Summary:From 1984 to 1996, 31 consecutive children without sibling donors, aged 5-19 years (median 8) with acute lymphoblastic leukaemia (ALL) in second complete remission (CR), received unpurged autologous bone marrow transplantation (ABMT) after melphalan and single fraction total body irradiation (TBI). ABMT was performed using fresh unmanipulated marrow harvested after standard reinduction and consolidation therapy 2-11 months (median 5) after relapse. With a median survival of 2.9 years the probability of survival for all patients in continuing second CR was 45.1% (95% CI, 24%-62%) after 5 years. Regimen-related and non-leukaemia mortality was 7% (95% CI, 2%-26%). The longest time to second relapse from ABMT was 3.1 years. Pituitary and gonadal dysfunction requiring hormonal replacement therapy occurred in the majority of long-term survivors. Twelve patients developed cataracts. ABMT with melphalan/single fraction TBI has proved an effective anti-leukaemia treatment with low regimen-related mortality but significant long-term morbidity. The current approach of allogeneic BMT from an unrelated donor when no sibling donor is available, following conditioning with cyclophosphamide/ fractionated TBI has resulted in a reduced relapse rate and improved short-term overall survival in the treatment of relapsed childhood ALL. However, long-term results are awaited. Bone Marrow Transplantation (2000) 25, 599-603. Keywords: childhood ALL; autologous BMT; melphalan/TBI; second remission Childhood acute lymphoblastic leukaemia (ALL) is curable in 60-70% of patients in first complete remission (CR) with first-line therapy. 1,2 However, the outcome of children in second or subsequent CR is much less favourable following second-line therapy with or without bone marrow transplantation (BMT). 3,4 The two most important factors that affect the long-term prognosis post relapse are the site of relapse (bone marrow vs extramedullary sites) and duration of first remission. 3,4 Allogeneic BMT from an HLA-matched sib-
To determine if physicians have improved the recognition and treatment of osteoporosis in patients with an acute hip fracture, we performed a retrospective analysis of discharge data from 1995 and 2000 at the University of Pittsburgh Medical Center, a large tertiary care, academic institution. We examined patients admitted with an acute hip fracture in 1995 and 2000 and age- and sex-matched patients admitted with community acquired pneumonia in 2000. Outcomes included age, gender, race, discharge diagnoses (from ICD-9 codes) and discharge medications (from discharge summaries) in all patients. There were 136 acute hip fracture patients (mean age 73+/-18 years) in 1995, 117 acute hip fracture patients (mean age 76+/-16 years) in 2000 and 116 patients with community-acquired pneumonia (mean age 78+/-7 years). Patients admitted in 2000 with an acute hip fracture were more likely to be diagnosed with osteoporosis (18% vs. 4%, P<0.02), more likely to be discharged on calcium (17% vs. 7%, P<0.02) and more likely to be discharged on antiresorptive therapy (15% vs. 2%, P<0.001) than those admitted in 1995. Moreover, patients admitted with community-acquired pneumonia were just as likely to receive calcium, vitamin D or antiresorptive agents at the time of discharge as those with an acute hip fracture in 2000. Patients with a diagnosis of osteoporosis in 2000 were older and more likely to receive antiresorptive agents than those without a diagnosis (29% vs. 11%, P<0.05). None of the patients received a bone mineral density examination while in the hospital. Although there was an improvement in the management of osteoporosis after an acute hip fracture from 1995 to 2000, there was no difference in management of patients with hip fracture versus pneumonia in the year 2000. However, patients with a "diagnosis" of osteoporosis in 2000 were more likely to be discharged on appropriate therapeutic options. We conclude that although we have improved our care of osteoporosis for elderly in general from 1995 to 2000, patients with an acute hip fracture are not receiving any additional treatment unless they have a diagnosis of osteoporosis. Further studies are needed to determine which factors are needed to target patients for appropriate diagnosis and treatment.
With the increasing concern over the role of hyperinsulinemia in the development of hypertension, 1 atherosclerosis,2,3 and dyslipidernia, the aim to decrease the dose of exogenous insulin by prescribing a com-
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