Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan: evidence from two longitudinal cohort studies 15 years apart

BACKGROUND

Oshikhandass is a rural village in northern Pakistan where a 1989-1991 verbal autopsy study showed that diarrhea and pneumonia were the top causes of under-5 mortality. Intensive surveillance, active community health education and child health interventions were delivered in 1989-1996; here we assess improvements in under-5 mortality, diarrhea, and pneumonia over this period and 15 years later.

METHODS

Two prospective open-cohort studies in Oshikhandass from 1989 to 1996 (Study 1) and 2011-2014 (Study 2) enrolled all children under age 60 months. Study staff trained using WHO guidelines, conducted weekly household surveillance and promoted knowledge on causes and management of diarrhea and pneumonia. Information about household characteristics and socioeconomic status was collected. Hurdle models were constructed to examine putative risk factors for diarrhea and pneumonia.

RESULTS

Against a backdrop of considerable change in the socioeconomic status of the community, under-5 mortality, which declined over the course of Study 1 (from 114.3 to 79.5 deaths/1000 live births (LB) between 1989 and 1996), exceeded Sustainable Development Goal 3 by Study 2 (19.8 deaths/ 1000 LB). Reductions in diarrhea prevalence (20.3 to 2.2 days/ Child Year [CY]), incidence (2.1 to 0.5 episodes/ CY), and number of bloody diarrhea episodes (18.6 to 5.2%) seen during Study 1, were sustained in Study 2. Pneumonia incidence was 0.5 episodes /CY in Study 1 and 0.2/CY in Study 2; only 5% of episodes were categorized as severe or very severe in both studies. While no individual factors predicted a statistically significant difference in diarrhea or pneumonia episodes, the combined effect of water, toilet and housing materials was associated with a significant decrease in diarrhea; higher household income was the most protective factor for pneumonia in Study 1.

CONCLUSIONS

We report a 4-fold decrease in overall childhood mortality, and a 2-fold decrease in childhood morbidity from diarrhea and pneumonia in a remote rural village in Pakistan between 1989 and 2014. We conclude that significant, sustainable improvements in child health may be achieved through improved socioeconomic status and promoting interactions between locally engaged health workers and the community, but that continued efforts are needed to improve health worker training, supervision, and the rational use of medications.

TRIAL REGISTRATION

Not Applicable.

Comparison of corn silage hybrids for yield, nutrient composition, in vitro digestibility, and milk yield by dairy cows

A study was undertaken to compare Novartis N29-F1, a dual-purpose 90-d relative maturity corn hybrid, and Novartis NX3018, a 90-d relative maturity leafy corn silage hybrid for dry matter (DM) yield, in vitro digestibility, plant components, nutrient composition, and lactational performance by Holstein cows. The two corn hybrids were planted in replicated 15.2- x 321-m plots. Plant population and DM yield were similar between the two corn hybrids. Novartis NX3018 had higher content of crude protein and ash, a higher proportion of leaves and stalks, and a lower proportion of grain compared with Novartis N29-F1. The cob, grain, and leaves of Novartis NX3018 had higher in vitro true DM and neutral detergent fiber disappearances compared with the respective plant components of Novartis N29-F1. Thirty-eight midlactation multiparous Holstein cows (78 +/- 23.0 days in milk) producing 47.2 +/- 8.9 kg of milk per cow per day were blocked and assigned randomly to one of two total mixed ration (TMR) containing (DM basis) approximately 26% Novartis N29-F1 or Novartis NX3018 corn silage. Cows were housed in a free-stall barn and group fed ad libitum. The lactation study was conducted as a crossover design with two 28-d periods. Samples and data were collected during the final 7 d of each period. The total mixed rations were formulated using the Cornell-Penn-Miner Dairy nutrition model. Cows that were fed the total mixed rations containing Novartis NX3018 corn silage produced higher yields of milk 3.5% fat-corrected milk (FCM), milk crude protein, and milk lactose compared to cows that were fed the TMR containing Novartis N29-F1 corn silage. In conclusion, the Novartis NX3018 corn hybrid was leafier and more digestible in vitro, and when fed to dairy cows as silage, promoted higher milk yield compared with the Novartis N29-F1 corn hybrid.

Effect of corn silage hybrid on dry matter yield, nutrient composition, in vitro digestion, intake by dairy heifers, and milk production by dairy cows

Three corn hybrids, Mycogen TMF94, Cargill F337 (which contains a brown midrib trait), and Pioneer 3861 were compared in a plot trial, an intake trial, and a lactation trial. In the plot trial, the three corn hybrids were planted in replicated 15.2 x 385-m plots. Mycogen TMF94 and Cargill F337 had lower yields of dry matter (DM), higher concentrations of neutral detergent fiber, and higher in vitro true DM disappearance compared with Pioneer 3861. Mycogen TMF94 had a higher yield of DM than Cargill F337 despite having a lower plant population. However, Cargill F337 had a higher in vitro true DM disappearance than Mycogen TMF94. In the intake trial, six individually penned Holstein heifers were blocked and assigned randomly to one of three total mixed rations containing 79% (DM basis) Mycogen TMF94, Cargill F337, or Pioneer 3861 corn silages in replicated 3 x 3 Latin squares. Heifers fed the Pioneer 3861-based TMR had lower DMI than heifers fed Mycogen TMF94 and Cargill F337-based TMR. In the lactation trial, 75 midlactation Holstein cows were blocked and assigned randomly to one of three total mixed rations containing 31% (DM basis) Mycogen TMF94, Cargill F337, or Pioneer 3861 corn silages used in the intake trial. Milk production was highest for cows fed Cargill F337-based total mixed rations. It is concluded from this study that Mycogen TMF94 was higher yielding, but less digestible, and resulted in lower milk production by lactating cows than Cargill F337. In addition, Mycogen TMF94 had higher in vitro true DM disappearance, and similar DM yield and milk production by lactating cows when compared with Pioneer 3861.

Historic landmarks in clinical transplantation: conclusions from the consensus conference at the University of California, Los Angeles

The transplantation of organs, cells, and tissues has burgeoned during the last quarter century, with the development of multiple new specialty fields. However, the basic principles that made this possible were established over a three-decade period, beginning during World War II and ending in 1974. At the historical consensus conference held at UCLA in March 1999, 11 early workers in the basic science or clinical practice of transplantation (or both) reached agreement on the most significant contributions of this era that ultimately made transplantation the robust clinical discipline it is today. These discoveries and achievements are summarized here in six tables and annotated with references.

Landmarks in the development of hematopoietic cell transplantation

The field of bone marrow transplantation has evolved over a period of 50 years. Reports of beneficial treatment of murine leukemia by irradiation and injection of marrow cells from another mouse stimulated interest in attempting to use these techniques to treat patients with leukemia. The first few bold attempts at human application were generally met with a total lack of success except for a few transplants involving identical twins. Understanding the HLA system led to the ability to select compatible sibling donors. The first successful long-term survivors were reported at the end of the 1960s. During the 1970's patients were given transplants for leukemia after failure of all other treatment. Survivals were poor, but some patients were cured. Transplantation early in the course of the disease resulted in greatly improved survival. During the 1980s improved control of infections, the use of peripheral blood as the source of stem cells, and the ability to select donors other than family members resulted in wide application of hematopoietic cell grafting.

Bone marrow transplantation: a review

Bone marrow transplantation has evolved over a period of 50 years. Laboratory observations and animal studies defined the essentials of transplantation biology. The first attempts to transfer these studies to patients met with little success. The definition of the complexities of the human leukocyte antigen (HLA) system made it possible to select compatible sibling donors and more recently unrelated donors. Transplantation of stem cells from marrow, blood, or cord blood is now the treatment of choice for a variety of hematological and genetic diseases. Transplantation using less toxic preparative regimens to induce mixed chimerism makes possible an application to autoimmune diseases. Laboratory and clinical research directed toward induction of tolerance and elimination of malignant cells point the way to a wider application of hematopoietic cell transplantation in the next decade.

Methotrexate and cyclosporine for graft-vs.-host disease prevention: what length of therapy with cyclosporine?

One hundred three patients with leukemia, aplastic anemia, or myelodysplastic syndrome were treated by marrow transplantation from genotypically HLA-identical siblings (n = 92) or HLA haploidentical family members differing for one HLA antigen on the nonshared haplotype (n = 11). To prevent graft-vs.-host disease (GVHD), they were administered postgrafting immunosuppression with a short course of intermittent methotrexate with daily cyclosporine for no more than 11 days. Customarily, we have given cyclosporine for 180 days after transplant. In the current study, we asked whether cyclosporine could be stopped earlier without affecting the risk of chronic GVHD. By day 60, patients who never had acute GVHD, or whose acute GVHD had resolved, were randomized to have cyclosporine stopped (n = 52) or continued for the usual 180 days (n = 51). Results were analyzed with a median follow-up of 9.3 years after transplant, and showed that patients in whom cyclosporine was discontinued on day 60 had a significantly more rapid onset (p = 0.001), but not a significantly higher overall incidence of chronic GVHD than those in whom the drug was stopped on day 180 (43 vs. 54%; p = 0.26). Transplant-related mortality was comparable among patients without preceding acute GVHD, regardless of when cyclosporine was discontinued (11% for both study arms). However, transplant-related mortality appeared to increase among patients with preceding acute GVHD in whom cyclosporine was stopped by day 60 (38 vs. 17%). Results suggest that cyclosporine can safely be discontinued early in patients who never had evidence of acute GVHD, while those with preceding acute GVHD would benefit from a longer course of the drug. Because of the relatively small sample sizes, these results would best be treated as promising preliminary findings that should be confirmed in larger randomized studies.

Pros and cons of stem cell transplantation for autoimmune disease

The data and discussion at this symposium have provided a most useful analysis of the autoimmune diseases and their potential for therapy by stem cell transplantation. These diseases are characterized by threat to life and particularly by chronic, painful and debilitating courses that warrant aggressive therapy. Selection of patients will be difficult because of the variable disease course and the necessity to choose patients who still have reversible disease. The safety of both autologous and allogeneic stem cell grafting has progressed to the point where, in many cases, the risks of the disease far outweigh those of transplantation. In my opinion the data presented at this symposium show that we should proceed cautiously with both autologous and allogeneic stem cell grafts. Purified stem cells, which have the advantage of being free of lymphocytes, should be used for the first series of autologous studies. These studies are attractive because of the low risk of transplant related complications but are less likely to be curative. Allogeneic grafts from perfectly matched donors have the advantage of providing a completely new immunological environment. For this reason, I believe that curative results are most probable after allogeneic stem cell engraftment. Emphasis should be on the identification of patients with HLA matched siblings. Initially, these studies will be carried out in patients with advanced disease, as was the case in the early days of transplantation for leukemia. In considering more aggressive treatment for autoimmune diseases it appears there are 3 possible approaches. First, and most conservative, is to store peripheral blood stem cells for possible future marrow rescue and then to give higher doses of immunosuppressive agents, especially in combination, to see whether there is an improvement over conventional doses. Second, for those who prefer a conservative approach to stem cell transplantation, is to give myeloablative and lymphoablative chemotherapy followed by purified (lymphocyte-free) hematopoietic stem cells. Third, and most likely to be curative, is myeloablative and lymphoablative therapy followed by stem cells from an HLA matched family member with subsequent short methotrexate and cyclosporine treatment to control GVHD. As we have heard, there are differences of opinion about whether the preparative regimen should include irradiation. It should be pointed out that total body irradiation is the most effective way to destroy lymphoid cells throughout the body. Careful monitoring of accumulating clinical results will pilot future investigation.

Marrow transplantation for chronic myeloid leukemia: the influence of plasma busulfan levels on the outcome of transplantation

The influence of busulfan (BU) plasma concentration on outcome of transplantation from HLA identical family members for the treatment of chronic myelogenous leukemia (CML) was examined in 45 patients transplanted in chronic phase (CP) (n = 39) or accelerated phase (AP) (n = 6). All patients received the same regimen of BU, 16 mg/kg orally and cyclophosphamide (CY), 120 mg/kg intravenously. Plasma concentrations of BU at steady state (C(SS)BU) during the dosing interval were measured for each patient. The mean C(SS)BU was 917 ng/mL (range, 642 to 1,749; median, 917; standard deviation, 213). Of patients with C(SS)BU below the median, seven (five of 18 in CP and two of four in AP) developed persistent cytogenetic relapse and three of these patients died. There were no relapses in patients with C(SS)BU above the median. The difference in the cumulative incidence of relapse between the two groups was statistically significant (P = .0003). C(SS)BU was the only statistically significant determinant of relapse in univariable or multivariable analysis. The 3-year survival estimates were 0.82 and 0.64 for patients with C(SS)BU above and below the median (P = .33). There was no statistically significant association of C(SS)BU with survival or nonrelapse mortality, although the power to detect a difference in survival between 0.82 and 0.64 was only 0.24, similarly C(SS)BU above the median was not associated with an increased risk of severe regimen-related toxicity. We conclude that low BU plasma levels are associated with an increased risk of relapse.

Detection of bcr-abl transcripts in Philadelphia chromosome-positive acute lymphoblastic leukemia after marrow transplantation

Thirty-six patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) were studied for the presence of the bcr-abl fusion mRNA transcript after an allogeneic matched related (N = 12), partially matched related (N = 4), matched unrelated (N = 14), autologous (N = 5), or syngeneic (N = 1) bone marrow transplant (BMT). Seventeen were transplanted in relapse, and 19 were transplanted in remission. Twenty-three patients had at least one positive bcr-abl polymerase chain reaction (PCR) assay after BMT either before a relapse or without subsequent relapse. Ten of these 23 relapsed after a positive assay at a median time from first positive PCR assay of 94 days (range, 28 to 416 days). By comparison, only 2 relapses occurred in the 13 patients with no prior positive PCR assays; both patients had missed at least one scheduled follow-up assay and were not tested 2 months and 26 months before their relapse. The unadjusted relative risk (RR) of relapse associated with a positive PCR assay compared with a negative assay was 5.7 (95% confidence interval 1.2 to 26.0, P = .025). In addition, the data suggest that the type of bcr-abl chimeric mRNA detected posttransplant was associated with the risk of relapse: 7 of 10 patients expressing the p190 bcr-abl relapsed, compared with 1 of 8 who expressed only the p210 bcr-abl mRNA (P = .02, log-rank test). The RR of p190 bcr-abl positivity compared to PCR-negative patients was 11.2 (confidence interval 2.3-54.8, P = 0.003), whereas a positive test for p210 bcr-abl was apparently not associated with an increased relative risk. In separate multivariable models, PCR positivity remained a statistically significant risk factor for relapse after separately adjusting for donor (unrelated and partially matched v matched, autologous, and syngeneic), remission status at the time of transplant, the presence of acute graft-versus-host disease (GVHD), and type of conditioning regimen (total body irradiation dose of < or = 1,200 cGy v > 1,200 cGy). The PCR assay appears to be a useful test for predicting patients at high risk of relapse after BMT and may identify patients who might benefit from therapeutic interventions. The finding that the expression of p190 bcr-abl may portend an especially high risk of relapse suggests a different clinical and biologic behavior between p190 and p210 bcr-abl.

Stem cell transplantation: past, present and future

The early attempts at human allogeneic marrow transplants in the 1950's and 1960's were largely unsuccessful. The probability of success has improved steadily in the past two decades. Cure rates now range from 90% for non-malignant diseases transplanted early to 15% for patients with advanced leukemia. Most marrow transplants have involved an HLA matched sibling donor but, more recently, a matched unrelated volunteer marrow donor can be found for many patients without a family donor. Current research is focused on new preparative regimens for elimination of malignant cells, better prevention of graft-versus-host disease, and the use of hematopoietic growth factors and cytokines. Autologous transplants, which use the patient's own marrow, are increasing, particularly for breast cancer. The hematopoietic stem cells are responsible for marrow regeneration after a transplant. Sufficient numbers of stem cells for transplantation can now be obtained from the peripheral blood after mobilization of these cells by chemotherapy or hematopoietic growth factors. Transplants can also be achieved using stem cells obtained from cord blood at the time of delivery, tissue typed, and cryopreserved for later use. A variety of technological advances has reduced the hospitalization time for transplant patients with a corresponding saving in cost.

Bone marrow transplantation from bench to bedside

Marrow grafting, now more appropriately called hematopoietic stem cell grafting, has come a long way from early bench studies and desperate bedside therapeutic attempts in terminal patients. Grafting of hematopoietic stem cells is now standard therapy for selected diseases and stages of disease, and increasing application on an outpatient basis is rapidly lowering the cost of the procedure. The combined efforts of the now many clinical marrow transplant teams and the interested basic science laboratories will undoubtedly make the coming decade an exciting and productive time for science and for the well-being of patients with otherwise incurable diseases.

Reconstitution of cellular immunity against cytomegalovirus in recipients of allogeneic bone marrow by transfer of T-cell clones from the donor

BACKGROUND

Cytomegalovirus (CMV) disease in immunocompromised patients correlates with a deficiency of CD8+ cytotoxic T lymphocytes specific for CMV. We evaluated the safety and immunologic effects of immunotherapy with clones of these lymphocytes in recipients of allogeneic bone marrow transplants.

METHODS

Clones of CD8+ cytotoxic T cells specific for CMV proteins were isolated from the blood of bone marrow donors. Fourteen patients each received four intravenous infusions of these clones from their donors beginning 30 to 40 days after marrow transplantation. The reconstitution of cellular immunity against CMV was monitored before and during the period of infusions and for up to 12 weeks after the final infusion. The rearranged genes encoding the T-cell receptor served as markers in evaluating the persistence of the transferred T cells.

RESULTS

No toxic effects related to the infusions were observed. Cytotoxic T cells specific for CMV were reconstituted in all patients. In vitro measurements showed that cytotoxic activity against CMV was significantly increased (P < 0.001) after the infusions in 11 patients who were deficient in such activity before therapy. The level of activity achieved after the infusions was similar to that measured in the donors. Analysis of rearranged T-cell-receptor genes in T cells obtained from two recipients indicated that the transferred clones persisted for at least 12 weeks. Cytotoxic-T-cell activity declined in patients deficient in CD4+ T-helper cells specific for CMV, suggesting that helper-T-cell function is needed for the persistence of transferred CD8+ T cells. Neither CMV viremia nor CMV disease developed in any of the 14 patients.

CONCLUSIONS

The transfer of CMV-specific clones of CD8+ T cells derived from the bone marrow donor is a safe and effective way to reconstitute cellular immunity against CMV after allogeneic marrow transplantation.

1994 Consensus Conference on Acute GVHD Grading

Grading acute graft-versus-host disease (GVHD) is usually based on quantification of rash, serum bilirubin and diarrhea. Standard criteria have been developed and used for > 20 years by most transplant centers. However, neither the standard GVHD grading system nor any of several revisions has been validated in the context of GVHD prophylaxis with cyclosporine. The 1994 Consensus Conference on Acute GVHD Grading held in Keystone in January 1994 provided an opportunity to: (1) review data regarding these standard criteria; (2) determine if there are sufficient data to revise these criteria; and (3) develop recommendations for reporting results of GVHD prevention trials. Data were provided for 8249 patients from 12 large transplant centers and 2 transplant registries. Standard GVHD grading criteria were found to distinguish different mortality risks and treatment response rates. Analysis of new data suggested that persistent nausea with histologic evidence of GVHD but no diarrhea be included as stage 1 gastrointestinal GVHD. Additional studies were recommended to evaluate heterogeneity of outcome within GVHD grades prior to making further revisions. To improve comparability between publications, reports of GVHD prevention trials should include an accurate description of the grading system used and should report actuarial rates of grades II-IV and III-IV GVHD corrected for graft failure and potential interventions for early relapse. Additional information should include indications for therapy of GVHD and response.

Transplantation of hematopoietic progenitor cells with emphasis on the results in children

Attempted human allogeneic marrow transplants in the 1950's and 60's were largely unsuccessful. In the past two decades the probability of success has improved steadily depending on the type and stage of disease. All marrow transplant teams have observed that the results for children are better than for adults. Long-term survival and apparent cure rates range from about 90 percent for non-malignant diseases transplanted early to 15 percent for patients with advanced leukemia. Most marrow transplants have involved an HL-A matched sibling donor but, more recently, through the worldwide marrow donor registries a matched unrelated volunteer marrow donor can be found for many patients without a family donor. Current research involves new preparative regimens for elimination of malignant cells, better prevention of graft-versus-host disease (GVHD), and the use of hematopoietic growth factors and cytokines. Autologous transplants, which use the patient's own marrow, are increasing. The hematopoietic stem cell, which is responsible for marrow regeneration after a transplant, has been isolated and characterized. Stem cells for transplantation can now be obtained from the peripheral blood after mobilization of these cells by chemotherapy or hematopoietic growth factors.

Marrow transplantation for patients in accelerated phase of chronic myeloid leukemia

The records were reviewed of 58 patients receiving transplants in Seattle with unmanipulated marrow from HLA-identical siblings during the accelerated phase (AP) of chronic myeloid leukemia. Variables examined for association with survival and relapse included the interval from diagnosis to transplant, the reasons for categorization as AP, age, regimen, and cytomegalovirus serology. Four patients relapsed. The 4-year probabilities of survival, relapse-free survival, nonrelapse mortality, and relapse were 0.49, 0.43, 0.51, and 0.12, respectively. After completion of the stepwise multivariate analysis, age less than 38 years and categorization as AP solely on the basis of chromosomal abnormalities emerged as being independently significantly associated with improved survival. The 4-year probability of survival for the 16 patients categorized as AP because of chromosomal abnormalities and receiving transplant less than 1 year from diagnosis was 0.74. The low probability of relapse in these patients suggests that more aggressive preparative regimens are not indicated for patients receiving transplants in AP because of the increased risk of transplant-related mortality.

Stem cell transplantation: past, present and future

Attempted human allogeneic marrow transplants in the 1950s and 60s were largely unsuccessful. In the past two decades the probability of success has improved steadily depending on the type and stage of disease. Cure rates range from about 90% for nonmalignant diseases transplanted early to 15% for patients with advanced leukemia. Most marrow transplants have involved an HLA matched sibling donor but, more recently, through the National Marrow Donor Program, a matched unrelated volunteer marrow donor can be found for many patients without a family donor. Current research involves new preparative regimens for elimination of malignant cells, better prevention of graft-versus-host disease, and the use of hematopoietic growth factors and cytokines. Autologous transplants, which use the patient's own marrow, are increasing. The hematopoietic stem cell, which is responsible for marrow regeneration after a transplant, has been isolated and characterized. Stem cells for transplantation can now be obtained from the peripheral blood after mobilization of these cells by chemotherapy or hematopoietic growth factors. A variety of technological advances makes it possible to perform transplants with less time in the hospital and a corresponding saving in cost.

Marrow transplantation for chronic myeloid leukemia: a randomized study comparing cyclophosphamide and total body irradiation with busulfan and cyclophosphamide

A prospective randomized study was conducted comparing two conditioning regimens for the treatment of patients with chronic myeloid leukemia in chronic phase by marrow transplantation from HLA identical siblings. Sixty-nine patients received 60 mg/kg of cyclophosphamide on each of 2 successive days followed by 6 fractions of total body irradiation each of 2.0 Gy (CY-TBI), and 73 patients received 16 mg/kg of busulfan delivered over 4 days followed by 60 mg/kg CY on each of 2 successive days (BU-CY). There was no significant difference between the CY-TBI and the BU-CY groups in the 3-year probabilities of survival (0.80 for both), relapse (0.13 for both), or event-free survival (CY-TBI, 0.68; BU-CY, 0.71) or in speed of engraftment or incidence of venocclusive disease of the liver. The 4-year probabilities of survival and event-free survival for patients transplanted within 1 year of diagnosis were 0.86 and 0.72, respectively, for each group. Significantly more patients in the CY-TBI group experienced major creatinine elevations. There was significantly more acute graft-versus-host disease in the CY-TBI group. Fever days, positive blood cultures, hospitalizations, and inpatient hospital days were significantly more common in the CY-TBI group than in the BU-CY group. In conclusion, the BU-CY regimen was better tolerated than, and associated with survival and relapse probabilities that compare favorably with, the CY-TBI regimen.

The effects of daily recombinant human granulocyte colony-stimulating factor administration on normal granulocyte donors undergoing leukapheresis

The effects of daily administration of recombinant human granulocyte colony-stimulating factor (rhG-CSF) to eight normal volunteers donating granulocytes for neutropenic relatives undergoing marrow transplantation were studied. Granulocyte donors consisted of seven marrow donors (5 syngeneic, 2 HLA identical) and one haploidentical son who had not donated marrow. All donors were administered daily rhG-CSF at a mean dose of 5 micrograms/kg/d (range 3.5 to 6.0) for a mean of 11.75 days (range 9 to 14 days), and granulocytes were collected a mean of 7.6 times (range 4 to 12). RhG-CSF was well tolerated and only minor side effects were observed. All donors became anemic from marrow donation and the removal of red blood cells during the collection procedures. Red blood cell transfusions were not given. All donors had a decrease in platelet counts and the magnitude of the decrement appeared to be greater than in historical donors. This was due in part to increased removal of platelets with the collection product, but a direct effect of rhG-CSF on platelet production cannot be excluded. The mean precollection granulocyte level was 29.6 x 10(9)/L (range 11.8 to 79.8), which was a 10-fold increase over baseline. The mean number of granulocytes collected was 41.6 x 10(9) (range 1.3 to 144.1), which was a six-fold increase over historical donors not receiving rhG-CSF. The mean granulocyte level 24 hours after transfusion into neutropenic recipients was 0.95 x 10(9)/L (median 0.57 and range .06 to 9.47). This study indicates that rhG-CSF is safe to administer to normal individuals, significantly improves the quantity of granulocytes collected, and results in significant circulating levels of granulocytes in neutropenic recipients. Further studies to evaluate rhG-CSF in normal granulocyte donors are warranted.

The use of radiolabeled anti-CD33 antibody to augment marrow irradiation prior to marrow transplantation for acute myelogenous leukemia

Disease recurrence remains a major limitation to the use of marrow transplantation to treat leukemia. Previous transplant studies have demonstrated that higher doses of total-body irradiation result in less disease recurrence, but more toxicity. In this study, the possibility of delivering radiotherapy specifically to marrow using a radiolabeled anti-CD33 antibody (p67) was explored. Biodistribution studies were performed in nine patients using .05-.5 mg/kg p67 trace-labeled with 131I. In most patients initial specific uptake of 131I-p67 in the marrow was seen, but the half-life of the radiolabel in the marrow space was relatively brief, ranging from 9-41 hr, presumably due to modulation of the 131I-p67-CD33 complex with subsequent digestion and release of 131I from the marrow space. In four of nine patients these biodistribution studies demonstrated that with 131I-p67 marrow and spleen would receive more radiation than any normal nonhematopoietic organ, and therefore these four patients were treated with 110-330 mCi 131I conjugated to p67 followed by a standard transplant regimen of cyclophosphamide plus 12 Gy TBI. All four patients tolerated the procedure well and three of the four are alive in remission 195-477 days posttransplant. This study demonstrates the feasibility of using a radiolabeled antimyeloid antibody as part of a marrow transplant preparative regimen and also highlights a major limitation of using conventionally labeled anti-CD33--namely, the short residence time in marrow. Strategies to overcome this limitation include the use of alternative labeling techniques or the selection of cell surface stable antigens as targets.

Methylation of the DXS255 hypervariable locus 5′ CCGG site may be affected by factors other than X-chromosome activation status

Differences in the methylation status of certain cytosine residues between active and inactive X chromosomes can be used to determine X-inactivation in females heterozygous for X-linked restriction fragment length polymorphisms. We have studied methylation patterns in 105 females heterozygous at the DXS255 locus by Southern blotting of PstI and MspI or HpaII double digests and hybridization with the probe M27B. Unequivocal patterns of unilateral or bilateral X-inactivation were obtained in 15/64 and 49/64 cases, respectively. In the remaining 41 cases the results were unclear due to the absence of HpaII digestion of one or both PstI fragments. In 7 samples an unequivocal digestion pattern was demonstrated on repeat analysis, suggesting that the initial ambiguous pattern was due to incomplete HpaII digestion. In certain individuals, methylation at the 5' CCGG DXS255 locus may be affected by factors other than X-inactivation, making analysis of clonality with the M27B probe impossible. These individuals should be clearly identified in studies of clonality.

Donor alloreactivity may predict acute graft-versus-host disease in HLA-matched bone marrow transplantation for leukemia in early remission

The pretransplant alloantigen-dependent responding and stimulating capacity of donors and of recipients was studied retrospectively, in a study of prediction of acute graft-versus-host disease. Donor responding capacity (DRC) and host stimulating capacity (HSC) were defined by mixed lymphocyte culture (MLC) and normalized by help of the pool response. High and low DRC and strong and weak HSC was defined by distribution plots. Kaplan-Meier estimates of the risk of developing Grade II or higher aGvHD showed that first remission patients (N = 125) had a significantly different risk if transplanted with marrow from a donor with high (N = 54) or low (N = 71) DRC (chi 2 = 9.49; d.f. = 1; p less than 0.002). This was not the case for patients transplanted in later remissions. Host SC status had no significant influence on the aGvHD status (chi 2 = 1.75 and 2.40; d.f. = 1; p = 0.19 and 0.12, defined by normal controls A and B respectively). In conclusion, the results indicate that pretransplant donor alloreactivity may predict aGvHD, confirming the results from a Scandinavian study. The results need to be confirmed in prospective studies of alloreactivity as risk factor for aGvHD.

Mixed leukocyte culture reactivity and graft-versus-host disease in HLA-identical marrow transplantation for leukemia

The results of pretransplant mixed leukocyte culture (MLC) assays were compared to subsequent risk of graft-versus-host disease (GVHD) in 783 patients receiving marrow transplants from HLA genotypically identical sibling donors. The mean MLC response observed between 1303 normal HLA identical sibling pairs was 0.0 +/- 4.2% RR. The donor anti-recipient MLC reaction, an in vitro response that presumably might be relevant to GVHD, was significantly increased (greater than mean + 2 sd) in 83 (10.6%) of the cases, most often in patients in relapse at the time of testing. No association was found, however, between this increased donor anti-recipient MLC reactivity pretransplant and the incidence or severity of subsequent acute or chronic GVHD. These data suggest that the increased MLC responses sometimes observed between leukemia patients and their HLA identical sibling donors prior to marrow transplantation do not represent genetic differences capable of causing GVHD.

Chimeric BCR-abl messenger RNA as a marker for minimal residual disease in patients transplanted for Philadelphia chromosome-positive acute lymphoblastic leukemia

We correlated polymerase chain reaction (PCR)-detectable BCR-abl fusion transcripts with cytogenetic status in 24 patients with acute lymphocytic leukemia (ALL). Of 10 Philadelphia chromosome negative (Ph-) patients, only one was found to exhibit a BCR-abl fusion transcript. Fourteen patients with Ph+ ALL, including eight in clinical remission, exhibited PCR-detectable BCR-abl rearrangements. A detectable Ph chromosome was present in only five of the eight patients in clinical remission. Of the three cytogenetically negative, BCR-abl-positive patients, two eventually succumbed to post-bone marrow transplantation (BMT) relapse. The third died of early transplant complications. Serial PCR analyses were performed on four Ph+ ALL patients in clinical remission who underwent allogeneic BMT. One patient who was PCR negative on post-BMT days 21 and 75 became PCR-positive on day 116 and died in relapse on day 154. One patient was weakly positive for BCR-abl on day 23, negative on day 56, but died of transplant complications on day 124. Two patients exhibited no post-BMT BCR-abl rearrangements and remain well on days 279 and 371. Our findings suggest that PCR analysis may be useful in the early identification of relapse in patients transplanted for Ph+ ALL.