Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen

Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen were first published by the British Committee for Standards in Haematology in 1996. Key aspects of these guidelines related to anti-infective prophylaxis, immunisation schedules and treatment of proven or suspected infection. A recent review of the guidelines was undertaken, with a view to updating the recommendations where necessary The guideline review process did not reveal any major change in patient groups considered at risk. Occupational exposure to certain pathogens may, however, be a new risk factor for some infections. The recommendations for anti-infective prophylaxis remain unchanged. New recommendations for vaccination include the use of meningococcal group C vaccine in previously non-immunised hyposplenic patients and a need to consider the use of seven-valent pneumococcal vaccine. Recommendations for treatment of suspected or proven infection have not been significantly amended, but a local protocol should take into account relevant resistance patterns. There is an identified urgent need for further research into the effectiveness of varying vaccination strategies in the hyposplenic patient, and audit of infective episodes in this patient group should continue long term. Key guidelines are summarised below, together with grades of recommendation.

hMYH cell cycle-dependent expression, subcellular localization and association with replication foci: evidence suggesting replication-coupled repair of adenine:8-oxoguanine mispairs

The human MutY homolog, hMYH, is an adenine-specific DNA glycosylase that removes adenines or 2-hydroxyadenines mispaired with guanines or 8-oxoguanines. In order to prevent mutations, this activity must be directed to the newly synthesized strand and not the template strand during DNA synthesis. The subcellular localization and expression of hMYH has been studied in serum-stimulated, proliferating MRC5 cells. Using specific antibodies, we demonstrate that endogenous hMYH protein localized both to nuclei and mitochondria. hMYH in the nuclei is distinctly distributed and co-localized with BrdU at replication foci and with proliferating cell nuclear antigen (PCNA). The levels of hMYH in the nucleus increased 3- to 4-fold during progression of the cell cycle and reached maximum levels in S phase compared to early G(1). Similar results were obtained for PCNA, while there were no notable changes in expression of 8-oxoguanine glycosylase or the human MutT homolog, MTH1, throughout the cell cycle. The cell cycle-dependent expression and localization of hMYH at sites of DNA replication suggest a role for this glycosylase in immediate post-replication DNA base excision repair.

Combined action of PSC 833 (Valspodar), a novel MDR reversing agent, with mitoxantrone, etoposide and cytarabine in poor-prognosis acute myeloid leukemia

PSC 833 (Valspodar) can reverse multidrug resistance (MDR) in patients with hematologic malignancies, but alters the pharmacokinetics of concomitant anticancer agents. A phase I, dose-finding study was initiated to define a safe and effective regimen of mitoxantrone, etoposide, and cytarabine (MEC) when administered with PSC 833 to patients with early relapsed or refractory acute myeloid leukemia (AML). Poor-prognosis AML patients refractory to first-line induction therapy or relapsing within 9 months of attaining complete remission (CR) were treated with cytarabine (1.0 g/m2/day), etoposide (30 mg/m2/day), and mitoxantrone at a dose of either 3.0 mg/m2/day (cohort 1) or 4.5 mg/m2/day (cohorts 2 and 3) for 6 days plus continuous-infusion PSC 833 (10 mg/kg/24 h with a 2.0 mg/kg loading dose) for 6 or 7 days each 21-day cycle. Patients achieving CR were given a 4-day MEC plus PSC 833 consolidation cycle. Twenty-three patients were enrolled (eight with primary refractory AML and 15 in relapse). Dose-limiting toxicity occurred in one of six patients in cohort 2 (grade 4 mucositis) and one of seven patients in cohort 3 (grade 4 hyperbilirubinemia). The maximum tolerated dose of mitoxantrone was defined as 4.5 mg/m2/day. Clinically significant grade 4 hyperbilirubinemia, possibly related to PSC 833, occurred in four patients. Hematologic toxicities were as expected in this patient population, but were not dose limiting. Mild to moderate cerebellar ataxia and paresthesia occurred in six (26%) and five (22%) patients, respectively, but were not dose limiting. Overall, six of 23 (26%) patients achieved CR, including five patients with demonstrated P-glycoprotein expression and/or function. The median overall survival was 4 months. All six patients with a CR were alive and four (17%) patients were disease free at 12 months. Blood levels of PSC 833 were well above the target level of 1000 ng/ml, a concentration that is known to reverse MDR in vitro. PSC 833 reduced the clearance of etoposide by approximately two-fold. No correlation was observed between the mitoxantrone or etoposide area under the curve and response. In conclusion, the MEC plus PSC 833 tested regimen was well tolerated and the 26% CR rate warrants further testing of this regimen in a randomized, phase III trial.

Electronic identification: Applications in beef production and research

Individual identification of beef cattle is not new to the Canadian beef industry, as traceback systems played a pivotal role in the eradication of bovine tuberculosis in the 1940s and 1950s and brucellosis in the 1970s and 1980s. Recent concerns over animal health (e.g., bovine spongiform encephaolopathy), export markets, product consistency, meat quality (e.g., tenderness, marbling) and safety (e.g., Escherichia. coli 0157:H7, Salmonella spp.) make reestablishment of a traceback system a logical approach to assuring consumer confidence in Canadian beef. Originally, simple Kurl-lockTM ear tags with a unique number were used to trace individuals back to their herd of origin. Although useful for addressing disease concerns, this system did not lend itself to compiling additional information (e.g., growth performance, animal health, breeding programs, carcass quality) for use in management or marketing decisions. More sophisticated electronic identification systems can readily interface with computers and make information management an even more pivotal component of beef production. Several electronic identification systems (e.g., bar codes, radio frequency identification, read–write systems) are being assessed for their effectiveness for identifying individual cattle under production conditions. In research applications, this technology has the potential for individual animals to become the experimental unit under group housing conditions. By combining electronic identification technology with devices that measure physiological (e.g., temperature, pH, body weight, feed intake) parameters, researchers will be able to collect data in natural production environments that were previously only obtainable under controlled experimental conditions with a limited number of animals. Key words: Electronic identification, beef, traceback, radio frequency identification

A randomized British National Lymphoma Investigation trial of CHOP vs. a weekly multi-agent regimen (PACEBOM) in patients with histologically aggressive non-Hodgkin's lymphoma

BACKGROUND

Between 1987 and 1991, the British National Lymphoma Investigation randomized 459 patients with non-Hodgkin's lymphoma with a large-cell component to either CHOP or the PACEBOM regimen.

PATIENTS AND METHODS

Four hundred fifty-nine eligible patients were included in this trial, four hundred one with diffuse large-cell lymphoma and fifty-eight with diffuse mixed-cell lymphoma according to the Working Formulation. Two hundred twenty-six patients were randomized to receive CHOP and two hundred thirty-three to receive PACEBOM. The two arms of the trial were well balanced for all potential prognostic factors.

RESULTS

The complete remission rate with PACEBOM was 64% and with CHOP 57% (NS). At eight years, the actuarial cause specific survival (CSS) in the PACEBOM arm is 59% compared to 49% in the CHOP arm (P = 0.09). Patients < 50 years of age fared significantly better in the PACEBOM arm both for CSS and overall survival (P = 0.002) and the CSS was also significantly improved in stage IV disease (P = 0.02).

CONCLUSIONS

The mature data from this trial suggest that an etoposide-containing multi-agent weekly regimen can be superior to CHOP.

Growth response of pastured Simmental calves to a high by-pass protein creep supplement

One hundred and thirty-seven cow-calf pairs on pasture in southeastern Alberta, were randomly allocated to one of two treatments no supplement (NOS) or a high by-pass protein (70% of CP) creep supplement (HPS) at an intake of 1.5 kg head−1 d−1. Calf weaning weights and pre-weaning ADG were higher (P < 0.01) in calves fed HPS (306.0 kg and 1.49 kg d−1) compared with NOS (298.2 kg and 1.41 kg d−1), respectively. However, it was uneconomical to feed this high by-pass creep as the feed cost of a kg of additional gain at weaning was $9.60. Key words: Creep supplement, pasture, growth, beef cattle

High-dose BEAM chemotherapy with autologous haemopoietic stem cell transplantation for Hodgkin's disease is unlikely to be associated with a major increased risk of secondary MDS/AML

Hodgkin's disease is curable in the majority of patients, although a proportion of patients are resistant to or relapse after initial therapy. High-dose therapy with autologous stem cell support has become the standard salvage therapy for patients failing chemotherapy, but there have been reports of a high incidence of myelodysplasia/acute myeloid leukaemia (MDS/AML) following such treatment. Patients who receive such therapy form a selected group, however, who have already been subjected to other leukaemogenic factors, such as treatment with alkylating agents. In order to ascertain the true risk of MDS/AML, comparison must be made with other patients subjected to the same risks but not undergoing transplantation. We report a retrospective comparative study of 4576 patients with Hodgkin's disease from the BNLI and UCLH Hodgkin's databases, which includes 595 patients who have received a transplant. Statistical analysis including Cox's proportional hazards multivariate regression model with time-dependent covariates was employed. This analysis reveals that the risk of developing MDS/AML was dominated by three factors, namely quantity of prior therapy (relative risk [RR] 2.01, 95% confidence intervals [CI] 1.49-2.71, for each treatment block, P < 0.0001) and whether the patient had been exposed to MOPP (RR 3.61, 95% CI 1.64-7.95, P = 0.0009) or lomustine chemotherapy (RR 4.53, 95% CI 1.96-10.44, P = 0.001). Following adjustment for these factors in the multivariate model the relative risk associated with transplantation was 1.83 (95% CI 0.66-5.11, P = 0.25). This study provides no evidence of a significantly increased risk of MDS/AML associated with BEAM therapy and autologous transplantation in Hodgkin's disease. Concern over MDS/AML should not mitigate against the timely use of this treatment modality.

Treatment of poor prognosis AML patients using PSC833 (valspodar) plus mitoxantrone, etoposide, and cytarabine (PSC-MEC)

The failure of convenional chemotherapy in relapsed or refractory and other poor risk AML patients has been linked to expression of the multidrug resistance gene (mdr 1) product P-glycoprotein (P-gp). PSC 833 is a non-competitive inhibitor of P-gp and has been shown in vitro and in vivo to restore sensitivity of resistant tumor cells to anticancer drugs (ACDs). Induction chemotherapy consisting of cytarabine (C) in combination with PSC 833 and escalating doses of mitoxantrone (M) and etoposide (E) over 5 or 6 days were tested in two phase I/II studies in poor prognosis AML. Overall, 59 patients were evaluated: their age ranged between 18 and 70 years. Fourteen patients had primary refractory disease, 25 had relapsed within 9 months from first complete remission (CR), 5 were in second relapse, 10 had secondary AML, and 4 had relapsed post-bone marrow transplantation. PSC 833 was given as a constant i.v. infusion at a rate of 10 mg/kg/24 h for 5 or 6 days, depending on the duration of chemotherapy. In both studies a loading dose of 2 mg/kg of PSC 833 was given on day 1. In the 5-day regimen, the final study doses of the cytotoxic agents were C 1 g/m2/d, M 4.0 mg/m2/d, and E 40 mg/m2/d. In the 6-day regimen, the final study doses of the cytotoxic agents were C 1 g/m2/d, M 4.5 mg/m2/d and E 30 mg/m2/d. The combined efficacy results of both studies indicate that PSC-MEC is active in all treatment indications, complete remission being achieved in 2/5 (40%) second relapses, 8/25 (32%) early relapses, 3/10 (30%) secondary AML, 3/15 (20%) refractory patients and 1/4 (25%) post-BMT relapses. Based on historical controls, this observed overall CR rate (29%) is higher than expected in this high risk patient population. Our data indicate that, in refractory/relapsed AML patients, PSC-MEC regimens had encouraging antileukemic effects, is well tolerated, and has led to Phase III trials in this setting.

Management of four pregnant women with multidrug-resistant tuberculosis

This case series describes the medical management of four pregnant women with active multidrug-resistant tuberculosis. None of the four patients were infected with human immunodeficiency virus. Three patients had disease due to multidrug-resistant Mycobacterium tuberculosis, and one had disease due to multidrug-resistant Mycobacterium bovis. Only one patient (patient 3) began retreatment during pregnancy, because her organism was susceptible to three antituberculosis drugs that were considered nontoxic to the fetus. Despite concern over teratogenicity of the second-line antituberculosis medications, careful timing of treatment initiation resulted in clinical cure for the mothers, despite some complications due to chronic tuberculosis and/or therapy. All infants were born healthy and remain free of tuberculosis. Pregnancy and multidrug-resistant tuberculosis need not be a public health disaster, as both conditions can be managed concurrently and successfully.

Radiographic evaluation of breech presentation: is it necessary?

The purpose of this study was to evaluate the use of ultrasound in identifying fetal position and cervical spine flexion in breech presentations. Radiographic and ultrasonographic determinations of the type of presentation (frank, complete or incomplete) and degree of cervical spine flexion in 52 breech presentations were compared. The angle of flexion was defined as the angle between the fetal mandible and main axis of the cervical spine and categorized as full flexion, military, partial extension and full extension. Ultrasound was concordant with radiographic assessment of the type of presentation in 77% and the angle of flexion in 64% of the subjects and was even more accurate in those in labor. All cases predicted as having full flexion (< 90 degrees C) of the cervical spine by ultrasound had an angle of flexion < or = 90 degrees C on radiographic assessment. Of subjects in labor, ultrasound accurately identified the type of breech presentation in all cases. In addition, sonographic identification of full flexion of the cervical spine excludes cases of fetal neck extension and precludes the need for radiographic assessment prior to a trial of labor.

High-dose therapy and autologous stem cell rescue for patients with Hodgkin's disease in first relapse after chemotherapy: results from the EBMT. Lymphoma Working Party of the European Group for Blood and Marrow Transplantation

The purpose of this study was to investigate the results of high-dose therapy and autologous stem cell transplantation in adult patients with Hodgkin's disease in first relapse after chemotherapy, to determine the overall and progression-free survival, identify prognostic factors for outcome, and to define the role of conventional dose salvage therapy given prior to the high dose regimen. A retrospective analysis of 139 adult patients reported to the lymphoma registry of the European Group for Blood and Marrow Transplantation (EBMT) between February 1984 and July 1995 is considered. Data on all patients were reviewed and prognostic factors determined in univariate analysis. The actuarial 5-year overall survival (OS) and progression-free survival (PFS) for the entire group of 139 patients were 49.4 and 44.7%, respectively. In univariate analysis for OS, disease bulk at the time of high-dose therapy, second-line regimen, initial remission duration and status at transplant had no predictive value. Status at transplant was predictive for OS when patients in second complete remission (CR) were analysed separately from those in chemosensitive relapse. Similar trends were observed for PFS. We concluded that high-dose therapy and autologous stem cell transplantation is an effective strategy for patients with Hodgkin's disease in first relapse after chemotherapy. These results suggest that it should be used regardless of initial remission duration. The role of conventional-dose salvage given prior to high-dose therapy is unclear, since disease status, disease bulk at the time of transplantation, and the second-line regimen had no significant effect on outcome. However, in view of the low patient numbers, no firm conclusion is possible, and this issue requires prospective assessment.

Potential use of video imaging and real-time ultrasound on incoming feeder steers to improve carcass uniformity

A study was conducted to evaluate two feeder cattle sorting systems for their ability to improve carcass backfat uniformity. One thousand and thirty-one yearling steers (407 kg; SD = 46.2 kg) were assembled and processed at three Alberta feedlots. Each steer was weighed and ultrasonically assessed for backfat thickness and l. dorsi area 88 to 154 d before slaughter. Rump height, frame score and muscle score were also recorded using an automated video imaging system, called the Musculo-Skeletal Imaging (MSI) Scanner. Sorting System 1 (MSI sorting system) used initial body weight, frame score and muscle score to hypothetically cluster animals into five "predicted days on feed" (PDOF) groups. Sorting System 2 (Oltjen sorting system) used initial body weight, rump height, backfat thickness, feeding inputs and a computer model of cattle growth to hypothetically cluster animals into five PDOF groups. Each sorting system was compared with the traditional system of visually sorting cattle at the end of the feeding period for its ability to reduce the variability in carcass backfat thickness. Steers were identified for slaughter when they reached the body weight and condition desired by the feedlot manager. The MSI sorting system decreased the variability in slaughter weight by 14.3% (P < 0.001), but had no effect on the variability in carcass backfat thickness compared with the observed variability. The change in predicted net return resulting from the MSI sorting system varied between feedlot from $−4.09 to $8.82 head−1 slaughtered. The Oltjen sorting system increased the variability in slaughter weight by 33.9% (P < 0.001) and decreased the variability in carcass backfat thickness by 15.5% (P < 0.001). The predicted net return from the Oltjen sorting system varied between feedlot from $−3.65 to $11.55 head−1 slaughtered. Further work is required to determine the actual effect of sorting systems on feed efficiency, carcass quality and net return. Key words: Sorting, computer model, electronic identification, steers

Traceback success rate of an electronic feedlot to slaughter information system for beef cattle

The traceback success rate of an electronic feedlot to slaughter information system was evaluated using 4186 yearling cattle from three Alberta feedlots. Each animal was identified with an external Allflex electronic identification (EID) eartag before the end of the feeding period. The EID number was scanned with stationary Allflex TIRIS readers at the abattoir and electronically linked to its carcass data. The traceback success rate was 39.8% from abattoir to feedlot and 46.4% from abattoir to herd of origin. Key words: Allflex, electronic identification, reliability, transponder, cattle

Engraftment and molecular monitoring of CD34+ peripheral-blood stem-cell transplants for follicular lymphoma: a pilot study

PURPOSE

A pilot study to validate the use of CD34+ selection (Ceprate SC) of blood stem-cell collection in patients with advanced follicular lymphoma receiving myeloablative chemoradiotherapy.

PATIENTS AND METHODS

Seventeen patients were entered onto the protocol. Thirteen of 17 patients have undergone transplantation; the median age is 42.5 years (range, 33 to 51), seven of 13 are stage IVB, two stage IVA, three stage IIIB, and one stage IIB. All except two patients were treated after first or subsequent relapses after receiving cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy to achieve a good partial (six of 13) or complete (seven of 13) response before stem-cell mobilization with cyclophosphamide 3 g/m2 and filgrastim 300 microg once daily.

RESULTS

Eleven of 13 patients had a detectable t(14;18) by nested polymerase chain reaction (PCR). Median CD34+ count before selection was 2.9 x 10(6)/kg (range, 1.17 to 11.3) and after CD34+ selection was 1.54 x 10(6)/kg (range, 0.88 to 7.6) with a median CD34+ yield of 62.4% (range, 17% to 95%) and purity of 60% (range, 39.3% to 73%). Of the 11 patients known to have t(14;18), 10 had PCR-detectable contamination of stem-cell harvests that became PCR negative in six of the 10 after CD34+ selection. Engraftment was rapid with a median day to absolute neutrophil count (ANC) greater than 0.5 x 10(9)/L of 13 days (range, 11 to 21) and platelet count greater than 20 x 10(9)/L of 14 days (range, 10 to 44). With a median follow-up duration of 15 months, three patients have remained persistently PCR-positive, two of whom received PCR-positive stem cells. Two have relapsed. Of the seven patients who received PCR-negative stem cells, five have had no PCR-detectable disease in posttransplant bone marrow samples.

CONCLUSION

Longer follow-up duration is required to determine the significance of these findings, but we have confirmed the feasibility of CD34+ selected cells to deplete peripheral-blood stem cells of tumor cells from patients undergoing high-dose therapy for follicular lymphoma.

Allogeneic peripheral blood stem cell transplantation for haematological malignancies--an analysis of kinetics of engraftment and GVHD risk

We have carried out an analysis of 44 patients undergoing allogeneic PBSC transplants from fully HLA-matched related donors with particular emphasis on engraftment kinetics and the incidence and severity of GVHD. The recipients had a median age of 37 years (range 5-56 years), 16 patients had standard-risk disease and 28 had poor-risk disease. GVHD prophylaxis was with cyclosporin A and methotrexate (n = 41), cyclosporin A alone (n = 2) or cyclosporin A and methyl-prednisolone (n = 1). Stem cells were mobilised using G-CSF, collecting a median of 5.75 x 10(6) CD34+ cells/kg recipient weight (range 0.94-35 x 10(6) CD34+ cells/kg). Engraftment times to a neutrophil count > 0.5 x 10(9)/1 and platelets > 20 x 10(9)/1 were achieved at a median of day +14 (range 10-25) and day +14 (range 9-130) respectively. Patients receiving > or = 4 x 10(6) CD34+ cells/kg had significantly accelerated neutrophil and platelet engraftment and this number of CD34+ cells would appear to be a prerequisite for maximum engraftment using PBSC. Acute GVHD occurred in 25 of 43 evaluable patients although in only 12 was this clinically significant (grades II-IV). Chronic GVHD has occurred in 17 out of 36 evaluable patients, there was no significant difference between the standard- and poor-risk groups in incidence of either acute or chronic GVHD. In conclusion, these results confirm the feasibility of using PBSC for allogeneic transplantation without evidence for increased risk of either acute or chronic GVHD and provide further evidence supporting the potential of PBSC to replace bone marrow as the major source of haemopoietic cells for allogeneic transplantation.

Crystal structure of an antagonist mutant of human growth hormone, G120R, in complex with its receptor at 2.9 A resolution

Human growth hormone binds two receptor molecules and thereby induces signal transduction through receptor dimerization. At high concentrations, growth hormone acts as an antagonist because of a large difference in affinities at the respective binding sites. This antagonist action can be enhanced further by reducing binding in the low affinity binding site. A growth hormone antagonist mutant Gly-120 --> Arg, has been crystallized with its receptor as a 1:1 complex and the crystal structure determined at 2.9 A resolution. The 1:1 complex is remarkably similar to the native growth hormone-receptor 1:2 complex. A comparison between the two structures reveals only minimal differences in the conformations of the hormone or its receptor in the two complexes, including the angle between the two immunoglobulin-like domains of the receptor. Further, two symmetry-related 1:1 complexes in the crystal form a 2:2 complex with a large solvent inaccessible area between two receptor molecules. In addition, we present here a native human growth hormone-human growth hormone-binding protein 1:2 complex structure at 2.5 A resolution. One important difference between our structure and the previously published crystal structure at 2.8 A is revealed. Trp-104 in the receptor, a key residue in the hormone-receptor interaction, has an altered conformation in the low affinity site enabling a favorable hydrogen bond to be formed with Asp-116 of the hormone.

Relationship between expected progeny differences of Canadian Hereford sires and performance of their progeny in commercial herds

Sire expected progeny differences (EPDs) for calf birth, weaning and yearling weight predicted genetic differences between progeny of sires. A 1-kg change in birth weight EPD corresponded to a 1.06 ± 0.14 kg (P < 0.001) change in actual calf birth weight. A 1-kg change in weaning weight EPD or yearling weight EPD corresponded to a 0.45 ± 0.18 kg (P = 0.012) change in 200-d weaning weight or a 0.78 ± 0.15 kg (P < 0.001) change in 365-d yearling weight. Calving ease EPD was not related (0.37 ± 0.27; P = 0.17) to calving ease score. Key words: EPD, calving ease, birth weight, weaning weight, yearling weight

Dose intensification with autologous bone-marrow transplantation in relapsed and resistant Hodgkin's disease: results of a BNLI randomised trial

High-dose chemotherapy and radiotherapy with autologous bone-marrow transplantation (ABMT) are increasingly used for the treatment of relapsed and resistant Hodgkin's disease, although there has been no randomised trial of this treatment. The British National Lymphoma Investigation therefore undertook a randomised comparison of high-dose chemotherapy (BEAM = carmustine, etoposide, cytarabine, and melphalan) plus ABMT with the same drugs at lower doses not requiring bone-marrow rescue (mini-BEAM) in patients with active Hodgkin's disease, for whom conventional therapy had failed. 20 patients were assigned treatment with BEAM plus ABMT and 20 mini-BEAM. All have been followed up for at least 12 months (median 34 months). 5 BEAM recipients have died (2 from causes related to ABMT and 3 from disease progression) compared with 9 mini-BEAM recipients (all disease progression). This difference was not significant (p = 0.318). However, both event-free survival and progression-free survival showed significant differences in favour of BEAM plus ABMT (p = 0.025 and p = 0.005, respectively). Recruitment to the trial became increasingly difficult because patients refused randomisation and requested ABMT. It was therefore closed early (40 patients rather than 66 intended). Nevertheless, we found a dose-response effect in these patients with relapsed and resistant Hodgkin's disease. High doses facilitated by ABMT can lead to better disease-free survival.

Treatment of aplastic anaemia (AA) with antilymphocyte globulin (ALG) and methylprednisolone (MPred) with or without androgens: a randomized trial from the EBMT SAA working party

134 patients with acquired aplastic anaemia (AA) were given HALG 15 mg/kg/d for 5 d and methylprednisolone for 1 month, and randomized to receive (n = 69) or not (n = 65) oxymetholone 2 mg/kg/d p.o. daily for 4 months. Early mortality (< 120 d) was comparable in the two arms 12/69 (17%) and 11/65 (17%), and correlated with the severity of the disease (39%, 10% and 6% respectively in patients with neutrophil counts (PMN) < 0.2, 0.2-0.5, > 0.5 x 10(9)/l). The response rate at 120 d was significantly greater in patients receiving androgens (56% v 40%; P = 0.04); it was 68% v 48% (P = 0.02) in patients surviving 120 d, and 78% v 27% (P = 0.03) in females with PMN less than 0.5 x 10(9)/l. In a multivariate Cox analysis on patients with less than 0.5 x 10(9)/l PMN, the probability of responding without androgens was reduced compared to the androgen treatment arm (P = 0.05). Survival was comparable in the two groups (71% v 65%). It was superior (74% v 50%), but not significantly (P = 0.1) in females with PMN < or = 0.5 x 10(9)/l receiving androgens. Side-effects, including biochemical abnormalities and virilization, could be controlled and were reversible. In conclusion, the addition of androgens to HALG and methylprednisolone as first line treatment of aplastic anaemia significantly improves the response rate at 4 months, particularly in females with low neutrophil counts, although there is no significant effect on short-term survival. The reversible side-effects warrant the use of androgens as an adjunct to the first course of ALG in females with severe AA.

The effect of altitude on umbilical cord blood gases

OBJECTIVE

Analysis of umbilical cord blood acid-base status has proven useful in the immediate care and resuscitation of the newborn and provides an objective measure of the intrapartum fetal environment. Our study was designed to determine whether there are any significant differences in the acid-base status of neonates delivered at a relatively high altitude of 6000 ft compared with sea-level controls.

METHODS

Our study population consisted of 300 women who had undergone spontaneous vaginal delivery after uncomplicated labor; 150 delivered at an institution located at an elevation of 5900 ft and the remainder at an elevation of 87 ft. Exclusion criteria were hypertensive disease, diabetes, suspected fetal growth retardation, fetal distress, meconium-stained amniotic fluid, and chorioamnionitis. All patients received continuous electronic fetal monitoring, and tracings were reviewed by a physician blinded to the umbilical acid-base results. Umbilical cord arterial and venous samples were collected and analyzed within 30 minutes of delivery.

RESULTS

Compared with sea-level controls, neonates delivered at high altitude had a significantly higher mean pH with lower mean carbon dioxide pressure values in both arterial and venous specimens (P less than .05). The difference between the mean arterial pH values was 0.026 (P less than .05, 95% confidence interval [CI] 0.015-0.037) and mean venous values was 0.037 (P less than .05, 95% CI 0.027-0.047). There were no significant differences in the arterial or venous oxygen pressure or oxygen saturation values between the study and control groups. There was a significant decrease in the mean birth weight of 320 g (P less than .05, 95% CI 199.5-441.3) and higher pre-delivery hematocrit values (2.4%; P less than .05, 95% CI 1.6-3.2) in the high-altitude population compared with the sea-level group.

CONCLUSIONS

Neonates delivered at high altitude have significant alterations in umbilical blood acid-base measurements compared with neonates at sea level. Other significant differences include a lower infant birth weight and a higher maternal hematocrit relative to pregnant women at sea level.

Transmission of Proteus syndrome from father to son?

We present a male infant with cranial hemi-hypertrophy, a lymphangioma, a lipoma, and epidermal naevi. A diagnosis of Proteus syndrome was made. His father had had a large lymphangioma resected from the right side of the face as a child. We propose that Proteus syndrome has been transmitted from father to son.

Successful treatment of acute myeloid leukemia beyond first remission with autologous bone marrow transplantation using busulfan/cyclophosphamide and unpurged marrow: the British autograft group experience

The results in 34 adult patients with acute myeloid leukemia (AML) who have undergone autologous bone marrow transplantation (ABMT) using busulfan and cyclophosphamide (Bu/Cy) in 12 United Kingdom (UK) centers have been analyzed. There were 19 females and 15 males; median age was 40 years (range, 21 to 62 years). Nine patients were in first relapse; 25 were in second remission. The median time of first remission for the whole group was 11.5 months (range, 1 to 56 months). All the patients in first relapse and six patients in second remission received first remission marrow. The leukemia-free survival (LFS) for the patients in first relapse was 33%, with a median follow-up of 20 months. The LFS for the patients in second remission was 48% with a median follow-up of 26 months. The length of second remission exceeds the length of first remission in 14 patients. Considerable toxicity with hemorrhagic cystitis (four patients; none fatal), venoocclusive disease (four patients; one fatal), pneumonitis (four patients; one fatal), intracranial hemorrhage (two patients; two fatal) has occurred. There have been four procedure-related deaths (12%). Hematologic recovery was satisfactory for neutrophils (median time to 0.5 x 10(9)/L, 22 days [range, 11 to 101 days]), but very slow for platelets (median time to 50 x 10(9)/L, 62 days [range, 15 to 1,080 days]). This study suggests that the use of Bu/Cy with ABMT for patients beyond first remission in AML compares favorably with chemotherapy, and although the procedure-related mortality is acceptable, it is associated with protracted platelet recovery.