What works for the management of PDPH; is the current evidence enough?

Post Dural Puncture Headache [PDPH] is apparently not an uncommon occurrence and in most cases need serious attention. Conservative, supportive non-pharmacological management to interventional invasive and pharmacological treatment of PDPH are reported in the literature. The PDPH treatment strategies can be divided into symptom management and mechanism directed therapies, both of which complement each other. Supportive management for symptom relief includes soft pain killers, non-steroidal anti-inflammatory drugs, oral hydration and caffeinated drinks. If PDPH does not resolve then epidural blood patch is considered a definitive intervention. Novel pharmacological therapies tested and reported include use of triptans. Over two decades, sumatriptan has been used in a staggered manner and some reports of its success and lack of effectiveness appeared in the literature. In this issue Riaz A. et al have reported the first successful use of Zolmitriptan for PDPH. Although recent Cochrane review is not supportive of triptan use in PDPH but the review could not include Zolmitriptan therapy in PDPH since the original research article in this issue is the first reported use of it. This editorial view discusses the PDPH prevention, current therapeutic strategies, and novel pharmacological management with triptans. Future research and reporting is encouraged for PDPH management and the clinicians might welcome 'whatever works strategy', if supported by clinical reasoning, scientific evidence and in practice safely without causing any harm

Postoperative nausea and vomiting [PONV]: a cause for concern

Postoperative nausea and vomiting [PONV] has been a cause for concern, not only for the anesthesiologist but also for the patients. It is troublesome and may cause many untoward physiological consequences. Various authors have studied risk factors associated with it and management strategies, but the results have been confusing. Many new drugs have been developed for preventing and treating PONV, including ondansetron and palonosetron, and the research for the more effective and safe anti-emetic drug continues. This editorial compliments an original article being published in this issue of 'Anesthesia, Pain and Intensive Care' on the same topic

Relapsed diffuse large B-cell lymphoma treated by reduced-intensity allogeneic stem cell transplantation with donor lymphocyte infusion

A 42 years old male with relapsed diffuse large B-cell lymphoma was given second-line chemotherapy followed by reduced intensity allogeneic stem cell transplantation from HLA matched brother. Twelve weeks posttransplant, his disease relapsed evidenced by the appearance of lymphoma cells in the peripheral blood and declining donor chimerism. Donor lymphocyte infusion was given that induced complete lymphoma remission. The patient is well 3 years posttransplant with his disease in complete remission

Post-transplant outcome in chronic myeloid leukaemia

To determine post-transplant survival in chronic myeloid leukaemia patients undergoing allogeneic stem cell transplant. Longitudinal, descriptive study. Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan, between April 2002 and August 2007. All patients of chronic myeloid leukaemia in chronic phase having HLA identical donor and age under 55 years, normal hepatic, renal and cardiac functions with good performance status were selected. Patients in accelerated phase or blast crisis, poor performance status, impaired hepatic, renal, cardiac functions or pregnancy were excluded. Survival was calculated from the date of transplant to death or last follow-up according to Kaplan-Meier and Cox [proportional hazard] regression analysis methods. Thirty seven patients with chronic myeloid leukaemia underwent allogeneic stem cell transplant from HLA identical sibling donors. Thirty two patients were male and five were females. Median age of patients was 28 years. All patients and donors were CMV positive. Post-transplant complications encountered were acute GvHD [Grade II-IV] [n=13, 35.1%], chronic GvHD in 18.9% [n=7], Veno Occlusive Disease [VOD] in 5.4% [n=2], acute renal failure in 2.7% [n=1], haemorrhagic cystitis in 2.7% [n=1], bacterial infections in 40.5% [n=15], fungal infections in 16.2% [n=6], CMV infection in 5.4% [n=2], tuberculosis in 5.4% [n=2], Herpes zoster infection 2.7% [n=1] and relapse in 2.7% [n=1]. Mortality was observed in 27% [n=10]. Major causes of mortality were GvHD, VOD, septicemia, CMV infection and disseminated Aspergillosis. Overall Disease Free Survival [DPS] was 73% with a median duration of follow-up of 47.4 +/- 12 months. DPS was 81% in standard risk and 54.5% in high-risk group. Results of allogeneic stem cell transplant in standard risk group CML patients were good and comparable with other international centres, however, results in high-risk CML patients need further improvement, although, number of patients in this group is small

Comparison of anthracycline-based combination chemotherapy with or without all-trans retinoic acid in acute promyelocytic leukemia

To compare survival in Acute Promyelocytic Leukemia [APL] patients treated with or without All-Trans Retinoic Acid [ATRA]. Longitudinal, comparative study. The Armed Forces Bone Marrow Transplant Centre [AFBMTC], Rawalpindi, Pakistan from May 2001 to April 2007. All consecutive newly diagnosed patients of acute promyelocytic leukemia, treated at Armed Forces Bone Marrow Transplant Centre, Rawalpindi, Pakistan, between May 2001 and April 2007, were included and given chemotherapy according to availability of ATRA. Diagnosis was confirmed on morphology/ karyotyping/ molecular analysis. Eligibility criteria included confirmed morphologic diagnosis and/or by demonstration of t[15;17] and/or PML/RAR alpha re-arrangement, no prior chemotherapy, normal hepatic and renal function, Eastern Cooperative Oncology Group [ECOG] performance status of 0 - 2 and no contraindications to ATRA [history of sensitivity to Vit. A or other retinoids]. All patients having history of cardiac failure [LVEF < 50] and arrhythmias, ECOG performance status 3 and 4, relapse / refractory disease, ALT twice normal values, serum creatinine > 150 micro mol/L and pregnancy were excluded from this study. Survival was calculated from the date of chemotherapy to death or last follow-up according to Kaplan-Meier and Cox [Proportional hazard] regression analysis methods. During the 6 years study period, 31 newly diagnosed patients with acute promyelocytic leukemia received treatment at AFBMTC. Seventeen patients received anthracycline-based remission induction and consolidation chemotherapy, while 14 received ATRA-based remission induction, consolidation and by two years maintenance therapy. Overall Survival [OS], Disease Free Survival [DFS] and mortality were 29.4%, 29.4% and 70.6% respectively in 17 patients who received anthracycline based chemotherapy, whereas in patients who received ATRA-based chemotherapy OS, DFS and mortality was 71.4%, 64.2% and 28.6% respectively. Major causes of mortality were septicemia and chemotherapy related toxicity. Response to ATRA-based chemotherapy in patient cohort was better as compared with anthracycline based chemotherapy [71.4% vs. 29.4%] in terms of survival and mortality

FLAG-IDA in the treatment of refractory/ relapsed acute leukaemias: Single center study

To evaluate the efficacy and toxicity profile of the combination of fludarabine, high dose cytarabine, idarubicin, and granulocyte colony stimulating factor in refractory relapsed cases of acute leukaemia, a study is being conducted at Armed Forces Bone Marrow Transplant Centre [AFBMTC] Rawalpindi since January 2003. Data up to June 2004 [early report] is being presented. Twelve Patients with refractory/relapsed [Ref/Rel] acute leukaemia [AL] were treated with fludarabine 30mg/m2 and cytosine arabinoside [AraC] Arac 2 g/m2 for 5 days, idarubicin 10mg/m2 for 3 days, and granulocyte colony stimulating factor G-CSF 5 micro g/kg from day 0 till neutrophil recovery [ANC >1.0 x 109/l]. Response was evaluated by bone marrow examination on day 20-post chemotherapy. Patients included were refractory acute lymphoblastic leukaemia [ALL] [n=2], relapsed ALL [n=3], refractory acute myeloid leukaemia [AML] [n=3], secondary AML [n=2] relapsed AML [n=1] and acute undifferentiated leukaemia [AUL] [n=1]. Complete remission [CR] was achieved in 8 [66.6%] patients. Three [25%] patients died of post chemotherapy complications and one patient failed to achieve remission. Out of 8 patients who achieved CR, 4 underwent allogeneic bone marrow transfusion [BMT], 1 is being evaluated for the same, 1 received idorubicin, AraC and etopuside [ICE] and high dose AraC, 1 did not receive further chemotherapy and 1 relapsed two months after remission. Seven patients are still in CR after a median follow up of 8 months [range 3-18]. Major complications encountered were diarrhoea, mucositis, toxic ileus, transient hepatic toxicity, fungal and bacterial infections. In our experience, FLAG-IDA is well tolerated and effective regimen in relapsed / refractory acute leukaemias. The toxicity is acceptable, enabling most patients to receive further treatment, including transplantation procedures

Role of isoniazid prophylaxis for prevention of tuberculosis in haemopoietic stem cell transplant recipients

To evaluate the role of isoniazid prophylaxis in prevention of tuberculosis among allogeneic stem cell transplant recipients. This study was conducted at Armed Forces Bone Marrow Transplant Center Rawalpindi, Pakistan from July 2001 to October 2003. Patients suffering from various haematological disorders undergoing allogeneic stem cell transplantation were included in the study. The demographic information, primary diagnoses and relevant investigations were recorded. Patients had negative tuberculin skin tests and chest X-Ray at pre-transplant assessment. First 25 patients [group I] did not receive isoniazid prophylaxis while the next 25 [group II] were given isoniazid in a dose of 5-10 mg/kg [maximum 300 mg/day]. Isoniazid prophylaxis was started on day-1 and continued for 6 months post transplant. The patients developing tuberculosis were treated with rifampicin, ethambutol, isoniazid, and pyrazinamide during first 3 months followed by 2 drugs for a total duration of 12 months. Minimum follow up in group I and II was 783 and 403 days respectively. There was significant difference [p<0.001] in frequency of tuberculosis between two groups. In group I, four patients developed Tuberculosis [frequency 16%] whereas none of the patients in group II had the disease. Out of these four cases 3 had extrapulmonary disease. One patient died two weeks after the start of anti tuberculosis treatment while others successfully completed the treatment. Tuberculosis in stem cell transplant recipients is an important opportunistic infection especially in areas of high disease prevalence like Pakistan. Isoniazid prophylaxis for 6 months is effective in preventing tuberculosis among this class of patients

Graft versus host disease in allogeneic stem cell transplantation - 3 l/2 years experience

To evaluate the frequency and outcome of graft versus host disease after allogeneic stem cell transplant in haematological disorders at Armed Forces Bone Marrow Transplant Centre, Rawalpindi from July 2001 to December 2004. Eighty-six patients with various haematological disorders namely aplastic anaemia [n=32], b-Thalassaemia [n=25], CML [n=22] ALL [n=3], AML [n=l] Fanconi's anaemia [n=2], and Gaucher's disease [n=l], underwent allogeneic stem cell transplantation. All patients received cyclosoprin, prednisolone and short course of methotrexate as GvHD prophylaxis. The patients who developed acute GvHD > grade-II or chronic extensive GvHD received steroids at a starting dose of 2 mg/kg body weight along with gradual increase in cyclosporine dosage [max dose 12.5 mg/kg]. The overall incidence of acute GvHD grade-II to IV was 44.2% [n=38/86] where as the incidence of chronic extensive GvHD was 14% [n=12/86]. Acute GvHD was 68% [n=17/25] in B-Thalassaemia, 50% [n=ll/22] in CML, 50% [n=2/4] in Acute Leukaemias and 25% [n=8/32] in Aplastic Anaemia. Chronic GvHD was 25% [n=l/4] in Acute Leukaemias, 18.8% [n=6/32] in Aplastic Anaemia, 18.2% [n=4/22] in CML and 4% [n=l/25] in B-Thalassaemia. The overall survival in acute GvHD was 84.2% [n=32] where as the overall survival in chronic GvHD was 50% [n=6]. The overall mortality in acute GvHD was 15.8% [n=6] and 50% in chronic GvHD [n=6]. The morbidity and mortality due to severe acute and chronic GvHD remains high despite standard prophylaxis against GvHD. New strategies are needed to prevent and treat GvHD

Posttransplant Guillain Barre Syndrome

This case report describes a patient with severe aplastic anaemia, who developed Guillain Barre Syndrome [GBS] 10 weeks after allogeneic haematopoietic stem cell transplantation [HSCT] from HLA-matched siblingíyounger sister. GBS was preceded by pneumonia, herpes labialis and oral candidiasis a week earlier. Treatment with ventilatory management, intravenous human immunoglobulin [IVIg] and antimicrobials resulted in smooth recovery in thirty-one days

Autopsy analysis in post-transplant patients: a basis for clinical audit

Two cases are hereby reported, where the exact diagnosis could only be made at autopsy and reflects the need for precise diagnosis of these complications and highlights the usefulness of autopsy examination in clinical audit and postgraduate education. This is a short communication

spectrum of disease in lower gastrointestinal tract: endoscopic biopsy findings

To evaluate the morphological spectrum of colonic disease and its clinical presentation in our patients from hospitals in and around Rawalpindi / Islamabad. Design: A retrospective data based study. Place and Duration of Study: Pathology Department of Army Medical College, Rawalpindi. Material and The colonic mucosal biopsies of 1268 patients received during the period of 1980-1995 were studied by routine histopathology methods. A higher frequency of colonic disease in males with a male to female ratio of 2.6:1 and an age range of 1.25 months to 80 years was observed. The clinical presentations mostly seen were bleeding per rectum [32.71%], mass abdomen [23.86%], diarrheal episodes [18.62%], constipation [13.38%] and bloody diarrhea [3.02%]. The major radiological diagnosis available in 71 cases was ulcerative colitis [32.39%], colonic growth [21.12%] and polyps [11.26%]. On endoscopy the most frequently suspected lesions were polyps [34.70%], colonic growth [29.16%], ulcerative colitis [11.66%] and nonspecific findings [9.23%], while 11.23% cases showed unremarkable mucosa. The histopathology revealed mostly nonspecific colitis [25.23%], followed by polyps [24.13%], colonic cancer [17.11%], ulcerative colitis [11.19%] and colonic aganglionosis [6.54%]. A small number of cases of amoebic, eosinophilic and collagenous colitis and Crohn's disease was also seen. A number of biopsies [6.30%] were unremarkable histologically. Anorectosigmoid was the most commonly involved site than rest of the colon with a ratio of 2.43:1 and therefore most lesions were within the reach of rectosigmoidoscope

juvenile polyps: a clinicopathological study of 239 cases

Between 1980 and 1996, 239 cases of juvenile polyps of the rectosigmoid and colon were studied. The polyps were mostly found below the age of 10 years, though some cases were also seen in adults. Males were affected more often than female with a ratio of 3.34.1. Whereas bleeding per rectum was the main presenting complaint [100%]; prolapsed of rectum [6 cases], passage of mucus mixed with blood [4 cases] were also noted.

These polyps were mostly solitary, situated mainly in the rectosigmoid and measured from 1 to 5 cm in diameter. The majority were ulcerated. The clincopathological observations are discussed and the role of histological examination emphasized

Qualitative and quantitative analysis of the cellular response in sterile acute inflammation

A study of the cellular response in acute inflammation produced by the intraperitoneal injection of sterile egg-albumin in adult male rabbits was carried out over a time interval of 06, 24 and 72 hours. The early response was stereotyped phenomenon and was accompanied by an increase in, polymorphs [P < 0.01] which completely disappeared at 24 hours. In the late hours gradual increase in mesothelial cells was noted which reached highest levels at 72 hours [P < 0.01]. The levels of lymphocytes started rising in the exudate [P < 0.05] at 72 hours. The eggalbumin caused a marked response of mesothelial cells in the peritoneal cavity, when the initial response of polymorphs was over