Mónica Sánchez-Cárdenas

High response rate to low-dose rituximab plus high-dose dexamethasone as frontline therapy in adult patients with primary immune thrombocytopenia

Corticosteroids as initial therapy for primary immune thrombocytopenia achieve a low rate of sustained remission.

Posterior Reversible Encephalopathy Syndrome Due to Malignant Hypercalcemia: Physiopathological Considerations

CONTEXT Posterior reversible encephalopathy syndrome (PRES) is a neurological entity characterized by seizures, headache, and reversible subcortical vasogenic edema. It is associated with many etiologies, most often hypertension, chronic renal failure, and chemotherapy. Hypercalcemia is rarely associated with PRES. OBJECTIVE The aim of this study is to describe and discuss a case of PRES that developed in a patient with malignant hypercalcemia, with emphasis on the possible pathophysiological mechanisms involved. PATIENTS AND METHODS A 38-year-old woman presented with altered mental status. She had a 2-month history of lumbar pain of moderate intensity, weight loss, and gastrointestinal complaints, in addition to a mass in her left breast. Her corrected serum calcium was 14.5 mg/dL. She was normotensive, had no focalizing signs, and her cerebrospinal fluid was normal. Despite treatment, her neurological state did not resolve, and she developed severe headaches at day 4 of her admission. Brain magnetic resonance imaging showed a bilateral and symmetric hyperintensity in the occipital and parietal lobes on T2-weighted and fluid-attenuated inversion recovery imaging, a characteristic highly suggestive of PRES. After correction of hypercalcemia, her symptoms and imaging abnormalities resolved. CONCLUSIONS The development of PRES in the setting of severe hypercalcemia is extremely rare. Hypercalcemia could lead to PRES in the absence of hypertension by various mechanisms, including vasospasm, endothelial dysfunction, and an inflammatory state. A high index of suspicion is needed in this setting because hypercalcemia can lead to neurological symptomatology, and prompt diagnosis is essential for adequate treatment.

Impact of outpatient non-myeloablative haematopoietic stem cell transplantation in quality of life vs. conventional therapy

The role of outpatient hematopoietic stem cell transplantation (HSCT) as a therapeutic tool has been strengthened significantly because of the increasing number of patients undergoing this treatment. Due the very nature of this procedure, one of the aspects that should not be overlooked is the quality of life (QOL) of patients undergoing HSCT. Thus, one must consider not only health status after treatment, but also, the psychosocial implications for the patient. This is an observational, longitudinal, and prospective study to assess QOL in patients undergoing outpatient HSCT vs. similar patients receiving medical treatment (MxTx). By applying the COOP/WONKA charts on five occasions (pre-HSCT/initial, post-HSCT/first month, and at 3, 6, and 9 months), thirty-eight patients were analysed, 19 with HSCT and 19 with MxTx with no differences in age, gender or diagnosis. The initial survey found significant differences only in pain perception, which was higher in the HSCT group (p = .08); at the first month, there was a greater tendency for feelings of depression or anxiety in the HSCT group (p = .016), with more limitations in social (p = .003) and daily (p = .044) activities. From 3 months post-HSCT, the results were very similar. The differences persisted only in the area of social activities. Four patients developed graft-versus-host disease with no significant difference in the scores obtained compared to other transplant patients at 3, 6, and 9 months (p = .26) of follow-up.

Cultural factors related to adherence to imatinib in CML: A Mexican perspective

Abstract Introduction The advent of imatinib as a therapeutic option of chronic myeloid leukemia (CML) has transformed this previously highly resistant disease into one that is susceptible to management with oral drugs that now offer high long-term survival rates. However, achieving an adequate adherence to treatment regimes is of critical importance. The characteristics of treatment compliance in Mexican patients have not been determined. Methods We evaluated 38 CML patients, members of the Glivec® International Patient Assistance Program (GIPAP). A bimonthly simplified medication adherence questionnaire was applied and the adherence rate was calculated by direct tablet counting. Results Two groups, one of local patients and another of out-of-town patients, were studied using an 85% adherence rate as a cut-off. The overall adherence rate was 85.9%. Fifteen patients were considered non-adherent (39.5%). The group of out-of-town patients presented a higher adherence rate of 92.8% in contrast with 76.3% in the local population (P = 0.021). The probability of achieving a complete cytogenetic response at some point of evolution after 8 years of follow-up was 93% in the adherent group vs. 58% in the group with an adherence rate <85% (P = 0.008). In patients with imatinib failure, the adherence rate was 75.8% compared to 95.5% (P = 0.008) in the optimal response group. Conclusions In Mexican patients with CML, non-adherence to treatment is a cause of the failure to achieve remission or the subsequent loss of a complete cytogenetic and major molecular response.

Is there a benefit to adding rituximab to CHOP in the overall survival of patients with B-cell non-Hodgkin's lymphoma in a developing country?

Abstract Rituximab (R) has changed the prognosis of patients with non-Hodgkin’s lymphoma (NHL) in developed countries, but its role has not been analyzed in underprivileged circumstances. One hundred and two patients with NHL treated in a developing country were analyzed: 28 patients with follicular lymphoma (FL) and 74 with diffuse large B-cell lymphoma (DLCL). Patients were treated upfront with either cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or R-CHOP; the decision to employ R depending solely on the ability of patients to defray it. In DLCL, 42 were given CHOP and 32 R-CHOP, whereas in FL, 19 were given CHOP and 9 R-CHOP. The impact of the addition of R was found to be clearer in FL than in DLCL. In patients with DLCL, the overall survival (OS) was 87% at 80 months for those treated with R-CHOP and 84% at 145 months for those treated with CHOP (not significant). In patients with FL, the OS was 89% at 88 months for those treated with R-CHOP and 71% at 92 months for those treated with CHOP (P = 0.05). In a multivariate analysis, other variables which were identified to be associated with the OS were IPI and number of cycles in DLCL. It is concluded that R produced a mild positive impact in the OS of patients with FL, but not in those with DLCL. Since the addition of R results in a 36-fold increase in treatment costs, these observations may be important to decide therapeutic approaches in NHL patients living in underprivileged circumstances.

Medication errors: electronic vs. paper-based prescribing. Experience at a tertiary care university hospital.

PURPOSE It has been estimated that medication errors (ME) are responsible for 7000 deaths each year. Some studies show that electronic prescribing systems have achieved health benefits and patient safety, resulting in a saving of resources. Other studies suggest that they may increase adverse events. OBJECTIVE The objective of this study was to compare medication errors between electronic and paper-based prescription detected during pharmacovigilance. METHODS This was an observational, cross-sectional comparative study of 600 randomized medical records that were systematically reviewed by a pharmacovigilance team, with a deliberate search for ME. Each error was classified according to its severity, National Coordinating Council for Medication Error and Prevention taxonomy and high-risk medications. The number of errors was calculated per 100 prescribed medications, number of errors per record and number of records with an error as a quality indicator. RESULTS A total of 229 ME were found with a mean per record of 0.38 (SD = 0.7), of which 155 corresponded to the paper-based method (1.04, SD = 1.67) and 74 to the electronic-based method (0.29, SD = 0.57) P = <0.001. The use of the electronic method was associated with an OR of 0.59 (95% CI 0.41-0.85) for the recording of at least one ME (P = 0.005), but to a greater severity of ME (<0.001). CONCLUSION The use of the electronic system was associated with a reduction in ME, compared with the paper-based method. Despite this, it was associated with more severe ME.

Safety and Cost-Effectiveness of a Simplified Method for Lumbar Puncture in Patients with Hematologic Malignancies

a manometer, and anesthetic patches, among others [12] . Sometimes the support of fluoroscopy or ultrasound is needed during the procedure [14, 15] . Even with the use of all these aseptic measures, serious infectious adverse events occur in <1% and non-infectious events in up to 30% of cases [12, 16] . All the aseptic measures used in the traditional method increase the cost of performing LP, representing a considerable burden for hematologic centers working with limited funding; therefore, simplified but equally safe and efficient methods are important in order to save economical resources [17, 18] . The aim of this study was to determine the safety and cost-effectiveness of LP in patients with hematological malignancies using a simplified method. We performed an observational and analytical study of LP procedures on patients with leukemia or lymphoma treated at the Hematology Service, Hospital Universitario Dr. José Eleuterio González, School of Medicine, Universidad Autónoma de Nuevo León, in Monterrey, Mexico. In the first phase of the study, information was collected retrospectively including LPs performed between July 2008 and July 2010. We conducted a second, prospective phase of the study from August 2010 to January 2011, including all consecutive patients who underwent diagnostic or therapeutic LPs. The information recorded includLumbar puncture (LP) is a diagnostic or therapeutic procedure frequently used in hematological disease. Successful treatment of certain hematological malignancies depends largely on systemic and intrathecal chemotherapy (IT), the latter administered via LP [1] . Various malignant pathologies such as acute leukemia and some lymphomas require periodic LP in the course of their medical treatment [2, 3] . The hematological disease that most often requires handling by IT is acute lymphoblastic leukemia [4] , with a total number of IT that varies from 4 to 22, depending on the treatment protocol [5–7] . LP is used to administer one or several drugs into the central nervous system [8, 9] . Although LP is generally a safe procedure, associated complications exist, such as infectious, noninfectious or traumatic events [10] . Red blood cell (RBC) contamination of cerebrospinal fluid (CSF) in the LP occurs in 8–19% of cases [11] . The most frequent complication is post-LP headache which occurs in 36.5–60% of patients [12] ; other less frequent complications are brain herniation, cardiorespiratory compromise, local or referred pain, hemorrhage, subarachnoid epidermoid cyst, and CSF leak [12] . Infectious adverse events can be cellulitis, abscesses (spinal or epidural) or even meningitis [13] . LPs are performed using resources that include sterile drapes, sterile gloves, gauze, masks, equipment for LP, Received: April 3, 2013 Accepted after revision: May 6, 2014 Published online: October 8, 2014