Characterization of clonogenic progenitors in autologous peripheral blood stem cell grafts: evaluation of a simple in vitro assay suitable for routine clinical use

Autologous peripheral blood stem cell (PBSC) transplantation has a low treatment-related morbidity and mortality when using appropriate criteria for patient selection and graft quality evaluation. It will be important to use simple and standardised procedures for evaluation of progenitor cell numbers when considering autografting in patients with malignant or non-malignant disorders and increased risk of prolonged posttransplant cytopenia. We determined the number of clonogenic cells in PBSC autografts after 7 days of in vitro culture, and these results were compared with both the total number of colonies and the numbers of colony subsets in conventional 14 days colony assays (colony-forming unit granulocyte-erythrocyte-macrophage-megakaryocyte, CFU-GEMM; CFU-E, CFU-GM; CFU-megakaryocyte). The total colony number after 7 days of culture correlated significantly with (i) the CD34+ cell number; (ii) the total colony number as well as the numbers of erythroid, nonerythroid and mixed colonies in a conventional assay using 14 days of culture; (iii) the number of megakaryocyte colonies. The total colony number after 7 days of in vitro culture is a simple in vitro parameter that seems to reflect the proliferative capacity of various progenitor subsets in PBSC autografts. This simple analysis may be used in combination with other in vitro techniques (e.g. estimation of stem cell viability and CD34+ cell subset analysis) for pretransplant evaluation of autografts. However, the possible clinical use of this parameter has to be examined in prospective clinical studies.     

Functional evaluation of proliferative T cell responses in patients with severe T lymphopenia: characterization of optimal culture conditions and standardized activation signals for a simple whole blood assay

In this methodological study, we describe an assay for analysis of proliferative T cell responses in patients with severe leukopenia. Severe treatment-induced cytopenia is observed in patients with malignant disorders who receive conventional intensive chemotherapy or autologous stem cell transplantation. The quantitative T cell defect can then be characterized by flow cytometric analysis of membrane molecule expression, whereas the functional status of the remaining T cell population is more difficult to evaluate. In the present study, we describe a standardized whole blood assay that requires small sample volumes and can be used for repeated analysis even in severely ill patients. The assay is based on the following strategy: (i) blood samples are diluted with the serum-free medium X-vivo 10, (ii) T cells are activated either with monoclonal immunoglobulin E (IgE) anti-CD3 or anti-CD3 plus anti-CD28; (iii) T cell proliferation is assayed by [(3)H]thymidine incorporation after 4 days of in vitro culture. These proliferative responses are not affected by the plasma levels of interleukin-2 (IL-2), sIL-2-R alpha, IL-7 and IL-15, and the kinetics of the response are not altered by the presence of exogenous cytokines. Detectable proliferation is observed for most patients with treatment-induced cytopenia. We conclude that the assay can be used for functional characterization of remaining T lymphocytes in patients with severe T lymphopenia.     

Appropriateness of quality indicators for older patients with advanced dementia and poor prognosis

OBJECTIVES: To evaluate the applicability of process-of-care quality indicators (QIs) to vulnerable elders and to measure the effect of excluding indicators based on patients' preferences and for advanced dementia and poor prognosis. DESIGN: The Assessing Care of Vulnerable Elders (ACOVE) project employed 203 QIs for care of 22 conditions (including six geriatric syndromes and 11 age-associated diseases) for community-based persons aged 65 and older at increased risk of functional decline or death. Relevant QIs were excluded for persons deciding against hospitalization or surgery. A 12-member clinical committee (CC) of geriatric experts rated whether each QI should be applied in scoring quality of care for persons with advanced dementia (AdvDem) or poor prognosis (PoorProg). Using content analysis, CC ratings were formulated into a model of QI exclusion. Quality scores with and without excluded QIs were compared. SETTING: Enrollees in two senior managed care plans, one in the northeast United States and the other in the southwest. PARTICIPANTS: CC members evaluated applicability of QIs. QIs were applied to 372 vulnerable elders in two senior managed care plans. MEASUREMENTS: Frequency and type of QIs excluded and the effect of excluding QIs on quality of care scores. RESULTS: Of the 203 QIs, a patient's preference against hospitalization or surgery excluded 10 and eight QIs, respectively. The CC voted to exclude 81.5 QIs (40%) for patients with AdvDem and 70 QIs (34%) for patients with PoorProg. Content analysis of the CC votes revealed that QIs aimed at care coordination, safety or prevention of decline, or short-term clinical improvement or prevention with nonburdensome interventions were usually voted for inclusion (90% and 98% included for AdvDem and PoorProg, respectively), but QIs directed at long-term benefit or requiring interventions of moderate to heavy burden were usually excluded (16% and 19% included, respectively). About half of QIs aimed at age-associated diseases were voted for exclusion, whereas fewer than one-quarter of QIs for geriatric syndromes were excluded. Thirty-nine patients (10%) in our field trial held preferences or had clinical conditions that would have excluded 68 QIs. This accounted for 5% of all QIs triggered by these 39 patients and 0.6% of QIs overall. The quality score without exclusion was 0.57 and with exclusion was 0.58 (P =.89). CONCLUSION: Caution is required in applying QIs to vulnerable elders. QIs for geriatric syndromes are more likely to be applicable to these individuals than are QIs for age-associated diseases. The objectives of care, intervention burdens, and interval before anticipated benefit affect QI applicability. At least for patients with AdvDem and PoorProg, identification of applicable or inapplicable QIs is feasible. In a community-based sample of vulnerable elders, few QIs are excluded.     

A case study of shifting a patient with percutaneous endoscopic gastrostomy (PEG) to home care

We studied the primary factor preventing a patient with PEG from being transferred to home care focusing on the dietetic situation. The study has revealed differences in not the age of the patient, the days of hospitalization or hematological and biochemical test data but in the condition of use of home care services or family makeup. In other words, insufficient use of social resources is considered to prevent shifting to home care or continuation of home care of patients with PEG. It is necessary to understand not only dietetic situation but social backgrounds of patients and supply information.     

Pharmacokinetic and Pharmacodynamic Properties of Insulin Aspart and Human Insulin

The preferred approach to determine the pharmacokinetic (PK) and pharmacodynamic (PD) properties of insulin analogues is the euglycemic glucose clamp. Currently, non-compartmental data analytical approaches are used to analyze data. The purpose of the present study is to propose a novel compartmental-model for analysis of data from glucose clamp studies. Data used in this trial only involved 18 of the 20 originally treated subjects. Data was obtained from a crossover trial where 18 healthy subjects each received a single subcutaneous (sc) dose of 1.2 nmol/kg (body weight) insulin aspart (IAsp) or 1.2 nmol/kg human insulin (HI) during a euglycemic glucose clamp after overnight fast. Serum insulin and glucose concentrations were measured and the glucose infusion rate (GIR) was adjusted after dosing, to maintain blood glucose near basal levels. Individual model parameters were estimated for IAsp, HI, and the corresponding glucose and GIR data. We found statistically significant differences between most of the HI and IAsp pharmacokinetic parameters, including the sigmoidicity of the time course of absorption (1.5 for HI vs. 2.1 for IAsp (unit less), P=0.0005, Wilcoxon Signed-rank test), elimination rate constant (0.010 min^–1 for HI vs. 0.016 min^–1 for IAsp (P=0.002)). The PD model parameters were mostly not different, except for the rate of insulin action (0.012 min^–1 for HI vs. 0.017 min^–1 for IAsp (P=0.03)). The model may provide a framework to account for different PK properties when estimating the PD properties of insulin and insulin analogues in glucose clamp experiments.     

Children,family and cancer survival in Norway

Models for all-cause mortality among 45,000 men and women with cancer in 12 different sites were estimated, using register and census data for complete Norwegian birth cohorts. This observed-survival method appeared to be an adequate approach. The results support the idea that women who were pregnant shortly before a breast cancer diagnosis may have a poorer prognosis than others. In principle, such an effect may also reflect that these women have a young child during the follow-up period and are burdened by that. However, this social explanation can hardly be very important, given the absence of a corresponding significant effect in men and for other cancer sites in women. Breast cancer is different from other malignancies also with respect to the effect of parenthood more generally, regardless of the timing of the pregnancies. On the whole, male and female cancer patients with children experience lower mortality than the childless, though without a special advantage associated with adult children. This suggests a social effect, perhaps operating through a link between parenthood, lifestyle and general health. No parity effect was seen for breast cancer, however, which may signal that the social effect is set off against an adverse physiologic effect of motherhood for this particular cancer. Among men, both marriage and parenthood were associated with a good prognosis. Married male cancer patients with children had mortality one-third lower than that among the childless and never-married. Women who had never married did not have the same disadvantage.     

A longitudinal study of the effects of tobacco smoking and other modifiable risk factors on ill health in middle-aged and old Americans: results from the Health and Retirement Study and Asset and Health Dynamics among the Oldest Old survey

BACKGROUND: While the effects of smoking and other modifiable risk factors on mortality and specific diseases are well established, their effects on ill health more generally are less known. Using two national, longitudinal surveys, the objective of this study was to analyze the effect of smoking and other modifiable risk factors on ill health, defined in a multidimensional fashion (i.e., disability, impaired mobility, health care utilization, and self-reported health). METHODS: The analyses were based on the Health and Retirement Study (HRS) (12,652 persons 50-60 years old surveyed in 1992, 1994, 1996, and 1998) and the Asset and Health Dynamics among the Oldest Old survey (8,124 persons 60-70 years old surveyed in 1993, 1996, and 1998). RESULTS: Smoking was strongly related to mortality and to ill health, with similar relative effects in the middle-aged and the elderly. There were consistent adverse dose-response relationships between smoking and ill health in the HRS. Persons who had quit smoking at least 15 years prior to the survey were no more likely than never smokers to experience ill health. A dose-response relationship was found between exercise and ill health. For body mass index and alcohol, there were U-shaped relationships with ill health. CONCLUSIONS: Public health efforts designed to encourage smoking cessation should emphasize improvements in ill health in addition to decreased mortality.