Arsine (arsineuretted hydrogen, AsH3) was first identified in 1775. It is a colourless, non-irritant gas that smells like garlic. After the initial demonstration of its toxicity in 1815, 454 cases of poisoning had been documented by 1974.' To date, a further 16 cases have been described,2`including one with permanent renal damage.6 Many cases probably go unrecognised as the attending medical staff may not be aware of the possibility of arsine gas poisoning. This may lead to delay in the diagnosis and management with increased mortality and morbidity.The prognosis of patients exposed to arsine gas depends on the effect on renal function. Previously anuria was a common cause of death but, with dialysis, patients should not die from renal failure. A problem arises with the adequate removal of arsine and its associated toxic complexes. In this respect dialysis alone is insufficient, and only the removal of the arsine haemoglobin haptoglobin complex by exchange transfusion will stop the toxic process.Several causes for the renal failure have been postulated by Muehrcke and Pirani.7 Firstly, arsine gas itself has a direct toxic effect on renal tissue. Secondly, as a result of haemolysis, haemoglobinuric casts may precipitate in the tubules resulting in tubular damage. Finally, the oxygen carrying capacity of blood is reduced by haemolysis and thus hypoxic damage to renal tissue may occur. The case we describe is of a worker at a metal refinery near Johannesburg; he was one of five cases of arsine poisoning seen at Johannesburg Hospital over the past six years. Methods Haemoglobin was measured by Coulter counter. Reticulocyte counts were done by hand and measurement of haptoglobin and haemopexin was performed by electroimmunodiffusion. Liver function tests and the urea and creatinine were measured by autoanalyser. Lactate dehydrogenase was measured automatically by means of the Multistat machine. Blood and urine arsenic concentrations were meaAccepted 29 July 1985 sured at the refinery's laboratory with prior preparation of the sample using the wet oxidation technique. Final results were obtained by means of a hydride atomic absorption reading. The patient was initially dialysed with a UDM machine using a Gambro 120M dialyser to remove fluid. Once he began diuresing a Gambro 120L dialyser was used. Case reportA 36 year old, previously completely well, white man was working on a metal reduction process with hydrochloric acid on 1 March 1983. Six to eight hours after completing the procedure he passed frankly red urine, shown later to contain haemoglobin. The patient felt nauseous and vomited profusely. His output of urine was appreciably decreased and he was referred to Johannesburg Hospital on 3 March. On admission he complained of pronounced abdominal pain and generalised muscle pain and tenderness. Slight pallor and jaundice were noted. His vital signs were normal. No cyanosis was present, and there was no evidence of respiratory distress. A small quantity of "dirty coloured" urine was obtained by means of a catheter,...
Summary:A single high-dose cycle of chemotherapy can produce response rates in excess of 50%. However, disease-free survival (DFS) is 15-20% at 5 years. The single most important predictor of prolonged DFS is achieving a complete response (CR). Increasing the proportion of patients who achieve a complete response may improve disease-free survival. Women with metastatic breast cancer and at least a partial response (PR) to induction chemotherapy received three separate high-dose cycles of chemotherapy with peripheral blood progenitor support and G-CSF. The first intensification was paclitaxel (825 mg/m 2 ), the second melphalan (180 mg/m 2 ) and the third consisted of cyclophosphamide 6000 mg/m 2 (1500 mg/m 2 /day ؋ 4), thiotepa 500 mg/m 2 (125 mg/m 2 /day ؋ 4) and carboplatin 800 mg/m 2 (200 mg/m 2 /day ؋ 4) (CTCb). Sixty-one women were enrolled and 60 completed all three cycles. Following the paclitaxel infusion most patients developed a reversible, predominantly sensory polyneuropathy. Of the 30 patients with measurable disease, 12 converted to CR, nine converted to a PR*, and five had a further PR, giving an overall response rate of 87%. The toxic death rate was 5%. No patient progressed on study. Thirty percent are progression-free with a median follow-up of 31 months (range 1-43 months) and overall survival is 61%. Three sequential high-dose cycles of chemotherapy are feasible and resulted in a high response rate. The challenge continues to be maintenance of response and provides the opportunity to evaluate strategies for eliminating minimal residual disease. Keywords: stem cell transplant; breast cancer; multicycle chemotherapy; tandem transplants Advanced breast cancer continues to be a highly treatable, albeit ultimately deadly disease, with a median survival of 2 to 2.5 years. 1 New cytotoxics and biologics may lengthen survival in the order of 1 to 5 months. However, long-term disease-free survival is rare. [2][3][4] The research interest in very high-dose chemotherapy sprang from the observation of a linear-log relationship between dose and tumor cell kill. Early clinical studies determined that 15 to 20% of women who achieved a complete response as a consequence of a single high-dose cycle of chemotherapy as consolidation for responding metastatic breast cancer maintained this response for longer than 5 years -in contrast to less than 5% observed in previous studies. 2 However, that the observation of improved survival might be due to selection bias is suggested in a retrospective review of a large database. 5 There are five randomized trials assessing high-dose chemotherapy with autologous stem cell support as a component of overall therapy in patients with metastatic breast cancer. Two of these trials demonstrate equivalence of a single high-dose cycle of chemotherapy with stem cell support to maintenance chemotherapy. 6,7 Survival was doubled in the small French trial, a difference that was not statistically significant. 8 The two Duke University trials compare a single high-dose cycle of chemothe...
The discussion panel at both the Perugia and Chicago meetings has reached a consensus regarding major aspects of the protocol of choice for haploidentical stem cell transplantation (SCT) in acute leukemia. These include specific parameters relating to patients eligibility, graft manipulation and cell composition of the final inoculum, conditioning of the patient and post-transplant treatment.
High-risk primary breast cancer patients treated with high-dose chemotherapy (HDC) and stem cell support (SCS) have shown prolonged disease-free survival (DFS) in many studies; however, only one trial has demonstrated an overall survival benefit (OS). We hypothesize that the period following myeloablative therapy is ideal for immunologic manipulation and studied the effects of two different methods of immunotherapy following HDC with SCS aimed at the window of immune reconstitution. Seventy-two women with high-risk stage II or III breast cancer were randomized following HDC to receive either interleukin 2 (IL-2) at 1 million units/m 2 SQ daily for 28 days or combined cyclosporine A (CsA) at 1.25 mg/kg intravenously daily from day 0 to þ 28 and interferon gamma (IFN-c) 0.025 mg/m 2 SQ every 2 days from day þ 7 to þ 28. At a median follow-up of 67 months, no significant difference was observed in DFS or OS between the two treatment groups. The IL-2 arm had a 59% DFS (95% CI (0.45, 0.78)) and a 72% OS (95% CI (0.58, 0.88)) at 5 years. The CsA/INF-c arm had a similar outcome with a 55% DFS (95% CI (0.40, 0.76)) and a 78% OS (95% CI (0.65, 0.94)) at 5 years. Treatment was well tolerated, without increased toxicity.
Summary: Between January and September 1985, 476 patients underwent two-dimensional and M-mode echocardiography . Left ventricular bands were noted in 104 of these individuals. Of these patients, 89 (85.6%) WCIY refemd for evaluation of a systolic murmur. In view of this high incidence of association between left ventricular bands and systolic murmurs, we decided to perform a prospective analysis on patients with the classical vibratory systolic murmur (Still's murmur) which is commonly found in children and young adults. The incidence of lcti ventricular bands would be compared with a group of individuals in whom no cardiac murmurs could be detected. It was hoped in this way to possibly determine whether there was a definite relationship between the vibratory systolic murmur and left ventricular bands. Echocardiographs were performed using an Advanced Tcchnical Laboratories machine and gain settings were adjusted such that all artefacts and normal structures could easily be distinguished from the ventricular bands. The vcntricular bands were divided into two types. Of significance, we felt, were those which crossed the left ventricular outflow tract and which could therefore have been responsible for the production of turbulence and thus a niuniiur reminiscent of the Still's murmur. This type of Icft ventricular band was noted in 76% of our patients with Still's niuniiurs as opposed to only 14% of the individuals without any murmur (p
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