[The anamnesis in antiquity; medical questions by Rufus Ephesius (1st to 2nd century AD)]. / De anamnese in de oudheid; de Geneeskundige vragen van Rufus Ephesius (Ie-2e eeuw n.Chr.).

Only one treatise devoted to medical history taking (anamnesis) has come down to us from antiquity: Medical questions by Rufus Ephesius (from about 80 to about 150 AD). The work was rediscovered, published and translated from Greek into French by Daremberg and Ruelle in the 19th century. The word 'anamnesis' for history taking only came into use halfway through the 19th century in German-speaking countries and in the Netherlands. The term was not used in this sense by physicians in antiquity. In contrast to several authors of the Corpus Hippocraticum (5th to 1st century BC), Rufus attached great importance to the interview with the patient and in particular to questions concerning the patient's lifestyle prior to the illness. In this respect, his opinions are remarkably close to modern views.

Prospective randomized placebo-controlled study of granulocyte-macrophage colony-stimulating factor without stem-cell transplantation after high-dose melphalan in patients with multiple myeloma.

PURPOSE: To evaluate the impact of granulocyte-macrophage colony-stimulating factor (GM-CSF) or placebo on the durations of intravenous (IV) antibiotic use, hospitalization, neutropenia, and fever, as well as remission rates, after high-dose melphalan (HDM) without stem-cell transplantation (SCT) in patients with multiple myeloma (MM). PATIENTS AND METHODS: One hundred two patients with high-risk MM were randomized 2:1 in a prospective multicenter trial to receive 5 microg/kg/d GM-CSF (69 patients) or placebo (33 patients) starting the day after 140 mg/m2 IV melphalan for up to 21 days. RESULTS: GM-CSF significantly reduced neutropenia after HDM (median, 23.5 v 29 days; P = .0468), with a trend to reduce the duration of hospitalization (median, 32 v 38 days; P = .0841). Nevertheless, GM-CSF did not significantly reduce infectious toxicity as regards the number of days with fever (median, 5 v 3; P = .359), the number of days with IV antibiotics (median, 22 v 27; P = .14), or early deaths, with an 11.5% treatment-related mortality rate in the GM-CSF group (eight of 69 v two of 32 patients in the placebo group; P = .686). There was no difference in response rates between the two groups of patients. CONCLUSION: GM-CSF after HDM without SCT is feasible and significantly shortens neutropenia with a trend toward reduction of hospitalization duration, but does not significantly reduce the morbidity and mortality of such therapy. Thus, when intensive therapy is indicated, given that the mortality of HDM followed by SCT reported in the literature is less than 5% and patients are discharged at approximately day 15, despite the risk of contamination by clonogenic malignant cells, SCT appears to be preferable to GM-CSF after HDM.

Clinical significance of bcl2 and p53 protein expression in diffuse large B-cell lymphoma: a population-based study.

PURPOSE: We studied the prognostic significance of bcl2 and p53 protein expression in relation to clinical and pathologic characteristics in patients with diffuse large B-cell lymphoma (LCL). PATIENTS AND METHODS: Three hundred seventy-two patients with LCL were retrieved from a population-based registry for non-Hodgkin's lymphoma (NHL). bcl2 and p53 protein expression was studied on paraffin-embedded tumor tissue by immunohistochemistry in relation to clinical factors. Response to therapy and survival were analyzed in 165 patients who were uniformly staged and treated and for whom all prognostic data were available according to the International Prognostic Index (IPI). RESULTS: Forty-five percent of tumors showed strong expression of the bcl2 protein (bcl2++), with a higher frequency in patients with primary nodal involvement. Disease-free survival (DFS) was significantly better in bcl2-negative/intermediate (bcl2-/+) cases as compared with bcl2++ cases (P = .0011). At 5 years, bcl2-/+ patients showed a DFS rate of 74%, in contrast to bcl2++ patients with a DFS rate of 41% (P = .002). Bcl2 was the strongest independent prognostic value in a multivariate analysis, with a relative risk (RR) of 3.0 in comparison to p53 expression and the clinical factors of the IPI. Overall survival (OS) was not significantly influenced by bcl2 protein expression. p53 protein expression was found in 13% of cases, with a higher frequency in patients with extensive disease. p53 expression did not influence the chance to achieve complete remission (CR) and survival. CONCLUSION: bcl2 protein is frequently expressed in LCL and is a strong independent prognostic factor for DFS. p53 expression is related with high tumor burden, but is not an independent risk factor for CR and survival.

Intensive postremission chemotherapy without maintenance therapy in adults with acute lymphoblastic leukemia. Dutch Hemato-Oncology Research Group.

PURPOSE: To investigate the value of intensive consolidation chemotherapy not followed by maintenance therapy in adult acute lymphoblastic leukemia (ALL). MATERIALS AND METHODS: A multicenter phase II trial was conducted in 130 adult patients with ALL between 16 and 60 years of age. After standard induction therapy, postinduction chemotherapy was given: three courses of high-dose cytarabine (2,000 mg/m2 every 12 hours for four doses) in combination with amsacrine (course one), mitoxantrone (course two), and etoposide (course three). CNS prophylaxis consisted of 10 injections of intrathecal methotrexate (IT MTX). Patients younger than 50 years with an HLA-identical sibling were eligible to receive allogeneic bone marrow transplantation (BMT). RESULTS: Ninety-five patients (73%) achieved complete remission (CR); 82% were younger than 50 years and 41% were older than 50 years. Seventeen patients (13%) were resistant to chemotherapy, and 18 (14%) died during induction treatment. Only age and performance status were significantly associated with response (P<.001 and .03, respectively). Death during consolidation occurred in four patients. The estimated 5-year overall survival (OS) was 22% for the entire group and 26% for patients younger than 35 years. Disease-free survival (DFS) at 5 years was 28% +/- 6 for patients younger than 35 years, 25% +/- 9 for patients between 35 and 50 years, and 0% for patients older than 50 years. Increasing age (P<.01) and expression of CD34 (P<.01) were adverse factors. Only three patients (3%) developed an isolated CNS relapse. CONCLUSION: Intensive consolidation including high-dose cytarabine not followed by maintenance therapy provides an outcome for adult patients with ALL that may be worse or even inferior compared with studies using long-term maintenance therapy. High-dose cytarabine in combination with IT MTX was effective for CNS prophylaxis.

Unrelated bone marrow transplantation as a rescue procedure following inadvertent loss of an autologous bone marrow graft.

We report a 27-year-old male patient with acute myeloid leukaemia who was successfully treated with an unrelated bone marrow graft within 7 days following the loss of his autologous bone marrow graft. Several factors were found to be essential in order to locate an HLA-ABDR (DRB1)DQ(DQB1) identical, sex-matched, CMV-negative and ABO compatible donor within a week. These included a common HLA phenotype of the patient, the presence of an experienced donor registry in close proximity to a blood bank associated with an HLA laboratory, a large donor file with fully HLA-ABDR typed donors and the almost exclusive use of blood bank donors as potential bone marrow donors. The possibility of further streamlining the logistics of finding a suitable unrelated bone marrow donor is discussed.

Trisomy of chromosome 22 in acute myelomonocytic leukemia.

A patient with acute myelomonocytic leukemia type M4, with a trisomy 22 as the only chromosomal abnormality is reported. All six previously published cases with this anomaly had acute myeloid leukemia. The subtype was AMMoL in five patients, and the subtype of the sixth one was not indicated.

der(1)t(1;9): a specific chromosome abnormality in polycythemia vera? Cytogenetic and in situ hybridization studies.

Two patients with polycythemia vera and an extra der(1)t(1;9) chromosome are reported. In one patient this was found as the sole abnormality. The other patient originally presented with trisomy 9 but later developed an extra der(1) during the further course of the disease with disapperance of the extra chromosome 9. In situ hybridization studies on this latter patient proved that the centromere of chromosome 1 was involved in the formation of the derivative chromosome.

Mitoxantrone, teniposide, chlorambucil and prednisone (MVLP) for relapsed non-Hodgkin's lymphoma. The impact of advanced age and performance status.

Fifty-seven patients with relapsed non-Hodgkin's lymphoma (NHL) of low, intermediate and high-grade malignancy were treated with mitoxantrone, teniposide (Vm26), chlorambucil (Leukeran) and prednisone (MVLP). The median age was 71 years; none of the patients was excluded due to poor performance status (PS). Out of 44 patients with PS (according to WHO) < or = 2, 38 responded with a median progression free survival (PFS) of 21.5 months. Of 13 patients with PS > 2, 6 responded with a median PFS of 8.2 months. Haematopoietic toxicity was related to PS rather than to dose intensity or bone marrow involvement. Three patients died within a short time due to toxicity; another two died later as a result of cardiac failure probably due to accumulated toxicity of adriamycin and mitoxantrone. MVLP chemotherapy is effective and feasible and has only moderate toxicity in patients with relapsed NHL and PS < or = 2, despite advanced age.

The factor VIII ratio in normal and pathological pregnancies.

The factor VIII ratio was measured in 102 pregnant women (43 uncomplicated pregnancies, 19 with pre-eclampsia without fetal growth retardation, 8 pre-eclampsia complicated by fetal growth retardation, 12 with only fetal growth retardation and 20 with gestational diabetes). The pathological pregnancies showed a statistically significant elevation of the factor VIII ratio compared to the normal pregnancies. The group of pre-eclampsia complicated by fetal growth retardation showed the most marked increase of the factor VIII ratio. The results are discussed in relation to the hypothesis that the elevated factor VIII ratio is mainly due to the release of factor VIII antigen by various forms of vascular stress.

[The 'Anemia in the midwife practice' standard issued by the Royal Dutch Organisation of Midwives: a risk of not recognizing iron deficiency and hemoglobinopathy]. / De standaard 'Anemie in de eerstelijns verloskundige praktijk' van de Koninklijke Nederlandse Organisatie van Verloskundigen (KNOV): risico voor het niet onderkennen van ijzergebrek en hemoglobinopathie.

The standard entitled 'Anaemia in the midwife practice' issued by the Royal Dutch Organisation of Midwives presumes that the only reason for iron therapy in pregnancy is the prevention of adverse pregnancy outcome due to a low haemoglobin level. Pregnant women are screened for iron deficiency anaemia by means of sequential testing of haemoglobin and mean corpuscular volume (MCV). As a result only 10% of pregnant women will receive iron supplements. This practice will lead to a deterioration in the already low iron status of Dutch premenopausal women. As the haemoglobin reference values are lower than hitherto used, only severely anaemic women will be detected. Due to the low diagnostic accuracy of the MCV test the subsequent selection will be an arbitrary one. The standard sets the cut-off values for haemoglobin in black women at an even lower level, which will reduce the number of haemoglobinopathies detected in the immigrant population. The non-carriers in this group will run an increased risk of adverse pregnancy outcome if these cut-off values are used. We are strongly in favour of the measurement of haemoglobin, erythrocyte indices and ferritin in early pregnancy. In this way, iron deficiency, iron deficiency anaemia, anaemia due to other causes and haemoglobinopathies, the latter highly underestimated in the standard, can be detected.

[Agranulocytosis caused by clozapine: the importance of leukocyte monitoring and efficacy of hematopoietic growth factors]. / Agranulocytose door clozapine: het belang van leukocytencontrole en het nut van bloedgroeifactoren.

In four patients, a woman aged 85 and three men aged 33, 42 and 70 years, clozapine-induced agranulocytosis was diagnosed. In three patients the white cell counts were not performed as they should have been. Two patients were treated for their agranulocytosis with granulocyte colony-stimulating factor (G-CSF; filgrastim). Two patients were not treated. The literature concerning clozapine-induced agranulocytosis and its treatment with growth factors consists of only a few case reports. Therefore a definite conclusion about the efficacy of the treatment for this particular indication is not yet possible.

[Are hematologic reference values applicable to the healthy elderly?]. / Zijn de hematologische referentiewaarden van toepassing op gezonde bejaarden?

In the healthy elderly (65-90 years; 80 men, 75 women) the variability of haematological findings was examined and compared with the reference range. In the men, the ranges for haemoglobin valves (7.4-10.5 mmol/l) and erythrocyte counts (3.8-5.5 x 10(12)/l) proved to be lower than the reference intervals (8.5-10.9 mmol/l and 4.4-6.0 x 10(12)/l respectively). For the women no discrepancies were found. The question arises whether the reference limits for haemoglobin and erythrocytes should be lowered for elderly men.

[Radioactive phosphorus (32P); an old but not bad treatment for polycythemia vera]. / Radioactief fosfor (32P); een oude, maar geen slechte behandeling voor polycythaemia vera.

OBJECTIVE: To determine if there is a place for radiophosphorus (32P) in the treatment of polycythaemia vera (PV) and essential thrombocytosis (ET). DESIGN: Retrospective. SETTING: Leyenburg Hospital, The Hague, the Netherlands. METHOD: Data on 144 patients with the diagnoses 'PV' or 'ET' from 1965 to 1994 were collected. Available data were insufficient in 19 of these. Regarding 125 patients, 80 with PV and 45 with ET, the survival and the frequency of acute leukaemia with various forms of treatment (32P, busulfan or combination of several treatment modalities) were studied. Moreover, in the PV group the duration of survival was compared with the expected duration of survival in a comparable group of the population. RESULTS: Of the 80 PV patients, five developed acute leukaemia: two in the 32P group (5%), two in the busulfan group (12%) and one in the group given combination therapy (4%). Of the 26 patients of the ET group treated with busulfan, one developed acute leukaemia (4%). The survival in the PV group was 4 years shorter than the expected duration of survival in a comparable group of the population. CONCLUSION: Since 32P is efficacious and causes little inconvenience, it should be the drug of first choice in the treatment of PV in the elderly.