Fall In Hemoglobin Level Research Articles

Continuous fall in hemoglobin level is a poor prognostic factor in patients with nasopharyngeal carcinoma treated with radiotherapy

Anemia can not only reduce the quality of life of patients with cancer, but also affect their survival. This study was to investigate the prognostic value of hemoglobin (Hb) level in patients with nasopharyngeal carcinoma (NPC) treated with radiotherapy. Clinical data of 520 NPC patients received definitive radiotherapy between 2000 and 2002 at Sun Yat sen University Cancer Center were analyzed. Patients were stratified into normal Hb level and anemia groups according to their Hb levels before, during, and after radiation. Anemia was defined according to World Health Organization criteria as Hb level < 130 g/L in men and < 120 g/L in women. Hb continuous decrease group and non decrease group were defined according to Hb changes in the patients during radiotherapy. Loco regional recurrence free survival (LRFS) and overall survival (OS) rates were estimated using the Kaplan Meier method. Multivariate analysis was performed using the Cox model to analyze the prognostic factors. Before radiation, the 5 year LRFS rates were 60.9% in anemia group and 63.9% in normal Hb level group (P = 0.337); the 5 year OS rates were 65.2% and 71.0%, respectively (P = 0.299). During radiation, the 5 year LRFS rates were 56.7% in anemia group and 67.9% in normal Hb level group (P = 0.013); the 5 year OS rates were 61.0% and 75.9%, respectively (P = 0.001). After radiation, the 5 year LRFS rates were 59.6% in anemia group and 64.9% in normal Hb level group (P = 0.169); the 5 year OS rates were 65.0% and 71.9%, respectively (P = 0.090). The 5 year LRFS and OS rates were significantly lower in Hb continuous decrease group than in Hb non decrease group (59.1% vs. 69.3%, P = 0.032; 66.2% vs. 76.4%, P=0.011). Multivariate analysis showed that the continuous decrease of Hb was an independent prognostic factor for OS. The change in Hb level during radiotherapy is an important prognostic factor affecting the OS of NPC patients.

Autoimmune hemolytic anemia in patients with chronic lymphocytic leukemia is associated with IgVH status

Autoimmune hemolytic anemia in patients with chronic lymphocytic leukemia is associated with IgVH status

Sublingual Misoprostol versus Intramuscular Oxytocin in the Active Management of Third Stage of Labor

Objective: To compare the efficacy and safety of 400 �gm of sublingual misoprostol with 10 units of intramuscular oxytocin in activemanagement of the third stage labor.Methods: The study was carried on 200 women undergoing vaginal delivery who were randomized alternatively into two groups of 100women each. Group 1 (misoprostol group) received 400 �gm misoprostol sublingually and group 2 (oxytocin group) received injectionoxytocin 10 units intramuscularly immediately after the delivery of the baby. Primary outcomes measures were amount of blood loss anddrop in hemoglobin level. Secondary outcomes were need for additional oxytocics, manual removal of placenta, operative intervention forPPH, and side effects of the drugs. The blood loss was measured by clinical estimation by weighing the linen, sponges and pads beforeand after the delivery. Duration of the third stage of labor, need for manual removal of placenta and the use of additional uterotonics, ifrequired, were noted. One hour after the delivery, the women were asked about the side effects of the drugs like nausea, vomiting,headache, chest pain, fever, shivering, etc. Hemoglobin estimation was done at time of admission and 24 hours after the delivery. At theend of the study, the data was analyzed using student �t� test and Chi-square test.Results: The mean age was 23.44 � 3.11 years and 23.78 � 2.47 years in group 1 and 2 respectively. There was no statistically significantdifference in the duration of third stage of the labor and mean fall in hemoglobin level in the two groups ( p > 0.05). The mean blood loss was260.35 � 97.45 ml in the misoprostol group and 264.20 � 103.68 ml in oxytocin group and the difference was not statistically significant.Conclusion: It is concluded from the present study that sublingual misoprostol is as effective as intramuscular oxytocin in activemanagement of third stage of labor and a good option especially for developing tropical countries like India where most of the deliveries areconducted at periphery by a nurse, midwife or a trained dai, and it is difficult to maintain the temperature chain.

Diamond Blackfan Syndrome

We report a case of Diamond Blackfan syndrome in 6yr old girl who was detected to have severe anaemia on D4 of life. The baby was detected to have polydactyly right hand (preaxial) and weak radial pulse on right side. On examination there was severe pallor without hepatosplenomegaly. The investigations revealed haemoglobin of 1.9 gm% with reticulocyte count of 0.3%. Other investigations were done to establish the cause of anaemia. The sickling test was negative, Peripheral blood smearrevealed macrocytic anaemia, Hb electrophoresis revealed fetal haemoglobin of 2.7 %. Bone marrow examination revealed markedly reduced erythroid series, stress cytogenetics study done later was negative for any chromosomal breakage. Based on the clinical profile and investigation reports the diagnosis of Diamond Blackfan Syndrome was made. The child was put on corticosteroids which were gradually tapered. Subsequently any attempt at withdrawl of steroids resulted in fall inhaemoglobin levels. Hence the child has been maintained on low dose steroids and has remained symptom free.

Myeloid sarcoma in essential thrombocythemia that transformed into acute myeloid leukemia

A 72-year-old man was diagnosed with essential thrombocythemia (ET) and was treated with hydroxyurea for approximately 5 years. He was well until April 2007. In May 2007, a slight fall in hemoglobin levels was found. In June 2007, an upper endoscopy performed to investigate the cause of anemia showed multiple polypoid lesions in the body of the stomach. A gastric biopsy showed a diffuse infiltration of very immature cells. Several additional immunohistochemical staining showed that the cells were positive for CD13, CD34, CD117, and HLA DR, but negative for myeloperoxidase, CD42b, glycophorin, B cell marker, T cell marker, cytokeratin and desmin. We finally diagnosed the condition as myeloid sarcoma. Subsequently, the patient's ET transformed into acute myeloid leukemia. To our knowledge, this is an exceedingly rare event involving a patient with essential thrombocythemia.

Pronóstico intrahospitalario de la hemoglobina en pacientes con síndrome coronario agudo

Many patients with acute coronary syndrome (ACS) suffer from anemia. The objective of this study was to determine the influence of the admission hemoglobin level and the post-admission fall in hemoglobin level on short-term prognosis during hospitalization. This retrospective study involved 542 highrisk ACS patients who were admitted during 2005. The hemoglobin level was recorded on admission and at least every 24 hours thereafter, with anemia being defined according to WHO criteria. Logistic regression modeling was used to assess the relationship of the admission hemoglobin level and the fall in hemoglobin level to allcause mortality and cardiogenic shock during hospitalization. During follow-up (median time, 7 days), the incidence of cardiogenic shock or mortality was 6.9% (37 patients). Anemia was present in 147 patients (27.1%) at admission, increasing to 266 patients (49.1%) during hospitalization (P<.0001). After adjusting for a range of variables, independent associations were found between the occurrence of adverse events and both the admission hemoglobin level (odds ratio [OR]=1.4 for each 1 g/dL below normal; 95% confidence interval [CI], 1.1-1.8; P=.003) and a fall in hemoglobin level >1.8 g/dL (OR=5.4; 95% CI, 1.5-18.8; P=.009). In high-risk ACS patients both the admission hemoglobin level and a subsequent fall in hemoglobin level >1.8 g/dL were associated with an increased risk of all-cause mortality or cardiogenic shock.

Influence of Hemoglobin Level on In-Hospital Prognosis in Patients With Acute Coronary Syndrome

Many patients with acute coronary syndrome (ACS) suffer from anemia. The objective of this study was to determine the influence of the admission hemoglobin level and the post-admission fall in hemoglobin level on short-term prognosis during hospitalization. This retrospective study involved 542 high-risk ACS patients who were admitted during 2005. The hemoglobin level was recorded on admission and at least every 24 hours thereafter, with anemia being defined according to WHO criteria. Logistic regression modeling was used to assess the relationship of the admission hemoglobin level and the fall in hemoglobin level to all-cause mortality and cardiogenic shock during hospitalization. During follow-up (median time, 7 days), the incidence of cardiogenic shock or mortality was 6.9% (37 patients). Anemia was present in 147 patients (27.1%) at admission, increasing to 266 patients (49.1%) during hospitalization (P< .0001). After adjusting for a range of variables, independent associations were found between the occurrence of adverse events and both the admission hemoglobin level (odds ratio [OR]=1.4 for each 1 g/dL below normal; 95% confidence interval [CI], 1.1-1.8; P=.003) and a fall in hemoglobin level >1.8 g/dL (OR=5.4; 95% CI, 1.5-18.8; P=.009). In high-risk ACS patients both the admission hemoglobin level and a subsequent fall in hemoglobin level >1.8 g/dL were associated with an increased risk of all-cause mortality or cardiogenic shock.

Complex Hepatic Injuries: an Audit from a Tertiary Center.

Nonoperative management is being increasingly employed in the management of blunt hepatic injuries. We analyzed patients with complex hepatic injuries over a period of 10 years (1996-2006). Two hundred and ten patients with blunt hepatic injury were admitted and 103 patients had complex liver injuries. The predominant mode of injury was road traffic accidents in 91.2%. The grade distribution of liver injuries was grade III (72.8%), grade IV (23.3%) and grade V (4.9%). Twenty-four patients (23.3%) underwent surgery for persistent hemodynamic instability, persistent fall in hemoglobin level, bile leaks and intra-abdominal collection with sepsis. Associated intra-abdominal injuries were present in 19.4%, and 58.4% had associated extra-abdominal injuries. The operative procedures included hepatectomy (1), suture hepatorraphy (12), T-tube drainage for bile duct injuries (5), perihepatic sponge and gel foam packing (9), liver abscess drainage (3), and resection and debridement of liver tissue in six patients. The mortality and morbidity in this series was 10.7 and 56.4%, respectively. Multiorgan failure was present in 5, single organ failure in 37, sepsis in 24, biliary complications in 16 and intra-abdominal collection in 17 patients. Endoscopic management for bile leaks was performed in five patients, image-guided pig-tail drainage for abscesses in 11 patients, while angioembolization was done in two patients for right hepatic artery bleed. The mortality was not significantly different in surgical and nonoperative groups but operated patients had significantly higher morbidity. Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.

Delayed haemolytic transfusion reaction due to anti‐Jkb in a patient with non‐Hodgkin’s lymphoma‐transient nature of anti‐Jkb and the importance of early serological diagnosis

Delayed haemolytic transfusion reactions (DHTRs) are relatively common following blood transfusions. In the UK, DHTRs were responsible for 10.2% of all serious transfusion-related hazards between 1996 and 2003. In most cases, there is minor or no morbidity, and the reaction may go unnoticed. However, in some cases, a large fall in haemoglobin level and major morbidity may occur. Even in such serious cases, the true cause of the patient's clinical deterioration may be unrecognized if serological investigation is not carried out immediately because of the often transient nature of the antibodies involved. Failure to make the correct diagnosis will lead to inappropriate treatment and expose the patient to risk of further serious transfusion reactions. We describe a case of DHTR caused by anti-Jk(b) antibodies, which illustrates the difficulty in diagnosing this common but under-recognized reaction and shows the transient nature of the antibody involved, which became undetectable within 4 weeks.

Relationship of high-sensitivity C-reactive protein to prognosis and other prognostic markers in outpatients with heart failure

Inflammatory markers are increased in chronic heart failure (CHF), including high-sensitivity C-reactive protein (hsCRP), but there is little information on its relationship to prognosis or other prognostic markers. We aimed to investigate the relationship between hsCRP and prognosis in patients with CHF and left ventricular systolic dysfunction (LVSD). Patients with CHF and LVSD (n = 957), but without infection or inflammatory disease, were identified. Patients had their medical history taken, underwent physical examination, had electrocardiographic and echocardiographic assessment, and had a 6-minute corridor walk test (6MWT) and blood tests, including hsCRP and N-terminal pro-B natriuretic peptide (NT-pro-BNP). Patients with worse New York Heart Association class (P = .02), shorter 6-minute corridor walk test distance (P < .001), higher NT-pro-BNP levels (P < .001), anemia (P < .001), and renal dysfunction (P < .001), but not lower LV ejection fraction, had higher plasma concentrations of hsCRP. Patients with a CRP of >11.0 pg/mL had a hazard ratio for death of 3.0 compared with those with a CRP of <2.8 pg/mL (P < .001). Of 402 patients who had a second sample taken for hsCRP at 1 year, 46% showed a substantial change from baseline levels. Marked increases in hsCRP were associated with a fall in hemoglobin level. NT-pro-BNP was noted to be a more accurate prognostic marker than hsCRP (area under the curve of 0.74 compared with 0.67 for hsCRP, P < .05). Patients with CHF and LVSD have increased serum concentrations of hsCRP that are related to functional limitation and prognosis but not to the severity of LV ejection fraction.

Púrpura trombocitopênica e anemia hemolítica auto-imune em pacientes internados com lúpus eritematoso sistêmico juvenil

OBJETIVO: avaliar o comprometimento hematológico (CHE) em pacientes internados com lúpus eritematoso sistêmico juvenil (LESJ). MÉTODOS: durante o período de 1994 a 2005, ocorreram 195 internações de 77 pacientes com LESJ (critérios do Colégio Americano de Reumatologia) e foram acompanhadas pela Unidade de Reumatologia Pediátrica do Instituto da Criança - Universidade de São Paulo. Essas internações foram avaliadas com relação à presença de CHE inicial ou evolutivo: anemia hemolítica auto-imune ou púrpura trombocitopênica. Todos os pacientes realizaram dois ou mais hemogramas. O diagnóstico de anemia hemolítica auto-imune (AHAI) foi estabelecido pela queda acentuada dos níveis de hemoglobina (acima de 2 g/dl), reticulocitose, aumento de desidrogenase láctica (DHL), aumento de bilirrubina indireta e teste de Coombs positivo. As manifestações hematológicas associadas à infecção, neoplasia e anemia aplásica foram excluídas. RESULTADOS: o CHE ocorreu em 14 pacientes (18,9%), com 15 internações. Destes, 11 eram do sexo feminino, sete apresentaram púrpura trombocitopênica, cinco, anemia hemolítica auto-imune e dois, síndrome de Evans. O CHE, como manifestação inicial e isolada do LESJ, foi evidenciado em três pacientes. Todos os pacientes com púrpura trombocitopênica apresentaram sangramento cutâneo (petéquias e/ou equimoses). Todos estavam em atividade da doença e apresentavam simultaneamente outras manifestações do LESJ, particularmente nefrite e vasculite. Inicialmente, todos receberam pulsoterapia com metilprednisolona e, posteriormente, prednisona. Em três pacientes, o tratamento foi predominantemente realizado para controle das manifestações hematológicas, com gamaglobulina endovenosa. Os imunossupressores mais utilizados foram pulsoterapia endovenosa com ciclosfosfamida, ciclosporina e azatioprina. Óbito ocorreu em uma paciente por sangramento de sistema nervoso central. Nenhum paciente necessitou de esplenectomia. CONCLUSÕES: o CHE isolado foi uma manifestação grave em pacientes internados com LESJ, habitualmente associado a uma doença ativa e sistêmica.

Small size new silastic drains: life-threatening hypovolemic shock after thoracic surgery associated with a non-functioning chest tube

We report a case of a massive haemothorax following bilateral surgical resection of apical bullae. Occult bleeding was not recognized until the onset of a life-threatening circulatory collapse associated with metabolic acidosis and a fall in haemoglobin level. Using a thoracotomy, large amounts of blood were evacuated from the thoracic cavity and bleeding originating from ruptured pleural adhesion was easily controlled. Thrombotic material with talc particles was found to obstruct the 19-French 4-channel Blake drain. Although this new silastic Blake tube has been recommended in cardiac surgical patients, extending its indication in thoracic surgery, particularly when talc pleurodesis is used, should be questioned given the enhanced postoperative prothrombotic state and risk of drain obstruction. In conclusion, caution should be exercised when new small-sized material is introduced in clinical practice, especially after talc pleurodesis following thoracic surgery.

Health-related quality of life before, during and after combination therapy with interferon and ribavirin in unselected Swedish patients with chronic hepatitis C

Objective. To study the relationship between health-related quality of life (HRQOL) and mode of acquisition, treatment discontinuations, drop in haemoglobin levels and treatment outcome in patients with chronic hepatitis C (CHC). Material and methods. Consecutive unselected Swedish patients with CHC completed the SF-36 questionnaire before, during and after treatment with interferon and ribavirin. Results. At baseline, HRQOL was reduced in all SF-36 subscales in our patients (n=147) as compared with the general Swedish population. Former intravenous drug users (IVDUs) scored significantly lower in social function (p=0.03) and mental health (p=0.03) than patients who had acquired their infection from blood transfusions (PTH). A decline of >40 points in HRQOL from baseline to week 12 was noticed in the role limitations-physical (RP) score for the IVDU and PTH groups (p<0.0001 and 0.001, respectively). Patients with a ≥20% fall in haemoglobin levels at treatment week 12 had a significantly poorer RP (p=0.006) and role limitations-emotional score (p<0.02) than patients with a <10% fall. Early treatment dropouts had significantly lower HRQOL scores at baseline than adherent patients. At follow-up, sustained viral responders had significantly higher scores than non-responders. Conclusions. Swedish outpatients with CHC have a marked reduction in their HRQOL as compared to the general population. Therapy reduces HRQOL most substantially in those with a marked reduction in haemoglobin. Early dropouts from therapy have significantly lower HRQOL scores at baseline than adherent patients, and sustained viral responders improve their HRQOL significantly more than non-responders.

High Efficacy of Combination Therapy with Pegylated Interferon and Ribavirin in Hemophiliacs with Chronic Hepatitis C.

Pegylated interferon (Peg-IFN) plus ribavirin is the standard treatment for patients with chronic hepatitis C. In a multicenter open trial, we assessed the efficacy and tolerability of this treatment in 78 HIV negative hemophiliacs (age: 20–64 years) with persistently high transaminase values. Sixty-four were naïve and 14 were relapsers to IFN monotherapy. Cirrhosis was clinically detected in 12 patients (15%). HCV genotype was 1 in 69%, 2a/c in 14%, 3a in 14% and 4 in 3%. Peg-IFN alpha-2b was given subcutaneously at doses of 1.5 mcg/Kg/week for 48 weeks in genotypes 1 and 4 and for 24 weeks in genotypes 2 and 3; oral ribavirin at 800–1200 mg/day based on body weight. Treatment was stopped in patients with polymerase chain reaction positive HCV-RNA at month 6.Results: 11 patients (14%) withdrew for side effects (4) or non-compliance (7). Neutropenia (<500 cells/mmc), decompensated diabetes, ALT flares, and vomiting not responding to antiemetic drugs were reasons for treatment discontinuation. The median fall in hemoglobin levels was 3.1 g/dL. Weight loss (38%), fatigue (33%) and cephalalgia (15%) were frequent side effects. Thirty-two patients (41%) required dose reduction of ribavirin (23, 29%) or Peg-IFN (20, 26%). At the end of the 6-month follow-up, sustained virological response (SVR) was achieved in 43 patients (55%): 40/64 naïve (63%) and 3/14 relapsers (21%, p = 0.007). Five patients (6%), all relapsers to IFN monotherapy, had a virological breakthrough during treatment and 4 (5%) relapsed during the post-treatment follow-up period. SVR was obtained in 86% genotypes 2/3 and 43% genotypes 1/4 (p = 0.001). Predictors of SVR were evaluated by univariate analysis in the 64 naïve patients. SVR was significantly associated with HCV infection type 2 and 3 (86% vs 50% in HCV type 1 and 4; p = 0.008), absence of cirrhosis (97.5% vs 75% in non-responders; p = 0.02) and higher pre-treatment serum ALT levels (111 vs 75 IU/L in non-responders; p = 0.02). SVR rates did not differ in relation to patient's age, pretreatment HCV viremia, median disease duration and compliance to full-dose treatment.Conclusions: combination therapy with Peg-IFN plus ribavirin is the recommended therapeutic option for hemophiliacs with hepatitis C chronic infection. Relapsers to IFN monotherapy may benefit of re-treatment with Peg-IFN plus ribavirin achieving at least 20% SVR. Genotype 2 and 3 infection is the most significant predictor of SVR.

Factors Associated with Ribavirin-Induced Anemia

Background: During treatment of hepatitis C, ribavirin-induced anemia (RIA) requires reduction of the ribavirin dose or initiation of erythropoietin in up to 20% of patients. RIA usually occurs in the first 8 weeks of treatment, and a decrease &gt;3 g/dL or a nadir &lt;10 g/dL is considered significant. Objective: To prospectively examine factors associated with RIA in a population of patients with hepatitis C. Methods: Consecutive patients with hepatitis C (hepatitis B virus and HIV negative) underwent treatment with pegylated interferon and weight-based ribavirin. Prospectively gathered data included demographics, alcohol consumption, and hepatitis C virus risk factors. Patients underwent laboratory studies at baseline and at intervals of 4–8 weeks after starting treatment. Results: One hundred eight patients were enrolled. Of these, 30 (27.8%) experienced a &gt;3 g/dL fall in hemoglobin levels in the first 8 weeks; in 10 (33%) patients, the change occurred by week 4. The initial hemoglobin level was higher in those with a decrease compared with those without a fall (15.3 vs 14.1 g/dL; p &lt; 0.001). In addition, for patients with a decrease, the iron saturation was higher (44.6% vs 30.1%; p = 0.002). Finally, those with fibrosis stage 6/6 (cirrhosis) had a greater percent fall in hemoglobin (27.0% vs 14.0%; p = 0.009) than those with less severe fibrosis. By logistic regression analysis, only iron saturation was associated with RIA (p = 0.002). Conclusions: In our patients, initial hemoglobin, serum iron, and fibrosis were associated with a potentially clinically important decrease in hemoglobin. In approximately one-third of the population, RIA occurred in the first 4 weeks of treatment. No patient had a severe complication.

Switching from subcutaneous to intravenous erythropoietin α in haemodialysis patients requires a major dose increase

A change in the licensing arrangements for the use of erythropoietin alpha in haemodialysis patients has required a switch in the route of administration from subcutaneous (SC) to intravenous (IV). Previous work suggested that the IV route was less efficacious but studies since the enforced switch have not confirmed this. We studied haemoglobin levels and the mean weekly dose of erythropoietin alpha in 86 haemodialysis patients at monthly intervals over the 6 month period before and after a change in the route of administration of erythropoietin alpha from SC to IV. Changes in other parameters known to be associated with erythropoietin response were also monitored. Mean haemoglobin level fell following the switch from 11.9 g/dl+/-1.4 at baseline to 11.3 g/dl+/-1.4 at 1 month (P = 0.001) and to a trough of 11.0 g/dl+/-1.3 at 2 months (P<0.001) before partial recovery to 11.4 g/dl+/-1.2 (P = 0.007) at 6 months. Mean weekly dose of erythropoietin after 2 months was significantly higher than baseline (8791 IU+/-5314 vs 8035 IU+/-4893). The dose continued to increase and by 6 months was 10605 IU (P<0.001), 32% higher than baseline. There was a small reduction in residual renal function, which was an independent predictor of change in dose requirement. There was a small increase in parathyroid hormone levels, but no change in serum ferritin, dosing frequency, total Kt/V, serum albumin, normalised protein catabolic rate, C-reactive protein, hospitalization rate and dialyser reuse rate. Switching from SC to IV erythropoietin alpha caused a significant fall in haemoglobin levels in the first 2 months. This was partially reversed by 6 months at the expense of a 32% dose increase in the dose of erythropoietin alpha by 6 months. The economic impact may be considerable.

Blood Transfusion Requirements for Patients With Sarcomas Undergoing Combined Radio- and Chemotherapy

Patients with bony and soft tissue sarcomas may require intensive treatment with chemotherapy and radiotherapy, which often leads to a fall in haemoglobin levels, requiring blood transfusion. There may be advantages in predicting which patients will require transfusion, partly because anaemia and hypoxia may worsen the response of tumours to chemotherapy and radiotherapy. Between 1997 and 2003, a total of 26 patients who received intensive treatment with curative intent were identified. Transfusions were given to maintain the haemoglobin at 10g/dl or above during chemotherapy, and at 12 g/dl or above during radiotherapy. Eighteen (69%) required a transfusion, the majority as a result of both the chemotherapy and RT criteria. There were 78 transfusion episodes, and 181 units of blood given. In the 18 patients who required transfusion, the average number of units was 10.1, but seven patients required more blood than this. The most significant factor influencing blood transfusion was choice of intensive chemotherapy. Intensive chemotherapy and presenting Hb less than 11.6 g/dl identified 13 out of 18 patients who needed transfusion. Adding a drop in haemoglobin of greater than 1.7 g/dl after one cycle of chemotherapy identified 16 out of 18 patients who required transfusion. The seven patients who had heavy transfusion requirements were identified by age 32 or less, intensive chemotherapy and a presenting Hb of 12 g/dl or less. Erythropoietin might be a useful alternative to transfusion in selected patient groups, especially those with heavy transfusion requirements.

Sustained Suppression of Hepatitis C by Pegylated Interferon and Ribavirin in Hemophilic Patients.

Pegylated interferon (PegIFN) and ribavirin therapy is the standard treatment option for patients with chronic hepatitis C. In a multicenter open trial, we assessed the efficacy and tolerability of PegIFN and ribavirin in 72 HIV negative hemophiliacs (age: 21–64 years) with persistently high ALT values. HCV genotype was 1 in 72%, 3 in 14%, 2 in 12% and 4 in 3%. Treatment: PegIFN alpha2b 1.5 mcg/Kg/week for 48 weeks in genotypes 1/4 or 24 weeks in genotypes 2/3 plus ribavirin 800–1200 mg/day based on viral type. Treatment was stopped in patients lacking virological response at month 6. All patients were assessed for 6 months post-treatment. Results: 11 patients withdrew for side-effects (6) or non-compliance (5). Sixteen patients (22%) did not achieve a primary virological response and 4 (6%) had a virological breakthrough. Therefore, 41 patients (57%) had had an end-of-treatment response. Post-treatment follow-up is ongoing in 7 patients. In 65 patients who completed the study, 2 were relapsers and 32 (49%) had a sustained virological response (SVR, 82% of genotypes 2/3 and 38% of genotypes 1/4). Neutropenia (<800 cells), high ALT and diabetes were reasons for treatment interruption. The median fall in hemoglobin levels was 3.1 g/dL. Leucopenia (40%), weight loss (39%), and fatigue (35%) were frequent side-effects. Thirty patients (42%) required dose reduction of ribavirin (21, 29%) and PegIFN (22, 30%). SVR rates were similar in patients who adhered to protocol and those requiring dose reduction (56% vs 45%). Conclusions: combination therapy with PegIFN and ribavirin improves SVR in HIV negative hemophiliacs with chronic hepatitis C.

Cefotetan-induced haemolytic anaemia. A review of 85 cases.

Reports of cefotetan-associated haemolytic anaemia have prompted a US Food and Drug Administration (FDA) review of the overall number, severity, and causality of such cases. A search of the FDA's Spontaneous Reporting System and the World Health Organization's database revealed 85 cases of haemolytic anaemia since the approval of cefotetan in 1985, 15 of them fatal. Moderate to severe haemolysis was reflected in a mean fall in haemoglobin levels by 6.65 mg/dl (n = 20) and a mean final haemoglobin concentration of 5.2 mg/dl (n = 52). Transfusion of packed red blood cells was required in 47 patients (55.3%). New onset renal dysfunction was noted in 7 patients (8.2%). The direct antiglobulin test was positive in 50 patients (59%), and serological studies revealed antibodies to cefotetan in 30 patients (35%). These data suggest that treatment with cefotetan may induce severe autoimmune haemolytic anaemia.

Caesarean myomectomy-a safe procedure. A retrospective case controlled study

Sixteen women, with uterine fibroids in pregnancy, who were treated by caesarean myomectomy, were compared retrospectively with 16 women, without uterine fibroids who had caesarean section during the same period. Myomectomy was performed at caesarean section after delivery of the baby and the placenta, with the administration of intravenous oxytocin. The fibroid defects were occluded with continuous interlocking and fixed sutures. Routine caesarean section was performed on the subjects in the control group. The comparative efficacy of the procedure was measured by comparing pre- and post-operative haemoglobin levels, measured blood loss, need for blood transfusion, post-operative febrile morbidity and length of hospital stay in both groups. Caesarean myomectomy resulted in a mean blood loss of 495 ml (range 200-1000 ml) compared with 355 ml (range 150-900 ml) in the control group (P =0.907). The caesarean myomectomy group had a mean fall in haemoglobin level of 1.7 g/dl compared with a fall of 1.4 g/dl in the control group. There were no significant differences between the groups in the need for blood transfusion, post-operative febrile morbidity or length of hospital stay. The results indicate that caesarean myomectomy is safe and offers no significant increased risk to the patient over caesarean section alone. This is beneficial to the health sector by the avoidance of an interval myomectomy hence justifying the cost effectiveness of the procedure.