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Biomedical subjects

D H Biesma

Publications and source records attributed to D H Biesma.

At least 37 records · Page 2Linked to original sources
PubMed1999

Abnormal clotting parameters before therapeutic ERCP: do they predict major bleeding?

A total of 399 consecutive patients undergoing 598 ERCPs (endoscopic retrograde cholangiopancreatographies), including 88 pre-cut papillotomies and 206 conventional papillotomies, are described in a retrospective study. Clotting parameters, haemoglobin levels, indications for pre-cut and/or conventional papillotomy and the use of drugs assumed to interfere with blood clotting (anticoagulants, platelet-aggregation inhibitors, low-molecular-weight heparin) were evaluated in order to detect risk factors for ERCP-associated bleeding. The overall incidence of ERCP-associated bleeding was 18/598 (3.0%). The incidence of bleeding in the group without papillotomy was 7/346 (2.0%). This group consisted of patients who underwent only a diagnostic ERCP, patients who had undergone papillotomy previously, patients in whom a renewed attempt was made to extract biliary stones, and patients in whom removal or change of a stent was necessary. The incidence of papillotomy-associated bleeding was 11/252 (4.4%). Pre-cut papillotomy did and conventional papillotomy did not significantly increase the incidence of bleeding: 15.2% (P < 0.001) and 1.9% (P= 1.00) respectively. The incidence of ERCP-associated bleeding in the group not using any drugs interfering with blood clotting was 2.5%. The use of low-molecular-weight heparin (10.3%) during ERCP significantly increased the risk of bleeding (P= 0.01). However, the use of platelet aggregation inhibitors (2.4%) did not (P= 1.00). As the incidence of bleeding in patients with normal clotting parameters, including the patients with abnormal parameters which were well corrected (4.3%), was higher than in patients with abnormal haemostatic screens (2.7%), abnormal coagulation tests did not predict ERCP-associated bleeding.

Anticoagulants↗
PubMed1999

Vincristine, doxorubicin and dexamethasone (VAD) administered as rapid intravenous infusion for first-line treatment in untreated multiple myeloma.

We examined the feasibility of achieving a rapid response in patients with previously untreated multiple myeloma by administering vincristine 0.4 mg and doxorubicin 9 mg/m2 as a rapid intravenous infusion for 4 d together with intermittent high-dose dexamethasone 40 mg (VAD) for remission induction treatment in patients who were scheduled to receive high-dose therapy. 139 patients (86 male, 53 female; median age 53 years, range 32-65 years; Durie & Salmon stage IIA: 42, IIB: one, IIIA: 89, IIIB: seven) were included in a prospective multicentre study in which VAD was administered as remission induction treatment and was followed by intensified treatment. The response was evaluated according to the criteria of the Eastern Cooperative Oncology Group (ECOG). The results of treatment were evaluable in 134 patients. Five patients died before evaluation. 86 patients (62%) achieved a partial response (PR) and seven patients (5%) achieved a complete response (CR), which equates to a response rate of 67%. The main side-effect was mild neurotoxicity, which was observed in 18% of the patients. Fever or infections were reported in 27% of the patients. VAD administered as an outpatient regimen, based on rapid intravenous infusion, is an effective induction regimen for untreated myeloma with a 67% response rate and acceptable toxicity.

Adult↗
PubMed1998

[Clinical judgment and decision making in medical practice. A retiree with fatigue and foot drop].

A 64-year-old former civil servant consulted his general practitioner because of severe fatigue. Later he began to lose weight and gradually developed chronic sensorimotor polyneuropathy characterized by sensory nerve loss which started in his legs. After a year he needed a wheel chair and developed cachexia. IgG paraprotein was detected. Morbid-anatomical examination of enlarged supraclavicular lymph nodes revealed plasma cell angiofollicular hyperplasia, characteristic of Castleman's disease. Treatment with corticosteroids led to marked improvement of the patient's condition. He was able to walk again, using an ankle orthosis on both legs.

Anti-Inflammatory Agents↗
PubMed1998

Methionine loading test is necessary for detection of hyperhomocysteinemia.

Hyperhomocysteinemia, defined as an elevated concentration of homocysteine in the fasting state or after methionine loading, is an independent risk factor for premature atherosclerosis and venous thrombosis. The role of the methionine loading test (MLT) is, however, controversial. To determine the additional value of the MLT for diagnosis of hyperhomocysteinemia, we prospectively studied 281 patients with premature arterial disease and 148 of their first-degree relatives in the outpatient clinic of a general hospital. Total plasma homocysteine (fasting and 6 hours after methionine loading), folic acid, cobalamin, pyridoxine, and creatinine concentrations were measured. Hyperhomocysteinemia was defined as a fasting homocysteine concentration and/or an increase in homocysteine concentration after methionine loading exceeding the 95th percentile of a healthy control group. Hyperhomocysteinemia was found in 141 (33%) of the 429 subjects: 15% were diagnosed by fasting homocysteine concentration and 18% by MLT. Seventy-eight (55%) of the 141 hyperhomocysteinemic persons were diagnosed only by the MLT. Folic acid was lower in the group with an elevated fasting homocysteine concentration than in those with only an abnormal MLT result (11 versus 15 nmol/L, p = 0.002). Folic acid was significantly negatively correlated, and creatinine significantly positively correlated, with both fasting homocysteine concentration and increase in homocysteine concentration. Negative correlations of cobalamin and pyridoxine with fasting homocysteine concentration were found. In conclusion, the MLT is necessary for diagnosis of hyperhomocysteinemia, because a considerable number of hyperhomocysteinemic persons (55%) remain undiagnosed with the determination of a fasting homocysteine concentration alone.

Adult↗
PubMed1998

Iron metabolism and erythropoiesis after surgery.

BACKGROUND: This was a prospective study comparing the effect of major and minor surgery on haematological variables concerning erythropoiesis, iron metabolism and acute-phase response proteins. METHODS: Thirty-one otherwise healthy patients, 15 having major orthopaedic surgery and 16 undergoing minor surgery, were studied. Blood samples were taken before surgery and 1, 4, 10 and 28 days after operation. RESULTS: Haemoglobin concentration was decreased for up to 4 weeks after surgery. Serum erythropoietin concentration and reticulocyte count were raised after major surgery only. Serum iron concentration dropped the day after major (to 23 per cent of its preoperative level) and minor (to 46 per cent of its preoperative level) surgery and remained lower for up to 28 days after major surgery. Serum transferrin concentration and transferrin saturation decreased after both types of surgery while ferritin concentration increased. Serum transferrin receptor concentration increased only 4 weeks after major surgery (P < 0.01). The interleukin 6 peak (day 1) was greater after major than minor surgery, as was the C-reactive protein peak (day 4). CONCLUSION: Both major and minor surgery induce a state of hypoferraemia in the presence of adequate iron stores. The degree of this transient form of 'anaemia of chronic disease' is related to the extent of surgery. Iron supplementation in the first weeks after surgery (if iron stores were normal before operation) is ineffective.

Acute-Phase Proteins↗
PubMed1997

Immunosuppressive therapy for hypoplastic myelodysplastic syndrome.

BACKGROUND: Hypoplastic myelodysplastic syndrome (MDS) is characterized by dysplasia and hypocellularity. The treatment of choice for young patients is bone marrow transplantation. METHODS: This report describes the effect of immunosuppressive therapy in two patients with hypoplastic MDS for whom no suitable bone marrow donors were available. RESULTS: Both patients had no human lymphocyte antigen-identical siblings and no suitable matched unrelated donor could be found. They received cyclosporin A (CsA), antithymocyte globulin (ATG), or a combination of the two. Treatment with CsA, ATG, or the combination led to clinical improvement (resolution of transfusion requirement), increase of bone marrow cellularity, and the disappearance of dysplastic characteristics in the two patients with hypoplastic MDS. At the time of recurrence, this disease was still responsive to immunosuppressive therapy. CONCLUSIONS: Treatment with ATG and CsA can be an attractive alternative for patients with hypoplastic MDS for whom there is no possibility of bone marrow transplantation.

Antilymphocyte Serum↗
PubMed1997

Life-threatening anaemia caused by B19 parvovirus infection in a non-immunocompromised patient.

A 21-year-old Surinam boy suffering from a combined heterozygous sickle-cell beta-thalassaemia presented with an extreme anaemia (haemoglobin concentration 0.7 mmol/l) and severe haemolysis without signs of increased erythropoiesis. An acute B19 parvovirus infection was diagnosed by a transient increase of IgM anti-B19 parvovirus titres and a positive polymerase chain reaction for B19 parvovirus. The patient recovered spontaneously after a short period of supportive care with red cell transfusions and mechanical ventilation.

Adult↗
PubMed1997

Cyclosporin for thrombotic thrombocytopenic purpura after autologous bone marrow transplantation.

Thrombotic thrombocytopenic purpura (TTP) after bone marrow transplantation (BMT) is a serious complication that, in contrast to classic TTP, is generally not responsive to therapeutic plasma exchange. We describe the remission of TTP after autologous BMT by administration of cyclosporin in four patients, either after failure of plasmapheresis (two patients) or as primary treatment modality (two patients). Cyclosporin may be an attractive drug for post autologous BMT-TTP.

Adolescent↗
PubMed1996

Primary extranodal CD3O-positive T-cell non-Hodgkins lymphoma of the oral mucosa. Report of two cases.

CD3O-positive extranodal T-cell lymphomas predominantly occur in the skin, and they are characterized by a rather indolent course with spontaneous regression of individual lesions. Their occurrence in the oral mucosa is rare and not well documented. Two cases are reported, one occurring in the oral mucosa in a 61-year-old man and originally presenting as a multifocal eosinophilic ulcer of the mucous membrane, and the other one mimicking periodontitis, occurring in the maxillary gingiva of a 75-year-old woman.

Aged↗
PubMed1996

Successful treatment of acute promyelocytic leukaemia with all-trans-retinoic-acid during late pregnancy.

We describe a patient with acute promyelocytic leukaemia (PML) diagnosed in the third trimester of pregnancy who presented with coagulopathy and prolonged bleeding time. Treatment with all-trans-retinoic-acid (ATRA) resulted in rapid normalization of the coagulopathy and complete remission of PML within 2 weeks. Induced labour resulted in an uneventful vaginal delivery without major blood loss with no signs of neonatal ATRA-induced embryopathy. ATRA therapy for PML during late pregnancy was effective in reversing the maternal bleeding tendency and inducing a complete remission of the PML without evidence of teratogenicity. Careful monitoring of bleeding time is important, even after normalization of clotting parameters and thrombocyte count, for determining the moment of induction of labour.

Adult↗
PubMed1995

Post-operative erythropoiesis is limited by the inflammatory effect of surgery on iron metabolism.

The decrease in haemoglobin concentration commonly observed after major surgery is usually corrected by red cell transfusions or oral iron medication. The increased awareness of blood-transmissible diseases has led to the restrictive use of homologous blood and to interest in alternatives for correcting anaemia. We investigated the pathophysiology of postoperative anaemia by studying variables of erythropoiesis, iron metabolism, and inflammation in 48 consecutive patients who underwent total hip replacement. Haemoglobin concentration remained low during 14 days after surgery with only a mild increase in erythropoietin concentration and reticulocyte count. No increase in serum transferrin receptor concentration was observed during the first 2 weeks after surgery. Postoperative serum ferritin increased, whereas serum iron, transferrin and transferrin saturation decreased significantly. There was a marked increase in interleukin-6 and C-reactive protein with maximal values on the 1st and 4th post-operative day, respectively. At 6 weeks after surgery, haemoglobin concentration and variables of iron metabolism were almost at the preoperative level and serum transferrin receptor concentration was significantly increased, indicating increased erythropoietic activity. These changes were preceded by the normalization of interleukin-6 and C-reactive protein levels. Haemoglobin, iron, transferrin, and ferritin concentrations were not influenced by iron therapy during the postoperative period and no differences of erythropoietic and iron variables were observed between transfused and non-transfused patients. In conclusion, post-operative erythropoiesis is associated with an inflammatory effect of surgery on iron metabolism, which can explain, despite a slightly increased production of erythropoietin, the persistence of anaemia and the lack of effect of iron supplementation after surgery.

Aged↗
PubMed1994

Lower homologous blood requirement in autologous blood donors after treatment with recombinant human erythropoietin.

The risk of blood-borne diseases has substantially increased the use of autologous blood transfusion. Many autologous donors, however, still need homologous transfusions. To find out whether recombinant erythropoietin (rhEPO) reduces requirements for homologous blood transfusion, we carried out a randomised, controlled trial, in which patients were stratified according to blood volume. We studied 95 autologous blood donors undergoing elective hip surgery. 50 patients were randomly assigned 500 U/kg rhEPO subcutaneously twice a week for 3 weeks, and 45 patients received no treatment (control group). The patients each donated two units of blood before surgery. Only 5 (10%) rhEPO-treated patients received homologous transfusions compared with 16 (36%) controls (p < 0.01). rhEPO was most useful in patients with a blood volume below 4 L and an estimated blood loss below 2 L or with a blood volume of 4-5 L and blood loss of 1-2 L. Continued administration of rhEPO caused no further increase in reticulocyte counts after the fourth injection, which was accompanied by a pronounced depletion of storage iron. rhEPO treatment had no effect on renal function, platelet count, or blood pressure. Subcutaneous rhEPO is an effective and safe way to reduce exposure to homologous blood in autologous donors. Its use can be restricted to a subpopulation of autologous blood donors, which improves the cost-effectiveness of this expensive approach.

Aged↗
PubMed1994

Recombinant human erythropoietin in autologous blood donors: a dose-finding study.

A dose-finding study of recombinant human erythropoietin (rhEPO) was performed in 60 autologous donors who donated 2 units of blood prior to orthopaedic or vascular surgery. The correction of phlebotomy-induced anaemia was studied in four groups of 15 patients who received 500 U/kg, 250 U/kg, 125 U/kg or no (controls) rhEPO subcutaneously twice per week during a 3-week period. Haemoglobin concentration in the 500 U/kg, 250 U/kg and 125 U/kg group and in the controls reached respectively 99.2, 98.8, 91.9 and 87.1% of pre-phlebotomy value. Flow cytometric analysis of reticulocytes showed a steady increase of reticulocyte count as the dose increased. Maximal levels of high fluorescence reticulocytes which represent early changes of erythropoiesis were reached after 7 d and decreased thereafter in each group. Serum ferritin decreased significantly to approximately 50% of baseline values in all groups; no differences in the decrease of serum ferritin were observed between the patients who received rhEPO and the controls. No severe adverse events were observed. This study demonstrates a dose-related effect of rhEPO on erythropoiesis in autologous donors during the first 2 weeks. No further increase of reticulocytes was observed despite continued rhEPO therapy, which may be due to the inability of the mononuclear phagocytic system to release additional iron. To restore pre-phlebotomy haemoglobin concentration, a dose of 250 U/kg rhEPO was sufficient.

Aged↗
PubMed1994

Erythropoietic activity and iron metabolism in autologous blood donors during recombinant human erythropoietin therapy.

The use of recombinant human erythropoietin (rhEPO) to intensify the erythropoietic response in autologous donors may reduce homologous blood requirement. We studied the effect of subcutaneous rhEPO (500 U kg-1 body weight twice weekly during a 3 week period) on variables of erythropoiesis and iron metabolism in 62 autologous blood donors, of whom 32 received rhEPO (epo group) and 30 did not (control group). Patients donated only 2 units of blood and received oral iron in order to restrict phlebotomy-induced decrease of iron stores. Pre-phlebotomy haemoglobin concentration (14.0 +/- 0.8 g dl-1) was completely regenerated in the epo group at surgery (13.7 +/- 1.3 g dl-1); haemoglobin concentration in the control group fell from 13.5 +/- 1.4 g dl-1 to 11.6 +/- 1.4 g dl-1 after the phlebotomies and did not improve during the pre-operative phase. Total erythropoietic activity expressed as serum transferrin receptor concentration (sTfR) showed a 4-fold increase from 3.8 +/- 0.9 micrograms ml-1 to 14.9 +/- 4.8 micrograms ml-1 in the epo group. Effective erythropoietic activity measured by absolute reticulocyte count, however, declined after the fourth rhEPO injection in the epo group. Serum ferritin was lower in the epo group, but no differences in serum iron, transferrin concentration and transferrin saturation were observed between the groups. A marked increase in free erythrocyte protoporphyrin (FEP) was observed in the epo group, whereas FEP levels in the controls remained within normal ranges. Despite oral iron supplementation and the limited number of phlebotomies, the effect of rhEPO therapy in autologous donors is restricted by iron depletion.

Aged↗
PubMed1994

Red blood cell transfusions for total hip replacement in a regional hospital. A six-year analysis.

To evaluate changes in the need for homologous blood and to assess the impact of autologous blood transfusion, red cell transfusions in unilateral total hip replacement surgery, performed electively in the period 1986-1991, were studied in a regional hospital. Transfusion data, perioperative blood loss and post-operative haemoglobin concentration of 495 patients were analysed. From 1986 to 1991, the percentage of patients not transfused with homologous blood increased from 18.5 to 45.5%. After the introduction of an autologous blood transfusion programme in 1987, 116 of 430 patients (27.0%) donated autologous blood. No increase in the percentage of autologous donors was observed during the study. Most common reasons for nonparticipation were the patient's age, doctors' underordering and logistic limitations. 81.9% of autologous donors had total hip replacement surgery without homologous transfusions. Mean blood loss reduced significantly from 1,373 +/- 781 ml in 1986 to 958 +/- 582 ml in 1991 (p < 0.001). Transfusion requirement in the nonautologous patients fell from 2.6 +/- 1.8 units in 1986 to 1.4 +/- 1.4 units per patient in 1989 and increased thereafter to 2.2 +/- 2.1 units in 1991 (p < 0.01) and showed a strong correlation with blood loss (r = 0.58; p < 0.001). No changes in postoperative haemoglobin concentration were observed throughout the study. In conclusion, collection of autologous blood is effective, albeit still underutilized, to reduce homologous blood requirement. The close correlation between blood loss and transfusion requirement accentuates the role of surgical practice in the reduction of homologous transfusions.

Aged↗