Progress in bone marrow transplantation in man

Assessment of psychological distress in prospective bone marrow transplant patients

Patient psychological distress is associated with many aspects of the bone marrow transplantation (BMT) process and has been linked with poor treatment outcomes. We assessed psychological distress in potential BMT candidates, and compared patient and nurse coordinator ratings of emotional distress at the time of initial BMT consultation. Fifty patients self-reported psychological distress using both the NCCN Distress Thermometer (DT) and the Hospital Anxiety and Depression Scale (HADS). Coordinators rated patient emotional distress using the DT and Coordinator Rating Scales that measure anxiety and depression. Fifty and 51% of patients self-reported clinically significant levels of emotional distress and anxiety, respectively, but only 20% self-reported clinically significant levels of depression. There was good correlation between ratings using the brief DT and the more comprehensive HADS. There was significant but only moderate agreement between patient and coordinator ratings of emotional distress and anxiety, with coordinators underestimating the number of patients with high levels of emotional distress. In addition, coordinator ratings of patient emotional distress primarily reflected anxiety, whereas anxiety and depression together only minimally accounted for patient self-reports of psychological distress. These findings suggest that: (1) the DT can be a useful screening device; (2) approximately half of patients at the time of initial consultation for BMT already experience significant levels of psychological distress; and (3) coordinators observe emotional distress primarily as anxiety, but patients experience psychological distress as something more than anxiety and depression.

Psychological and immunological reactions of family members to patients undergoing bone marrow transplantation

The authors' goal was to evaluate the impacts of patients' bone marrow transplant (BMT) on their spouse/partner's (subjects) psychological and immunological status at four key points in the course of their transplant. Subjects' (N = 24) psychological and immunological status was prospectively evaluated at four key points in the patient's BMT which included: at patients' admission to hospital and 0-, 20-, and 34-day intervals after BMT infusion. Psychological variables examined included: a) general psychological distress and negative affect; b) tendency to respond in a socially desirable manner; c) state negative affect; and d) coping style, specifically if escape-avoidance coping was used. Immune variables examined included: percentages of total T cells and of CD4+, CD8+ cells, B cells, and natural killer (NK) cells, and NK cytotoxicity. Greatest abnormality in immune variables was detected before the initiation of BMT (i.e., between admission and day 0) with normalization between days 21 and 34 thereafter. During the waiting period before BMT, the subjects had the highest scores on negative affects, escape-avoidance coping, and psychological symptoms. These progressively declined after the BMT procedure. Significant correlations were found among trait anxiety, escape-avoidance coping, and total percentage of T cells and of CD4+ cells. Escape-avoidance coping was reliably correlated with percentage of B cells. The greatest psychological and immunological impacts on spouse/partners of BMT patients were found in the period directly after hospital admission and before BMT infusion. Alterations in immune values occurred in anticipation of BMT in the spouse/partners. Psychological symptoms followed this same pattern, being most elevated before BMT and decreasing in the successive evaluations post-BMT for the spouse/partners. The most significant and consistent psychological variable in predicting immune changes was escape-avoidance coping, with less escape-avoidance coping predicting better immune functioning.

Synergism between T and non-T cells in the in vivo induction and in vitro expression of graft-vs.-host disease-induced natural suppressor cells

We have been studying the mitogen hyporesponsiveness and immunosuppression induced in chronic murine graft-vs.-host disease (GVHD) induced across minor histocompatibility (MiHA) barriers. In this system, donor and recipient mice are major histocompatibility complex- and mls-identical, and are nonreactive in primary mixed leukocyte reactions. Spleen cells from B10.D2 (H-2d, mls b) mice were injected into irradiated (600 rad) BALB/c (H-2d, mls b) recipients. Recipient spleen cells are hyporesponsive to mitogens, and contain natural suppressor (NS) cells. We investigated the cellular requirements for both the in vivo induction and the in vitro expression of this GVH suppression. T cells are required in the graft, but they are not sufficient to induce suppression, and a non-T cell population is also required for maximum induction in vivo. T cells are also required for the maximum expression of NS cell suppressive ability in vitro. Early in the course of GVH, the suppressor cells are able to suppress the Con A and LPS response of all mouse strains tested (except for the relative difficulty in suppressing the B10.D2 LPS response). Later, they become almost completely unable to suppress the B10.D2 LPS response; while still being able to suppress the Con A and LPS response of all other strains tested (including the B10.D2 Con A response). This inability to suppress a B10.D2 LPS response can be brought back to almost complete suppression by the addition of concanavalin A supernatant (CAS). We present a hypothesis to explain what may be a common mechanism for GVH-induced suppression, total lymphoid irradiation-induced suppression, and neonatal tolerance. These situations all include rapidly proliferating lymphohematopoietic stem cell populations, and also have large numbers of NS cells. NS cells can suppress proliferating lymphoid populations, and their development and activity are greatly enhanced by T cell signals such as are supplied by donor T cells in chronic GVHD. Thus, NS cells may feed back on and downregulate self-reactive T cells or T cells responding to introduced foreign antigens.