Clinical and pathological feature of bone marrow granulomas: A modern Australian series.

INTRODUCTION: Marrow granulomas have been commonly associated with mycobacterial infections, prompting extensive investigations in some cases where they are found, but in the setting of changing infectious epidemiology, there is a lack of recent data to guide the search for probable causes. METHODS: A retrospective case series examining the clinical and pathological findings in all cases where marrow granulomas were reported over a 10-year period at The Canberra Hospital, Australia. RESULTS: Of the 6062 marrow biopsies performed, 73 (1.2%) from 66 individuals had confirmed granulomas. Some patients had multiple potential causes found. B-cell non-Hodgkin Lymphoma, sarcoidosis and autoimmune disease were the most frequently observed causes. Infections were less common in this cohort than in the previous series, with no tuberculosis seen. The presence of granulomas in the marrow did not signify the presence of active malignancy in the marrow. There were no associations with any specific morphological characteristics of the granulomas and the presumed causes. CONCLUSION: Marrow granulomas are seen in a variety conditions. Neither their presence nor their morphological features are a guide to further investigations, which should be determined by the clinical presentation as appropriate.

Selecting haematological malignancy patients for intravenous immunoglobulin.

Prior randomised studies of immunoglobulin replacement therapy have studied mixed populations with or without a history of infections. Immunoglobulin therapy is expensive and in limited supply suggesting that optimising patient selection is of value. In this retrospective study, infection history identified high-risk groups benefiting from treatment. A group of patients without any infection history had a low risk of infection without immunoglobulin.

Low haemoglobin density for detecting iron deficiency across a large population, including pregnancy.

INTRODUCTION: Low haemoglobin density (LHD%) from Coulter counters has been suggested as a means to detect iron deficiency. Its performance in a broad population group, including pregnancy, has not been evaluated. METHODS: A retrospective study of adult and paediatric (under 12 years old) patient samples referred for blood counts and iron studies between October 2013 and March 2015. Receiver operator characteristic (ROC) curves were constructed to evaluate the performance of LHD% adults, children, and in the antenatal subgroup. RESULTS: Using a strict definition for iron deficiency, compared with a selected normal cohort, LHD% had a ROC area under the curve (AUC) of 0.90 (0.89-0.91), but in an unselected cohort, the AUC fell to 0.74 (0.73-0.75) with a sensitivity of 74% and specificity of 60% at a cut-off value of 5.9%. In the paediatric cohort, the AUC was 0.79(0.73-0.85), giving a sensitivity and specificity of 75% and 68%, respectively. LHD% did not effectively identify iron deficiency in pregnancy with an AUC of 0.60 (0.54-0.65) and was no better than MCV at detecting iron deficiency. CONCLUSION: LHD% detects iron deficiency in adult and paediatric populations, but not in the antenatal setting, and does not appear superior to MCV.

Placental involvement by non-Hodgkin lymphoma in a Crohn disease patient on long-term thiopurine therapy.

We report the first published case of aggressive diffuse large B-cell (non-Hodgkin) lymphoma in a 35-year-old pregnant woman who had Crohn disease and was taking long-term thiopurine therapy: the patient developed placental insufficiency, and there was intrauterine fetal death.

Risk factors for alloimmunisation in the general patient population.

For hospitals providing services to regional populations, difficulties are associated with transferred patients with poorly communicated medical history and a risk of alloimmunisation. Identification of patients at risk would assist in treatment planning. A retrospective study of alloimmunised patients was undertaken, comparing the demographics and diagnoses of this population with a control patient population. A preponderance of diagnoses of Sepsis, Haematological Malignancy, GIT Bleeds and Renal Failure was demonstrated in the alloimmunised population. Consistent with prior studies, RhD negative patients and female patients were over-represented in the study group, which was also on average significantly older.

Outcomes of haematology/oncology patients admitted to intensive care unit at The Canberra Hospital.

BACKGROUND: Outcomes for haematology/oncology patients have improved; however, determining their suitability for intensive care unit (ICU) admission remains challenging and controversial. AIM: Examine outcomes of patients admitted to an Australian tertiary hospital ICU and explore potential prognostic factors. METHODS: A retrospective review of patients with haematological and solid tumour malignancies non-electively admitted to The Canberra Hospital (TCH) ICU, between January 2008 and December 2012. Patient demographics, cancer details, reasons for ICU admission and Acute Physiologic and Chronic Health Evaluation (APACHE) II scores were collected, and survival rates calculated and correlated with potential prognostic factors. RESULTS: Of 205 patients, 113 (55%) had haematological malignancies, and 92 (45%) had solid tumours: 58% male and mean age 60.3 years (standard deviation (SD) 13.4). Eighty-two per cent of solid tumour patients had metastatic disease and 55% received palliative chemotherapy. Primary reasons for ICU admission included sepsis (59%), respiratory distress (37%) and hypotension/shock (18%). Mean APACHE II score was 20.1(SD 0.55); mean length of stay in ICU, 4 days (SD 5.2); ICU survival was 76% with 62% and 41% alive at 30 days and 6 months respectively. Overall 1-year survival was 36%. High APACHE II scores and ≥2 organs failing were significant risk factors for 30-day mortality. CONCLUSION: Short-term outcomes were similar to contemporary studies from a general tertiary hospital setting and better than historical data. Sixty-two per cent of patients were alive 30 days post-ICU admission, with a significant minority alive at 12 months, confirming some patients achieved worthwhile outcomes. Further research is needed to ensure appropriate patient selection and to explore quality of life post ICU.

Gestación multifetal yatrogénica / Iatrogenic multifetal pregnancy

Los embarazos múltiples ocurren de forma espontánea, en una de cada 90 gestaciones en el caso de las gemelares, y en una de cada 8.100 en las triples. Sin embargo, desde el desarrollo de las unidades de reproducción humana se ha identificado un incremento del 52% de gestaciones gemelares y del 404% en las de mayor orden. Ante la elevada morbimortalidad perinatal y materna de estos embarazos y con el fin de incrementar las posibilidades de supervivencia de los fetos resultantes y minimizar la morbilidad a largo plazo en los recién nacidos, surge la embriorreducción selectiva. A pesar de ser una técnica rentable, puede implicar compromisos éticos y es un procedimiento no exento de riesgos. Por todo esto, consideramos que la actitud más eficaz ante las gestaciones múltiples es su prevención primaria (AU)

Multiple pregnancies spontaneously occur in one out of 90 pregnancies for twins and in one out of 8,100 for triplets. However, since the introduction of human reproduction units, there has been a 52% increase in twins, and a 404% increase in high-order pregnancies. Given the high perinatal and maternal morbidity and mortality in these pregnancies, selective embryo reduction was developed to increase fetal survival and reduce long-term morbidity in neonates. Although effective, this procedure represents a technical and ethical challenge for the practitioner. Consequently, we believe that the most effective approach to multifetal pregnancies is primary prevention (AU)