Evaluation of the Coulter Counter model S-Plus IV

Association between Neutrophil-to-Lymphocyte Ratio with Abdominal Obesity and Healthy Eating Index in a Representative Older Spanish Population

Poor diet quality and obesity, especially abdominal obesity, have been associated with systemic inflammation. The neutrophil-to-lymphocyte Ratio (NLR) is an available and inexpensive inflammation biomarker. The aim of the present study was to determine the association of dietary patterns and obesity with an inflammatory state. A group of 1747 Spanish noninstitutionalized older adults individuals were included, and a food-frequency questionnaire was applied. The Global Food Score (GFS) and Healthy Eating Index for Spanish population (SHEI) were calculated. Weight, height and waist (WC) and hip circumferences were measured, and BMI, waist-to-height ratio (WHtR), and waist-to-hip ratio (WHR) determined. In addition, body-fat percentage was measured by bioimpedance. NLR was calculated (NLR ≥ p80: 2.6; 2.8 and 2.4 as inflammatory status in the entire population, men and women, respectively). The men with inflammatory status presented significative higher values of WC, WHtR, WHR, and body-fat percentage (101.82 ± 10.34 cm, 0.61 ± 0.06, 0.98 ± 0.06, and 31.68 ± 5.94%, respectively) than those with better inflammatory status (100.18 ± 10.22 cm, 0.59 ± 0.06, 0.97 ± 0.07, and 30.31 ± 6.16%, respectively). Those males with worse inflammatory state had lower scores for protein foods (OR = 0.898 (0.812–0.993); p = 0.037). The women with NLR ≥ 2.4 had higher WHtR and WHR (0.62 ± 0.09 and 0.91 ± 0.09) than those with NLR < 2.4 (0.60 ± 0.08 and 0.90 ± 0.08). In multiple linear regression analysis, NLR was positively related with WHtR and negatively related with SHEI score (β = 0.224 ± 0.094; R² = 0.060; p < 0.05 and β = −0.218 ± 0.101; R² = 0.061; p < 0.05), adjusting by sex, age, marital status, education level, smoking, hours of sleeping and inflammatory diseases. In women, the higher the SHEI and GFS scores were and the better meeting the aims of cereal and vegetable servings, the less the odds of inflammatory status (OR = 0.970 (0.948–0.992); p = 0.008; OR = 0.963 (0.932–0.995); p = 0.024; OR = 0.818 (0.688–0.974); p = 0.024 and OR = 0.829 (0.730–0.942); p = 0.004, respectively). WHtR and quality of diet is related to the inflammation status in older adults regardless to the sex.

Impact of clinical factors and allograft leukocyte content on post-transplant lymphopenia, monocytopenia, and survival in patients undergoing allogeneic peripheral blood haematopoietic cell transplant

BACKGROUND

We have previously shown that lymphopenia and monocytopenia at 2-3 months post-allogeneic haematopoietic cell transplant (HCT) is associated with poor survival in recipients of both myeloablative and reduced intensity conditioning regimens. It is not known whether the graft leukocyte content has a role in early lymphocyte and monocyte recovery following allogeneic T-cell replete peripheral blood HCT.

METHODS

Haematologic recovery data, including absolute lymphocyte and monocyte counts (ALC and AMC, respectively) at day +15, +30, +60, and +100, and outcomes data were pooled from two prior independent cohorts, and parameters were correlated with leukocyte graft content in those individuals receiving peripheral blood progenitor cell grafts. 216 consecutive patients from 2001-2010 were included in the analysis.

RESULTS

Neither infused allograft lymphocyte, monocyte, granulocyte, nor CD34+ cell number per kilogram recipient body weight correlated with haematologic recovery parameters or overall survival in this cohort. Prognostic factors for overall survival based on multivariate analysis were as expected from the results of the previous independent cohorts and included severity of chronic GVHD (p < 0.001), development of post-transplant relapse (p = 0.001), day +60 AMC > 0.3 x 10(9) cells/L (p = 0.0015), and day +100 ALC > 0.3 x 10(9) cells/L (p < 0.001). Low monocyte and lymphocyte counts at the day +60 and day +100 time points were significantly associated with acute GVHD and/or CMV viraemia.

CONCLUSIONS

This study suggests that graft cell count does not influence post-transplant monocyte and lymphocyte recovery following T-cell replete allogeneic peripheral blood HCT. Post-transplant complications such as acute GVHD and/or CMV viraemia negatively influenced monocyte and lymphocyte recovery, and hence the survival. Further studies aimed at understanding the mechanisms behind sustained lymphopenia and monocytopenia post-transplant are needed.

Infused autograft lymphocyte to monocyte ratio and survival in diffuse large B cell lymphoma

Infused autograft absolute lymphocyte count is a prognostic factor for survival after autologous peripheral hematopoietic stem cell transplantation (APHSCT) for diffuse large B cell lymphoma (DLBCL). CD14(+) HLA-DR(low/neg) immunosuppressive monocytes affect tumor growth by suppressing host antitumor immunity. Thus, we set out to investigate if the infused autograft lymphocyte to monocyte ratio (A-LMR), as a biomarker of host immunity (ie, lymphocytes) and immunosuppression (ie, monocytes), affects survival after APHSCT. From 1994 to 2012, 379 DLBCL patients who underwent APHSCT were studied. The 379 patients were randomly divided into a training set (n = 253) and a validation set (n = 126). Receiver operating characteristic and area under the curve identified an A-LMR ≥1 as the best cut-off value, which was validated by the k-fold cross-validation in the training set. Multivariate analysis showed A-LMR to be an independent prognostic factor for survival in the training set. Patients with an A-LMR ≥ 1.0 experienced superior overall survival (OS) compared with patients with an A-LMR <1.0 (median OS: 167.2 versus 17.6 months; 5-year OS: 73% [95% confidence interval (CI), 63% to 80%] versus 30% [95% CI, 2% to 38%], P < .0001, respectively) in the training set. In the validation set, an A-LMR ≥ 1 showed a median OS of 181.2 months versus 19.5 months for an A-LMR <1, and 5-year OS rates of 67% (95% CI, 52% to 79%) versus 35% (95% CI, 25% to 47%), P < .0001, respectively. The A-LMR provides a platform to engineer immunocompetent autograft to improve clinical outcomes in DLBCL patients undergoing APHSCT.

Peripheral blood absolute lymphocyte/monocyte ratio during rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone treatment cycles predicts clinical outcomes in diffuse large B-cell lymphoma

A limitation of the prognostic factor peripheral blood absolute lymphocyte/monocyte ratio (ALC/AMC) at diagnosis in diffuse large B-cell lymphoma (DLBCL) is its inability to sequentially assess the host/tumor microenvironment interaction and clinical outcomes during treatment. Therefore, we studied the ALC/AMC ratio at each rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) cycle as a predictor for survival. We studied 107 consecutive patients with DLBCL diagnosed, treated only with R-CHOP and followed at the Mayo Clinic. Unsupervised hierarchical clustering identified four clusters based on the patterns of ALC/AMC ratio recovery during cycles. The most inferior survival was seen in the cluster with ALC/AMC ratio < 1.1 in all cycles. By multivariate analysis, ALC/AMC ratio < 1.1 during all cycles was an independent predictor for inferior overall survival and progression-free survival. The ALC/AMC ratio during R-CHOP cycles predicts survival and provides a platform to develop therapeutic modalities to manipulate the ALC/AMC ratio during R-CHOP cycles to improve DLBCL clinical outcomes.

Day 100 Peripheral Blood Absolute Lymphocyte/Monocyte Ratio and Survival in Classical Hodgkin's Lymphoma Postautologous Peripheral Blood Hematopoietic Stem Cell Transplantation

Day 100 prognostic factors of postautologous peripheral blood hematopoietic stem cell transplantation (APBHSCT) to predict clinical outcome in classical Hodgkin lymphoma (cHL) patients have not been evaluated. Thus, we studied if the day 100 peripheral blood absolute lymphocyte/monocyte ratio (Day 100 ALC/AMC) affects clinical outcomes by landmark analysis from day 100 post-APBHSCT. Only cHL patients achieving a complete remission at day 100 post-APBHSCT were studied. From 2000 to 2010, 131 cHL consecutive patients qualified for the study. The median followup from day 100 was 4.1 years (range: 0.2-12.3 years). Patients with a Day 100 ALC/AMC ≥ 1.3 experienced superior overall survival (OS) and progression-free survival (PFS) compared with Day 100 ALC/AMC < 1.3 (from day 100: OS, median not reached versus 2.8 years; 5 years OS rates of 93% (95% CI, 83%-97%) versus 35% (95% CI, 19%-51%), resp., P < 0.0001; from day 100: PFS, median not reached versus 1.2 years; 5 years PFS rates of 79% (95% CI, 69%-86%) versus 27% (95% CI, 14%-45%), resp., P < 0.0001). Day ALC/AMC ratio was an independent predictor for OS and PFS. Thus, Day 100 ALC/AMC ratio is a simple biomarker that can help to assess clinical outcomes from day 100 post-APBHSCT in cHL patients.

Peripheral blood absolute lymphocyte/monocyte ratio recovery during ABVD treatment cycles predicts clinical outcomes in classical Hodgkin lymphoma

The peripheral blood absolute lymphocyte/monocyte count ratio at diagnosis (ALC/AMC-DX) predicts survival in classical Hodgkin lymphoma (cHL). However, a limitation of the ALC/AMC-DX is the inability to assess sequentially the host/tumor interaction during treatment. Therefore, we retrospectively examined the ALC/AMC ratio, as a surrogate marker of host immunity (ALC) and tumor microenvironment (AMC), at each adriamycin, bleomycin, vinblastine and dacarbazine treatment cycle as a predictor for clinical outcomes. From 1990 until 2008, 190 cHL patients were diagnosed, treated and followed at Mayo Clinic Rochester and qualified for the study. The ALC/AMC ratio at each treatment cycle was a predictor for overall survival (OS) and progression-free survival (PFS). An ALC/AMC ratio 1.1 versus ALC/AMC <1.1 during treatment cycles was an independent predictor for OS (hazard ratio (HR)=0.14; 95% confidence interval (CI): 0.04-0.40; P<0.0002) and for PFS (HR=0.19; 95% CI: 0.05-0.82; P<0.03). The ALC/AMC ratio during treatment cycles is a predictor for survival and provides a platform to develop therapeutic modalities to manipulate the ALC/AMC ratio during chemotherapy to improve clinical outcomes in cHL.

Impact of lymphocyte and monocyte recovery on the outcomes of allogeneic hematopoietic SCT with fludarabine and melphalan conditioning

We have recently shown that lymphocyte and monocyte recovery by day +100 are associated with survival post myeloablative allogeneic hematopoietic transplant for acute leukemia. We hypothesized that lymphocyte and monocyte recovery would have a similar impact on survival in the reduced intensity setting. To test this hypothesis, we analyzed clinical data from 118 consecutive fludarabine/melphalan-conditioned patients by correlating peripheral blood absolute lymphocyte counts and monocyte counts (ALC and AMC, respectively) at days +15, +30, +60 and +100 with the outcomes. Multivariate analysis revealed that day +100 AMC (risk ratio (RR) 0.22, 95% confidence interval (CI) 0.07-0.73, P=0.01) and mild chronic GVHD (RR 0.09, 95% CI 0.005-0.43, P=0.008) were independently associated with survival. To explore whether the patterns of lymphocyte and monocyte recovery had a prognostic value, we performed unsupervised hierarchical clustering on the studied hematopoietic parameters and identified three patient clusters, A-C. Patient clusters A and B both had improved OS compared with cluster C (77.8 months vs not reached vs 22.3 months, respectively, P<0.001). No patient in cluster C had a day +100 AMC >300. Both severe acute GVHD and relapse occurred more frequently in cluster C. Our data suggest that patients with low AMC by day +100 post fludarabine/melphalan-conditioned allogeneic hematopoietic SCT may be at risk for poor outcomes.

Absolute monocyte/lymphocyte count prognostic score is independent of immunohistochemically determined cell of origin in predicting survival in diffuse large B-cell lymphoma

The absolute monocyte/lymphocyte count prognostic score (AMC/ALC score) has not been directly compared with the cell of origin (COO) to predict overall survival (OS) and progression-free survival (PFS) in diffuse large B-cell lymphoma (DLBCL). Thus, we retrospectively examined a new cohort of 99 patients with DLBCL treated from 2008 to 2010, (1) to validate whether AMC/ALC score affects survival, (2) to investigate whether AMC/ALC score is independent of COO to predict survival and (3) to assess whether AMC/ALC score can further stratify clinical outcomes by COO. By univariate analysis, the AMC/ALC score was a predictor for OS and PFS. On multivariate analysis performed including the COO and the International Prognostic Index, AMC/ALC score remained an independent predictor for OS and PFS. The AMC/ALC score was able to further stratify DLBCL clinical outcomes by COO. The AMC/ALC score was independent of COO and added to its ability to identify patients with high-risk disease.

The absolute monocyte count is associated with overall survival in patients newly diagnosed with follicular lymphoma

Follicular lymphoma is characterized by a highly variable clinical course ranging from early transformation and disease-related mortality to prolonged periods of disease stability or even spontaneous remissions. This clinical heterogeneity is likely explained by differences in the tumor microenvironment, including variable infiltration by monocyte-derived cells. Therefore, we examined the absolute monocyte count obtained from a standard complete blood count with differential at the time of diagnosis as a prognostic factor in a cohort of patients with follicular lymphoma (n = 355) treated at a single institution between 1998 and 2007. We found that the absolute monocyte count at diagnosis is associated with overall survival, independent of the Follicular Lymphoma International Prognostic Index (FLIPI). Furthermore, the absolute monocyte count improved the ability to identify high-risk patients when used in conjunction with the FLIPI. These results further support the central role of non-neoplastic myeloid-lineage cells in follicular lymphoma biology.

Peripheral blood lymphocyte/monocyte ratio at diagnosis and survival in classical Hodgkin's lymphoma

BACKGROUND

Lymphopenia and tumor-associated macrophages are negative prognostic factors for survival in classical Hodgkin's lymphoma. We, therefore, studied whether the peripheral blood absolute lymphocyte count/absolute monocyte count ratio at diagnosis affects survival in classical Hodgkin's lymphoma.

DESIGN AND METHODS

We studied 476 consecutive patients with classical Hodgkin's lymphoma followed at the Mayo Clinic from 1974 to 2010. Receiver operating characteristic curves and area under the curve were used to determine cut-off values for the absolute lymphocyte count/absolute monocyte count ratio at diagnosis, while proportional hazards models were used to compare survival based on the absolute lymphocyte count/absolute monocyte count ratio at diagnosis.

RESULTS

The median follow-up period was 5.6 years (range, 0.1-33.7 years). An absolute lymphocyte count/absolute monocyte count ratio at diagnosis of 1.1 or more was the best cut-off value for survival with an area under the curve of 0.91 (95% confidence interval, 0.86 to 0.96), a sensitivity of 90% (95% confidence interval, 85% to 96%) and specificity of 79% (95% confidence interval, 73% to 88%). Absolute lymphocyte count/absolute monocyte count ratio at diagnosis was an independent prognostic factor for overall survival (hazard ratio, 0.18; 95% confidence interval, 0.08 to 0.38, P<0.0001); lymphoma-specific survival (hazard ratio, 0.10; 95% confidence interval, 0.04 to 0.25, P<0.0001); progression-free survival (hazard ratio, 0.35; 95% confidence interval, 0.18 to 0.66, P<0.002) and time to progression (hazard ratio, 0.27; 95% confidence interval, 0.17 to 0.57, P<0.0006).

CONCLUSIONS

The ratio of absolute lymphocyte count/absolute monocyte count at diagnosis is an independent prognostic factor for survival and provides a single biomarker to predict clinical outcomes in patients with classical Hodgkin's lymphoma.

Critical evaluation and guidance for using the Coulter method for counting subvisible particles in protein solutions

In this paper, we evaluate the suitability of Coulter method for detecting and quantifying subvisible particles in protein solutions and compare results with other particle-counting technologies. The effects of key instrument and operational parameters such as aperture diameter, solution conductivity, and cleaning procedures are demonstrated. Degraded and nondegraded intravenous immunoglobulin and human serum albumin were chosen as model proteins and sample types for this evaluation. Multisizer™4 was able to obtain reproducible and linear particle counts; however, customized analysis and cleaning procedures are needed depending on the protein analyzed and the sample type (degraded or nondegraded). The Coulter method consistently detected more particles than micro-flow imaging and light obscuration. The presence of translucent particles likely accounts for this observation because detection by the Coulter method does not depend on the optical properties of the particles or solution.

Peripheral blood lymphocyte and monocyte recovery and survival in acute leukemia postmyeloablative allogeneic hematopoietic stem cell transplant

Many previous studies of immune reconstitution (IR) postallogeneic hematopoietic stem cell transplantation (HSCT) have focused on lymphocyte recovery. Recognizing that IR involves complex interactions between innate and adaptive immune networks, we hypothesized that patterns of both monocyte and lymphocyte recovery could provide additional prognostic information. To test our hypothesis, we analyzed data from 135 consecutive patients undergoing myeloablative allogeneic HSCT for acute myeloid (AML) and lymphoblastic leukemia (ALL) from 2001 to 2010. The absolute lymphocyte and monocyte counts (ALC and AMC, respectively) were determined longitudinally at days +15, +30, +60, and +100, and correlated with clinical outcomes. At the day +30 time point, both ALC and AMC >0.3 × 10(9) cells/L were strongly associated with improved survival (overall survival [OS] 29.6 months versus 5.4 months, P = .006 and 25.3 months versus 5.1 months, P = .01 respectively), a pattern that generally continued through the day +100 evaluation. Multivariate analysis revealed the following independent prognostic factors: early disease status at transplantation, the development of chronic GVHD, the day +30 AMC, day +100 AMC, and day +100 ALC. To further explore whether any inherent patterns in the timing of lymphocyte and monocyte recovery had prognostic value post-HSCT, we performed unsupervised hierarchical clustering on the longitudinal hematopoietic parameters studied in this cohort. Four clusters of patients were identified: clusters A-D. Patient clusters B and D both demonstrated improved ALC and AMC recovery at the day +60 and day +100 time points and had significantly improved OS compared with clusters A and C (57.8 months versus 19.7 and 4.4 months, respectively, P < .001). Our data suggest that patients with poor lymphocyte and monocyte recovery beyond the day +60 time points may be at risk for poorer outcomes, and that further investigation into lymphoid/myeloid interactions in developing individualized immunotherapy is warranted.

The absolute monocyte and lymphocyte prognostic score predicts survival and identifies high-risk patients in diffuse large-B-cell lymphoma

Despite the use of modern immunochemotherapy regimens, almost 50% of patients with diffuse large-B-cell lymphoma will relapse. Current prognostic models, including the International Prognostic Index, incorporate patient and tumor characteristics. In contrast, recent observations show that variables related to host adaptive immunity and the tumor microenvironment are significant prognostic variables in non-Hodgkin lymphoma. Therefore, we retrospectively examined the absolute monocyte and lymphocyte counts as prognostic variables in a cohort of 366 diffuse large-B-cell lymphoma patients who were treated between 1993 and 2007 and followed at a single institution. The absolute monocyte and lymphocyte counts in univariate analysis predicted progression-free and overall survival when analyzed as continuous and dichotomized variables. On multivariate analysis performed with factors included in the IPI, the absolute monocyte and lymphocyte counts remained independent predictors of progression-free and overall survival. Therefore, the absolute monocyte and lymphocyte counts were combined to generate a prognostic score that identified patients with an especially poor overall survival. This prognostic score was independent of the IPI and added to its ability to identify high-risk patients.

Lymphopenia assessed during routine follow-up after immunochemotherapy (R-CHOP) is a risk factor for predicting relapse in patients with diffuse large B-cell lymphoma

A specific predictor during routine follow-up to ascertain risk for relapse after standard chemotherapy in non-Hodgkin's lymphoma (NHL) has not been identified. Thus, we studied absolute lymphocyte count (ALC) as a marker of poststandard chemotherapy (rituximab, cyclophosphamide, adriamycin, vincristine and prednisone (R-CHOP)) NHL relapse in patients with diffuse large B-cell lymphoma (DLBCL). ALC was obtained at the time of confirmed relapse and at last follow-up. From 2000 until 2006, 149 consecutive DLBCL patients, originally diagnosed, treated with R-CHOP and followed up at Mayo Clinic, Rochester, were included in this study. Patients at last follow-up without relapse (N=112) had a higher ALC compared with those with relapsed lymphoma ((N=37) median ALC x 10(9)/l of 1.43 (range: 0.33-4.0) versus 0.67 (range: 0.18-1.98), P<0.0001, respectively). ALC at the time of confirmed relapse was a strong predictor for relapse with an area under the curve =0.91 (P<0.0001). An ALC <0.96 x 10(9)/l at the time of confirmed relapse had a positive predictive value of 72% and a positive likelihood ratio of 7.4 to predict relapse after R-CHOP in DLBCL. Patients with an ALC>or=0.96 x 10(9)/l (N=103) had a cumulative incidence of relapse of 6 versus 79% with an ALC <0.96 x 10(9)/l (N=46) (P<0.0001). This study suggests that lymphopenia measured by ALC can be used as a marker to assess risk of DLBCL relapse during routine follow-up after standard chemotherapy.

Dietary strategies for improving folate status in institutionalized elderly persons

The aim of this work was to compare the efficacy of two strategies designed to improve folate status: increasing the intake of vegetables, and the consumption of a folic acid-fortified food. Residents (126) from three old people's homes in the Madrid region (Spain) were studied. To each centre a dietary intervention was assigned to be followed for 6 months: (1) the consumption of margarine fortified with 200 microg folic acid/10 g portion (centre M), (2) increasing the consumption of vegetables to three servings per day (centre V), (3) control (centre C). At the beginning and end of the intervention period the subjects' intakes, serum and erythrocyte concentrations of folate were measured. The use of fortified margarine (centre M) led to a significant increase in folate intake (260.9 microg/d), serum concentration (10.3 (sd 8.3) nmol/l) and erythrocyte concentration (638.4 nmol/l). At centre V the increase in total vegetable intake achieved was very poor; these foods met with very poor acceptance, although the intake of certain vegetables particularly rich in folate improved. Therefore, the intake of this vitamin increased a little (26.7 (sd 33.0) microg/d); erythrocyte folate concentration also increased somewhat (460.5 nmol/l), althought less than centre M. The daily consumption of margarine fortified with folic acid was the more effective strategy for improving the folate status of the study subjects.

Absolute lymphocyte count at the time of first relapse predicts survival in patients with diffuse large B-cell lymphoma

Peripheral blood absolute lymphocyte count (ALC) is a survival prognostic factor in hematological malignancies. No reports have addressed whether ALC at the time of first relapse (ALC-R) predicts survival. Thus, we assessed the prognostic significance of ALC-R in diffuse large B-cell lymphoma (DLBCL). Patients were required to have been diagnosed with first relapsed DLBCL, have ALC-R values, and to be followed at Mayo Clinic, Rochester. From Feb 1987 until March 2006, 97 first relapsed DLBCL patients qualified for the study. The overall survival (OS) and progression-free survival (PFS) were measured from the time of first relapse. The value of ALC-R >or= 1.0 x 10(9)/L was used for the analysis. Both groups (ALC-R >or= 1 or < 1 x 10(9)/L) were balanced for the international prognostic index at relapse (IPI-R) (P = 0.3), and for autologous stem cell transplantation (P = 0.4). Superior OS and PFS were observed with an ALC-R >or= 1.0 x 10(9)/L (N = 60) versus ALC-R < 1.0 x 10(9)/L (N = 37) [median OS: 28.7 months, 5 years OS rates of 39% versus median OS: 10.2 months, 5 years OS rates of 14%, P < 0.002; and median PFS: 14.8 months, 5 years PFS rates of 21% versus median PFS: 6.5 months, 5 years PFS rates of 8%, P < 0.004, respectively]. ALC-R was an independent prognostic factor for OS [RR = 0.4, P < 0.01] and PFS [RR = 0.5, P < 0.005]. ALC-R predicts survival suggesting that host immunity is an important variable predicting survival in first relapsed DLBCL.

Early lymphocyte recovery predicts superior survival after autologous stem cell transplantation in non-Hodgkin lymphoma: a prospective study

Day 15 absolute lymphocyte count (ALC-15) after autologous peripheral blood hematopoietic stem cell transplantation (APHSCT) has been reported to be a significant predictor for survival in multiple hematologic malignancies. Limitations of previous reports included their retrospective nature and the lack of ALC-15 lymphocyte subset analyses. To address these limitations, from February 2002 until February 2007, 50 non-Hodgkin lymphoma (NHL) patients were enrolled in a prospective study. The primary endpoint of the study was to confirm prospectively the ALC-15 survival role after APHSCT in NHL. The secondary endpoint was to identify the ALC-15 lymphocyte subset affecting survival after APHSCT. With a median follow-up of 22.2 months (range: 6-63.7 months), patients with an ALC-15 > or =500 cells/microL (n = 35) experienced superior overall survival (OS) and progression-free survival (PFS) compared with those who did not; median OS: not reached versus 5.4 months, 3-year OS rates of 80% (95% confidence interval [CI]: 55%-95%) versus 37% (95% CI: 15%-65%), P < .0001; and median PFS: not reached versus 3.3 months, 3-year PFS rates of 63% (95% CI: 40%-85%) versus 13% (95% CI: 4%-40%), P < .0001, respectively. Univariately, CD16+/56+/CD3- natural killer (NK) cells were the only ALC-15 lymphocyte subset identified as a predictor for survival. Patients with an NK cell count > or =80 cells/microL (n = 38) experienced superior OS and PFS compared with those who did not (median OS: not reached versus 5 months, 3-year OS rates of 76% [95% CI: 57%-92%] versus 36% [95% CI: 11%-62%], P < .0001; and median PFS: not reached versus 3 months, 3-year PFS rates of 57% [95% CI: 38%-85%] versus 9% [95% CI: 1%-41%], P < .0001, respectively). Multivariate analysis showed that NK cells are an independent predictor for survival. This is the first study confirming the ALC-15 survival role prospectively and identifying NK cells as the key ALC-15 lymphocyte subset affecting survival after APHSCT.

Prediction of survival using absolute lymphocyte count for newly diagnosed patients with multiple myeloma: a retrospective study

Absolute lymphocyte count (ALC) recovery after autologous stem cell transplantation for multiple myeloma (MM) has been reported to be an independent prognostic factor for clinical outcome. The role of ALC on survival in newly diagnosed untreated MM patients is unknown. Between 1994 and 2002, we analysed retrospectively 537 MM patients of 1835 consecutive MM patients that were neither uniformly treated nor part of a clinical trail, but originally diagnosed and followed at the Mayo Clinic. The primary endpoint was to assess the role of ALC at the time of MM diagnosis on overall survival (OS). The median follow-up was 35.1 months (range: 1-152.5 months). ALC, as a continuous variable, was identified as prognostic factor for OS (Hazard ratio = 0.473, 95% confidence interval = 0.359-0.618, P < 0.0001). MM patients with an ALC >/=1.4 x 10(9)/l experienced superior OS compared with MM patients with an ALC <1.4 x 10(9)/l (65 vs. 26 months, P < 0.0001). Multivariate analysis identified ALC as an independent prognostic factor for OS. This study showed that, in newly diagnosed MM, ALC is an independent prognostic factor for OS, suggesting a significant role of host immune status in the survival of MM.

Modification of iron status in young overweight/mildly obese women by two dietary interventions designed to achieve weight loss

AIMS

To determine the modification of iron status in a group of overweight/mildly obese women following two different weight control programs.

METHODS

The study subjects were 57 women who were assigned to one of two slightly hypocaloric diets: V (increased consumption of vegetables), or C (increased consumption of cereals, especially breakfast cereals). All data were determined at the start of the study and at 2 and 6 weeks into the dietary intervention period.

RESULTS

Both diets led to a reduction in body weight and heme iron intake, and an increase in the intake of total and non-heme iron, at 2 and 6 weeks. At 6 weeks, a reduction in transferrin levels was seen in C subjects. Subjects with the worst initial iron status (hemoglobin <P25: 12.6 g/l) following C diet showed an increase of mean corpuscular hemoglobin concentration at 2 and 6 weeks and improved hemoglobin levels at 6. Also at 6 weeks, the C subjects had more erythrocytes than similar V subjects (only considering women with hemoglobin <P25: 12.6 g/l).

CONCLUSIONS

A well-designed hypocaloric diet need not entail a risk of iron deficiency. Breakfast cereals are an important source of non-heme iron and could help to improve iron status, especially in women with poor initial iron levels.

Impact of long-term oral iron supplementation in breast-fed infants

OBJECTIVE

To weigh benefits of oral iron supplements on infant's growth against its potential hazards.

METHODS

248 exclusively breast-fed infants aged 4-6 months were consecutively enrolled and divided into treatment group given iron containing multivitamin (TG = 198) and control group (placebo, PG = 50) given the same multivitamin but without is subdivided according to clinical assessment into group A (well nourished) and group B (malnourished); both were further stratified according to basal blood iron status. Assessment was done after 6 and 12 months with concurrent collection of morbidity parameters (diarrhea and fever). Data were normalized and analyzed using SPSS and Eurogrowth softwares.

RESULTS

After 6 months treatment, weight and length gain was better in TG compared to placebo especially evident in anemic malnourished infants (P 0.05). Morbidity risk was linked to immunologic background of infant; odds ratio for diarrhea and fever was higher in malnourished compared to well nourished (P 0.05) or iron therapy (P for well-nourished non-anemic treatment vs PG > 0.05).

CONCLUSION

Oral iron supplementation resulted in better effects on growth velocity of breast fed infants especially those who were initially malnourished and anemic or at least iron depleted, with less marked morbidity than in iron replete infants.

Smoking and Passive Smoking as Conditioners of Folate Status in Young Women

OBJECTIVE

For women of fertile age, an adequate supply of folate is important for preventing a range of health problems, especially congenital malformations in their offspring. Since congenital deformities are more common in children of mothers who smoke, the objective was to analyse the folate status of smokers, passive smokers and non-smokers.

METHODS

Folate intake was monitored in 319 women aged 18-35 (112 smokers, 100 passive smokers and 107 non-smokers) using a three day food record. Serum and erythrocyte folate concentrations were measured by radioimmunoassay. Exposure to tobacco smoke was established by a questionnaire on present and past tobacco consumption, the number of hours in contact with smokers, and by assessing urine cotinine concentrations.

RESULTS

The folate intake of smokers (S) (159.1 +/- 65.7 microg/day) and passive smokers (PS) (165.2 +/- 66.6 microg/day) was lower than that of non-smokers (N) (181.7 +/- 72.4 microg/day) (p < 0.05 between S and N). No subject fully met the recommended intake of the vitamin, but S and PS subjects both took less than N subjects (39.8 +/- 16.4% and 41.3 +/- 16.6% compared to 45.4 +/- 18.1% respectively). Serum folate concentrations were also lower in S and PS subjects grouped together (16.6 +/- 5.9 nmol/L) compared to N subjects (18.4 +/- 6.7 nmol/L) (p < 0.05).

CONCLUSIONS

None of the studied women took the 400 microg/day of folate recommended. 6.7% had serum folate concentrations of < 9.2 nmol/L. The situation was worse in S and PS subjects, which might contribute to an increased risk of developing certain diseases and to giving birth to children with congenital deformations.

Thiamin status during the third trimester of pregnancy and its influence on thiamin concentrations in transition and mature breast milk

Thiamin deficiency remains an important public health problem in some populations. The aim of the present investigation was to study thiamin status during the third trimester of pregnancy and its influence on the concentration of this vitamin in transition (days 13-14 of lactation) and mature breast milk (day 40 of lactation) in a group of Spanish women. The pregnancies and lactation periods of fifty-one healthy women 18-35 (mean 26.7 (SD 3.7)) years old were monitored. Vitamin intake during the third trimester was determined by recording the consumption of foods over 5 d and of the quantities provided by dietary supplements. Thiamin status during this stage of pregnancy was determined by measuring the activation coefficient of erythrocyte transketolase (alpha-ETK). Milk thiamin content was estimated (in 41% of the subjects) by oxidizing thiamin to thiocrome and measuring fluorescence. Subjects with thiamin intakes above that recommended (group H) had more satisfactory serum alpha-ETK coefficients (1.01 (SD 0.19)) than did those with lower intakes (group L) (1.21 (SD 0.30); P<0.05). Mature milk thiamin concentrations were significantly higher in group H subjects (0.59 (SD 0.44) micromol/l) than group L subjects (0.25 (SD 0.07) micromol/l). Subjects with alpha-ETK coefficients >1.25 in the third trimester had significantly lower mature milk thiamin concentration (0.31 (SD 0.10) micromol/l) than did subjects with more satisfactory alpha-ETK levels at this time (0.55 (SD 0.42) micromol/l; P<0.05). The thiamin status of women can be improved since 25.5% of subjects took less than that recommended and 13.7% showed signs of severe deficiency (alpha-ETK >1.25). The influence of maternal thiamin intake on alpha-ETK coefficients and on mature breast milk thiamin concentration is confirmed.

Effect of immune-mediated erythrocyte agglutination on analysis of canine blood using a multichannel blood cell counting system

Blood from six dogs with in vitro immune-mediated erythrocyte agglutination resulted in analytical errors in directly measured counting and sizing functions on a multichannel blood analysis system with histogram capability. Errors in the directly measured values, mean cell volume (MCV), and erythrocyte count were attributed to agglutinated erythrocyte particles that persisted during the relatively short reagent contact time of the analysis. Agglutinated particles less than 240 fl were visible on erythrocyte histograms and resulted in a false low erythrocyte count and false high MCV. Agglutinated cell particles greater than 240 fl were not present on the histogram scale. Because these latter particles exceeded the upper threshold, they did not influence determination of MCV, but resulted in a further decrease in the erythrocyte count. As a result, the other dependent erythrocyte indices were in error. These included false low hematocrit and false high mean corpuscular hemoglobin concentration (MCHC), when compared to corrected reference blood values. Similar errors occurred when analyzing blood samples that were agglutinated in vitro by incubating erythrocytes with incompatible plasma. The counting and sizing errors observed with electronic counting techniques were eliminated or greatly reduced by incubating blood in cell counting diluent for 10 minutes followed by analysis on a single channel counter with attached particle size analyzer. Error in erythrocyte measurement on a multichannel system may be anticipated if there is overt erythrocyte agglutination in a blood sample, an abnormally high MCHC is reported by the system, or subpopulations of large volume (agglutinated cells) are observed on a volume distribution histogram.

Peripheral blood film review. The demise of the eyecount leukocyte differential

The automated hematology analyzer with CBC and differential results has replaced the traditional manual or individual assay methods for hematologic parameters and the eyecount leukocyte differential as the initial screening and detection system for hematologic abnormalities in modern hospitals and clinics. The traditional review of all automated hematology instrument results by preparation, staining, and microscopic examination of a blood film has disappeared in most institutions. The reasons are the more accurate detection of specimens with distributional or morphologic abnormalities by the instruments than by the traditional eyecount method. The opportunity for a clinician to request a microscopic examination of a blood film, whether or not it is flagged, must be preserved, because the clinician's knowledge of the patient's history, physical findings, and current or prior therapy may indicate review to discover an abnormality that may not have been apparent from the instrument results alone. There has also been a dramatic reduction of the numbers of medical technologists and technicians in medical laboratories. Automation of the CBC and differential counts has reduced the number of technologists needed for performance of these tests. But other factors have had a negative effect, such as the necessity to reduce costs. Consolidation of hematology and chemistry laboratories in core laboratories may produce savings in labor costs, but may also create problems of creating and maintaining areas of expertise, such as hematologic morphology, because of the cross-training required and the necessity of personnel to do all things. This article suggests and documents a number of measures that can be infinity stituted by the laboratory and by clinicians to reduce the number of eyecount differentials and blood film reviews that need to be performed. The first effort is to convince clinicians that valid data exist that confirm that a policy of allowing the laboratory to initiate blood film review based on findings of the CBC and automated differential is a more sensitive and accurate method of detecting patients with blood film abnormalities than routine blood film review of all specimens by technologists. Clinicians need to recognize that daily differential results or differentials at intervals of less than a week are not medically necessary in most patients. The laboratory, however, must provide opportunities for the clinician to request differentials at any time for specific medical reasons. The laboratory must establish the validity of screening criteria for detection of distribution and morphologic abnormalities of leukocytes by clinical correlation studies or adopt criteria established by laboratories with the same instrumentation and which have conducted clinical evaluations. A final observation on the eyecount differential is that it was the only way to identify cell types and their relative proportion for nearly 100 years. Cells were identified by their shape, intracellular structures, and staining characteristics. Many studies were able eventually to correlate some aspect of each cell type's function with their morphologic appearance. It has also been learned that the bone marrow is the source of production of most circulating cells and a great deal of the controls of cell production and release into the peripheral blood have been learned. But leukocytes have many functions, almost none of which are performed in the peripheral blood. The peripheral blood is mainly a conduit from the bone marrow to the tissues where the leukocytes perform their function in the case of the neutrophils and monocytes. It is mainly a recirculation and redistribution system for lymphocytes that usually receive their instructions from antigen processing cells in the tissues and allow these modified cells to home to sites where their functions occur. Cellular morphology and staining characteristics tell little about the maturation stage and functional capabilities of leukocytes. One cannot tell the difference between a band and a segmented neutrophil or whether a lymphocyte is a T or B cell on the conventional eyecount differential. One cannot tell the mature granulocyte of a patient with chronic myeloid leukemia from a normal mature neutrophil. Increasingly, techniques are being developed to identify better the maturation stages of cells and association with specific functional capabilities by flow cytometric techniques. The neoplastic nature of some normal-appearing leukocytes can be identified by techniques, such as fluorescent in situ hybridization. With the rapid advances in many approachs to understand the nature and functional capability of leukocytes, the eyecount differential with the traditional Romanowsky stain may be past the apogee of its ascent and beginning its trip into history along with the hemocytometer counting chamber and the Sahli pipet. The development and implementation of new laboratory cornerstone techniques for diagnosis of hematologic disease are eagerly awaited. On the other hand, the red cells and platelets exist to function in the peripheral blood. More emphasis is needed in the development of automated methods of determining the nature and functional capabilities of these true blood cells as part of the CBC.

Riboflavin levels in maternal milk: the influence of vitamin B2 status during the third trimester of pregnancy

OBJECTIVE

The aim of the present investigation was to study the relationship between riboflavin status during the third trimester of pregnancy and levels of this vitamin in transition milk (days 13 to 14 of lactation) and mature milk (day 40 of lactation).

METHODS

The pregnancies and lactation periods of 57 healthy women between 18 and 35 years of age (27+/-3.7 years) were monitored, vitamin intake during the third trimester was determined by recording the consumption of foods over five days and by registering the quantities provided by dietary supplements. Riboflavin status during this stage of pregnancy was determined via the measurement of the activation of erythrocyte glutathione reductase (EGR) by flavine adenine dinucleotide (FAD). Milk riboflavin levels were determined by fluorometry.

RESULTS

Those subjects with riboflavin intakes below recommended (1.6 mg/day) (Group L) showed lower consumption of milk products (305.2+/-88.5 g/day) than did those with greater intakes (Group H) (507.9+/-137.2 g/day). The consumption of riboflavin containing supplements was very low and was seen only in two H subjects. Transition and mature milk riboflavin levels were significantly higher in H subjects (948.1+/-700.1 nmol/L for transition milk and 993.8+/-436.6 nmol/L for mature milk) than L subjects (574.9+/-258.7 nmol/L for transition milk and 725.4+/-254.3 nmol/L for mature milk). Subjects with alpha-EGR coefficients over 1.2 in the third trimester showed significantly lower mature milk riboflavin levels (704.1+/-241.8 nmol/L) than did subjects with more satisfactory alpha-EGR coefficients (996.4+/-302.9 nmol/L).

CONCLUSION

The influence of maternal vitamin B2 status during pregnancy on breast milk riboflavin levels was confirmed.

The female Spanish population: a group at risk of nutritional iron deficiency

Iron deficiency is one of the most common nutritional problems in the world. It is frequent in both developed and developing countries and mainly affects women of childbearing age. The aim of the present study was to investigate the prevalence of iron deficiency in a group of young women from Madrid, Spain. The study subjects were a group of 130 women aged between 19 and 35 (24.53 +/- 0.24 years). Measurements were made of iron intake and also of the haematological and biochemical indicators of iron status. 10.7% of subjects showed iron deficiency (defined as the recording of at least two indicator parameters with values below normal). The high incidence of iron deficiency at blood level (10.7%) coincided with the low iron intake of these subjects (11.08 +/- 2.98 mg/day). 98.3% of subjects showed intakes below recommended. Observed intake covered only 61.6% of recommended intake. 3.9% of subjects presented ferropenic anaemia, i.e. they showed both iron deficiency and low haemoglobin levels.

Enumeration of cells in bone marrow and peripheral blood stem cell collections: technical issues and prospects for standardization

Enumeration of total nucleated cells and mononuclear cells is a fundamental part of the laboratory evaluation and quality control program for bone marrow and peripheral blood stem cell collections intended for transplantation. Measurement of the total nucleated cell content is especially useful for providing rapid feedback about the bone marrow product during or immediately after the harvest. However, the mononuclear cell content may be more informative because the nucleated cell population contains a variable number of mature granulocytes and nucleated red cells, which do not contribute to hematopoietic engraftment. The lack of comparative data among various laboratories and among different types of cell counting methods has hindered standardization of these assays among bone marrow processing laboratories. Specific issues needing attention in assay standardization include sample preparation and handling, identification and elimination of artifacts in automated counting, relative advantages and disadvantages of manual and automated counting methods, and criteria for differential counting of nucleated cells. The establishment of standards for bone marrow and other stem cell counting methods, as well as other evaluation procedures, should be preceded by collection and analysis of comparative data, and followed by a proficiency testing program for bone marrow processing laboratories.

Influence of smoking on folate intake and blood folate concentrations in a group of elderly Spanish men

OBJECTIVE

To investigate the relationship between smoking habits and folate status in a group of elderly Spanish men.

DESIGN

We studied folate intake, serum and erythrocyte folate concentrations, hematological and biochemical data in 72 elderly males (comparing 24 smokers data with 44 nonsmokers ones).

RESULTS

Percentage deficiencies for folate intake, serum and erythrocyte levels were higher in smokers. Serum folate levels were significantly higher in nonsmokers. Smokers had higher mean corpuscular volume than did nonsmokers.

CONCLUSIONS

Smoking could be harmful to the intake and folate status. For smokers who will not give up the habit, improved dietary intake or a folate supplement is advisable.

Use of a mildly restrictive administrative protocol to reduce orders for manual blood film examination from the emergency department

In order to conserve laboratory resources, we instituted a mildly restrictive administrative protocol requiring a telephone request by emergency physicians or their designees in order to obtain a manual blood film examination (BFE). This test includes a manual differential leukocyte count (DLC), examination of red cell morphology, and platelet estimate. The protocol resulted in a marked reduction of the number of BFE's performed on emergency department patients from the previous level of one for every complete blood count (CBC). Retrospective chart review of a sample of patients not receiving manual BFEs indicated no apparent adverse effect on patient care. We speculate that the availability of an electronic partial differential count, providing enumeration of lymphocytes and neutrophils along with the CBC, facilitated in part the reduced ordering of manual BFEs.

EDTA-dependent pseudothrombocytopaenia: a 12-month epidemiological study

The phenomenon of in vitro platelet clumping and consequent pseudothrombocytopaenia in the presence of EDTA has been studied in 33,623 subjects referring to a general hospital in a 1-year period. The observed frequency was 0.13%. EDTA-dependent pseudothrombocytopaenia (PTP) was suspected when a routine blood counting by the Coulter S-Plus IV/D showed a peculiar leucocyte histogram and pseudoleucocytosis. Confirmation was obtained by the manual count and by the finding of platelet aggregates in a stained blood smear. EDTA-dependent PTP was diagnosed when the platelet number and the morphological examination of blood anticoagulated with sodium citrate from the same patient were normal. EDTA-dependent PTP was found in 23 subjects aged from 19 to 79 years (0.068% of the study population): 17 were patients suffering from miscellaneous diseases, while six were apparently healthy. As a rule, platelet clumping was evident within 60 minutes from blood collection, but a longer latency (2-3 h) was observed in a few cases. EDTA-dependent PTP is a rare, but misleading phenomenon, the recognition of which is important in order to avoid expensive and potentially harmful procedures.