Clinical standards for specialist community rehabilitation services in the UK

OBJECTIVE

To develop a set of clinical standards for specialist community rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services.

DESIGN AND METHODS

The proposed set of standards was adapted from the previously published standards for inpatient services, by a working party of the British Society for Rehabilitation Medicine (BSRM). Consensus was then achieved by an iterative consultation process in five rounds. A postal survey was conducted on behalf of the BSRM amongst its consultant members providing community rehabilitation services in the UK, who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability.

RESULTS

Fifty consultants who ran specialist community rehabilitation services agreed to participate, of whom 29 (58%) actually responded. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Twenty-five (89%) felt the standards were helpful and 26 (93%) felt that they covered the main aspects of specialist community rehabilitation services: 23 (79%) found them at least partially applicable to their own service.

CONCLUSIONS

Proposed clinical standards have been developed for specialist community rehabilitation services in the UK. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Substantial linkage disequilibrium across the insulin-degrading enzyme locus but no association with late-onset Alzheimer's disease

Insulin-degrading enzyme (IDE; insulysin; EC 3.4.24.56) is a 110-kDa neutral metallopeptidase that can degrade a number of peptides including beta-amyloid. The gene encoding IDE is located on chromosome 10 close to a region of linkage for late-onset Alzheimer's disease (LOAD) and thus is a functional and positional candidate for this disorder. We analysed all of the coding exons, untranslated regions and 1000 bp of 5'-flanking sequence of IDE by using denaturing high-performance liquid chromatography and sequencing. We detected eight single nucleotide polymorphisms (SNPs), three in the 5' flanking sequence and five in the coding sequence, of which three were found at lower than 5% frequency. None of them changed the amino acid sequence. We genotyped the five SNPs with allele frequencies of more than 5% in 133 Caucasian LOAD cases and 135 controls collected in the UK and 95 cases and 117 controls collected at the Mayo Clinic, Rochester, USA. Two of the SNPs were analysed in a further independent case-control sample (Washington University, St. Louis: 86 cases, 94 controls). No significant association was found with any individual SNP in any of the samples or with any haplotypes. Analysis of the marker D10S583, which maps 36 kb upstream of IDE, also failed to show association in 134 cases and 111 matched controls from the UK ( P=0.63). Strong linkage disequilibrium was detected between the five SNPs that spanned the whole of the 120-kb genomic region of IDE and one major and a number of minor haplotypes were detected in the populations studied. We conclude that IDE does not make a substantial contribution to the aetiology of LOAD and therefore cannot account for the linkage between LOAD and 10q.

Activation of CD1d-restricted T cells protects NOD mice from developing diabetes by regulating dendritic cell subsets

CD1d-restricted invariant NKT (iNKT) cells are immunoregulatory cells whose loss exacerbates diabetes in nonobese diabetic (NOD) female mice. Here, we show that the relative numbers of iNKT cells from the pancreatic islets of NOD mice decrease at the time of conversion from peri-insulitis to invasive insulitis and diabetes. Conversely, NOD male mice who have a low incidence of diabetes showed an increased frequency of iNKT cells. Moreover, administration of alpha-galactosylceramide, a potent activating ligand presented by CD1d, ameliorated the development of diabetes in NOD female mice and resulted in the accumulation of iNKT cells and myeloid dendritic cells (DC) in pancreatic lymph nodes (PLN), but not in inguinal lymph nodes. Strikingly, injection of NOD female mice with myeloid DC isolated from the PLN, but not those from the inguinal lymph nodes, completely prevented diabetes. Thus, the immunoregulatory role of iNKT cells is manifested by the recruitment of tolerogenic myeloid DC to the PLN and the inhibition of ongoing autoimmune inflammation.

Does avoidance of cardiopulmonary bypass decrease the incidence of stroke in diabetics undergoing coronary surgery?

BACKGROUND

The adverse effects of diabetes mellitus on the coronary circulation and the higher incidence of cardiovascular events in diabetic patients are well documented [Johnson 1982]. Improvements in myocardial protection, revascularization techniques, and anesthetic management have had favorable impacts on coronary artery bypass grafting (CABG) outcome in diabetic patients. Despite that, diabetic patients are significantly more likely to have a prior history of myocardial infarction, congestive heart failure, peripheral vascular disease, and hypertension, as well as having a significantly greater baseline serum creatinine. The aim of our study was to record, compare, and analyze the stroke rate among patients with a history of preoperative diabetes undergoing "off-pump" CABG (OPCAB) with conventional cardiopulmonary bypass (CPB) CABG to determine whether the stroke rate in this higher risk population could be decreased by off-pump techniques.

METHODS

The records of 1,227 patients with a pre-operative history of diabetes undergoing conventional CABG (973 patients, 79.3%) using cardiopulmonary bypass and off-pump CABG 254 (20.7%) were analyzed from 1995 through 1999. There were no differences in age, sex, or elective/urgent status of patients. Preoperative risk factors (gender distribution, carotid disease, ejection fraction, CHF, hypertension, previous MI) were identical in both groups. The goal of the operations were complete revascularization, which was achieved via median sternotomy in both groups.

RESULTS

Our reported series reveals a stroke rate of 3.6% in the CPB group and 1.2% in the off-pump group. This evidence alone was not statistically significant, but two other high-risk criteria for stroke, re-do CABG and calcified aortas, revealed that the off-pump series had a higher percentage of each (26.4% redos in off-pump vs. 8.7% CPB redos, p < 0.005; 7.1% calcified aorta cases in the off-pump group vs. 2.9% in the CPB group, p < 0.004). The threefold reduction in stroke may be clinically significant in light of the higher-risk profile of the off-pump group. The limitations of this study are that it was retrospective, there were a small number of events, and different surgeons were involved in the two different approaches to these patients.

CONCLUSIONS

Improvements in myocardial protection, revascularization techniques, and anesthetic management have made significant, favorable impacts on CABG outcome in diabetic patients. New diagnostic and therapeutic strategies must be developed to lessen the medical and economic implications of stroke. A larger series or a more effective way of analyzing preoperative risk may well have shown a statistically significant difference in the stroke incidence given the differences in preoperative risk factors/stroke predictors. Until such advances occur, a threefold reduction of stroke incidence using OPCAB certainly makes this technique a favorable one for high-risk diabetics requiring coronary revascularization.

HLA transgenic mice as models of human autoimmune diseases

MHC class II alleles have been linked to several human autoimmune diseases such as rheumatoid arthritis (RA), Type I diabetes, and multiple sclerosis (MS). Although the mechanisms by which expression of certain MHC class II molecules predispose an individual to a particular autoimmune disease are not known, it is clear that increased susceptibility is associated with the polymorphic regions unique to these predisposing HLA alleles. These polymorphic differences may influence susceptibility by selecting potential autoreactive T cells during thymic education. Alternatively, nonsusceptible alleles may either delete or fail to select these potential autoimmune T cells, thus reducing the possibility of developing disease. In the periphery, the unique specificity of the HLA molecule derived from a susceptible allele may then recognize and present an autoantigenic peptide or foreign peptide that may cross-react with an autoantigen, activating these autoreactive T cells and leading to disease. To dissect these possibilities and to determine the exact role of particular HLA-DR or DQ molecules in disease susceptibility, we have generated several lines of HLA-DR and DQ transgenic mice. In this review, we present data summarizing the functions of these HLA class II molecules using well-established mouse models for autoimmune diseases.

[Metopic suture craniosynostosis: sodium valproate teratogenic effect. Case report]

OBJECTIVE

the aim of this report is to warn that sodium valproate used during pregnancy can produce craniosynostosis in the newborn, particularly trigonocephaly.

METHOD

we describe a case of trigonocephaly in a six month-old girl, daughter of a young non-smoker couple, whose mother had used phenobarbital 100 mg daily and sodium valproate 500 mg twice daily during the whole pregnancy. We also review current literature about this topic.

RESULT

bone sclerosis over the metopic suture was confirmed during surgery. Bibliographical review yields previous reports on valproate teratogenicity, mainly determining metopic suture craniosynostosis.

CONCLUSION

sodium valproate used during pregnancy can produce craniosynostosis by teratogenic effect, specially trigonocephaly (premature fusion of metopic suture).

[Brain vascular disease presenting as first manifestation of temporal arteritis: report of two cases]

Brain vascular disease as the first presentation of temporal arteritis is unusual. We present two cases in which the diagnosis emerged from the anamnesis. A 54 years old woman has had a left cerebral infarct 3 months ago. She was getting better when severe visual loss occurred and the family decided to get a second opinion. The patient have had right hemiparesis, aphasia and a left visual disturbance in the first episode; now she had severe bilateral visual disturbance. We suspected temporal arteritis was the etiology. HSR was 97 mm and fundoscopy disclosed severe ischemic optic neuritis. A 75 years old man presented Wallenberg syndrome. The history disclosed temporal headache and the examination showed inflammation in temporal artery. HSR was 70 mm and biopsy confirmed the diagnosis. "Tecnolatry" is affecting medical practice; it's necessary to put back in the center the clinical sovereignty.

Radiation-associated pneumonitis following autologous stem cell transplantation: predictive factors, disease characteristics and treatment outcomes

High-dose therapy followed by autologous stem cell transplantation (ASCT) prolongs survival in patients with multiple myeloma and is relatively safe with treatment-related mortality rates of only 1-5%. Interstitial pneumonitis (IP) is normally an infrequent complication of ASCT with a reported incidence of 0-16%. Between 1992 and 1998, 94 myeloma patients at our center underwent ASCT using a high-dose regimen of etoposide (60 mg/kg), melphalan (160 mg/m2) and fractionated TBI 12 Gy. An unusually high incidence of IP (29/94 (31%)) was noted. Mortality in the IP patients was high at 45%. Patients developing IP were more frequently anemic than those who did not have pulmonary complications (hemoglobin <100 g/l) prior to transplant (P = 0.03) but no other pre-transplant factors were predictive (ie age, gender, smoking history, CMV status, pulmonary function, creatinine, beta2-microglobulin or C-reactive protein, prior cumulative chemotherapy or chest irradiation). A significantly lower IP rate was noted in 32 contemporaneous myeloma control patients conditioned with BU-CY without TBI at our center (3/32 (9%); P=0.03) and in 32 lymphoma control patients conditioned with the same melphalan and etoposide regimen minus the TBI (2/32 (6%); P = 0.003). In contrast, when using the same TBI-containing regimen in 32 concurrently treated lymphoma patients, an increase in IP similar to that seen in our myeloma cohort (7/32 (22%); P = 0.3) was noted. This strongly suggests that TBI is the predominant factor contributing to lung toxicity. We conclude that radiation-associated pneumonitis cannot be easily predicted by pretransplant variables. Therefore surveillance, early recognition and prompt therapy are recommended.

Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach

Reoperative left anterior descending artery (LAD) revascularization can be performed through a left anterior small thoracotomy (LAST approach) in patients requiring isolated LAD revascularization. If the left internal mammary artery has been previously used, however, the operation is generally performed either through a median sternotomy or through a full posterolateral thoracotomy for the necessity of connecting the vein graft to the ascending aorta or to the descending thoracic aorta, thus losing the advantages of a minimally invasive approach. In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the left internal mammary artery as the inflow site of a saphenous vein coronary graft to the LAD.

Susceptibility locus for Alzheimer's disease on chromosome 10

The apolipoprotein E (APOE) gene is the only genetic risk factor that has so far been linked to risk for late-onset Alzheimer's disease (LOAD). However, 50 percent of Alzheimer's disease cases do not carry an APOE4 allele, suggesting that other risk factors must exist. We performed a two-stage genome-wide screen in sibling pairs with LOAD to detect other susceptibility loci. Here we report evidence for an Alzheimer's disease locus on chromosome 10. Our stage one multipoint lod score (logarithm of the odds ratio for linkage/no linkage) of 2.48 (266 sibling pairs) increased to 3.83 in stage 2 (429 sibling pairs) close to D10S1225 (79 centimorgans). This locus modifies risk for Alzheimer's disease independent of APOE genotype.

Clinical standards for inpatient specialist rehabilitation services in the UK

OBJECTIVE

To develop a set of clinical standards for specialist inpatient rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services.

DESIGN

The proposed set of standards was developed by group consensus followed by an iterative consultation process. A postal survey was conducted on behalf of the British Society for Rehabilitation Medicine (BSRM) amongst its consultant members in the UK (n = 163), who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability.

RESULTS

The response rate was 61%, of which 81 respondents ran an inpatient rehabilitation service. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Specific suggestions were incorporated into the revised standards. Further work is required to establish agreed outcomes that are systematically measured and recorded: only half the respondents (50%) routinely recorded a standardized outcome measure, and only a quarter (26%) routinely reviewed patients to record long-term outcome.

CONCLUSIONS

Clinical standards have been developed for specialist inpatient rehabilitation services in the UK. The BSRM proposes to adopt these standards for a test period of 2-3 years in the first instance. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Overview of autologous stem cell transplantation

There has been a dramatic increase in the number of autologous peripheral blood stem cell transplants over the last decade. Faster recovery of cell counts, lesser transplant morbidity, shorter hospital stay and reduced cost compared with marrow autografts have been the main advantages of autologous peripheral blood cell over marrow transplants. In this paper we attempt to review the advances in the biology and mobilization of stem cells, and focus on clinical results of autologous peripheral stem cell and marrow transplants for disease specific sites such as breast cancer, myeloma, autoimmune diseases, germ cell tumors, the acute and chronic leukemias, the non-Hodgkin's lymphomas and Hodgkin's disease. We also discuss transplant related complications, gene therapy and the different methods of purging. This review was intended for autologous peripheral stem cell transplants, however, unavoidably, it also discusses autologous marrow transplantation and aspects common to both procedures.

Dental post-operative sensitivity associated with a gallium-based restorative material

INTRODUCTION

This study forms part of a 2-year longitudinal clinical trial to compare the performance of a gallium-based restorative material (Galloy) with a high copper, mercury based (Dispersalloy) control material.

METHOD

Following Ethical Committee approval, 25 galloy restorations and 25 Dispersalloy controls were placed in 14 adult patients, by a single operator. The cavities were of moderate size, indicating the use of amalgam as the restorative material. All restorations were polished within 1 week of placement, photographed and a silicone impression of the tooth and restoration recorded. In addition, a visual analogue scale (VAS), indicating the extent of any post-operative sensitivity, was completed by each patient for each restoration, immediately prior to polishing. A score of 0 indicated no sensitivity, while a score of 10 indicated the greatest possible sensitivity. At 6-month recall, the VAS scores, silicone impressions and photographs were repeated.

RESULTS

The mean sensitivity scores for the galloy and Dispersalloy restorations at 1 week were 5.1 (+/- 3.4) and 1.0 (+/- 1.5), respectively and at 6 months, 1.8 (+/- 3.0) and 0.2 (+/- 0.1) respectively. The differences between these means at 1 week and at 6 months were significant (P < 0.01).

CONCLUSION

Galloy restorations were associated with a much greater severity of post-operative sensitivity than Dispersalloy restorations.

Organizational cynicism: bases and consequences

Organizational cynicism is the belief that an organization lacks integrity, which, when coupled with a powerful negative emotional reaction, leads to disparaging and critical behavior. In this article, the author attempts to theoretically clarify the process by which five forms of cynicism develop in the workplace and to empirically relate them to affective outcomes. Societal, employee, and organizational change cynicisms may be attributed to psychological contract violations; work cynicism may be related to burnout; and person-role conflict and personality cynicism may be related to innate hostility. Empirically, personality cynicism emerged as the strongest predictor of organizational cynicism, adversely affecting all of the criteria. Other forms of cynicism had more selective effects. Organizational change cynicism induced job dissatisfaction and alienation, and employee cynicism affected organizational commitment. Societal cynicism actually increased both job satisfaction and commitment. Both personality and work cynicisms were related to organizational citizenship indirectly, through alienation. Theoretical and practical implications are discussed.

Preferential fluorescent staining of heterochromatic regions in human chromosomes 9, 15, and the Y by D 287/170

The utility of a newly synthesized chemical variation of DAPI (4'-6-diamidino-2-phenyl-indole), D 287/170, for differential staining of constitutive heterochromatin in man is demonstrated. Direct staining of human chromosomes with D 287/170 results in brilliant fluorescence of the paracentromeric C-band of chromosome 9, of a proximal short-arm segment of chromosome 15, and of certain heterochromatic regions in the Y. Bright, but less conspicuous fluorescence is occasionally seen at the centromeres of other chromosomes. The staining differentiation obtained by D 287/170 is very distinct, and the intensity of the fluorescent light is unusually high. The new fluorochrome should prove particularly useful for detecting and analyzing human chromosome 9 heterochromatin at various stages of the cell cycle in normal and structurally altered chromosomes.

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass

BACKGROUND

Myocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians.

METHODS

Of 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group). Revascularization of the circumflex system or right coronary artery were not considered contraindications to off-pump grafting. Demographic data, preoperative risk factors, comorbid conditions, angiographic findings, postoperative complications, and outcomes were compared.

RESULTS

The groups were comparable for age, sex, Canadian Cardiovascular Society class, operative priority (elective, urgent, or emergent), preoperative risk factors, and left ventricular ejection fraction. A significantly higher proportion of reoperations was observed in the off-pump cohort (16 of 97, 16.5%) compared with the CPB cohort (8 of 172, 4.7%) (p = 0.002). There was a trend toward a higher graft-patient ratio in the CPB group (3.3 versus 1.8; p = not significant). Freedom from postoperative complications was significantly higher in the off-pump group than in the CPB group (83 of 97, 85.6%, versus 129 of 172, 75%; p = 0.04). The incidence of stroke was 0% in the off-pump cohort compared with 9.3% (16 of 172) in the CPB cohort (p < 0.0005). Although there was a trend toward higher 30-day and risk-adjusted mortality rates in the off-pump group than in the CPB group (10.3% versus 5.2% and 2.8% versus 1.8%, respectively), the differences were not significant. The length of hospitalization was slightly lower in the off-pump group (9.1 versus 10.8 days; p = not significant).

CONCLUSIONS

This investigation suggests that patients 80 years of age and older undergoing off-pump coronary artery bypass grafting can experience significantly lower rates of perioperative stroke and overall complications compared with those undergoing the same procedure with CPB, although a trend toward higher mortality rates was observed in the off-pump group.

Evaluation of two standards of arm/head ratios in neonatal nutritional assessment

OBJECTIVE

To evaluate the percentage agreement between two standards of arm/head ratios in neonatal nutritional assessment.

DESIGN

The nutritional status of newborn infants was determined using a standard of arm/head ratio on gestational age and another standard of arm/head ratio on birthweight. The two assessments were then compared for percentage agreement in the study sample and in sub-groups of birthweight categories.

SETTING

Newborn Unit, Specialist Hospital, Yola, Nigeria.

SUBJECTS

Two hundred and seventy two neonates including 74 low birthweight infants and 198 infants with birthweight > or = 2.5 kg.

INTERVENTIONS

The nutritional status of each infant was determined, using the two standards of arm/head ratios. The percentage agreement between the two methods was investigated.

MAIN OUTCOME MEASURES

Neonatal nutritional status (malnourished and well-nourished) and percentage agreement between methods.

RESULTS

In the study sample of 272 infants, the percentage agreement was 94.1%. In the sub-group of low birthweight infants, the percentage agreement was 83.8% while in the larger infants, it was 89.9%.

CONCLUSION

This report is a further confirmation of the clinical usefulness of the newer standard of arm/head ratio on birthweight in neonatal nutritional assessment. It is particularly recommended for its independence of precise maturity determination.

The role of job control as a moderator of emotional dissonance and emotional intelligence-outcome relationships

Job control may be defined as the latitude to make decisions and the freedom to select the most appropriate skills to complete the task. Emotional dissonance may be defined as the conflict between expressed and experienced emotions. In this study, job control and self-efficacy were theorized to jointly affect emotional dissonance. Individuals with high self-efficacy were found to be more satisfied under conditions of little job control, whereas those with low self-efficacy favored high job control. The impact of job control on emotional intelligence was also studied. Emotional intelligence may be defined as the set of skills that contribute to accurate self-appraisal of emotion as well as the detection of emotional cues in others and the use of feelings to motivate and achieve in one's life. Emotional intelligence and job control explained significant amounts of the variance in both job satisfaction and organizational commitment. Theoretical and practical implications are discussed.

High dose chemotherapy and autologous blood stem cell support in women with breast carcinoma and isolated supraclavicular lymph node metastases

BACKGROUND

The prognosis of patients with isolated supraclavicular lymph node (SCN) metastases is similar to patients with metastatic breast carcinoma involving other sites. Because these patients have a lower disease burden compared with women with distant metastases, their outcome after high dose chemotherapy (HDCT) may be superior.

METHODS

The authors evaluated event free survival (EFS) and overall survival in a series of 20 consecutive women with SCN metastases as the only site of metastatic disease who were treated with HDCT and peripheral blood stem cell transplantation at The Toronto Hospital. All patients had responded to 4-6 cycles of induction CT using either an anthracycline-containing regimen or a single agent taxane, and received intensive therapy comprised of mitoxantrone, 64 mg/m(2); cyclophosphamide, 6000 mg/m(2); and carboplatin, 800-2000 mg/m(2), each divided over 4 days followed by the infusion of autologous peripheral blood stem cells. Involved field radiation therapy (RT) was administered when possible after transplantation to the supraclavicular fossa and tamoxifen was given to previously untreated patients if they were hormone receptor positive or if their hormone receptor status was unknown.

RESULTS

At a median follow-up of 28 months, 13 of the 20 women were alive, 11 of whom (55%) remained in continuous complete remission. There were no treatment-related deaths. The median overall survival was 37 months and the median progression free survival was 32 months from the date of transplantation. Consolidative RT was delivered to 11 women and on univariate analysis was found to be significantly associated with better EFS (P = 0.02).

CONCLUSIONS

The long term outcome of women with breast carcinoma and isolated SCN metastases whose disease is sensitive to CT appears to be favorable; whether this result is superior to that achieved with standard therapy alone remains to be confirmed in prospective, randomized trials.

EGF receptor transactivation by G-protein-coupled receptors requires metalloproteinase cleavage of proHB-EGF

Cross-communication between different signalling systems allows the integration of the great diversity of stimuli that a cell receives under varying physiological situations. The transactivation of epidermal growth factor receptor (EGFR)-dependent signalling pathways upon stimulation of G-protein-coupled receptors (GPCRs), which are critical for the mitogenic activity of ligands such as lysophosphatidic acid, endothelin, thrombin, bombesin and carbachol, provides evidence for such an interconnected communication network. Here we show that EGFR transactivation upon GPCR stimulation involves proHB-EGF and a metalloproteinase activity that is rapidly induced upon GPCR-ligand interaction. We show that inhibition of proHB-EGF processing blocks GPCR-induced EGFR transactivation and downstream signals. The pathophysiological significance of this mechanism is demonstrated by inhibition of constitutive EGFR activity upon treatment of PC3 prostate carcinoma cells with the metalloproteinase inhibitor batimastat. Together, our results establish a new mechanistic concept for cross-communication among different signalling systems.

Intensification of the stem cell transplant induction regimen results in increased treatment-related mortality without improved outcome in multiple myeloma

Randomized trials conducted by the Intergroupe Française du Myelome (IFM) demonstrate that the use of high-dose chemotherapy (HDCT) and stem cell transplantation (SCT) improves event-free (EFS) and overall survival (OS) in younger patients with multiple myeloma (MM). Nevertheless, current HDCT regimens remain inadequate as all patients ultimately relapse following SCT. In an attempt to improve the OS of MM patients post-SCT we used an escalated HDCT regimen incorporating both intensified melphalan (160 mg/m2) and fractionated total body irradiation (12 Gy) to maximize the dose response of myeloma cells to these agents and included infusional etoposide 60 mg/kg in an attempt to eradicate clonal B cells potentially contributing to the myeloma clone. One hundred patients with MM received this intensified SCT regimen. The 100-day treatment-related mortality was 12% predominantly reflecting the development of interstitial pneumonitis (IP) in 28% of patients of whom 7/28 (25%) died. The predicted 5-year OS and EFS following the diagnosis of MM were 60% and 35%, respectively. The median OS from the time of transplant is 41 months and the median EFS is 28 months. More than two prior chemotherapy regimens, previous radiation therapy (RT) and the presence of an abnormal karyotype involving chromosomes 11 or 13 were significantly predictive of poor outcome. Interferon maintenance was not associated with improved outcome. Intensification of the HDCT regimen utilizing etoposide together with escalated melphalan and TBI increases morbidity and mortality without increasing OS beyond that reported with less toxic regimens.