor handwriting is related to the severity of neurological dysfunction and to dysfunctions of complex supraspinal circuitries. Impaired visuomotor integration is associated with the presence of any of the most common types of MND.     

Identification of ACTH-producing intrathoracic tumors by measuring ACTH levels in aspirated specimens

Three patients with Cushing syndrome secondary to ectopic adrenocorticotropic hormone (ACTH) production underwent direct 22-gauge needle aspiration of bronchial (two cases) and mediastinal (one case) carcinoid tumors. High levels of ACTH were measured in all three tumors. This technique permits absolute identification of an ectopic source of ACTH before surgery.     

Bleeding time and bleeding: an analysis of the relationship of the bleeding time test with parameters of surgical bleeding

The bleeding time is currently the only clinically available comprehensive test to explore primary hemostasis. It is currently performed mostly as a screening procedure before surgery, to detect otherwise unknown defects in platelet-vessel wall interactions, but its use in this specific setting has been seriously questioned by recent reanalyses of previously published literature. We studied the relationship of the bleeding time from a standardized cutaneous incision with other parameters of bleeding derived from the analysis of the bleeding time curve and prospectively investigated possible correlations of these alternative parameters, as well as of the bleeding time, with a number of indices of actual bleeding during or after coronary bypass surgery. Four parameters (bleeding time, total bleeding, peak bleeding rate, and time to peak bleeding) were derived from the analysis of bleeding time curves measuring blood losses from a standardized cutaneous incision at 30-second intervals in 118 subjects. Parameters from the bleeding time curve were subsequently obtained in duplicate as a preoperative assessment in 40 patients with a negative bleeding history and no recent intake of non-steroidal anti- inflammatory drugs who were undergoing elective pure coronary bypass surgery performed by the same operator. These parameters were correlated in simple linear regression analysis with estimates of surgical bleeding (chest tube drainage, transfusion requirements, percentage of hematocrit, percentage of platelet level decrease, and times to hematocrit and platelet level nadir) and then, in multiple regression analysis, with indices of operation complexity (number of bypasses, total duration of the operation, and duration of the extracorporeal circulation). Bleeding time was significantly correlated, among parameters derived from the bleeding time curve, with total bleeding and peak bleeding rate, but not with time to peak bleeding. Bleeding time, total bleeding, and peak bleeding rate were similarly affected by acute interventions with intravenous aspirin (500 mg) and sublingual nitroglycerin (0.3 mg). None of these parameters, which were obtained in duplicate in each patient preoperatively, was significantly related to actual indices of bleeding at surgery. Thus, in patients with a negative history of bleeding and no recent intake of non-steroidal anti-inflammatory drugs, higher values for bleeding time and bleeding time-related parameters are not associated with higher indices of perioperative and postoperative bleeding at coronary bypass surgery. Therefore, we do not recommend the use of the test in this setting to predict perioperative or postoperative bleeding.     

Endovascular treatment of scalp arteriovenous fistulas associated with a large varix

Ten patients with scalp arteriovenous fistulas associated with a large varix (cirsoid aneurysms) were treated with a combination of interventional neuroradiologic procedures. These procedures included transarterial embolization, transarterial embolization followed by surgical excision, and two new methods of treatment of cirsoid aneurysms: transvenous embolization and direct puncture of the fistula for embolization. The embolic materials included liquid adhesive agents, particulate agents, detachable balloons, and wire coils. The embolization was performed to lodge the embolic agents in the fistula or proximal draining vein, not just the feeding vessels. Surgery was performed in two cases to remove a small residual nidus of fistula that could not be completely treated with intravascular embolization. With the use of these forms of treatment, cures were obtained in seven patients, and clinical and angiographic improvement was achieved in three patients. No major morbidity, blood loss, or mortality occurred during the treatment of these patients. The follow-up period ranged from 1 month to 8 years.     

Liver transplant rejection: value of the resistive index in Doppler US of hepatic arteries

The authors prospectively evaluated the accuracy of the resistive index (RI) in Doppler ultrasound (US) for the detection of the increased vascular resistance that theoretically occurs with acute liver transplant rejection. RIs were calculated for the proximal hepatic artery and a more distal hepatic artery branch in 67 liver transplant recipients. Biopsies were performed within 24 hours of transplantation, with no intervening therapy. Examination of biopsy specimens by a single pathologist revealed findings of no, minimal, or moderate to severe rejection. RIs in hepatic arteries showed no significant differences among the three pathologic groups. No correlation was found between the RI and improved or worsened rejection in 11 patients who underwent biopsy and US more than once. RIs in hepatic arteries are of no value in the prediction of liver transplant rejection.