Turkish Journal of Hematology Volume: 35 - Issue: 4

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LETTERS TO THE EDITORTurk J Hematol 2018;35:300-314patient achieved a very good partial remission (vgPR) of MM.Owing to age, comorbidities, and the patient’s preferences, hewas considered transplant-ineligible and so thalidomide (100mg/day) and dexamethasone (20 mg/week) were continued.The patient has had no apparent bleeding since March 2016, hehas been transfusion-free since October 2016, and he receivedthe last parenteral iron supplementation in October 2017, soGIA endoscopy was not repeated. MM evaluations revealedcontinuous vgPR after 22 months of treatment; the patientis asymptomatic, suffers no side effects, and continues withthalidomide maintenance (Table 1).The efficacy of thalidomide as a first-line treatment incombination regimens and as maintenance therapy for MMis well established [8]. Despite the irrefutable success of somenovel therapeutic agents, such as proteasome inhibitors andnext-generation immunomodulatory drugs, thalidomide stillrepresents a valid treatment choice, especially in countries withlimited healthcare resources. Thalidomide has an emerging rolein GIA treatment, with shown efficacy in a small randomizedtrial [5] and multiple case reports (nicely reviewed by Bauditz[6]). Certain patients, especially those with several susceptibleconditions as in the case presented here, seem to achieve utmostclinical benefit and improvement in quality of life. The optimaldosage of thalidomide in GIAs is currently not defined, and theside-effect profile might limit its long-term use for diseasecontrol. Nevertheless, its efficacy and side-effect manageabilitymake further research worthwhile.Keywords: Thalidomide, Angiodysplasia, Recurrent bleeding,Multiple myeloma, AntiangiogenicAnahtar Sözcükler: Talidomid, Anjiodisplazi, Tekrarlayankanama, Multipl myelom, AntianjiojenikConflict of Interest: The authors of this paper have no conflictsof interest, including specific financial interests, relationships,and/or affiliations relevant to the subject matter or materialsincluded.References1. Makris M, Federici AB, Mannucci PM, Bolton-Maggs PH, Yee TT, Abshire T,Berntorp E. The natural history of occult or angiodysplastic gastrointestinalbleeding in von Willebrand disease. Haemophilia 2015;21:338-342.2. Duarte BKL, de Souza SM, Costa-Lima C, Medina SS, Ozelo MC. Thalidomidefor the treatment of gastrointestinal bleeding due to angiodysplasia in apatient with Glanzmann’s thrombasthenia. Hematol Rep 2017;9:6961.3. Alam MA, Sami S, Babu S. Successful treatment of bleeding gastro-intestinalangiodysplasia in hereditary haemorrhagic telangiectasia with thalidomide.BMJ Case Rep 2011:2011.4. Becq A, Rahmi G, Perrod G, Cellier C. Hemorrhagic angiodysplasia of thedigestive tract: pathogenesis, diagnosis, and management. GastrointestEndosc 2017;86:792-806.5. Ge ZZ, Chen HM, Gao YJ, Liu WZ, Xu CH, Tan HH, Chen HY, Wei W, Fang JY,Xiao SD. Efficacy of thalidomide for refractory gastrointestinal bleedingfrom vascular malformation. Gastroenterology 2011;141:1629-1637.6. Bauditz J. Effective treatment of gastrointestinal bleeding with thalidomide- chances and limitations. World J Gastroenterol 2016;22:3158-3164.7. Kumar SK, Vij R, Noga SJ, Berg D, Brent L, Dollar L, Chari A. Treating multiplemyeloma patients with oral therapies. Clin Lymphoma Myeloma Leuk2017;17:243-251.8. Aguiar PM, de Mendonça Lima T, Colleoni GWB, Storpirtis S. Efficacy andsafety of bortezomib, thalidomide, and lenalidomide in multiple myeloma:an overview of systematic reviews with meta-analyses. Crit Rev OncolHematol 2017;113:195-212.This study was previously presented as a poster in the Croatian language at the 7 th Croatian Congress of Hematologists in Šibenik, Croatia, in September 2017.©Copyright 2018 by Turkish Society of HematologyTurkish Journal of Hematology, Published by Galenos Publishing HouseAddress for Correspondence/Yazışma Adresi: Dražen PULANIĆ, M.D., University Hospital Center Zagreb,Department of Internal Medicine, Division of Hematology, Zagreb, CroatiaE-mail : dpulanic@yahoo.com ORCID-ID: orcid.org/0000-0002-1177-8921Received/Geliş tarihi: February 19, 2018Accepted/Kabul tarihi: June 18, 2018DOI: 10.4274/tjh.2018.0074306
Turk J Hematol 2018;35:300-314LETTERS TO THE EDITORTreatment of Chronic Back and Chest Pain in a Patient with SickleCell Disease Using Spinal Cord StimulationOrak Hücre Hastasında Kronik Sırt ve Göğüs Ağrısının Spinal Kord Stimülatörü ile TedavisiDamla Yürük 1 , İbrahim Aşık 21Bursa Yüksek İhtisas Training and Research Hospital, Clinic of Algology, Bursa, Turkey2Ankara University Faculty of Medicine, Department of Algology, Bursa, TurkeyTo the Editor,Pain with sickle cell disease can occur in two forms: acuteor chronic. Acute pain is often treated with analgesicsin emergency services or at home and can intermittentlyrelapse. In the later stages of the disease, chronic pain occursdue to central sensitization. Here we report a patient withsickle cell pain who was treated with a spinal cord stimulator(SCS).Our patient was a 28-year-old female. She was admitted to thehospital due to painful crises and had a history of operationsdue to vertebral fracture, femoral head osteonecrosis, andpulmonary hypertension. Her back and chest pain was rankedas 9 on a numeric rating scale when she was referred to thepain clinic. Non-enhancing areas involving vertebral bodies atdorsal and lumbar levels, suggestive of infarcts, were shownby magnetic resonance imaging (Figure 1). Pain control couldnot be achieved medically; all nonsteroidal anti-inflammatorydrugs and opioids had been unsuccessful. After evaluation bythe local pain council of the hospital, the patient underwentimplantation of an SCS.In the operating room she was placed in the prone position.Under fluoroscopic guidance a 15-gauge Tuohy needle wasinserted into the T6-T7 interlaminar space. Eight-electrode leadswere inserted through the needle and advanced until the tip layat the T1-T4 epidural level (Figure 2). Parameters of stimulationwere pulse width of amplitude 2.5 mA and frequency of 10 kHz.Following more than 60% pain relief throughout the trial period,the lead was connected to an implantable pulse generator,which was placed into the left buttock. During 1-year follow-upof the implantation of the high-frequency SCS, excellent painrelief continued with improvement of both the patient’s painand her ability to perform activities of daily living.SCS has become popular in recent years. It is a neuromodulatorand manages cases of certain chronic pain for which otherprocedures have failed, including failed back syndrome [1],ischemic limb pain [2], angina pectoris [3], and painful peripheralFigure 1. Magnetic resonance imaging shows multiple infarctsinvolving vertebral column T2 and T1 sagittal images. Nonenhancingareas involving vertebral bodies at dorsal and lumbarlevels suggest infarcts.Figure 2. Plain X-ray demonstrating placement of spinal cordstimulator electrodes at the level of T1-T4.neuropathies [4]. The mechanism of pain relief by the SCS isstill not clear [5]. According to the gate control theory, in theperipheral nerve system the afferent activity of large fibers orsmall fibers is controlled by the dorsal column cells, associatedwith central transmission of pain. When a surplus of large-fiberactivity occurs, this gate closes [6]. The pathophysiology ofsickle cell disease could also be related to autonomic nervoussystem efficiency [7]. Constriction or obstruction of a bloodvessel usually causes a reduction in blood flow and oxygendelivery to the tissues and thus insufficient perfusion [8]. Small307
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