Floating treatment wetlands for domestic wastewater treatment

Floating islands are a form of treatment wetland characterized by a mat of synthetic matrix at the water surface into which macrophytes can be planted and through which water passes. We evaluated two matrix materials for treating domestic wastewater, recycled plastic and recycled carpet fibers, for chemical oxygen demand (COD) and nitrogen removal. These materials were compared to pea gravel or open water (control). Experiments were conducted in laboratory scale columns fed with synthetic wastewater containing COD, organic and inorganic nitrogen, and mineral salts. Columns were unplanted, naturally inoculated, and operated in batch mode with continuous recirculation and aeration. COD was efficiently removed in all systems examined (>90% removal). Ammonia was efficiently removed by nitrification. Removal of total dissolved N was ∼50% by day 28, by which time most remaining nitrogen was present as NO(3)-N. Complete removal of NO(3)-N by denitrification was accomplished by dosing columns with molasses. Microbial communities of interest were visualized with denaturing gradient gel electrophoresis (DGGE) by targeting specific functional genes. Shifts in the denitrifying community were observed post-molasses addition, when nitrate levels decreased. The conditioning time for reliable nitrification was determined to be approximately three months. These results suggest that floating treatment wetlands are a viable alternative for domestic wastewater treatment.

Comparison of matched unrelated and matched related donor myeloablative hematopoietic cell transplantation for adults with acute myeloid leukemia in first remission

Hematopoietic cell transplantation (HCT) from a matched related donor (MRD) benefits many adults with acute myeloid leukemia (AML) in first complete remission (CR1). The majority of patients do not have such a donor, however, requiring use of an alternative donor if HCT is undertaken. We retrospectively analyzed 226 adult AML CR1 patients undergoing myeloablative unrelated donor (URD) (10/10 match, n=62; ≤9/10, n=29) or MRD (n=135) HCT from 1996–2007. Five-year estimates of overall survival (OS), relapse, and non-relapse mortality (NRM) were 57.9%, 29.7%, and 16.0%, respectively. Failure for each of these outcomes was slightly higher for 10/10 URD than MRD HCT, although statistical significance was not reached for any endpoint. The adjusted hazard ratios (HR) were 1.43 (0.89–2.30, p=0.14) for overall mortality, 1.17 (0.66–2.08, p=0.60) for relapse, and 1.79 (0.86–3.74, p=0.12) for NRM, respectively, and the adjusted odds ratio (OR) for grades 2–4 acute graft-versus-host disease was 1.50 (0.70–3.24, p=0.30). Overall mortality among 9/10 and 10/10 URD recipients was similar (adjusted HR=1.16 [0.52–2.61], p=0.71). These data indicate that URD HCT can provide long-term survival for CR1 AML; outcomes for 10/10 URD HCT, and possibly 9/10 URD HCT, suggest that this modality should be considered in the absence of a suitable MRD.

The impact of midlevel providers on productivity in outpatient oncology clinics at National Comprehensive Cancer Network (NCCN) institutions

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Background: An ASCO workforce study has predicted an oncologist shortage by 2020. Increased reliance on mid-level providers (PA/NPs) has been proposed to ameliorate the physician shortage. However, no methods currently exist to assess the impact of PA/NPs as physician extenders in an oncology setting. Obtaining productivity data is challenging due to variations in PA/NP utilization and billing. NCCN developed a survey to evaluate the use of PA/NPs in cancer centers and to pilot test PA/NP productivity metrics in outpatient oncology clinics. Methods: An online survey instrument was developed in consultation with oncologists, executive administrators, and PA/NP leaders at NCCN institutions. It included questions on work characteristics, allocation of time and labor, and productivity. PA/NP outpatient clinic productivity was measured as the average number of new and follow-up patients seen per half-day clinic (patients per clinic, PPC). A convenience sample was obtained through 15 NCCN institutions that distributed the survey through their own internal PA/NP e-mail lists. Results: A total of 206 PA/NPs completed the survey. A greater proportion of respondents were NPs (54%) than PAs (46%). Most responding PA/NPs listed their primary specialty as medical oncology (MO, 34%), followed by hematologic malignancies/BMT (HM/BMT, 28%) and surgical oncology (SO, 23%). The highest reported productivity was observed for SO specialists (mean = 8.7 PPC, SD = 3.5), followed by MO (mean = 7.6, SD = 4.3), and HM/BMT (mean = 6.1, SD = 2.8). Within the SO and HM/BMT specialties, little difference was observed between NP and PA productivity. Among MO specialists, NPs reported seeing more follow-up patients per clinic (mean = 7.2, SD = 4.3) than PAs (mean = 5.5, SD = 2.7, p = 0.04). In most cases, productivity was unrelated to seniority. However, more experienced HM/BMT NPs were more productive with new patients (rs = 0.46, p = 0.03). Conclusions: Mid-level providers have a measurable impact on productivity in outpatient oncology clinics. Refining productivity metrics for PAs/NPs will help inform workforce projections and staffing decisions for oncology practices/specialists and cancer centers, especially in the face of future physician shortages.

No significant financial relationships to disclose.

Murine marrow cellularity and the concept of stem cell competition: geographic and quantitative determinants in stem cell biology

In unperturbed mice, the marrow cell numbers correlate with the stem cell numbers. High levels of long-term marrow engraftment are obtained with infusion of high levels of marrow cells in untreated mice. To address the issue of stem cell competition vs 'opening space', knowledge of total murine marrow cellularity and distribution of stem and progenitor cells are necessary. We determined these parameters in different mouse strains. Total cellularity in BALB/c mice was 530+/-20 million cells; stable from 8 weeks to 1 year of age. C57BL/6J mice had 466+/-48 million marrow cells. Using these data, theoretical models of infused marrow (40 million cells) replacing or adding to host marrow give chimerism values of 7.5 and 7.0%, respectively; the observed 8-week engraftment of 40 million male BALB/c marrow cells into female hosts (72 mice) gave a value of 6.91+/-0.4%. This indicates that syngeneic engraftment is determined by stem cell competition. Our studies demonstrate that most marrow cells, progenitors and engraftable stem cells are in the spine. There was increased concentration of progenitors in the spine. Total marrow harvest for stem cell purification and other experimental purposes was both mouse and cost efficient with over a four-fold decrease in animal use and a financial saving.

Low molecular weight heparin for the treatment of venous thromboembolism in pregnancy: a case series

OBJECTIVES

To assess the use of low molecular weight heparin for the treatment of venous thromboembolism in pregnancy.

DESIGN

A prospective observational study.

SETTING

The maternity units in two university teaching hospitals and one district general teaching hospital.

POPULATION

Thirty-six consecutive women presenting with objectively diagnosed venous thromboembolism during pregnancy and the immediate puerperium.

METHODS

Treatment with the low molecular weight heparin enoxaparin, approximately 1 mg/kg s.c., twice daily, based on early pregnancy weight.

MAIN OUTCOME MEASURES

Peak anti-Xa activity (three hours post-injection), alterations in treatment, side effects and the use of regional anaesthesia.

RESULTS

In 33 women, the initial dose of enoxaparin provided satisfactory peak anti-Xa activity (median 0.8 u/mL, range 0.44-1.0 u/mL) and was continued. Three women required dose reduction since peak anti-Xa activities were above the therapeutic range (1.2, 1.2 and 1.1 u/mL). No woman developed thrombocytopaenia, haemorrhagic complication or further thromboembolic episode. Two women developed allergic skin reactions on enoxaparin and were changed to tinzaparin. Fifteen women had regional anaesthesia for delivery, with a reduced dose of enoxaparin (40 mg once daily), all without complication.

CONCLUSIONS

Enoxaparin is a safe and effective treatment for venous thromboembolism during pregnancy and confers a major advantage over unfractionated heparin through its simplified regimen of administration.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) priming with successive concomitant low-dose Ara-C for elderly patients with secondary/refractory acute myeloid leukemia or advanced myelodysplastic syndrome

Patients with advanced MDS and secondary AML respond poorly to chemotherapy. Granulocyte-macrophage colony-stimulating factor (GM-CSF) can stimulate proliferation of leukemic blasts and sensitize these cells to the cytotoxic effects of S-phase-specific drugs. This is the first report of safety and efficacy of GM-CSF prior to and during cytarabine in a low-dose, intermittent regimen for elderly patients with poor risk acute myelogenous leukemia or myelodysplastic syndrome. Twenty patients, age 68 to 86 years, each received 250 microg/m2 of GM-CSF (Sargramostatin; Immunex, Seattle, WA, USA) subcutaneously (s.c.) or intravenously (i.v.) for 3 days followed by GM-CSF at the same dose and cytarabine 100 mg/m2 i.v. for 3 days. GM-CSF and cytarabine were both administered for 3 days during weeks 2 and 3 followed by a 3-week rest period. Rates of CR and PR were 20% and 40%, respectively. These included clinically significant resolution of cytopenias and transfusion requirements. Many of the responding patients had been heavily pretreated prior to enrollment. One- and 2-year survival estimates are 44% and 19%, respectively. Myelosuppression was the most significant toxicity. Our findings suggest that this novel combination of GM-CSF with sequential and concomitant low-dose cytarabine can benefit patients with poor risk myeloid malignancies.

Host marrow stem cell potential and engraftability at varying times after low-dose whole-body irradiation

High levels of chimerism in syngeneic BALB/c transplants were reported when hosts were exposed to 1 Gy (100 cGy) whole body irradiation (WBI) and infused with 40 x 10(6) marrow cells. The recovery of host stem cells and alterations of enhanced host engraftability at varying times after 1 Gy WBI have now been evaluated in this study. Male BALB/c marrow (40 x 10(6) cells) was infused into female BALB/c hosts immediately or at 6, 12, and 24 weeks after 1 Gy WBI of host female BALB/c mice; engraftment percentages 8 weeks after cell injection at week 0, 6, 12, or 24 were 68% +/- 12%, 45% +/- 15%, 51% +/- 12%, or 20% +/- 8%, respectively. Eight-week engraftment levels in nonirradiated hosts average 7.7%. Conversely, engraftable stem cells measured at 8 weeks postengraftment in 1 Gy--exposed hosts were reduced to 8.6% +/- 3% of nonirradiated mice at time 0, 35% +/- 12% 6 weeks later, 49% +/- 10% at 3 months, and 21% +/- 7% at 6 months. Engraftment was still increased and stem cell decreased 1 year after 1 Gy. Furthermore, the primary cells transplanted into 1 Gy hosts can be serially transplanted, and the predominant effect of 1 Gy is directly on engrafting stem cells and not through accessory cells. These data show that transplantation in 1 Gy mice may be delayed until recovery of hematopoiesis, suggesting strategies in allogeneic transplantation to avoid the adverse effects of cytokine storm. The incomplete recovery of engraftable stem cells out to 12 months indicates that stem cell expansion, especially in patients previously treated with radiomimetic drugs, may not be feasible. (Blood. 2001;98:1246-1251)

Variables to predict engraftment of umbilical cord blood into immunodeficient mice: usefulness of the non-obese diabetic--severe combined immunodeficient assay

Umbilical cord blood is an alternative stem cell source for patients without matched family donors. In this study, we examined several parameters that have not been studied in detail -- radiation dose, cell dose, age of mice, and maternal and neonatal characteristics of the cord blood donor -- that affect engraftment of cord blood in non-obese diabetic-severe combined immunodeficient (NOD--scid) mice. Engraftment, measured using flow cytometry analyses of human CD45(+) cells, was highest in 400 cGy-treated mice. Successful engraftment was demonstrated up to 6 months, with a mean engraftment of 31% (range 0--67%) of human cells in recipient bone marrow. Engraftment was skewed to B lymphocytes. The radiation dose of 350 cGy resulted in superior survival of the murine recipients compared with 400 cGy (P = 0.03). The sex of the NOD--scid recipients had a significant effect on survival (female superior to male, P = 0.01), but not on engraftment. There were high levels of variability among different cord units and among animals injected with the same cord unit. This variability may limit the clinical usefulness of the NOD--scid mice as hosts for the quantification of human stem cells.

Stem cell engraftment strategies

The donor stem cell phenotype and host microenvironment determine the outcome of a stem cell transplant. In a series of transplant studies in syngeneic male to female or congenic Ly5.1/Ly5.2 models in which hosts have received no or minimal irradiation (100 cGy), evidence overwhelmingly supports the concept that syngeneic engraftment is determined by stem cell competition. These approaches can be extended to H-2 mismatched allogeneic mouse combination when antigen pre-exposure and CD40-CD40 ligand antibody blockage are employed. A human trial in patients with resistant neoplasia infusing pheresed blood with 10(8) CD3 cells/kg showed that tumor responses and complete chimerism occur with very low levels of CD34+ cells/kg and that the extent of previous treatment is a critical factor in determining chimerism. A major feature of transplants is the phenotype of the donor stem cell. This phenotype shows dramatic reversible plasticity involving differentiation, adhesion protein expression, and engraftment with cytokine-induced cell-cycle transit. Homing is probably also plastic. Marked fluctuations in engraftment capacity are also seen at different points in marrow circadian rhythm.

Epidemiology, evolution, and future of the HIV/AIDS pandemic

We used mathematical models to address several questions concerning the epidemiologic and evolutionary future of HIV/AIDS in human populations. Our analysis suggests that 1) when HIV first enters a human population, and for many subsequent years, the epidemic is driven by early transmissions, possibly occurring before donors have seroconverted to HIV-positive status; 2) new HIV infections in a subpopulation (risk group) may decline or level off due to the saturation of the susceptible hosts rather than to evolution of the virus or to the efficacy of intervention, education, and public health measures; 3) evolution in humans for resistance to HIV infection or for the infection to engender a lower death rate will require thousands of years and will be achieved only after vast numbers of persons die of AIDS; 4) evolution is unlikely to increase the virulence of HIV; and 5) if HIV chemotherapy reduces the transmissibility of the virus, treating individual patients can reduce the frequency of HIV infections and AIDS deaths in the general population.

Bigger is better: maternal and neonatal predictors of hematopoietic potential of umbilical cord blood units

Umbilical cord blood (CB) is a useful stem cell source for patients without matched family donors. CB banking is expensive, however, because only a small percentage of the cord units stored are used for transplantation. In this study, we determined whether maternal factors, such as race, age, and smoking status have an effect on laboratory parameters of hematopoietic potential, such as viability, cell counts, CD34+ cell counts, and CFU-GM. We studied the effect of neonatal characteristics such as birth order, birth weight, gestational age, and sex of the baby on the same laboratory parameters. Race and maternal age had no effect on these laboratory parameters. In multivariate analysis, babies of longer gestational age had higher cell counts, but lower CD34+ cell counts and CFU-GM. Bigger babies had higher cell counts, more CD34+ cells, and more CFU-GM. Women with fewer previous live births also produced cord units with higher cell counts, CFU-GM, and CD34+ cell counts. Specifically, each 500 g increase in birth weight contributed to a 28% increase in CD34+ cell counts, each week of gestation contributed to a 9% decrease in CD34+cell counts, and each previous birth contributed to a 17% decrease in CD34+ cell counts (all P < 0.05). These data may be used to select the optimal cord blood donors and allow CB banks efficient resource allocation.

Phenotype of the engrafting stem cell in mice

The present data on engraftment into non-myeloablated mice strongly suggest that engraftment is determined by host-donor ratios as opposed to opening space. Theoretically, if the ratios of donor to host stem cells could be altered, especially without causing toxicity to the host animal, then the phenotypic readout could be increased in a clinically applicable manner. To research this further, we investigated low-dose irradiation (100 cGy) for its effects on marrow, spleen and peripheral blood counts, as well as engrafting stem cell levels. We found a transient but significant depression in the white blood cell and platelet counts in the peripheral blood which returned to normal by two weeks, with no apparent deleterious effect on the animals. However, the same irradiation dose after two months impaired marrow repopulation and reduced engraftment potential to less than 20% capacity. These results suggested that we could obtain much higher phenotypic readouts after engraftment with this model; thus, we assessed the engraftment of 40 million male BALB/c marrow cells into female hosts exposed to 100 cGy at two, five and eight months after cell infusion. The resultant high levels of chimerism, reaching 100% in many cases, strongly suggest that the key to engraftment in these models is host-donor stem cell ratios. One important issue relative to the above finding is whether cytokine-stimulated proliferating stem cells have irreversibly lost engraftment capacity or whether changes in the engraftment capacity are of a plastic nature, possibly related to cell cycle transit. A number of experiments following engraftment have shown that the engraftment defect is reversible and can be repeatedly lost and regained during the initial portions of a cytokine-stimulated culture. The above results suggest that, at least at the more primitive stem cell level, hematopoietic stem cell regulation may in part be based on a cell cycle model rather than a hierarchical system.

Manipulation of the stem cell as a target for hematologic malignancies

Hematologic malignancies affect more than 80,000 patients in the United States each year. Some patients with lymphoma and leukemia are cured with conventional chemotherapy treatments. For others, autologous or allogeneic bone marrow transplantation may be the best therapeutic option. This chapter will explore novel therapies for the hematologic malignancies, using the stem cell as a target. We review work in the murine model looking at (1) the phenotype of the engrafting cells, (2) stem cell competition and host stem cells, (3) allochimerism with low-dose total body irradiation, and (4) the tolerance approach with costimulator blockade. Human data, including stem cell migration, adhesion receptor expression, and manipulations for gene therapy, are reviewed. The NOD/scid mouse model serves as a bridge between the basic bench work and human clinical trials, and we discuss applications related to umbilical cord blood and gene therapy, as well as discuss the inherent variability of this system. Finally, we address unique clinical applications in gene therapy, high-dose cell transplants, minimal myeloablation, and cellular immune therapy as approaches to treatment of for patients with hematologic malignancies.

Successful autologous bone marrow transplant without the use of blood product support

We describe a successful autologous bone marrow transplant without the use of any blood products. The patient had relapsed large cell lymphoma. He was a Jehovah's Witness and would not accept transfusions of red blood cells or platelets. He enrolled in our Bloodless Medicine and Surgery Program and was maintained on a regimen of erythropoietin, iron, Amicar, and G-CSF throughout the transplant. He tolerated the transplant well and is alive with no evidence of disease 10 months after autografting.

High-dose chemotherapy for high-risk primary breast cancer: an on-site review of the Bezwoda study

BACKGROUND

The efficacy of high-dose chemotherapy with progenitor-cell rescue for women with breast cancer is a controversial issue. Although historically controlled trials have suggested a survival advantage for high-dose chemotherapy, several randomised studies have yet to confirm this advantage. Two studies, however, by Bezwoda, of patients with high-risk and metastatic disease, seemed to show a significant survival advantage for high-dose compared with conventional-dose chemotherapy for metastatic and high-risk primary breast cancer.

METHODS

To corroborate the study results before starting a large international confirmatory study, a US team did an on-site review of records for patients in the high-risk study. Limited numbers of records were made available for review, all of which were for patients who received the high-dose-chemotherapy regimen.

FINDINGS

There was much disparity between the reviewed records and the data presented at two international meetings. In addition, the reviewers saw no signed informed consent, and the institutional review committee had no record of approval for the investigational therapy. After the site visit, Bezwoda admitted scientific misconduct by using a different control chemotherapy regimen from that described in presented data.

INTERPRETATION

The Bezwoda study should not be used as the basis for further trials to test the efficacy of the cyclophosphamide, mitoxantrone, etoposide regimen for high-dose chemotherapy in women with high-risk primary breast cancer. This review validates the essential nature of on-site audits, especially in single-institution studies.

Effect of ex vivo cytokine treatment on human cord blood engraftment in NOD-scid mice

Umbilical cord blood transplantation is considered an alternative to traditional bone marrow transplantation for patients who do not have matched sibling donors. In this study, we examined the effects of ex vivo treatment of human cord blood cells with cytokine mixtures and assessed the ability of treated cells to engraft in NOD-scid mice. We incubated the cord blood with a four-factor cytokine mixture of interleukin (IL)-3, IL-6, IL-11 and stem cell factor, or with a two-factor cytokine mixture of thrombopoietin and flt-3. Incubation of cord blood for 48 h with either cytokine mixture did not affect progenitor cell number or proliferative potential as measured by the high proliferative potential (HPP) assay. Cytokine-treated cord blood injected into irradiated NOD-scid mice resulted in multilineage human engraftment. Overall, incubation with cytokines resulted in variable levels of engraftment with different cord blood samples. Incubation of cord blood with the four-factor cytokine mixture resulted in increased survival of irradiated NOD-scid recipients. These results demonstrate that short-term ex vivo treatment of human progenitor cells gives variable results on in vivo multipotential capabilities.

Modified intranuclear organization of regulatory factors in human acute leukemias: reversal after treatment

Acute leukemias arise secondary to chromosomal aberrations that cause dysfunctions in gene regulation and regulatory factors. Significant differences in morphology between acute leukemic and nonleukemic hematopoietic cells are readily observed. How morphologic changes of the nuclei of acute leukemic cells relate to the underlying functional alterations of gene expression is minimally understood. Spatial modifications in the representation and/or organization of regulatory factors may be functionally linked to perturbations of gene expression in acute leukemic cells. Using in situ immunofluorescence microscopy, we addressed the interrelationships of modifications in nuclear morphology with the intranuclear distribution of leukemia-related regulatory factors (including ALL-1, PML, and AF-9) in cells from patients with acute leukemia. We compared the localization of leukemia-associated proteins with various factors involved in gene transcription and RNA processing (e.g., RNA polymerase II and SC-35). Our findings suggest that there are leukemia-associated aberrations in mechanisms that direct regulatory factors to sites within the nucleus. This misplacement of key cognate factors may contribute to perturbations in gene expression characteristic of leukemias.

Women and the world of dentistry

It was only in 1895 that the first woman dentist in the UK graduated from Edinburgh Dental School, and a further 17 years until a women was granted a dental qualification from The Royal College of Surgeons of England. At around this time cartoons began to appear, flippantly depicting women to be working in a profession regarded by many as masculine. Over the following years women dentists became more accepted, although as recently as the 1960's women were encouraged to enter certain branches of the profession where it was thought that they would be most useful. Government publications of this era encouraged women dentists to join the Maternity and Child Welfare Service and the School Health Service. It was felt that this work would be particularly suitable for them and that child patients would react more favourably to women dentists.

Safety and cost of hyperhydration for the prevention of hemorrhagic cystitis in bone marrow transplant recipients

Hemorrhagic cystitis is a major cause of morbidity after bone marrow transplantation. Traditional methods of prevention have included mesna (2-mercaptoethane sodium sulfonate) and bladder irrigation. We report the use of hyperhydration as an alternative to these prophylactic measures. One hundred consecutive patients who underwent autologous or allogeneic bone marrow transplantation received high dose cyclophosphamide with hyperhydration using 5% dextrose normal saline at the rate of 250 ml/h and furosemide to maintain a urine output of >150 ml/h. Seventy-one of these patients also received high dose cyclophosphamide as mobilization chemotherapy. There were no episodes of hemorrhagic cystitis following mobilization chemotherapy. The incidence of hemorrhagic cystitis after transplant conditioning was 7% with 2 patients developing clinically significant hemorrhagic cystitis; one was a severe episode. The cost of hyperhydration was US$ 20 per course as opposed to US$ 1,500 per course for mesna, based on acquisition costs at our institution. We conclude that hyperhydration is a safe, inexpensive means of preventing hemorrhagic cystitis associated with high dose cyclophosphamide in bone marrow transplant recipients.

High-dose paclitaxel plus G-CSF for malignant mesothelioma: CALGB phase II study 9234

BACKGROUND

New agents with activity in mesothelioma are sorely needed. The Cancer and Leukemia Group B (CALGB) therefore performed a phase II study of high-dose paclitaxel in patients with malignant mesothelioma who had no prior chemotherapy.

PATIENTS AND METHODS

Thirty-five patients accrued to this multi-institutional phase II study of paclitaxel given as a 24-hour infusion at 250 mg/m2 every three weeks plus filgrastim (G-CSF) 300 mcg subcutaneously days 3-18.

RESULTS

There were three (9%) regressions of evaluable disease. The median survival was five months (95% confidence interval (95% CI): 1.9-9.6 months), the one-year survival rate was 14% and the two-year survival rate was 6%. Toxicity was tolerable with one death from pneumonia (without neutropenia) on day 18 and a 23% rate of grade 4 granulocytopenia.

CONCLUSIONS

The level of activity seen with paclitaxel is similar to that seen in other CALGB trials of the single agents carboplatin, trimetrexate and 5-azacytidine. Future studies of of paclitaxel (at lower doses) in combination with synergistic agents could be considered.

Lymphohematopoietic stem cell engraftment

Traditional dogma has stated that space needs to be opened by cytoxic myeloablative therapy in order for marrow stem cells to engraft. Recent work in murine transplant models, however, indicates that engraftment is determined by the ratio of donor to host stem cells, i.e., stem cell competition. One hundred centigray whole body irradiation is stem cell toxic and nonmyelotoxic, thus allowing for higher donor chimerism in a murine syngeneic transplant setting. This nontoxic stem cell transplantation can be applied to allogeneic transplant with the addition of a tolerizing step; in this case presensitization with donor spleen cells and administration of CD40 ligand antibody to block costimulation. The stem cells that engraft in the nonmyeloablated are in G0, but are rapidly induced (by 12 hours) to enter the S phase after in vivo engraftment. Exposure of murine marrow to cytokines (IL-3, IL-6, IL-11 and steel factor) expands progenitor clones, induces stem cells into cell cycle, and causes a fluctuating engraftment phenotype tied to phase of cell cycle. These data indicate that the concepts of stem cell competition and fluctuation of stem cell phenotype with cell cycle transit should underlie any new stem cell engraftment strategy.

Atrial fibrillation: prevalence and management in an acute general medical unit

BACKGROUND

Atrial fibrillation (AF) is a common comorbid condition in patients admitted to hospital. In managing patients with AF, recent research has highlighted the importance of heart rate control, cardioversion, maintenance of sinus rhythm and anticoagulation for the prevention of thromboembolism.

AIM

To determine the prevalence of AF in patients admitted acutely to the general medical service at Auckland Hospital and to assess the adequacy of heart rate control, the number cardioverted and the use of warfarin to prevent thromboembolism.

METHODS

Prospective review of all acute admissions to the general medical service over a 12 week period. Information was collected from hospital notes on the patients' present and past medical conditions, admission and discharge cardiac medication and the use of investigations, particularly thyroid function tests and echocardiography. The heart rate on discharge, number cardioverted either during the admission or after discharge and the number given warfarin and aspirin were recorded.

RESULTS

One hundred and forty-seven patients (aged 38-96, mean age 76 years and 52% male) were admitted in AF 165 times out of the 1637 admissions over the study period (a prevalence of 10.4%, 95% CI 8.6-11.5%). The main causes of admission were heart failure (23%), pneumonia or sepsis (17%), cerebrovascular accident (CVA) or transient ischaemic attack (TIA) (14%) and ischaemic heart disease (11%). Past medical history included hypertension (46%), ischaemic heart disease (39%), congestive heart failure (58%), valvular heart disease (12%), chronic obstructive airways disease (24%), CVA, TIA or thromboembolic event (24%) and diabetes (17%). Thyroid function tests were performed in 50% of patients and echocardiograms in 38%. Heart rate control at discharge could not be assessed, as this was not recorded prior to any patient's discharge. Seventy-eight per cent of patients were discharged on digoxin but only 29% on drugs that control the heart rate with exercise. Five patients out of 11 considered for cardioversion had a successful cardioversion in hospital and two were later cardioverted as outpatients. Twenty-eight per cent were discharged on warfarin, 33% on aspirin and one patient on both. Fifty-two per cent were considered to have contraindications to warfarin therapy. Prescribing rates for warfarin did not vary according to the patients' clinical risk for thromboembolism.

CONCLUSION

AF is a common comorbid condition in the acute general medical ward. Standard investigations were under-utilised. Attention needs to be paid to the recording and control of heart rate at rest and on exercise. Cardioversion is considered infrequently. This patient group had a high risk for thromboembolism and after excluding the large group in whom warfarin was contraindicated, warfarin was still under-utilised.

Coverage of bone marrow transplant patients: a survey of American and Canadian institutions

Personnel involved in supportive care of bone marrow transplant (BMT) patients include fellows (F), medical house-staff (HS), nurse practitioners (NP), physician assistants (PA), and moonlighting physicians (MP). We have obtained surveys from 108 American and Canadian transplant centers on the composition of inpatient support teams. Eighty-seven percent of institutions responding to the survey were university-based programs. Eighty-eight percent of the centers performed both allogeneic and autologous transplants, and 60% performed unrelated donor grafts. The mean number of transplants performed annually at each center was 101 (range 4-515). For daytime coverage, the percent of programs involving F, HS, NP, PA, or MP was 57, 50, 35, 25, and 0%, respectively, and for nighttime coverage, the composition was 50, 56, 7, 6, and 13%, respectively. Medical HS were incorporated into the care of BMT patients at some level in 93% of the programs. Involvement by HS included full 24-hour coverage (44%), full nighttime coverage (8%), stat coverage (18%), and code blue only coverage (21%). HS involvement was similar in small and large transplant programs. HS were more involved in university-based programs. Programs on the East Coast had more HS involvement, with 54% of the programs reporting full 24-hour coverage by HS compared with 32% of the programs in the Pacific region. Coverage of transplant patients varies throughout the country, and nonphysician providers are often used. HS are more active in university-based programs, and their role is similar in both large and small programs.

The fluctuating phenotype of the lymphohematopoietic stem cell with cell cycle transit

The most primitive engrafting hematopoietic stem cell has been assumed to have a fixed phenotype, with changes in engraftment and renewal potential occurring in a stepwise irreversible fashion linked with differentiation. Recent work shows that in vitro cytokine stimulation of murine marrow cells induces cell cycle transit of primitive stem cells, taking 40 h for progression from G0 to mitosis and 12 h for subsequent doublings. At 48 h of culture, progenitors are expanded, but stem cell engraftment is markedly diminished. We have investigated whether this effect on engraftment was an irreversible step or a reversible plastic feature correlated with cell cycle progression. Long-term engraftment (2 and 6 mo) of male BALB/c marrow cells exposed in vitro to interleukin (IL)-3, IL-6, IL-11, and steel factor was assessed at 2-4-h intervals of culture over 24-48 h using irradiated female hosts; the engraftment phenotype showed marked fluctuations over 2-4-h intervals, with engraftment nadirs occurring in late S and early G2. These data show that early stem cell regulation is cell cycle based, and have critical implications for strategies for stem cell expansion and engraftment or gene therapy, since position in cell cycle will determine whether effective engraftment occurs in either setting.

Lymphohematopoietic engraftment in minimally myeloablated hosts

The concept that myeloablation to open space was a prerequisite for marrow stem cell engraftment has been challenged by studies showing high rates of engraftment in nonmyeloablated mice (Stewart et al, Blood 81:2566, 1993; Quesenberry et al, Blood Cells 20:97, 1994; Brecher et al, Blood Cells 5:237, 1979; Saxe et al, Exp Hematol 12:277, 1984; and Wu et al, Exp Hematol 21:251, 1993). However, relatively large numbers of marrow cells were necessary to achieve high long-term donor percentages. We have demonstrated, using a BALB/c male/female marrow transplant model and detecting male DNA in host tissues by Southern blot or fluorescent in situ hybridization, that exposure to doses of irradiation that cause minimal myeloablation (50 to 100 cGy) leads to very high levels of donor chimerism, such that relatively small numbers of marrow cells (10 to 40 million) can give donor chimerism in the 40% to 100% range. Studies of radiation sensitivity of long-term engrafting cells have shown that 100 cGy, although not myelotoxic, is stem cell toxic, and indicate that the final host:donor ratios are determined by competition between host and donor stem cells. These data indicate that low levels of irradiation should be an effective approach to nontoxic marrow transplantation in gene therapy or in attempts to create allochimerism to treat such diseases as cancer, sickle cell anemia, or thalassemia.

The population genetics of antibiotic resistance. II: Analytic theory for sustained populations of bacteria in a community of hosts

The phenomenon of antibiotic resistance is of practical importance and theoretical interest. As a foundation for further studies by simulation, experiment, and observation, we here develop a mathematical model for the dynamics of resistance among the bacteria resident in a population of hosts. The model incorporates the effects of natural selection within untreated hosts, colonization by bacteria from the environment, and the rapid increase of resistance in hosts who receive antibiotics. We derive explicit formulas for the distribution of resistance among hosts and for the rise or fall of resistance when the frequency of treatment is changed.

Spontaneous tibial artery thrombosis associated with varicella pneumonia and free protein S deficiency

Pneumonia is the most common serious complication of varicella infection in adults. A variety of thrombotic complications including purpura fulminans and disseminated intravascular coagulation have been reported in children with varicella but not in adults. Two men with varicella pneumonia who had profound lower extremity ischemia caused by thrombosis of the profunda femoris and tibial arteries are reported. Both patients had free protein S deficiency and vascular thrombosis in association with varicella pneumonia without overt evidence of disseminated intravascular coagulation or purpura fulminans. Antiphospholipid immunoglobulin G and immunoglobulin M antibodies were present in one, whereas the other had evidence of the lupus anticoagulant. The proposed pathogenesis and management options including intraarterial thrombolytic therapy with urokinase and the need for long-term anticoagulation are discussed.

Chiaroscuro hematopoietic stem cell

These observations suggest several immediate clinical strategies. In gene therapy, approaches could be targeted to obtain cycling of hematopoietic stem cells and gene-carrying retrovirus vector integration followed by engraftment at an appropriate time interval which favors engraftment. The same type of approach can be utilized for stem cell expansion approaches. Alternatively marrow or peripheral stem cell engraftment can be obtained with minimal to no toxicity in allochimeric strategies in such diseases as sickle cell anemia or thalassemia. A similar approach could be useful in obtaining cell engraftment with minimal toxicity in therapies employing cellular immune (T-cell and NK-cell) attack against cancer. These areas of clinical application are outline in Table 3.

Adoptive immunotherapy

Some of the most dramatic advances in the treatment of cancer have used the immune system in combination with conventional or transplantation chemotherapy. Adoptive immunotherapy has been used for relapses after allogeneic bone marrow transplantation, and it has been particularly effective for chronic myeloid leukemia. Adoptive immunotherapy also has been used for Epstein-Barr virus-related lymphomas developing after allogeneic marrow transplantations. Cellular therapy, including the infusion of tumor-reactive immune cells, has been used to mediate response of established solid tumors. This has been used for therapeutic benefit for renal cell carcinoma, melanoma, lung cancer, and breast cancer. Current research is focusing on reducing the toxicity of these approaches as well as further defining the appropriate target tissue.

Clinical impact of chemotherapy dose escalation in patients with hematologic malignancies and solid tumors

PURPOSE

To review published controlled clinical trials examining the benefit of escalated chemotherapy in patients with hematologic and solid malignancies.

METHODS

Studies were obtained by searching Medline and CancerLit and by review of bibliographies of published trials. We reviewed studies that examined dose-intense (DI) chemotherapy alone, in combination with hematopoietic colony-stimulating factors (CSFs), or high-dose therapy (HDT) with autologous bone marrow support (ABMT).

RESULTS

DI therapy without CSF or ABMT has not been shown to improve overall outcome in any tumor except consolidative therapy of acute myelogenous leukemia (AML). In solid tumors, many published studies suggest that less than standard-intensity chemotherapy is suboptimal, but few studies that examined higher compared with standard-dose therapy have shown a significant difference in outcome. No studies have convincingly demonstrated improved overall survival (OS) with DI therapy with CSF support. The use of HDT with ABMT has been shown to improve survival in multiple myeloma (MM), as well as relapsed intermediate- and high-grade non-Hodgkin's lymphoma (NHL). High-dose chemotherapy with ABMT is promising in patients with metastatic breast cancer (MBC), but it should not yet be considered a standard approach for these patients.

CONCLUSION

DI chemotherapy is an acceptable and standard therapeutic maneuver for patients with AML in first remission, MM, and relapsed aggressive NHL. In solid tumors, the use of DI chemotherapy either alone or with cytokine support has not been shown to improve outcome and should not be considered standard therapy. Current randomized trials should provide definitive answers about the role of DI therapy in solid tumors.

Cytokine-facilitated transduction leads to low-level engraftment in nonablated hosts

Using a murine bone marrow transplantation model, we evaluated the long-term engraftment of retrovirally transduced bone marrow cells in nonmyeloablated hosts. Male bone marrow was stimulated in a cocktail of interleukin-3 (IL-3), IL-6, IL-11, and stem cell factor (SCF) for 48 hours, then cocultured on the retroviral producer line MDR18.1 for an additional 24 hours. Functional transduction of hematopoietic progenitors was detected in vitro by reverse transcriptase-polymerase chain reaction (RT-PCR) amplification of multiple drug resistance 1 (MDR1) mRNA from high proliferative potential-colony forming cell (HPP-CFC) colonies. After retroviral transduction, male bone marrow cells were injected into nonablated female mice. Transplant recipients received three TAXOL (Bristol-Myers, Princeton, NJ) injections (10 mg/kg) over a 14-month period. Transplant recipient tissues were analyzed by Southern blot and fluorescence in situ hybridization for Y-chromosome-specific sequences and showed donor cell engraftment of approximately 9%. However, polymerase chain reaction amplification of DNAs from bone marrow, spleen, and peripheral blood showed no evidence of the transduced MDR1 gene. RT-PCR analysis of total bone marrow RNA showed that transcripts from the MDR1 gene were present in a fraction of the engrafted donor cells. These data show functional transfer of the MDR1 gene into nonmyeloablated murine hosts. However, the high rates of in vitro transduction into HPP-CFC, coupled with the low in vivo engraftment rate of donor cells containing the MDR1 gene, suggest that the majority of stem cells that incorporated the retroviral construct did not stably engraft in the host. Based on additional studies that indicate that ex vivo culture of bone marrow induces an engraftment defect concomitantly with progression of cells through S phase, we propose that the cell cycle transit required for proviral integration reduces or impairs the ability of transduced cells to stably engraft.

Late regression of the dilated site after coronary angioplasty: a 5-year quantitative angiographic study

BACKGROUND

Limited data are available on the changes that occur at the dilated site late after coronary angioplasty. The aim of this study was to evaluate with quantitative angiography the natural history of changes that occur in the dilated segment between "early" (approximately 6 months) and "late" (approximately 5 years) follow-up after angioplasty.

METHODS AND RESULTS

Of 127 consecutive patients (174 lesions) with successful angioplasty, 125 underwent early angiography. Three patients subsequently died, and 24 underwent revascularization surgery or repeated angioplasty, giving a study-eligible population of 98 patients. Quantitative angiographic analysis was performed before and immediately after angioplasty and at early and late follow-up in the study population of 84 patients (115 lesions), which was 86% of study-eligible patients. Mean lesion diameter stenosis decreased from 36.3+/-14.2% at early to 29.6+/-13.5% at late follow-up (P<.0001). No lesion developed late restenosis by the 50% diameter loss criterion. Late regression was related to stenosis severity at early angiography (r=-.58, P<.001). Subgroups at early angiography of 40% to 49% stenosis and > or = 50% stenosis showed significant regression at late angiography.

CONCLUSIONS

Lesion regression at the dilated site is common late after angioplasty. The more severe a stenosis is at early angiography, the more likely the chance that there will be late regression. A strategy of watchful waiting may be appropriate for patients with restenotic lesions of borderline severity.

Spontaneous splenic rupture following administration of granulocyte colony-stimulating factor (G-CSF): occurrence in an allogeneic donor of peripheral blood stem cells

Granulocyte colony-stimulating factor (G-CSF) has been used to improve granulocyte count in chronic neutropenia and myelodysplasia, to minimize the incidence and duration of neutropenia during conventional chemotherapy, and to mobilize peripheral blood stem cells prior to leukapheresis for use in autologous and allogeneic marrow transplantation. The most common toxicity is bone pain, and other reactions such as inflammation at the site of injection have also occurred. In patients with chronic neutropenia, splenomegaly has been described with long-term use, and extramedullary hematopoiesis has also been reported. However, thus far, no life-threatening sequelae of these effects are found in the literature. We now describe a case of spontaneous splenic rupture four days following a six-day course of G-CSF therapy in an allogeneic donor of peripheral blood stem cells.

Stem cell transplantation in the normal nonmyeloablated host: relationship between cell dose, schedule, and engraftment

In previous studies we have shown high rates of stable engraftment when 40 million male BALB/c cells were infused intravenously daily for 5 days (a total of 200 million cells) to normal nonmyeloablated female hosts. The present studies evaluate engraftment of male BALB/c bone marrow cells in female host marrow, spleen, and thymus 20-25 weeks after transplantation using varying cell dosages within a 5-day schedule. Engraftment in recipient mice was assessed by detection of male specific sequence in recipient DNA from each organ. When 40 million cells were given per daily injection for 1, 2, 3, 4, or 5 days, engraftment percentages in host marrow were 11 +/- 0.83, 20 +/- 2.0, 23 +/- 2.5, 32 +/- 6.3, and 39% +/- 5.7 (+/- standard error of mean), respectively, yielding engraftment percentages per million cells infused of 0.28, 0.25, 0.19, 0.20, and 0.20%, respectively. When levels of 2.5, 5, 10, 20, or 40 million cells were injected 5 times over a 5-day schedule into normal BALB/c female hosts, progressively increasing levels of engraftment from 3 +/- 0.6 to 39% +/- 5.7 were seen in host marrow. Highest levels of engraftment per million cells injected were obtained on days 1 and 2 of a 5-day schedule and with a level of 10 million cells given daily over 5 days. Engraftment profiles varied with spleen and thymus and percent engraftment was generally lower than for marrow. The present work indicates that regardless of cell level infused or number of infusions, rates of engraftment observed in marrow approached or exceeded the highest rates of engraftment estimated by theoretical calculations based on replacing host cells ("replacement model") or adding to host cells ("incremental model"). Engraftment in spleen and thymus was lower, but also at times approached or exceeded theoretical maxima. These data show extraordinary levels of engraftment in normal hosts, suggesting that rates in this competitive model are superior to those seen in irradiated hosts; alternatively, there may be selective repression of host stem cell proliferation and differentiation.

The population genetics of antibiotic resistance

Mathematical models are used to ascertain the relationship between the incidence of antibiotic treatment and the frequency of resistant bacteria in the commensal flora of human hosts, as well as the rates at which these frequencies would decline following a cessation of antibiotic use. Recent studies of the population biology of plasmid-encoded and chromosomal antibiotic resistance are reviewed for estimates of the parameters of these models and to evaluate other factors contributing to the fate of antibiotic-resistant bacteria in human hosts. The implications of these theoretical and empirical results to the future of antibacterial chemotherapy are discussed.

Sex differences in case fatality before and after admission to hospital after acute cardiac events: analysis of community based coronary heart disease register

OBJECTIVE

To determine whether the reported higher case fatality in hospital after an acute cardiac event in women can be explained by sex differences in mortality before admission and in baseline risk factors.

DESIGN

Analyses of data from a community based coronary heart disease register.

SETTING

Auckland region, New Zealand.

SUBJECTS

5106 patients aged 25-64 years with an acute cardiac event leading to coronary death or definite myocardial infarction within 28 days of onset, occurring between 1986 and 1992.

MAIN OUTCOME MEASURES

Case fatality before admission, 28 day case fatality for patients in hospital, and total case fatality after an acute cardiac event.

RESULTS

Despite a more unfavourable risk profile women tended to have lower case fatality before admission than men (crude odds ratio 0.88; 95% confidence interval 0.77 to 1.02). Adjustment for age, living arrangements, smoking, medical history, and treatment increased the effect of sex (0.72; 0.60 to 0.86). After admission to hospital, women had a higher case fatality than men (1.76; 1.43 to 2.17), but after adjustment for confounders this was reduced to 1.18 (0.89 to 1.58). Total case fatality 28 days after an acute cardiac event showed no significant difference between men and women (0.85; 0.70 to 1.02)

CONCLUSIONS

The higher case fatality after an acute cardiac event in women admitted to hospital is largely explained by differences in living status, history, and medical treatment and is balanced by a lower case fatality before admission.

The nature and prevalence of memory disorder late after stroke

This study aimed to investigate the incidence and nature of memory impairment late after stroke. Out of 193 patients between 12 to 36 months post-cerebrovascular accident contacted in a postal survey, 113 replied that they had experienced memory impairment following the stroke. Seventy of these patients were assessed on an adapted version of the Rivermead Behavioural Memory Test, Warrington's Recognition Memory Test for words and faces, and an every day memory questionnaire. The Token Test and the Benton Facial Recognition Test were also administered as measures of language and visuoperceptual processing. Thirty-five of the patients were impaired on one or more of the memory measures. Of these, 16 showed no evidence of dysphasia or visuoperceptual impairment. The 16 cases of selective memory impairment typically had mild to moderate deficits, and only three were impaired across all three tests. The results suggest that memory impairment following stroke does not necessarily involve general memory impairment. The evidence for material-specific memory deficits was much weaker.

Adaptation to cognitive deficit? An exploration of apparent dissociations between everyday memory and test performance late after stroke

It is widely believed that spontaneous improvements in functioning late after brain damage are due to processes of adaptation to permanent cognitive deficits. Reports of everyday memory and the pattern of performance on memory tests were investigated in 70 patients more than a year after a stroke. Contrary to the adaptation hypothesis, performance on simulations of everyday tasks (Rivermead Behavioural Memory Test) correlated strongly with performance on a test where there was little scope for compensatory strategies (forced-choice recognition memory for words). In 12 cases, initial assessment with the EMQ20 questionnaire suggested few cognitive failures in everyday life despite poor test performance. However, where further investigation was possible, it seemed that unreliability of measures or subtle everyday effects of non-verbal memory impairment could explain the apparent discrepancies. In addition, patients who did poorly on tests were not reported to make frequent use of memory aids. Adaptation to deficit does not therefore appear to be a major influence on everyday memory performance late after stroke, but it may have subtle effects or may be important in other areas of functioning. Implications for clinical memory assessment are discussed.

Relationships between heavy metal and metallothionein concentrations in lesser black-backed gulls, Larus fuscus, and Cory's shearwater, Calonectris diomedea

Metallothionein, cadmium, zinc, copper, and mercury concentrations were measured in adult lesser black-backed gulls, Larus fuscus; and metallothionein, cadmium, zinc, and copper concentrations were measured in fledgling Cory's shearwaters, Calonectris diomedea. In gulls, metallothionein was positively correlated with cadmium (kidney r = 0.83, liver r = 0.46), zinc (kidney r = 0.46, liver r = 0.37), and copper (kidney r = 0.28, liver r = 0.34). Mercury levels in lesser black-backed gulls showed no correlations with metallothionein or with any other metal. In shearwaters metallothionein was positively correlated with cadmium in the kidney (r = 0.41) but not in liver, zinc in kidney (r = 0.43) and liver (r = 0.52), and copper in kidney (r = 0.55) but not in liver. Cadmium levels were the most important factor determining tissue metallothionein concentrations in adult lesser black-backed gulls demonstrating the role of metallothionein in heavy metal detoxification. In fledgling Cory's shearwaters, the most important factor in determining metallothionein concentrations in kidney was copper concentrations, and in liver, zinc concentrations. During the latter phases of chick growth high levels of zinc are required for feather development, and at this time the binding of cadmium may be masked by the presence of a large amount of zinc- and copper-bound metallothionein. These results illustrate disparate roles of metallothionein, the levels of which will be in a state of flux both seasonally and annually.

The intrinsic rate of increase of HIV/AIDS: epidemiological and evolutionary implications

A method derived from demographic theory is presented for modeling the epidemiology of an infectious disease. For long-term infections, this method better accounts for host variation in survival and transmission rates than classical compartment models. Examples of the applications of this method focus on a single long-term infectious disease, HIV/AIDS. The method is employed to examine (1) how changes in transmission rates during different stages of infection affect the rate of spread of HIV/AIDS both in wholly susceptible populations and in populations where the number of potential hosts is limited, (2) the way the relative frequencies of the different stages of infection vary over time, (3) how the rate at which the epidemic is growing (or diminishing) affects the fraction of HIV-infected individuals who manifest the symptoms of AIDS, (4) the effect of treatment on the rate of spread of HIV, and (5) the potential effects of natural selection on the virulence of HIV.

Improved engraftment of human cord blood stem cells in NOD/LtSz-scid/scid mice after irradiation or multiple-day injections into unirradiated recipients

Human lymphoematopoietic stem cells engraft in irradiated immunodeficient mice that are homozygous for the severe combined immunodeficiency (scid) mutation. Engraftment levels in C.B-17-scid/scid mice, however, have been low and transient, decreasing the utility of this model for investigation of the development potential and function of human stem cells. In the present study, we have used NOD/LtSz-scid/scid mice as recipients and human cord blood as a source of donor stem cells. Our results demonstrate that NOD/LtSz-scid/scid mice support approximately fivefold higher levels of human stem cell marrow engraftment than do C.B-17-scid/scid mice. Human CD34+ cells are present in the marrow of recipient mice, and the engrafted cells readily peripheralize to the circulation of the host. Terminal differentiation of the stem and progenitor cells into mature progeny is limited. Using a multiple-day injection protocol developed in mice, which allows engraftment of stem cells between congenic mice in the absence of irradiation preconditioning, we observed high levels of human cell engraftment in unirradiated NOD/LtSz-scid/scid recipients after three or five consecutive-day injections. These results demonstrate that NOD/LtSz-scid/scid mice support high levels of human stem cell engraftment and that xenogeneic lymphohematopoietic stem cells can engraft in unirradiated hosts without the need for ablative reconditioning. This model will be useful for the in vivo investigation of human stem cells and for the preclinical analysis of human stem cells for transplantation.

Cytokines in stem cell transplantation

The use of cytokines in stem cell transplantation is still in the early stages of development. Efficacy has not been established consistently at the present time. When cytokines are employed in the treatment setting, they should be employed in a study setting evaluating whether there has been real patient benefit-palliation without compromise of therapeutic outcome or, preferably, a survival advantage. Cost effectiveness has not been established and, in any case it should not be a consideration until therapeutic efficacy has been established. The determination of various biologic parameters on cells such as cytokine receptors may permit more precise use of HGFs. In some cases there probably are subsets of patients who are benefited, while there are subsets who are harmed. The challenge of the future is to define these subsets.

Retrovirally marked CD34-enriched peripheral blood and bone marrow cells contribute to long-term engraftment after autologous transplantation

We report here on a preliminary human autologous transplantation study of retroviral gene transfer to bone marrow (BM) and peripheral blood (PB)-derived CD34-enriched cells. Eleven patients with multiple myeloma or breast cancer had cyclophosphamide and filgrastim-mobilized PB cells CD34-enriched and transduced with a retroviral marking vector containing the neomycin resistance gene, and CD34-enriched BM cells transduced with a second marking vector also containing a neomycin resistance gene. After high-dose conditioning therapy, both transduced cell populations were reinfused and patients were followed over time for the presence of the marker gene and any adverse effects related to the gene-transfer procedure. All 10 evaluable patients had the marker gene detected at the time of engraftment, and 3 of 9 patients had persistence of the marker gene for greater than 18 months posttransplantation. The marker gene was detected in multiple lineages, including granulocytes, T cells, and B cells. The source of the marking was both the transduced PB graft and the BM graft, with a suggestion of better long-term marking originating from the PB graft. The steady-state levels of marking were low, with only 1:1000 to 1:10,000 cells positive. There was no toxicity noted, and patients did not develop detectable replication-competent helper virus at any time posttransplantation. These results suggest that mobilized PB cells may be preferable to BM for gene therapy applications and that progeny of mobilized peripheral blood cells can contribute long-term to engraftment of multiple lineages.

An update on non-Hodgkin's lymphomas

The non-Hodgkin's lymphomas are a diverse group of diseases characterized by enlargement of the lymph nodes and are indolent or aggressive. The histopathologic subtype provides the best guide to the nature of these diseases. In most patients the etiology is unknown. Painless peripheral adenopathy is the usual presenting feature. A careful clinical staging without laparotomy is recommended to establish disease extent, prognosis and treatment. In patients with indolent (low grade) lymphomas, a period of observation prior to treatment may be appropriate if the patient is asymptomatic. Symptomatic patients with low grade lymphoma require therapy. For patients with aggressive disease (intermediate or high grade), immediate treatment with curative intent is indicated. High dose therapy with bone marrow transplantation may be used to cure a small number of patients who relapse following initial chemotherapy.

Seasonal variation in heavy metal levels in tissues of common guillemots, Uria aalge from northwest Scotland

Mercury, cadmium, zinc, and copper concentrations were analyzed in three samples of common guillemot (in April, June, and November). Levels measured were uniformly low, and not enough to have any toxic effects. Adult guillemots had significantly more cadmium in their livers and kidneys than juveniles, with juvenile levels ranging from 25% to 89% of adult levels. Mercury concentrations in liver and kidney were also higher in adults. Juvenile levels represented from 80% to 94% of adults, but there were no age differences in feather and muscle mercury. Mercury levels declined throughout the year in internal tissues from April through June to November. There was a strong seasonal fluctuation in cadmium levels in liver and kidney, rising significantly between April and June and declining in both adult and juvenile birds. The influences of seasonal processes (namely breeding and moult) and seasonal dietary differences as causative factors in the changes in metal burdens are discussed. These findings have implications for the use of seabirds as monitors of heavy metals in the marine environment.