Busulfan plus cyclophosphamide followed by autologous blood stem-cell transplantation for patients with acute myeloblastic leukemia in first complete remission: a report from a single institution.

PURPOSE: To determine if peripheral-blood stem cells (PBSC) collected during the recovery of standard induction and consolidation chemotherapy in acute myeloblastic leukemia (AML) can be used as a safe tool for autologous transplantation, and to study aspects of the autologous blood stem-cell transplantation (ABSCT) procedure and their results in AML patients in first remission. PATIENTS AND METHODS: Twenty-four AML patients in first remission received busulfan (BU; 16 mg/kg) and cyclophosphamide (CY; 200 mg/kg) followed by ABSCT. PBSC were collected by continuous-flow leukaphereses after induction and consolidation courses. RESULTS: The median numbers of mononuclear cells (MNCs) and colony-forming unit granulocyte-macrophage (CFU-GM) administered were 6 x 10(8)/kg and 11 x 10(4)/kg, respectively. ABSCT induced engraftment in 22 patients and there were two graft failures. The median times to reach a polymorphonuclear (PMN) leukocyte count of 0.5 x 10(9)/L and a platelet count of 50 x 10(9)/L were 13 and 19 days, respectively. Fatal hepatic veno-occlusive disease (VOD) was observed in two cases. Other toxicities were mild and uncommon. Twelve patients relapsed between 1 and 9 months posttreatment. Actuarial disease-free survival (DFS) and actuarial risk of relapse at 30 months were 35% (95% confidence interval [CI], 25% to 45%) and 60% (95% CI, 50% to 72%), respectively. CONCLUSION: These preliminary results show the fast hematopoietic recovery and the low infectious and hemorrhagic morbidity associated with the procedure and strongly suggest that ABSCT may be as effective as autologous bone marrow transplantation (ABMT) in AML. However, further strategies for reducing leukemic relapse must still be investigated.

Surgery for gastroesophageal reflux disease: a comparative study between the open and laparoscopic approaches.

OBJECTIVE: Given the demonstrated effectiveness of medical treatment together with the eminent acceptance of the laparoscopic approach, the indications of surgery in the treatment of gastroesophageal reflux disease (GERD) are currently subject to continuous controversy. To participate in this debate, we have the following work hypothesis: "The results of the 360 masculine short and floppy laparoscopic fundoplication are superior to those of open surgery". CLINICAL DESIGN: Prospective, clinical, non-randomized study. PATIENTS: Our work was developed between November 1991 and December 1998 by means of a prospective, non-randomized clinical rehearsal with two groups of patients: Group I (n = 75): 360 degree short and floppy laparoscopic fundoplication in Hospital Dr. Peset, Valencia (Spain). Group II (n = 28): 360 degree short and floppy, open fundoplication in Hospital General, Valencia (Spain). We evaluated the preoperative parameters and found no differences, which allows us to know that both groups were comparable. RESULTS: The analysis of peroperative results (morbidity and surgical time) and of clinical follow-up (every three months and later annually) and instrumental follow-up (TEGD, upper digestive endoscopy, pHmetry and manometry) show no differences, while the postoperative analysis shows statistically significant (s.s.) differences regarding recovery (pain, oral intake, hospital stay and return to previous activities). CONCLUSIONS: The results of the 360 degree short and floppy laparoscopic fundoplication are similar to those of the open approach, but favor the former approach with a better postoperative tolerance.

Recent improvements in outcome for elderly patients with de novo acute myeloblastic leukemia.

A retrospective analysis was performed on 263 consecutive patients aged over 60 with de novo acute myeloid leukemia (AML) diagnosed in a single institution between 1979 and 1998. Eighty-nine patients (33%) received only palliative treatment, while 174 patients (67%) were treated with different intensive chemotherapy regimens. The 5- and 10-year overall survival (OS) for the whole series was 7.7+/-1.2 and 4.3+/-1.6%, respectively. For patients receiving chemotherapy, OS was 10.5+/-2.5 and 7+/-2.6%, while for those patients receiving supportive treatment it was 1.1+/-1.1 and 0%, respectively (P=0.002). Within the group of patients receiving chemotherapy, the complete remission (CR) rate was 46%; treatment failure rate was 54% (36% due to treatment-related mortality and 18% due to resistant disease). Variables influencing CR rate were FAB subtype, CD7 positivity, chemotherapy regimen, creatinine level, hepatomegaly, and period of diagnosis. Median disease-free survival (DFS) duration was 8.4 months with a probability of being disease-free at 10 years of 10+/-5%. There were no significant differences in DFS according to age. According to the period of diagnosis (1979-1986 vs. 1987-1998), improvements in the CR rate (27 vs. 56%, P=0.0002), and OS (10.9 vs. 15.7 months, P=0.0007) were observed. This large single-center study of unselected de novo AML elderly patients substantiates the progressive improvement achieved in the management of elderly patients with AML, probably due to an improvement in supportive care and the administration of conventional induction chemotherapy.

Refractory anemia with monosomy 2 and a double minute chromosome.

We present a case of refractory anemia with monosomy 2 in the 41 cells of the bone marrow studied and a double minute chromosome (dmin) in 68% of these cells. The illness developed over a period of 3 years and the patient died of cerebral hemorrhage without developing leukemia.

Acute Promyelocytic Leukaemia. Relationship of Cytochemical Pattern with Clinical, Morphologic and Immunological Characteristics, and Outcome.

In a series of 61 acute promyelocytic leukemia (APL) cases multiple clinical and biological characteristics were studied in order to assess their prognostic significance and to evaluate the relationship of cytochemical pattern with clinical, morphologic, and immunological characteristics and outcome. Alpha-naphthyl acetate esterase (ANAE) activi1:y was expressed in 23 out of 41 cases (56%). Sodium fluoride-sensitive naphthol AS-D acetate esterase was evident in only one out of 22 cases (5 %). ANAE reactivity was more frequently found in typical hypergranular APL (P = 0.003) and was associated with a shorter interval symptoms-diagnosis (P = 0.04). The expression of HLA-DK, CD33, CD13 and CD11b did not show any correlation with ANAE reactivity. Complete remission (CR) was achieved in 64 % of treated patients. The actuarial median remission duration was 22 ± 3 months. CR rate was significantly related to the presence of fever, age, absolute reticulocyte count, and albumin level, while the remission duration was associated with absolute reticulocyte, leucocyte and granulocyte counts, and albumin level. In our study ANAE activity did not reflect any important clinical and biological features of APL, apart from its obvious correlation with morphological subtype. In addition ANAE activity did not correlate with early response to therapy nor related with long-term prognosis.

Acute myeloblastic leukemia with minimal myeloid differentiation (FAB AML-M0): a study of eleven cases.

The main clinical, morphological, cytochemical, immunological features and therapy results of eleven patients diagnosed as acute myeloblastic leukemia M0 (AML-M0) are reported here. There were no clinical characteristics, abnormalities on physical examination or initial laboratory parameters that distinguished these eleven patients. Bone marrow aspirates were hypocellular in four patients. The leukemic cells were undifferentiated by light microscopy and myeloperoxidase (MPO) and/or Sudan Black B (SBB) stains were negative in all cases. Myeloid differentiation antigens were present on the leukemic cells of all eleven patients, whereas B and T cell markers were clearly negative except for CD4 and CD7 antigens. Whatever the treatment employed survival was very short. Eight of the eleven patients were treated and two achieved complete remission (CR) but only one of them is alive in continuous CR. Our results like those previously reported, suggest that AML-M0 patients have a very poor prognosis with standard induction therapies and should perhaps be considered for experimental therapeutic approaches.

Beta-blockade and exercise capacity in patients with mitral stenosis in sinus rhythm.

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine whether beta-blocker treatment (atenolol) improves cardiopulmonary exercise performance and ventilatory response in patients with mitral stenosis in sinus rhythm. METHODS: A prospective study comparing the results of cardiopulmonary exercise tests (CPETs) was performed before and after atenolol therapy in 17 patients in NYHA classes I and II with mitral stenosis in sinus rhythm. Transthoracic echocardiography was performed pre-study, and left ventricular diameters, ejection fraction and mitral valve area monitored. CPETs (Naughton protocol) were performed by two different investigators before and after one-week atenolol therapy (50 mg/day). The second investigator was blinded to the result of the baseline test. O2 consumption, CO2 production, ventilatory parameters and respiratory exchange ratios were measured on line. RESULTS: Maximal O2 uptake (VO2max) did not differ significantly before and after beta-blockade (median 16.8 and 15.0 ml/kg/min, respectively. Median heart rate at rest (72 versus 55 beats/min; p = 0.0003) and during peak exercise (153 versus 105 beats/min; p = 0.0003), and anaerobic threshold (10 versus 8.9 ml/kg/min; p = 0.02) were lower with beta-blockade compared with the baseline state. Minute ventilation at maximum exercise (41 versus 40 l/min) and ventilatory equivalent for CO2 (34 versus 35) were unchanged with atenolol therapy, indicating no improvement in ventilatory performance. When patients were grouped into those in whom VO2max was improved with atenolol therapy (n = 7) and those in whom it was impaired (n = 10), there were no inter-group differences with respect to age, left ventricular function, severity of mitral stenosis, NYHA class and grade of beta-blockade reached. Four patients felt symptomatically worse during atenolol treatment (lower NYHA functional class). CONCLUSION: Beta-blockade does not improve exercise tolerance in patients with mitral stenosis in sinus rhythm. In addition, ventilatory performance does not change with treatment.

[Surgical trauma from laparoscopic cholecystectomy]. / Traumatismo quirúrgico de la colecistectomía laparoscópica.

UNLABELLED: The authors present a prospective study whose objective is to estimate the degree of injury from laparoscopic cholecystectomy, by means of the determination of the neuroendocrine response to the surgical aggression. By means of a simple randomization, two study groups are established: group A, consisting of 17 patients subjected to laparoscopic cholecystectomy, and group B, consisting of 18 patients subjected to different techniques of open surgery. EXCLUSION CRITERIA: transfusion of blood derivatives or therapy with corticosteroids. The groups are homogeneous with regard to age, sex, Quetelet index, duration of the intervention, and anaesthetic drugs. A postoperative increase of plasma ACTH, growth hormone, insulin, cortisol and T3 was found in both groups (p < 0.05), and a significant postoperative increase of cortisol and catecholamines in 24 hour urine was found especially in group B. It can be concluded that even though there is an increase of the contraregulatory hormones in the postoperative phase of both groups, the neuroendocrine response is lower after laparoscopic cholecystectomy.

[Venous reservoirs: the late complications according to the route of implantation. The Interhospital Group of Valencia (GIHV)]. / Reservorios venosos: complicaciones tardías según la vía de implantación. Grupo Interhospitalario Valenciano (GIHV).

UNLABELLED: The aim of the study which we present is to analyze the incidence of late complications, clinical and sub-clinical, of venous reservoirs implanted through two access routes, subclavian (group A), and brachial (group B). It is a multi-centric clinical study, initiated in 1992, in which the general surgery departments of three general hospitals of the Valencian Community were involved. It is made up of 87 patients, 48 men and 39 women, with a mean age (SD) of 57.1 (12.6) years, of whom we made a late review of 41 patients (29 from group A and 12 from group B). They were subjected to a physical examination, bacterial cultures of the entrance, and phlebograms of the upper extremities through the dorsal veins of the hands. RESULTS: The incidence of clinical complications was 39% in group A and 77% in group B (p = 0.0507). The main clinical complications were minimally symptomatic venous thrombosis, catheter thrombosis, infection, and miscellaneous (migration, paresthesias, articular movement alterations, etc.). And the prevalence of phlebographic venous thrombosis was 18% in group A and 40% in group B (p = 0.051). CONCLUSIONS: The subclavian access for the implantation of venous reservoirs has a lower incidence (with a tendency towards clinical significance) of clinical complications and subclinical venous thrombosis (Phlebogram) than the brachial access.

Laparoscopic reconstruction of intestinal continuity following Hartmann's procedure.

Laparoscopy-guided reversal of Hartmann's procedure was performed in eleven patients who had been treated surgically for inflammatory disease or cancer of the colon. Restoration of intestinal continuity was achieved in ten of them. There were no postoperative complications. The mean surgical time was 144 minutes and the mean duration of postoperative ileus was 48 hours (range: 30 to 60 hours). The mean hospital stay was 7 days. Our results suggest that laparoscopic reversal of Hartmann's procedure is safer than and as effective as open surgery.

Early results of laparoscopic resection of colorectal cancer.

OBJECTIVE: To study the immediate and early postoperative results obtained in patients subjected to laparoscopic resection of colorectal cancer. PATIENTS AND METHOD: A prospective, observational cohort study was initiated in January 1993, involving 50 patients subjected to laparoscopic resection for colorectal adenocarcinoma (rectal amputation in 10 cases, lower rectal resection in 13, recto-sigmoidectomy in 18, and miscellaneous colectomies in 9 cases). Seventy-percent of the tumors were in IUCC stages II and III. Mean follow-up was 21 months. RESULTS: Conversion to open surgery was required in 18 cases (36%). Intraoperative problems were limited to a single urethral lesion, while postoperative complications were recorded in 11 patients (22%), and were managed conservatively: a urinary fistula secondary to the aforementioned urethral lesion; subclinical dehiscence of the anastomosis (2 cases); phlebitis (1 case); infection of the surgical wound (4 cases), and urinary and pulmonary infection (1 case each). There were no differences between converted surgery (i.e., conventional laparotomy) and those operations completed endoscopically (with a final assisted or combined minilaparotomy) in terms of the length of the surgical resection piece, the length of the distal margin of the specimen or the number of lymph nodes. Global hospital stay ranged from 9-12 days, versus 5-7 in the group without complications. Global survival is 78% at 42 months, with a disease-free interval of 53% at this time. CONCLUSIONS: Laparoscopic colorectal resection presents an incidence of intra- and postoperative complications characteristic of major surgery, with no differences in surgical specimen size with respect to those operations converted to laparotomy. Global survival is similar to that reported in the literature for open surgery.

Laparoscopic choledochotomy in the management of choledocholithiasis. A report of 32 cases.

OBJECTIVE: we describe a choledochotomy technique for the laparoscopic removal of calculi in the management of choledocholithiasis, with an analysis of the results obtained in our first 32 patients. METHODS: a prospective study was made of all patients who underwent laparoscopic choledochotomy in our surgical service in the period between December 1993 and December 1996. A total of 112 patients diagnosed as having choledocholithiasis were operated on in our service in the course of the study. Of the 54 patients who initially underwent laparoscopic surgery, 32 underwent cholecystectomy, choledochotomy, extraction of stones and laparoscopic choledochorrhaphy. RESULTS: in 30 patients (93.75%) laparoscopic surgery could be completed without resorting to open surgery; in 5 of these patients primary choledochorrhaphy was performed, and in the remaining patients suturing was performed on a Kehr T-tube. Mean surgical time was 176 min. Two slight complications (one acute gastric dilatation and one small biliary fistula) and one severe complication (bowel fistula) were recorded. Mean hospital stay was 7 days. CONCLUSIONS: choledocholithiasis was successfully managed with laparoscopic choledochotomy and the extraction of stones, with no increase in morbidity or mortality in comparison to other therapeutic modalities.

Tobacco use and its determinants in HIV-infected patients on antiretroviral therapy in West African countries.

BACKGROUND: Tobacco smoking is common in human immunodeficiency virus (HIV) infected patients from industrialised countries. In West Africa, few data concerning tobacco consumption exist. METHODS: A cross-sectional survey of the International Epidemiological Database to Evaluate AIDS (IeDEA) network in West Africa was conducted. Health workers administered a questionnaire assessing tobacco and cannabis consumption among patients receiving antiretroviral treatment. Regular smokers were defined as current smokers who smoked >1 cigarette per day for >or=1 year. RESULTS: Overall, 2920 patients were enrolled in three countries. The prevalence of ever smokers and regular smokers were respectively 46.2% (95%CI 42.8-49.5) and 15.6% (95%CI 13.2-18.0) in men and 3.7% (95%CI 2.9-4.5) and 0.6% (95%CI 0.3-0.9) in women. Regular smoking was associated with being from Côte d'Ivoire or Mali compared to Benin (OR 4.6, 95%CI 2.9-7.3 and 7.7, 95%CI 4.4-13.6), severely impaired immunological status at highly active antiretroviral treatment initiation (OR 1.5, 95%CI 1.1-2.2) and history of tuberculosis (TB; OR 1.8, 95%CI 1.1-3.0). CONCLUSION: There are marked differences in smoking prevalence among these West African countries. This survey approach also provides proof of the association between cigarette smoking and TB in HIV-infected patients, a major public health issue in this part of the world.

Cerebral venous sinus thrombosis associated with refractory anaemia with excess of blasts.

The present report describes a case of cerebral venous thrombosis occurring in a patient suffering from refractory anaemia with excess of blasts (RAEB). This unusual complication suggests that RAEB could be considered a potential prothrombotic state.

[Chronic lymphatic leukemia. I. Clinico-biological features and survival analysis. Study of 187 patients]. / Leucemia linfática crónica (I). Características clínico-biológicas y análisis de supervivencia. Estudio de 187 pacientes.

A review was carried out of 187 previously untreated cases of chronic lymphocytic leukaemia diagnosed between 1969 and 1988. The median age of the patients was 65 years (range, 36-87). There were 118 males (M/F ratio, 1.7). In accordance with Rai's staging system the patients were distributed as follows: 0.29%; I, 20%; II, 25%; III, 13%; IV, 13%, and according to Binet's staging the distribution was: A, 55%; B, 21%; C, 24%. The most frequently found physical findings were lymph node enlargement (55%), splenomegaly (32%) and hepatomegaly (28%). Anaemia was present in 20% of the cases and thrombocytopenia in 13%. The mean lymphocyte count was 62 x 10(9)/L (range, 6-475 x 10(9)/L). Bone marrow infiltration of over 80% was seen in 46% of the patients. Bone marrow biopsy was performed on 97 patients, the diffuse pattern of involvement being most commonly found (44%). Increased BUN (55%), alkaline phosphatase (42%) and LDH (38%) were the most frequent biochemical alterations. Hypogammaglobulinaemia was present in 55% of the patients, IgM being the most commonly affected immunoglobulin (66%). Monoclonal gammopathy was seen in 4% of the cases. LDT, measured in 75 patients, was less than a year in 32%. No antileukaemic drugs were needed in 34% of the patients. When concluding this study, 100 patients had died. The median survival was 57 months and death was related to chronic lymphocytic leukaemia in 53% of such patients.