A Comprehensive Study of the Epidemiology of Haematological Malignancies in North Queensland

BACKGROUND

There is an absence of clinically relevant epidemiological data in regional Australia pertaining to haematological malignancies.

AIM

To determine the incidence and geographical variation of haematological malignancies in North Queensland using a clinically appropriate disease classification.

METHODS

Retrospective, observational study of individual patient data records of all adults diagnosed with a haematological malignancy between 2005-2014 and residing within The Townsville Hospital Haematology catchment region. We report descriptive summaries, incidence rates and incidence-rate ratios of haematologic malignancies by geographic regions.

RESULTS

1581 haematological malignancies (69% lymphoid, 31% myeloid) were diagnosed over the 10-year study period. Descriptive data is presented for 58 major subtypes as per the WHO diagnostic classification of tumours of haematopoietic and lymphoid tissues. The overall median age at diagnosis was 66 years with a male predominance (60%). We demonstrate a temporal increase in the incidence of haematologic malignancies over the study period. We observed geographical variations in the age-standardised incidence rates per 100,000 ranging from 0.5 to 233.5. Our data suggests an increased incidence rate ratio for haematological malignancies in some postcodes within the Mackay area compared to other regions.

CONCLUSION

This study successfully reports on the incidence of haematological malignancies in regional Queensland using a clinically meaningful diagnostic classification system and identifies potential geographic hotspots. We advocate for such contemporary, comprehensive, and clinically meaningful epidemiological data reporting of blood cancer diagnoses in wider Australia. Such an approach will have significant implications toward developing appropriate data-driven management strategies and public health responses for haematological malignancies. This article is protected by copyright. All rights reserved.

Characteristics and outcome of patients with relapsed/refractory Hodgkin lymphoma following front-line escalated BEACOPP-based chemotherapy: a report from the Australasian Lymphoma Alliance

The optimal management of the small number of patients who experience early failure of eBEACOPP in Hodgkin lymphoma (HL) is unclear. We identified 12 patients with HL who progressed within 12 months of the front-line therapy between January 2010 and July 2019. Median time of first progression following diagnosis was 7 months (range 2.1-13.2). Nine patients proceeded to stem cell therapy following salvage therapy (8 autografts, 1 allograft). Seven patients received novel therapy after relapse, of these, 6 were alive at census, versus 2 out of 5 of those who had standard therapy alone. At the end of follow up (median 22 months), 4 were deceased from progressive disease, 6 were in complete remission and 2 in partial remission on continuing therapy. The outcome of patients with primary refractory HL to eBEACOPP therapy is better than expected and the use of a novel agents after relapse may be a contributing factor.

A 14-year retrospective analysis of indications and outcomes of autologous haemopoietic stem cell transplantation in regional Queensland: a single-centre experience

BACKGROUND

The Townsville Hospital is a tertiary hospital in North Queensland with one of the largest regional transplant centres in Australia, performing primarily autologous haemopoietic stem cell transplants (HSCT) for various haematological malignancies.

AIMS

This single-centre, retrospective, observational study aims to describe the activity and outcomes of autologous HSCT at The Townsville Hospital between 2003 and 2017 to verify safety standards.

METHODS

Patient-level data were collected, including demographics, frequency and indication for transplant, conditioning, current clinical status and cause of death. Key outcomes included overall survival, non-relapse mortality, incidence of therapy-related neoplasm and causes of death. Progression-free survival in the multiple myeloma (MM) subgroup was also assessed.

RESULTS

There were 319 autologous HSCT in 286 patients, with a median age of 58 years (range 14-71 years); 62% of patients were male. Indications for transplantation were: MM 53.7%, non-Hodgkin lymphoma 29.4%, Hodgkin lymphoma 5.0% and other 11.9%. Causes of death were: disease progression/relapse (65.2%), second malignancy (17.0%), infection (9.8%) and other (8.0%). Non-relapse mortality was 1.2% (95% confidence interval 0.4-3.0) and 3.2% (1.7-5.7) at 100 days and 1 year, respectively, post-HSCT. Overall survival at 2 years was 81.0% (73.8-86.4) for MM and 69.6% (58.8-78.1) for non-Hodgkin lymphoma. The median progression-free survival in the MM cohort was 3.3 years.

CONCLUSION

The Townsville Hospital transplant centre provides an important transplant service in regional Queensland, with outcomes comparable to national data. We reported a relatively high rate of second malignancy as a cause of death.

Outcomes of stage I/II follicular lymphoma in the PET era: an international study from the Australian Lymphoma Alliance

Management practices in early-stage (I/II) follicular lymphoma (FL) are variable and include radiation (RT), systemic therapy, or combined modality therapy (CMT). There is a paucity of data regarding maintenance rituximab in this cohort. We conducted an international retrospective study of patients with newly diagnosed early-stage FL staged with positron emission tomography (PET)-computed tomography and bone marrow biopsy. Three hundred sixty-five patients (stage I, n = 221), median age 63 years, treated from 2005-2017 were included, with a median follow-up of 45 months. Management included watchful waiting (WW; n = 85) and active treatment (n = 280). The latter consisted of RT alone (n = 171) or systemic therapy (immunochemotherapy [n = 63] or CMT [n = 46]). Forty-nine systemically treated patients received maintenance rituximab; 72.7% of stage I patients received RT alone, compared to 42.6% with stage II (P < .001). Active therapies yielded comparable overall response rates (P = .87). RT alone and systemic therapy without maintenance rituximab yielded similar progression-free survival (PFS) (hazard ratio [HR], 1.32; 95% confidence interval [CI], 0.77-2.34; P = .96). Maintenance rituximab improved PFS (HR, 0.24; 95% CI, 0.095-0.64; P = .017). The incidence of transformation was lower with systemic therapy compared to RT or WW (HR, 0.20; 95% CI, 0.070-0.61; P = .034). Overall survival was similar among all practices, including WW (P = .40). In the largest comparative assessment of management practices in the modern era, variable practices each resulted in similar excellent outcomes. Randomized studies are required to determine the optimal treatment in early-stage FL.

Hg-supported phospholipid monolayer as rapid screening device for low molecular weight narcotic compounds in water

This study positions the fabricated Pt/Hg-supported phospholipid sensor element in the context of more conventional biomembrane-based screening platforms. The technology has been used together with immobilised artificial membrane (IAM) chromatography and COSMOmic simulation methods to screen the interaction of a series of low molecular weight narcotic organic compounds in water with phosphatidylcholine (PC) membranes. For these chemicals it is shown that toxicity to aquatic species is related to compound hydrophobicity which is associated with compound accumulation in the phospholipid membrane as modelled by IAM chromatography measurements and COSMOmic simulations. In contrast, the Hg-supported dioleoyl phosphatidylcholine (DOPC) sensor element records membrane damage/modification which is indirectly related to general toxicity and directly related to compound structure. Electrochemical limit of detection (LoD) values depend on molecular structure and range from 20 μmolL^-1 for substituted phenols to 23 mmolL^-1 for aliphatics. Rapid cyclic voltammetry (RCV) "fingerprints" showed that the major structural classes of compounds: alkyl/chlorobenzenes, substituted phenols, quaternary ammonium compounds and neutral amines interacted distinctively with the DOPC on Hg and that these observations correlated with and supported those predicted by the COSMOmic simulations of the compound/DMPC association. In addition, the compatibility of the electrochemical and COSMOmic methods validates the electrochemical device as a meaningful high throughput technology to screen compounds in water and report on the mechanistic details of their interaction with phospholipid layers.

Development of acquired haemophilia A in a patient treated with alemtuzumab for multiple sclerosis

This case illustrates a 36-year-old man who presented with a factor VIII (FVIII) inhibitor (acquired haemophilia A) with cutaneous bleeding and a significant thigh haematoma. No traditional risk factors for the development of a FVIII inhibitor were identified. However, previous treatment with alemtuzumab for multiple sclerosis was noted in the patient's history. Alemtuzumab is an anti-CD52 monoclonal antibody and is known to be associated with the development of a number of autoimmune conditions, with a delay in onset of these conditions as long as 5 years after the cessation of treatment. To our knowledge, there have only been three previously documented cases of a FVIII inhibitor in the setting of alemtuzumab therapy. This case adds further evidence to the current body of literature suggesting alemtuzumab as a causative agent for the development of an FVIII inhibitor.

091 Poems syndrome treated with autologous stem cell transplant

Introduction

Acquired demyelinating neuropathies comprise a diverse spectrum of individual diseases and pathophysiological processes. Differential diagnoses can be distinguished through assessment of region of involvement, time course, neurophysiology and ancillary testing. Where an atypical presentation of chronic inflammatory demyelinating polyradiculoneuropathy arises, further investigation and changes to management are required. We present a single case report from the Townsville Hospital.

Case

A 45 year old man presented with two months of altered sensation in the distal lower extremities. Lower limb weakness developed, and three months after symptoms onset the patient had bilateral foot drop, and developed sensory disturbance in the upper limbs. Electrophysiological testing revealed severely reduced lower limb CMAPs with demyelinating range conduction velocity without conduction block; upper limb SNAPs were normal in amplitude with conduction velocity slowing. A lumbar puncture revealed elevated CSF protein 870 mg/L without raised white cells. A trace lambda IgG band of uncertain significance was detected. IVIG was commenced and symptoms initially stabilised. After four months of monthly IVIG, symptoms worsened and neurophysiology revealed further neurogenic changes. Skeletal survey and whole Spine MR STIR sequences did not reveal any bony lesions, and bone marrow biopsy revealed 5% plasmacytosis. The patient’s functional status deteriorated to full-time wheelchair use despite escalation of therapy. Sural nerve biopsy revealed axonal loss and demyelination without inflammation. A final diagnosis of POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, skin changes) syndrome was confirmed with vascular endothelial growth factor elevation, and the patient underwent an autologous stem cell transplant with significant improvement in symptoms and functional status by day 100.

Conclusion

POEMS syndrome is a rare disorder and should be suspected in atypical cases of CIDP particularly when treatment resistance is present. Extensive investigation is often required to meet diagnostic criteria for POEMS.

Predicting the phospholipophilicity of monoprotic positively charged amines

The sorption affinity of eighty-six charged amine structures to phospholipid monolayers (log K_IAM) was determined using immobilized artificial membrane high-performance liquid chromatography (IAM-HPLC). The amine compounds covered the most prevalent types of polar groups, widely ranged in structural complexity, and included forty-seven pharmaceuticals, as well as several narcotics and pesticides. Amine type specific corrective increments were used to align log K_IAM data with bilayer membrane sorption coefficients (K_MW(IAM)). Using predicted sorption affinities of neutral amines, we evaluated the difference (scaling factor Δ_MW) with the measured log K_MW(IAM) for cationic amines. The Δ_MW values were highly variable, ranging from -2.37 to +2.3 log units. For each amine type, polar amines showed lower Δ_MW values than hydrocarbon based amines (C_xH_yN⁺). COSMOmic software was used to directly calculate the partitioning coefficient of ionic structures into a phospholipid bilayer (K_{DMPC-W,cation}), including quaternary ammonium compounds. The resulting root mean square error (RMSE) between log K_{DMPC-W,cation} and log K_MW(IAM) was 0.83 for all eighty-six polar amines, and 0.47 for sixty-eight C_xH_yN⁺ amines. The polar amines were then split into five groups depending on polarity and structural complexity, and corrective increments for each group were defined to improve COSMOmic predictions. Excluding only the group with sixteen complex amine structures (≥4 polar groups, M_w > 400, including several macrolide antibiotics), the resulting RMSE for corrected K_{DMPC-W,cation} values improved to 0.45 log units for the remaining set of 138 polar and C_xH_yN⁺ amines.

Phospholipophilicity of CxHyN(+) amines: chromatographic descriptors and molecular simulations for understanding partitioning into membranes

Using immobilized artificial membrane high-performance liquid chromatography (IAM-HPLC) the sorption affinity of 70 charged amine structures to phospholipids was determined. The amines contained only 1 charged moiety and no other polar groups, the rest of the molecule being aliphatic and/or aromatic hydrocarbon groups. We systematically evaluated the influence of the amine type (1°, 2°, 3° amines and quaternary ammonium), alkyl chain branching, phenyl ring positioning, charge positioning (terminal vs. central in the molecule) on the phospholipid-water partitioning coefficient (KPLIPW). These experimental results were compared with quantum-chemistry based three-dimensional (3D) molecular simulations of the partitioning of charged amines, including the most likely solute conformers, using a hydrated phospholipid bilayer in the COSMOmic module of COSMOtherm software. Both IAM-HPLC retention data and the simulations suggest that the molecular orientation of charged amines at the location in the bilayer with the lowest calculated Gibbs free energy exerts a strong influence over the partitioning within the membrane. The most favourable position of charged amines coincides with the region where the phosphate anions in the phospholipid bilayer are most abundant. Hydrocarbon units oriented in this layer are located more towards the aqueous phase and contribute less to the overall membrane affinity than hydrocarbon units extending into the more hydrophobic core of the bilayer. COSMOmic simulations explain most of the trends between the structural differences observed in IAM-HPLC based KPLIPW. For this set of cationic structures, the mean absolute difference between COSMOmic simulations and IAM-HPLC data, accounting only for amine type corrective increments, is 0.31 log units.

Prediction of immobilised artificial membrane chromatography retention factors using theoretical molecular fragments and structural features

Many in silico alternatives to aquatic toxicity tests rely on hydrophobicity-based quantitative structure-activity relationships (QSARs). Hydrophobicity is often estimated as log P, where P is the octanol-water partition coefficient. Immobilised artificial membrane (IAM) high performance liquid chromatography (HPLC) may be a more biologically relevant alternative to log P. The aim of this study was to investigate the applicability of a theoretical structural fragment and feature-based method to predict log k IAM (the logarithm of the retention index determined by IAM-HPLC) values. This will allow the prediction of log k IAM based on chemical structure alone. The use of structural fragment values to predict log P was first proposed in the 1970s. The application of a similar method using fragment values to predict log k IAM is a novel approach. Values of log k IAM were determined for 22 aliphatic and 42 aromatic compounds using an optimised and robust IAM-HPLC assay. The method developed shows good predictive performance using leave-one-out cross validation and application to an external validation set not seen a priori by the training set also generated good predictive values. The ability to predict log k IAM without the need for practical measurement will allow for the increased use of QSARs based on this descriptor.

Aquatic toxicity of cationic surfactants to Daphnia magna

Quantitative structure-activity relationship (QSAR) modelling of aquatic toxicity for cationic surfactants has received limited attention despite the fact that surfactants of this type are generally more toxic than predicted by general narcosis or polar narcosis equations. Here we report measurement of log P for three types of aromatic quaternary ammonium halides at sub-micellar concentrations, refinement of earlier rules for log P calculation, and development of a hydrophobicity based QSAR, using both calculated and measured log P values, for the aquatic toxicity of quaternary ammonium halides to Daphnia magna. The QSAR for cationics has a substantially larger intercept than the log P-based QSARs for nonionic and anionic surfactants. This is rationalised in terms of the head group interactions with membrane phospholipid in a two-dimensional partitioning model. The effect of the positive nitrogen on the log P contributions of methylene groups along alkyl chains varies, depending on the other groups bonded to the positive nitrogen. We propose a mechanistic explanation, but until these effects can be put on a more predictable quantitative basis it is recommended that, for quaternaries other than the three types discussed here, calculated log P values should not be relied on and experimental values should be determined, e.g. for prediction of toxicity by the QSAR equation reported here.

Database of published retention factors for immobilized artificial membrane HPLC and an assessment of the effect of experimental variability

A database was collated of published experimental logarithmic values for the relative retention factors (log k(IAM)) measured using an immobilized artificial membrane column and high-performance liquid chromatography (IAM HPLC). Log k(IAM) is an alternative measure of hydrophobicity to the octanol/water partition coefficient (log K(OW)). While there are several accepted methods to measure log K(OW), no standardized method exists to determine log k(IAM). The database of collated log k(IAM) values includes 13 key experimental parameters and contains 1,686 values for 555 compounds, which are predominantly polar organic compounds and include drug molecules and surfactants. These compounds are acidic, basic, and neutral and both ionized and un-ionized under the conditions of analysis. The data compiled demonstrated experimental variability for each experimental parameter considered, including column stationary phase, pH, temperature, and mobile phase. Reducing the experimental variability allowed for greater consistency in the datasets.

Practical methods for the measurement of logP for surfactants

Hydrophobicity is a commonly used parameter in quantitative structure activity relationships. The ability to determine the octanol-water partition coefficient (logP) empirically for non-ionizing, non-surfactant type chemicals using traditional stir-flask methods has been successful and well documented. In comparison the ability to measure logP for surfactants is considered impractical due to their amphiphilic nature, which gives them a tendency to form micelles and reside at the octanol-water interface. In this study we have shown that working with compounds below their critical micelle concentrations (CMC), at the experimental concentrations, it is possible to obtain experimental logP values for a series of sulphobetaines using the stir-flask method coupled with reversed phase-high performance liquid chromatography (RP-HPLC). Until now the ability to verify calculated logP values for surfactants has been limited. Measuring logP as described here can now be applied to other surfactants to validate existing and new modifications to the fragment method.

Nitrogen mediates above-ground effects of ozone but not below-ground effects in a rhizomatous sedge

Ozone and atmospheric nitrogen are co-occurring pollutants with adverse effects on natural grassland vegetation. Plants of the rhizomatous sedge Carex arenaria were exposed to four ozone regimes representing increasing background concentrations (background-peak): 10-30, 35-55, 60-80 and 85-105 ppb ozone at two nitrogen levels: 12 and 100 kg N ha(-1) yr(-1). Ozone increased the number and proportion of senesced leaves, but not overall leaf number. There was a clear nitrogen x ozone interaction with high nitrogen reducing proportional senescence in each treatment and increasing the ozone dose (AOT40) at which enhanced senescence occurred. Ozone reduced total biomass due to significant effects on root biomass. There were no interactive effects on shoot:root ratio. Rhizome tissue N content was increased by both nitrogen and ozone. Results suggest that nitrogen mediates above-ground impacts of ozone but not impacts on below-ground resource translocation. This may lead to complex interactive effects between the two pollutants on natural vegetation.

Necrotizing fasciitis as a complication of percutaneous endoscopic gastrostomy

Necrotizing fasciitis of the abdominal wall is a rare clinical entity. The following case study is the first report of necrotizing fasciitis as a complication of percutaneous endoscopic gastrostomy.

Effect of gentamicin on isolated glomeruli and proximal tubules of the rabbit

Alterations in both glomerular filtration rate and tubular transport occur in clinical gentamicin nephrotoxicity. We have studied the function of isolated tubules and glomeruli from rabbits treated with gentamicin. Gentamicin was administered subcutaneously to sexually immature (1400 to 1800 gm) or sexually mature (3800 to 4600 gm) New Zealand White rabbits in a dose of 15 mg/kg twice a day. Immature rabbits were treated for 28 to 31 days and developed only minimal renal insufficiency. About one-half of the mature rabbits developed azotemia. The mature rabbits that did not become azotemic were sacrificed after 28 to 30 days, and those that became azotemic were killed when their serum creatinine reached 2.5 mg/dl or higher (10 to 24 days). Animals were anesthetized and kidneys were removed for histologic examination and isolation of tubules and glomeruli. The ratio of p-aminohippuric acid (PAH) concentration in isolated tubule cells to that in medium after incubation in 3H-PAH (1 microM) at 37 degrees C for 30 minutes (T/M PAH) was used as an indicator of transport capacity of tubules. T/M PAH ratios averaged 196 +/- 18 and 111 +/- 21 for control immature and mature rabbits, respectively, and 135 +/- 22, 80 +/- 16, and 9 +/- 2 for gentamicin-treated immature and mature nonazotemic and mature azotemic rabbits, respectively. Glomeruli were isolated and filtration induced in vitro by a transcapillary oncotic gradient. Ultrafiltration coefficient, Kf, of glomeruli of immature and mature control rabbits averaged 3.78 +/- 0.29 and 5.84 +/- 0.51 nl/minute X mm Hg. Kf from gentamicin-treated immature rabbits averaged 2.82 +/- 0.20 and from mature azotemic rabbits 3.14 +/- 0.44 nl/minute X mm Hg. Kf of both mature and immature rabbits were decreased compared with controls (p less than 0.01). When all animals were considered, relative glomerular filtration rate, estimated from 1/serum creatinine, was positively correlated with the T/M PAH and Kf. When only experimental animals were studied, 1/serum creatinine and T/M PAH were also correlated. Decreased glomerular filtration rate and dysfunction of proximal tubules were also correlated with abnormal tubule histology. We suggest that injury to glomeruli and tubules may represent independent manifestations of gentamicin toxicity. Dysfunction may be present even when there are only mild histologic changes and glomerular filtration rate is near normal. Kf does not appear to limit glomerular filtration rate after treatment with gentamicin; rather, some direct or indirect effect of tubular injury may determine the decrement in glomerular filtration rate.

Silica fragments from millet bran in mucosa surrounding oesophageal tumours in patients in northern China

Millet bran is a component of the diet in the area of highest oesophageal cancer incidence in northern China. Millet bran was found to contain up to 20% by weight of silica; some of this silica occurs as friable sheets or sharply-pointed fibres. These types of silica in millet bran are the most likely source of an unusual contamination with fragments of silica found in the oesophageal mucosa surrounding tumours in patients in northern China. A group of mucosal samples analysed together contained over 5,000 particles/g (100 parts per million by weight), ten times as many as were found in tissue from normal controls taken at necropsy in London. The modal diameter was 10 microgram (1-70 microgram). The particles were in the body of the mucosa and were not simply a surface contaminant. Silica fragments and fibres of similar size originating from other plant species occur in the diet in the two other regions of greatest incidence of oesophageal cancer, the Transkei and Iran. If such fragments enter the mucosa, they must cause some degree of trauma, and they may also be able to stimulate proliferation by providing anchorage. These findings suggest the possibility that silica particles might be involved in the aetiology of oesophageal cancer.

Training sensory awareness and spatial organization in people with right brain damage

Building on a methodology to improve scanning and academic skill performance behavior in persons with acquired right brain damage due to stroke, this study presents 2 additional treatment methods: training in sensory awareness and spatial organization. The 53 patients studied were divided into two groups, experimental (N = 30) and control (N = 23). The experimental group received a treatment program incorporating the 2 new methods as well as a condensed version of the original program. The controls received standard rehabilitation. Both groups were retested after 1 month. Analyses revealed that the performance of those in the experimental group exceeded that of the controls, that those patients in the experimental group with severe impairments improved more than those with mild impairments, and that combined multiple-treatment produces greater generalization than the original single treatment program.

Visual scanning training effect on reading-related tasks in acquired right brain damage

This study presents a method for analyzing and remediating the visual perceptual deficits often found in persons with acquired right brain injury due to stroke. A total of 57 patients were randomly assigned to experimental (N=25) or control (N=32) groups. All patients were administered the same test battery prior to assignment. Experimentals received the specific training program and the controls received standard rehabilitation. Both groups were retested after a period of one month. Analysis revealed the superior performance of the experimental group. The results suggest that the academic disorders found in right brain damage can be treated as secondary to a primary disturbance in visual scanning behavior.