David Martinez

Tumor lysis syndrome in patients with acute myeloid leukemia: identification of risk factors and development of a predictive model

Tumor lysis syndrome may represent a life-threatening complication during induction chemotherapy of acute myeloid leukemia. This study shows that pretreatment elevated serum lactate dehydrogenase, increased serum creatinine, high uric acid, and markedly elevated white blood cell counts represent independent risk factors for this complication. See related perspective on page 9. Background Despite the prophylactic use of allopurinol, tumor lysis syndrome (TLS)-related morbidity and mortality still occur in a number of patients with acute myeloid leukemia (AML). The aim of this study was: (i) to analyze the incidence and outcome of TLS in a large series of patients with AML receiving hyperhydration and allopurinol, (ii) to identify risk factors for TLS, and (iii) to develop a prognostic scoring system for estimating individual risk of TLS. Design and Methods The study included 772 adult patients with AML receiving induction chemotherapy between 1980 and 2002. TLS was divided into laboratory TLS (LTLS) or clinical TLS (CTLS). The population study was randomly divided into training and test subsets, so that a prognostic model for CTLS was developed in one set and validated in the other. Results Overall, 130 patients (17%) developed TLS (5% CTLS and 12% LTLS). Unlike LTLS, CTLS was associated with a higher rate of death from induction therapy. Multivariate analysis showed that pretreatment serum lactate dehydrogenase (LDH) levels above laboratory normal values, creatinine >1.4 mg/dL, uric acid >7.5 mg/dL and white blood cell (WBC) counts >25 × 109/L were independent risk factors for CTLS and LTLS. The scoring system, based on pretreatment WBC counts, and uric acid and LDH serum levels, had excellent discrimination and was accurate for predicting CTLS and LTLS. Conclusions TLS is frequently observed in AML patients during induction therapy. Only the development of CTLS had an impact on higher mortality rate from induction therapy. The scoring system derived from this study can be used to obtain an accurate estimate of the individual risk of TLS, allowing for risk-adapted prophylaxis against this complication.

Single-Unit Umbilical Cord Blood Transplantation from Unrelated Donors in Adult Patients with Chronic Myelogenous Leukemia

Clinical studies focused on outcomes of umbilical cord blood transplantation (UCBT) for patients with chronic myelogenous leukemia (CML) in need of allogeneic stem cell transplantation and lacking an HLA-matched adult donor are limited. We analyzed the outcome of 26 adults with CML receiving single-unit UCBT from unrelated donors after myeloablative conditioning at a single institution. Conditioning regimens were based on combinations of thiotepa, busulfan, cyclophospamide or fludarabine, and antithymocyte globulin. At the time of transplantation, 7 patients (27%) were in first chronic phase (CP), 11 (42%) were in second CP, 2 (8%) were in accelerated phase (AP), and 6 (23%) were in blast crisis (BC). The cumulative incidence (CI) of myeloid engraftment was 88% at a median time of 22 days and was significantly better for patients receiving higher doses of CD34(+) cells. The CI of acute graft-versus-host disease (GVHD) grade II-IV was 61%, that of acute GVHD grade III-IV was 39%, and that of chronic extensive GVHD was 60%. Treatment-related mortality (TRM) was 41% for patients undergoing UCBT while in first or second CP and 100% for patients in AP or BC (P < .01). After a median follow-up of 8 years, none of the patients relapsed, giving an overall disease-free survival (DFS) at 8 years of 41%. The DFS for patients undergoing UCBT while in any CP was 59%. These results demonstrate that UCBT from unrelated donors can be a curative treatment for a substantial number of patients with CML. Advances in supportive care and better selection of cord blood units and patients are needed to improve TRM.

Aunque te sientas inútil... Relato de una experiencia

Work in the health field can be very demanding at the affective level. The emotional component in the personal relationship affects all those involved: patients, families and professionals. It can lead us to feel upset, as in this story, when we believe that our actions have proved futile. On numerous occasions we do not come to know our real impact on the lives of patients. All health professionals have some experience that moves us. This is mine.

Más allá de las ¿indiciones?. Reflexión sobre la comunicación a partir de una vivencia

The aim of this paper is to describe a reflection based on an experience about the communication. In this experience, the interpretation of the message was essential. The first step of the sanitary intervention is the interview with the patient. After that, we can detect their needs and begin to act properly. The inadequate interpretation of the data obtained by the interview may conduct to unexpected outcomes. Frequently, the patients reinterpret or even reinvent the names of the drugs which are part of their usual treatment. Sometimes, it may also happen with the name of their diseases or the description of their underlying pathology. They may be influenced by several factors (cultural, geographical, etc). Decipher its true meaning may pose a real challenge sometimes. A recent conversation with my grandmother led me to reflect on the relationship between healthcare professionals and patients. This reflection is presented in this paper.

Enfermedad de Kienböck, a propósito de un caso

A white female patient of 30 years of age, who works as a waitress at a restaurant is presented; she refers the antecedent of pain in the central zone of the right wrist of 8 months of evolution that has not gotten better after treatments. The clinical and imagenological diagnosis of kienböck disease is carried out. Surgical treatment takes place practicing a closing wedge osteotomy with shortening of the radius; it is fixed with plate and screws; an excellent result in the post-operative evolution is obtained.