The role and activities of the ISCT Regulatory Affairs Committee

The following article is written as part of a series of reviews addressing regulatory issues relevant to the field of cellular therapy. The first in the series describes the activities and mission of the Legal and Regulatory Affairs Committee of ISCT.

Localization of astrovirus in experimentally infected turkeys as determined by in situ hybridization

Twenty-one 3-day-old turkey poults from British United Turkeys of America were orally inoculated with a recently characterized astrovirus, TAstV-2, isolated from turkeys with poult enteritis and mortality syndrome. At 1, 2, 3, 4, 5, 7, and 9 days postinfection (dpi), three inoculated birds were euthanatized, and tissues (intestines, spleen, bursa, and thymus) were collected immediately into 10% neutral buffered formalin. Inoculated birds were diarrheic by 3 dpi, and frothy feces persisted throughout the experimental period. Histologically, there was only slight evidence of enteric damage, which was characterized by mild epithelial necrosis, lamina propria infiltrates, minimal villus atrophy, and mild crypt hyperplasia. In situ hybridization, using a negative sense digoxigenin-labeled riboprobe to the capsid gene of TAstV-2, revealed viral RNA in intestinal epithelial cells at the basal margins of the villi, in distal small intestine, and in cecum at 2 dpi, with subsequent extension to epithelium of the large intestine and proximal small intestine (3-5 dpi). Minimal virus remained by 9 dpi.

Comparison of CD34+ cell collection efficiency on the COBE Spectra and Fenwal CS-3000 Plus

Optimal collections of mobilized CD34+ cells are important in terms of both patient toxicity and cost. The factors that determine CD34+ collection efficiency (CD34eff) of cell separators have not been well studied. In addition, because several cell separators are available, the type of collection device may also be a significant variable. Previous studies comparing the Baxter-Fenwal CS3000 and the COBE Spectra have not yielded consistent conclusions. Therefore, we retrospectively analyzed the collection outcomes of 163 consecutive donors with a peripheral CD34+ cell concentration (pCD34) of > or =5 cells/microl on the first collection that had been harvested on one or the other device. The CS3000 was found to yield a significantly higher CD34eff (50% vs. 39%, P = 0.006). However, donors were not balanced for several prognostic factors, which may contribute to CD34eff including mobilization with G-CSF vs. chemotherapy+G-CSF, average flow rate, and total volume of peripheral blood processed. When appropriate variables were included in a stepwise multiple variable analysis, cell separator type emerged as a significant independent predictive factor for CD34eff (P = 0.018). Our data indicates that the CS3000 will, on average, show a higher absolute CDeff of 8%. Furthermore, since the two devices differ in mechanism, prognostic factors may also differ. Comparisons suggest that peripheral blood WBC and hematocrit may be more important predictors for the CS3000.

Prostate-Specific Ets (PSE) factor: a novel marker for detection of metastatic breast cancer in axillary lymph nodes

Prostate Specific Ets factor is a recently identified transcriptional activator that is overexpressed in prostate cancer. To determine whether this gene is overexpressed in breast cancer, we performed a virtual Northern blot using data available online at the Cancer Genome Anatomy Project website. Ninety-five SAGE libraries were probed with a unique sequence tag to the Prostate Specific Ets gene. The results indicate that Prostate Specific Ets is expressed in 14 out of 15 breast cancer libraries (93%), nine out of 10 prostate cancer libraries (90%), three out of 40 libraries from other cancers (7.5%), and four out of 30 normal tissue libraries (13%). To determine the possibility that the Prostate Specific Ets gene is a novel marker for detection of metastatic breast cancer in axillary lymph nodes, quantitative real-time RT-PCR analyses were performed. The mean level of Prostate Specific Ets expression in lymph nodes containing metastatic breast cancer (n=22) was 410-fold higher than in normal lymph node (n=51). A receiver operator characteristic curve analysis indicated that Prostate Specific Ets was overexpressed in 18 out of 22 lymph nodes containing metastatic breast cancer (82%). The receiver operator characteristic curve analysis also indicated that the diagnostic accuracy of the Prostate Specific Ets gene for detection of metastatic breast cancer in axillary lymph nodes was 0.949. These results provide evidence that Prostate Specific Ets is a potentially informative novel marker for detection of metastatic breast cancer in axillary lymph nodes, and should be included in any study that involves molecular profiling of breast cancer.

Dimensions of self-rated mood in depressed, manic, and normal subjects

Self-rated scales allow the comparison of subjective mood across the spectrum of manic, depressive, and euthymic states. This study examined the self-reported mood of manic, depressed, and normal subjects using a 23-item research instrument based on the Carroll-Klein model of bipolar disorder. The Multiple Visual Analog Scale (MVAS) measures the following dimensions: consummatory reward (seven items), incentive reward (two items), psychomotor speed (seven items), and central pain (seven items). The MVAS was completed by 31 manic inpatients, 43 depressed inpatients, and 29 normal volunteer subjects. Total scores, average item scores, and total dimension scores were obtained. Subjects also completed a global mood VAS and the Carroll Depression Scale (CDS). Groups were compared by analysis of variance (ANOVA) and post hoc Bonferroni-Dunn methods. In a separate post hoc analysis, the group of manic patients was divided at the median CDS score into "pure" and "dysphoric" manic subgroups. We found excellent congruence of average 23-item total MVAS scores with global VAS and CDS scores. Dimension scores on the MVAS conformed to the predictions of the Carroll-Klein model. Depressed patients differed significantly from both manic and normal subjects on each dimension. MVAS dimension scores of normal subjects did not differ significantly from those of manic patients. On the dimension of central pain, normal subjects had significantly less inhibited scores than the "pure" subgroup of manics. The results confirmed that the dimensions of the Carroll-Klein model are bipolar and orthogonal. By the MVAS technique, the self-reported mood of normal subjects is similar to the self-reported mood of manic patients on all dimensions of the Carroll-Klein model of bipolar disorder. The positive scores of both groups are clearly distinguished from the negative scores of depressed patients. Average MVAS scores of normal subjects approximated the conventional zero score only on the dimension of central pain. Normal subjects exhibit megalothymic (hyperthymia) on most dimensions of subjective mood. The negative MVAS scores of depressed patients are even more deviant from normal than the conventional scoring system would suggest.

Preselective gene therapy for Fabry disease

Fabry disease is a lipid storage disorder resulting from mutations in the gene encoding the enzyme alpha-galactosidase A (alpha-gal A; EC ). We previously have demonstrated long-term alpha-gal A enzyme correction and lipid reduction mediated by therapeutic ex vivo transduction and transplantation of hematopoietic cells in a mouse model of Fabry disease. We now report marked improvement in the efficiency of this gene-therapy approach. For this study we used a novel bicistronic retroviral vector that engineers expression of both the therapeutic alpha-gal A gene and the human IL-2Ralpha chain (huCD25) gene as a selectable marker. Coexpression of huCD25 allowed selective immunoenrichment (preselection) of a variety of transduced human and murine cells, resulting in enhanced intracellular and secreted alpha-gal A enzyme activities. Of particular significance for clinical applicability, mobilized CD34(+) peripheral blood hematopoietic stem/progenitor cells from Fabry patients have low-background huCD25 expression and could be enriched effectively after ex vivo transduction, resulting in increased alpha-gal A activity. We evaluated effects of preselection in the mouse model of Fabry disease. Preselection of transduced Fabry mouse bone marrow cells elevated the level of multilineage gene-corrected hematopoietic cells in the circulation of transplanted animals and improved in vivo enzymatic activity levels in plasma and organs for more than 6 months after both primary and secondary transplantation. These studies demonstrate the potential of using a huCD25-based preselection strategy to enhance the clinical utility of ex vivo hematopoietic stem/progenitor cell gene therapy of Fabry disease and other disorders.

Multiply scattered light tomography and confocal imaging: detecting neovascularization in age-related macular degeneration

A novel technique, Multiply Scattered Light Tomography (MSLT), and confocal Infrared Imaging are used to provide diagnostic information using a comfortable, rapid, and noninvasive method. We investigated these techniques in detecting neovascularization in age-related macular degeneration. The MSLT used a Vertical Cavity Surface Emitting Laser (VCSEL) at 850 nm, while the confocal imaging technique used either the VCSEL or a 790 nm laser diode. Both were implemented into the topographical scanning system (TopSS, Laser Diagnostic Technologies, Inc.) Confocal imaging with both lasers provided different information about neovascularization as a function of focal plane, and different also from MSLT.

Scanning laser reflectometry of retinal and subretinal tissues

Measurements of the human ocular fundus that make use of the light returning through the pupil are called reflectometry. Early reflectometry studies were limited by poor light return from the retina and strong reflections from the anterior surface of the eye. Artifacts produced misleading results in diseases like age-related macular degeneration. Novel laser sources, scanning, confocal optics, and digital imaging provide improved sampling of the signal from the tissues of interest: photoreceptors and retinal pigment epithelial cells. A wider range of wavelengths is now compared, including the near infrared. Reflectometry now provides functional mapping, even in severe pathology.

Correlation of maternal and fetal hepatitis B antibody titers following maternal vaccination in pregnancy

The objective of this study was to compare the levels of hepatitis B antibody in maternal and cord blood following maternal vaccination in pregnancy and to determine the level of maternal hepatitis B surface antibody (HbsAb) associated with a seroprotective level in cord blood. Thirty-seven (37) healthy gravidas who were identified as seronegative for hepatitis B surface antigen (HbsAg) and antibody (HbsAb) on initial prenatal assessment and subsequently began a series of three vaccinations in the pregnancy with hepatitis B recombinant DNA vaccine (Engerix-B, SmithKline Beecham) were studied. These mothers represented the first group of gravidas delivering between 6/1/97 and 8/1/97 following the iniatiation of a new protocol of offering hepatitis B vaccination to all patients testing seronegative to HbsAg and HbsAb. All gravidas were given a dose of 20 microg into the deltoid muscle utilizing a 1 1/2-inch needle at a schedule of 0, 1, and 6 months. At the time of delivery specimens were obtained for maternal serum levels and paired cord blood levels of HbsAb. Levels were determined utilizing a quantitative enzyme-linked immunoadsorbent assay (ELISA) analysis (AUSAB-EIA Abbott Lab; Abbott Park, IL). A serum titer of > or =10 mLU/mL was considered seroprotective. Maternal and cord blood groups identified by seroprotection status were then sudivided by number of maternal vaccines received. Data were compared using the Student's t-test and Chi-square or Fisher's exact test. Eighteen gravidas (49%) had seroprotective titers at the time of delivery. Of these, 16 (88%) had seroprotective cord blood levels. All maternal specimens with a HbsAb titer > or =35 mLU/mL were associated with cord blood tiers > or =10 mLU/mL. When maternal titers achieved seroprotective levels of HbsAb, there was no difference in the frequency of cord blood seroprotection comparing groups by number of maternal vaccine doses received. When maternal titers of HbsAb achieve seroprotective levels following vaccination, cord blood seroprotection was achieved in 88% of studied patients. Maternal HbsAb titers > or =35 mLU/mL were associated with cord blood seroprotective levels in all cases.

Hepatitis B vaccination in pregnancy: factors influencing efficacy

OBJECTIVE

To determine seroprotective antibody response after hepatitis B vaccination during pregnancy and to assess factors influencing the rate of maternal seroprotection.

METHODS

Records of 80 healthy gravidas who elected hepatitis B vaccination during pregnancy, after being identified as hepatitis B surface antigen (HbsAg) and antibody (HbsAb) negative on initial prenatal screen, were analyzed retrospectively. Each gravida was begun on a series of three recombinant hepatitis B vaccines at 0, 1, and 6 months. At 36-40 weeks' gestation, all gravidas were rescreened for seroprotective levels of HbsAb using qualitative enzyme-linked immunosorbent assay analysis. The women were grouped by maternal age (less than 25 years or at least 25 years), smoking history, maternal weight, body mass index (BMI) (less than 30, at least 30, less than 34, or at least 34), number of vaccinations received, race-ethnicity, gestational age at vaccination, and vaccination-to-rescreening interval. Data were compared by t test, chi2 test, or Fisher exact test. Stepwise logistic regression analysis was done.

RESULTS

At rescreening, 39 (49%) of the 80 women had seroprotective HbsAb conversion. After two vaccinations, obese women (BMI at least 30) (P = .04), women at least 25 years old (P = .04), and women with smoking histories (P = .005) were significantly less likely to respond to the vaccine. Logistic regression analysis for predicting failure of seroprotective response after two vaccinations showed significantly increased odds for severe obesity with BMI at least 34 (odds ratio [OR] 16.2; 95% confidence interval [CI] 1.7, 154.7), smoking history (OR 7.5; 95% CI 2.0, 27.7), and age at least 25 years (OR 3.9; 95% CI 1.1, 14.4).

CONCLUSION

Maternal obesity, advancing age, and smoking have negative influences on the efficacy of hepatitis B vaccination in pregnant women.

Diagnosis of von Willebrand disease type 2N: a simplified method for measurement of factor VIII binding to von Willebrand factor

Diagnosis of von Willebrand disease Type 2N (vWD 2N), which mimics hemophilia A and its carrier state, is important for accurate genetic counseling and appropriate therapy. To make testing for the disorder more clinically applicable, we developed a simplified method for measurement of factor VIII (FVIII) binding to von Willebrand factor (vWF) using commercially available reagents and standard clinical assays. FVIII binding to vWF was measured by capture of patient vWF by polyclonal antibodies on cyanogen bromide-activated Sepharose beads, reaction with recombinant FVIII, and assay of unbound FVIII by clotting methods. Unbound vWF was measured in patient plasma after capture by the Laurell method. The ratio of bound FVIII/bound vWF was normal in hemophilia A, vWD Type 1, and vWD Type 3 patients, and abnormal in 5 subjects from two families, all of whom had vWD 2N mutations. Patient 1, with FVIII 8 U/dl, vWF: Ag 61 U/dl, vWF:RC 74 U/dl, and FVIII binding nil, was homozygous for the Arg91 Gln mutation. She was followed during pregnancy and delivered an unaffected heterozygous son. Patient 2 had FVIII 8 U/dl, vWF:Ag 73 U/dl, and vWF:RC 71 U/dl, and very low FVIII binding. She was heterozygous for Arg91Gln, as were her mother and sister; no second vWD 2N mutation was found. Her brother, with FVIII 14 U/dl, vWF:Ag 113 U/dl, and vWF:RC 72 U/dl, has no evidence of vWD 2N. With an X-linked inheritance pattern of bleeding tendency, this family is the first reported with combined hemophilia A and vWD 2N.

Women's perception of pain and distress during intravenous catheterization and urethral mini-catheterization

A study was done to prospectively compare the pain and distress of urethral mini-catheterization (MC) with the pain and distress of intravenous (IV) catheterization in women. Ten-centimeter visual analog scales were used on which the left end represented "no pain" or "no distress" and the right "the worst pain imaginable" or "extreme distress." Distress was defined to include embarrassment, anxiety, or fear. A convenience sample of 40 adult women who presented to a university emergency department and were undergoing both procedures as part of their management appraised pain and distress after IV placement and urethral MC. The mean IV pain score was 4.2 cm, whereas the mean MC score was only 2.6 cm (P = .02). The IV and MC distress score means were similar (2.3 v 2.6 cm, P = .55). These results suggest that patients perceive urethral MC as less painful than IV placement. The distress scores of these two procedures did not differ and were low in both instances.

Spiking mortality of turkey poults: 1. Experimental reproduction in isolation facilities

Spiking mortality of turkeys (SMT) is an infectious disease of 5-to-25-day-old turkey poults characterized by acute enteritis and bursal and thymic atrophy. Brooding 1-day-old poults on litter taken from naturally occurring cases successfully reproduced SMT 5 days postexposure. Oral exposure to an organ homogenate made of tissue samples from naturally occurring cases successfully reproduced SMT 5 days postinoculation. Coronaviruses were present in intestinal and bursal contents taken from poults with naturally occurring SMT. They were also present 5 days after exposure in the experimentally reproduced disease. Severe intestinal villus atrophy, bursal follicular lymphoid depletion, and thymic cortical atrophy were present histologically in naturally occurring SMT and in SMT reproduced by either experimental method.

A multicenter, randomized, double-blind, placebo-controlled trial of influenza immunization in multiple sclerosis

We determined the effect of influenza vaccine in patients with relapsing/remitting MS. Considerable controversy surrounds the question of whether to administer influenza vaccines to MS patients. Prevention of a febrile viral illness is clearly desirable in MS, and previous studies suggest that immunization is safe. Despite this, many clinicians avoid vaccination because they fear precipitating an MS exacerbation. We conducted a multicenter, prospective, randomized, double-blind trial of influenza immunization in patients with relapsing/remitting MS. In the autumn of 1993, 104 patients at five MS centers received either standard influenza vaccine or placebo. Patients were followed for 6 months for evaluation of neurologic status and the occurrence of influenza. Influenza was operationally defined as fever > or = 38 degrees C in the presence of coryza, cough, or sore throat at a time when the disease was present in the community. Attacks were defined in the standard manner, requiring objective change in the examination. Patients were examined at 4 weeks and 6 months after inoculation and were contacted by telephone at 1 week and 3 months. They were also examined at times of possible attacks but not when they were sick with flu-like illness. Three vaccine patients and two placebo patients experienced attacks within 28 days of vaccine (no significant difference). Exacerbation rates in the first month for both groups were equal to or less than expected from published series. The two groups showed no difference in attack rate or disease progression over 6 months. Influenza immunization in MS patients is neither associated with an increased exacerbation rate in the postvaccination period nor a change in disease course over the subsequent 6 months.

Concurrent validity of the Beck Depression Inventory as a measure of depression

The Beck Depression Inventory was administered, along with measures of anxiety, locus of control, and self-concept, to 211 undergraduates at a major southern institution to test for concurrent validity. Correlations of scores on Beck's scale with other scores provide additional support for Beck's scale as a valid measure of depression.

Benchmarking and networking through collaborative groups

The search for better ways to deliver healthcare services at lower cost led a group of hospitals in the Carolinas, 2 years ago, to pioneer a new concept, the collaborative group. A collaborative group typically is composed of five or six similar (but not competing) hospitals that work together closely to help each other make the changes necessary to survive in an increasingly competitive marketplace. Hospital staff members at all levels are able to work together to discover improvement opportunities through benchmarking teams and networking efforts. This article describes their experiences, achievements, and lessons learned.

Biochemical and genetic characterization of Corynebacterium pseudotuberculosis

Isolates (n = 94) of Corynebacterium pseudotuberculosis were obtained from sheep, goats, horses, and cattle from various parts of the world. The isolates were characterized biochemically and by restriction endonuclease analysis of DNA. We found near homogeneity in the ability of isolates to ferment carbohydrates and to produce urease. All isolates produced phospholipase D and catalase. The ability of isolates from horses to reduce nitrate, the inability of isolates from sheep and goats to do so, and the correlation of this characteristic with results of restriction endonuclease analyses confirmed the existence of 2 biovars of C pseudotuberculosis. We propose that these biovars be referred to as biovar equi for isolates that reduce nitrate and biovar ovis for isolates that fail to do so.