Abstract Bone marrow transplantation (BMT) has become an important innovative treatment for hematological malignancies, solid tumors, immunodeficiency diseases and metabolic disorders. It has evolved over the last decade from a controversial research procedure to a standard therapeutic modality, which prolongs remission of some patients and cures others. Historically, the BMT procedure is divided into several stages, each of which have accompanying emotional problems. In providing psychological care for transplant recipients, donors and families, care‐givers must be familiar with the psychological stages of the procedure, the psychological themes such as body image, rebirth and the patient's mechanisms of coping with the extreme stress of such protocols. Its complex medications, high‐dose chemotherapy, total‐body irradiation (TBI), germ‐free environment, graft‐versus‐host disease (GvHD), Broviac or Hickman line catheterization and total parenteral nutrition (TPN), can precipitate significant psychological sequelae with immediate and long‐term consequences. In response to their illness, transplant patients may also develop emotional disturbances of anxiety, depression, agitation, non‐compliance and rare suicidal thoughts. These reactions, and the occasional presence of concurrent psychiatric illness, require recognition and development of guidelines for management. This paper is the first in a series of two and will inform the reader about: (1) the biology, epidemiology, history and economics of BMT; (2) informed consent issues and the psychological/social assessment of patients and families prior to BMT; (3) the psychological care of patients during BMT; and (4) address special issues concerning donation of marrow, donor registries, family issues, children as patients and prevention of staff burn‐out. Part II of this series will review the psychosocial adjustment and quality of life of BMT patients as they convalesce and re‐enter normal daily routines. A summary is given of research into which psychosocial factors predict better post‐BMT outcome.
Childhood cancer patients have a greater likelihood of long‐term survival than ever before. This study examined both the perceived family functioning of adolescents who had successfully completed treatment for pediatric cancer and the relationship between family functioning and post‐treatment adjustment. Eighty‐eight adolescent survivors of hematologic malignancies were assessed regarding their family functioning, mental health, self‐esteem, global competence, and problem behaviors. Contrary to expectations about the influence of cancer on these families, adolescent cancer survivors reported lower levels of family cohesion than the normative sample of healthy adolescents and their families. While current age, gender, age at diagnosis, and time since treatment completion were generally not associated with adolescents' adjustment, perceived family cohesion and adaptability were strongly related to post‐treatment psychological adjustment.
Monoamine oxidase inhibitors have been associated with male retarded ejaculation and impotence. The authors describe three cases of female anorgasmia secondary to this class of antidepressants. To the author's knowledge only one incidental finding of this kind has been reported.
To assess the efficacy and toxicity of cyclosporin A in patients with severe, treatment-refractory rheumatoid arthritis.Prospective randomized, double-blind 6-month trial.Thirty-one patients who had classic seropositive rheumatoid arthritis with active synovitis unresponsive to conventional therapy.Patients were randomly assigned to high-dose (10 mg/kg body weight.d) or low-dose (1 mg/kg.d) cyclosporin A therapy. A reduction in the dose was permitted for adverse side effects. After 6 months of therapy, patients who showed clinically relevant improvement, defined as a 40% or greater reduction in their total joint activity score, were given the option to continue receiving the therapy for an additional 6 months.At 6 months, clinically relevant improvement occurred in 10 of 15 patients (95% CI, 38 to 88) receiving high-dose therapy and in 4 of 16 patients (CI, 7 to 52) receiving low-dose therapy (P = 0.02). Statistically significant improvements in individual measures were shown only in the high-dose group. Improvements were noted in the number of tender joints (-18.8; CI, -24.5 to -13.1) and swollen joints (-12.1; CI, -15.4 to -8.6), as well as in physician's global scores (-1.5; CI, -2.1 to -0.9) and patient's global scores (-1.1; CI, -1.9 to -0.5). Improvement in disease activity was maintained through 12 months in the high-dose group. The clinical responses to cyclosporin A were most evident in patients with depressed in-vitro proliferative responses of peripheral blood mononuclear lymphocytes to soluble recall antigens. Toxicities, such as fatigue, gastrointestinal and neurologic complaints, and hypertrichosis were frequent but often reversible with a reduction in the dose. Nephrotoxicity, with a 20% increase in the serum creatinine level, was seen in 27 of 31 patients (CI, 71 to 97).Cyclosporin A is an effective therapy for severe, treatment-refractory rheumatoid arthritis. Side effects, particularly nephrotoxicity, are common.
