SummaryA joint working group established by the Haemato-oncology subgroup of the British Committee for Standards in Haematology, the British Society for Bone Marrow Transplantation and the UK Clinical Virology Network has reviewed the available literature and made recommendations for the diagnosis and management of respiratory viral infections in patients with haematological malignancies or those undergoing haematopoietic stem cell transplantation. This guideline includes recommendations for the diagnosis, prevention and treatment of respiratory viral infections in adults and children. The suggestions and recommendations are primarily intended for physicians practising in the United Kingdom.

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A 58-year-old builder was commenced on cyclophosphamide, thalidomide and dexamethasone (CTD) chemotherapy for immunoglobulin (Ig) A kappa myeloma. A skeletal survey performed at presentation showed a high burden of skeletal disease including multiple levels of endplate depression fractures and anterior wedge compression fractures of the thoracic spine. He also had several rib fractures resulting in a considerable amount of pain for which he was referred for radiotherapy. After his third cycle of CTD, he mentioned that his chest looked abnormal. Clinical examination showed marked pectus excavatum (left). Chest radiology was suggestive of a sternal fracture and this was further evaluated by computerized tomographic (CT) scanning. The CT scan confirmed a depressed pathological fracture of the sternum (right). Urgent orthopaedic and cardiothoracic reviews were sought and analgesia was optimized. The patient was advised to avoid any heavy manual labour as this could potentially depress the fracture further. He was referred for radiotherapy and received 8 Gy to his sternum.Sternal fractures are potentially serious and even life threatening. Severely deformed or comminuted fractures require surgical intervention. Pathological fractures of the sternum demonstrate a tendency to greater deformity and heal more slowly than traumatic sternal fractures. Sternal fractures are exquisitely painful and adequate analgesia is essential. Radiotherapy can be used for pain control and reduction in local disease burden, which aids healing. The role of surgery for pathological sternal fractures is less well defined, although solitary plasmacytomas have been resected successfully.

Choices in medicine come with responsibility. With several TKI's (Tyrosine kinase inhibitors) available for front-line management of CML (Chronic Myeloid Leukemia), an astute clinician has to personalise, rationalise and take a pragmatic approach towards selection of the best drug for the ‘patient in question’. Though it is hotly debated as to which TKI will triumph, the truth of this debate lies in individualising treatment rather than a general ‘all size fits all’ approach with imatinib. I personally believe that the second generation TKI's will suit most patient clinical profiles rather than prescribing imatinib to all and I have strived to make a strong case for them in front line treatment of CML. Though Imatinib may remain the first line choice for some patients, my efforts in this debate are mainly geared towards breaking the myth that imatinib is the sole ‘block buster’ on the CML landscape

FIG URE 1 Peripheral blood (PB) film, case 1 FIG URE 2 Karyogram, case 1