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Patient and family education is an important component of the organ transplant programs at the University of Nebraska Medical Center. The Medical Center is in the process of planning a new transplant center which will employ the family-centered, educationally-intensive cooperative care concept. This approach was chosen as the model for the delivery of care at the Lied Transplant Center because it emphasizes efficient, effective clinical care by requiring active participation by the family or essential other, thereby better preparing both the patient and the family for the transition to home and to the community. This article presents the evolution of patient education in our transplant programs, discusses the educational needs of transplant patients across the continuum of care, provides insight into the process of planning educational programs for the new center and provides a sample module for teaching which is based on the Cooperative Care concept.

Of 364 patients with lymphoid malignancy who underwent high-dose therapy with autologous bone marrow transplantation (ABMT) or peripheral stem cell transplantation (PSCT), 169 patients have had progressive disease after the procedure. The median survival from the time of relapse for patients with Hodgkin's disease (HD) who progressed after the transplant was 10.5 months. This compares with a median survival of 3 months for relapsed non-Hodgkin's lymphoma (NHL) patients (P = .0036). After failing transplantation, 56 patients were treated with further chemotherapy, 35 with involved field irradiation therapy, and 18 patients were treated with combination chemotherapy and irradiation. Seven patients received biologic therapy and seven patients underwent a second bone marrow transplant. The remainder of the patients were believed to be too ill for further therapy or chose not to receive further treatment for their recurrent lymphoid malignancy. Sixty of the 169 patients with progressive disease after the transplant are still alive; however, only 18 patients are alive off therapy without evidence of active disease after their relapse. Ten of the 18 patients are still less than 12 months past their posttransplant salvage therapy and are at high-risk for relapse. Five patients are progression free at 15 to 36 months after their posttransplant relapse. Only three patients (two NHL and one HD) treated with other modalities after autologous transplant failure are alive without evidence of disease and have been observed at least 4 years postrelapse. Although a few patients will have a durable response to subsequent therapy, the majority of patients who have progressive disease after an autologous transplant for lymphoid malignancy will succumb to recurrent disease within a short period of time.

A white cocoon membrane emanating from an inferotemporal focus in the iris stroma totally ensheathed a Binkhorst four-loop iris plane lens 18 months after implantation. The membrane was removed and studied by scanning (SEM) and transmission (TEM) electron microscopy. By SEM the external surface of the membrane was characterized by a fibrillar meshwork, with only an occasional scattered spindle-shaped or rounded inflammatory cell occupying the surface. One-micron plastic sections revealed both spindle and polyhedral heavily pigmented cells in the outer aspect of the membrane, and compressed elongated nonpigmented spindle cells scattered throughout the central portions. By TEM cells clinging to the outermost aspects were bipolar iris stromal melanocytes with small melanosomes, inactive fibroblasts, or histiocytes with cytoplasmic ruffles. The larger rounded pigmented cells in the superficial region were viable or degenerated iris pigment epithelial cells or macrophages. Most of the substance of the membrane was composed of collagen fibrils 100-500 A in diameter with and without 640 A periodicity; these fibrils were generally oriented parallel to the spindle cells but did not display distinct bundling or a lamellar architecture. The spindle cells in the center of the lesion were active fibroblasts with abundant rough-surfaced endoplasmic reticulum and scattered actin myofilaments; they contained rare small and large melanin granules indicative of phagocytosis. It has been concluded that the membrane was produced predominantly by iris stromal fibroblasts probably activated by the haptics of the IOL or McCanell suture.

Three new cases of epibulbar choristomas, all containing lacrimal tissue, are presented and compared with those reported previously in the literature. The first and second cases were unilateral, complex choristomas, consisting of ectopic lacrimal tissue, smooth muscle, and cartilage; the first case was also remarkable for the presence of lesional tissue in the peripheral cornea and evidence of progressive growth during puberty. The third case was a bilateral, complex choristoma, manifesting epibulbar lacrimal tissue, cartilage, and smooth muscle; also associated were bilateral optic nervehead colobomas and a uniocular focus of posterior scleral cartilage demonstrated by computed tomography (CT) scanning. On clinical examination, all three lesions displayed highly vascularized thickenings of the conjunctiva with diagnostically useful gelatinous elevations, which corresponded microscopically to lobules of lacrimal tissue. In addition, all three cases had the interesting diagnostic feature of superficial corneal scarring or sclerosis, with a fine vascularity adjacent to the conjunctival lesional tissue. Electron microscopy of the third case demonstrated completely normal cytoarchitecture of the lacrimal tissue. Because of the frequent presence of Müller's smooth muscle in epibulbar lacrimal choristomas, the authors propose that these lesions represent embryologic ectopias or overly extensive field effects of the palpebral lobe of the lacrimal gland.

A malignant ciliary body melanoma received proton-beam irradiation. After an apparent failure of the tumor to respond, the eye was enucleated. A predominantly epithelioid cell tumor appeared viable by light microscopy, and a low degree of mitotic activity persisted, despite therapy. The tumor cells, however, displayed degenerative changes ultrastructurally, presumably results of the radiotherapy. These consisted of numerous cytoskeletal filaments, lipid vacuoles, prominent phagolysosomes, and nuclear convolutions and fragmentations. The mitochondria were fewer in number in the present tumor than typically encountered in epithelioid cells. A rare leptomeric structure was discovered, probably an organizational modification of the cytoplasmic filaments. The tumor's capillaries showed radiation-induced changes in terms of thickened basement membranes and perivascular fibrin deposition. The foregoing features are indicative of cellular and metabolic injury from the radiotherapy, but these were evidently not sufficiently injurious to sterilize the tumor.

A 10-year-old white boy presented with a diffuse pigmented lesion of the choroid of his right eye that had led to a partial secondary retinal detachment. Because of the fear of a diffuse choroidal melanoma (a lesion never before reported in an individual within the first two decades of life), the eye was enucleated. An incisional P-32 study, compared with an uninvolved region, was positive at 154% uptake. Pigmented tissue was discovered surrounding the distal meninges of the optic nerve, on the posterior surface of the eye, and within the orbital soft tissues adherent to the globe. This led to fear of extraocular extension of a malignant melanoma. Light microscopic examination of the enucleated globe demonstrated that the choroid was diffusely and massively thickened by polygonal, hyperpigmented tumor cells that were also present in compressed spindled forms between the lamellae of scleral collagen, in the scleral emissaries, on the surface of the eyeball, and in the distal optic nerve dura. The choroidal tumor cells had the features of those normally encountered in localized optic nerve head benign melanocytomas. Electron microscopy demonstrated the presence of large, well-melaninized melanosomes (but no macromelanosomes), confirming the diagnosis of a diffuse uveal melanocytoma. The differential diagnosis of this new entity and its relationship to previously reported pigmented lesions of the uvea is discussed.