Reduced-intensity conditioned allogeneic haematopoietic stem cell transplantation results in durable disease-free and overall survival in patients with poor prognosis myeloid and lymphoid malignancies: eighty-month follow-up

The long-term outcome of patients with haematological malignancies treated with reduced-intensity conditioned allogeneic peripheral blood stem cell transplantation is not known. We report the outcome of 79 patients with poor-risk myeloid and lymphoid malignancies transplanted with reduced-intensity conditioning (RIC) regimens. The diagnoses include AML/myelodysplastic syndrome (n=43), non Hodgkin's lymphoma (n=30), Hodgkin's lymphoma (n=3), ALL (n=2) and CML (n=1). For the entire cohort, the disease-free survival (DFS) and OS were 61.2 and 35.7%, respectively. Twenty patients relapsed, 18 within the first three years, and 14 patients succumbed to progressive disease. Overall, 31 patients died from transplant-related complications within the first three years. Day 100 non-relapse mortality correlated with a higher total nucleated cell dose in the graft (odds ratio: 3.9). For those in CR at 3 years, the DFS and OS were 84.2 and 81.1%, respectively. Furthermore, of 43 patients with active disease at the time of transplantation, 16 remained in CR after 3 years. The majority of the long-term survivors were functioning independently. One patient died from a second malignancy. No post-transplant lymphoproliferative disorder was seen. In conclusion, durable disease control was achieved after RIC allogeneic stem cell transplantation for patients with advanced myeloid and lymphoid malignancies.

Intermediate-dose CY and G-CSF more efficiently mobilize adequate numbers of PBSC for tandem autologous PBSC transplantation compared with low-dose CY in patients with multiple myeloma

BACKGROUND

Autologous PBSC transplantation is the standard care for patients with multiple myeloma. The most common regimen used to mobilize PBSC consists of CY and G-CSF.

METHODS

We retrospectively analyzed the efficacy and toxicity of two regimens of CY for PBSC mobilization: low-dose CY (1-2 g/m(2), LD-CY, n=61) plus G-CSF, and intermediate-dose CY (3-4 g/m(2), ID-CY, n=26) plus G-CSF.

RESULTS

In the LD-CY group, 5.17 (0.23-17.3)x10(6) CD34(+) cells/kg, and in the ID-CY group 7.71 (0.08-26.4)x10(6) CD34(+) cells/kg (P=0.018), were collected. Although >/=2x10(6)/kg CD34(+) cells were collected in 89% of the LD-CY group and 92% of the ID-CY group, this was achieved after a single leukapheresis in 54% of the LD-CY group and 92% of the ID-CY group (P=0.0001). Patients who are to have tandem autologous PBSC transplants require >/=4x10(6)/kg CD34(+) cells. This was achieved in only 65% patients in the LD-CY group but 88% in the ID-CY group (P=0.05). Among patients who had not had prior melphalan and/or >12 months of prior treatment, 74% in the LD-CY group and 100% in ID-CY group mobilized >/=4x10(6)/kg CD34(+) cells. Febrile neutropenia was more frequent in the ID-CY group (38% vs. 13%).

DISCUSSION

In conclusion, compared with LD-CY, patients receiving ID-CY were more likely to collect a total CD34(+) cell number adequate for tandem autologous PBSC transplantation. The increased toxicity was manageable and considered acceptable.

Kappa immunoglobulin light chain polymorphisms and survival after allogeneic transplantation for B-cell malignancies: a potential graft-vs-leukaemia target

In the human leucocyte antigen (HLA)-matched haematopoietic stem cell transplantation (HSCT) setting, minor histocompatibility antigen (mHA) disparities between recipient and donor can lead to graft-vs-host disease (GVHD) or graft rejection. Graft-vs-leukaemia (GVL) effect is a beneficial T-cell-mediated immune response that can also occur following HLA-matched HSCT. mHAs with tissue expression restricted to cells of the haematopoietic system are particularly relevant as immunotherapeutic targets for destroying malignant cells without inducing GVHD. Therefore, it is important to identify further haematopoietic-restricted polymorphic mHAs, which may have the potential to be used clinically for adoptive immunotherapy. Polymorphic mismatching of minor antigens, such as the B-cell-specific protein, the kappa immunoglobulin light chain (kappa) may play a role in the incidence of GVL and therefore the survival of transplant recipients following transplantation for B-cell malignancies. Polymorphisms in the constant region of the immunoglobulin kappa polypeptide chain have been defined involving single amino acid changes at positions 153 and 191. In this study, 51 HLA-matched B-cell malignancy transplant pairs were kappa typed by polymerase chain reaction and restriction enzyme digestion to investigate the association between kappa allotype disparity and outcome after transplantation. Kappa allotype disparity between transplant pairs may be associated with an increased survival compared with pairs not mismatched for kappa, as kappa mismatched recipients had a higher percentage of complete remissions and a decreased level of relapse in comparison with the nonmismatched recipients. HLA peptide prediction software was used to determine which HLA types were the best binders for kappa peptides. It was observed that patients with tissue types predicted to bind the kappa Km(1,2) peptides had better survival outcomes and no relapse compared with those with tissue types not predicted to bind the kappa Km(1,2) peptides. This study may contribute to the assessment of the clinical role of kappa with regard to the outcome of allogeneic transplantation for B-cell malignancies.

First Fossil Bandicoots from the Pliocene

FOUR fossil peramelemorphians are currently recognised ? Yarala burchfieldi from Miocene deposits of Riversleigh (Muirhead and Filan 1995; Muirhead in press), Ischnodon australis from the Early to Middle Pliocene Palankarinna Fauna (Stirton 1955), Perameles allinghamensis from the Early Pliocene Bluff Downs Local Fauna (Archer 1976) and P. bowensis from the Early Pliocene Bow Local Fauna (Muirhead et al. 1997). Three of these fossil taxa are referable to modern families. Ischnodon australis represents the Thylacomyidae, while Perameles allinghamensis and P. bowensis represent the Peramelidae. Yarala burchfieldi, in contrast, represents the superfamily Yaraloidea (Muirhead in press).

The Evolutionary History and Diversity of Australian Mammals

Palaeodiversity and relationships of all groups of Australian mammals are reviewed. The fossil record spanning this time is of variable quality. 'Dark Ages' about which nothing is known in terms of Australian mammal evolution include the late Triassic to late Jurassic, late Cretaceous to late Paleocene and middle Eocene to middle Oligocene. Very little is known about the early Cretaceous and late Miocene. The late Oligocene to middle Miocene record documents the highest levels of biodiversity known for the continent, comparable to that which characterises the lowland rainforests of Borneo and Brazil. Order Monotremata spans at least the last 110 million years and includes four families. The enigmatic Ausktribosphenos from 115 million-year-old sediments in Victoria may represent an archaic monotreme, specialised peramurid or previously undocumented order of mammals but is unlikely to represent a placental as suggested in the initial description. Order Microbiotheria is represented in the early Eocene (~55 mya) by two genera similar in morphology to early Eocene taxa from Argentina. Order Peramelemorphia spans the early Eocene to Holocene and includes at least five families. Order Dasyuromorphia spans at least the late Oligocene to Holocene and includes at least three families. Other dasyuromorphian-like marsupials are indeterminate in terms of family-level affinities. Order Notoryctemorphia spans the early Miocene to Holocene with one family. Order Yalkaparidontia spans the late Oligocene to middle Miocene with one genus. Order Diprotodontia spans the late Oligocene to Holocene, represented throughout by three major groups: Phalangerida (eight families), Vombatomorphia (seven families) and Macropodoidea (at least three families). A possible placental condylarth (Tingamarra) has been recorded from the early Eocene. An archaeonycteridid bat (Australonycteris) is known from the early Eocene. Among bats, the late Oligocene to middle Miocene is dominated by rhinolophoids, many of which have European, Asian and African affinities. Mystacinids, megadermatids, hipposiderids and molossids are well-represented in the Oligocene to Miocene deposits. Vespertilionids are uncommon in the Oligocene to Miocene but become more diverse in the Pliocene to Holocene. Emballonurids and rhinolophids appear for the first time in the Plio-Pleistocene. Pteropodids are unknown prior to the Holocene. Murids span the early Pliocene to Holocene. In the oldest assemblage at Riversleigh, one undescribed lineage resembles archaic forms otherwise only known from the fossil records of Africa and Eurasia.

Fossil Bandicoots of Chillagoe (Northeastern Queensland) And the First Known Specimens of The Pig-Footed Bandicoot Chaeropus Ogilby, 1838 From Queensland

NA

Positive expectations predict health after heart transplantation

We explored the relations between positive expectations and adjustment, adherence, and health in cardiac transplant patients. Thirty-one patients and their nurse completed questionnaires before transplantation and at 3 times after surgery. As predicted, patients' self-reported positive expectations were generally associated with good mood, adjustment to the illness, and quality of life, even in patients who experienced health setbacks. High preoperative expectations predicted later adherence to a complex medical regimen. Positive expectations measured before the transplant predicted a substantial amount of the variance in the nurse's ratings of physical health 6 months after surgery, covarying for adherence behavior and preoperative health.

Scratching the surface: mental health training for rural health workers

This paper will describe the Mental Health Training for Rural Health Workers Project that was completed in 1995 under the Rural Health Support Education and Training Program. The lack of specialist mental health services in rural areas means that generalist health workers need to provide mental health services in rural communities. Generalist health workers often feel ill-equipped to help people who require mental health services. The aim of this project was to provide generalist workers in rural areas with practical skills and knowledge in order to help people with mental health disorders and promote positive mental health. The project involved an initial needs survey, the development of education and training material, the implementation of the training, and evaluation of the project.

Positive expectations predict health after heart transplantation

We explored the relations between positive expectations and adjustment, adherence, and health in cardiac transplant patients. Thirty-one patients and their nurse completed questionnaires before transplantation and at 3 times after surgery. As predicted, patients' self-reported positive expectations were generally associated with good mood, adjustment to the illness, and quality of life, even in patients who experienced health setbacks. High preoperative expectations predicted later adherence to a complex medical regimen. Positive expectations measured before the transplant predicted a substantial amount of the variance in the nurse's ratings of physical health 6 months after surgery, covarying for adherence behavior and preoperative health.

Additional Parts of The Type Specimen of Thylacinus macknessi (Marsupialia: Thylacinidae) From Miocene Deposits of Riversleigh, Northwestern Queensland

A revised diagnosis and description of Thylacinus macknessi Muirhead, 1992 is presented following recovery of the previously unknown anterior half of the holotype. This provides the most completely represented lower dentition of a species of thylacinid other than T. cynocephalus. The new part of the holotype further confirms the thylacinid nature of this taxon by displaying additional features that in combination are only known in that family. The molar and premolar region suggest that selection pressure to elongate the face and shearing crest system were greater at the front of the dentition. This specialisation differs significantly from that of most dasyurids which appear to have been under pressure to shorten the facial region by premolar Joss.

Heart transplantation in children: indications, complications, and management considerations

Heart transplantation in children has increased in the last 5 years because of the availability of cyclosporine and improved surgical techniques. The primary indications for transplantation in children are dilated cardiomyopathy and complex congenital heart disease. The major complications affecting morbidity and mortality are infection and rejection. However, the development of accelerated coronary artery disease represents a serious complication limiting long-term survival. Successful rehabilitation and long-term survival depend on careful selection of potential recipients, application of stringent medical and psychosocial criteria, operative technique, comprehensive medical surveillance, and thorough and effective patient and family education.

Quality of life and coping in patients awaiting heart transplantation

The psychosocial adaptation of patients awaiting heart transplantation has not been defined. Forty-one patients (36 men, 5 women; mean age, 48 years) completed standardized questionnaires before transplantation to assess quality of life, physical symptoms, marital/social adjustment, psychiatric morbidity, coping, and compliance to medical regimens. Also, data were obtained from spouses/partners and the transplantation nurse coordinator. Unlike previously reported findings with patients after transplantation, those awaiting transplantation report moderate dissatisfaction with quality of life. Patients report physical symptoms, functional disabilities, sexual dysfunction, and psychological distress. Nonetheless, reported levels of compliance with the medical regimens and of social support were high, and both patients and spouses/partners provided marital adjustment ratings on the Dyadic Adjustment Scale that were comparable to those of well-adjusted, happily married couples. High levels of coping also were recorded. Having a positive attitude and seeking social support were the most common coping strategies, whereas confrontation, acceptance, and escapism were relatively uncommon. In conclusion, patients awaiting heart transplantation, although dissatisfied with quality of life, maintain positive psychological and social adjustment.

Heart and heart-lung transplantation

The fields of heart and combined heart-lung transplantation are in a constant state of evolution. As greater experience is gained in posttransplant management, more patients with end-stage heart and lung disease can be treated. Because the postoperative course and rehabilitation phase may be extremely difficult, only candidates who meet specific medical and psychosocial criteria are selected. During the waiting period, critical care nurses along with the transplant team are instrumental in stabilizing the emotional and physical condition of the transplant candidate. Postoperative complications requiring intensive therapy include decreased cardiac output, respiratory dysfunction, rejection, and infection. Graft atherosclerosis, obliterative bronchiolitis, and malignancy are long-term complications that may limit survival. Life-long immunosuppression and careful long-term medical surveillance are crucial to the health of the recipient. Although there are numerous emotional and physical challenges related to potentially life-threatening complications and other disturbances in daily living, the quality of life for most recipients has greatly improved.

Chronic hyperplastic candidosis and secretor status

A prospective study was undertaken of 22 patients with chronic hyperplastic candidosis and 50 age and sex matched individuals with no evidence of oral mucosal disease. Specifically the relationship between the inherited ability to secrete blood group antigens in saliva and chronic hyperplastic candidosis was investigated. The proportion of non-secretors of blood group antigens was significantly higher in patients with chronic hyperplastic candidosis (68%) compared to the control subjects (38%). The inability to secrete blood group antigens in saliva may therefore be a risk factor in the development of, or persistence of chronic hyperplastic candidosis.

Heart and heart-lung transplantation

The fields of heart and combined heart-lung transplantation continue to evolve, allowing treatment of more individuals with end-stage heart and lung disease. The postoperative course and rehabilitation phase may be arduous, emphasizing the importance of selecting candidates who meet specific medical and psychosocial criteria. Life-long immunosuppression and meticulous long-term medical surveillance are mandatory practices to promote the health of the recipient. The major complications that contribute to morbidity and mortality, especially during the first post-transplant year, are infection and rejection. Graft atherosclerosis, obliterative bronchiolitis, and malignancy are long-term complications that may limit survival. In spite of the emotional and physical challenges related to potentially life-threatening complications and other disturbances in daily living, the quality of life for most recipients has markedly improved.

Perioperative beta blockade with propranolol: reduction in myocardial oxygen demands and incidence of atrial and ventricular arrhythmias

To determine the effect of beta blockade with propranolol on myocardial oxygen demands and postoperative arrhythmias in patients having coronary bypass operations, 50 patients with chronic stable angina undergoing operation were randomized in a double-blind fashion to receive either propranolol (60 mg every 6 hours) or a placebo. Drug administration began 24 to 48 hours prior to operation and continued through the operative period and for one month after operation. There were no deaths. Two perioperative myocardial infarctions occurred, both in patients receiving a placebo. Myocardial oxygen demand as measured by the rate-pressure product (heart rate X mean arterial pressure) was significantly reduced during induction of anesthesia (7,658 +/- 451 versus 5,786 +/- 340; p less than 0.002) and during sternotomy (8,400 +/- 550 versus 6,756 +/- 384; p less than 0.02) in propranolol-treated patients. In the first two postoperative days, nitroprusside was required for control of hypertension of 10 patients in the placebo group but in only 3 patients given propranolol (p less than 0.05). Postoperatively, 15 of the 26 patients who received a placebo had 45 episodes of arrhythmia. Seven of the 24 propranolol-treated patients had 17 episodes (p less than 0.04). We conclude that propranolol given perioperatively in doses large enough to induce beta blockade significantly reduces myocardial oxygen demands in the vulnerable period during induction of anesthesia and sternotomy, reduces the need for antihypertensive therapy in the immediate postoperative period, and causes a marked reduction in the incidence and frequency of both supraventricular and ventricular arrhythmias in the postoperative period.

Repair of atrioventricular canal malformation in the first year of life

Disappointing results with pulmonary artery banding and subsequent correction led to the decision in 1977 that all infants presenting to our hospital with atrioventricular (AV) canal and evidence of severe heart failure, lack of growth, or pulmonary hypertension should have early operative correction. Since that time 24 consecutive infants have undergone repair. All had refractory heart failure. Average age at operation was 18 weeks (3 to 38) and average weight was 4.3 kg (2.3 to 6.4). Only four patients were older than 6 months of age at operation. Preoperative peak pulmonary artery pressure was 81 +/- 3.3 mm Hg, which was equal to systemic arterial pressure in all cases. Mean pulmonary-to-systemic resistance ratio was 0.28 +/- 0.05. five patients had moderate mitral regurgitation and five had a ductus arteriosus. Three had significant associated malformations. Profound hypothermia and circulatory arrest were utilized in all patients. Common AV valve tissue was divided and valvular integrity was ensured by resuspension to a single Dacron patch which closed both the atrial and ventricular defects. Operative death occurred in two patients (8%) both with associated defects (one with total anomalous pulmonary venous connection and the other with coarctation). One late death occurred in a patient with associated partial anomalous pulmonary venous connection, and one patient has had a pacemaker implanted. Survivors have been followed for 7 to 60 months. All patients are growing at an increased rate postoperatively. All cardiac medications have been discontinued in 16 of 21 patients. Operative repair of complete atrioventricular canal can be performed in infancy with low operative and late death rates and will relieve signs and symptoms of heart failure and allow more normal growth and development. On the basis of this experience, it appears unnecessary to delay operative correction with the known increased risk of the development of pulmonary hypertension.