Autotrasplante (AT) de progenitores hematopoyéticos en mieloma múltiple: Experiencia clínica / Autologous transplant (AT) with peripheral-blood stem-cell rescue for multiple myeloma: A clinical experience

Background:Multiple myeloma is rarely curable. Advances in high dose chemotherapy and stem cell transplantation have improved overall survival and event-free disease periods, but relapses are inevitable. Aim: To report our experience with AT in multiple myeloma, between 1994 and 2003. Material and Methods: Retrospective analysis of 20 patients (12 women), with a mean age of 51.1 years. VAD (vincristine, doxorubicin and dexamethasone) was used as initial therapy in 19 patients. High dose cyclophosphamide (11 patients) and variations of VAD regimen (7) associated with granulocyte colony stimulating factor were used for peripheral-blood stem cell harvest. The conditioning regimen consisted of melphalan 200 mg/m2 followed by the reinfusion of peripheral-blood stem cells 24 hours later. The median number of CD34 cells infused was 3,3x106/kg. Three patients were subjected to a second auto graft and one to a non-myeloablative transplant. Mean follow up was 35.5 months. Results: Mucositis and febrile neutropenia were common complications. The median number of days for neutrophyl engraftment was 9 (range 8-11) and for platelets, 10 (range 7-13). No patient died. Complete remission was obtained in 60% (12/20), progession-free survival was 30 months and overall median survival, 47 months. Conclusions: The AT with high-dose melphalan is a safe procedure in our hospital, without mortality and engraftment in all the patients. Complete remission and progression free survival were similar to those reported abroad but the overall median survival was lower.

Proteína S libre en embarazadas normales: comparación entre dos métodos / Free protein S (PS) in normal pregnancy: A comparison between two analytical methods

Background: Pregnancy is a physiological hypercoagulable state with an increased incidence of thromboembolic phenomena. There is an increase in the concentrations of most clotting factors, a decrease in concentration of some of the natural anticoagulants and reduced fibrinolytic activity. Changes in PS levels have also been reported. Aim: To establish referral range values of functional PS and free PS antigen, during the second (2nd T) and third trimester (3rd T) of normal gestation. Patients and methods: Forty one normal pregnant women were included in our study, 20 during the 2nd T (22-24 weeks) and 21 during the 3rd T (29-38 weeks). Functional PS was measured by a clot based test and free PS antigen by ELISA. Results: Free PS Antigen was 65.8±18.3% during the 2nd T and 62.3±16.5% during the 3rd T. The figures for normal controls were 106±6.5%. Functional PS was 43.8±13.3 and 25.9±14.6% during the 2nd T and 3rd T, respectively. The figures for normal controls were 97±24% (p <0.001 compared with pregnant women). Free PS antigen did not change from the 2nd to the 3rd T (p=NS), however functional PS fell significantly from the 2nd to the 3rd T (p <0.001) and was significantly lower than free PS antigen in both trimesters (p <0.001). Conclusions: Pregnancy is associated to a decrease in PS. This abnormality is more pronounced for functional PS than free PS antigen and functional PS falls progressively during pregnancy. These assays should not be used to screen for PS deficiency during pregnancy because they could lead to a misdiagnosis.

Frecuencia y características de la resistencia a aspirina en pacientes cardiovasculares chilenos / Frequency and characteristics of aspirin resistance in Chilean cardiovascular patients

Background: Studies performed in Anglo-Saxon countries show that 5 percent of patients are resistant to the antiplatelet effects of aspirin. Aim: To assess the prevalence of aspirin resistance in a sample of Chilean cardiovascular patients and its association with clinical and laboratory characteristics. Patients and Methods: Ninety nine patients (30 women, 63n10 years) treated for stable cardiovascular diseases with aspirin 100-325 mg/day were studied. Clinical and basic coagulation variables were assessed. Platelet aggregation was studied with platelet rich plasma using three different agonists in an optical aggregometer. Aspirin resistance was defined as an aggregation >20 percent with arachidonic acid and an aggregation >70 percent with ADP or collagen. Results: Eleven patients (11.11 percent, 95 percent CI= 4.95-17.27 percent) complied with both criteria and were classified as aspirin resistant. Current smoking was more common in aspirin resistant patients (63.6 vs 29.6 percent, p=0.039). Conclusions: Aspirin resistance was found in a significant proportion of cardiovascular patients and was more common among current smokers.

Aplicación del tiempo de tromboplastina parcial activado (TTPA) con tiempo de incubación modificado en el diagnóstico del anticoagulante lúpico (AL) / Clinical application of the activated partial thromboplastin time (APTT) with modified incubation time for the diagnosis of lupus anticoagulant (LA)

Background: Although several tests are used to screen for the presence of LA, none detects all its types. The shortening of APTT observed when the pre-incubation period is prolonged, proved to be a sensitive test for the presence of LA. Material and methods: We determined the APTT, performed with a 4 or 15 min preincubation period (APTTs and APTT15 respectively), in 22 healthy subjects, 3 commercial positive controls for LA, 16 patients with a previous diagnosis of LA and 54 patients with recurrent fetal loss and/or infertility. Evidence of LA was established by a positive Staclot-LA test. Results: APTTs and APTT15 were 31.5±4.7 and 28.4±4.5 seconds respectively in samples from 22 normal subjects. The figures in samples with LA, were 71.5±20.3 s and 58.6±18 s respectively. The difference between the two APTTs performed on an individual sample was defined as the APTT 4-15 and was 2.6±2.0 in normal subjects 2.5±2.8 in 13 patients anticoagulated with warfarin, -10.0±6.5 in 13 patients receiving heparin, and 13.2±4.9 in 15 patients with LA. The test values for LA patients were significantly higher than those for normal subjects (p <0.0001). For values over 5, the APTT 4-15 had 93.3 per cent sensitivity and 100 per cent specificity. In one patient with recurrent fetal loss or infertility, who was LA positive, the APTT 4-15 was positive with a value of 14. Conclusions: This modified TTPA is easy to perform, and provides a reasonably discriminatory value for the presence of LA. Therefore, we recommend the TTPA 4-15 to screen for LA.

Larva migrante visceral (toxocariasis humana) causa de hipereosinofilia y granulomas viscerales en el adulto / Visceral larva migrans (human toxocariasis) cause of hypereosinophilia and visceral granulomas in the adults

A 24-year -old woman 2-3 months after a normal parturation presented geophagy. Due to hypermenorrhea she consulted a gynecologist and in a hemogram a 57 percent (6, 893 x mm3) hypereosinophilia was detected. A chest TAC showed bilateral pulmonary nodules. The following tests resulted positive: ELISA IgG for toxocariasis 1: 1000, isohemagglutinins anti A 1:2048 and anti B 1:512. The patient was treated with albendazole and prednisone during 10 days. One month after treatment eosinophilia decreased to 2.590 x mm3 and ELISA IgG for toxocariasis descended to 1:128. Different aspect of human toxocariasis are commented. When hypereosinophia is observed in adult patients, toxocariasis must be checked

Infecciones en el paciente neutropénico / Infections in neutropenic patients

Estudio prospectivo de 74 períodos consecutivos de neutropenia severa (menor o igual a 500 u/L) en 38 pacientes hematológicos del Hospital Clínico de la U. de Chile. La leucemia aguda constituye la principal enfermedad de base y la quimioterapia fue utilizada en el 81 por ciento de los episodios. En 60 períodos (81 por ciento) se logró demostrar infección y 51 de ellos (69 por ciento) cursaron febriles. Destacamos la presencia de 9 episodios de infección de curso afebril por constituir un hecho excepcional en estos pacientes. En los 60 períodos de neutropenia con infección se logró demostrar en el 80 por ciento uno o más focos, destacando el pulmonar, orofaríngeo, mucocutáneo y abdominal. El estudio microbiológico fue positivo en el 45 por ciento de los episodios febriles; se aislaron 34 microorganismos (bacilos Gram (-) 62 por ciento, cocáceas Gram (+) 26,3 por ciento, hongos 8,8 por ciento y virus 2,9 por ciento. Se constataron 11 bacteremias, todas por bacilos Gram (-) predominando K. pneumoniae y E. coli. El esquema ceftazidima-amikacina fue el más utilizado y se modificó en más del 50 por ciento de los casos (se asoció vancomicina, anfotericina B, u otro, o se reemplazó por imipenem, vancomicina y anfotericina B), con éxito terapéutico en el 75 por ciento de los casos. Se produjeron 17 fallecimientos, 13 de causa infecciosa. La mortalidad se asoció al diagnóstico de leucemia aguda, neutropenia prolongada, foco pulmonar y bacteremia por Gram (-). Los episodios febriles sin foco ni bacteriología se asociaron a buen pronóstico

Prolongación exitosa de gestación gemelar de pretérmino complicada con un feto muerto y coagulación intravascular diseminada / Succesfully prolongation of twin preterm gestation complicated with one fetal death and disseminated intravascular coagulation

Se presenta un caso clínico de embarazo gemelar con coagulación intravascular diseminada y un feto muerto in utero en la semana 24, en el cual se utilizó heparina para prolongar la gestación. Se describe el uso de heparina y su efecto en el perfil hemostático de la paciente y su importancia en la resolución del caso