Aging in the Amish community

The experience of aging in The Old Order Amish Community, of Lancaster County, Pennsylvania, is explored from the viewpoint of the elderly. Through personal interviews with elderly Amish and others knowledgeable about the community, the influence of religious beliefs and practices as the core of their lifestyle becomes evident. The entire community, not just family members, cares for the elders with respect and loving care, generally without recourse to any external resources from the non-Amish.

Single adult human CD34(+)/Lin-/CD38(-) progenitors give rise to natural killer cells, B-lineage cells, dendritic cells, and myeloid cells

Marrow stromal cultures support adult CD34(+)/Lin-/HLA-DR- or CD34(+)/Lin-/CD38(-) cell differentiation into natural killer (NK) or myeloid cells, but unlike committed lymphoid progenitors (CD34(+)/Lin-/CD45RA+/CD10(+)), no B cells are generated. We tested whether different microenvironments could establish a developmental link between the NK and B-cell lineages. Progenitors were cultured in limiting dilutions with interleukin-7 (IL-7), flt3 ligand (FL), c-kit ligand (KL), IL-3, IL-2, and AFT024, a murine fetal liver line, which supports culture of transplantable murine stem cells. NK cells, CD10(+)/CD19(+) B-lineage cells and dendritic cells (DC) developed from the same starting population and IL-7, FL, and KL were required in this process. Single cell deposition of 3,872 CD34(+)/Lin-/CD38(-) cells onto AFT024 with IL-7, FL, KL, IL-2, and IL-3 showed that a one time addition of IL-3 at culture initiation was essential for multilineage differentiation from single cells. Single and double lineage progeny were frequently detected, but more importantly, 2% of single cells could give rise to at least three lineages (NK cells, B-lineage cells, and DC or myeloid cells) providing direct evidence that NK and B-lineage differentiation derive from a common lymphomyeloid hematopoietic progenitor under the same conditions. This study provides new insights into the role of the microenvironment niche, which governs the earliest events in lymphoid development.

Choice of mitral prosthesis in the elderly. An analysis of actual outcome

BACKGROUND

In younger patients requiring mitral valve replacement (MVR), mechanical prostheses (MPs) have been reported to give better freedom from all valve-related complications (VRCs) because of the high incidence of late valve degeneration (VD) associated with bioprostheses (BPs). In older patients, however, the risk of VD may be reduced because of the large competing risk of noncardiac death (NCD). Previous studies on VD in the elderly have used actuarial analysis, which overestimates the risk of VD in this population because it assumes that dead patients are still at risk. In contrast, cumulative incidence (actual) analysis acknowledges that patients who die have no risk of VD. This study compares the results of both "actual" and "actuarial" analyses of the freedom from VD in elderly patients undergoing MVR.

METHODS AND RESULTS

From June 1976 through January 1996, 504 patients > or = 70 years of age underwent MVR at our institution. Isolated mitral operations were performed in 159 patients, and 169 had concomitant CABG. Hospital mortality was 59 of 374 (15.9%) for tissue prosthesis versus 24 of 130 (18.5%) for mechanical prosthesis (P = NS). For tissue versus mechanical prosthesis, 10-year freedom from noncardiac death was 75.0% versus 67.6% (P = NS); 10-year actuarial freedom from valve degeneration was 79.8% versus 93.4% (P = NS); 10-year actual freedom from valve degeneration was 92.6% versus 95.4% (P = NS); and 10-year actual freedom from all VRCs was 84.4% versus 92.3% (P = NS).

CONCLUSIONS

In elderly patients undergoing MVR, actuarial analysis overestimates the 10-year risk of VD compared with actual analysis (20.2% versus 7.4% for BP, 6.6% versus 4.6% for MP). In these patients, the actual freedoms from VD and all VRCs do not differ significantly between BP and MP. Thus, in this age group, the necessity for anticoagulation or its avoidance may be the predominant factor in choosing a replacement mitral valve.

Comparative analysis of autografting in chronic myelogenous leukemia: effects of priming regimen and marrow or blood origin of stem cells

The aims of this study were (1) to evaluate the effect of intermediate (cyclophosphamide alone) or intensive (mitoxantrone, cytosine arabinoside, cyclophosphamide) priming on the cytogenetic response in mobilized bone marrow (BM) or peripheral blood (PB) progenitors in patients with chronic myelogenous leukemia (CML), (2) to determine the incidence of cytogenetic remissions after mobilized progenitor transplantation in CML, and (3) to determine the effect of in vivo priming on the ability to select Philadelphia chromosome-negative (Ph-negative) CD34(+)HLA-DR- cells from mobilized BM or PB in quantities sufficient for transplantation. Between February 1994 and March 1997, 44 patients were enrolled in three sequential protocols. Although the duration of neutropenia after only cyclophosphamide mobilization was shorter, clinical morbidity for the intermediate and intensive priming protocols was similar. Cytogenetic responses in mobilized PB progenitors were similar after mobilization with either intermediate or intensive chemotherapy. The degree of Ph negativity in the mobilized product correlated with disease stage at the time of mobilization (early chronic phase [ECP] > late CP > accelerated phase). Cytogenetic responses after transplantation with mobilized progenitors obtained after the different regimens were similar. The cytogenetic status of the graft predicted the cytogenetic status of marrow obtained 3 weeks after transplantation whereas cytogenetic responses 3, 6, and 12 months after transplantation correlated with the number of BCR/ABL-negative CD34(+)HLA-DR- cells, but not the number of Ph-negative metaphases in the graft. In patients with ECP CML, mobilized PB collections yielded significantly more CD34(+)HLA-DR- cells than from steady state or mobilized BM. CD34(+)HLA-DR- cells were Ph negative and polyclonal (X-chromosome inactivation) in the majority of ECP CML patients, before and after mobilization and irrespective of the mobilization regimen. Because infusion of large numbers of Ph-negative CD34(+)HLA-DR- cells predicted superior outcome after transplantation, approaches in which CD34(+)HLA-DR- cells are selected from mobilized PB may result in longer lasting and clinically significant cytogenetic responses after transplantation.

The changing face of long-term care

When it comes to long-term care insurance, most people think of elderly clients. Providers who understand the benefits of this type of insurance can suggest this option to individuals to ensure that they can remain at home.

Graft-versus-leukemia is sufficient to induce remission in juvenile myelomonocytic leukemia

It has been unclear whether a graft-versus-leukemia (GVL) effect assists in the control of juvenile myelomonocytic leukemia (JMML) following allogeneic bone marrow transplant. We describe a patient with JMML who relapsed early after an unrelated donor transplant, and following withdrawal of immunosuppression developed graft-versus-host disease (GVHD). Associated with GVHD the proportion of donor cells measured by variable nucleotide tandem repeat (VNTR) analysis increased, and peripheral blasts and cutaneous disease were eliminated. These findings strongly suggest that GVL has a role in the control of JMML.

Activated peripheral blood mononuclear cells from patients receiving subcutaneous interleukin-2 following autologous stem cell transplantation prolong survival of SCID mice bearing human lymphoma

Interleukin-2 (IL-2) after autologous stem cell transplantation (SCT) is being explored as a way of reducing relapse. To determine the immunostimulating effect of low-dose subcutaneous IL-2 following SCT, the in vitro and in vivo activity of patient peripheral blood mononuclear cells (PBMNC) was studied. A predominantly natural killer (NK) lymphocytosis was induced and sustained throughout most of the IL-2 treatment period. The in vivo primed PBMNC had enhanced lytic activity against a variety of tumor targets. The in vitro cytotoxicity of in vivo IL-2-primed PBMNC could be increased further by overnight incubation in 1000 U/ml IL-2. The SU-DHL-4 B cell lymphoma xenotransplantation model was used as an in vivo system for testing the efficacy of cellular therapy. PBMNC obtained by apheresis from autografted patients that had received post-transplant IL-2 for 35-42 days were infused i.v. into SU-DHL-4 bearing C.B-17 severe combined immunodeficient (SCID) mice. Control mice died of disseminated lymphoma at a median of 35.2 days, while murine recipients of in vivo activated human PBMNC cells from IL-2-treated SCT patients survived significantly longer (58.2 days). The in vivo effect of human PBMNC on survival of tumor-bearing mice correlated well with their in vitro cytolytic activity as assessed by 51Cr release assays, indicating that the SCID SU-DHL-4 lymphoma model can be utilized reliably to test the efficacy of cellular therapy in vivo.

Three new ellagic acid derivatives from the bark of Eschweilera coriacea from the Suriname rainforest

Bioassay-guided fractionation of Eschweilera coriacea collected in the lowland wet forest of Suriname yielded the new but only weakly active ellagic acid derivative eschweilenol A (1) and the two new but inactive ellagic acid derivatives eschweilenol B (2) and eschweilenol C (3). The four known compounds, sucrose, ellagic acid, 3-O-galloylepigallocatechin, and epigallocatechin, were also isolated. The structures of the three new compounds were determined by spectrometric methods, primarily from the HMQC, HMBC, NOESY, and ROESY NMR techniques, and chemical methods, including methylation and triethylsilylation. The location of a hydroxyl group in one ellagic acid derivative was determined by a new technique involving an NOE correlation of the protons of a triethylsilyl derivative with a proton on a neighboring aromatic ring.

Ex vivo culture of CD34+/Lin-/DR- cells in stroma-derived soluble factors, interleukin-3, and macrophage inflammatory protein-1alpha maintains not only myeloid but also lymphoid progenitors in a novel switch culture assay

We have demonstrated that long-term culture initiating cells (LTC-IC) are maintained in a stroma noncontact (SNC) culture where progenitors are separated from stroma by a microporous membrane and LTC-IC can proliferate if the culture is supplemented with interleukin-3 (IL-3) and macrophage inflammatory protein-1alpha (MIP-1alpha). We hypothesize that the same conditions, which result in LTC-IC proliferation, may also maintain lymphoid progenitors. Natural killer (NK) cells are of lymphoid lineage and a stromal-based culture can induce CD34+/Lin-/DR- cells to differentiate along the NK cell lineage. We developed a three-step switch culture assay that was required to demonstrate the persistence of NK progenitors in CD34+/Lin-/DR- cells assayed in SNC cultures supplemented with IL-3 and MIP-1alpha. When CD34+/Lin-/DR- progeny from the SNC culture were plated sequentially into "NK cell progenitor switch" conditions (contact with stromal ligands, hydrocortisone-containing long-term culture medium, IL-2, IL-7, and stem cell factor [SCF]) followed by "NK cell differentiation" conditions (contact with stromal ligands, human serum, no hydrocortisone, and IL-2), significant numbers of CD56+/CD3- NK resulted, which exhibited cytotoxic activity against K562 targets. All steps are required because a switch from SNC cultures with IL-3 and MIP-1alpha directly to "NK cell differentiation" conditions failed to yield NK cells suggesting that critical step(s) in lymphoid commitment were missing. Additional experiments showed that CD34+/CD33- cells present after SNC cultures with IL-3 and MIP-1alpha, which contained up to 30% LTC-IC, are capable of NK outgrowth using the three-step switch culture. Limiting dilution analysis from these experiments showed a cloning frequency within the cultured CD34+/CD33- population similar to fresh sorted CD34+/Lin-/DR- cells. However, after addition of FLT-3 ligand, the frequency of primitive progenitors able to develop along the NK lineage increased 10-fold. In conclusion, culture of primitive adult marrow progenitors ex vivo in stroma-derived soluble factors, MIP-1alpha, and IL-3 maintains both very primitive myeloid (LTC-IC) and lymphoid (NK) progenitors and suggests that these conditions may support expansion of human hematopoietic stem cells. Addition of FLT-3 ligand to IL-2, IL-7 SCF, and stromal factors are important in early stages of NK development.

Minimally invasive port-access coronary artery bypass grafting with early angiographic follow-up: initial clinical experience

OBJECTIVE

New techniques for minimally invasive coronary artery bypass grafting have recently emerged. The purpose of this study was to determine the safety and efficacy of Port-Access (Heartport, Inc., Redwood City, Calif.) coronary revascularization and to evaluate with angiography the early graft patency rate with this new approach.

METHODS

From October 1996 to May 1997, 31 patients underwent Port-Access coronary artery bypass grafting with an anterior minithoracotomy and endovascular-occlusion cardiopulmonary bypass. There were 26 men and 5 women with a mean age of 62 years (range 42 to 82 years). Fifteen patients underwent single bypass; 12 patients underwent double bypass, and 4 patients underwent triple bypass. Bypass conduits included the left internal thoracic artery (n = 30), right internal thoracic artery (n = 2), radial artery (n = 10), and saphenous vein (n = 6). Three sequential grafts were used. Angiographic studies of the bypass grafts were performed in 27 of 31 patients (87%).

RESULTS

There were no deaths, neurologic deficits, myocardial infarctions, or aortic dissections. Conversion to sternotomy was not required in any case. There were two reoperations for bleeding, one reoperation for tamponade, and one reoperation for pulmonary embolus. Postoperative angiography revealed anastomotic patency of the left internal thoracic artery to left anterior descending artery in 26 of 26 grafts (100%) with overall anastomotic patency in 43 of 44 grafts (97.7%).

CONCLUSION

These results demonstrate that Port-Access coronary artery bypass can be performed accurately and safely with acceptable morbidity. This approach allows for multivessel revascularization on an arrested, protected heart with excellent anastomotic precision and reproducible early graft patency.

The nucleotide sequence of RNA-1 of Indian peanut clump furovius

The nucleotide sequence of RNA-1 of an isolate of the H serotype of Indian peanut clump virus (IPCV-H) was shown to comprise 5,841 nucleotides. The RNA contains three open reading frames (ORF) which are between nucleotides 133 and 3,522, nucleotides 3,526 and 5,103 (assuming expression by suppression of the ORF 1 termination codon) and nucleotides 5,168 and 5,539. The encoded polypeptides have M(r), of 129,687 (p130), 60,188 (p60) and 14,281 (p14). ORF 2 is thought to be expressed by suppression of the termination codon of ORF 1 to produce a M(r) 189,975 product (p190). p130 contains sequences characteristic of proteins with methyl transferase and NTP-binding properties and p190 contains these and sequences characteristic of RNA-dependent RNA polymerases. The nucleotide sequence of IPCV RNA-1 is similar to that of peanut clump virus (PCV) and corresponding encoded polypeptides are 88% (p130), 95% p60 and 75% (p14) identical. The sequences of the translation products are also similar to those of soil-borne wheat mosaic virus and barley stripe mosaic virus. Oligonucleotide primers, designed on the basis of the sequences of RNA-1 of IPCV and PCV, were effective in reverse transcription-PCR amplification of these RNAs and that of IPCV isolates of the serologically distinct L and T serotypes.

Early results of posterior leaflet folding plasty for mitral valve reconstruction

BACKGROUND

Standard reconstruction for posterior mitral leaflet (PML) disease is quadrangular resection and annular plication; when the PML is excessively high, a sliding plasty is used. We have developed an alternative technique, a posterior leaflet folding plasty. It is performed by folding down the cut vertical edges of the PML. The central height of the PML is reduced, leaflet coaptation is moved posteriorly, and annular plication is unnecessary.

METHODS

From March 1995 to August 1996, 26 (17.9%) of 145 patients undergoing mitral reconstruction had a posterior leaflet folding plasty. Concomitant procedures included anterior leaflet resection or resuspension and myotomy and myectomy. In 3 patients, the PML resection extended to a commissure.

RESULTS

There was one death and no reoperations. The mean New York Heart Association class was improved from 2.4 preoperatively to 1.4. There was no major postoperative mitral insufficiency in the 26 patients. Systolic anterior motion was transiently seen in 1 patient in whom left ventricular outflow tract obstruction was present preoperatively.

CONCLUSIONS

The data demonstrate the safety and short-term efficacy of posterior leaflet folding plasty. This technique may help avoid systolic anterior motion after reconstruction of the PML.

FLT-3 ligand and marrow stroma-derived factors promote CD3gamma, CD3delta, CD3zeta, and RAG-2 gene expression in primary human CD34+LIN-DR- marrow progenitors

We hypothesize that early lymphoid commitment from primitive hematopoietic marrow progenitors is governed by signals from the marrow microenvironment leading to sequential induction of lineage-specific genes. Using expression of lymphoid genes as markers of differentiation, we characterize a highly purified population (>99.8% by double sorting) of primary human CD34+Lin-DR- progenitors. This population was then used to evaluate the effects of supplemental cytokines (interleukin-2 [IL-2], IL-3, IL-7, c-kit ligand), FLT-3 ligand (FL), and stroma-derived factors on lymphoid differentiation in vitro. CD3, RAG-1, Ikaros, CD10, and TdT transcripts were detected in the starting CD34+Lin-DR- population. By contrast, CD3gamma, CD3delta, CD3zeta, and RAG-2 transcripts were not present in any samples tested. The presence of supplemental cytokines alone at culture initiation permitted stimulation of the expression of CD3zeta, but not of CD3gamma or CD3delta. However, when FL and stroma-derived factors were added to cytokines, CD3 gene expression was induced in all samples. The predominant CD3 transcripts induced by optimal culture conditions were alternatively spliced isoforms lacking transmembrane sequences (CD3delta and CD3gamma) and portions of the intracellular and extracellular domains (CD3gamma). The combination of cytokines, FL, and stromal factors also provided a potent stimulus for RAG-2 gene expression. These findings show that FL in combination with stroma-derived factors provide important signals to promote early events required for lymphoid differentiation.

Aggressiveness of Isolates of Phytophthora infestans from the Columbia Basin of Washington and Oregon

ABSTRACT The aggressiveness of 22 isolates of Phytophthora infestans collected from naturally infected potato plants in the Columbia Basin of Washington and Oregon was determined on detached potato leaflets at 18 degrees C in an incubator. Selected isolates were evaluated on whole plants in a greenhouse. Aggressiveness was measured by using the area under the lesion expansion curve (AULEC), incubation period, latent period, sporulation capacity, and lesion size on detached leaflets and the area under the disease progress curve and sporulation capacity on whole plants. The detached-leaflet assay was useful in that a large number of isolates were tested, several components of aggressiveness were studied, and significant differences were found among isolates. Significant variation for components of aggressiveness was found within and among isolates classified according to genotype. Significant interactions among isolates and cultivars were found for some components of aggressiveness, so results were pooled according to cultivar. On average, US-8 and US-11 isolates had higher AULEC scores, indicating aggressiveness higher than that of US-7, US-6, and US-1 genotypes. One US-8 genotype isolate had a higher standardized sporulation capacity than isolates of the other genotypes. US-6 genotype isolates were the least aggressive group, as indicated by low AULEC, sporulation capacity, and lesion size values. The replacement of the US-1 genotype by the US-8 genotype in the Columbia Basin may be partially explained by the increased aggressiveness of US-8 isolates. Additionally, potato growers may need to shorten intervals between fungicide applications and begin applications earlier.

Valve repair versus replacement for mitral insufficiency: when is a mechanical valve still indicated?

OBJECTIVES

Although many advantages of mitral valve reconstruction have been demonstrated, whether specific subgroups of patients exist in whom mechanical valve replacement offers advantages over mitral reconstruction remains undetermined.

METHODS

This study examined the late results of mitral valve surgery in patients with mitral insufficiency who received either a St. Jude Medical valve (n = 514) or a mitral valve reconstruction with ring annuloplasty (n = 725) between 1980 and 1996.

RESULTS

Overall operative mortality was 7.2% in the patients receiving a St. Jude Medical mitral valve and 5.4% in those undergoing mitral valve reconstruction (no significant difference); isolated mortality was 2.5% in the St. Jude Medical group and 2.2% in the valve reconstruction group (no significant difference). The follow-up interval was more than 5 years for 340 patients with a mean of 39.8 months (98.5% complete). Overall 8-year freedom from late cardiac death, reoperation, and all valve-related complications was 72.8% for the St. Jude Medical group and 64.8% for valve reconstruction group (no significant difference). For patients with isolated, nonrheumatic mitral valve disease, 8-year freedom from late cardiac death and reoperation was better in the mitral valve reconstruction group (88.3%) than in the St. Jude Medical valve group (86.0%; p = 0.05). Furthermore, Cox proportional hazards regression revealed that mitral valve reconstruction was independently associated with a lesser incidence of late cardiac death (p = 0.04), irrespective of preoperative New York Heart Association class. However, the St. Jude Medical valve offered better 8-year freedom from late cardiac death, reoperation, and all valve-related complications than did mitral valve reconstruction in patients with multiple valve disease (77.0% vs 45.3%; p < 0.01).

CONCLUSIONS

Therefore, mitral valve reconstruction appears to be the procedure of choice for isolated, nonrheumatic disease, whereas insertion of a St. Jude Medical valve should be preferred for patients with multiple valve disease.

Innovative therapy for chronic myelogenous leukemia

Innovative therapies for chronic myelogenous leukemia (CML) have focused mainly on combining autologous transplantation with another modality of therapy for purging of the graft or treatment of the patient after transplant. Of the three categories of innovative therapies, two are based on studies that demonstrate the bcr/abl gene rearrangement in the pathogenesis of CML, whereas the third is based on the observation that allogeneic disparity is important to maintain remissions in CML. The rationale and data supporting these innovative approaches are reviewed in this article and future strategies are discussed.

Ruptured aortic pseudoaneurysm 28 years after gunshot wound: case report and review of the literature

Penetrating injuries to the abdominal aorta most often result in rapid exsanguination and death. Immediate surgical intervention may result in control of hemorrhage and survival of the patient. Rarely, hemorrhage after aortic injury may be contained by surrounding tissues, resulting in pseudoaneurysm formation. Traumatic pseudoaneurysms may rupture at any time, and this is usually a fatal event. A 47-year-old man recently presented with a supraceliac abdominal aortic pseudoaneurysm that ruptured into the right chest 28 years after a gunshot wound to the back. This report describes the pathophysiology, diagnosis, and treatment of traumatic pseudoaneurysms of the abdominal aorta and includes a review of the literature. This is a case in which a traumatic pseudoaneurysm of the abdominal aorta was successfully repaired by surgery after rupture into the thorax and is the first such case to be reported in the literature.

Primary bone marrow progenitors of both granulocytic and monocytic lineages are susceptible to infection with the agent of human granulocytic ehrlichiosis

Human granulocytic ehrlichiosis (HGE) is an emerging tickborne infection resulting in an acute febrile illness associated with cytopenias and characteristic intracellular organisms within peripheral blood granulocytes. The etiologic agent of HGE has recently been isolated and cultivated in the HL-60 promyelocytic leukemia cell line, but the spectrum of host cells that it naturally infects remains unknown. To determine if normal hematopoietic progenitors could be targets of infection, CD34+ primary human bone marrow cells, stimulated to differentiate along myelomonocytic lineages, were incubated with the HGE agent. Immature marrow progenitors and, remarkably, not only granulocytic but also CD14+ monocytic cells from these cultures supported replication of the HGE agent, suggesting that all are potential targets of infection in vivo. Infection of bone marrow progenitors may contribute to the hematologic manifestations of HGE. Furthermore, the ability of the agent to interact with monocytes has significant implications regarding disease pathogenesis and host response.

Genome structure of cucumber leaf spot virus: sequence analysis suggests it belongs to a distinct species within the Tombusviridae

The complete nucleotide sequence of cucumber leaf spot virus (CLSV) has been determined and the sizes and locations of predicted viral proteins deduced. The genome consists of 4432 nucleotides and contains five long ORFs. The 5' proximal ORF encodes a 25 kDa product that terminates in an amber codon which may be readthrough to produce an 84 kDa protein (ORF 2). ORF 3 codes for the 41 kDa coat protein (CP). ORFs 4 and 5 are completely overlapping at the 3' terminus and code for 27 and 17 kDa products, respectively. The CLSV genome structure is similar to that of tombusviruses and nearly identical to pothos latent virus (PoLV), a newly proposed, atypical, member of the Tombusviridae. It is proposed that CLSV and PoLV be considered strains of a new tombusvirus species. Amino acid sequence comparisons of the CLSV CP and the CPs of several small spherical plant viruses suggest that CLSV is most closely related to melon necrotic spot carmovirus (MNSV), red clover necrotic mosaic dianthovirus (RCNMV) and cucumber necrosis tombusvirus (CNV). These viruses, like CLSV, are transmitted by the soil inhabiting fungus, Olpidium bornovanus.

The role of autologous natural killer cells in chronic myelogenous leukemia

Chronic myelogenous leukemia (CML) is a lethal disease of the hematopoietic stem cell. Bone marrow transplantation has highlighted the importance of allogeneic disparity in maintaining remissions in CML. However, it has been unclear whether the immune effect against CML is mediated by T cells, natural killer cells (NK) or a combination of both. We have previously demonstrated that autologous activated NK are capable of selectively lysing malignant CML progenitors while sparing benign progenitors. NK effectors may play an important role in CML since NK lytic function, clonogenic frequency and proliferative capacity decrease as CML progresses from chronic phase to advanced phase and blast crisis. Incubation of CML NK with IL-2 is capable of restoring cytolytic activity to normal levels. We hypothesize that activated NK represent a potential therapy against CML to maintain remissions in a minimal residual disease setting induced by autologous transplantation. Clinical trials are in progress to test whether IL-2 based immunotherapy and activated cell infusions play a therapeutic role in CML.

Natural killer (NK) cells are functionally abnormal and NK cell progenitors are diminished in granulocyte colony-stimulating factor-mobilized peripheral blood progenitor cell collections

Granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood progenitor cell (PBPC) collections are increasingly emerging as the graft of choice in many centers for autologous transplantation, and with increasing frequency for allogeneic transplantation. However, the role of myeloid cytokines in lymphoid function, lymphoid progenitors, and immune-mediated antitumor responses is not known. We studied PBPC collections from normal donors mobilized with G-CSF (10 microg/kg). CD56+/CD3- natural killer (NK) cells sorted from PBPC products exhibited a diminished ability to kill tumor targets, were less responsive in acquiring increased cytolysis with interleukin-2 (IL-2), and proliferated less than NK cells from normal unprimed peripheral blood. This abnormality was not explained by a change in phenotype of NK cells normally circulating in the blood after G-CSF administration. We could not demonstrate any direct suppressive effect on normal unprimed NK cell proliferation or cytotoxicity by culture with pharmacologic concentrations of G-CSF. We next evaluated the effects of G-CSF on CD34+ NK cell progenitors. CD34+/CD2+, CD34+/CD7+, and CD34+/CD10+ progenitors were markedly diminished in G-CSF-mobilized PBPC products. CD34+ cells cultured in limiting dilution assays showed a sixfold decrease in NK cell progenitors when derived from G-CSF-mobilized CD34+ PBPCs compared with CD34+ cells derived from unprimed marrow. The finding of decreased NK cell function, inhibited proliferation, and diminished cloning frequency after treatment with G-CSF could be mimicked in vitro by culture of primitive marrow progenitors (CD34+, lineage-negative, HLA-DR-) on stromal layers in the presence of exogenous G-CSF. The findings presented here show that G-CSF administration to normal donors decreases NK cell function and the relative frequency of NK cell progenitors within the CD34+ progenitor population. Overcoming this diminished lymphoid capacity may be important to facilitate early posttransplant immunotherapy. Our in vitro model will be used in future studies to determine the mechanism of the G-CSF-induced suppression of NK cell progenitors, which may occur early in the differentiation process.

Port-Access coronary artery bypass grafting

New techniques for minimally invasive cardiac surgery have recently emerged. This report describes the Port-Access technique for coronary artery bypass grafting, which involves a small left anterior thoracotomy, femoral cannulation for endovascular cardiopulmonary bypass, and cardioplegic arrest using an endoaortic occlusion catheter and cardioplegia delivery system. This technique allows for minimally invasive single or multivessel revascularization in an arrested, protected heart, while maintaining a high level of anastomotic precision. The Port-Access surgical techniques are described, along with the indications and contraindications for this procedure. The initial New York University clinical results with Port-Access coronary bypass grafting are presented.

Endogenous IL-2 production by natural killer cells maintains cytotoxic and proliferative capacity following retroviral-mediated gene transfer

Interleukin (IL)-2 therapy given at tolerable doses is insufficient to induce maximum activation of natural killer (NK) cells. We recently demonstrated that NK cells expanded in vivo can be maximally activated by short-term ex vivo incubation with 1000 U/mL IL-2. However, IL-2 withdrawal, which would occur with reinfusion, may lead to a rapid loss of cell viability and function. We hypothesized that retroviral transduction could provide an endogenous source of IL-2 to maintain NK function as measured by proliferation and cytotoxicity. Enriched NK cells were transduced with supernatants containing an MFG-based retrovirus designed to express murine IL-2 cDNA. Several supernatant transduction strategies were evaluated. NK cells were initially cultured in 1000 U/mL of huIL2 for 7-8 days, harvested, and replated prior to transduction (4 hours at 37degrees C); this proved insufficient to sustain NK proliferation or maintain cytotoxicity after exogenous human IL-2 (huIL-2) withdrawal. An alternative transduction procedure using phosphate-depleted medium, centrifugation, and transduction for 16 hours at 32degrees C was then evaluated. NK cells transduced under these conditions maintained significant NK proliferation in the absence of exogenous IL-2 compared with sham-transduced controls. Two consecutive daily transductions resulted in less proliferation, suggesting that several exposures to retroviral supernatant may inhibit subsequent NK proliferation. Cytotoxicity of the transduced NK cells against K562 and Raji was maintained under these conditions without exogenous IL-2. Sham-transduced NK cells produced 8.3+/-2.6 U/mL of murine IL-2 (muIL-2) by ELISA (background) after 7 days without exogenous IL-2. In contrast, 109+/-23 U/mL muIL-2 was produced by NK cells transduced with supernatant from the MFG/muIL-2 producer line. These experiments demonstrate that NK cells can be successfully transduced with retroviruses and induced to express sufficient IL-2 to maintain their proliferative and cytotoxic functions. Transduction of IL-2 genes into NK cells may offer advantages over exogenous IL-2 administration in maintaining maximum function for use in antitumor immunotherapy.

Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation

Gastric rupture is a rare complication of difficult airway management. In cases of vigorous mouth-to-mouth ventilation, bag-valve-mask ventilation, or esophageal intubation, gastric rupture and massive intraperitoneal free air may cause tension pneumoperitoneum. Hemodynamic instability necessitates immediate intervention, including needle decompression of the peritoneum followed by surgical exploration. We recently encountered two cases of gastric rupture with tension pneumoperitoneum that occurred after difficult endotracheal intubation. This report describes the presentation, treatment, and prevention of this entity.

Postoperative pain control after lumbar spine fusion. Patient-controlled analgesia versus continuous epidural analgesia

STUDY DESIGN

A prospective, randomized, double-blind clinical trial.

OBJECTIVE

To compare the efficacy of postoperative continuous epidural analgesia versus patient-controlled analgesia in patients undergoing lumbar fusion.

SUMMARY OF BACKGROUND DATA

Controversy remains regarding the optimal strategy for postoperative pain control.

METHODS

Fifty-four patients were divided into two treatment groups. There was no difference between the groups with respect to age, levels fused, estimated blood loss, and use of spinal instrumentation. Patient-controlled analgesia or epidural analgesia was administered in a double-blind manner for a 3-day postoperative course. Each patient received both an epidural and a patient-controlled analgesia delivery system; 26 received the epidural active agent and 28 received patient-controlled analgesia. Postoperative time to liquids and solid food, ambulation, length of stay, and side effects was recorded. Pain was evaluated by a visual analog scale on postoperative days 1, 2, and 3.

RESULTS

Results showed no difference between the groups with reference to diet, ambulation, length of stay, and visual analog scale scores. Minor side effects occurred in 71% of patients in both groups. No major complications occurred. Epidural catheter dislodgment occurred in 11% of patients. The total cost for epidural analgesia was approximately $550 more than that for patient-controlled analgesia for a 3-day postoperative course.

CONCLUSIONS

These data suggest that there is no clinical advantage of epidural opiate/local anesthetic analgesia over systemic opiate by patient-controlled analgesia for spinal fusion patients. However, possible technical limitations (namely, the low dosage of bupivacaine and placement of the catheter tip) may have prevented adequate delivery of anesthetic to the involved segments. Although the incidence of side effects is similar, cost factors and a high incidence of epidural catheter dislodgment favor use of patient-controlled analgesia.

A clinically suitable ex vivo expansion culture system for LTC-IC and CFC using stroma-conditioned medium

FACS-selected CD34+ HLA-DR- cells (DR- cells) may provide a source of benign stem cells suitable for autografting in chronic myelogenous leukemia (CML) and other hematological malignancies. However, DR- cell selection depletes the majority of committed hematopoietic progenitors, which may be important for early engraftment. Furthermore, only a small number of DR- cells may be selectable in certain patients. These impediments to the use of DR- cells for autografting may be overcome through the development of ex vivo culture systems that support expansion and initial differentiation of primitive progenitors. Because 2-week culture of DR- cells in a stroma "noncontact" system supplemented with interleukin-3 (IL-3) and macrophage inflammatory protein 1-alpha (MIP-1alpha) expands both long-term culture-initiating cells (LTC-ICs) and colony-forming cells (CFCs), we adapted this system to a clinically applicable method for expanding LTC-ICs and CFCs ex vivo. In initial small-scale studies, DR cells were grown in stroma conditioned medium (SCM) supplemented with IL-3 with or without additional growth-promoting cytokines and the chemokines PF-4 and BB10010, all approved for clinical use. An IL-3 dose-dependent expansion of committed progenitors and LTC-ICs was observed when DR- cells were cultured in tissue culture plates in SCM+IL-3 for 2 weeks. Similar CFC expansion along with increased (5-fold) LTC-IC expansion was observed following addition of PF-4 to SCM+IL-3 cultures. The addition of stem cell factor (SCF), but not of IL-6, IL-11, granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage (GM)-CSF, IL-1, and IL-7, increased CFC and LTC-IC expansion beyond the levels observed with SCM+IL-3 alone. We next evaluated the suitability of this culture system for scale-up. Culture of 2-6 x 10(5) DR- cells in gas-permeable bags with SCM+IL-3 resulted in similar CFC and LTC-IC expansion as seen in small-scale cultures. In addition, we observed that progenitors capable of differentiating to natural killer (NK)-cells were maintained under these conditions. Finally, we found that BCR/ABL mRNA-negative CFCs and LTC-ICs present in DR- cells selected from steady-state CML marrow could be expanded in large-scale SCM+IL-3 cultures. We conclude that culture of DR- cells for 2 weeks in SCM+IL-3 culture, with or without PF-4 or SCF, results in significant CFC and LTC-IC expansion and lymphoid NK progenitor maintenance. This culture system is readily adaptable to the expansion of primitive progenitors for autotransplantation.

Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty

The purpose of this study was to determine if intra-articular injection of morphine or bupivacaine significantly decreased postoperative pain as well as the use of intravenous narcotics for pain relief in patients undergoing total knee arthroplasty (TKA). In a prospective, double-blind, randomized fashion, 105 patients undergoing TKA were divided into the following 4 groups defined by the intra-articular injection they received: group 1 (n = 27) received saline solution, group 2 (n = 26) received morphine sulfate (5 mg), group 3 (n = 24) received bupivacaine (50 mg), and group 4 (n = 28) received a combination of morphine sulfate and bupivacaine. The injections were administered immediately after wound closure by the Hemovac drainage tubing that remained clamped for 45 minutes after surgery to allow for absorption. Before surgery and at 2, 4, 6, 24, and 48 hours after surgery, pain intensity was recorded using a visual analog scale. Postoperative supplemental intravenous morphine and/or meperidine was administered via a patient-controlled analgesia device, and 24-hour drug usage was tabulated. Results were suggestive of a modest short-term reduction in pain scores in the morphine and bupivacaine treatment groups compared with placebo (saline); however, results were statistically significant only at 4 hours because of the great variability in the pain score data. The total amount of postoperative pain medication used in the first 24 hours after surgery was not statistically significant between the 4 treatment groups. Thus, the results put into question the benefit of postoperative intra-articular administration of morphine or bupivacaine in patients undergoing TKA.

Characterization of the Phytophthora infestans Population in the Columbia Basin of Oregon and Washington from 1992 to 1995

ABSTRACT Isolates of Phytophthora infestans collected from 1992 to 1995 from potato fields in the Columbia Basin of Oregon and Washington were analyzed for compatibility type, metalaxyl sensitivity, and glucose-6-phosphate isomerase (Gpi) genotype. In 1992, 30 of 31 isolates were of the US-1 multilocus genotype. A single metalaxyl-resistant isolate of the US-6 (A1 Gpi 86/100) genotype was found near the end of the growing season. In 1993, only 2 of the 59 isolates collected were A1 isolates with Gpi 86/100. Ten isolates were of the A2 compatibility type, seven with Gpi 100/111, two with Gpi 100/100, and one was undetermined. The remaining isolates were metalaxyl-resistant A1 compatibility types with either Gpi 100/100 or 100/111. The first A2 isolates in the Columbia Basin were found in 1993. In 1994, 10 of 18 isolates were of the US-1 genotype. The remaining isolates were US-6 and US-8 genotypes. In 1995, 97% of 268 isolates tested were of the US-8 genotype. Five isolates were A2 compatibility type with Gpi 100/122. One A2, metalaxyl-resistant isolate was Gpi 100/100/111, and two A1 isolates were Gpi 100/111/122. The population of P. infestans quickly changed between 1992 and 1995, from a population comprised almost exclusively of the US-1 genotype to a population represented by new or recombinant genotypes.

Phenotypic and functional characterization of committed and primitive myeloid and lymphoid hematopoietic precursors in human fetal liver

We studied the phenotypic and functional properties of colony-forming cells (CFCs), primitive long-term culture initiating cells (LTC-ICs) and lymphoid precursors present in human fetal liver (FL) and compared these with their adult bone marrow (BM) counterparts. FL (7-14-week) cells were selected by fluorescence-activated cell sorting based on increasing CD34 antigen expression (34+, 34++, or 34 ), CD38 antigen expression (CD34++/ CD38+, or CD38-), and HLA-DR antigen expression (CD34++/ HLA-DR+ or HLA-DR-). 13 +/- 0.6% of FL CD34-positive cells were 34 . Significantly more FL CD34++/ cells were CD38- (49 +/- 2.4%) and HLA-DR-(72 +/- 6.7%) than BM CD34++ cells (6.8 +/- 0.7% CD38- and 13.3 +/- 3.2% HLA-DR-). FL and BM CFCs were CD34+/++, CD38+, and HLA-DR+. However, significantly more FL CFCs were erythroid (40%) than adult BM CFCs (15%), and FL colonies were larger (8111 +/- 738 cells/CFC) than BM colonies (3466 +/- 272 cells/CFC, p < 0.001). As is seen in adult BM, FL LTC-ICs were CD34++/ CD38-. In contrast to BM LTC-ICs, FL LTC-ICs were almost exclusively CD34++/ HLA-DR+. In addition, a single FL LTC-IC gave rise to >30 CFCs at 5 weeks compared with only 5 +/- 0.9 CFCs per LTC-IC from BM. Finally, we demonstrate that the FL CD34++/ /CD38-/HLA-DR+ population, which contains 3.7% LTC-ICs, also contains primitive lymphoid progenitors capable of differentiating into natural killer (NK) cells. In conclusion, the phenotype of primitive human FL progenitors such as LTC-IC and primitive NK progenitors is CD34++/ /CD38-/HLA-DR+, suggesting that this population may contain FL hematopoietic stem cells. The phenotypic characterization of FL primitive LTC-ICs and NK progenitors will facilitate further studies of the functional properties of these progenitors.

Low dose subcutaneous interleukin-2 after autologous transplantation generates sustained in vivo natural killer cell activity

Autologous transplantation can induce extended remission in some patients with advanced breast cancer and lymphoma yet nearly 80% and 50%, respectively, will ultimately relapse. In vitro studies suggest that activated natural killer cells (NK) mediate lytic activity against breast cancer and lymphoma cell lines. Therefore, immunotherapy with interleukin-2 (IL-2, Amgen) to activate NK may improve long-term disease-free survival when administered in a post-transplant minimal residual disease setting. To determine the feasibility of administering IL-2 and activation of NK post-transplant, twelve patients (6 breast cancer, 6 lymphoma) were enrolled on a phase I dose escalation study after autologous transplantation (median day + 94, range 50-166). IL-2 was self administered at 0.25 x 10(6) (n = 6) or 0.5 x 10(6) (n = 6) U/m2/day subcutaneously for 84 consecutive days. The best tolerated dose was 0.25 x 10(6) U/m2/day (75% of planned doses given vs. 48% at the higher dose). Dose limiting toxicity occurred in 6 patients (n = 2 at 0.25 x 10(6) U/m2/day, n = 4 at 0.5 x 10(6) U/m2/day) consisting of decreased performance status (n = 2), thrombocytopenia (n = 3, 1 at the lower dose), and mild neutropenia (n = 1 at the lower dose). However, all symptoms resolved within a week following discontinuation of IL-2 and no patient required hospitalization. Circulating soluble IL-2 receptor levels were significantly increased in all patients receiving IL-2. Patients receiving at least 28 days of IL-2 exhibited a greater than 10-fold increment in circulating CD56+bright/CD3- NK. Furthermore, lytic function was increased against NK resistant targets, MCF-7 (breast cancer), and Raji (lymphoma). In vivo IL-2 primed NK cells obtained by lymphapheresis were activated in large-scale ex vivo incubation in high dose IL-2 (1,000 U/mL) at high cell density (10 x 10(6)/mL), in gas permeable bags, and using serum-free media. NK lytic function against MCF-7 and Raji targets was further enhanced. We conclude that low dose subcutaneous IL-2 based immunotherapy is feasible, relatively safe, can be administered in an outpatient setting and hypothesize that additional ex vivo incubation in IL-2 may be used to generate NK cells with potent antitumor effects in vivo.

Potato Late Blight in the Columbia Basin: An Economic Analysis of the 1995 Epidemic

The cost of managing late blight in potatoes during a severe epidemic caused by new, aggressive strains of Phytophthora infestans in the Columbia Basin of Washington and Oregon in 1995 was documented. The mean number of fungicide applications per field varied from 5.1 to 6.3 for early- and midseason potatoes, and from 8.2 to 12.3 for late-season potatoes in the northern and southern Columbia Basin, respectively. In 1994, a year when late blight was not severe, the mean number of fungicide applications per field made to early- and midseason potatoes was 2.0; whereas late-season potatoes received a mean of 2.5 applications. The mean per acre cost of individual fungicides applied varied from $4.90 for copper hydroxide to $36.00 for propamocarb + chlorothalonil. Total per acre expenses (application costs plus fungicide material) for protecting the crop from late blight during 1995 ranged from $106.77 to $110.08 for early and midseason potatoes in different regions of the Columbia Basin and from $149.30 to $226.75 for lateseason potatoes in the northern and southern Columbia Basin, respectively. Approximately 28% of the crop was chemically desiccated before harvest as a disease management practice for the first time in 1995, resulting in an additional mean cost of $34.48/acre or $1.3 million for the region. Harvested yields were 4 to 6% less than in 1994. The total cost of managing late blight in the Columbia Basin in 1995 is estimated to have approached $30 million.

CD3 gamma, CD3 delta, and CD3 zeta mRNA in adult human marrow hematopoietic progenitors correlates with surface CD2 and CD7 expression

Hematopoietic stem cells from adult marrow, cord blood, or fetal liver can differentiate into myeloid and lymphoid lineages. Early steps in this differentiation process are not yet fully understood. To correlate surface antigen expression with molecular events occurring during early lymphopoietic differentiation, we examined CD3 gamma, CD3 delta, and CD3 zeta gene expression in adult human CD34+ marrow progenitors and their subsets. Purification by fluorescence-activated cell sorter (FACS) was used to obtain 1) a CD34+ Lin-DR- population known to contain primitive, uncommitted progenitors; 2) CD34+/CD7+/CD2+ and 3) CD34+/CD7+/CD2+ cells expressing receptors associated with natural killer (NK) cell or T cell lineage commitment. We demonstrate that CD34+Lin-DR- cells do not contain CD3 gamma, CD3 delta, or CD3 zeta transcripts, consistent with the primitive uncommitted nature of progenitors in this cell population. Expression of the CD34+/CD7+/CD2- phenotype correlates with the transcription of CD3 zeta but not CD3 gamma or CD3 delta, a pattern of transcription observed in mature blood NK but not T cells. Expression of both CD7 and CD2 on CD34+ cells is associated with not only CD3 zeta gene transcription but also CD3 gamma and CD3 delta, a pattern found in T cells but not mature NK cells. We have identified unique patterns of mRNA transcription in phenotypically distinct lymphoid progenitors found in the marrow. These findings raise the possibility that although primitive NK and T cell progenitors share a common differentiation pathway, divergent NK and T lineage commitment steps may occur very early in lymphopoiesis. Our findings suggest that application of in vitro marrow and thymus culture techniques may be utilized to more fully describe commitment and differentiation of early lymphoid progenitors and define the role of the microenvironment in this process.

Production of human natural killer cells for adoptive immunotherapy using a computer-controlled stirred-tank bioreactor

Large-scale ex vivo expansion of human natural killer (NK) cells for adoptive immunotherapy requires assurance of good manufacturing practices. However, maximal expansion of NK is also desired to facilitate clinical trials with large numbers of IL-2-activated NK (ANK). A closed-system stirred-tank bioreactor is amenable to computer control of culture variables, thereby reducing the risk of contamination. We demonstrate that NK cultured in 250-ml spinner flasks expand 2.5-fold more than NK cultured in stationary tissue culture wells. We further show that during 33 days of culture, it is feasible to control the pH between 7.0 and 7.2 and the dissolved oxygen concentration at 40% of air saturation via direct on-line computer control in a 750-ml stirred-tank bioreactor. On-line measurement of optical density by a laser turbidity sensor, as a measure of cell concentration, correlated well with actual cell count data. NK expansion in the 750-ml bioreactor was 7-fold greater than in stationary tissue culture controls and 3-fold greater than in spinner flask controls. Consumption rates of glucose and oxygen and the production rate of lactate were measured and will be used to develop a nutrient feeding strategy to convert the batch reactor experiment into closed-system fed-batch or continuous flow modes. Computer-controlled stirred-tank bioreactors may facilitate clinical trials with high-purity ANK populations for adoptive immunotherapy.

CD56+bright and CD56+dim natural killer cells in patients with chronic myelogenous leukemia progressively decrease in number, respond less to stimuli that recruit clonogenic natural killer cells, and exhibit decreased proliferation on a per cell basis

Human natural killer cells (NK) require accessory cell-derived contact and soluble factors for maximal expansion. However, it is unclear whether increased recruitment of clonogenic NK, increased proliferation on a per cell basis, or a combination of both is responsible for the increased expansion. We show that expansion of both CD56+dim and CD56+bright NK from normal donors is increased in the presence of M2-10B4 accessory cell-soluble factors. In contrast, the addition of M2-10B4 stromal ligands further augments only the expansion of CD56+bright NK. Using single-cell sorting of CD56+bright NK, M2-10B4-soluble and contact factors independently increase both recruitment of clonogenic NK and proliferation on a per cell basis. This well-defined M2-10B4 accessory cell system was used to investigate potential defects in NK from patients with CML. Although we have previously shown diminished interleukin-2 (IL-2)-activated NK outgrowth and function from patients with chronic myelogenous leukemia (CML) as their disease progresses, it has been unclear if this is due to a defect in an accessory cell function or an inherent abnormality of CML NK themselves. CD56+/CD3- NK purified by fluorescence-activated cell sorting from 21 patients (7 early chronic phase [ECP] patients, 10 late chronic and accelerated phase [LCP/AP], and 4 blast crisis [BC] patients) were studied. The proliferative capacity, clonogenic frequency, and cytotoxic capacity of CML NK were compared with NK from normal donors. The absolute number of circulating NK per milliliter of peripheral blood is significantly decreased in patients with CML compared with normal donors (normal, 63,700 +/- 6,400; ECP, 40,700 +/- 6,700; LCP/AP, 31,900 +/- 6,000; BC, 10,700 +/- 5,200). Additionally, the unique CD56+bright NK subset, analyzed as a percentage of the total circulating NK pool, is significantly reduced in all patients with CML (normal, 5.7% +/- 0.8% v CML [all stages combined], 2.5% +/- 0.5%, P = .001]. After purification of NK to correct for differences in circulating NK number, resting NK cytotoxicity against K562 tumor targets is significantly reduced in patients with CML on or recently on hydroxyurea therapy. However, this reduced cytotoxicity can be corrected by 18 hours of incubation with 1,000 U/mL recombinant IL-2. When plated in limiting dilution on viable M2-10B4, which maximally stimulates NK from normal donors, we show that both NK clonogenic frequency and proliferative capacity are significantly reduced as CML progresses, demonstrating an inherent defect in their ability to respond to normal NK stimuli. Although NK cloning efficiency between normal donors and ECP CML patients was the same, significant differences were observed in (1) the absolute number of circulating CD56+/CD3- NK, (2) the absolute number of circulating CD56+bright NK, and (3) proliferation on a per cell basis. Unlike resting NK function, prior cytotoxic therapy alone did not account for these observed abnormalities. These data suggest that, although NK are not derived from the malignant clone, they are inherently affected by their malignant microenvironment.

A radiographic comparison of neutral cervical posture with cervical flexion and extension ranges of motion

OBJECTIVE

To radiographically assess, using a pilot study, the relationship between the neutral cervical curve and cervical segmental ranges of motion (ROM) for flexion and extension in asymptomatic subjects.

DESIGN

Survey.

SETTING

Chiropractic college student health center and private practice.

PATIENTS

Sixteen asymptomatic adult students with no radiographic evidence of degenerative changes.

INTERVENTION

No therapeutic intervention.

MAIN OUTCOME MEASURES

Neutral segmental alignment and flexion and extension segmental ranges of motion for C2-C6 evaluated relative to the subjacent segment.

RESULTS

Correlations between neutral posture variables (segmental tilt and global posture) and their corresponding ROMs (segmental and global) were computed. A strong correlation was found for flexion at C4 (r = -.76, p = .0006) and at C5 (r = -.84, p = .0001). Correlations were not as strong at other vertebral levels for flexion and at all levels for extension (r = .01 to r = .52). The error in prediction of motion from neutral posture is given by the standard error of the estimate (SEE). The SEE for flexion ROM ranged from 2.6 degrees at C5 to 3.9 degrees at C6, and the SEE for extension ranged from 3.8 degrees at C4 to 6.5 degrees at C2.

CONCLUSION

Correlation between neutral cervical posture and flexion or extension ranges of motion was only strong at the C4 and C5 vertebral levels. Generally, there was not good predictability of ROM from neutral posture as indicated by the R2 values and the standard errors of estimate. Further investigation is needed to determine if other variables, such as angle of the facet joints, may be influential in these postural-functional relationships.

BCR/ABL-negative primitive progenitors suitable for transplantation can be selected from the marrow of most early-chronic phase but not accelerated-phase chronic myelogenous leukemia patients

We have previously reported that selection of marrow cells on the basis of the CD34+HLA-DR- phenotype (34+DR-) may result in the recovery of Philadelphia chromosome (Ph)- and BCR/ABL-negative long-term culture-initiating cells (LTC-IC) in selected patients with chronic myelogenous leukemia (CML). We now present data on 27 early chronic-phase ([ECP] studied within 1 year after diagnosis) and 23 advanced-phase ([AP] late chronic phase, ie, studied >1 year from diagnosis, or accelerated phase) CML patients. Fluorescence-activated call-sorting (FACS)-selected 34+DR- and 34+DR+ cells were subjected to reverse transcriptase-polymerase chain reaction and fluorescence in situ hybridization. These cells were also cultured in long-term bone marrow culture for 1 to 5 weeks to examine the number of LTC-IC and the presence or absence of the BCR/ABL gene rearrangement in progeny of primitive LTC-IC. The number of 34+DR- cells and LTC-IC present in ECP CML marrow was similar to that in normal (NL) marrow, whereas the numbers were reduced in AP CML. Furthermore, 34+DR- cells from more than 80% of ECP CML patients were BCR/ABL mRNA- and Ph-negative and contained only BCR/ABL mRNA- and Ph-negative LTC-IC, whereas 34+DR- cells and LTC-IC from less than 40% of AP CML patients were BCR/ABL mRNA- and Ph-negative. In contrast to NL marrow, 34+DR+ cells from CML marrow, irrespective of clinical stage, contained large numbers of LTC-IC. CML 34+DR+ cells and LTC-IC were BCR/ABL mRNA- and Ph-positive. Since these studies suggested that a population of primitive progenitors that are Ph-negative can be selected from steady-state marrow in some ECP CML patients, we determined if similar results could be obtained when large quantities of marrow sufficient for transplantation are processed. We demonstrate that 1 to 3 x 10(5) BCR/ABL mRNA-negative 34+DR- cells/kg recipient body weight, containing only BCR/ABL mRNA-negative LTC-IC, can be obtained from a 2- to 2.5-L marrow collection by sequential COBE Spectra apheresis (COBE BCT, Lakewood, CO), CD34+ enrichment using the CEPRATE SC Cell-Concentrator (CellPro, Bothell, WA), and high-speed FACS. Thus, large-scale selection of a BCR/ABL mRNA- and Ph-negative 34+DR- cell population is possible in a fraction of chronic-phase CML patients, in whom these cells could be used to reconstitute the hematopoietic compartment following autologous transplantation.

Malignant neoplasms following bone marrow transplantation

We undertook an analysis of 2,150 recipients of bone marrow transplant (BMT) at the University of Minnesota to determine the incidence of post-BMT malignant neoplasms (MNs). Fifty-one patients developed 53 MNs, compared with 4.3 expected from general population rates (standardized incidence ratio [SIR], 11.6, 95% confidence interval [CI], 8.2-14.5). These included 22 occurrences of B-cell lymphoproliferative disorder (BLPD), 17 solid nonhematopoietic tumors, 10 myelodysplastic syndromes (MDS), 1 acute myelogenous leukemia (AML), 2 non-Hodgkin's lymphoma (NHL), and 1 Hodgkin's disease (HD). The estimated actuarial incidence of any post-BMT malignancy was 9.9% +/- 2.3% at 13 years posttransplant. The cumulative probability of BLPD plateaued at 1.6% +/- 0.3% by 4 years from transplant and factors independently associated with increased risk included in vitro T-cell depletion of marrow (relative risk (RR) = 11.9, P < .001), HLA mismatch (RR = 8.9, P < .001), use of antithymocyte globulin (ATG) for graft versus host disease (GVHD) prophylaxis (RR = 5.9, P < .001) or in the preparative regimen (RR = 3.1, P = .03) and primary immunodeficiency (RR = 2.5, P = .06). The cumulative probability of developing solid malignancy was 5.6% +/- 2.2% at 13 years from BMT. Malignant melanomas were the most common (SIR, 10.3, 95% CI 1.9 to 25.4). The actuarial incidence of MDS/AML plateaued at 2.1% +/- 0.8% at 9 years and was seen most often in older patients receiving autologous peripheral blood stem cells for HD or NHL. These data document that BMT recipients are at an increased risk of later malignancy, which may add significant morbidity and mortality to the transplant process. Methods for screening and identification of individuals at increased risk need to be addressed in future studies.

Autologous activated natural killer cells suppress primitive chronic myelogenous leukemia progenitors in long-term culture

A graft-versus-leukemia effect has been well documented to prevent relapse in chronic myelogenous leukemia (CML) after allogeneic marrow transplantation. One type of lymphocytes that may contribute to this effect are natural killer cells (NK), which after activation with interleukin (IL)-2, exhibit a broad range of cytolytic activity against allogeneic and autologous cells. We have previously demonstrated that IL-2-activated NK (ANK) can be generated from blood of patients with CML and are benign in origin. Their proliferation and function, however, diminish with disease progression in CML, suggesting a role in tumor surveillance. We studied the effect of IL-2-activated NK (ANK) on normal and malignant primitive and committed progenitors in a novel long-term bone marrow culture (LTBMC) assay. Because ANK destroy marrow stromal layers, the use of classic stroma-dependent long-term cultures is not possible. Therefore, we used the stroma noncontact LTBMC system developed in our laboratory to analyze the effect of autologous ANK cells on primitive hematopoietic progenitors. Autologous ANK (CD56+/CD3-) were generated from the peripheral blood of 10 patients with chronic phase CML and from six normal individuals by culturing CD5/CD8-depleted mononuclear cells for 14 days in 1,000 U/mL IL-2. At the same time ANK cultures were initiated, sorted normal (CD34+/DR+) marrow populations were plated in Transwell inserts of the stroma noncontact culture. On day 15, hydrocortisone, which rapidly inhibits ANK function, was removed, and autologous ANK were added to the Transwell inserts with fresh LTBMC medium without hydrocortisone but supplemented with 1,000 U/mL IL-2. After 48 hours, the number of colony-forming cells (CFC) was enumerated in methylcellulose culture. To determine the effect of ANK on more primitive long-term culture-initiating cells (LTCIC), the IL-2-supplemented LTBMC medium was replaced with fresh hydrocortisone containing LTBMC medium, and cultures were maintained for an additional 5 weeks. We demonstrate that autologous ANK did not suppress normal CFC or LTCIC. In contrast, ANK from eight patients with CML with potent cytotoxicity against NK-sensitive (K562) NK-resistant (Raji) tumor targets exhibited an ANK dose-dependent suppression of both CFC and LTCIC. Interestingly, ANK from two patients with CML who exhibited diminished cytotoxicity also did not suppress autologous CFC and LTCIC. These studies indicate that ANK with potent major histocompatibility complex unrestricted cytotoxic activity suppress malignant hematopoiesis. This effect was not mediated by soluble factors and was absolutely dependent on direct cell-to-cell contact. We further demonstrate that the beta2 integrin receptor is involved in ANK recognition of CML targets. These observations support the use of autologous ANK therapy to prevent relapse of CML after autologous marrow transplantation or use of ANK to purge CML marrow for autologous transplantation.

Human natural killer cell expansion is regulated by thrombospondin-mediated activation of transforming growth factor-beta 1 and independent accessory cell-derived contact and soluble factors

Natural killer cells (NK) were studied to determine factors important in their expansion. Flourescence-activated cell sorter (FACS) purified CD56+/CD3- NK cells cultured alone for 18 days in rIL-2 containing medium (1,000 U/mL) showed enhanced cytotoxicity but only minimal expansion. NK expansion was increased (12.5 +/- 1.6-fold) by coculturing NK with soluble factors produced by irradiated peripheral blood mononuclear cells (PBMNC) in which the two populations were separated by a microporous membrane. However, maximal NK expansion was always observed when NK were cocultured in direct contact with irradiated PBMNC (49.4 +/- 5.9-fold). To determine if marrow stroma, which supports differentiation of primitive NK progenitors, was a better accessory cell population than irradiated PBMNC, NK were cocultured in direct contact with primary marrow stromal layers. NK expansion with marrow stroma was similar to PBMNC. Fibroblast cell lines (M2-10B4, NRK-49F, NIH-3T3) and human umbilical vein endothelial cells (HUVEC), all homogeneous populations and devoid of monocytes, also exhibited a similar contact-dependent increase in NK expansion. Experiments were designed using fixed M2-10B4 stromal cells to separate the contact-induced proliferative stimuli from soluble factors. NK plated directly on ethanol/acetic acid-fixed M2-10B4, which leaves stromal ligands (cell membrane components and ECM) intact, resulted in increased NK expansion compared with medium alone. We further show that the combination of independent contact and soluble factors is responsible for maximal late NK expansion (days 28 through 40) but paradoxically inhibits early NK expansion (day 7). The proliferation inhibitory effects were verified by 3H-thymidine uptake and could be detected at days 2 through 6 but no longer 14 days after the initiation of the culture. We show that both laminin and thrombospondin inhibit early NK proliferation, whereas only thrombospondin was capable of also stimulating late NK expansion. The effect of thrombospondin on early NK proliferation is related to activation of transforming growth factor-beta 1 (TGF-beta) because anti-TGF-beta neutralizing antibody completely abrogated thrombospondin-mediated inhibition of early NK proliferation. Although inhibitory early in culture, active TGF-beta added only at culture initiation increases late NK expansion similar to thrombospondin. TGF-beta was not present in the thrombospondin preparation but latent TGF-beta in serum, or TGF-beta transcripts identified in IL-2-activated NK could explain paracrine or autocrine mechanisms for the regulation of NK proliferation. Finally, anti-TGF-beta neutralizing antibody only minimally affects stroma-mediated inhibition of early NK proliferation suggesting that aside from thrombospondin/TGF-beta, additional contact factors are important for the regulation of NK proliferation.