Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

A-23 Mental Health Outcomes of Elite Athletes Following Sport Related Concussion

Objective

Investigation of anxiety and depression symptoms at baseline and following sport related concussion in a population of professional and collegiate football players.

Method

A quasi-experimental prospective longitudinal design was implemented. Participants included 198 Canadian Football League and University of Alberta varsity football players at baseline. Additionally, this study tracked 13 concussed athletes, 12 orthopaedic control athletes, and 15 healthy control athletes over approximately a 2 month period. Statistical analysis included an ANOVA and repeated measures ANOVA to identify differences in mental health at baseline as well as after injury at 3 time points (24-48 hours post injury, asymptomatic, and 1 month post return to play).

Results

At baseline, players who had a history of 1 or more concussions reported a greater number of anxiety and depression symptoms in comparison to players who did not have a history of concussion (F(2, 197) = 66.75, (p =.000)). At the group level, there were no differences in anxiety and depression symptoms between players who sustained a concussion, orthoepic injury, or no injury across the four time points measured (depression (F(3, 58) = 1.05, (p =.404); anxiety (F(3, 58) = 1.65, (p =.151)). However, individuals who sustained a concussion displayed significant changes in symptoms of anxiety (F(3, 12) = 9.004, (p =.000)) and depression (F(3, 12) = 11.396, (p =.000)) over time. Specifically, concussed players reported an increase in anxiety related symptoms between baseline report and 24-48 hours post injury (p = .042), a decrease between 24-48 hours and 1 month post return to play (p = .002) and a decrease between asymptomatic and 1 month post return to play (p = .036) time points. Additionally, players who sustained a concussion reported a significant increase in depressive symptoms between 24-48 hours post injury and 1 month post return to play (p = .029) and a decrease between asymptomatic and 1 month post return to play (p = .014) time points. This change over time was not found in the orthopaedic injury (depression (F(3, 11) = 2.467, (p =.14); anxiety (F(3, 11) = 2.242, (p =.15)) or healthy control groups (depression; (F(3, 14) = 2.177, (p =.17); anxiety; F(3, 14) = 1.435, (p =.30)).

Conclusions

Results from this study suggest that a history of concussion impacts baseline self-report of anxiety and depression symptoms. Furthermore, players who sustained a concussion experienced subtle increases in anxiety and depressive symptoms in the short term and not in the long term. Players with who sustained an orthopaedic injury and healthy players did not show these changes in anxiety and depression symptom report. It appears that in this small sample concussion produced unique outcomes related to mental health functioning in the short term.

The effect of bisphosphonate treatment on osteoclast precursor cells in postmenopausal osteoporosis: The TRIO study

Bisphosphonates are used to treat bone disease characterised by increased bone resorption by inhibiting the activity of mature osteoclasts, resulting in decreased bone turnover. Bisphosphonates may also reduce the population of osteoclast precursor cells. Our aims were to investigate the effect of bisphosphonates on i) osteoclast precursor cells and ii) circulating cytokine and cytokine receptor in postmenopausal women with osteoporosis compared with healthy premenopausal women. Participants were 62 postmenopausal women (mean age 66) from a 48-week parallel group trial of bisphosphonates. They received ibandronate 150mg/month (n=22), alendronate 70mg/week (n=19) or risedronate 35mg/week (n=21). Fasting blood was collected at baseline, weeks 1 and 48. At baseline, blood was also collected from 25 healthy premenopausal women (mean age 37) to constitute a control group. Peripheral blood mononuclear cells were extracted and stained for CD14, M-CSFR, CD11b and TNFRII receptors. Flow cytometry was used to identify cells expressing CD14⁺ and M-CSFR⁺ or CD11b⁺ or TNFRII⁺. RANKL and OPG were measured to evaluate potential mediation of the bisphosphonate effect. After 48weeks of treatment, there was a decrease in the percentage of cells expressing M-CSFR and CD11b receptors by 53% and 49% respectively (p<0.01). Cells expressing M-CSFR and CD11b were decreased with ibandronate and risedronate after 48weeks to the lower part of the premenopausal reference interval. These effects were not significantly different between each of the treatment groups. There was no significant effect on RANKL and OPG throughout the study period. Bisphosphonates inhibit bone resorption in the short-term by direct action on mature osteoclasts. There is also a later effect mediated in part by a reduction in the population of circulating osteoclast precursors.

Understanding the effects on HR-QoL of treatment for overactive bladder: a detailed analysis of EQ-5D clinical trial data for mirabegron

BACKGROUND

Analysis of EQ-5D data often focuses on changes in utility, ignoring valuable information from other parts of the instrument. The objective was to explore how the utility index, EQ-5D profile, and EQ-VAS captured change in clinical trials of mirabegron, a new treatment for overactive bladder (OAB).

DATA

Data were pooled from three phase III clinical trials that investigated the efficacy and safety of mirabegron vs placebo. Tolterodine ER 4 mg was included as an active control in one study: (1) placebo, mirabegron 50 mg and 100 mg, and tolterodine 4 mg ER; (2) placebo, mirabegron 50 mg and 100 mg; (3) placebo, and mirabegron 25 mg and 50 mg. Data were collected at baseline, week 4, 8, and 12.

METHODS

Analyses were performed on full analysis and modified intention to treat (ITT) data sets using UK utilities. Analysis controlled for relevant patient characteristics. Analysis of Covariance identified changes from baseline at each time point in utilities and EQ-VAS. Areas Under the Curve were estimated to summarize inter-temporal differences in effect. EQ-5D profile data were analysed using the Paretian Classification of Health Change.

RESULTS

In modified ITT analyses, mirabegron 50 mg was superior to tolterodine 4 mg in changes from baseline utilities after 12 weeks (p < 0.05); similarly, AUC results showed mirabegron 50 mg to be superior to tolterodine (p < 0.05) and placebo (p < 0.05) with the benefit already apparent at 4 weeks (p < 0.05). EQ-VAS more consistently indicated superior outcomes: all three mirabegron doses showed statistically significant greater effectiveness compared to tolterodine at 12 weeks. Individual EQ-5D dimensions and the overall profile showed no significant differences between study arms.

CONCLUSION

Mirabegron showed quicker and superior improvement in HR-QoL compared to tolterodine 4 mg ER. A limitation of the study is that EQ-5D was a secondary outcome in the pivotal trials, which were not powered to measure differences on EQ-5D.

(Meth)Acrylate Vinyl Ester Hybrid Polymerizations

In this study vinyl ester monomers were synthesized by an amine catalyzed Michael addition reaction between a multifunctional thiol and the acrylate double bond of vinyl acrylate. The copolymerization behavior of both methacrylate/vinyl ester and acrylate/vinyl ester systems was studied with near-infrared spectroscopy. In acrylate/vinyl ester systems, the acrylate groups polymerize faster than the vinyl ester groups resulting in an overall conversion of 80% for acrylate double bonds in the acrylate/vinyl ester system relative to only 50% in the bulk acrylate system. In the methacrylate/vinyl ester systems, the difference in reactivity is even more pronounced resulting in two distinguishable polymerization regimes, one dominated by methacrylate polymerization and a second dominated by vinyl ester polymerization. A faster polymerization rate and higher overall conversion of the methacrylate double bonds is thus achieved relative to polymerization of the pure methacrylate system. The methacrylate conversion in the methacrylate/vinyl ester system is near 100% compared to only ~60% in the pure methacrylate system. Utilizing hydrophilic vinyl ester and hydrophobic methacrylate monomers, polymerization-induced phase separation is observed. The phase separated domain size is on the order of ~1 μm under the polymerization conditions. The phase separated domains become larger and more distinct with slower polymerization and correspondingly increased time for diffusion.

Orthopedic outcomes of long-term daily corticosteroid treatment in Duchenne muscular dystrophy

OBJECTIVE

To document the effects of long-term daily corticosteroid treatment on a variety of orthopedic outcomes in boys with Duchenne muscular dystrophy.

METHODS

We reviewed the charts of 159 boys with genetically confirmed dystrophinopathies followed at the Ohio State University Muscular Dystrophy Clinic between 2000 and 2003. Charts were reviewed for ambulation status, type and duration of steroid treatment (if any), and orthopedic complications including presence and location of long bone fractures, vertebral compression fractures, and the presence and degree of scoliosis.

RESULTS

The cohort consisted of 143 boys (16 boys with Becker dystrophy were excluded); 75 had been treated with steroids for at least 1 year, whereas 68 boys had never been treated or had received only a brief submaximal dose. The mean duration of daily steroid treatment was 8.04 years. Treated boys ambulated independently 3.3 years longer than the untreated group (p < 0.0001) and had a lower prevalence of scoliosis than the untreated group (31 vs 91%; p < 0.0001). The average scoliotic curve was also milder in the treated group (11.6 degrees) compared with the untreated group (33.2 degrees; p < 0.0001). Vertebral compression fractures occurred in 32% of the treated group, whereas no vertebral fractures were discovered in the steroid naive group (p = 0.0012). Long bone fractures were 2.6 times greater in steroid-treated patients.

CONCLUSIONS

Although boys with Duchenne muscular dystrophy on long-term corticosteroid treatment have a significantly decreased risk of scoliosis and an extension of more than 3 years' independent ambulation, they are at increased risk of vertebral and lower limb fractures compared with untreated boys.

Second autologous transplant with cyclosporin/interferon α-induced graft versus host disease for patients who have failed first-line consolidation

The prognosis for patients with non-Hodgkin's lymphoma (NHL) and advanced Hodgkin's disease (HD) who relapse following autologous transplant is poor. We report on a pilot study designed to evaluate the feasibility of using Cyclosporin A and interferon alpha to induce autologous GVHD following a second autologous transplant for relapsed lymphoma. In all, 10 patients entered the study with median age 46.5 years. Diagnosis was NHL (n=7) or Hodgkin's lymphoma (n=3). All had relapsed from a prior autologous transplant. The second transplant was well tolerated by all patients. Histological changes consistent with cutaneous GVHD developed in 30% of patients at a median of 22.5 days from transplant and settled spontaneously in all cases. Five patients have died (four from progressive disease) at a median 7 months from second transplant. Five patients are still alive and in complete remission at a median of 20 months from transplant. Median overall survival for the group is 13.5 months and median relapse-free survival has not been reached at 42 months. This is a well-tolerated regimen for use in this poor-risk group of patients with lymphoma. The overall survival and event-free survival are encouraging, however further studies are necessary.

Simple model of errors in chirped fiber gratings

A simple etalon based model is presented to show the origin of the wavelength-dependent ripples in the group delay and phase, and in the intensity of optical signals reflected from chirped fiber gratings. The simplicity of the model allows intuitive understanding of the effects, and quantitative predictions. We derive accurate scaling laws that allow the experimenter to make quantitative connections between the grating writing process parameters and grating performance.

Prokaryote multidrug efflux proteins of the major facilitator superfamily: amplified expression, purification and characterisation

In bacterial genomes 3-12% of open reading frames are predicted to encode membrane transport proteins. These proteins can be vital for antibiotic efflux, protein/ toxin secretion, cell nutrition, environmental sensing, ATP synthesis, and other functions. Some, such as the multidrug efflux proteins, are potential targets for the development of new antibacterials and also for applications in biotechnology. In general membrane transport proteins are poorly understood, because of the technical difficulties involved in isolating sufficient protein for elucidation of their structure-activity relationships. We describe a general strategy for the amplified expression, purification and characterisation of prokaryotic multidrug efflux proteins of the 'Major facilitator superfamily' of transport proteins, using the Bacillus subtilis multidrug resistance protein, 'Bmr', as example.

Expansion of Philadelphia chromosome-negative CD3(+)CD56(+) cytotoxic cells from chronic myeloid leukemia patients: in vitro and in vivo efficacy in severe combined immunodeficiency disease mice

We have developed culture conditions for the efficient expansion of cytotoxic effector cells from peripheral blood mononuclear cells (PBMNCs) by the timed addition of interferon-gamma (IFN-gamma), interleukin-2 (IL-2), and the monoclonal antibody (MoAb) OKT3. These cells, termed cytokine-induced killer (CIK) cells, are composed primarily of T cells, and the population of cells with the greatest cytotoxic activity is an otherwise rare population of CD3(+)CD56(+) cells that expand dramatically under these culture conditions. CIK cells were expanded from PBMNCs from 13 patients with chronic myeloid leukemia (CML). These cultures contained a variable number of T cells at the start of the culture (median 44%, range 1% to 64%), yet after 21 to 28 days of culture, virtually all of the cells were CD3(+) T cells (median 97%, range 90% to 99%). The CD3(+)CD56(+) subset of cells expanded significantly (median 25-fold, range 2.2- to 525-fold). CIK cells from all patients showed cytotoxicity against the tumor cell lines OCI-LY8 and K562. In four patients the expanded CIK cells suppressed colony growth of autologous CML blast cells and myeloid progenitor cells. Allogeneic CIK cells from normal donors also suppressed CML colony growth but did not inhibit growth of normal hematopoietic colonies. Twelve of the 13 cultures were exclusively composed of Philadelphia (Ph)-negative cells and one culture had 1 out of 20 Ph-positive metaphases after 4 weeks in culture. Intracellular cytokine production was assayed by fluorescence-activated cell sorter (FACS), and the expanded T-cell cultures produced IL-2, IFN-gamma, and tumor necrosis factor-alpha (TNF-alpha), but not IL-4. Both the CD4(+) and CD8(+) subsets secreted this cytokine profile. To test the in vivo activity of the expanded CIK cells, CML was engrafted into severe combined immunodeficiency disease (SCID) mice using matrigel. After 4 weeks, 4 x 10(7) autologous CIK cells were injected intravenously by tail vein injection into groups of mice, and the animals were sacrificed after a total of 18 weeks. Bcr-abl was detected in the bone marrow or spleen of 5 out of 6 control mice and only 2 out of 13 mice who received the autologous CIK cells (P = .02). In an additional series of animals, the mice did not engraft with CML but instead developed large human Epstein-Barr virus-associated lymphomas by 12 weeks. The mice who received autologous CIK cells at 4 weeks had either no tumor (5) or small tumors (5), whereas all 10 mice that received CIK cells at week 8 developed lymphomas; however, these were not as large as in the 10 control mice who did not receive CIK cells (P = . 03). This study shows that CIK cells, which are Ph chromosome-negative, can be expanded from patients with CML and have potent in vitro and in vivo efficacy against autologous tumor cells.

Learning impairments following injection of a selective cholinergic immunotoxin, ME20.4 IgG-saporin, into the basal nucleus of Meynert in monkeys

Four groups of monkeys (Callithrix jacchus) were injected with saline or increasing amounts of the immunotoxin, ME20.4 IgG-saporin, directly into the basal nucleus of Meynert via a frontal trajectory which avoided damage to the overlying basal ganglia. ME20.4 IgG binds to the primate p75 low-affinity neurotrophin receptor, when the saporin derivitized antibody is injected into the basal forebrain, it selectively destroys the magnocellular neurons of the basal nucleus of Meynert which are the cells of origin of the cholinergic projection to the neocortex. The highest dose of ME20.4 IgG-saporin produced a significant impairment on acquisition of a perceptually difficult visual discrimination. There was no significant effect on retention of tasks learnt before or after surgery, nor on concurrent acquisition of several perceptually easy discriminations or serial reversal of an easy discrimination. These results suggest that the impairment is not due to visual, motor or motivational difficulties and does not consist of difficulties with the formation of reward associations. Rather the impairment is largely confined to acquisition of perceptual discriminations. There was a significant correlation between the density of ME20.4 immunostaining in the basal nucleus of Meynert and the density of acetylcholinesterase histochemical staining in the frontal and temporal cortex and an inverse correlation between both of these and the degree of learning impairment in the animals. Lesioned animals also showed significant impairment on acquisition and reversal of perceptually easy discriminations when treated with a dose of scopolamine which did not impair performance in control animals. These results provide further evidence that cortical cholinergic neurotransmission contributes to certain forms of learning. The availability of a selective cholinergic immunotoxin effective in primates provides an important new tool for the study of cholinergic function and its involvement in ageing, Alzheimer's disease and other pathological states.

Learning impairment induced by lesion of the CA1 field of the primate hippocampus: attempts to ameliorate the impairment by transplantation of fetal CA1 tissue

Monkeys with bilateral excitotoxic lesion of the CA1 field of the hippocampus were severely impaired at learning visuospatial conditional tasks. This was not a general spatial impairment, because the animals were not impaired on serial spatial reversal, which requires response flexibility in the spatial domain; they were not impaired at learning to choose the position furthest away from a single stimulus, which requires analysis of spatial layout of the test area, and they were not impaired at discriminating between two patterns that differed only in orientation. CA1-lesioned monkeys were impaired at learning a visuospatial conditional task when trials of the two component types "if AA go left" and "if BB go right" were presented according to either a pseudorandom or alternating schedule; but they were not impaired if one component type of trial was presented until three consecutive correct responses were made, followed by the other type of trial, to three consecutive correct responses. In all cases testing continued until a criterion of 27 of 30 consecutive correct responses across both types of trial was achieved. Although this suggests that CA1-lesioned animals are particularly prone to interference effects, they had no difficulty in learning ten concurrent visual discriminations presented against either a uniform background or with each discrimination presented against its own distinctive background, a condition that might reduce interference in unoperated monkeys. Interference following hippocampal damage might occur at a deeper level than stimulus identification such that animals with hippocampal damage may be able to learn about many aspects of different stimuli in parallel but may be unable to learn about multiple related aspects of the same subject matter. Monkeys with grafts of fetal CA1 tissue in the lesioned CA1 field showed significant improvement relative to CA1-lesioned animals on those tasks on which CA1-lesioned animals were impaired, although they remained impaired relative to control animals. This suggests that the grafts had produced some improvement in performance. Grafted monkeys did not differ from unoperated control monkeys or from CA1-lesioned monkeys on those tasks that were not sensitive to CA1 damage. This demonstrates that the grafts did not have an additional deleterious effect on cognitive performance.

Characterisation of expression of mDMAHP, a homeodomain-encoding gene at the murine DM locus

We examined the expression of the murine homologue of myotonic dystrophy associated homeodomain protein (mDMAHP) using two different strategies. The first approach, RT-PCR, detected spliced transcripts in a wide range of embryonic and adult tissues, in a pattern overlapping substantially with the expression of mDMPK. A second approach, the generation of transgenic mice expressing the lacZ reporter gene from a 4.3 kb promoter fragment, also demonstrated expression in a range of tissues with potential links to the phenotype in myotonic dystrophy. We conclude that murine DMAHP has a similar pattern of expression to human DMAHP and will serve as a useful model for functional studies of this gene, although species differences, such as the reduced CpG island (1.8 kb compared with 3.5 kb) must be carefully considered.

Transferrin and its receptor in the development of genetically determined neural tube defects in the mouse embryo

The iron-binding growth factor transferrin is taken up and localised in the hindgut of midgestation mouse embryos. We investigated whether the distribution of transferrin may be disturbed in mutant curly tail embryos, a proportion of which exhibit a cell proliferation defect affecting the hindgut endoderm, as part of the pathogenetic sequence leading to development of neural tube defects. Immunostaining revealed a reduction in the binding and/or uptake of transferrin by hindgut epithelial cells in affected curly tail embryos compared with their unaffected littermates. There was no apparent difference between the two embryo types, however, in the distribution or level of expression of the transferrin receptor. The receptor is expressed specifically in the hindgut endoderm of the 10.5-day embryo, although its mRNA is present in all tissues of the posterior neuropore region, suggesting posttranscriptional control of gene expression. These findings may indicate a role for transferrin binding and/or uptake in the regulation of cell proliferation in the hindgut endoderm, with a defect in this process in the curly tail mutant. However, an alternative explanation is suggested by our finding that transferrin immunostaining is more intense in the hindgut of unaffected curly tail embryos than in nonmutant CBA/Ca and CD-1 embryos. Thus, mutant embryos may increase their uptake of transferrin in an attempt to compensate for defective cell proliferation in the hindgut resulting from a defect in another pathway. Only a proportion of embryos are able to mount this compensatory response leading to the observed partial penetrance of developmental defects in the curly tail mutant mouse.

Transplantation of enriched and purged peripheral blood progenitor cells from a single apheresis product in patients with non-Hodgkin's lymphoma

High-dose chemotherapy with or without radiotherapy followed by autologous transplantation of hematopoietic progenitor cells is an effective treatment for patients with high-risk or relapsed non-Hodgkin's lymphoma. Chemotherapy and/or hematopoietic growth factors have been used to mobilize progenitor cells in the peripheral blood for transplantation. However, the mobilized blood cell products have been found to be frequently contaminated with tumor cells, and techniques have not been developed to purge tumor cells from these products. In addition, the minimum number of hematopoietic progenitor cells required for engraftment has not yet been fully elucidated. We treated 21 patients with a single infusion of cyclophosphamide (4 g/m2) followed by daily administration of granulocyte colony-stimulating factor (G-CSF). After recovery of the white blood cell count, a single 3-hour apheresis collection was performed. The apheresis product was then applied to a discontinuous Percoll gradient. The low-density fractions resulting from this separation procedure were enriched for CD34+ progenitor cells (total cell yield, 19.5%; CD34+ cell recovery, 81.2%). These enriched cellular products were treated with a panel of anti-B cell or anti-T cell monoclonal antibodies and complement in an effort to remove residual tumor cells. After treatment of the patient with myeloablative therapies, the enriched and purged cells were reinfused. Hematologic recovery was rapid, with median neutrophil engraftment in 10 days [absolute neutrophil count (ANC), greater than 0.5 x 10(9)/L] and 11 days (ANC, greater than 1.0 x 10(9)/L). Median platelet transfusion independence required 13 days. The rapidity of multilineage engraftment correlated with the number of CD34+ cells per kilogram that were infused. Patients who received more than 2 x 10(6) CD34+ cells per kilogram had rapid hematologic engraftment, whereas those patients transplanted with less than 2 x 10(6) CD34+ cells per kilogram had slower platelet recovery. Modeling studies using a lymphoma cell line with a t(14; 18) chromosomal translocation demonstrated the successful removal of tumor cells assayed using the polymerase chain reaction (PCR) after the processing and purging. Four of the 21 patients had PCR-detectable lymphoma cells in the bone marrow and peripheral blood; however, the enriched and purged blood products reinfused in all four did not contain detectable tumor cells.(ABSTRACT TRUNCATED AT 400 WORDS)

Life-threatening infections occurring more than 3 months after BMT. 18 UK Bone Marrow Transplant Teams

We sent a questionnaire to 22 teams performing allogeneic and autologous bone marrow transplants (BMT) in the UK enquiring about routine use of prophylactic antimicrobials post-transplant, use of CMV-negative blood products and the incidence of major infection acquired more than 3 months post-BMT. Eighteen centres (82%) responded. To prevent Pneumocystis infection 17 centres routinely gave cotrimoxazole at various doses for periods varying between 3 and 12 months (or sometimes longer if chronic GVHD was present) and six centres gave nebulised pentamidine to patients intolerant of cotrimoxazole. Six centres gave penicillin for 1-3 years to allograft patients. Thirteen centres gave only CMV-negative blood products to CMV neg/neg patients, one centre gave CMV immunoglobulin and five centres continued acyclovir to 6 months. During the period 1986-90, 818 autologous and 1007 allogeneic BMT patients were reported, of whom 113 (6.2%) developed severe infections requiring readmission to hospital. The commonest infections were CMV (n = 19), Pneumocystis (n = 12), Pneumococcus (n = 15), Pseudomonas (n = 7) and Aspergillus (n = 8). Some patients with severe infections were not receiving 'appropriate' prophylaxis. Only two of the patients with Pneumocystis were taking cotrimoxazole. We conclude that the duration of continuing prophylaxis against Pneumocystis and pneumococcal infections after BMT needs careful consideration; prophylaxis may be especially important in patients with persisting immune suppression.

Autografting for patients with CML in chronic phase: an update. Hammersmith BMT Team LRF Centre for Adult Leukaemia

Between 1984 and 1992, 21 patients with chronic myeloid leukaemia (CML) in chronic phase (CP) were treated with high-dose chemotherapy (or chemoradiotherapy) followed by autografting with unmanipulated peripheral blood stem cells (PBSC). 12 of these patients survive at a median of 82 months from the time of autografting (range 9-105 months). Nine patients died, six of leukaemia in transformation and three from other causes. Survival of these 21 autograft patients was compared to that of 636 age-matched controls on the Medical Research Council's (MRC) data base, who had been treated with conventional chemotherapy over the same period. Autografted patients had a significantly longer survival at 5 years post autograft than chemotherapy patients (56% v 28%) even after appropriate allowance for time at risk before autograft (Mantel-Byar, 2P = 0.003). There was no difference in survival whether autografting was performed early in the disease or later or whether the PBSC had been harvested soon after diagnosis or later. If the benefits of autografting in chronic phase seen in this non-randomized series can be confirmed in a randomized study, autografting might be the treatment of choice for younger CML patients who do not have suitable donors for allogeneic transplant.

Autografting for patients with chronic myeloid leukemia--the Hammersmith experience

The optimal approach for curing patients with chronic myeloid leukemia (CML) in chronic phase (CP) is an allogeneic bone marrow transplant (BMT). However, this approach is not available to the majority of patients. Autografting, using either purged or unpurged bone marrow or peripheral blood stem cells (PBSC), could be beneficial for patients who are not eligible for BMT. Between 1984 and 1992, 21 patients with CML in CP were autografted using unmanipulated PBSC harvested either at diagnosis or thereafter. Ten of 21 patients survived at a median of 84 months following autografting (range: 12-108 months). Eleven patients died, seven of blast transformation and four from other causes. The timing of the autograft or the harvest does not appear to have a bearing on survival.

Pyomyositis in a patient with myeloma responding to antibiotics alone

Pyomyositis is a rare purulent infection of skeletal muscle with striking clinical features. It usually occurs in patients living in the tropics but is increasingly being reported in immunosuppressed patients. The traditional approach to management has been surgical with drainage and debridement of the multiple muscle abscesses. We report a patient with myeloma who developed multiple muscle and lung abscesses associated with a Staphylococcus aureus septicaemia. The case was successfully managed with intravenous antibiotics alone with no recurrence of the abscesses during a later episode of neutropenia. The advantages of avoiding surgical intervention in immunosuppressed and thrombocytopenic patients are obvious.

Peripheral blood stem cell autografts in CML

The treatment of patients with CML in chronic phase by high dose chemotherapy followed by transfusion of autologous haemopoietic stem cells collected and cryopreserved previously may theoretically prolong survival. This benefit could result from reducing the number of leukaemia stem cells at risk for transformation or by partial re-establishment of Ph-negative haematopoiesis. In practice some patients achieve partial Ph-negative haematopoiesis after autografting but most patients have entirely Ph-positive haematopoiesis by one year after autografting. Results may be improved if methods to favour reconstitution with Ph-negative haematopoiesis can be perfected.

Development of left/right handedness in the chick heart

The chick heart tube develops from the fusion of the right and left areas of precardiac mesoderm and in almost all cases loops to the embryo's right-hand side. We have investigated whether any intrinsic difference exists in the right and left areas of precardiac mesoderm, that influences the direction of looping of the heart tube. Chick embryos incubated to stages 4,5 and 6 were cultured by the New method. Areas of precardiac mesoderm were exchanged between donor and host embryos of the same stage and different stages to form control, double-right and double-left sided embryos. Overall, double-right sided embryos formed many more left-hand loops than double-left sided embryos. At stages 4 and 5 a small percentage of double-right embryos formed left-hand loops (13%) whereas at stage 6 almost 50% of hearts had left-hand loops. Control embryos formed right-hand loops in 97% of cases. The stability of right-hand heart looping by double-left sided embryos, may be related to the process of ‘conversion’, whereas the direction of looping by double-right sided embryos has become randomised. There is some indication that an intrinsic change occurred in the precardiac mesoderm between stages 5 and 6 that later influenced the direction of looping of the heart tube. The direction of body turning is suggested to be linked to the direction of heart looping.

Dual infection with Pneumocystis carinii and respiratory viruses complicating bone marrow transplantation

Pneumonia due to dual infection with Pneumocystis carinii and respiratory viruses is a rare but formidable complication of bone marrow transplantation. We report here two cases of viral infections complicating P. carinii pneumonia in bone marrow transplant recipients who, at the time of infection, were not taking P. carinii prophylaxis. Both patients died following the pneumonia. Potential factors contributing to the dual infection included graft-versus-host disease, high-dose steroids and cyclosporin A. P. carinii prophylaxis should be continued for 12 months, or longer in bone marrow transplant recipients requiring prolonged immunosuppressive therapy. As specific antiviral therapy becomes available for some respiratory viral infections, performing regular viral surveillance cultures and responding with active early treatment may help improve the outcome in these immunocompromised patients.

Immunolocalization of tumour necrosis factor alpha in lung tissue from patients dying with adult respiratory distress syndrome

Using a mouse monoclonal antibody raised against recombinant human tumour necrosis factor alpha (TNF alpha), we have studied immunostained paraffin-embedded autopsy lung tissues from 13 patients dying with adult respiratory distress syndrome and 10 control patients dying of unrelated conditions. Material from 12 of the 13 cases showed positive staining, strong in six, less strong in the remaining six. TNF alpha was located principally within epithelial cells resembling type II pneumocytes in both early and late stages of adult respiratory distress syndrome. In the early stages the TNF alpha positive cells were scattered and appeared disorganized, but in later cases they formed an epithelium. The cells were confirmed as epithelial by their staining pattern with monoclonal antibodies reactive with epithelial, cytokeratin and macrophage antigens, and by double staining for epithelial membrane antigen and TNF alpha. In the control group, staining for TNF alpha was confined to very occasional plump type II pneumocytes, and a weak reaction in bronchial lining cells. Macrophages were only weakly stained in either group. It is suggested that TNF alpha is synthesized (or possibly absorbed) by type II pneumocytes and may be involved in the production of, or recovery from, adult respiratory distress syndrome.

Proton MR spectroscopy and imaging of the brain in AIDS: evidence of neuronal loss in regions that appear normal with imaging

Central nervous system involvement is increasingly being recognised as a common manifestation of the acquired immunodeficiency syndrome (AIDS), either as a direct effect of the human immunodeficiency virus, or as a result of secondary infection or malignancy. A subset of patients with clinical or psychometric evidence of CNS involvement have normal appearances on imaging. This report describes proton magnetic resonance spectroscopy (1H MRS) in two patients with AIDS and discusses the role of 1H MRS in providing a marker of neuronal loss in patients with normal or borderline imaging.

Can bone marrow transplantation be offered to more patients in south east Scotland?

The number of patients with haematological malignancies and aplastic anaemia treated by allogeneic bone marrow transplantation in South East Scotland between 1983-1986 is apparently greater than that estimated by the Black Report in 1982. The potential for increasing the use of this effective therapy by using bone marrow donors from the extended family or national volunteer panels is discussed.

A Ki-1 (CD30)-positive human cell line (Karpas 299) established from a high-grade non-Hodgkin's lymphoma, showing a 2;5 translocation and rearrangement of the T-cell receptor beta-chain gene

We describe the characterization of a new human cell line, Karpas 299 (K299), established from blast cells in the peripheral blood of a 25-year-old white man. His illness, which began with enlarged occipital and axillary nodes and weight loss, ended after 7 months with generalized lymphadenopathy, pleural effusion, and bone marrow involvement. A lymph node biopsy showed a large cell lymphoma mainly sinusoidal in distribution. The blast cells with pleomorphic nuclei resembled primitive histiocytes. The cells, which expressed the T-cell-associated markers CD4 and CD5, were positive for HLA-DR, epithelial membrane antigen, and CD30 (Ki-1 antigen). The karyotype was aneuploid and included a translocation 2;5. The site of translocation on chromosome 5 (at 5q35.1) is in the region of the locus of the c-fms oncogene (receptor of the monocyte-macrophage colony-stimulating factor MCSF or CSF-1). The cell line Karpas 299 has the same karyotype and pattern of antigen expression as the patient's cells. Northern blot analysis of RNA showed an active rearrangement of the T-cell receptor beta-chain gene. This is to our knowledge the first Ki-1 antigen-positive line to be established from a case of non-Hodgkin's lymphoma.

Translocation 5;21 and interstitial deletion of chromosome 7 in a case of chronic myelomonocytic leukemia

We report a case of chronic myelomonocytic leukemia with a translocation involving chromosome 5 and 21, namely, t(5;21)(q35.3;q22.1), and an interstitial deletion of the long arm of chromosome 7. High-resolution analysis at the 900-band stage has shown that the lesion in chromosome 7 is an interstitial deletion involving loss of the segments q22-q35 of the long arm of chromosome 7 and retaining the telomere.

Idiopathic thrombocytopenia in childhood. Edinburgh experience 1962-82

This retrospective review of 136 children with idiopathic thrombocytopenia assesses the prognostic significance of various presenting parameters and the effect of therapy. Initial haemoglobin, white cell count, actual platelet count, splenomegaly, hepatomegaly and lymphadenopathy had no significant effect upon the final outcome. Cases of acute I.T.P. were associated with a higher incidence of preceding infection, a shorter history of bleeding and a preponderance of males. The presence of greater than 20 per cent lymphocytes in the bone marrow was associated with a longer time to achieve a normal platelet count (p = 0.05). Steroid therapy shortened the time for acute cases of I.T.P. to obtain a normal platelet count (p = 0.05), but had no effect on long-term prognosis. Chronicity occurred in 25 children (18%) and nine of these had spontaneous remissions. Immunosuppressive therapy was ineffective, but nine out of 12 children were cured by splenectomy. Mortality was 0.7 per cent (one death) and general morbidity was low.

Acute autonomic neuropathy in association with systemic lupus erythematosus

A patient is described with acute autonomic neuropathy, developing post partum in association with systemic lupus erythematosus, and showing a rapid clinical response to steroids. The pattern of tissue damage is suggestive of an immunologically mediated mechanism.

Pyogenic meningitis due to a vertebral abscess

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Prolonged treatment of pulmonary sarcoidosis with corticosteroids

The results are described of prolonged corticosteroid treatment in 52 patients with pulmonary sarcoidosis observed for a mean duration of 10·5 years from diagnosis. Twenty of the patients were treated for less than one year, the remainder for a mean of five years. The mean length of observation after discontinuing treatment was 5·5 years. Selection of patients for treatment was based on (1) evidence from radiographic observation, even for two years or more, that the disease was progressive so that spontaneous remission was improbable; and (2) evidence of disturbed lung function, especially the onset of dyspnoea or an impaired diffusing capacity. Treatment, conveniently with prednisone at a maintenance dose of about 15 mg. daily, should be continued for at least a year and often for much longer until withdrawal is not followed by radiographic relapse. Such treatment does not increase the chance of a complete remission even when given at an early stage of the disease; and relief of dyspnoea is unpredictable and seldom considerable. But prolonged treatment will halt progressive lung destruction and appears to curb the eventual mortality.