First report of pediatric hematopoietic stem cell transplantation activities in the eastern mediterranean region from 1984 to 2011: on behalf of the pediatric cancer working committee of the eastern mediterranean blood and marrow transplantation group

To describe the hematopoietic stem cell transplantation (HSCT) activities for children in the Eastern Mediterranean (EM) region, data on transplants performed for children less than 18 years of age between 1984 and 2011 in eight EM countries (Egypt, Iran, Jordan, Lebanon, Oman, Pakistan, Saudi Arabia and Tunisia) were collected. A total of 5187 transplants were performed, of which 4513 (87%) were allogeneic and 674 (13%) were autologous. Overall, the indications for transplantation were malignant diseases in 1736 (38.5%) and non-malignant in 2777 (61.5%) patients. A myeloablative conditioning regimen was used in 88% of the allografts. Bone marrow (BM) was the most frequent source of stem cells (56.2%), although an increasing use of PBSC was observed in the last decade. The stem cell source of autologous HSCT has shifted over time from BM to PBSC, and 80.9% of autologous HSCTs were from PBSCs. The donors for allogeneic transplants were matched-related in 94.5% of the cases, and unrelated transplants, mainly cord blood (99%) in 239 (5.5%) cases. This is the first report to describe the pediatric HSCT activities in EM countries. Non-malignant disorders are the main indication for allogeneic transplantation. Frequency of alternate donor transplantation is low.

Clinical and molecular findings of chronic granulomatous disease in Oman: family studies

Chronic granulomatous disease (CGD), a rare inherited disorder of the innate immune system, results from mutations in any one of the five genes encoding the subunits of the nicotinamide adenine dinucleotide phosphate-oxidase (NADPH) oxidase enzyme, and is characterized by recurrent life-threatening bacterial and fungal infections. Molecular analysis of 14 Omani CGD patients from 10 families, diagnosed to have CGD on clinical (recurrent infections) and biochemical grounds (positive for both the nitroblue tetrazolium (NBT) test and the dihydrorhodamine (DHR-1,2,3 assay), revealed that only one patient had X-linked CGD, with a large deletion involving both the gp91-phox gene (CYBB) and the McLeod gene (XK). The remaining 13 patients were all homozygotes from a previously described c.579G>A (p.Trp193X) mutation in the NCF1 gene on chromosome 7, responsible for autosomal recessive CGD (AR-CGD). Although X-linked CGD is the most common type of CGD disorder in most population groups, AR-CGD is the most prevalent type in Oman.

Special issues related to hematopoietic SCT in the Eastern Mediterranean region and the first regional activity report

Although several centers are now performing allogeneic hematopoietic SCT (HSCT) in the Eastern Mediterranean (EM) region, the availability is still limited. Special issues including compatible donor availability and potential for alternative donor programs are discussed. In comparison to Europe and North America, differences in patterns of diseases and pre-HSCT general status, particularly for patients with BM failure, are described. Other differences including high sero-positivity for CMV, hepatitis B and C infection, and specific observations about GVHD and its relation to genetically homogeneous communities are also discussed. We report that a total of 17 HSCT programs (performing five or more HSCTs annually) exist in 9 countries of the EM region. Only six programs are currently reporting to European Group for Blood and Marrow Transplantation or Center for International Blood and Marrow Transplantation Research. A total of 7617 HSCTs have been performed by these programs including 5701 allogeneic HSCTs. The area has low-HSCT team density (1.56 teams per 10 million inhabitants vs 14.43 in Europe) and very low-HSCT team distribution (0.27 teams per 10 000 sq km area vs <1-6 teams in Europe). Gross national income per capita had no clear association with low-HSCT activity. Much improvement in infrastructure and formation of an EM regional HSCT registry are needed.

Hematopoietic stem cell transplantation in Oman

Hematopoietic SCT (HSCT) is an integral part of the management of patients with hematologic disorders. The Sultanate of Oman, with a population of 2.3 million, has an HSCT program based in the Sultan Qaboos University (SQU) hospital. Initiated in 1995, this two-bed unit continues to be the only program in the country. Between June 1995 and August 2006, a total of 128 patients underwent HSCT in this center, averaging about 10-12 transplants per year. The median age of these patients was 11 years (2 months to 45 years). Hematologic malignancies (49%) and inherited disorders (42%) constituted the major transplant indications, whereas BM failure accounted for the remaining. The majority of transplants carried out so far have been HLA-matched sibling-donor allogeneic HSCTs. Among the inherited disorders, homozygous beta-thalassemia and primary immunodeficiency are important transplant indications in this center. The approximate cost of an uncomplicated transplant in this center is US$50,000. The success of this program has now led to the initiation of a new and larger HSCT complex to provide the opportunity for more patients to benefit from this treatment modality within the country.

Randomized trial of two different conditioning regimens for bone marrow transplantation in thalassemia – the role of busulfan pharmacokinetics in determining outcome

In total, 94 patients with homozygous beta thalassemia were randomized to two different conditioning regimens: busulfan 600 mg/m2 + cyclophosphamide 200 mg/kg or busulfan 16 mg/kg + cyclophosphamide 200 mg/kg and antilymphocyte globulin (47 in each group), for bone marrow transplantation, to see whether increased myeloablation or increased immunosuppression would reduce rejection. Busulfan pharmacokinetics in determining outcome was evaluated. There was no significant difference in engraftment, graft-versus-host disease, rejection, and overall and disease-free survival in the two groups. Systemic exposure to busulfan was significantly higher in the 600 mg/m2 group, but in both groups there was a wide interindividual variation in the busulfan kinetics. Six patients rejected the graft, two in the busulfan 600 mg group and four in busulfan 16 mg group (P = 0.677 CI -0.17, 0.07), but in five patients (pharmacokinetic data not available in one patient) who rejected the graft busulfan first dose trough level (C(min)-1) was below 150 ng/ml while it was above this level in the 66 of 68 patients with successful engraftment (P < or = 0.001). This randomized trial shows that rejection is influenced by busulfan levels and suggests that monitoring of busulfan levels and dose adjustment based on first-dose kinetics may reduce the risk of rejection.

Heterozygous methylene tetrahydrofolate reductase mutation with mild hyperhomocysteinemia associated with deep vein thrombosis

Hyperhomocysteinemia is known to be associated with arterial occlusive vascular disease and venous thrombosis. Here, we report a young ethnic Omani patient with recurrent venous thrombosis who was found to be heterozygous for 677C-T mutation in the methyltetrahydrofolate reductase (MTHFR) enzyme. Moderate hyperhomocystenemia was also observed, in the presence of normal red cell folate and serum B12 levels. No other documented marker of hereditary thrombophilia could be demonstrated in this patient, in spite of extensive investigation on multiple occasions.

A pilot study of HTLV-I infection in high-risk individuals & their family members from India

BACKGROUND & OBJECTIVES

Human T lymphotropic virus-I (HTLV-I) has been associated with adult T cell lymphoma/leukemia (ATLL). There are Indian studies on HTLV-I infection among people with sexually transmitted infection, but no large study has been conducted on individuals with haematological malignancies. In this group of individuals, serology is known to under-diagnose HTLV-I infection. This study was carried out to identify serologically and where possible with molecular techniques, HTLV-I infection in individuals with haematological malignancies. To understand the modes of transmission, family members of individuals with proven HTLV-I infection were also studied. Individuals with sexually transmitted infection (STI), blood donors and pregnant women were also studied.

METHODS

Particle agglutination test was used to detect antibody to HTLV-I. HTLV genome was amplified by polymerase chain reaction (PCR) and detected with probes by digoxiginin (Dig) ELISA.

RESULTS

There was no serological evidence of HTLV-I infection among the healthy blood donors and pregnant women studied. High prevalence of anti-HTLV-I antibody was identified in the patients with haematological malignancies (8 of 86 patients, 9.3%) and a lower prevalence in individuals with STI (8 of 670 individuals, 1.2%). In the STI group, all 8 individuals seroreactive to HTLV-I were coinfected with human immunodeficiency virus (HIV). In the group with haematological malignancies, three of 22 (13.6%) patients with leukemia, 3 of 11 (27.3%) with cutaneous T-cell lymphoma (CTCL) and 2 of 53 (3.8%) with lymphoma were reactive for anti-HTLV-I antibody. In this group, PCR identified all the seroreactive individuals tested. There were also seronegative infected individuals who were only identified by PCR. There was also a large number of seronegative family members who were only positive by PCR.

INTERPRETATION & CONCLUSION

The study revealed a strong disease association of HTLV-I with haematological malignancies and evidence for both horizontal and vertical transmission of the infection in the Indian population. HTLV-I infection appears to be common among family members of individuals with HTLV-I associated haematological malignancies.

Allogeneic bone marrow transplantation in the developing world: experience from a center in India

We describe our experience of setting up an allogeneic BMT program at the Christian Medical College Hospital, Vellore over a period of 13 years, from October 1986 to December 1999. Two hundred and twenty-one transplants were performed during this period in 214 patients, with seven patients undergoing second transplants. Indication for BMT were thalassemia major - 106 (48%), CML - 30, AML - 35, ALL - 10, SAA - 22, MDS - six and six for other miscellaneous disorders. The mean age of this patient cohort was 15.6 years (range 2-52). Graft-versus-host disease of grades III and IV was seen in 36 patients (17%) and this was the primary cause of death in 20 patients (9.2%). All patients and donors were CMV IgG positive. Sepsis was the primary cause of death in 16 patients (7.4%), 10 bacterial, four fungal and two viral. One hundred and ten of this series of patients are alive and disease free (50%) with a median follow-up of 24 months (range 2-116). These results are comparable to those achieved for patients with similar disease status in transplant units in the Western world and cost a mean of US$15 000.

Glutathione S-transferase activity influences busulfan pharmacokinetics in patients with beta thalassemia major undergoing bone marrow transplantation

Busulfan, at a dose of 16 mg/kg, is widely used in combination with cyclophosphamide as a conditioning regimen for patients undergoing bone marrow transplantation. Wide interindividual variation in busulfan kinetics and rapid clearance of the drug have been reported, especially in children. Some of the factors contributing to interpatient variability have been identified. They include circadian rhythms, age, disease, drug interaction, changes in hepatic function, and busulfan bioavailability. In this study, we demonstrate that hepatic glutathione S-transferase (GST) activity correlates negatively with busulfan maximum and minimum concentrations (Pearson's correlation r = -0.74 and -0.77, respectively) and positively with busulfan clearance (Pearson's correlation r = 0.728) in children with thalassemia major in the age range of 2 to 15 years. We also found that plasma alpha GST levels were 5 to 10 times higher in patients with thalassemia than in normal controls and age-matched leukemic patients, either reflecting extensive liver damage, elevated expression of the enzyme, or both in thalassemic patients. Plasma alpha GST concentrations showed a similar correlation with busulfan kinetic parameters to that observed for hepatic GST. The status of hepatic GST activity accounts, at least in part, for the observed interindividual variation in busulfan kinetics, while the observed association with plasma alpha GST is difficult to explain at present.

Nerve injuries of the elbow, wrist, and hand in athletes

Upper extremity compression neuropathies are fairly rare in athletes. Initially, most can be managed conservatively. These conditions can follow direct contusion of the tissues that overlay these peripheral nerves or can result from vigorous, repetitive, athletic activity leading to tissue swelling and ischemia with nerve compression symptoms. A complete history and physical examination, including a neurologic examination, should be paramount when treating athletes with upper extremity injuries. Early diagnosis and treatment with conservative measures such as splinting, rest, activity modification, and medications can afford the athlete an earlier return to sports. Surgery can be employed when conservative treatment fails and a specific diagnosis has been ascertained.

Thyrotropin regulation of cyclic adenosine monophosphate production in human coronary artery smooth muscle cells

Thyroid disease has been associated with the occurrence of pathophysiologic changes in the vasculature that may result in part from altered serum thyroid hormone and serum lipid levels. Thyrotropin (TSH) levels are also altered in thyroid disease, but a direct effect of TSH on vascular smooth muscle has not previously been considered. In the present study, human coronary artery smooth muscle cells (CASMC) were induced into two morphologically distinct forms by culturing in either (1) growth factor supplemented, 0.5% serum medium (SmGM-3) or (2) basal medium (SmBM) plus 10% fetal bovine serum (FBS). Intracellular cyclic adenosine monophosphate (cAMP) accumulation was determined by radioimmunoassay after exposure to increasing doses of bovine TSH. Cells grown in SmBM/10% FBS for 3 days exhibited a dose-dependent increase in intracellular cAMP that reached a level 10 times higher than baseline at the highest dose examined (100 mIU/mL). In contrast, cells grown in SmGM-3 medium exhibited no change in intracellular cAMP on exposure to increasing TSII. Low serum (0.5% FBS) reduced the ability of TSH to stimulate cAMP above the control value in CASMC. Pretreatment of CASMC with either transforming growth factor-beta1 (TGF-beta1) or tumor necrosis factor-alpha (TNF-alpha) lowered basal levels of cAMP production, but did not inhibit the ability of TSH to stimulate cAMP production. Human, but not rat aortic smooth muscle cells in culture also responded to TSH with a significant increase in cAMP. The results of this study suggest that TSH may exert direct effects on vascular smooth muscle mediated by adenylate cyclase activation that could conceivably affect the progression of vascular disease associated with thyroid dysfunction.

Van Gogh and lithium. Creativity and bipolar disorder: perspective of a writer/photographer

Diana Dennison has suffered from manic depression since her teenage years in the 1960s but only realised that she had the condition when, in her 30s, she learnt that her uncle was manic depressive. Diana endured her low states with either no medication or with what was for her the unsatisfactory effect of tricyclic antidepressants. Her untreated hypomanic states cut a swathe through her life. She has never been hospitalised for her condition. Her marriage did not survive but her daughters did and she is now a proud and doting grandmother who skis and scuba dives. Only in the last 4 years did Diana seek help for the treatment of her condition. Diana is a free-lance writer, researcher and photographer.

Diagnostic imaging and arthroscopy for wrist pain

Chronic wrist pain may be evaluated by physical examination, imaging, and arthroscopy. Arthroscopy provides an attractive diagnostic and therapeutic modality in selected patients. Currently the correlation between arthroscopic findings and symptomatic pathology is not clear, because arthroscopy often identifies asymptomatic pathology. Nevertheless, the ability to diagnose and treat intra-articular pathology simultaneously provides a substantial advantage over radiographic analysis.

Pharmacokinetics of oral busulphan in children with beta thalassaemia major undergoing allogeneic bone marrow transplantation

The pharmacokinetics of busulphan were studied in 23 thalassaemic children undergoing BMT. Patients received busulphan at a dose of either 16 mg/kg with cyclophosphamide and ATG (Group A) or 600 mg/m2 (with cyclophosphamide alone) (Group B) in 16 divided doses every 6 h over 4 days. Busulphan levels were analyzed by a modified GC-MS method. The dose of busulphan/kg for patients in group B was 64% (range 56-71%) higher than that for patients in group A. The mean AUC, Css, Cmax and MRV were significantly higher in group B as compared with group A for both doses 1 and 13. There was no significant difference in Vd/F, T1/2 and Kel between the two groups. A significant decrease in AUC and Css was found between 1st and 13th doses in group B, but not in group A. The Cl/F values in group A were significantly higher than those in group B after dose 1, but not after dose 13. No increase in toxicity due to the higher dose of busulphan was noted. We conclude that busulphan at 600 mg/m2 results in much higher systemic exposure to the drug as compared to 16 mg/kg, without increase in toxicity in children with beta thalassaemia major.

High-performance liquid chromatographic method for quantification of busulfan in plasma after derivatization by tetrafluorothiophenol

A high-performance liquid chromatographic (HPLC) method was developed and validated for the determination of busulfan in plasma. Busulfan was extracted in toluene, derivatized by 2,3,5,6-tetrafluorothiophenol to obtain di-TFTP-butane, the derivatization product was then re-extracted in toluene and injected into the HPLC system with ultraviolet detection (wavelength: 275 nm). Recovery from extraction was 80%, the limit of quantification was 50 ng/ml and linearity ranged from 50 to 2000 ng/ml. In addition, forty-two samples obtained from pediatric patients treated with busulfan were analyzed by the HPLC and GC-MS assays based on the same derivatization procedure. The correlation between the di-TFTP-butane concentrations was highly significant (p<0.0001), demonstrating that the two methods were in good agreement.

Low-dose intermittent factor replacement for post-operative haemostasis in haemophilia

Recommendations for factor replacement therapy for postoperative haemostasis in haemophilia are often empirical and based on the physiological understanding of haemostatic requirements. This report describes the haemostatic management of patients with severe haemophilia undergoing major surgery using lower than usually recommended levels of factor replacement therapy. Eighteen adults (11 with FVIII and seven with FIX deficiency) with an average weight of 52 kg (range: 27-69) underwent 20 major surgical procedures. Factor concentrates were administered by intermittent bolus infusions. The dose of FVIII infused before surgery was 76 mu kg-1 (range: 51-113) and that of FIX was 77 mu kg-1 (range: 50-104). The preoperative levels achieved were 107% (range: 80-180) and 73% (range: 60-90), respectively. Between days 1 and 3 after surgery, an average of 29 mu kg-1 day-1 (range: 20-46) of FVIII and 23 mu kg-1 day-1 (range: 12-42) of FIX was used resulting in mean trough levels of 36% (range: 12-62) and 34% (range: 11-52), respectively. After day 4, an average of 19 mu kg-1 day-1 (range: 15-25) of FVIII and 18 mu kg-1 day-1 (range: 10-37) of FIX was administered until wound healing. The average duration of factor replacement was 11 days (range: 8-16). The mean dose of factor concentrate per patient was 260 mu kg-1 (range: 179-338) of FVIII and 300 mu kg-1 (range: 183-524) of FIX. The total amount of factor used per patient ranged from 12,380 to 19,980 units of FVIII and 8000 to 23,600 units of FIX. Only one patient had post-operative bleeding which was due to a surgical cause. It is concluded that it may be possible to use much lower than recommended levels of factor replacement therapy for postoperative haemostasis in severe haemophilia.

Quantification of busulfan in plasma by gas chromatography-mass spectrometry following derivatization with tetrafluorothiophenol

A specific and highly sensitive method has been developed for the determination of busulfan in plasma by gas chromatography-mass spectrometry using a deuterium-labeled busulfan (busulfan-d8) as internal standard. Plasma containing busulfan and busulfan-d8 were extracted with ethyl acetate and derivatized with 2,3,5,6-tetrafluorothiophenol prior to the monitoring of specific ions. The limit of quantification of the assay was 20 ng/ml and the calibration curve was linear over the range of 10 to 2000 ng/ml of derivatized busulfan. This method was in good agreement with the GC-MS assay using derivatization with sodium iodide and measuring diiodobutane. In addition, a pharmacokinetic study of busulfan was conducted in six children. The apparent oral clearance was 5.7+/-1.9 ml/kg/min and the volume of distribution was 1.0+/-0.4 l/kg and were similar to those previously reported in pediatric patients.

Pediatric hyperfibrotic myelodysplasia: an unusual clinicopathologic entity

This study is presented to highlight a rare pediatric bone marrow pathology in which features of bone marrow dysplasia coexist with severe fibrosis in a clinical setting of fever, anemia, and organomegaly. Fourteen children (nine males, five females) clinically presented with fever, anemia, and hepatosplenomegaly. Extensive bone marrow fibrosis with dysplastic features was seen in their marrow precursor cells. Peripheral blood smears showed teardrop poikilocytes thrombocytopenia, and occasional blasts. In conclusion, pediatric hyperfibrotic myelodysplasia is a distinct clinicopathologic entity. Myeloproliferative and dysmyelopoietic syndromes are complex disorders that are interrelated and not always easily diagnosed only on morphologic grounds.

NESTROFT as a screening test for the detection of thalassaemia & common haemoglobinopathies--an evaluation against a high performance liquid chromatographic method

The NESTROFT method (Naked Eye Single Tube Red Cell Osmotic Fragility Test) was evaluated against a high performance liquid chromatographic (HPLC) method for its usefulness in screening for beta-thalassaemia and some of the common haemoglobinopathies. Blood samples (137) from patients with suspected haemoglobin disorders were analyzed by both methods. Among the 63 patients with heterozygous beta-thalassaemia on HPLC, NESTROFT was positive for 49, 'doubtful' for 13 and negative for 1. Of the 32 patients with other haemoglobin disorders, 28 were positive on NESTROFT and 4 were 'doubtful'. Of the 42 'normal' samples, NESTROFT was positive for 6, 'doubtful' for 8 and negative for 28. This test showed an overall sensitivity of 98.7 per cent, specificity of 66.6 per cent, positive predictive value of 87 per cent and negative predictive value of 96.5 per cent. We conclude that, NESTROFT is a suitable test for screening for beta-thalassaemia and the common haemoglobinopathies seen in India. It is easy to perform, simple, inexpensive and does not require sophisticated equipment. Subjects who are NESTROFT 'positive' or 'doubtful' deserve further investigation.

Infections in haematological malignancies: an autopsy study of 72 cases

Autopsy material from 72 patients with haematological malignancies treated in India was reviewed. Thirty-seven patients (51%) had documented infections; 20 (27%) had bacterial infections, 14 of which were Gram-negative organisms (Pseudomonas species in 10); tuberculosis was present in 2 patients (2.7%). Twenty-one patients (29%) had systemic fungal infections; invasive pulmonary aspergillosis and gastrointestinal candidiasis were present in 10 patients each. Only 3 patients (4%) had viral infection, all of which were due to cytomegalovirus. Eleven patients (15%) had polymicrobial infections. No patient had any parasitic infection. Systemic fungal infections due to Aspergillus and Candida predominated, while Gram-negative bacterial infections were also common.

Prenatal diagnosis of beta-thalassaemia mutations using the reverse dot blot technique

BACKGROUND

Beta-thalassaemia is the most common genetic disorder among Indians and a number of mutations causing this disease have been reported. Since effective treatment of thalassaemia major is complicated and very expensive, prenatal diagnosis has become an important option for those at risk of having an affected foetus. We report the use of a rapid hybridization method called 'reverse dot blot' for detection of specific mutations of the beta-globin gene.

METHODS

DNA was obtained from a 12-week-old foetus by chorionic villus sampling and was amplified using specific primers by the polymerase chain reaction and analysed by the reverse dot blot test. Results were available within 36 hours after sampling.

RESULT

The father and mother were found to be heterozygous for codon 15 (G-A) mutation of the beta-globin gene. The foetus was normal.

CONCLUSION

Reverse dot blot is a rapid and reliable technique for mutation detection in the beta-globin gene and can be useful for antenatal diagnosis.

Preventing factitious gingival injury in an autistic patient

A 34-year-old man with a history of autism developed a deep gingival cleft. During clinical evaluation, the patient repeatedly scraped the affected area with his fingernail. The lesion's clinical features were consistent with focal inflammatory hyperplasia, periodontal disease and factitious stomatitis. This article describes the case and discusses diagnostic and behavioral issues important in treating any patient whose mental age is impaired.

Comparison of HPLC & EMIT methods of cyclosporine assay in blood after bone marrow transplantation

Cyclosporine (CsA) analysis in blood from patients who had undergone bone marrow transplantation for various haematological disorders was done both by high performance liquid chromatography (HPLC) and enzyme multiplied immunoassay technique (EMIT) and the results were compared. HPLC kit from Biorad Laboratories, USA, and EMIT kit from SYVA, UK, were used. The procedure for EMIT was slightly modified in-house to suit the Hitachi 704 discrete selective analyser. The CsA values obtained by these two methods correlated well within the therapeutic range (r value 0.96), HPLC method being most suitable outside the therapeutic range. Although HPLC is the ideal method for CsA, EMIT is quite suitable and can be adopted by any laboratory with an autoanalyser incorporating our modified procedure.

Thermal regulation of patients during the perioperative period

Surgery patients often become hypothermic during surgical procedures. The body's thermostat, the hypothalamus, strives to maintain a normal temperature; however, when a patient's temperature drops too low, the thermoregulatory processes are suppressed, and hypothermia occurs. Cardiopulmonary bypass procedures use induced hypothermia; however, inadvertent hypothermia may occur in many other surgical procedures during which the body temperature is not systematically monitored and regulated. Hypothermia may cause complications such as protein catabolism, hypokalemia, and changes in glucose metabolism and glomerular filtration. Nursing interventions used intraoperatively to maintain a normothermic state include applying warm and temperature regulating blankets, decreasing the amount of skin exposure, and warming operating rooms.

Infections in bone marrow transplant recipients in south India--a post-mortem study

A study of post-mortem material obtained from ten patients who had undergone bone marrow transplantation is presented. The cause of death in all patients was infection. Six patients had fungal infection, two had bacterial infection and three had cytomegalovirus infection. Pneumocystis carinii and tuberculous infections were not detected.

Treatment of childhood acute lymphoblastic leukaemia with the BFM regimen

Thirty-eight children with acute lymphoblastic leukaemia were treated with the BFM regimen. Thirty-six (94.7%) achieved complete remission (CR). Twenty 58.8%) of 34 evaluable patients are in continuous complete remission (CCR) at a median follow-up of 33 (range 19-81) months. Long-term disease-free survival was better in the 2-9 years age group (83%) when compared to the 10-14 years group (43%) (P < .05).

Treatment of acute lymphoblastic leukaemia in adults with modified BFM regimen

Sixty-two adults with acute lymphoblastic leukaemia (ALL) were treated with a modified BFM regimen. Forty-two (70%) achieved complete remission (CR). Twenty-one percent of all evaluable patients and 32.4 percent of complete responders are in continuous complete remission (CCR) at a median follow-up of 41 months (range 24-81 months). Long-term survival was better in T- ALL (47.1%) when compared to precursor-B ALL (4.8%) (P < 0.04).

Transfusion associated HIV infection in patients with haematologic disorders in southern India

Seventy patients with congenital coagulation disorders (group A) and 202 other patients (group B) attending the Haematology clinic at the Christian Medical College and Hospital, Vellore (India) were screened for HIV infection between March 1989 and April 1991. Fifty five patients in group A and 131 patients in group B had received blood or blood products in the past. Nineteen transfused patients (9 in group A and 10 in group B) had received blood or blood products exclusively from the hospital blood bank and none of them was HIV infected. Among the remaining 167 transfused patients, 14 (30.4%) of the 46 patients in group A and 6 (4.9%) of the 121 patients in group B were found to be positive for HIV. In group A, 13 of the 14 infected patients had received commercially available cryoprecipitate which was thus found to be the most frequent source of infection. In group B the source of infection was most probably unscreened HIV infected blood which was transfused.

Surgery in patients with congenital coagulation disorders

BACKGROUND

Surgery is occasionally necessary in patients with congenital coagulation disorders. Major surgery for patients with haemophilia was not being done in India until recently. This paper reports the experience of a single referral centre.

METHODS

The data of 52 patients who were operated upon were collected from the hospital records retrospectively between 1984 and 1986 and prospectively thereafter. They included the surgical procedure performed, replacement therapy used and complications encountered.

RESULTS

Fifty-nine procedures were performed of which 26 were major, 30 minor and 3 were diagnostic angiograms. Blood components produced in the hospital blood bank were commonly used for replacement and primary haemostasis was achieved in all patients. Delayed bleeding due to inadequate factor levels occurred in 12 procedures and was controlled by increasing the factor replacement. One patient died of suspected acute myocardial ischaemia.

CONCLUSION

In India surgical procedures can be safely performed in patients with congenital coagulation disorders.

Satisfaction of senior citizens in a nutrition education program with and without computer-assisted instruction

This study assessed the receptiveness of senior citizens to the use of microcomputers in a nutrition education program at participating senior citizen subsidized housing sites. Participants in group A received the nutrition education program with computer-assisted instruction (CAI). Group B participants received the same nutrition education program, but without CAI. A validated Program Satisfaction Questionnaire was administered to assess overall satisfaction, satisfaction with the method of instruction, and satisfaction with the dietary analysis printout. Independent t-test analysis showed that group A was as satisfied as group B. The majority in group A indicated that learning to use the computer was not difficult and was "somewhat enjoyable" to "very enjoyable." These results indicated that senior citizens were receptive to CAI. Additionally, the use of the microcomputer with older adults was deemed possible for health-related educational programming. Appropriate modification of software was recommended to meet the physical limitations which occur with this age group.

Pneumocystis carinii pneumonitis following bone marrow transplantation

Pneumocystis carinii pneumonitis (PCP) can occur in immunocompromised hosts, especially AIDS and cancer patients. Although recent research has focused on PCP in AIDS patients, few studies have described the clinical presentation of PCP in recipients of bone marrow transplantation (BMT). Between 1976 and 1991, of 1454 BMT patients at the University of Minnesota, PCP was documented in only 19. Eighteen of these had not been receiving PCP prophylaxis. Patients presented with a brief period (2-10 days) of symptoms including dyspnea, cough, and fever in greater than 75% of patients, but had only scant abnormal physical findings. Chest X-rays showed bilateral infiltrates in 58% of all patients, though 15% had no or minimal X-ray findings. Bronchoscopic alveolar lavage confirmed the diagnosis most often, but 13% of lavages were negative and required biopsy for the diagnosis. High dose trimethoprim-sulfamethoxazole was the initial treatment for 84% of the patients though 25% of these patients were later switched to pentamidine due to poor response or hypersensitivity reactions. Despite prompt diagnosis and therapy, overall survival was poor, with only 37% of patients surviving pneumonitis. Patients developing PCP less than 6 months post-BMT had greater mortality (89%) versus only 40% in later onset PCP (p less than 0.0001). Despite this better survival in the late-onset PCP cohort, the development of pneumonitis in these patients underscores the necessity for continued PCP prophylaxis beyond 1 year in some patients. Ongoing immunocompromise and need for prophylaxis should be appreciated in patients with graft-versus-host disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Nutrient analysis methodology: a review of the DINE developmental literature

In 1986, a collaborative effort among professional associations resulted in the publication of Worksite Nutrition: A Decision Maker's Guide (The American Diabetic Association, 1986). The booklet describes nutrient analysis methodology as a good "promotional gimmick". The development of DINE was an effort to move nutrient analysis from the gimmick level to a viable educational component level. A few examples of the innovative effects of this methodology are (1) individuals' using their own data can learn energy balance by monitoring their food intake and physical activity, (2) individuals can learn the Dietary Goals for the United States (U. S. Senate Select Subcommittee on Nutrition and Human Needs, 1977) and are able graphically to compare how their diet approximates or is different from these goals, and (3) individuals can also learn, from verifications of their own food records, which of their food selections were high in calories, total fat, saturated fat, and cholesterol, and low in complex carbohydrates and dietary fiber. Alternative healthful food choices are identified and the effects of reducing or increasing portion sizes is described. The DINE development team has been working for the past eight years to decrease nutrient analysis variability so that the procedure can be used as an effective independent measure to improve nutritional behavior. Research has been conducted related to database validity and reliability. Formative and process evaluations have been conducted to improve interactive aspects of the software and related manuals and books. DINE procedures have been modified for ease of use, in general, and specifically for elementary students and university students.

Distributional shape of nutrition data

Nutrition data from 111 undergraduate college students (51 males and 60 females, ranging in age from 17 to 24) were studied with respect to the shape of the underlying probability distributions. Three-day averages for total energy, percent protein, percent saturated fat, percent unsaturated fat, percent complex carbohydrates, percent refined carbohydrates, cholesterol, sodium, vitamin C, and iron (measured in milligrams) were computed, and their distributions were compared with the normal (Gaussian) distribution. The distribution of values of sodium for females and, to a lesser extent, cholesterol for females and of cholesterol and vitamin C for males, differed from the normal distribution. The remaining distributions appeared to be reasonably close to normal in shape. It is recommended that nutrition researchers verify the normal distribution assumptions prior to applying parametric techniques to their data and that they use nonparametric (distribution-free) techniques to analyze their data whenever those assumptions are not valid.

Effect of seeding density and time in culture on vascular smooth muscle cell proteins

The purpose of this work was to determine the effect of seeding density and time in culture on quantitative and qualitative characteristics of myosin in primary cultures of vascular smooth muscle cells (VSMCs). Enzymatically dispersed VSMCs from femoral arteries and saphenous veins of adult dogs were seeded at a density of 10(3)-10(5) cells/cm2 and assayed after 7 days or at 10(5) cells/cm2 and assayed between 1 and 10 days. Myosin, actin, and total protein contents as well as electrophoretic and immunoreactive characteristics of myosin heavy chains (MHCs) were determined. Total and contractile protein contents were independent of seeding density and increased with time in culture. Freshly dispersed cells exhibited two MHCs (MHC-1 and MHC-2) but, within 24 h after culturing, only cells attached to the dish expressed a third protein band (MHC-3), which had electrophoretic mobility and immunoreactivity similar to purified platelet MHC. MHC-3 appeared before onset of cell division and, by 4 days in culture when cells were proliferating, became the dominant MHC form. Loss of MHC-1 and MHC-2 could be prevented by growing cells in a serum-free, defined media that prevented proliferation. These data indicate that seeding density does not affect myosin content, but that with time in culture expression of a MHC with characteristics similar to nonmuscle myosin occurs. Expression of MHC-3 is associated with cell attachment, whereas loss of MHC-1 and MHC-2 requires proliferation.

Production and characterization of monoclonal antibodies to rabbit lymphocyte subpopulations. I. Tissue immunofluorescence and flow cytometric analysis

Nine monoclonal antibodies to rabbit T cells and B subpopulations have been generated from three separate fusions of spleen cells from mice immunized with fractionated populations of rabbit lymphocytes. These monoclonal antibodies, as well as a previously described rabbit T cell monoclonal antibody, 9AE10, have been analyzed by immunofluorescence staining on frozen tissue sections of rabbit thymus, spleen, and appendix. This screening method permits rapid identification of the lymphocyte subdomains in each tissue which is not possible by other screening methods. Each monoclonal antibody selected has a unique tissue staining pattern. Flow cytometric analysis of these monoclonal antibodies, using indirect immunofluorescence techniques on thymocytes, splenocytes, and PBL, revealed varying percentages of positive cells and individual mean fluorescence intensities indicating different epitope densities for each antigen. These monoclonal antibodies are now being used to characterize normal lymphocyte function and the role of specific lymphocyte subpopulations in experimental disease models in the rabbit.

Production and characterization of monoclonal antibodies to rabbit lymphocyte subpopulations. I. Tissue immunofluorescence and flow cytometric analysis

Nine monoclonal antibodies to rabbit T cells and B subpopulations have been generated from three separate fusions of spleen cells from mice immunized with fractionated populations of rabbit lymphocytes. These monoclonal antibodies, as well as a previously described rabbit T cell monoclonal antibody, 9AE10, have been analyzed by immunofluorescence staining on frozen tissue sections of rabbit thymus, spleen, and appendix. This screening method permits rapid identification of the lymphocyte subdomains in each tissue which is not possible by other screening methods. Each monoclonal antibody selected has a unique tissue staining pattern. Flow cytometric analysis of these monoclonal antibodies, using indirect immunofluorescence techniques on thymocytes, splenocytes, and PBL, revealed varying percentages of positive cells and individual mean fluorescence intensities indicating different epitope densities for each antigen. These monoclonal antibodies are now being used to characterize normal lymphocyte function and the role of specific lymphocyte subpopulations in experimental disease models in the rabbit.