Coronavirus (COVID-19), Coagulation, and Exercise: Interactions That May Influence Health Outcomes

The proinflammatory cytokine storm associated with coronavirus disease 2019 (COVID-19) negatively affects the hematological system, leading to coagulation activation and endothelial dysfunction and thereby increasing the risk of venous and arterial thrombosis. Coagulopathy has been reported as associated with mortality in people with COVID-19 and is partially reflected by enhanced D-dimer levels. Poor vascular health, which is associated with the cardiometabolic health conditions frequently reported in people with severer forms of COVID-19, might exacerbate the risk of coagulopathy and mortality. Sedentary lifestyles might also contribute to the development of coagulopathy, and physical activity participation has been inherently lowered due to at-home regulations established to slow the spread of this highly infectious disease. It is possible that COVID-19, coagulation, and reduced physical activity may contribute to generate a “perfect storm,” where each fuels the other and potentially increases mortality risk. Several pharmaceutical agents are being explored to treat COVID-19, but potential negative consequences are associated with their use. Exercise is known to mitigate many of the identified side effects from the pharmaceutical agents being trialled but has not yet been considered as part of management for COVID-19. From the limited available evidence in people with cardiometabolic health conditions, low- to moderate-intensity exercise might have the potential to positively influence biochemical markers of coagulopathy, whereas high-intensity exercise is likely to increase thrombotic risk. Therefore, low- to moderate-intensity exercise could be an adjuvant therapy for people with mild-to-moderate COVID-19 and reduce the risk of developing severe symptoms of illness that are associated with enhanced mortality.

Blood donation by healthy individuals with haemochromatosis

AIM

To determine how many individuals with haemochromatosis undergoing therapeutic venesections in our department might be eligible for blood donation.

METHODS

Patients with genetic haemochromatosis were assessed with respect to complications of their disorder, the presence of other medical conditions and their suitability to be blood donors.

RESULTS

Of 74 patients, 53 have been tested and shown to be homozygous for the Cys282Tyr mutation, and 30 of these (40%) fulfilled criteria for blood donation. This group is having 409 units of blood removed annually or 13-units per individual that is currently discarded. Of these 30 patients, all (100%) were keen to be blood donors.

CONCLUSION

It is timely to review the policy regarding use of this wasted blood for transfusion.

Efficacy of pamidronate in reducing skeletal events in patients with advanced multiple myeloma. Myeloma Aredia Study Group

BACKGROUND

Skeletal complications are a major clinical manifestation of multiple myeloma. These complications are caused by soluble factors that stimulate osteoclasts to resorb bone. Bisphosphonates such as pamidronate inhibit osteoclastic activity and reduce bone resorption.

METHODS

Patients with stage III multiple myeloma and at least one lytic lesion received either placebo or pamidronate (90 mg) as a four-hour intravenous infusion given every four weeks for nine cycles in addition to antimyeloma therapy. The patients were stratified according to whether they were receiving first-line (stratum 1) or second-line (stratum 2) antimyeloma chemotherapy at entry into the study. Skeletal events (pathologic fracture, irradiation of or surgery on bone, and spinal cord compression), hypercalcemia (symptoms or a serum calcium concentration > or = 12 mg per deciliter [3.0 mmol per liter]), bone pain, analgesic-drug use, performance status, and quality of life were assessed monthly.

RESULTS

Among 392 treated patients, the efficacy of treatment could be evaluated in 196 who received pamidronate and 181 who received placebo. The proportion of patients who had any skeletal events was significantly lower in the pamidronate group (24 percent) than in the placebo group (41 percent, P < 0.001), and the reduction was evident in both stratum 1 (P = 0.04) and stratum 2 (P = 0.004). The patients who received pamidronate had significant decreases in bone pain and no deterioration in performance status and quality of life. Pamidronate was tolerated well.

CONCLUSIONS

Monthly infusions of pamidronate provide significant protection against skeletal complications and improve the quality of life of patients with stage III multiple myeloma.

British type alpha 0-thalassaemia in New Zealand

Alpha zero-thalassaemia of the British type is described for the first time in a New Zealand family. Microcytic, hypochromic red blood cells were found in affected individuals. Exclusion of iron deficiency and beta-thalassaemia suggested alpha-thalassaemia as a possible cause. This was confirmed by the detection of haemoglobin (Hb) H inclusion bodies. Definitive characterisation of the alpha-thalassaemia defect required DNA mapping which demonstrated the British alpha zero-thalassaemia deletion involving both alpha globin genes. alpha zero-thalassaemia should no longer be considered a disorder affecting individuals of Mediterranean or Asian backgrounds. Anglo-Saxons are also an at risk group. Co-inheritance of this abnormality with a second alpha-thalassaemia defect can lead to Hb H disease or Hb Bart's hydrops fetalis.

Elimination of T cells from human peripheral blood and bone marrow using a cocktail of three anti-T cell immunotoxins

Four anti-T cell monoclonal antibodies were coupled to ricin-A and tested for their ability to kill T cells in peripheral blood and bone marrow using a clonogenic assay to quantify T cell survival. The immunotoxins (IT) prepared from RFT11 (CD2) and WT1 (CD7) antibodies were the most toxic to peripheral blood T cells. The immunotoxin prepared from RFT1 (CD5) was the next most efficient toxin and the immunotoxin prepared from RFT8 (CD8) was the least toxic. When these reagents were applied to peripheral blood cells at 3 x 10(-8) M the number of T cell colonies was reduced by an average of 95%, 94%, 84% and 50%, respectively. Peripheral blood T cells from different donors showed marked variability in their sensitivity to ITs. However, a cocktail of three ITs prepared from RFT11, WT1 and RFT1 gave superior and consistent killing (mean 99.9%; range 99.8-100%) of peripheral blood T cells from six donors. When this cocktail was applied to bone marrow cells from six donors, an average of 99.6% (range 99.5-99.8%) of the T cells were killed. Under the same conditions there was little or no reduction in the number of normal haematopoietic progenitors (CFU-GM, CFU-GEMM, CFU-Meg and BFU-E).

Haemorrhagic cystitis in bone marrow transplantation patients: possible increased risk associated with prior busulphan therapy

Following bone marrow transplantation employing conditioning including 'high-dose' cyclophosphamide, 65 patients were studied for the subsequent development of symptomatic haemorrhagic cystitis. There was no protection from the urothelial toxicity of cyclophosphamide metabolites afforded by the concurrent administration of 2-mercaptoethane sodium sulphonate (mesna) if timing errors in administration were made. Other factors which might increase the risk of haemorrhagic cystitis due to cyclophosphamide administration include the prior administration of busulphan to patients with chronic granulocytic leukaemia, in whom the incidence of haemorrhagic cystitis was 36% compared with 4% in all other patients. We have also investigated the use of intravesical prostaglandin E2 as a treatment for haemorrhagic cystitis in eight patients, two of whom appeared to obtain major benefit.

JM, a Thy-ALL cell line produces both inhibitory and stimulatory lymphokines for bone marrow progenitor cells

Normal and malignant T cells as well as T-cell hybridomas have frequently been reported to produce factors which stimulate the growth of committed hemopoietic progenitors. One previous report described a lymphokine produced by a T-cell clone which inhibited hemopoietic progenitor cell proliferation. We now describe the simultaneous production of two activities by a Thy-ALL cell line (JM), a sub-line of Jurkat. Two sets of culture conditions were used: the Fauser & Messner and Iscove's assays. We have been able to separate both inhibitory and stimulatory factors for the growth of multipotent and committed bone marrow progenitors (CFU-GEMM, BFU-E, CFU-E and CFU-GM). The stimulatory factor has an apparent mol. wt of less than 30,000 and the inhibitor an apparent mol. wt of 65-80,000. The growth promoting activity for BFU-E and CFU-GEMM could replace that of phytohemagglutinin stimulated leucocyte conditioned medium (PHA-LCM). We do not know if the production of both activities is due to the malignant phenotype or if there is a normal counterpart to JM that could produce both inhibitory and stimulatory factors.

Graft rejection following HLA matched T-lymphocyte depleted bone marrow transplantation

Bone marrow graft rejection following HLA-matched bone marrow transplantation (BMT) for leukaemia has been a rare problem. However, with the introduction of T-lymphocyte depleted BMT, graft rejection is recognized as a new complication. At the Royal Free Hospital (RFH) in London T-depletion is achieved using two monoclonal antibodies with complement mediated lysis. The methodology was extended to other centres and in total 56 patients have received T-depleted, HLA matched BMT. Twelve of 56 patients have had graft rejection. At the RFH three of 41 (7%) patients have had rejection whereas at collaborating centres nine of 15 (60%) patients have had rejection. We have investigated these rejections in order to identify factor(s) responsible. Rejection was not restricted by patient or donor characteristics, nor disease status. Patient management, chemotherapy conditioning, efficiency of T-depletion, graft versus host disease (GvHD), and infection post BMT, were not consistently implicated. The major difference between the RFH and all other centres was in the radiotherapy (RT) conditioning: The RFH prescribed a single fraction of 7.5 Gy total body irradiation (TBI) whilst collaborating centres gave 10 or 12 Gy fractionated TBI. We conclude that the different incidence of rejection (7% v. 60%) relates primarily to the RT conditioning although the mechanisms(s) of rejection remain unknown. We conclude that where T-depleted BMT is used, compensation by more intensive RT conditioning is required in order to avert graft rejection.

T lymphocyte regeneration after transplantation of T cell depleted allogeneic bone marrow

The regeneration of T cell subsets was studied with double immunofluorescence marker methods in 37 patients who received HLA matched T lymphocyte depleted bone marrow transplants (BMT) as part of the treatment for their haematological disease. A cocktail of anti-pan-T (CD6: MBG6) and anti-suppressor/cytotoxic-T cell (CD8: RFT8) monoclonal antibodies was used with rabbit serum as a source of cytolytic complement to achieve selective T cell lysis. The T8+ cells reached low normal values around 60 days post-transplant and remained within the normal range throughout the study (greater than 150 days). This observation is in contrast to our previously published results in patients who, after receiving BMT without efficient T cell depletion, had increased numbers of circulation T8+ cells from 60 days post-transplant. In the present study Leu-7+, RFT8- cells reached normal values rapidly but the reconstitution of T4+ lymphocytes was slow: low normal levels were reached only around day 150 following BMT. The degree of graft-versus-host disease (GVHD) seemed to be related to the number of residual T cells infused: two of the three patients who received the highest numbers of T cells developed Grade II III; otherwise GVHD was minimal. Among the clinical parameters studied cytomegalovirus (CMV) immune status moderately influenced reconstitution: at 55-90 days post-transplant T8+ cells were present at the upper normal levels in seven out of 15 patients receiving BMT from CMV seronegative donors, but in none of the 16 individuals receiving BMT from seropositive donors. CMV related complications were relatively uncommon. Thus the most significant factor in preventing 'T8+ cell overshoot' and T cell imbalance during regeneration appears to be the depletion of T (including T8+) lymphocytes from marrow. The differences of T8+ cell reconstitution in this and previous studies may reflect a different regeneration pattern from T cell precursors as opposed to inoculated mature T cells.

Virological and serological diagnosis of cytomegalovirus infection in bone marrow allograft recipients

To detect cytomegalovirus (CMV) infections, a total of 1,074 cultures of urine, saliva, or blood were collected weekly from 43 consecutive patients undergoing allogeneic bone marrow transplantation. Twenty-three patients were seronegative before transplant and primary infection occurred in 2 (9%). Twenty patients were initially seropositive and recurrent infections occurred in 5 (25%). Three patients in the recurrent group had proven CMV pneumonitis; viraemia was detected in two recipients, while the third had CMV isolated only from bronchial lavage fluid. The serological response of the 43 patients was defined by testing 559 serial sera for specific IgG and IgM antibodies by radioimmunoassay. Passive acquisition of IgG antibodies from blood products was found in 78% of initially seronegative recipients. One patient with primary infection responded in a pattern typical of immunocompetent individuals with long-term production of specific IgG and transient production of specific IgM antibodies. The second patient also had a typical response, but this was delayed until several weeks after the start of virus excretion. In patients with recurrent infections, specific IgM production did not correlate with episodes of virus excretion. Three of five such patients failed to mount a specific IgM response, and these were the only patients in the study to develop CMV pneumonitis. We conclude that CMV infection in bone marrow recipients can only be diagnosed by detection of virus; therefore, the ability of these patients to mount humoral immune responses should not be relied upon for diagnostic purposes.

The role of monoclonal antibodies in the prevention of graft versus host disease

We have previously reported that the elimination of T-lymphocytes (greater than 99%) from the donor bone marrow prevents significant graft versus host disease (GvHD). This has been confirmed by other centres. Many of these groups have applied monoclonal antibodies with cytolytic rabbit complement. In some of these studies mostly patients with fully matched sibling donors have been studied and no further immunosuppression has been given during the regeneration period. The experience here shows that the haemopoietic regeneration (to recover a total leucocyte count of 1.0 X 10(9)/l) has only been minimally delayed (mean 25 days) when compared to patients receiving standard methotrexate (Mtx) GvHD prophylaxis (22 days). The incidence of cytomegalovirus (CMV) infections (14%; none fatal) was lower than that in our previous 54 patients (43% CMV infections, 13% fatal). Furthermore, no fatal pneumonitis was seen. The regeneration of T-cells in our patients has shown normal values of T8-positive cells in the circulation from 45 to 50 days onwards, as opposed to the previous groups of patients whose T8-positive cells regenerated to 3-4 times higher than normal values. These observations indicate that T-cell depletion with monoclonal antibodies is an effective method for preventing GvHD, but further studies are necessary to investigate the cause(s) of a new occasional complication, the rejection of the newly established bone marrow.

Rapid diagnosis of cytomegalovirus infection in immunocompromised patients by detection of early antigen fluorescent foci

Cell-cultures of cytomegalovirus (CMV) were fixed after 24 hours' incubation and examined by a monoclonal antibody based immunofluorescence method for the detection of CMV-specific early antigens. 385 urine, saliva, or blood samples from 63 immunocompromised patients were inoculated onto cell-cultures. Comparison with the results of conventional cell-cultures in patients who remained uninfected showed that the new technique had a specificity of 100%. The sensitivity was 80%. This immunofluorescence method gave positive results 27h after inoculation of the specimens instead of the mean of 17 X 5 days with the conventional method based on detection of cytopathic effect. 3 saliva samples, from patients who had previously excreted CMV, reacted in the immunofluorescence method but CMV, reacted in the cell-cultures-perhaps because the assay identified defective, interfering particles in these samples. The monoclonal antibodies were also used successfully in another immunofluorescence system to diagnose cytomegalovirus pneumonitis in 3 patients by testing material obtained by bronchoalveolar lavage.

A and B blood group antigen expression on mixed colony cells and erythroid precursors: relevance for human allogeneic bone marrow transplantation

Using anti-A and anti-B blood group monoclonal antibodies and fluorescent activated cell sorting of human bone marrow, A (or B) blood group antigen was shown to be on 5.2 +/- 5.9 (mean +/- SD) % of CFU-GEMM and 12.5 +/- 19.6% of the erythroid burst forming cells (designated BFU-GEMM) as defined by the mixed colony assay, and 49.5 +/- 20% of the BFU-E and 83.5 +/- 9.9% of the CFU-E as defined by the erythroid colony assay. This antigen expression on the BFU-GEMM is consistent with the concept that erythroid bursts stimulated by leucocyte conditioned medium are less mature, and are closer in development to the pluripotent stem cell than the BFU-E. These results help to explain the delayed erythropoiesis, and perhaps impaired engraftment of all cell lineages, that may occur in some recipients of ABO incompatible bone marrow transplants with persistent and high anti-A titres.

Aplastic crisis and other effects of the human parvovirus infection

Human parvovirus infections are common, provoke aplastic crises in patients with congenital haemolytic anaemia and cause fifth disease. An unknown proportion of the infections are subclinical. Parvoviraemia occurs in the early acute stage of infection and specific IgM can be detected during recovery. Most patients commencing an aplastic crisis are viraemic, but fifth disease arises after the viraemia. Serological tests for HPV, available at a small but increasing number of laboratories, will soon be complemented by tests for HPV DNA sequences present in blood, marrow and at other sites. Human parvovirus infection is occasionally fatal in patients with severe forms of congenital haemolytic anaemias and further study may reveal other unusual serious consequences of this ubiquitous infection. Short-term protection of vulnerable patients may be achievable with normal immunoglobulin, but there are still considerable obstacles to the preparation and use of a human parvovirus vaccine.

Allogeneic bone marrow transplantation in a patient with acute myeloid leukemia secondary to Hodgkin's disease

A patient with Hodgkin's disease entered complete clinical remission by combination radiochemotherapy. He developed dyshematopoiesis 1.5 years later and an overt acute nonlymphocytic leukemia 3 years after diagnosis. A complete remission was achieved following 2 courses of intensive polychemotherapy. Four months later, while still in remission, he underwent an allogeneic bone marrow transplantation (BMT) from an HLA-identical sister. Mild chronic graft versus host disease of the skin occurred 3 months after BMT, and now the patient has been in complete remission of leukemia for over 2 years. This appears to be a unique case of prolonged remission of a leukemia secondary to an intensively treated Hodgkin's disease.

Depletion of T lymphocytes in donor marrow prevents significant graft-versus-host disease in matched allogeneic leukaemic marrow transplant recipients

For more than 15 years preclinical studies have suggested that acute graft-versus-host disease (aGvHD) might be prevented by the removal of immunocompetent T lymphocytes from the donor marrow inoculum. To test this observation in man 14 patients were given marrows virtually (greater than 99%) depleted of identifiable donor marrow T lymphocytes by the use of a "cocktail" of specific anti-T-cell monoclonal antibodies (MBG6 and RFT8) and rabbit complement. Patients were not given immunosuppressive prophylaxis after bone-marrow transplantation. Moderate to severe (grades II-IV) GvHD was totally prevented. 2 of 13 evaluable patients showed mild (grade I) skin GvHD only. Although peripheral blood recovery was slower than that obtained with other forms of GvHD prophylaxis, no fatal infections occurred. All patients survived the early post-transplant period.

Allogeneic bone marrow transplantation: the monitoring of granulocyte macrophage colonies following the collection of bone marrow mononuclear cells and after the subsequent in-vitro cytolysis of OKT3 positive lymphocytes

Marrow nucleated cells from eight normal allogeneic donors was layered on Ficoll-Metrizoate to isolate the mononuclear cell fraction. The cells were then washed to remove Ficoll-Metrizoate and coagulation factors prior to resuspension in a balanced salt solution and the addition of the murine anti-human T-lymphocyte monoclonal antibody OKT3 and rabbit complement. The procedures were assessed for their effect on mononuclear cell viability (mean recovery 84.4%); the ability of the cells to proliferate granulocyte-macrophage colonies (mean recovery 57.4%); the in-vitro T-lymphocytolysis (mean 75.7%) and the removal of rabbit complement (greater than 99%). Following marrow transplantation with this treated mononuclear fraction the mean day to recovery of greater than or equal to 1.0 X 10(9)/l leucocytes was 20 d, with three patients developing greater than or equal to Grade II acute graft versus host disease (GvHD). Thus, treatment of donor marrow with OKT3 and complement in a large volume system was not detrimental to subsequent engraftment, nor effective in complete T-lymphocytolysis, nor in prevention of severe GvHD.

A technique for the concentration of nucleated bone marrow cells for in vitro manipulation or cryopreservation using the IBM 2991 blood cell processor

27 bone marrow aspirates were processed on the IBM 2991 Blood Cell Processor to achieve a reduction in volume (greater than 80%) and in red blood cell contamination (greater than 75%), without loss (less than 20%) of nucleated cells. The procedure was used to concentrate nucleated bone marrow cells either prior to cryopreservation for subsequent autologous transplantation, or prior to incubation with a murine monoclonal antibody (OKT3) for allogeneic transplantation. We conclude that the procedures used for the concentration, cryopreservation, thawing and infusion do not adversely affect the viability of cells as assessed by in vitro culture (CFU-GM). Of the marrows processed, 12 have been reinfused and resulted in successful engraftment.

Acyclovir prophylaxis against herpes virus infections in severely immunocompromised patients: randomised double blind trial

Twenty patients undergoing allogeneic bone marrow transplantation and 39 patients receiving remission induction chemotherapy for acute leukaemia were entered into a double blind, placebo controlled stratified trial of acyclovir prophylaxis against herpes group virus infections. Within the transplant group intravenous acyclovir 5 mg/kg twice daily given throughout the period of granulocytopenia completely prevented oropharyngeal herpes simplex virus infection compared with a 50% incidence in the placebo arm (p = 0.033). The acyclovir group also had fewer days of fever during the trial and a shorter duration of leukopenia, possibly because of the prevention of herpes simplex virus infections. There was a high incidence of herpes infections after the trial in patients who received either acyclovir or placebo. In the non-transplant group there was also a significant reduction of herpes simplex virus infection in the oropharynx and oesophagus (two out of 19 patients as compared with 10 out of 20; p = 0.018). Herpes simplex virus was isolated in the acyclovir arm within a day after starting the trial in one patient, and the other failure was due to a virus with reduced sensitivity to acyclovir in a patient who had had several previous courses of the drug. The incidence of herpes infections after stopping treatment was low. The influence of acyclovir on excretion of Epstein-Barr virus in saliva in either group was inconclusive. One patient (transplant group) developed a cytomegalovirus infection while receiving acyclovir. Acyclovir provides effective prophylaxis against oropharyngeal and oesophageal herpes simplex virus infection in severely immunocompromised seropositive (greater than or equal to 1/8) patients. In patients given bone marrow transplants this may have the additional benefit of reducing the time to recovery of an adequate blood count and the number of days of fever.

Surface antigenic determinants on human pluripotent and unipotent hematopoietic progenitor cells

RFB-1 is a monoclonal antibody previously shown to react with granulocyte-monocyte progenitors (CFU-GM) and immature lymphoid cells in human bone marrow. RFB-HLA-DR is a monoclonal antibody that reacts with HLA-DR (la-like) antigens. The present study shows that the bone marrow subset reactive with both RFB-1 and RFB-HLA-DR contains all the cells that give rise to mixed hematopoietic colonies (derived from CFU-GEMM; a pluripotent human progenitor cell) as well as to megakaryocytic (megakaryocyte-CFU-derived) and erythropoietic (derived from erythroid burst-forming units, BFU-E) colonies, as shown by fluorescence-activated cell sorting and complement-mediated cytotoxicity. These results indicate that CFU-GEMM, BFU-E, and megakaryocyte-CFU express RFB-1 and la-like antigens. RFB-1 antigen is also expressed on erythroid colony-forming units (CFU-E). RFB-1 and RFB-HLA-DR are useful reagents in the study of hematopoietic stem cells.

Absence of close linkage between Hereditary spherocytosis (SPH) and 24 genetic marker systems including HLA and GM

A total of 250 individuals belonging to 19 different families, identified through established propositi were simultaneously screened for hereditary spherocytosis (SPH), using stringent criteria, and 27 well-known polymorphic genetic marker systems. The segregation analysis indicated that the pattern of inheritance of SPH in these families, being autosomal and dominant, had a 100% penetrance. A statistical analysis, using the LIPED computer program of Ott (1974), revealed the absence of close linkage between SPH and ABO, ACP1, ADA, AK1, C3, DIA2, ESD, FY, GC, GLO1, GM, GPT1, HLA, HPA, JK, K, KM, MNS, P, PGD, PGM1, PGP, PI, and RH. Since an earlier study by other investigators had convincingly suggested a linkage between SPH and GM, we subjected the data to further analysis and found no significant heterogeneity in our recombination values of linkage between SPH and GM, or any of the other informative loci.

ABO-incompatible bone-marrow transplantation: removal of red blood cells from donor marrow avoiding recipient antibody depletion

Eight patients with acute leukaemia undergoing allogeneic bone-marrow transplantation from ABO-incompatible donors received red-cell-depleted donor marrow without any procedure to diminish their anti-ABO antibody titres. Successful marrow red-cell removal (mean 98.8%) was achieved by means of a large-volume separation technique on Ficoll-Metrizoate in the IBM 2991 blood-cell processor. Clinically significant ABO-haemolytic reaction was prevented in all patients, and there was neither failure of engraftment nor rejection. This approach used alone is satisfactory for most ABO-incompatible marrow-transplant recipients, although combining this with some method of recipient antibody depletion, such as plasma exchange, is recommended in the occasional patient with high anti-ABO titres.

Ketoconazole versus nystatin plus amphotericin B for fungal prophylaxis in severely immunocompromised patients

72 patients severely immunocompromised by their underlying disease (marrow aplasia, acute leukaemia, or solid tumour) or by the treatment they were receiving, or both, were randomised to receive antifungal prophylaxis with either oral ketoconazole or conventional doses of oral amphotericin B and nystatin. All patients also had gut decontamination with non-absorbable antibiotics, skin antisepsis, sterile food, and oral cotrimoxazole. Protection against fungal infection was significantly superior with ketaconazole. When patients who had received allogeneic bone-marrow transplant were studied separately, there was no significant difference between the two treatments, probably because there was a fall-off in ketoconazole absorption from the end of the third week after the transplant. However, ketoconazole greatly reduced the likelihood of fungal infection in non-transplant patients.

A technique for rapid isolation of bone marrow mononuclear cells using Ficoll-Metrizoate and the IBM 2991 blood cell processor

Marrow from seven normal donors and patients has been layered onto Ficoll-Metrizoate (FM) under pressure in the IBM 2991 blood cell processor to isolate the mononuclear cell (MNC) population prior to allogeneic transplantation or cryopreservation. This separation method, which takes less than 90 min, is a further development since our previous report detailing the use of the IBM 2991 to produce a concentrated marrow 'buffy coat' for infusion (Gilmore & Prentice, 1981). By adding FM to the system, marrow stem cells are further concentrated in a small volume with removal of unwanted granulocytes and red blood cells. This facilitates in in vitro treatment of marrow with monoclonal antibodies (Granger et al. 1982) or drugs, for either the selective elimination of malignant cells prior to autologous bone marrow transplantation (BMT), or T lymphocytes in an attempt to prevent graft versus host disease (GvHD) in allogeneic BMT. Five of the seven marrows processed by this procedure have thus far been infused into lethally irradiated recipients with engraftment (allogeneic); the other two marrows have been cryopreserved.

Use of anti-T-cell monoclonal antibody OKT3 to prevent acute graft-versus-host disease in allogeneic bone-marrow transplantation for acute leukaemia

Seventeen patients who received allogeneic bone-marrow transplants from matched or slightly mismatched (in four patients) siblings were observed for at least 60 days or until acute graft-versus-host disease (GvHD) developed. All donor marrows after preliminary manipulation were incubated with 1 mg of the murine monoclonal antibody OKT3 before infusion in an attempt to deplete them of immunocompetent T lymphocytes (opsonisation). In three of the seventeen patients acute GvHD of grade II or greater developed. Two of these patients died, but they had disseminated cytomegalovirus infection as well as GvHD. Eleven patients showed no evidence of acute GvHD, and four had transient limited skin rashes (grade I GvHD). Opsonisation of T lymphocytes has reduced the incidence of severe acute GvHD in this unit from 79% in an earlier group of 14 patients to 18% when added to prophylactic methotrexate.

Plasma exchange in Goodpasture's syndrome

The clinical course and levels of anti-glomerular basement membrane (GBM) antibody were compared in 20 patients with Goodpasture's syndrome treated with plasma exchange and immunosuppression (8 patients), immunosuppression alone (4 patients) or no specific therapy (8 patients). There was a more rapid fall in the level of anti-GBM antibody and pulmonary hemorrhage was less protracted in the 8 patients treated with plasma exchange and immunosuppression. In this group, 1 patient who presented with severe renal failure showed a marked improvement of renal function and there was no progression of disease in the 4 with milder renal involvement. 2 of the 4 patients treated with immunosuppression alone, and only 2 of the 8 patients who received no specific therapy, maintained normal renal function. In the group which received no specific therapy, 1 of the 6 patients who progressed to renal failure had mild renal involvement initially. There was a significant correlation between the level of anti-GBM antibody and the severity of the morphological changes seen at renal biopsy but not between the level of anti-GBM antibody and the severity of lung hemorrhage. The course and outcome of the disease in those patients not treated, or treated with immunosuppression alone, was better than that described in early reports of this disease, while those patients with plasma exchange and immunosuppression fared even better. An adequately stratified controlled trial of immunosuppression and plasma exchange versus immunosuppression alone is in order.

Serological complications of a major ABO incompatible bone marrow transplantation in a Polynesian with aplastic anemia

A 24-year-old, blood-group O Polynesian woman with multiple red blood cell antibodies received a group A, HLA-compatible, sex-matched bone marrow transplantation as treatment for severe aplastic anemia. High retransplantation titers of ABO isohemagglutinins were successfully reduced by repeated plasmaphereses. Despite gross in vitro incompatibility in the routine crossmatch, technetium-labelled red blood cell survival studies performed immediately prior to transplantation predicted that a small proportion of the donor erythrocytes would neutralize residual postplasmapheresis isoantibody. Donor marrow was subsequently infused without significant hemolysis. Although anti-A titers were low immediately posttransplantation, these rose progressively, approaching pretransplantation levels at the time of documented marrow engraftment at day 18. One week later the bone marrow graft was rejected. Retransplantation was successfully performed using marrow from an ABO compatible, sex-mismatched sibling donor. Radioisotopic studies were helpful in evaluating donor-recipient red blood cell incompatibility during the ABO incompatible transplantation, and again at retransplantation in the presence of circulating isoantibody to donor red blood cells. High levels of ABO isoagglutinins prior to plasmapheresis and rapidly rising titers posttransplantation may have predicted bone marrow graft rejection in this patient.

Improved survival from acute lymphoblastic leukemia in adolescents and adults

Nineteen adult patients with acute lymphoblastic leukemia were treated with combination chemotherapy to induce remission in the period from 1971 to 1979. Those patients achieving remission received intensive post-remission therapy with central nervous system (CNS) prophylaxis, followed by two-drug maintenance therapy, and reinduction courses of chemotherapy every six months. Remissions were achieved in 17 of the 19 patients (89%). Twelve patients (63%) are alive, 11 currently in complete remission. Two patients who experienced relapses in recent months have successfully undergone transplantation with allogeneic marrow from sex-matched, HLA-compatible sibling donors. The median survival and median duration rates of first remissions have not yet been reached, but to date are 36+ months and 29+ months, respectively with a predicted five-year survival rate of 61%. These results not only are significantly better than those achieved in the years 1968 to 1971 in our institution, but also are superior to others reported in the world medical literature. The combination of optimal treatment protocols with allogeneic marrow transplantation for patients with poor prognoses is expected to improve the survival of adult patients even further in the next decade.

Serum ferritin in patients with hereditary spherocytosis

Serum ferritin was measured in 61 patients with autosomal dominant hereditary spherocytosis (HS), 44 splenectomized and 17 with intact spleens. In the majority (78%) the serum ferritin concentration was not elevated. Thirteen (22%) had midly elevated levels, including five splenectomized females (range 181--236 microgram/l), and eight males, two with intact spleens (range 236--436 microgram/l). The serum ferritin was not raised in 15 of the 17 non-splenectomized individuals. This group included one female who had been venesected for iron overload and further investigations have shown that both the genes for HS and haemochromatosis are present in her family. These results demonstrate that iron stores are usually normal in HS, and that prevention of iron overload alone is not an indication for splenectomy. The rare report of a patient with HS and severe iron overload may perhaps be explained by the fact that the gene frequency for haemochromatosis is common in the population.

Comparison of 7 and 12 day bone marrow CFUc culture in adult acute non lymphoblastic leukaemia

Bone marrows from 17 patients with acute nonlymphoblastic leukaemia (ANLL) were serially cultured on semisolid agar during periods of intensive remission induction chemotherapy and during remission. Of 12 patients achieving remission, six showed recovery of 7 and 12 day colony forming units (CFUc) culture to normal. However, in four of the six patients, recovery was short-lived with reappearance of typically leukaemic culture patterns while still in remission by bone marrow and peripheral blood criteria. In individual patients, serial 7 day cultures frequently showed persisting or recurring leukaemia-associated patterns while 12 day cultures were normal. This study confirms the heterogeneity observed in the cultural characteristics of the CFUc in acute non lymphoblastic leukaemia. Bone marrow cultures in patients with ANLL following intensive remission induction chemotherapy appear to provide a more reliable indication of persisting leukaemia or early relapse if they are interpreted earlier at 7 days.

Therapeutic plasmapheresis by continuous flow cnetrifugation

This report reviews the experience at Auckland Hospital with continuous flow centrifugation as a mean of carrying out therapeutic plasmapheresis. Over a three year period from August 1975, 26 patients, most with dysproteinaemias or Goodpasture's syndrome, were treated with a total of 260 therapeutic procedures.

Use of modified subcutaneous right-atrial catheter for venous access in leukaemic patients

A large-diameter indwelling subcutaneous right-atrial catheter was inserted in 25 patients with haematological malignancies and neutropenia to provide ready access to the venous system for all infusions and blood aspirations. The median duration of catheter placement was 70 days. In 23 patients (92%) the catheter was used successfully until remission or death. Catheter-related exit-site infectons, generally mild, occurred in 14 patients (56%), Staphylococcus epidermidis being the predominant organism cultured. Septicaemia occurred in 11 neutropenic patients (44%). In 2 patients the same organism was grown from blood and exit site. The use of this catheter greatly facilitates patient care and support, minimises discomfort, and is associated with an acceptable rate of complications.

Control of thrombocytosis by plateletpheresis using a cell separator

Three patients with marked thrombocythaemia secondary to myeloproliferative disorders were treated with plateletpheresis using an Aminco cell separator and myelosuppressive agents. Immediate control of the raised platelet count was achieved by plateletpheresis and long-term control by the concomitant cytotoxic therapy. The indications for plateletpheresis in patients with marked thrombocytosis are discussed.

Bone marrow transplantation in a child with acute lymphoblastic leukaemia

A caucasian female infant with acute lymphoblastic leukaemia in second remission received a bone marrow transplantation. Engraftment was confirmed at 14 days following infusion of bone marrow from a sex-matched, ABO and HLA compatible sibling. 171 days posttransplantation the patient is clinically well and in haematological remission. A mild transient skin rash and hepatocellular disturbance, the only manifestations of graft versus host disease, responded successfully to high dose prednisone.

The survival of cryopreserved human bone marrow stem cells

Two methods for cryopreservation of bone marrow stem cells were compared using bone marrow obtained from 36 patients. Included in this group were 21 persons with the diagnosis of leukaemia including 14 either with acute myeloid or lymphoblastic leukaemia in remission following intensive remission induction chemotherapy. After freeze-preservation and reconstitution, all marrow samples were tested for nucleated cell (NC) recovery and grown on agar to assess colony forming units (CFUC) and cluster forming units in culture (CluFUc). A slow dilution reconstitution method using freezing media containing AB negative plasma resulted in recovery of 85% of the CFUc activity of fresh marrow. This result was significantly better than the 47% CFUc recovery obtained when freezing media without plasma and a rapid dilution reconstitution technique were used. NC recoveries following slow dilution (51%) and rapid dilution (44%) were not significantly different. CluFUc were disproportionately reduced compared with CFUc although yielding similar results with both methods (26% and 32%). No correlation was found for either method between CFUc and NC recovery or between CFUc and CluFUc recovery in cryopreserved bone marrow.