Causal Attributions and Perceived Severity as Predictors of Posttraumatic Stress Symptoms after a First Myocardial Infarction / Atribuciones causales y gravedad percibida como predictores de síntomas de estrés post-traumático tras un primer infarto de miocardio

Recent meta-analyses have shown a significant link between symptoms of anxiety and depression, and cardiovascular diseases (CVDs). The presence of these symptoms has a direct impact on the course and the recovery from the CVDs. A less analyzed aspect is the role played by the stress induced by the onset of CVDs conditions and, especially, by acute myocardial infarction (AMI). In this study, we assessed posttraumatic stress symptoms (PTSS), emotional state, health habits, and subjective perception of the event and causal attributions regarding the infarct, in a sample of 76 patients who had suffered an AMI in the previous 48-72 hours. Structural equation analyses and path analyses showed that the severity of PTSS was predicted by the perceived severity of the AMI and by two specific beliefs (i.e., considering that the AMI is a hereditary condition and that the help of others will not be beneficial). The results suggest the possibility of early identification of patients with a higher risk of suffering a high level of stress derived from the AMI. Based on this evidence, we discuss the possibilities of making effective interventions to reduce these symptoms, often ignored in clinical practice, and improve the medical and psychological prognosis of people with AMI.(AU)

Metanálisis recientes han demostrado una asociación significativa entre los síntomas postraumáticos y las enfermedades cardiovasculares (ECV). La presencia de este tipo de síntomas psicopatológicos tiene un impacto directo en el curso y la recuperación de dichas enfermedades. Un aspecto menos estudiado es el papel que juega el estrés provocado por la vivencia de una enfermedad cardiovascular, y, en especial, por el infarto agudo de miocardio (IAM). En este estudio se evaluaron los síntomas postraumáticos, el estado emocional, los hábitos de salud, la percepción subjetiva del suceso y las atribuciones causales respecto al infarto, en una muestra de 76 pacientes que habían sufrido un IAM en las 48-72 horas previas. El análisis de ecuaciones estructurales y el análisis de sendero (path analysis) mostraron que tanto la gravedad percibida del IAM, como dos creencias concretas (considerar que el infarto es un problema hereditario y que la ayuda de otros no es beneficiosa), predecían la gravedad percibida de los síntomas postraumáticos. Los resultados sugieren la posibilidad de identificar precozmente a los pacientes con mayor riesgo de sufrir un alto nivel de estrés derivado del IAM, gracias a sus atribuciones y su percepción de la gravedad del infarto. En base a esta evidencia, se discuten las posibilidades de realizar intervenciones efectivas para reducir estos síntomas y mejorar el pronóstico de las personas que han sufrido un IAM.(AU)

Miopatía necrosante inmunomediada seronegativa con afectación miocárdica / Seronegative immune-mediated necrotising myopathy with myocardial involvement

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Association of Fluid Overload With Clinical Outcomes in Critically Ill Children With Bronchiolitis: Bronquiolitis en la Unidad de Cuidados Intensivos Pediátricos (BRUCIP) Study.

OBJECTIVES: Increasing evidence supports the association of fluid overload with adverse outcomes in different diseases. To our knowledge, few studies have examined the impact of fluid balance on clinical outcome in severe bronchiolitis. Our aim was to determine whether fluid overload was associated with adverse clinical outcomes in critically ill children with severe bronchiolitis. DESIGN: Descriptive, prospective, multicenter study. SETTING: Sixteen Spanish PICUs. PATIENTS: Severe acute bronchiolitis who required admission from October 2014 to May 2015 were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Total fluid intake and output were prospectively recorded during PICU assistance. Fluid balance was measured at 24, 48, and 72 hours after PICU admission. A total of 262 patients were enrolled; 54.6% were male. Median age was 1 month (interquartile range, 1-3 mo). Patients had a positive fluid balance during the first 4 days of PICU admission, reaching a neutral balance on day 4. A positive balance at 24 hours in patients admitted to the PICU with severe bronchiolitis was related with longer stay in PICU (p < 0.001), longer hospital stay (p < 0.001), longer duration of mechanical ventilation (p = 0.016), and longer duration of noninvasive ventilation (p = 0.0029). CONCLUSIONS: Critically ill patients with severe acute bronchiolitis who present a positive balance in the first 24 hours of PICU admission have poorer clinical outcomes with longer PICU and hospital length of stay and duration of invasive and noninvasive mechanical ventilation.

Prospective Multicentre Study on the Epidemiology and Current Therapeutic Management of Severe Bronchiolitis in Spain.

Objective. To determine the epidemiology and therapeutic management of patients with severe acute bronchiolitis (AB) admitted to paediatric intensive care units (PICUs) in Spain. Design. Descriptive, prospective, multicentre study. Setting. Sixteen Spanish PICUs. Patients. Patients with severe AB who required admission to any of the participating PICUs over 1 year. Interventions. Both epidemiological variables and medical treatment received were recorded. Results. A total of 262 patients were recruited; 143 were male (54.6%), with median age of 1 month (0-23). Median stay in the PICU was 7 days (1-46). Sixty patients (23%) received no nebuliser treatment, while the rest received a combination of inhalation therapies. One-quarter of patients (24.8%) received corticosteroids and 56.5% antibiotic therapy. High-flow oxygen therapy was used in 14.3% and noninvasive ventilation (NIV) was used in 75.6%. Endotracheal intubation was required in 24.4% of patients. Younger age, antibiotic therapy, and invasive mechanical ventilation (IMV) were risk factors that significantly increased the stay in the PICU. Conclusions. Spanish PICUs continue to routinely use nebulised bronchodilator treatment and corticosteroid therapy. Despite NIV being widely used in this condition, intubation was required in one-quarter of cases. Younger age, antibiotic therapy, and IMV were associated with a longer stay in the PICU.

Role of Medical Nutrition Therapy in the Management of Gestational Diabetes Mellitus.

Medical nutrition therapy (MNT) plays an important role in the management of gestational diabetes mellitus (GDM), and accordingly, it has a significant impact on women and newborns. The primary objective of MNT is to ensure adequate pregnancy weight gain and fetus growth while maintaining euglycemia and avoiding ketones. However, the optimal diet (energy content, macronutrient distribution, its quality and amount, among others) remains an outstanding question. Overall, the nutritional requirements of GDM are similar for all pregnancies, but special attention is paid to carbohydrates. Despite the classical intervention of restricting carbohydrates, the latest evidence, although limited, seems to favor a low-glycemic index diet. There is general agreement in the literature about caloric restrictions in the case of being overweight or obese. Randomized controlled trials are necessary to investigate the optimal MNT for GDM; this knowledge could yield health benefits and cost savings.

[Factors associated with atelectasis following extubation in very low weight premature newborns]. / Atelectasia por extubación en neonatos prematuros con muy bajo peso. Factores relacionados con su presencia.

BACKGROUND: Atelectasis is a decrease of lung volume caused by airway obstruction or pressure on the external part of the lung. It is common after surgery and extubation. The purpose of this investigation was to determine factors related with alectasis following extubation in preterm neonates with a weight under 1250 g who were referred to a neonatal intensive care unit. METHODS: The study was conducted in neonates admitted to a neonatal intensive care unit requiring mechanically assisted ventilation. Preterm neonates born at 28 to 36 weeks' gestation and with 0 to 28 days' extrauterine life, with mechanically assisted ventilation for at least 24 hours, and that when undergoing planned extubation had a weight under 1250 g were included. Two comparative groups were formed: group A, with alectasis after extubation; group B, without alectasis after extubation. RESULTS: As factors associated with alectasis after extubation, reintubation in two or more occasions and cycling higher than 20 per minute, which were statistically relevant, were identified. CONCLUSIONS: In addition to previous general measures to prevent alectasis, extubation with ventilation not higher tan 20 cycles per minute should be programmed and reintubation should be avoided as much as possible.

INTRODUCCIÓN: la atelectasia es la disminución del volumen pulmonar causada por obstrucción de las vías aéreas o presión en la parte externa del pulmón. Es común después de una cirugía y de la extubación. El objetivo de esta investigación fue determinar los factores relacionados con la atelectasia posterior a extubación en recién nacidos prematuros con peso menor de 1250 g que fueron referidos a una unidad de cuidados intensivos neonatales. MÉTODOS: el estudio se realizó en los neonatos que ingresaron a una unidad de cuidados intensivos neonatales y que ameritaron asistencia mecánica para la ventilación. Se incluyeron los recién nacidos pretérmino de 28 a 36 semanas de gestación y de 0 a 28 días de vida extrauterina, con asistencia mecánica para la ventilación por lo menos durante 24 horas y que al ser extubados en forma planeada tuvieron un peso menor a 1250 g. Se formaron dos grupos comparativos: grupo A, con atelectasias posterior a extubación; grupo B, sin atelectasia posterior a extubación. RESULTADOS: como factores relacionados con la atelectasia posterior a la extubación se identificó la reintubación en dos o más ocasiones y el ciclado mayor de 20 por minuto, que fueron estadísticamente relevantes. CONCLUSIONES: además de las medidas generales previas, para evitar la atelectasia debe programarse la extubación con parámetros de ventilación no mayores de 20 ciclos por minuto y evitar, en la medida de lo posible, las reintubaciones.

Esophageal multichannel intraluminal impedance and pH testing in the study of apparent life threatening episode incidents in infants.

INTRODUCTION: The conventional 24-hour pH monitoring is the gold standard for the diagnosis of gastro-esophageal reflux (GER), a possible cause of Apparent Life Threatening Episodes (ALTE). However, multichannel intraluminal impedance (MII) may provide advantages. OBJECTIVES: Comparison of the results of MII and pH monitoring in patients undergoing MII-pH monitoring in the 3-year study period because of having suffered from ALTE. MATERIAL AND METHODS: Prospective study of MII-pH monitoring performed in our unit to infants < 12 months of ageadmitted for ALTE for a 3-year period. RESULTS: Thirty nine patients studied. 2,692 pH monitoring episodes, with median of 24 (IQ: 15-44) episodes/patient, 1.30 (IQ: 0.80-2.60) reflux/hour, 1 (IQ: 0-4) reflux episode > 5 min per patient and clearance of 1.20 (IQ: 0.70-2.20) min/reflux. With pH monitoring analysis, 14 children (35.9 %) could have been diagnosed as GER (8 mild, 4 moderate and 2 severe) based on the classical criteria. MII identified a total of 8,895 events; only 3,219 among them were refluxes, with a median of 75 (IQ: 54-111) per patient, 1.30 (IQ: 1.3-2.6) episodes/hour). With MII-pH monitoring combination there were 21.60 (SD 15.21) acid reflux episodes, 67.33 weekly acid (SD 32.09) and 3.34 (SD 7.23) non-acid, being finally diagnosed 33 patients as GER. CONCLUSIONS: The association of pH monitoring and MII provides additional information that improves GER diagnostic performance without posing any additional risk to the infant patient. The non-acid/weekly acid refluxes, not detected by pH monitoring, account for a high percentage of episodes, this may have diagnostic and therapeutic significance, especially in infants. Further studies are needed to assess the normality of MMI in pediatric patients.

[Anthropometric and biochemical indices in the nutritional assessment of the newborn with extremely low weight]. / Índices antropométricos y bioquímicos en la valoración nutricional del neonato de peso muy bajo.

OBJECTIVE: To evaluate anthropometric and biochemical indices of the nutritional status of newborn with extremely low weight. METHODS: It was carried out a cohort study with 10 patients included, of both sexes, and weight at birth between 700-1200 g, who were under treatment with parenteral nutrition (PN), and/or minimal enteric stimulus (MES). RESULTS: Nine patients (90 %) received PN plus MES. One patient received only oral or enteric nutrition. Daily increase in weight was 7-23.8 g with an average of 15.6 g. In size, weekly increase was 0.30-1.5 cm with an average of 0.78 cm. In cephalic perimeter, the weekly increase was between 0.1-1.1 cm weekly with an average of 0.57 cm. Once the PN treatment was stopped and the patients were managed only with oral feeding, the weigh increases ranged between 12.5-35 g per day with an average of 22.7 g/day; height increased weekly from 0.45 to 1.1 cm, with an average of 0.89 cm/week; cephalic perimeter increased weekly from 0.45 to 1.3 cm, with an average of 0.80 cm. All the patients (100 %) had a positive nitrogen balance. CONCLUSIONS: The treatment of PN and MES is a useful strategy in order to keep a positive nitrogen balance and promote the increase in weight, size and cephalic perimeter so that the newborn could get the rate of growth in utero.

OBJETIVO: evaluar los índices antropométricos y bioquímicos del neonato de peso extremadamente bajo. MÉTODOS: estudio de cohorte en el que se evaluaron 10 pacientes con peso al nacer entre 700 y 1200 g, a quienes se les proporcionó nutrición parenteral y enteral. RESULTADOS: 90 % de los recién nacidos recibió nutrición parenteral más estímulo enteral mínimo, con los que registró un incremento diario de peso de 7 a 23 g, con una media de 15.6 g; en la talla, el incremento fue de 0.30 a 1.5 cm semanales, con una media de 0.78 cm; y en el perímetro cefálico, entre 0.1 y 1.1 cm semanales, con una media de 0.57 cm. Al suspender la nutrición parenteral y administrar vía oral exclusiva, el incremento del peso osciló entre 12.5 y 35 g diarios, con una media de 22.7 g; la talla aumentó de 0.45 a 1.1 cm semanales, con una media de 0.89 cm; el perímetro cefálico, de 0.45 a 1.3 cm semanales, con una media de 0.80 cm. Todos los neonatos tuvieron balance nitrogenado positivo. CONCLUSIONES: se debe iniciar la nutrición parental total desde el primer contacto con el paciente y, de ser posible, el estímulo enteral mínimo para mantener un balance nitrogenado positivo y favorecer el aumento de peso, talla y perímetro cefálico para alcanzar la tasa de crecimiento in utero.

Impedanciometría esofágica multicanal y pHmetría en el estudio del episodio de riesgo vital aparente del lactante / Esophageal multichannel intraluminal impedance and pH-testing in the study of apparent life threatening episode incidents in infants

Introducción: la pHmetría convencional de 24 horas constituye el patrón de oro para el diagnóstico de episodios de riesgo vital aparente (ALTE). La impedanciometría intraluminal multicanal (IIM) puede aportar ventajas en el lactante. Objetivos: comparación de los resultados de IIM y pHmetría en los pacientes sometidos a IIM-pHmetría en el periodo de estudio por causa de estudio de ALTE. Material y métodos: estudio retrospectivo de IIM-pHmetrías realizadas en nuestro servicio a lactantes < 12 meses de edad ingresados por ALTE durante tres años. Resultados: 39 pacientes estudiados. La pHmetría registró 2.692 reflujos, con medianas de 24 (IQ: 15-44) reflujos/paciente, índice de reflujo de 1,30 (IQ: 0,80-2,60) reflujos/hora, 1 (IQ: 0-4) episodio de reflujo > 5 min por paciente y aclaramiento de 1,20 (IQ: 0,70-2,20) min/reflujo. Por pHmetría 14 niños (35,9 %) fueron diagnosticados de RGE. Mediante IIM se registraron 8.895 eventos; 3.219 fueron reflujos, con mediana de 75 (IQ: 54-111) reflujos/ paciente, 1,30 (IQ: 1,3-2,6) reflujos/hora. Mediante IIM-pHmetría, la media de reflujos ácidos por paciente fue de 21,60 (DE 15,21), débilmente ácidos 67,33 (DE 32,09) y no ácidos 3,34 (DE 7,23), pudiéndose diagnosticar finalmente a 33 pacientes de RGE. Conclusiones: la asociación de IMM y pHmetría proporciona información adicional que mejora el rendimiento diagnóstico, sin suponer ningún riesgo adicional para el paciente. Los reflujos no ácidos/débilmente ácidos, los cuales no son detectados mediante pHmetría, suponen un porcentaje elevado, sobre todo en lactantes; esto tiene gran importancia diagnóstica en el estudio del ALTE. Aún son necesarios estudios para valorar la normalidad en IIM en pacientes pediátricos (AU)

Introduction: The conventional 24-hour pH monitoring is the gold standard for the diagnosis of gastro-esophageal reflux (GER), a possible cause of Apparent Life Threatening Episodes (ALTE). However, multichannel intraluminal impedance (MII) may provide advantages. Objectives: Comparison of the results of MII and pH monitoring in patients undergoing MII-pH monitoring in the 3-year study period because of having suffered from ALTE. Material and methods: Prospective study of MII-pH monitoring performed in our unit to infants < 12 months of age admitted for ALTE for a 3-year period. Results: Thirty nine patients studied. 2,692 pH monitoring episodes, with median of 24 (IQ: 15-44) episodes/patient, 1.30 (IQ: 0.80-2.60) reflux/hour, 1 (IQ: 0-4) reflux episode > 5 min per patient and clearance of 1.20 (IQ: 0.70-2.20) min/reflux. With pH monitoring analysis, 14 children (35.9 %) could have been diagnosed as GER (8 mild, 4 moderate and 2 severe) based on the classical criteria. MII identified a total of 8,895 events; only 3,219 among them were refluxes, with a median of 75 (IQ: 54-111) per patient, 1.30 (IQ: 1.3-2.6) episodes/hour). With MII-pH monitoring combination there were 21.60 (SD 15.21) acid reflux episodes, 67.33 weekly acid (SD 32.09) and 3.34 (SD 7.23) non-acid, being finally diagnosed 33 patients as GER. Conclusions: The association of pH monitoring and MII provides additional information that improves GER diagnostic performance without posing any additional risk to the infant patient. The non-acid/weekly acid refluxes, not detected by pH monitoring, account for a high percentage of episodes, this may have diagnostic and therapeutic significance, especially in infants. Further studies are needed to assess the normality of MMI in pediatric patients (AU)

Low-carbohydrate diet for the treatment of gestational diabetes mellitus: a randomized controlled trial.

OBJECTIVE: Medical nutrition therapy based on the control of the amount and distribution of carbohydrates (CHO) is the initial treatment for gestational diabetes mellitus (GDM), but there is a need for randomized controlled trials comparing different dietary strategies. The purpose of this study was to test the hypothesis that a low-CHO diet for the treatment of GDM would lead to a lower rate of insulin treatment with similar pregnancy outcomes compared with a control diet. RESEARCH DESIGN AND METHODS: A total of 152 women with GDM were included in this open, randomized controlled trial and assigned to follow either a diet with low-CHO content (40% of the total diet energy content as CHO) or a control diet (55% of the total diet energy content as CHO). CHO intake was assessed by 3-day food records. The main pregnancy outcomes were also assessed. RESULTS: The rate of women requiring insulin was not significantly different between the treatment groups (low CHO 54.7% vs. control 54.7%; P = 1). Daily food records confirmed a difference in the amount of CHO consumed between the groups (P = 0.0001). No differences were found in the obstetric and perinatal outcomes between the treatment groups. CONCLUSIONS: Treatment of women with GDM using a low-CHO diet did not reduce the number of women needing insulin and produced similar pregnancy outcomes. In GDM, CHO amount (40 vs. 55% of calories) did not influence insulin need or pregnancy outcomes.

Stress-related symptoms and positive emotions after a myocardial infarction: a longitudinal analysis.

BACKGROUND: There is a controversy as to whether the diagnostic umbrella of post-traumatic stress reactions is directly applicable to serious health conditions like myocardial infarction (MI). OBJECTIVE: The principal objective of this study was to examine longitudinally the prevalence of posttraumatic stress-related symptoms, throughout three measurement periods, for patients who had suffered a first MI. In addition to the analysis of symptoms related to stress and general distress, the presence of and temporary evolution of positive emotions and optimism in these patients was also evaluated. DESIGN: A longitudinal study with three periods of evaluation after the MI (Time 1 (T1): 48-72 hours, Time 2 (T2): 5 months, and Time 3 (T3): 13 months). RESULTS: In T1 few symptoms related to the stressful event were found. The probable prevalence of PTSD was 8-11% at 5 months after the MI and 0-3% 13 months after the event. With regard to subjective severity of the infarction, although in the first instance patients did not regard the event as excessively traumatic, in the periods T2 and T3 this perception increased significantly [F (2, 32)=20.00; p=0.0001]. At all times during the measurement period the mean positive affect was significantly greater than the negative affect. CONCLUSIONS: As the results show, the probable prevalence of PTSD, as well as the severity of different symptom clusters, is low at all times of the evaluation. The diagnostic implications of these findings are discussed as well as the uses and abuses of diagnostic labels to characterize the psychological experiences lived through after a potentially life-threatening health problem.

Identification of leptomeningeal disease in aggressive B-cell non-Hodgkin's lymphoma: improved sensitivity of flow cytometry.

PURPOSE: Here, we evaluate the sensitivity and specificity of a new 11-parameter flow cytometry (FCM) approach versus conventional cytology (CC) for detecting neoplastic cells in stabilized CSF samples from newly diagnosed aggressive B-cell non-Hodgkin's lymphoma (B-NHL) at high risk of CNS relapse, using a prospective, multicentric study design. PATIENTS AND METHODS: Moreover, we compared the distribution of different subpopulations of CSF leukocytes and the clinico-biologic characteristics of CSF+ versus CSF-, patients, in an attempt to define new algorithms useful for predicting CNS disease. RESULTS: Overall, 27 (22%) of 123 patients showed infiltration by FCM, while CC was positive in only seven patients (6%), with three other cases being suspicious (2%). CC+/FCM+ samples typically had more than 20% neoplastic B cells and/or >or= one neoplastic B cell/microL, while FCM+/CC- samples showed lower levels (P < .0001) of infiltration. Interestingly, in Burkitt lymphoma, presence of CNS disease by FCM could be predicted with a high specificity when increased serum beta2-microglobulin and neurological symptoms coexisted, while peripheral blood involvement was the only independent parameter associated with CNS disease in diffuse large B-cell lymphoma, with low predictive value. CONCLUSION: FCM significantly improves the sensitivity of CC for the identification of leptomeningeal disease in aggressive B-NHL at higher risk of CNS disease, particularly in paucicellular samples.

Emociones positivas y crecimiento postraumático en el cáncer de mama / Positive emotions and posttraumatic growth after breast cancer

Cada vez hay más interés por el estudio del papel del afecto positivo (AP) en personas sanas y en la enfermedad. El AP puede tener un rol importante en el inicio, desarrollo y mantenimiento de diversas enfermedades a través de vías directas (ej. Sistema inmunológico) o indirectas (ej. Promoviendo formas de afrontamiento más adecuado). En este trabajo se revisan brevemente los resultados más relevantes en este campo de investigación. El afecto y las cogniciones positivas, además de su posible papel causal, pueden ser también un resultado de situaciones de salud amenazantes para la vida y en general de situaciones altamente traumáticas. A veces estas situaciones extremas (ej. El diagnóstico o el padecimiento de un cáncer) pueden producir secuelas psicológicas beneficiosas en quienes las padecen. El nuevo concepto de Crecimiento Postraumático (CPT) recoge esta idea. En este artículo hacemos una revisión de los datos existentes sobre las relaciones entre CPT y el cáncer de mama, así como los factores sociodemográficos y clínicos que parecen más relevantes como mediadores de dichas relaciones. Se discute la utilidad clínica del concepto, su relación con medidas de resultados clínicos y la conveniencia de diseñar intervenciones en esta área. Finalmente se sugieren nuevas vías de investigación en este campo prometedor (AU)

There is a growing interest to analyze the role that positive affect (PA) may have in both health and illness. PA may play an important role in the onset, development and maintenance of different illnesses either through direct pathways (e.g., immunological system) or indirect ones (e.g., immunological system) or indirect ones (e.g., by promoting adaptive ways of coping). In this paper we review the most relevant results in this research field. Resides their possible causal role, positive emotions and cognitions may also be an outcome of life-threatening conditions and, in general, of highly traumatic situations. Sometimes, these extreme situations (e.g., having been diagnosed with cancer or suffering cancer) may produce secondary psychological benefits in those who suffer them. The new concept of Posttraumatic Growth (PTG) precisely captures this idea. In this paper we specifically review the most relevant literature that has explored the association between PTG and breast cancer. We also review the main sociodemographic and clinical variables that may moderate those relationships. The clinical utility of the PTG concept is discussed as well as its relation with clinical outcomes and the convenience of designing interventions to foster PTG. Finally, we suggest new research areas within this promising field (AU)

Erythrophagocytosis in de novo-philadelphia-positive acute leukemia of ambiguous lineage.

Erythrophagocytosis by neoplastic cells in acute leukemia has been most frequently associated with FAB M4 and M5 subtypes, with the t(8;16) and with C-MOZ rearrangements, however it is exceptional in acute lymphoblastic leukemia and has not been previously reported in Philadelphia-positive (Ph+) acute leukemia. We herein present a case of Ph+ acute leukemia of ambiguous lineage in which erythrophagocytosis is an outstanding feature. The implications between the different postulated leukemogenic pathways and the hypothesized mechanism of erythrophagocytosis are concisely reviewed and discussed.