Search

JACIE was initiated as a small pilot project in Spain in 2000 and launched as a formal Europe-wide inspection program in January 2004. Since 2000, over 150 applications for accreditation have been received by the JACIE Office and more than 130 inspections have been completed in European centers and facilities. Almost all of these were found to be functioning at a high level of excellence, with the majority having only minor deficiencies in compliance with the standards. In one-third of centers there were more significant deficiencies. The most common deficiencies were in quality management. Following correction of deficiencies 86 centers have to date achieved full accreditation and many more are nearing the completion of the process. Implementation of JACIE involves a significant investment of time and resources by applicant centers. The majority require at least 18 months to prepare for accreditation and 85% have needed to employ a quality manager and/or data manager on an ongoing basis. However, all centers felt their program had benefited from the implementation of JACIE. JACIE is also working closely with other international organisations related to cellular therapy as part of the Alliance for the Harmonisation of Cell Therapy Accreditation (AHCTA), which is examining the differences in existing standards and aiming to develop international standards for all aspects of stem cell transplantation. In particular the requirements for safety of imported tissues and cells has emphasised the need for global harmonisation. The recent implementation of Directive 2004/23/EC and the associated Commission Directives 2006/1 7/EC and 2006/86/EC has provided an impetus for the implementation of JACIE in European Union (EU) member states. It will be important in the future to examine how JACIE can co-operate with the EU Competent Authorities (CA) to ease the burden of the inspection process for haemopoietic stem cell (HSC) transplant programs.

JACIE (Joint Accreditation Committee of the ISCT and the EBMT) launched its first official inspection programme in January 2004. Since then, 35 centres in Europe have been inspected. Almost all were found to be functioning at a high level of excellence, with the majority having only minor deficiencies in compliance with the standards. In one-third of centres there were more significant deficiencies. The most common deficiencies were in quality management, and a survey of the applicant centres confirmed this was the area where centres experienced most difficulty in preparation for accreditation. Following correction of deficiencies, 28 centres have at the time of writing achieved full accreditation. Implementation of JACIE required a significant investment of time and resources by applicant centres. The majority required at least 18 months to prepare for accreditation and 85% needed to employ a quality manager and/or data manager on an ongoing basis. However, all centres felt their programme had benefited from the implementation of JACIE. In addition to the inspection and accreditation of individual centres, JACIE maintains an educational programme including training courses for inspectors and for centre preparation. JACIE is also working closely with other international organisations working in cellular therapy to develop international standards for all aspects of stem cell transplant. The recent implementation of Directive 2004/23/EC has provided an impetus for the implementation of JACIE in EU member states and in particular the requirements for safety of imported tissues and cells have emphasised the need for global harmonisation.

In 2001, guidelines for the diagnosis and management of myeloma were published by the Guidelines Working Group of the UK Myeloma Forum (UKMF) on behalf of the British Committee for Standards in Haematology (BCSH) (UK Myeloma Forum; British Committee for Standards in Haematology, 2001). That same year, the second edition of guidelines prepared by the Nordic Myeloma Study Group (NMSG) in 1995 was issued (in the Scandinavian languages; http:// www.myeloma-nordic.org). As both sets of guidelines were intended to be evidence based, it was reassuring to note that the recommendations were similar. Subsequently, informal contact between members of the two groups led to the decision to prepare these common, updated guidelines. These revised and updated guidelines include new sections on imaging and the management of skeletal disease, cover new developments in disease classification and staging and the use of new therapeutic approaches, such as thalidomide, bortezomib and reduced-intensity allogeneic transplantation. The guidelines are presented in specific sections as follows

Autologous (ASCT) and allogeneic stem cell transplantations (alloBMT) are well-established therapies for multiple myeloma. However, patients continue to relapse at a constant rate. We present here 15 out of 163 patients who underwent SCT and relapsed with plasmacytomas only without evidence of bone marrow disease progression (14/147 post-ASCT and 1/16 post-alloBMT). The median time from SCT to plasmacytoma relapse was 24 months. The sites of plasmacytoma included bone, skin, rectum, and testicles. Five patients were treated with local radiotherapy, while seven patients received a combination of radiotherapy and chemotherapy or thalidomide, and two patients received chemotherapy alone with or without thalidomide. The recipient of alloBMT was initially treated with VAD-chemotherapy and local radiotherapy followed by a mini-allograft from the original donor. Eleven patients died at a median of 10 months following diagnosis of the plasmacytoma. Four are still alive, 12-20 months post-plasmacytoma diagnosis. These cases of unconventional disease recurrence are likely to be seen due to sub-clinical seeding of tumour cells suggestive of the presence of an extramedullary (EM) clone of plasma cells with a high degree of chemoresistance. We also review all the available data in the literature for the optimal therapy for patients with isolated EM relapse.

Most patients with plasma cell neoplasia have generalized disease at diagnosis, i.e. multiple myeloma (MM). However, a minority (

High-dose therapy with autologous stem cell transplantation (ASCT) has become the treatment of choice for symptomatic eligible patients with multiple myeloma (MM). We report our centre experience and analyse retrospectively the prognostic influence of pretransplant characteristics and transplant modalities on response and survival. A total of 127 MM patients (median age: 55.2 years) were transplanted between 1994 and 2001. In all, 69 patients had IgG, 28 IgA, 23 light chain, one IgD and six non secretory MM. At the time of autograft, 6% of patients were in complete remission (CR), 73% in partial remission (PR), 12% showed minor response to previous treatment and 9% had stable or refractory disease. Prior to autograft, 79% of cases had received only one line of chemotherapy and 21% two or more lines. All patients received PBSC support after conditioning with 200 mg/m(2) melphalan alone (100 patients) or melphalan and TBI (27 patients). We evaluated the influence of age (using as cutoff value the ages of 55, 60 and 65 years), type of MM, status pre- and post-ASCT, number of lines of previous regimens, time of ASCT from diagnosis, year of autograft, dose of reinfused CD34+ cells, plasma cell infiltration and beta(2)-microglobulin at diagnosis on overall (OS) and progression-free survivals (PFS) to define patients with better prognosis. Following ASCT, 15% of patients were in CR and 81% in PR, while only two patients progressed. Median OS and PFS from transplantation were 50.4 and 23.5 months, respectively. Median OS from diagnosis was 79.7 months. Transplant-related mortality was 2.3%. Low levels of beta(2)-microglobulin and the achievement of CR post-transplant correlated with longer PFS (P

We report the results of a non-randomized pilot study of an oral regimen comprising CCNU (lomustine; 25 or 50 mg/m2 on day 1), idarubicin (4-demethoxydaunorubicin) (10 mg/m2 on days 1-3) and dexamethasone (10 mg b.d. on days 1-4) in patients with relapsed or refractory myeloma. Treatment was given every 28 d for a maximum of six courses. Sixty patients were entered of whom 57 were evaluable. Overall response rate (partial or minor response) was 49% with 30% of patients achieving a partial response (50% tumour reduction). Response rates were higher in patients with untested relapse than in those with refractory disease (overall response rates 56% vs. 31%). The major toxicity was neutropenia and the regimen was otherwise well tolerated. The median survival from entry of all patients was 15 months, with 30% of patients alive at 2 years. This regimen represents a useful addition to available treatment options.

Cell lines RPMI 8226, JJN3, U266 B1, NCI-H929 (all EBV-) and ARH77 and HS-Sultan (both EBV+) have been extensively characterized in this study. EBV- lines expressed the phenotype (CD138-, CD19+, CD20+) whereas EBV+ were (CD138+, CD19-, CD20-). CD56 expression was restricted to EBV- cell lines, with the exception of U266 B1, whereas PCA-1 was strongly expressed on five of the six cell lines. Only EBV+ cell lines bound peanut-agglutinin (PNA). However, all cell lines bound the lectin Jacalin that binds the same receptor as PNA, irrespective of the receptors sialylation status. By RT-PCR and direct sequencing of their IgH V/D/J domains, ARH77 was demonstrated to use the germline sequence VH4-34/dm1/JH6b, whereas no arrangement was demonstrated for RPMI 8226, suggesting IgH gene deletion or mutation. HLA class I and II antigens were detected using HLA typing on all cell lines warranting their use as suitable targets for HLA-restricted cytotoxic T cells. By sensitive RT-PCR, mRNA for IL-6, IL-6R and TNFbeta was found expressed in all cell lines. IL-1 mRNA expression was predominantly associated with the EBV+ phenotype. Although mRNA for IL-3 and GM-CSF was never detected, transcripts for c-kit ligand and, more commonly, its receptor were. Likewise GM-CSF, M-CSF and erythropoietin mRNA transcripts were detected in the majority of cell lines.

Thirty-six patients with multiple myeloma (23 PR1, nine PR2, four stable disease) were entered into a pilot study evaluating the use of CD34+-selected peripheral blood progenitor cell transplantation (PBPCT) following high-dose melphalan alone or high-dose melphalan and total body irradiation. Peripheral blood progenitor cells (PBPCs) were mobilized with cyclophosphamide and granulocyte colony stimulating factor (G-CSF). CD34+ selection using the Cellpro Ceprate-SC system was performed in 22 cases with an adequate yield in 20. 10 patients failed to mobilize sufficient cells to permit selection and in four cases selection was not performed for other reasons. 16 patients therefore received unselected PBPC. Tumour cell contamination was evaluated by IgH gene fingerprinting (fpPCR). Harvested PBPC were fpPCR positive in 13/20 CD34+-selected cases and remained positive after selection in seven. Harvested PBPC were studied in 9/16 patients receiving unselected cells; fpPCR was positive in five and negative in four. There was no difference in event-free survival (EFS) between the CD34+-selected group and the unselected group (median 21 and 26 months, respectively, P=ns). The CD34+-selection process therefore reduced contamination but did not eliminate it completely, and in this small non-randomized study there was no apparent clinical benefit of CD34+selection.

Autologous bone marrow- and blood progenitor cell transplantation was performed in 130 patients with multiple myeloma in 16 European centers between 1986 and 1993. At the time of follow-up, 77 patients were alive and 53 were dead. Complete remission after transplantation was obtained in 47% of all patients. The actuarial survival at 65 months was 28%. The median duration of relapse-free survival among patients who were in complete remission after transplantation was 29 months. The following factors were predictive for longer survival and freedom of progression in a univariate analysis: Male sex, age less than 45 years, a low serum-beta-2-microglobulin value at diagnosis, prior administration of only one treatment regimen, response on conventional chemotherapy immediately pretransplant and the use of a preparative regimen including melphalan. The last factor, in addition to stage I disease at diagnosis, male sex and responsive disease immediately pretransplant, were also demonstrated as independent predictive variables for longer survival in a multivariate analysis. Progression-free survival was significantly better for patients who were in complete remission after transplantation, as compared to those with persisting signs of disease. We conclude that high-dose chemo-radiotherapy with autologous stem cell transplantation can induce long-term responses, primarily in younger, male patients with chemotherapy-responsive early disease. High-dose melphalan, as single drug or in combination, appeared to be superior to other regimens. The chance of being persistently disease-free seemed to be greatest for patients being in complete remission already before the transplantation.

JACIE was initiated as a small pilot project in Spain in 2000 and launched as a formal Europe-wide inspection program in January 2004. Since 2000, over 150 applications for accreditation have been received by the JACIE Office and more than 130 inspections have been completed in European centers and facilities. Almost all of these were found to be functioning at a high level of excellence, with the majority having only minor deficiencies in compliance with the standards. In one-third of centers there were more significant deficiencies. The most common deficiencies were in quality management. Following correction of deficiencies 86 centers have to date achieved full accreditation and many more are nearing the completion of the process. Implementation of JACIE involves a significant investment of time and resources by applicant centers. The majority require at least 18 months to prepare for accreditation and 85% have needed to employ a quality manager and/or data manager on an ongoing basis. However, all centers felt their program had benefited from the implementation of JACIE. JACIE is also working closely with other international organisations related to cellular therapy as part of the Alliance for the Harmonisation of Cell Therapy Accreditation (AHCTA), which is examining the differences in existing standards and aiming to develop international standards for all aspects of stem cell transplantation. In particular the requirements for safety of imported tissues and cells has emphasised the need for global harmonisation. The recent implementation of Directive 2004/23/EC and the associated Commission Directives 2006/17/EC and 2006/86/EC has provided an impetus for the implementation of JACIE in European Union (EU) member states. It will be important in the future to examine how JACIE can co-operate with the EU Competent Authorities (CA) to ease the burden of the inspection process for haemopoietic stem cell (HSC) transplant programs.

The projected outcome of allogeneic BMT for myeloma based on the EBMT data is as follows: for patients transplanted after first line therapy there is a 30% risk of transplant related death, a 55% chance of being alive at 5 years and a 35% chance of being alive in complete remission at 5 years. If BMT is performed later in the course of the disease, the risk of transplant related death is increased and the chance of long term relapse-free survival correspondingly reduced. Conversely, ABMT has a low mortality risk, but there is currently no evidence that ABMT using unpurged marrow can produce long term cure as no series has shown any evidence of a plateau in remission duration. The early results of maintenance interferon are encouraging but longer follow-up is needed to determine whether the proportion of patients in continuing remission at 5 years will approach that seen after allogeneic BMT. Early results of peripheral blood stem cell transplantation are also encouraging but longer follow-up is required. It remains extremely important when comparing results of ABMT with chemotherapy alone to compare similar patient groups, bearing in mind that patients who have autologous transplantation in first response are by definition responders with good performance status and without significant renal failure. In order to address this problem in a prospective manner, a randomised study has been planned by the EORTC in collaboration with the EBMT. In this study, patients with adequate renal function will be randomised at diagnosis to chemotherapy followed by either autologous BMT or continuing chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is a recognized treatment option for patients with relapsed Hodgkin's lymphoma. We have analysed 67 patients who underwent ASCT after LACE (lomustine (CCNU), cytarabine (Ara-C), cyclophosphamide, etoposide) conditioning for relapsed (n=61) or primary refractory (n=6) Hodgkin's lymphoma. The 100-day treatment-related mortality was 3%. With a median follow-up of 67 months (range 3.3-161.0) the probabilities of overall survival (OS) and progression-free survival (PFS) at 5 years were 68 and 64%, respectively. Probabilities for OS and PFS at 5 years for patients with chemosensitive relapse (n=40) were 81 and 78% versus 50 and 35%, respectively, for patients (n=27) with chemoresistant relapse (P=0.012 for OS, P=0.002 for PFS). In multivariate analysis mixed cellularity classical or lymphocyte-depleted classical histology subtype and haemoglobin level of 10 g/dl or less at the time of ASCT were identified as risk factors for worse OS, whereas stage III or IV disease at diagnosis and disease status at ASCT other than complete or partial remission predicted inferior PFS. LACE followed by ASCT is an effective treatment for the majority of patients with chemosensitive relapsed Hodgkin's lymphoma and a proportion of chemorefractory patients also benefit.

High-dose therapy with autologous stem cell therapy (ASCT) has become the treatment of choice for eligible patients with myeloma. We analysed retrospectively the prognostic influence of pre-transplant characteristics and transplant modalities on response and survival in 211 myeloma patients who were transplanted in our centre between 1994 and 2004. All patients received peripheral blood stem cell support after conditioning with melphalan alone (183 patients), or melphalan and total blood irradiation (28 patients). We evaluated the influence of age, type of multiple myeloma, status prior and post ASCT, previous treatment regimens, time of ASCT from diagnosis, year of autograft, dose of re-infused CD34(+) cells, plasma cell infiltration and beta2-microglobulin at diagnosis on overall survival (OS) and event-free survival (EFS) to define patients with better prognosis. Median OS and EFS from transplantation were 50.9 and 20.1 months, respectively. Median OS from diagnosis was 68.8 months. Transplant-related mortality was 1.4%. Lower beta2-microglobulin levels, achievement of complete remission (CR) post transplant and lower plasma cell infiltration at diagnosis and transplant correlated with longer EFS and OS, whereas CR at transplant and low international prognostic index at transplant correlated with better EFS. Higher CD34(+) cell dose correlated with improved OS. We conclude that ASCT is safe and effective and the outcome is independent of age, time from diagnosis, previous treatment and conditioning regimen.

Part 1. History of multiple myeloma Epidemiology and etiology of plasma cell neoplasms Part 2. The immune system in myeloma Molecular biology and cytogenetics Biology of the malignant plasma cell Pathophysiology of myeloma bone disease Part 3. Clinical features Hematologic investigations: Morphologic and phenotypic Part 4. Biochemical and immunological investigations The role of imaging in multiple myeloma Innovative approaches for diagnosis and monitoring Differential diagnosis and prognosis Part 5. Principles of management Chemotherapy, steroids and interferon Radiotherapy Autologous stem cell transplantation Allogeneic transplantation and treatment with donor lymphocytes Supportive care Biological basis of therapy: New molecular targets Immunotherapeutic approaches Part 6. Management of bone disease Management of myeloma patients with renal failure Neurologic aspects of monoclonal gammopathy of undetermined significance, multiple myeloma, and related disorders Part 7. Monoclonal gammopathies of undetermined significance: the transition from MGUS to myeloma Solitary bone and extramedullary plasmacytoma Plasma cell leukaemia AL amyloidosis Heavy-chain diseases Waldenstroma (TM)s disease

Patients in complete clinical remission after myeloablative allogeneic stem cell transplantation (allo-SCT) were enrolled in a longitudinal study to assess the predictive value of molecular monitoring. Using polymerase chain reaction (PCR) for immunoglobulin gene rearrangements it was possible to generate a clone-specific molecular marker in 48 of 70 patients. Of these 48 patients, 16 (33%) attained durable PCR-negativity after transplantation, whereas 13 (27%) remained persistently PCR-positive and 19 (40%) showed a mixed pattern. The cumulative risk of relapse at 5 years was 0% for PCR-negative patients, 33% for PCR-mixed patients, and 100% for PCR-positive patients. Within the group studied it was not possible to identify any clinical feature predictive of durable PCR-negativity. We believe that these findings could prompt the design of prospective studies to evaluate if the treatment of molecular disease can extend remission duration and survival.

Would like to report four young patients with MDS in whom vasculitis was the presenting feature. Clinical and haematological features at presentation to hospital are summarised

Enhanced bone resorption is a characteristic finding in multiple myeloma (MM). The aim of this study was to assess the newer biochemical bone markers in patients with myeloma. We studied 17 MM patients—10 males (3 untreated, 5 in remission, 2 responding), 7 females (3 in remission, 4 responding) and 15 normal controls. Serum bone specific alkaline phosphatase (BSALP), osteocalcin (OC) and procollagen type 1 C-terminal peptide (PICP) were determined as markers of bone formation, while serum tartrate resistant acid phosphatase (TRAP), urinary deoxypyridinoline (Dpyr) and calcium (Ca) were determined as markers of bone resorption and the ratio of the levels of bone formation/resorption were determined. All markers were measured by enzyme immunoassays (Metra Biosystems), except for TRAP by an in-house enzymatic assay and Ca by the cresolphthalein method. The Dpyr and Ca were expressed as a ratio to urinary creatinine (Cr) excretion. There were significantly higher (i) (Dpyr/Cr)/PICP ratio in male MM patients than in controls (P < 0.05); (ii) (a) urinary Dpyr excretion (P < 0.001), (b) (Dpyr/Cr)/BSALP ratio (P < 0.0001) and (c) (Dpyr/Cr)/PICP (P < 0.0001) in the untreated male MM subgroup than controls; (iii) (Dpyr/Cr)/BSALP ratio (P < 0.05) in the untreated than in the responding male MM subgroup, (iv) (Dpyr/Cr)/PICP ratio (P < 0.05) in untreated male patients than in those in the remission subgroup. In conclusion, (a) Dpyr is a sensitive marker in assessment of bone resorption in MM patients; (b) (Dpyr/Cr)/BSALP or (Dpyr/Cr)/PICP ratio is even more sensitive in distinguishing the untreated from the other MM subgroups and controls. Therefore, the use of a combination of these markers may have a potential role in the management of patients with MM.

Analysis of prognostic factors has been made in 369 allogeneic transplants for multiple myeloma reported to the registry of the European Group for Blood and Bone Marrow Transplantation (EBMT). Favorable prognostic factors for obtaining a complete remission (CR) were stage I at diagnosis (CR 77%), one line of treatment before conditioning (CR 52%), CR before conditioning (CR 60%), and Ig A or light chain myeloma (CR 43% and 42%). Factors that predicted significantly for favorable survival in a univariate analysis included having received only one line of treatment, female sex, stage I at diagnosis, stage I at conditioning and a β2-Microglobulin less than 4 mg/l. Favorable post-BMT factors consisted of obtaining a CR following BMT and not being in graft-versus-host disease stage III or IV. A multivariate analysis of pre-BMT factors showed that the sex of the patient and the number of lines of treatment pretransplant were independent prognostic factors. Allogeneic BMT is a promising treatment method for patients who have received only one line of treatment, particularly if they are of the female sex. BMT late in the course of the disease is usually unsuccessful.

Aplastic anaemia is characterized by multilineage bone marrow failure resulting in pancytopenia. We have successfully treated a young woman with severe aplastic anaemia (SAA) who was resistant to antilymphocyte globulin (ALG) and corticosteroids, with a combination therapy consisting of erythropoietin, cyclosporin A and granulocyte-colony stimulating factor (G-CSF). The patient received erythropoietin and CSA for a period of 10 months without success before G-CSF treatment was started. After 6 weeks of G-CSF therapy she responded with a sustained trilineage recovery. This suggests that immunosuppression together with haemopoietic growth factors may be an effective treatment in patients with SAA who are ALG resistant and cannot be treated by BMT.

CD34+ selection of peripheral blood progenitor cells (PBPC) was used in Multiple Myeloma (MM) in an attempt to reduce tumor cell contamination and relapse rate. From May 1995 to November 1999, 127 patients from 17 EBMT centers with newly diagnosed advanced MM were entered into a phase III trial. Responders to 3 cycles of VAD were randomized to receive either CD34+ selected (arm A) or unselected PBPC (arm B) following myeloablative conditioning treatment. PBPC were harvested following mobilization with cyclophosphamide 4g/m² and G-CSF (Filgrastim, AMGEN, Europe). Conditioning regimen in both arms was TBI and high dose melphalan 140 mg/m². CD34+ cell selection was performed in arm A using the CellPro Ceprate-SC device. The analysis concerns the 111 patients who were transplanted (56 arm A and 55 arm B). The median follow-up at the time of the analysis was 65 months. CD34+ selection resulted in a median purity of 87% and a yield of 50%. Molecular analysis showed a median tumor cell depletion of 2.0 log (range 0.3–85.5). The median number of CD34+ cells reinfused/kg was 5.8 x 106 (1.42–50.4) in arm A and 7.4x106 (1.85–99.2) in arm B. The median time to neutrophil engraftment (ANC >0.5x109/l) was 10 days (range 8–14) in arm A and 10 days (range 8–21) in arm B. The median time to platelet engraftment (plts>20 x 109/l) was 11 days (range 5–26) in arm A and 9 days (range 5–42) in arm B (p=0.005). One patient died before platelets engraftment in arm A. Twelve patients experienced at least one episode of serious infection (total episodes =17) before day 100 in arm A compared to 3 patients (total episodes = 6) in arm B (p=0.02). For 3 patients in arm A, these infections were fatal (including the patient who died before time to platelet engraftment). There was no significant difference in CR rate at 1 year as defined by EBMT/IBMTR/ABMTR criteria (27% in arm A and 20% in arm B). The 5 year overall survival (OS) was 51% in arm A and 45% in arm B (p=0.80). The 5 year event free survival was 20% in arm A and 18% in arm B (p=0.45). The increased incidence of severe infections in the CD34+ selected arm in the early post transplant may be due to impaired immune reconstitution. Thus, no long term clinical benefit is obtained by CD34+ selection despite significant tumor cell reduction.

A 63-year-old man with erythraemia was found to have a high affinity haemoglobin which was subsequently identified as Hb San Diego beta 109 (G11) Val leads to Met, recently described in a Filipino family (Nute et al, 1974). The oxygen affinity of the haemolysates was increased approximately two-fold at pH values between 6.04 and 7.90. The n value was nearly normal (2.5-2.9) in the upper range of saturation (70-95% oxygenation) but was somewhat diminished (1.9-2.1) below this range. In vitro biosynthesis of globin by reticulocytes showed that there was balanced synthesis of alpha and beta chains (alpha:beta ratio = 1).

A case is reported of a child with Down's syndrome who developed acute megakaryoblastic leukaemia, and in whom the evolution of the disease was accompanied by increasing cytogenetic abnormalities. A review of the literature suggests that the presence of an abnormal chromosome 21 may predispose to the development of this type of leukaemia.

SummaryFurther studies have been carried out in a previously reported family with congenital antithrombin III (AT III) deficiency due to an abnormal variant of AT III (AT III Northwick Park). The variant has been identified in five members of the family, three of whom had a history of venous thrombosis. Inheritance followed an autosomal dominant pattern. The affected family members have reduced levels of antithrombin heparin cofactor (41–67%) and progressive antithrombin activity (44–62%) but normal levels of immunoreactive AT III (91–162%). Two dimensional immunoelectrophoresis (2 DIE) of AT III in the absence of heparin revealed an abnormal fast-moving peak in addition to the normal peak but 2 DIE in the presence of heparin appeared normal. Further studies confirmed that the abnormal AT III binds completely to heparin but has no heparin cofactor or progressive antithrombin activity. These results would be consistent with a mutation affecting the binding site for thrombin.

Summary. Long-term warfarin therapy was changed to subcutaneous heparin to cover a planned pregnancy in a patient with congenital antithrombin III (AT III) deficiency. Satisfactory anticoagulation was easily maintained in spite of low levels of biologically active AT III. Delivery and the puerperium were covered by a reduced dose of heparin and alternate day infusions of AT III concentrate. A mean dose of 0.77 U/kg of AT III concentrate produced a rise of 1% in AT III and the half-life was of the order of 24 h, with no evidence of increased consumption during labour and delivery. Pregnancy and labour were uncomplicated and resulted in delivery of a healthy female infant. The importance of early and adequate anticoagulation during pregnancy is emphasized.

Summary. Active tuberculous infection was present in 4.6% of patients with haematological diseases as compared to 0.2% of other patients admitted over a similar period of time. There was no evidence either in the literature or in these cases that tuberculosis gave rise to an unusual leukaemoid response. It was more likely that the blood disorder (leukaemia, marrow failure or vitamin B12 deficiency) resulted in loss or diminution of the normal immune response and that this permitted reactivation of an old tuberculous lesion or in a new opportunistic infection.

SUMMARY The incorporation of [15N]δ-aminolaevulinic acid and [15N]glycine into haemoglobin haem and early labelled bilirubin was measured in subjects with various haematological disorders. The clearance of [14C] bilirubin was used to measure bilirubin production rate, and the magnitude of the various sources of bilirubin production and the percentage ineffective erythropoiesis were calculated. Ineffective erythropoiesis was found to be a major factor in the production of the anaemia in patients with the following disorders: megaloblastic anaemia associated with the Lesch-Nyhan syndrome, thalassaemia intermedia, sideroblastic anaemia, and the anaemia of chronic disorders. In three patients with iron-deficiency anaemia ineffective erythropoiesis was increased, but was of minor importance in the production of the anaemia, while in two patients with aplastic anaemia and one with macrocytosis of alcoholism there was no increase in ineffective erythropoiesis.

The incorporation of [15N]delta-aminolaevulinic acid and [15N glycine into haemoglobin haem and early labelled bilirubin was measured in subjects with various haematological disorders. The clearance of [14C bilirubin was used to measure bilirubin production rate, and the magnitude of the various sources of bilirubin production and the percentage ineffective erythropoiesis were calculated. Ineffective erythropoiesis was found to be a major factor in the production of the anaemia in patients with the following disorders: megaloblastic anaemia associated with the Lesch-Nyhan syndrome, thalassaemia intermedia, sideroblastic anaemia, and the anaemia of chronic disorders. In three patients with iron-deficiency anaemia ineffective erythropoiesis was increased, but was of minor importance in the production of the anaemia, while in two patients with aplastic anaemia and one with macrocytosis of alcoholism there was no increase in ineffective erythropoiesis.

Ineffective erythropoiesis was assessed in a series of 32 patients with rheumatoid arthritis by means of a new in-vitro method which measures the release of haem from a labelled cohort of erythroblasts in culture. Haem release was significantly increased in patients with the anaemia of chronic disorders but was normal in those who were not anaemic or who had an iron-deficiency anaemia. In 2 patients with anaemia of chronic disorders haem release returned to normal after successful antirheumatic therapy. The increased ineffective erythropoiesis in patients with rheumatoid arthritis and anaemia of chronic disorders appeared to be unrelated to functional iron deficiency and was not attributable to a serum factor.

A simple in vitro method has been developed for the assessment of ineffective erythropoiesis by measuring the release of heme from a labeled cohort of erythroblasts in short-term suspension culture. The release of labeled heme was shown to correlate with the death of erythroblasts in culture determined by cell counting. Heme release was markedly increased in conditions where there is known to be excessive ineffective erythropoiesis, while in hematologic disorders where ineffective erythropoiesis is thought to be normal, heme release was within the normal range.

Ineffective erythropoiesis was quantitated in a series of patients with pernicious anaemia at different times in relation to vitamin B12 therapy by measuring the incorporation of [15N]delta aminolaevulinic acid and [15N]glycine into early labelled bilirubin. Prior to therapy ineffective erythropoiesis was grossly increased but this was reversed within 24 h of giving vitamin B12, suggesting that most of the existing megaloblasts are enabled to mature into circulating red cells.

A high performance liquid Chromatographic (HPLC) method is described for the rapid and specific determination of the activity of the enzyme δ-aminolaevulinic acid synthase (ALA-S) in mitochondria prepared by sonication of human bone marrow cells. After incubation with 14C-α-ketoglutarate the 14C-δ-aminolaevulinic acid (ALA) formed is converted to a pyrrole derivative, 2-methyl-3-carbethoxy-4-(3-propionic acid) pyrrole. This is isolated by reversed-phase ion-pair chromatography on a Hypersil-SAS column with methanol-water (45:155, v/v) in the presence of 0.005 mol/1 1-heptanesulphonic acid (PIC B-7) as the mobile phase. The radioactivity of the isolated pyrrole is determined by scintillation counting. The optimal substrate concentration and pH were 0.17 mmol/1 α-ketoglutarate and pH 7.4, with an optimal period of sonication of 18 s. Under these conditions ALA production was proportional to the concentrations of erythroblasts in the initial sample and was linear with time up to 60 min. The addition of pyridoxal phosphate (PLP) did not affect ALA-S activity in normal subjects. The mean ALA-S activity in 10 haematologically normal control subjects was found to be 318.8 pmol-lO−6 erythroblasts · h−1 (S.D.± 125.8, range 193-444.6).

High-dose therapy (HDT) and autologous transplantation prolongs remission duration and survival in multiple myeloma (MM), but relapse still occurs at a median of 2 years post-HDT. In order to investigate whether the number of residual tumour cells in the bone marrow (BM) after transplantation can predict the duration of response, a quantitative allele-specific oligonucleotide polymerase chain reaction (qASO-PCR) assay was used to measure tumour load in BM at 3-6 months post-HDT in 67 patients. The method of maximally selected log-rank statistics was used to test for the existence of a cut-off value in the BM tumour load data set. A cut-off value with respect to progression-free survival (PFS) was identified (P = 0.001). The estimated threshold for placing patients into a "good" or "bad" prognostic group was 0.015% (n = 22 and 38 respectively) with a median PFS of 64 months vs. 16. Multivariate analysis showed grouping by PCR result to be an independent prognostic factor for PFS (estimated hazard ratio after shrinkage, 3.91). This study identifies for the first time a threshold of the post-HDT tumour load with prognostic significance for PFS in MM. Quantitative molecular assessment thus may help to identify those patients who are in need of further treatment early after autologous transplantation.