Impact of Giving Patients Your Personal Phone Number in Otolaryngology-Head & Neck Surgery

OBJECTIVE

Patient-provider communication is a major barrier to care, with some providers giving their personal phone number (PPN) to patients for increased accessibility. We investigated participant utilization of provider's PPN, its effect on participant satisfaction, provider's ability to predict abuse of this practice, and evolving provider perceptions.

STUDY DESIGN

Prospective, randomized study.

SETTING

Single institution, tertiary referral center.

METHODS

During a 2-week period, otolaryngology patients were randomized to either receive their provider's PPN or not. Providers predicted the likelihood of abuse. All calls/texts were documented for 4 weeks. At the study's conclusion, participants were surveyed using Press Ganey metrics. Providers were surveyed before and after to assess their likelihood of providing patients with their PPN and its impact on work demands.

RESULTS

Of the 507 participants enrolled, 266 were randomized to the phone number group (+PN). Of 44 calls/texts from 24 participants, 8 were considered inappropriate. Ten participants were predicted to abuse the PPN, but only one was accurately identified. Participants in the +PN group had a greater mean composite satisfaction score than the control group (4.8 vs 4.3; Welch's t-test, P < .0011). At the conclusion of the study, providers were more likely to share their PPN (Wilcoxon signed-rank test, P < .0313), and their perceived impact of this practice on workload was lower (Wilcoxon signed-rank test, P < .0469).

CONCLUSION

This study demonstrates low patient utilization of provider PPNs, and poor provider predictive ability of patient abuse. Receipt of provider's PPN was associated with improved patient satisfaction.

Elastic nail fixation versus plate fixation of paediatric femoral fractures in school age patients - A retrospective observational study

INTRODUCTION

The management of paediatric femoral fractures continues to spark debate in published literature, with poor quality evidence guiding current guidelines on the optimum treatment in children. Many centres report excellent results for both elastic intramedullary nailing and plate fixation of diaphyseal femoral fractures. This study aimed to investigate the outcomes of femoral fractures treated with elastic nail fixation versus those treated with plate fixation in a tertiary children's trauma unit, and discuss the advantages and disadvantages of each technique.

MATERIALS AND METHODS

A retrospective review of all femoral fractures undergoing fixation at a level one paeditric trauma and tertiary referral unit, between 1st April 2009 and 30th April 2017, was performed.Clinical notes and radiographs were reviewed to determine patient demographics and injury, operative and hospital stay data. Radiological union, defined as bridging callus present on at least three out of four cortices on orthogonal radiographs, was determined at 12 weeks. Outcomes were determined using the Flynn Criteria. Patients were followed up for a minimum of 2 years. Data was statistically analysed, and a p value < 0.05 was considered significant.

RESULTS

There were a total of 28 patients- 14 in each treatment group. Patients undergoing elastic nail fixation were significantly older than plate fixation (9.7 ± 1.9 Vs 7.7 ± 1.8; p = 0.008). A male preponderance was noted (21/28), with no difference between groups (10 Vs 11; p = 1.00). Plate fixation demonstrated a tendency towards shorter length of stay (6.3 ± 2.1 Vs 7.8 ± 3.0; p = 0.134), earlier radiological union at 12 weeks (14 Vs 10; p = 0.098), lower postoperative analgesia requirements (0.82 ± 0.45 Vs 1.12 ± 0.97; p = 0.200), and better outcomes, as determined by the Flynn criteria.

CONCLUSIONS

In the authors opinion, plate fixation is a safe, effective alternative to elastic nail fixation with equivocal outcomes as determined by the Flynn Criteria. Plate fixation may offer advantages in shorter length of stay, reduced postoperative pain and earlier weightbearing. Further large scale, prospective research is required to determine whether these are borne out in practice.

Results of the randomized phase IIB ARCTIC trial of low-dose rituximab in previously untreated CLL

ARCTIC was a multicenter, randomized-controlled, open, phase IIB non-inferiority trial in previously untreated chronic lymphocytic leukemia (CLL). Conventional frontline therapy in fit patients is fludarabine, cyclophosphamide and rituximab (FCR). The trial hypothesized that including mitoxantrone with low-dose rituximab (FCM-miniR) would be non-inferior to FCR. A total of 200 patients were recruited to assess the primary end point of complete remission (CR) rates according to IWCLL criteria. Secondary end points were progression-free survival (PFS), overall survival (OS), overall response rate, minimal residual disease (MRD) negativity, safety and cost-effectiveness. The trial closed following a pre-planned interim analysis. At final analysis, CR rates were 76 FCR vs 55% FCM-miniR (adjusted odds ratio: 0.37; 95% confidence interval: 0.19-0.73). MRD-negativity rates were 54 FCR vs 44% FCM-miniR. More participants experienced serious adverse reactions with FCM-miniR (49%) compared to FCR (41%). There are no significant differences between the treatment groups for PFS and OS. FCM-miniR is not expected to be cost-effective over a lifetime horizon. In summary, FCM-miniR is less well tolerated than FCR with an inferior response and MRD-negativity rate and increased toxicity, and will not be taken forward into a confirmatory trial. The trial demonstrated that oral FCR yields high response rates compared to historical series with intravenous chemotherapy.

A comparison of clofarabine with ara-C, each in combination with daunorubicin as induction treatment in older patients with acute myeloid leukaemia

The study was designed to compare clofarabine plus daunorubicin vs daunorubicin/ara-C in older patients with acute myeloid leukaemia (AML) or high-risk myelodysplastic syndrome (MDS). Eight hundred and six untreated patients in the UK NCRI AML16 trial with AML/high-risk MDS (median age, 67 years; range 56-84) and normal serum creatinine were randomised to two courses of induction chemotherapy with either daunorubicin/ara-C (DA) or daunorubicin/clofarabine (DClo). Patients were also included in additional randomisations; ± one dose of gemtuzumab ozogamicin in course 1; 2v3 courses and ± azacitidine maintenance. The primary end point was overall survival. The overall response rate was 69% (complete remission (CR) 60%; CRi 9%), with no difference between DA (71%) and DClo (66%). There was no difference in 30-/60-day mortality or toxicity: significantly more supportive care was required in the DA arm even though platelet and neutrophil recovery was significantly slower with DClo. There were no differences in cumulative incidence of relapse (74% vs 68%; hazard ratio (HR) 0.93 (0.77-1.14), P=0.5); survival from relapse (7% vs 9%; HR 0.96 (0.77-1.19), P=0.7); relapse-free (31% vs 32%; HR 1.02 (0.83-1.24), P=0.9) or overall survival (23% vs 22%; HR 1.08 (0.93-1.26), P=0.3). Clofarabine 20 mg/m2 given for 5 days with daunorubicin is not superior to ara-C+daunorubicin as induction for older patients with AML/high-risk MDS.

Retrospective study of alemtuzumab vs ATG-based conditioning without irradiation for unrelated and matched sibling donor transplants in acquired severe aplastic anemia: a study from the British Society for Blood and Marrow Transplantation

This retrospective national study compared the use of alemtuzumab-based conditioning regimens for hematopoietic SCT (HSCT) in acquired severe aplastic anemia with antithymocyte globulin (ATG)-based regimens. One hundred patients received alemtuzumab and 55 ATG-based regimens. A matched sibling donor (MSD) was used in 87 (56%), matched unrelated donor (MUD) in 60 (39%) and other related or mismatched unrelated donor (UD) in 8 (5%) patients. Engraftment failure occurred in 9% of the alemtuzumab group and 11% of the ATG group. Five-year OS was 90% for the alemtuzumab and 79% for the ATG groups, P=0.11. For UD HSCT, OS of patients was better when using alemtuzumab (88%) compared with ATG (57%), P=0.026, although smaller numbers of patients received ATG. Similar outcomes for MSD HSCT using alemtuzumab or ATG were seen (91% vs 85%, respectively, P=0.562). A lower risk of chronic GVHD (cGVHD) was observed in the alemtuzumab group (11% vs 26%, P=0.031). On multivariate analysis, use of BM as stem cell source was associated with better OS and EFS, and less acute and cGVHD; young age was associated with better EFS and lower risk of graft failure. This large study confirms successful avoidance of irradiation in the conditioning regimens for MUD HSCT patients.

Post-transplant T cell chimerism predicts graft versus host disease but not disease relapse in patients undergoing an alemtuzumab based reduced intensity conditioned allogeneic transplant

In this multicentre retrospective study we have studied the impact of T cell chimerism on the outcome of 133 patients undergoing an alemtuzumab based reduced intensity conditioning allograft (RIC). The median age of the patients was 50 years (range 42-55 years). 77 patients were transplanted using an HLA identical sibling donor while 56 patients received a fully matched volunteer unrelated donor graft. 64 patients had a lymphoid malignancy and 69 were transplanted for a myeloid malignancy. 38 patients (29%) relapsed with no significant difference in risk of relapse between patients developing full donor and mixed donor chimerism in the T-cell compartment on D+90 and D+180 post transplant. Day 90 full donor T cell chimerism correlated with an increased incidence of acute GVHD according to NIH criteria (p=0.0004) and the subsequent development of chronic GVHD. Consistent with previous observations, our results confirmed a correlation between the establishment of T cell full donor chimerism and acute GVHD in T deplete RIC allografts. However our study failed to identify any correlation between T cell chimerism and relapse risk and challenge the use of pre-emptive donor lymphocyte infusions (DLI) in patients with mixed T cell chimerism transplanted using an alemtuzumab based RIC regimen.

Guidelines on obtaining consent for systemic anti-cancer therapy in adults

This guideline, initially drawn up for use in the UK, is essentially based on ethical principles and should be applicable across other jurisdictions. The document specifically addresses the issues which surround obtaining consent from adults for the administration of systemic anti-cancer therapy in the haemato-oncology setting. Consenting to a treatment or procedure is a complex medical, ethical, and legal issue. The process of obtaining consent and the general steps that should be taken by the healthcare professional involved in obtaining consent from a patient are discussed, and the potential legal and ethical pitfalls which can be encountered are outlined. Of fundamental importance are the requirements that agreement must be given voluntarily, based on adequate information, and the patient must have the ability to understand and retain the information given and be in a position to use it in order to reach a decision. The consenting process should include an explanation of the expected outcomes and possible side effects of treatment even if these are unlikely to occur, and the nature of the consenting process undertaken should be clearly documented. Obtaining consent in an emergency situation is also discussed, as is the process of consenting in individuals with impaired capacity or special needs. Withdrawal of consent and refusal of treatment are also considered.

Resuscitation feedback and targeted education improves quality of pre-hospital resuscitation in Scotland

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality and serious neurological morbidity in Europe. Recent studies have demonstrated the adverse physiological consequences of poor resuscitation technique and have shown that quality of cardiopulmonary resuscitation (CPR) is a critical determinant of outcome from OHCA. Telemetry of the defibrillator transthoracic impedance (TTI) trace can objectively measure quality of pre-hospital resuscitation. This study aims to analyse the impact of targeted resuscitation feedback and training on quality of pre-hospital resuscitation.

METHODS

Prospective, single centre, cohort study over 13 months (1st December 2009-31st December 2010). Baseline pre-hospital resuscitation data was gathered over a 3-month period. Modems (n=40) were fitted to defibrillators on ambulance vehicles. Following a resuscitation attempt, the event was sent via telemetry and the TTI trace analysed. Outcome measures were time spent performing chest compressions, compression rate, the interval required to deliver a defibrillator shock and use of automatic or manual cardiac rhythm analysis. Targeted resuscitation classes were introduced and all ambulance crews received feedback following a resuscitation attempt. Pre-hospital resuscitation quality pre and post intervention were compared.

RESULTS

111 resuscitation traces were analysed. Mean hands-on-chest time improved significantly following feedback and targeted resuscitation training (73.0% vs 79.3%, p=0.007). There was no significant change in compression rate during the study period. There was a significant reduction in median time-to-shock interval from 20.25s (IQR 15.50-25.50s) to 13.45 s (IQR 2.25-22.00 s) (p=0.006). Automatic rhythm recognition fell from 50% to 28.6% (p=0.03) following intervention.

CONCLUSION

Telemetry and analysis of the TTI trace following OHCA allows objective evaluation of the quality of pre-hospital resuscitation. Targeted resuscitation training and ambulance feedback improves the quality of pre-hospital resuscitation. Further studies are required to establish possible survival benefit from this technique.

The addition of arsenic trioxide to low-dose Ara-C in older patients with AML does not improve outcome

Most patients with acute myeloid leukaemia (AML) are older, with many unsuitable for conventional chemotherapy. Low-dose Ara-C (LDAC) is superior to best supportive care but is still inadequate. The combination of arsenic trioxide (ATO) and LDAC showed promise in an unrandomised study. We report a randomised trial of LDAC versus LDAC+ATO. Patients with AML according to WHO criteria or myelodysplastic syndrome with >10% blasts, considered as unfit for conventional chemotherapy, were randomised between subcutaneous Ara-C (20 mg b.d. for 10 days) and the same LDAC schedule with ATO (0.25 mg/kg) on days 1-5, 9 and 11, for at least four courses every 4 to 6 weeks. Overall 166 patients were entered; the trial was terminated on the advice of the DMC, as the projected benefit was not observed. Overall 14% of patients achieved complete remission (CR) and 7% CRi. Median survival was 5.5 months and 19 months for responders (CR: not reached; CRi: 14 months; non-responders: 4 months). There were no differences in response or survival between the arms. Grade 3/4 cardiac and liver toxicity, and supportive care requirements were greater in the ATO arm. This randomised comparison demonstrates that adding ATO to LDAC provides no benefit for older patients with AML.

The impact of HLA matching on long-term transplant outcome after allogeneic hematopoietic stem cell transplantation for CLL: a retrospective study from the EBMT registry

We analyzed 368 chronic lymphocytic leukemia patients who underwent allogeneic hematopoietic stem cell transplantation reported to the EBMT registry between 1995 and 2007. There were 198 human leukocyte antigen (HLA)-identical siblings; among unrelated transplants, 31 were well matched in high resolution ('well matched' unrelated donor, WMUD), and 139 were mismatched (MM), including 30 matched in low resolution; 266 patients (72%) received reduced-intensity conditioning and 102 (28%) received standard. According to the EBMT risk score, 11% were in scores 1-3, 23% in score 4, 40% in score 5, 22% in score 6 and 4% in score 7. There was no difference in overall survival (OS) at 5 years between HLA-identical siblings (55% (48-64)) and WMUD (59% (41-84)), P=0.82. In contrast, OS was significantly worse for MM (37% (29-48) P=0.005) due to a significant excess of transplant-related mortality. Also OS worsened significantly when EBMT risk score increased. HLA matching had no significant impact on relapse (siblings: 24% (21-27); WMUD: 35% (26-44), P=0.11 and MM: 21% (18-24), P=0.81); alemtuzumab T-cell depletion and stem cell source (peripheral blood) were associated with an increased risk. Our findings support the use of WMUD as equivalent alternative to HLA-matched sibling donors for allogeneic HSCT in CLL, and justify the application of EBMT risk score in this disease.

Superiority of reduced-intensity allogeneic transplantation over conventional treatment for relapse of Hodgkin's lymphoma following autologous stem cell transplantation

This study compares outcome of reduced-intensity conditioned transplant (RIT) with outcome of conventional non-transplant therapy in patients with Hodgkin's lymphoma relapsing following autograft. There were 72 patients in two groups who had relapsed, and received salvage therapy with chemotherapy+/-radiotherapy. One group (n=38) then underwent alemtuzumab-containing RIT. The second group-historical controls (n=34), relapsing before the advent of RIT-had no further high-dose therapy. This group was required to respond to salvage therapy and live for over 12 months post-relapse, demonstrating potential eligibility for RIT, had this been available. Overall survival (OS) from diagnosis was superior following RIT (48% at 10 years versus 15%; P=0.0014), as was survival from autograft (65% at 5 years versus 15%; P< or =0.0001). For the RIT group, OS at 5 years from allograft was 51%, and in chemoresponsive patients was 58%, with current progression-free survival of 42%. Responses were seen in 8 of 15 patients receiving donor lymphocyte infusions (DLI) for relapse/progression, with durable remission in five patients at median follow-up from DLI of 45 months (28-55). These data demonstrate the potential efficacy of RIT in heavily pre-treated patients whose outlook with conventional therapy is dismal, and provide evidence of a clinically relevant graft-versus-lymphoma effect.

Indications for allogeneic stem cell transplantation in chronic lymphocytic leukemia: the EBMT transplant consensus

The aim of this project was to identify situations where allogeneic stem cell transplantation (allo-SCT) might be considered as a preferred treatment option for patients with B-cell chronic lymphocytic leukemia (CLL). Based on a MEDLINE search and additional sources, a consented proposal was drafted, refined and approved upon final discussion by an international expert panel. Key elements of the consensus are (1) allo-SCT is a procedure with evidence-based efficacy in poor-risk CLL; (2) although definition of 'poor-risk CLL' requires further investigation, allo-SCT is a reasonable treatment option for younger patients with (i) non-response or early relapse (within 12 months) after purine analogues, (ii) relapse within 24 months after having achieved a response with purine-analogue-based combination therapy or autologous transplantation, and (iii) patients with p53 abnormalities requiring treatment; and (3) optimum transplant strategies may vary according to distinct clinical situations and should be defined in prospective trials. This is the first attempt to define standard indications for allo-SCT in CLL. Nevertheless, whenever possible, allo-SCT should be performed within disease-specific prospective clinical protocols in order to continuously refine transplant indications according to new developments in risk assessment and treatment of CLL.

Electrolyzed oxidizing anode water as a sanitizer for use in abattoirs

The effectiveness of electrolyzed oxidizing anode (EOA) water (oxidation-reduction potential, 1,120 mV; pH 2.0) as a sanitizer for use in abattoirs was compared with the iodophor (IOD) Mikroklene (25 ppm), a sanitizer approved for use by regulatory authorities in Canada and the United States. A total of 240 swab (100 cm2) samples were obtained from 4 sites on the kill floor and 16 sites in the secondary processing areas, during two visits within a 4-week period to each of three meat packing plants, processing < or =50 animals per week. Swabs were obtained 12 h after the application of IOD and EOA and were analyzed for the presence of total aerobic bacteria, total coliforms, and total Escherichia coli. Total aerobic bacteria (log CFU/ 100 cm2) recovered from the 20 sample sites were lower (P < 0.0001) in EOA as compared with IOD (2.94 +/- 0.12 versus 3.75 +/- 0.12, respectively). Plant A was 1.5 times more likely (P < 0.0001) to have a sampling site positive for the presence of coliforms and E. coli than plants B and C. There was no difference (P > 0.05) between treatment IOD or EOA in the likelihood of obtaining a positive sample for the presence of total coliforms or E. coli among the three plants. When the kill floor and secondary processing areas are compared, the likelihood of obtaining a sample positive for coliforms or E. coli was similar (P > or = 0.05). Results indicate that EOA was more effective than IOD in reducing populations of total aerobic bacteria on equipment surfaces in the three meat packing plants studied. Because the likelihood of obtaining a positive sample for coliforms or E. coli in EOA as compared with IOD was similar, EOA may be a suitable alternative or complement to IOD as a sanitizer in small- to medium-sized abattoirs. Additional research is required to further evaluate the effectiveness of EOA to sanitize processing equipment on the basis of subsequent isolation of aerobes, coliforms, and E. coli from meat products.

A phase III trial comparing CHOP to PMitCEBO with or without G-CSF in patients aged 60 plus with aggressive non-Hodgkin's lymphoma

The management of older patients with aggressive non-Hodgkin's lymphoma presents a challenge to the physician. Age is a poor prognostic indicator, due to reduced ability to tolerate and maintain dose-intensive chemotherapy. Generally, older patients demonstrate a lower response rate, reduced survival and increased toxicity, although the majority of large randomised trials exclude older patients. This randomised trial was conducted in patients 60 years or over to compare CHOP (cyclophosphamide 750 mg m⁻², doxorubicin 50 mg m⁻², vincristine 1.4 mg m⁻², prednisolone 100 mg) with PMitCEBO (mitoxantrone 7 mg m⁻², cyclophosphamide 300 mg m⁻², etoposide 150 mg m⁻², vincristine 1.4 mg m⁻², bleomycin 10 mg m⁻² and prednisolone 50 mg). Due to the myelosuppressive nature of these regimens, patients were also randomised to the addition of G-CSF. The formal results of this trial with long-term follow-up are now reported. Data were analysed to assess efficacy and toxicity. Overall response rate was 84% in the CHOP arm and 83% in the PMitCEBO arm, with overall response rates of 83% for the use of G-CSF and 84% for no G-CSF. At median 44 months follow-up, there was no significant difference in failure-free, progression-free or overall survival between the CHOP and PMitCEBO arms. At 3 years, the actuarial failure-free survival was 44% in CHOP recipients and 42% in PMitCEBO recipients and the 3-year actuarial overall survival was 46% and 45% respectively. There was no significant difference in the failure-free, progression-free or overall survival with the addition of G-CSF.

Management of chronic myeloid leukaemia in relapse following donor lymphocyte infusion induced remission: a retrospective study of the clinical trials committee of the British Society of Blood & Marrow Transplantation (BSBMT)

Donor lymphocyte infusion (DLI) can restore remission in a high percentage of patients with chronic myeloid leukaemia (CML) who relapse after allogeneic stem cell transplant (SCT). Subsequent relapses after a DLI-induced remission do occur and the optimal management of these patients is not defined. A retrospective study of the practice of UK transplant centres was conducted. In all, 13 patients from seven centres were identified: all were treated for relapse post allogeneic SCT with DLI and achieved either a complete cytogenetic (n=5) or molecular (n=8) remission. All patients subsequently had a second relapse, at molecular (n=7), cytogenetic (n=4) and haematological (n=2) levels. Further DLI was used in the treatment of 11 patients, imatinib mesylate in three and chemotherapy in two. The two patients with haematological relapse died of blastic disease. The remaining 11 patients achieved either a complete cytogenetic (n=2) or molecular (n=9) remission. Nine patients remain in molecular remission at a median follow-up of 29 months, seven of whom had received DLI alone as treatment for second relapse, one DLI plus imatinib and one imatinib alone. Toxicity following DLI for second relapse was low. Longer follow-up will be required to see if these second DLI-induced remissions will be durable.

Reduced-intensity conditioning lowers treatment-related mortality of allogeneic stem cell transplantation for chronic lymphocytic leukemia: a population-matched analysis

To elucidate whether reduced-intensity conditioning (RIC) decreases treatment-related mortality (TRM) after allogeneic stem cell transplantation (allo-SCT) for chronic lymphocytic leukemia (CLL), we retrospectively compared 73 RIC cases from a recent EBMT survey with 82 patients from the EBMT database who had undergone standard myeloablative conditioning (MC) for CLL during the same time period. The two populations were matched by adjusting the primary risk factor, the conditioning regimen, in a series of Cox models for age, sex, donor type, remission status at transplant and analyzed for its effect on TRM, relapse incidence, event-free (EFS) and overall survival (OS). After adjustment, a significant reduction of TRM became evident for the RIC population (hazard ratio (HR) 0.4 (95% confidence interval 0.18-0.9); P=0.03). On the other hand, RIC was associated with an increased relapse incidence (HR 2.65 (0.98-7.12); P=0.054). There was no significant difference between RIC and MC in terms of EFS (HR 0.69 (0.38-1.25); P=0.22) and OS (HR 0.65 (0.33-1.28); P=0.21). We conclude that RIC appears to favorably influence TRM after allo-SCT for CLL. This observation, as well as possible detrimental effects of RIC on relapse risk, should be confirmed by prospective studies.

Treatment-related mortality and graft-versus-leukemia activity after allogeneic stem cell transplantation for chronic lymphocytic leukemia using intensity-reduced conditioning

Allogeneic stem cell transplantation (SCT) using reduced-intensity conditioning (RIC) has potential to be a promising treatment of aggressive chronic lymphocytic leukemia (CLL). Since available clinical data obtained with this novel approach are very limited, we have performed a survey on this issue. Data of 77 patients were collected from 29 European Group for Blood and Marrow Transplantation centers. Median age was 54 (30-66) years, and the median number of previous chemotherapy regimens was 3 (0-8). HLA-identical sibling donors were used in 81% of the cases. Moderate conditioning regimens (mainly low-dose total body irradiation (TBI) or fludarabine-cyclophosphamide combinations) were administered to 56% of the patients, whereas the remainder received more intense conditioning consisting of fludarabine-busulfan or high-dose melphalan combinations. In 40% of the patients, in vivo T-cell depletion (TCD) with anti-thymocyte globulin or CAMPATH-1H was part of the conditioning regimen. Cumulative treatment-related mortality (TRM) was 18% (95% CI 9; 27) after 12 months. Complete chimerism as well as best response was not achieved immediately post-transplant but took a median of 3 months to develop. The 2-year probability of relapse was 31% (95% CI 18; 44), with no event occurring later than 12 months post transplant in the absence of TCD. With one exception, relapses were not observed after onset of chronic graft-versus-host disease. Event-free and overall survival at 24 months were 56% (95% CI 43; 69) and 72% (95% CI 61; 83), respectively. The median follow-up was 18 (1-44) months. Donor lymphocyte infusions or secondary transplants were performed in 19 patients with insufficient disease control and/or incomplete donor chimerism post-transplant, leading to a response in seven patients (37%). Preliminary multivariate analysis identified less than PR at transplant (hazard ratio (HR) 3.5; P&<0.01) and alternative donor (HR 3.1; P=0.02) as significant risk factors for relapse, whereas number of previous regimens >2 (HR 5.4; P=0.03), TBI (HR 2.5; P=0.05), and alternative donor (HR 2.3; P=0.08) were risk factors for survival. We conclude that RIC might favorably influence the outcome after allogeneic SCT for CLL by reducing TRM while preserving graft-versus leukemia activity.

CAMPATH-1 antibodies in stem-cell transplantation

BACKGROUND

CAMPATH-1 (CD52) Abs have been used in stem-cell transplants for the prevention of GvHD and graft rejection. These complications can effectively be prevented by depletion of T lymphocytes from both donor and recipient. However, donor lymphocytes might contribute an anti-leukemia effect and lymphocyte depletion may exacerbate problems with immune reconstitution. There is a fine balance between the risks of GvHD and host-versus-graft reactions, relapse and infection.

METHODS

Clinical outcomes for 4264 patients were reported to a central registry and analyzed by univariate and multivariate methods to determine the superior protocols. Various protocols of lymphocyte depletion were tested, using either CAMPATH-1M (IgM) plus complement or CAMPATH-1G (IgG2b) to treat the donor BM ex vivo and CAMPATH-1G in vivo to treat the recipient. The humanized antibody CAMPATH-1H has recently replaced CAMPATH-1G. A meeting of the clinical collaborators was convened to discuss the results and to review the experiences of individual centers.

RESULTS

Interest focused on the use of mobilized PBSC for transplantation and on the use of reduced-intensity conditioning regimens ('mini' or 'non-Correspondence myeloablative' transplants). These approaches are likely to become increasingly important in the future and will allow transplant procedures to be used for relatively older patients. The use of CAMPATH-1G or CAMPATH-1H was associated with a low incidence of GvHD or rejection, though there were some differences that might be related to the longer half-life of the humanized antibody. An unexpected and apparently paradoxical effect of post-transplant CYA was observed - it appeared to reduce the risk of dying from infection after 6 months. Although part of the benefit could be explained by a reduction in GvHD, the effect was still evident when patients with GvHD or graft rejection were excluded from analysis.

DISCUSSION

CAMPATH-1H appears to have a useful role in the prevention of graft rejection and GvHD, particularly in patients who are at high risk of these complications. It can equally well be used by admixture with the infused stem cells, or by administration to the patient prior to the transplant. Future studies will seek to understand the mechanism of the CYA effect and to improve the quality of immune reconstitution.

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.