Antibody responses after first and second Covid-19 vaccination in patients with chronic lymphocytic leukaemia

B-cell chronic lymphocytic leukaemia (CLL) is associated with immunosuppression and patients are at increased clinical risk following SARS-CoV-2 infection. Covid-19 vaccines offer the potential for protection against severe infection but relatively little is known regarding the profile of the antibody response following first or second vaccination. We studied spike-specific antibody responses following first and/or second Covid-19 vaccination in 299 patients with CLL compared with healthy donors. 286 patients underwent extended interval (10-12 week) vaccination. 154 patients received the BNT162b2 mRNA vaccine and 145 patients received ChAdOx1. Blood samples were taken either by venepuncture or as dried blood spots on filter paper. Spike-specific antibody responses were detectable in 34% of patients with CLL after one vaccine (n = 267) compared to 94% in healthy donors with antibody titres 104-fold lower in the patient group. Antibody responses increased to 75% after second vaccine (n = 55), compared to 100% in healthy donors, although titres remained lower. Multivariate analysis showed that current treatment with BTK inhibitors or IgA deficiency were independently associated with failure to generate an antibody response after the second vaccine. This work supports the need for optimisation of vaccination strategy in patients with CLL including the potential utility of booster vaccines.

Multicentre study on pulmonary arterial hypertension therapies in fontan patients: underutilised or of limited use?

Introduction

The Fontan circulation is successful in abolishing cyanosis and chronic volume overload in congenital heart disease (CHD) patients with single ventricle physiology. “Fontan failure” is a major cause of poor quality of life and mortality in these patients. Recently, pulmonary arterial hypertension (PAH) therapies have been used in Fontan patients with variable success, even though patients included in these studies are generally at the best end of the spectrum.

Aim

To assess contemporary patterns of PAH therapy in Fontan patients in large specialist CHD centres.

Methods

We identified all adult patients with a Fontan-type circulation under active follow-up in 8 specialist CHD centres between 2009 and 2019. Patients on PAH therapies were matched by age and gender to untreated patients (1:1 or 1:2). Baseline data were collated immediately prior to initiation of therapy (treated group) or from a synchronous routine clinical assessment (untreated group).

Results

During the study period, 70 Fontan patients were started on PAH therapy (6.5% of those under follow-up). The majority 63 (90.0%) were started on monotherapy with a phosphodiesterase-5 (PDE5) inhibitor, 6 (8.6%) patients were started on an endothelin receptor antagonist (ERA) and 1 (1.4%) received early sequential therapy with a PDE5 inhibitor and ERA. Prostacyclin analogues were not used, and no patients received triple therapy. Overall, 51 (72.9%) patients started therapy electively (49% in outpatient clinic, 51% as day case admission), while 18 (25.7%) were treated following urgent hospital admission with fluid overload +/− acute kidney injury. The remainder (2,2.9%) started therapy following cardiac surgery. Adverse events during treatment were rare. Patients starting PAH therapy were matched to 112 untreated patients (table 1). Patients were well matched between groups for age (p=0.52) and sex (p=0.27). Treated patients were more likely to be significantly impaired than matched patients (56.7% vs. 8.6% in NYHA class III/IV, p<0.0001) and were more likely to have ascites (16.2% vs. 0.9%, p=0.0002). Treated patients were also more likely to have a lower albumin level (43 [14–56] vs. 45 [29–54], p=0.01) or to be on a loop diuretic e.g. furosemide (p<0.0001), at a higher daily dose (p<0.0001) than matched patients. Only a quarter of patients on therapies had no high-risk features (24.2%), 80% of whom were from a single centre.

Conclusion

A small minority of Fontan patients followed in specialist centres receive PAH therapies. PAH therapy was reserved in most centres for patients with more advanced disease, targeting predominantly those with a “failing Fontan” in an individualised approach, in line with the recent adult CHD American Heart Association (AHA) guidelines. Further studied are needed to establish the role of PAH therapies in Fontan patients, provided that adult patients with advanced disease who are at increased risk of adverse outcome are included.

Figure 1

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Constantine received an educational grant from Actelion Pharmaceuticals, a Janssen company of Johnson & Johnson, which helped to pay for travel for data collection.

P254 Congenitally corrected transposition of the great arteries with an ebstenoid tricuspid valve, aortic atresia, hypoplastic aortic arch and a dysplastic pulmonary valve

Funding Acknowledgements

No financial support received

Introduction

Congenitally corrected transposition of the great arteries (CCTGA) is a rare cardiac malformation accounting for around 0.5% of congenital heart disease. Common associations are ventricular septal defects (VSD), pulmonary stenosis and heart block. CCTGA associated with aortic atresia is very rarely described in the literature.

Description

We present a case of a term neonate weighing 2.5kg. Fetal echo had initially made the diagnosis at 21/40.

The baby was born in good condition and the postnatal echo confirmed the diagnosis of CCTGA. There were 2 secundum atrial septal defects, the sub-systemic tricuspid valve was ebstenoid with remarkably trivial regurgitation, there were multiple muscular ventricular septal defects with predominantly left to right flow, although flow appeared bi-directional in some views. The atretic aortic valve was anterior and to the left of the dysplastic, bicuspid pulmonary valve. The pulmonary valve leaflet motion was restricted with peak velocity of 2.4m/s and mild incompetence. The hypoplastic aortic arch filled retrogradely via the arterial duct. There was discrete coarctation with peak velocity of 2.2m/s down the descending aorta. The persistent left SVC drained to the coronary sinus.

Following several discussions there was agreement that the most appropriate management for him would be to receive palliative care. He was discharged home at a week of age and continued to have intensive support from his local hospice and the cardiac team, until he passed away peacefully at home at 16 days of age.

Discussion

The multidisciplinary team decided surgery was extremely high risk due to the anatomy described above particularly in the context of his dysplastic, bicuspid pulmonary valve, which would have provided systemic outflow if intervention had been undertaken.

Figure 1: 4 chamber view showing reverse offsetting of the atrioventricular valves, arch view showing a hypoplastic aortic arch with restrograde flow from the arterial duct, short axis view showing the semilunar valves and their relative positions, long axis view showing aortic atresia with retrograde flow into the ascending aorta

Abstract P254 Figure 1

Maternal and fetal outcomes in pregnancies complicated by the inherited aortopathy Loeys-Dietz syndrome

OBJECTIVE

Pregnancies in women with Loeys-Dietz syndrome (LDS) are rare and are typically documented in case reports only. Early reports suggested high rates of maternal complications during pregnancy and the puerperium, including aortic dissection and uterine rupture, but information on fetal outcomes was very limited.

DESIGN

A retrospective cohort study.

SETTING

Eight specialist UK centres.

SAMPLE

Pregnant women with LDS.

METHODS

Data was collated on cardiac, obstetric, and neonatal outcomes.

MAIN OUTCOME MEASURES

Maternal and perinatal outcomes in pregnancies complicated by LDS.

RESULTS

Twenty pregnancies in 13 women with LDS were identified. There was one miscarriage, one termination of pregnancy, and 18 livebirths. In eight women the diagnosis was known prior to pregnancy but only one woman had preconception counselling. In four women the diagnosis was made during pregnancy through positive genotyping, and the other was diagnosed following delivery. Five women had a family history of aortic dissection. There were no aortic dissections in our cohort during pregnancy or postpartum. Obstetric complications were common, including postpartum haemorrhage (33%) and preterm delivery (50%). In all, 14/18 (78%) of deliveries were by elective caesarean section, at a median gestational age at delivery of 37 weeks. Over half the infants (56%) were admitted to the neonatal unit following delivery.

CONCLUSION

Women with LDS require multidisciplinary specialist management throughout pregnancy. Women should be referred for preconception counselling to make informed decisions around pregnancy risk and outcomes. Early elective preterm delivery needs to be balanced against a high infant admission rate to the neonatal unit.

TWEETABLE ABSTRACT

Pregnancy outcomes in women with Loeys-Dietz syndrome.

Immunological function in marine invertebrates: responses to environmental perturbation

The inception of ecological immunology has led to an increase in the number of studies investigating the impact of environmental stressors on host immune defence mechanisms. This in turn has led to an increased understanding of the importance of invertebrate groups for immunological research. This review discusses the advances made within marine invertebrate ecological immunology over the past decade. By demonstrating the environmental stressors tested, the immune parameters typically investigated, and the species that have received the greatest level of investigation, this review provides a critical assessment of the field of marine invertebrate ecological immunology. In highlighting the methodologies employed within this field, our current inability to understand the true ecological significance of any immune dysfunction caused by environmental stressors is outlined. Additionally, a number of examples are provided in which studies successfully demonstrate a measure of immunocompetence through alterations in disease resistance and organism survival to a realized pathogenic threat. Consequently, this review highlights the potential to advance our current understanding of the ecological and evolutionary significance of environmental stressor related immune dysfunction. Furthermore, the potential for the advancement of our understanding of the immune system of marine invertebrates, through the incorporation of newly emerging and novel molecular techniques, is emphasized.

Two-stage revision for prosthetic joint infection: predictors of outcome and the role of reimplantation microbiology

Objectives

We describe rates of success for two-stage revision of prosthetic joint infection (PJI), including data on reimplantation microbiology.

Methods

We retrospectively collected data from all the cases of PJI that were managed with two-stage revision over a 4 year period. Patients were managed with an antibiotic-free period before reimplantation, in order to confirm, clinically and microbiologically, that infection was successfully treated.

Results

One hundred and fifty-two cases were identified. The overall success rate (i.e. retention of the prosthesis over 5.75 years of follow-up) was 83%, but was 89% for first revisions and 73% for re-revisions [hazard ratio = 2.9, 95% confidence interval (CI) 1.2–7.4, P = 0.023]. Reimplantation microbiology was frequently positive (14%), but did not predict outcome (hazard ratio = 1.3, 95% CI 0.4–3.7, P = 0.6). Furthermore, most unplanned debridements following the first stage were carried out before antibiotics were stopped (25 versus 2 debridements).

Conclusions

We did not identify evidence supporting the use of an antibiotic-free period before reimplantation and routine reimplantation microbiology. Re-revision was associated with a significantly worse outcome.

Effect of the UK postcode lottery on survival of patients with metastatic renal cancer: an audit of outcomes in patients with metastatic renal cancer suitable for treatment with tyrosine kinase inhibitors

AIMS

To determine whether primary care trusts' agreement or refusal to fund sorafenib or sunitinib affects outcomes for patients with metastatic renal cell carcinoma.

MATERIALS AND METHODS

This retrospective audit was conducted in a tertiary referral centre for urological cancer. Requests to prescribe drugs not approved by the National Institute for Health and Clinical Excellence are recorded on a trust database. We obtained details of all requests made for sunitinib and sorafenib for patients with renal cell carcinoma since licence in 2006. Outcome measures analysed were overall survival measured from the date of request for funding and hospital resource use as measured from Payment by Results data. Known prognostic factors and the patient's Index of Multiple Deprivation score were assessed at baseline as potential confounders of survival difference.

RESULTS

Seventy-nine patients were identified. The groups were similar with respect to prognostic factors and Index of Multiple Deprivation scores. Thirty-seven and eight patients had funding approved for sunitinib and sorafenib, respectively; 21 and 13 were turned down. Seven patients who were denied funding received one or other of these drugs by self-funding treatment. Survival was longer for patients who received treatment with a drug for which they had applied for funding than for those who did not (hazards ratio 0.46; 95% confidence interval 0.21-1.01; chi(2)=3.80; 1 d.f.; P=0.05); the advantage was similar for patients receiving sunitinib (hazards ratio=0.49; 95% confidence interval 0.18-1.36; chi(2)=1.86; 1 d.f.; P=0.17) and sorafenib (hazard ratio=0.44; 95% confidence interval 0.11-1.69; chi(2)=1.58; 1 d.f.; P=0.21). Overall National Health Service resource use apart from funding for the renal cancer drugs was similar for both groups.

CONCLUSIONS

Compared with patients receiving treatment, patients denied access to sunitinib and sorafenib had substantially worse survival outcomes, despite receiving treatment from the same clinical team. Access to the new drugs did not have an effect on overall use of National Health Service resources by funded patients. Modern treatments for advanced renal cancer should be available to all National Health Service patients with the disease.

Endoplasmic reticulum generates calcium signalling microdomains around the nucleus and spindle in syncytial Drosophila embryos

Cell cycle calcium signals are generated by inositol trisphosphate-mediated release of calcium from internal stores [Ciapa, Pesando, Wilding and Whitaker (1994) Nature (London) 368, 875–878; Groigno and Whitaker (1998) Cell 92, 193–204]. The major internal calcium store is the ER (endoplasmic reticulum): the spatial organization of the ER during mitosis is important in defining a microdomain around the nucleus and mitotic spindle in early Drosophila embryos [Parry, McDougall and Whitaker (2005) J. Cell Biol. 171, 47–59]. Nuclear divisions in syncytial Drosophila embryos are accompanied by both cortical and nuclear localized calcium transients. Mitosis is prevented by the InsP3 antagonists Xestospongin C and heparin. Nuclear-localized transients and cortical transients rely on extraembryonic calcium, suggesting that ER calcium levels are maintained by calcium influx.

Immune-dependent thrombocytopaenia in mice infected with Schistosoma mansoni

As has been shown previously, immunologically intact mice with patent Schistosoma mansoni infections had a significantly lower mean platelet number than intact uninfected mice (P<0.0001). However, platelet numbers in T-cell deprived mice with patent infections were not significantly different from those in uninfected T-cell deprived mice. Also, platelet counts in both the infected and uninfected T-cell deprived groups were not significantly different from those in intact uninfected mice. The S. mansoni-induced thrombocytopaenia in mice is thus seemingly immune dependent. Immunologically intact mice with chronic 12-week-old S. mansoni infections had IgG antibodies that were reactive in an ELISA-type assay with whole fixed platelets of both mouse and human origin. In Western immunoblots the IgG antibodies from chronically-infected mice reacted in particular against mouse and human platelet antigens of 90, 37 and 30 kDa. Antisera raised from 2 rabbits, immunized respectively with mouse and human platelet antigens, cross-reacted with antigens of the larval, adult worm and egg stages of S. mansoni. These results support the hypothesis that an anti-platelet antibody response may be the cause of the thrombocytopaenia observed in mice with patent schistosome infections.

Identification of a fibrinolytic enzyme in Schistosoma mansoni eggs and modulated blood fibrinogen metabolism in S. mansoni-infected mice

Aqueous extracts of Schistosoma mansoni eggs have been shown to have fibrinolytic activity inhibitable by a serine protease inhibitor. Fibrinolytic activity was not present in extracts of either adult worms or cercariae. A 27 kDa enzyme that was proteolytically active on fibrinogen in zymography and that degraded fibrinogen in a pattern similar to that of plasmin, is presumed to be responsible for the schistosome egg fibrinolytic activity. Anti-human fibrinogen antisera were shown to have antibodies that cross-reacted with mouse fibrinogen in Western immunoblots. Electroblotted sera from S. mansoni-infected and control uninfected mice displayed different antigenic profiles when probed with the cross-reactive anti-human fibrinogen antibodies, suggesting an alteration in mouse host fibrinogen metabolism as a result of the parasitic infection. We discuss the possibility that modulation of fibrinogen metabolism is a factor in a recently discovered anti-atherogenic effect exerted by schistosomes.

Effect of cigarette smoking on levels of bioavailable testosterone in healthy men

The effect of smoking on androgen levels is important given the recent interest in the link between low levels of androgens and the development of cardiovascular disease. Numerous studies examining the effects of cigarette smoking on the levels of total and free testosterone have reported conflicting findings, but there has been no accurate assessment of the effects of cigarette smoking on the levels of bioavailable testosterone [not bound to sex hormone-binding globulin (SHBG)]. We attempted to determine whether smoking affects the level of bioavailable testosterone. We undertook a case-control study of 25 healthy male smokers and 25 healthy never-smokers, matched by age and body mass index. Early morning levels of total, free and bioavailable testosterone, 17beta-oestradiol, SHBG and cotinine were determined and compared between the two groups. Levels of total (18.5+/-4.6 nM versus 15.1+/-4.9 nM, P=0.01) and free testosterone (462+/-91 pM versus 402+/-93 pM, P=0.03) were found to be higher in smokers compared with non-smokers respectively, as was SHBG (34.1+/-12.8 versus 28.1+/-9.0 nM, P=0.06). There were no significant differences in the levels of bioavailable testosterone (3.78+/-1.59 versus 3.51+/-1.26 nM, P=0.49) or 17beta-oestradiol (44.5+/-11.4 versus 42.3+/-11.5 pM, P=0.50) between smokers and non-smokers respectively. These data suggest that cigarette smoking has no significant effect on the biologically active fraction of testosterone, but may influence the levels of total and free testosterone through changes in the levels of SHBG.

Smoking, alcohol consumption, and leukocyte counts

Blood was collected from 684 healthy volunteers and examined for total and differential white blood cell (WBC) counts. A subgroup also was tested for numbers of T cells, B cells, and CD4 and CD8 subsets. Smoking status and alcohol consumption were determined by means of questionnaire, and smoking status was verified with serum cotinine concentration. High smoking rate was associated with increases in all counts. Former smokers abstinent less than 5 years still demonstrated elevated counts, whereas those abstinent more than 5 years had WBC counts comparable to those in persons who were never smokers. Compared with levels in those who had never smoked, total WBC counts were 27% higher in current smokers and 14% higher in former smokers who were abstinent for less than 5 years. Lymphocyte counts were 9% higher in those consuming more than one alcoholic drink per day than in those consuming less alcohol, but drinking was not associated with other cell populations.

Regulation of nitric oxide synthesis by dimethylarginine dimethylaminohydrolase

1. Dimethylarginine dimethylaminohydrolase (DDAH), an enzyme that metabolizes the endogenous nitric oxide synthase inhibitors NG-monomethyl-arginine and NG,NG-dimethy-L-arginine to citrulline, was identified by Western blotting in rat and human tissue homogenates. 2. S-2-amino-4(3-methylguanidino)butanoic acid (4124W) inhibited the metabolism of [14C]-NG-monomethyl-L-arginine to [14C]-citrulline by rat liver homogenates (IC50 416 +/- 66 microM; n = 9), human cultured endothelial cells (IC50 250 +/- 34 microM; n = 9) and isolated purified dimethylarginine dimethylaminohydrolase. 3. Addition of 4124W to culture medium increased the accumulation of endogenously-generated NG,NG-dimethy-L-arginine in the supernatant of human cultured endothelial cells from 3.1 +/- 0.3 to 5 +/- 0.7 microM (n = 15; P < 0.005). 4. 4124W (1 microM - 1 mM) had no direct effect on endothelial nitric oxide synthase activity but caused endothelium-dependent contraction of rat aortic rings (1 mM 4124W increased tone by 81.5 +/- 9.6% of that caused by phenylephrine 100 nM). This effect was reversed by L-arginine (100 microM). 4124W reversed endothelium-dependent relaxation of human saphenous vein (19.2 +/- 6.7% reversal of bradykinin-induced relaxation at 1 mM 4124W). 5. These data suggest that inhibition of dimethylarginine dimethylaminohydrolase increases the intracellular contraction of NG,NG-dimethyl-L-arginine sufficiently to inhibit nitric oxide synthesis. Inhibiting the activity of DDAH may provide an alternative mechanism for inhibition of nitric oxide synthases and changes in the activity of DDAH could contribute to pathophysiological alterations in NO generation.

The 190 kDa centrosome-associated protein of Drosophila melanogaster contains four zinc finger motifs and binds to specific sites on polytene chromosomes

Microinjection of a bacterially expressed, TRITC labelled fragment of the centrosome-associated protein CP190 of Drosophila melanogaster, into syncytial Drosophila embryos, shows it to associate with the centrosomes during mitosis, and to relocate to chromatin during interphase. Indirect immunofluorescence staining of salivary gland chromosomes of third instar Drosophila larvae, with antibodies specific to CP190, indicate that the protein is associated with a large number of loci on these interphase polytene chromosomes. The 190 kDa CP190 protein is encoded by a 4.1 kb transcript with a single, long open reading frame specifying a polypeptide of 1,096 amino acids, with a molecular mass of 120 kDa, and an isoelectric point of 4.5. The central region of the predicted amino acid sequence of the CP190 protein contains four CysX2CysX12HisX4His zinc-finger motifs which are similar to those described for several well characterised DNA binding proteins. The data suggest that the function of CP190 involves cell cycle dependent associations with both the centrosome, and with specific chromosomal loci.

P-COMM-B induction chemotherapy in intermediate and high grade non-Hodgkin's lymphoma

57 patients with newly diagnosed intermediate or high grade non-Hodgkin's lymphoma with stage II to IV disease were treated with P-COMM-B (prednisolone, cyclophosphamide, vincristine, mitozantrone, methotrexate and bleomycin). 46% patients achieved a complete remission and 26% achieved a partial remission. Projected disease-free survival in complete remission at 5 years is 56% and projected overall survival at 5 years is 37%. Neutropenia and proximal myopathy were the commonest severe toxicities encountered and two deaths were clearly related to treatment (3.5%). P-COMM-B is effective first-line chemotherapy in intermediate and high grade non-Hodgkin's lymphoma. The efficacy and toxicity of P-COMM-B appear to be comparable to those of the best contemporary regimen, CHOP.

Mutations in aurora prevent centrosome separation leading to the formation of monopolar spindles

We show that female sterile mutations of aurora (aur) are allelic to mutations in the lethal complementation group ck10. This lies in a cytogenetic interval, 87A7-A9, that contains eight transcription units. A 250 bp region upstream of both aur and a divergent transcription unit corresponds to the site of a specific chromatin structure (scs') previously proposed to be a barrier to insulate enhancers of the major hsp70 gene at 87A7. Syncytial embryos derived from aur mothers display closely paired centrosomes at inappropriate mitotic stages and develop interconnected spindles in which the poles are shared. Amorphic alleles result in pupal lethality and in mitotic arrest in which condensed chromosomes are arranged on circular monopolar spindles. The size of the single centrosomal body in these circular figures suggests that loss of function of the serine-threonine protein kinase encoded by aur leads to a failure of the centrosomes to separate and form a bipolar spindle.

Evidence that interleukin-4 suppression of lymphokine-activated killer cell induction is mediated through monocytes

Recombinant human interleukin-4 (IL-4) and transforming growth factor-beta (TGF-beta) reduce recombinant interleukin-2 (IL-2) induction of lymphokine-activated killer (LAK) cell activity from human peripheral blood mononuclear cells (PBMC). Monocytes can be removed from PBMC by adherence, leaving a peripheral blood lymphocyte population (PBL) which also responds to IL-2 to generate LAK activity. PBL generation of LAK cytotoxicity is susceptible to inhibition by TGF-beta, but not by IL-4. Readdition of purified monocytes to PBL is accompanied by return of the suppressive action of IL-4 on the generation of LAK activity. Induction of LAK cytolysis from Percoll-isolated T cells (greater than 90% CD3+) is also refractory to the inhibitory effect of IL-4. When PBMC were cultured in IL-2, with and without IL-4, subsequent sorting of CD3+ and CD3- lymphocytes by flow cytometry demonstrated that IL-4 had suppressed LAK induction in both effector populations. This suggests that, although isolated CD3+ cells are not susceptible to IL-4 suppression of IL-2 activation, they are sensitive to inhibition when part of a mixed PBMC population. Evidence is presented for the first time that this suppression is mediated via the action of IL-4 on monocytes.

Bacterial meningitis following spinal anaesthesia for caesarean section

We report a case of meningitis caused by inadvertent introduction of bacteria following spinal anaesthesia for Caesarean section. The technique of performing the spinal anaesthesia is reviewed. Meningitis may occur, although very rarely, despite meticulous aseptic techniques. It is vital that meningitis should be considered in the differential diagnoses of post-spinal headache when patients present with headaches, pyrexia and meningism in the postoperative or postpartum period.

Single-dose i.v. dexamethasone--an effective anti-emetic in cancer chemotherapy

We conducted a randomised, single-blind, placebo-controlled crossover study to assess the efficacy of a single i.v. dose of 20 mg dexamethasone as an anti-emetic in 31 patients receiving cancer chemotherapy. Patients receiving dexamethasone experienced significantly less nausea and vomiting (P less than 0.001 and P less than 0.01, respectively), and appetite and activity were normal in a majority of the treated group. Side effects were insignificant. We conclude that single-dose dexamethasone given i.v. at a dose of 20 mg is a safe and effective anti-emetic for patients receiving cancer chemotherapy excluding cisplatin.

VIM-D salvage chemotherapy in Hodgkin's disease

A total of 15 patients with relapsed or resistant Hodgkin's disease were treated with a combination of etoposide (VP16), ifosfamide, mitozantrone and dexamethasone (VIM-D). The regime was well tolerated, the only major toxicity being myelosuppression. Complete remissions (CRs) were obtained in 4 patients and were maintained for 2, 4, 10 and 14 months. 10 subjects subsequently received an autologous bone marrow transplant with high-dose chemotherapy (ABMT). Previous exposure to VIM-D did not appear to predict for or prejudice the response to subsequent ABMT.

Early mobilisation of patients with cervical cord injury using the halo brace device

The halo brace device for cervical spine stabilisation has been in use predominantly in North America since 1959. It has not yet found widespread use for the management of the spinal cord injured in the UK. At the Yorkshire Regional Spinal Injuries Unit we have used the device over 2 years on 20 patients with complete and incomplete traumatic cervical spinal cord injuries, and compared our results with those for the previous 20 patients with similar injuries treated with skull calipers and bed rest. Patients using a halo brace device begin more active rehabilitation earlier as they are mobilised on average 5 weeks earlier than those whose traction is administered via skull calipers. Halo brace patients begin weekend leave usually within 7 weeks of their injury compared to 14 weeks post-injury for caliper treated patients and were discharged on average 2 months earlier than the comparison group. We believe that earlier mobilisation, weekend leave and discharge for halo brace patients in the absence of any neurological deterioration afford significant physical, psychological and management benefits.

Quadriplegic care: an assessment of the impact of the carer

Thirty-three voluntary carers living with dependent quadriplegics completed a questionnaire survey which recorded their views on the assistance they received. Disruption to sex life, wheelchair restrictions, personality change in the quadriplegic person, and problems with bladder care were the features they most disliked. We have introduced a self-help group. Respite care would assist them with the valuable service they provide at considerable personal cost.

Acute lymphoblastic leukemia supervening in a case of chronic lymphocytic leukemia after continuous 3-year treatment with chlorambucil

A case is presented of a patient with classical chronic lymphatic leukemia (CLL) treated with continuous chlorambucil for 3 years who presented with a picture of acute leukemia. The peripheral blood still showed a prevalence of mature lymphocytes with a few blast cells, whereas the bone marrow showed a predominant population of blast cells possessing a null acute lymphoblastic leukemia phenotype. Karyotype analysis showed a prevalent hyperdiploid clone of 67 to 68 chromosomes with endoreduplication and marker chromosomes. The coexistence of a CLL-type population with the blastic, undifferentiated cell clone suggests a second malignancy superimposed on the previous leukemic process, and possibly brought about by the continuous chlorambucil treatment.

Prostaglandin E2-mediated enhancement of human plasma cell differentiation

Addition of prostaglandin E2 (PGE2) to blood mononuclear cell cultures containing pokeweed mitogen (PWM) enhances plasma cell (PC) differentiation measured by intracytoplasmic immunoglobulin 7 days later. T-cell mitogenesis to concanavalin A is inhibited using the same concentrations of PGE2. PGE2 failed to enhance the PC differentiation of lymphocytes from patients with systemic lupus erythematosus (SLE). Indomethacin, on the other hand, either had no effect or suppressed PC differentiation. The data is discussed in terms of the effect of PGE2 on human suppressor T-cell function.

A plasma factor inhibiting prostacyclin-like activity in thrombotic thrombocytopenic purpura

The plasma from a patient with thrombotic thrombocytopenic purpura contained a low molecular weight dialysable factor which inhibited the synthesis and release or activity of prostacyclin-like activity from vascular tissue. This factor was not an immunoglobulin or complement component. Following fresh plasma infusions the ability of the patient's plasma to stimulate the release of prostacyclin-like activity returned but no clinical improvement occurred.

Rapidly fatal respiratory failure and angioimmunoblastic lymphadenopathy: possible contributions of immunoblastic leukaemia, chemotherapy, and multiple antibodies directed against mature blood cells

A patient with angioimmunoblastic lymphadenopathy, immunoblastic leukaemia, pulmonary immunoblastic infiltration, and multiple antihaemocytic antibodies in his serum deteriorated rapidly after chemotherapy due to severe progressive respiratory of dysfunction. The haematological and immunological changes that accompanied this are described and discussed in the light of the pulmonary changes observed at necropsy of pulmonary oedema, fibrinous thrombi within venules, and immunoblastic infiltration of these thrombi and the venule walls. A pathophysiological mechanism is postulated in an attempt to rationalise these findings, and to act as a guide for the future assessment and management of similar cases.

Reduced prostacyclin activity in systemic lupus erythematosus

When fresh rabbit aorta is incubated with plasma, prostacyclin, a potent inhibitor of platelet aggregation, is normally released. Plasma obtained from 2 patients with systemic lupus erythematosus (SLE) inhibited prostacyclin activity, while plasma from 22 other patients with SLE and 40 normal control subjects showed normal activity. Absence of prostacyclin activity did not appear to correlate with the clinical severity of the underlying disease. The possible association of this finding and the presence of thrombotic lesions in both patients is discussed.

Cation transport across the guinea-pig placenta perfused in situ

1. The guinea-pig placenta perfused in situ via the umbilical circulation has been used to measure unidirectional fluxes of Na from mother to fetus, and in the reverse direction, with 24Na and 22Na. There was no significant difference between the two fluxes, each being 22 mumole.min-1. 2. Ouabain 10(-5) M in the perfusion fluid had no detectable effect on radioisotopic movements of Na in either direction. 3. Unidirectional fluxes of 42K in both directions were approximately equal at 1.7 mumole.min-1 mother fetus and 1.8 mumole.min-1 in the reverse direction, despite a K concentration of 3.4 mM on the maternal side and 5.0 mM on the fetal side of the placenta. 4. Extraction of 42K and 86Rb from the perfusion fluid was inhibited by 43% by 10(-5) M-ouabain in the fluid. This effect was largely due to a reduction of isotope uptake by the placental tissue. 5. The relative permeabilities of the placenta, mother to fetus, were Rb approximately K (3.2) greater than Na (1.0) greater than Li (0.55). 6. Under the experimental conditions, the electrical potential difference between perfusion fluid and maternal blood was 6 mV (fetus negative). It was shifted towards the positive by a low Na fluid. 7. The results suggest the presence of a dominant Na-K pump (active component towards mother) sited at the maternal-facing membrane of the syncytiotrophoblast together with a subsidiary pump oriented in the opposite direction and probably sited together with a subsidiary pump oriented in the opposite direction and probably sited at the fetal-facing membrane of the syncytiotrophoblast. 8. A high proportion of Na movement particularly towards the fetus is probably passive, occurring through water-filled spaces, whilst K movement is more dependent on active transport.