Hematopoietic growth factors for graft failure after bone marrow transplantation: a randomized trial of granulocyte-macrophage colony- stimulating factor (GM-CSF) versus sequential GM-CSF plus granulocyte- CSF

Delay in hematologic recovery after bone marrow transplantation (BMT) can extend and amplify the risks of infection and hemorrhage, compromise patients' survival, and increase the duration and cost of hospitalization. Because current studies suggest that granulocyte- macrophage (GM) colony-stimulating factor (CSF) may potentiate the sensitivity of hematopoietic progenitor cells to G-CSF, we performed a prospective, randomized trial comparing GM-CSF (250 micrograms/m2/d x 14 days) versus sequential GM-CSF x 7 days followed by G-CSF (5 micrograms/kg/d x 7 days) as treatment for primary or secondary graft failure after BMT. Eligibility criteria included failure to achieve a white blood cell (WBC) count > or = 100/microL by day +21 or > or = 300/microL by day +28, no absolute neutrophil count (ANC) > or = 200/microL by day +28, or secondary sustained neutropenia after initial engraftment. Forty-seven patients were enrolled: 23 received GM-CSF (10 unrelated, 8 related allogeneic, and 5 autologous), and 24 received GM- CSF followed by G-CSF (12 unrelated, 7 related allogeneic, and 5 autologous). For patients receiving GM-CSF alone, neutrophil recovery (ANC > or = 500/microL) occurred between 2 and 61 days (median, 8 days) after therapy, while those receiving GM-CSF+G-CSF recovered at a similar rate of 1 to 36 days (median, 6 days; P = .39). Recovery to red blood cell (RBC) transfusion independence was slow, occurring 6 to 250 days (median, 35 days) after enrollment with no significant difference between the two treatment groups (GM-CSF: median, 30 days; GM-CSF+G- CSF; median, 42 days; P = .24). Similarly, platelet transfusion independence was delayed until 4 to 249 days (median, 32 days) after enrollment, with no difference between the two treatment groups (GM- CSF: median, 28 days; GM-CSF+G-CSF: median, 42 days; P = .38). Recovery times were not different between patients with unrelated donors and those with related donors or autologous transplant recipients. Survival at 100 days after enrollment was superior after treatment with GM-CSF alone. Only 1 of 23 patients treated with GM-CSF died versus 7 of 24 treated with GM-CSF+G-CSF who died 16 to 84 days (median, 38 days) after enrollment, yielding Kaplan-Meier 100-day survival estimates of 96% +/- 8% for GM-CSF versus 71% +/- 18% for GM-CSF+G-CSF (P = .026). These data suggest that sequential growth factor therapy with GM-CSF followed by G-CSF offers no advantage over GM-CSF alone in accelerating trilineage hematopoiesis or preventing lethal complications in patients with poor graft function after BMT.(ABSTRACT TRUNCATED AT 400 WORDS)     

Use of fecal occult blood testing in hospitalized patients: Results of an audit

BACKGROUND:

The fecal occult blood test (FOBT), widely used as a colorectal cancer screening tool, continues to be used in hospitalized patients. However, the utility of this test for hospitalized patients is unclear.

OBJECTIVE:

To assess FOBT use in a large urban regional health authority.

METHODS:

Reports of all FOBTs performed between April 1, 2011 and March 30, 2012 from two academic and four community hospitals in Winnipeg (Manitoba) were extracted. Of 650 hospitalizations with a positive FOBT result and 1254 with a negative FOBT result, random samples of 230 and 97 charts, respectively, were reviewed. Information including demographics, admission diagnos(es), indication(s) for ordering the FOBT and clinical management was extracted.

RESULTS:

Thirty-four percent (650 of 1904) of hospitalizations with an FOBT had a positive FOBT result. Family medicine physicians ordered approximately one-half of the reviewed FOBTs. The most common indication for ordering an FOBT was anemia. Of those with a positive FOBT, 66% did not undergo further gastrointestinal investigations. Of those with a positive FOBT and overt gastrointestinal bleeding and/or melena who underwent endoscopy, 60% had their endoscopy performed before the FOBT result being reported while 38% underwent their endoscopy ≥3 days after the stool sample was collected. There were minimal differences in clinical practices between academic and community hospitals.

CONCLUSIONS:

The present study suggests that FOBT results in hospitalized patients may have little beneficial impact on clinical management. Hospital laboratories may be better served in directing resources to other tests.     

Government Leadership in Addressing Public Health Priorities: Strides and Delays in Electronic Laboratory Reporting in the United States

For nearly a decade, interest groups, from politicians to economists to physicians, have touted digitization of the nation’s health information. One frequently mentioned benefit is the transmission of information electronically from laboratories to public health personnel, allowing them to rapidly analyze and act on these data.Switching from paper to electronic laboratory reports (ELRs) was thought to solve many public health surveillance issues, including workload, accuracy, and timeliness. However, barriers remain for both laboratories and public health agencies to realize the full benefits of ELRs.The New York City experience highlights several successes and challenges of electronic reporting and is supported by peer-reviewed literature. Lessons learned from ELR systems will benefit efforts to standardize electronic medical records reporting to health departments.LABORATORY REPORTS SUPPORT passive public health surveillance, providing highly specific data about health conditions in a community. Efficient electronic exchange of laboratory information can facilitate time-sensitive decision-making.1 This is particularly true for infectious diseases, which require timely, accurate data to confirm diagnoses, detect outbreaks, and prevent transmission of disease to additional people. As public health agencies expand their mission to address chronic diseases, such as diabetes, laboratory reporting will also have an important role. At present, electronic laboratory reports (ELRs) offer a more accurate, complete, and efficient data source for public health surveillance than do paper reports.2 Significant progress has been made in using ELRs, but challenges still exist for this public health reporting system.Since early in the 21st century, clinical laboratories have been transitioning from a system of mailing or faxing test results to exclusively transmitting data electronically to health departments. After September 11, 2001, Congress set up the Terrorism Preparedness and Emergency Response funds to support the public health emergency preparedness activities of the Centers for Disease Control and Prevention (CDC). This revenue initiated many state and local ELR systems, but funds have declined from $970 million in FY 2003 to $657 million in FY 2012.3 The National Electronic Disease Surveillance System coordinated by CDC provides standards and software and hardware resources to state and local health departments to implement standards-based ELR systems between clinics, health departments, and CDC. This national surveillance program has both accelerated ELR adoption, by providing standards, and delayed development, because of funding shortages and a lack of infrastructure support.4 In New York City, local public health legislation also facilitated ELR adoption.5 Improvements in technology, such as the incorporation of some messaging syntax standards into laboratory information management systems, have accelerated the shift to ELRs.2 In 2010, 42 US states reported having general communicable disease surveillance systems that incorporate ELRs,4 but how complete these systems are is unclear.Federal legislation such as the Health Information Technology for Economic and Clinical Health Act, part of the American Reinvestment and Recovery Act of 2009, further advanced the use of ELRs in health care facilities that employ electronic medical records (EMRs). This act created Meaningful Use (MU), a federal program with financial incentives to implement, upgrade, and demonstrate meaningful use of certified electronic health record technology. ELRs were included as part of the stage 1 MU incentives.4,6 MU, however, does not provide financial incentives for commercial clinical laboratories to make technology upgrades. A broader goal of the health information technology legislation and MU is for health care providers to eventually communicate with public health agencies electronically, rather than by paper or phone. For several reasons, EMR adoption has been a challenge.7 An efficient ELR surveillance system will be a valuable resource for public health, and the lessons learned from ELR implementation, such as the establishment of standards, will help inform the subsequent use of EMRs for public health surveillance.After reviewing the peer-reviewed literature addressing the topic of ELRs published between January 2000 and July 2012, we identified both substantial accomplishments and remaining challenges. The decision logic for the literature review and article inclusion is presented in Figure 1. To outline the issues, we studied the New York City Department of Health and Mental Hygiene (DOHMH) experience and followed the flow of a report from the clinical laboratory to the public health department. Along this cascade of information we identified major strides, delays, and possible solutions.Open in a separate windowFIGURE 1—Literature review inclusion decision tree for electronic laboratory reports in public health.Note. ELR = electronic laboratory report; LOINC = Logical Observation Identifiers Names and Codes. The term SNOMED was not included in the search criteria because it did not noticeably improve the results of the search over using the term LOINC alone.     

Soft x-ray instrumentation and its applications at the advanced photon source

Knowledge of the intermediate energy range from 0.5-4 keV, bridging the "soft" and "hard" x-ray regions, is relatively underdeveloped. However, recent developments in the techniques of microscopy and magnetic circular dichroism have emphasized the need to operate in this energy range for microelectronic, biological, and materials science related experiments. The strong dipole-allowed 3d to 4f transitions in rare-earth magnetic materials fall in this region, as do the K-shells of many of the second and third row elements of the periodic table. Two beamlines to be constructed at the Advanced Photon Source (APS) have been designed to cover this energy region. The proposed undulator source, the beamline layout, and the experimental programs for these beamlines are described.     

von Willebrand factor-collagen binding activity is increased in newborns and infants

ABSTRACT. von Willebrand factor (vWF) antigen (vWF:Ag) and vWF-collagen binding activity (vWF:CBA) were measured in plasma by parallel quantitative ELISAs in normal newborns and infants ( n =71). The medians for vWF:Ag (IUjml) and vWF:CBA (Ujml), respectively, were 1.46 and 1.91 for 2-7 day-old (n = 43), 1.22 and 1.40 for 2-4 week-old (n = 14), 1.22 and 1.15 for 2-6-month-old (n = 14) infants and 0.98 and 1.08 (n = 36) in normal adults. Elevated levels of vWF:Ag, but particularly vWF:CBA were seen for up to 4 weeks of life reaching adult levels between 2 and 6 months of life. The elevated levels of the vWF parameters indicate that caution should be exercised when interpreting laboratory data and diagnosing von Willebrand disease in newborns and young infants and warrant the use of age-specific reference ranges. The efficient haemostasis observed during early neonatal life may in part be due to the increased ability of vWF to interact with collagen.     

Echocardiogram‐gated multislice spiral CT in functionally univentricular heart following long‐lasting Waterston–Cooley anastomosis

Waterston–Cooley anastomosis may be carried out in patients with tricuspid atresia to provide pulmonary perfusion. It is associated with several complications, including preferential blood flow to the right lung, hypoplasia of the left pulmonary artery, obstruction of the anatomosis or rupture of pulmonary aneurysms. We study a patient with thrombosis in the pulmonary arteries following surgical construction of a Waterston shunt in childhood. Imaging findings and clinical symptoms are discussed with emphasis on echocardiogram‐gated multislice spiral CT.