Development of permanent national register of blood component use utilizing electronic hospital information systems.

BACKGROUND AND OBJECTIVES: We wanted to establish a permanent national database system, which can be utilized to study transfusion recipients and blood use in Finland. MATERIALS AND METHODS: A regularly updated register for permanent use was developed. To study the usability of the database, years 2002 and 2003 were further analysed. Database included all transfused patients in major blood-transfusing hospitals from four university and five central hospital districts managing altogether 63% of Finnish inpatient hospital episodes. RESULTS: Audit of gathered data reveal 96.8% match in adult blood components with Finnish Red Cross, Blood Service sales figures. Model data set includes 59,535 transfused patients (44.3% men and 55.7% women) having received 529,104 blood components. Half of all blood units were transfused in connection with surgical operations. Most of the blood recipients were elderly (51.6% are over 64 years of age). Blood-component use and transfusion-related costs varied widely between hospitals. CONCLUSION: Hospital data managing systems can be useful for creating a population-based database system to monitor and compare transfusion practices. This record provides information about transfusion epidemiology for transfusion professionals, hospital management, and hospital administration.

Pulmonary inflammatory mediators after sevoflurane and thiopentone anaesthesia in pigs.

BACKGROUND: Volatile anaesthetics have been shown to affect the release of pulmonary inflammatory mediators and exacerbate pulmonary injury after experimental aspiration. Thus, in theory, volatile anaesthetics may worsen inflammatory pulmonary injury and disease. We have previously described that no significant changes in alveolar ultrastructure are seen after sevoflurane anaesthesia. However, this does not exclude any possible physiological alterations. The aim of our study was to evaluate pulmonary inflammatory mediators in bronchoalveolar lavage (BAL) after sevoflurane and thiopentone anaesthesia in pigs with intact lungs. METHODS: Sixteen pigs were randomly selected to receive either a continuous thiopentone infusion (control group, n = 8) or sevoflurane (n = 8) at 4.0% inspiratory concentration (1.5 MAC) in air for 6 h. Bronchoalveolar lavage samples were collected at the end of the study to determine pulmonary inflammatory markers. RESULTS: Compared with thiopentone anaesthesia, significant increases in BAL leukotriene C4 (LTC4), NO3-, and NO2- levels were observed after sevoflurane anaesthesia. In addition, there was a significant decrease in total blood leukocyte count in sevoflurane-treated animals. CONCLUSION: We conclude that sevoflurane increases pulmonary LTC4, NO3-, and NO2- production in pigs, indicating an inflammatory response.

Autologous blood cell transplantation in multiple myeloma: impact of CD34+ cell selection with long follow-up.

Positive CD34(+) selection to purge blood cell harvests is one way to attempt to reduce the high relapse risk after high-dose chemotherapy (HDT) supported by autologous blood cell transplantation (ABCT) in patients with multiple myeloma (MM). Until recently, however, the impact of CD34(+) selection, if any, on long-term clinical outcome in MM has remained obscure. We have analyzed engraftment kinetics, response to HDT, progression-free survival (PFS), and overall survival (OS) for 64 consecutive MM patients who have been treated with up-front HDT plus ABCT at our institution between 1993 and 1998. Nonrandomized comparisons were made between transplants with unselected (39 patients) and CD34(+)-selected (25 patients) grafts. The engraftment kinetics, need of blood product support, discharge time from hospital, and response to HDT were similar for both unselected and selected transplants. The median PFS was also similar (26 and 30 months, respectively) for the both groups. With a median follow-up time for the survivors of 67.5 months, the median OS (78 and 75 months, respectively) did not differ between transplants with unselected and selected grafts. In conclusion, this nonrandomized study suggests that positive CD34(+) selection has no beneficial impact on long-term outcome of patients with MM.

Cell cycle regulators p27 and pRb in lymphomas - correlation with histology and proliferative activity.

The cell cycle is a complex event in which multiple regulator-proteins participate. The G(1)/S checkpoint of the cell cycle is controlled by pRb protein, which functions in its hypophosphorylated form as a negative regulator of growth. p27 (Kip1), a member of CIP/KIP family of cyclin inhibitory proteins, participates in inhibition of forming complexes that allow pRb to phosphorylate and lead the cell into mitosis. The expression of these important cell cycle regulator proteins was studied in a total of 96 non-Hodgkin's lymphoma (NHL) samples, which were classified according to the REAL classification. The expression of p27, pRb and the cell proliferation marker Ki-67 (MIB-1) was evaluated in lymphomas using immunohistochemistry. This study showed that there were coordinate changes in the expression of p27 and pRb in NHL. When compared to low-grade lymphomas, high-grade lymphomas showed significantly reduced expression of p27 and inversely pRb expression was increased (P< 0.001). Increase in expression of Ki-67 was parallel with pRb expression, and was mainly seen in cells that lacked p27 expression (P< 0.0001). This study suggests that changes in the control of the cell cycle closely relate to the pathobiology of NHL.

Neutrophil response of transgenic mice expressing human group IIA phospholipase A2 in bacterial infections.

Group IIA phospholipase A2 (PLA2) is a newly recognized acute phase protein with marked antibacterial properties. We have shown previously that transgenic C57BL/6 J mice expressing human group IIA PLA2 (PLA2+ mice) are more resistant to bacterial infections than nontransgenic C57BL/6 J mice that, among mice, are unusual in that they lack the mouse analogue of group IIA PLA2 (PLA2- mice). To elucidate the possible mechanisms involved in the host response of these mice in bacterial infection, peripheral inflammatory cell responses of PLA2+ and PLA2- mice were studied after i.p. administration of Escherichia coli, E. coli lipopolysaccharide or Staphylococcus aureus. Uninfected PLA2+ mice had higher numbers of lymphocytes and polymorphonuclear neutrophil leukocytes (PMNs) in their blood than PLA2- mice. In PLA2+ mice, the number of PMNs increased in peripheral blood in parallel with the concentration of group IIA PLA2 after the administration of bacteria, whereas these responses were not seen in PLA2- mice. High concentrations of group IIA PLA2 in PLA2+ mice may increase the synthesis of bioactive molecules, such as prostaglandins, which in turn may mobilize PMNs into circulation. Our results support the hypothesis that group IIA PLA2 is an important inflammatory mediator in bacterial infections.

Serum oncostatin M in multiple myeloma: impact on disease severity and prognosis.

Since high levels of serum IL-6 predict a poor prognosis of patients with multiple myeloma (MM), we investigated if a related cytokine, oncostatin M (OSM), correlates with clinical or biochemical findings or has prognostic significance in patients with MM. Among 82 newly diagnosed MM patients, OSM was detected in the sera in 45 (55%). Serum OSM had a borderline statistical correlation with serum IL-6 (r = 0.198, p = 0.074) and C-reactive protein (r = 0.199, p = 0.074) concentrations. However, OSM did not have prognostic significance alone or in combination with other factors. The median survival of patients with detectable serum OSM concentration was 41 months (range 2-124 months) and of OSM negative patients 35 months (1-75 months). Serum OSM concentration was not associated with clinical factors or severity of bone disease at diagnosis. We conclude that serum OSM concentration is not a prognostic factor in MM patients.

Single values of serum transferrin receptor and transferrin receptor ferritin index can be used to detect true and functional iron deficiency in rheumatoid arthritis patients with anemia.

OBJECTIVE: To elucidate the use of serum transferrin receptor (sTfR) to distinguish between iron-deficiency anemia (IDA) and anemia of chronic disease (ACD), and to establish an improved scheme to identify functional iron deficiency (FID) in rheumatoid arthritis (RA) patients with anemia. METHODS: We studied 30 anemic RA patients whose iron status was confirmed by bone marrow examination and determination of the sTfR level, serum ferritin level, and sTfR-log ferritin index (TfR-F Index). All patients with diminished or exhausted iron stores (n = 18) received oral iron supplementation. RESULTS: Baseline values of sTfR and the TfR-F Index predicted the response correctly in all patients who received supplementation treatment and were normal in 10 of 11 patients with normal initial iron stores (ACD). CONCLUSION: The results of this study elucidate the roles of sTfR and the TfR-F Index in the differential diagnosis between IDA and ACD and provide direct evidence that these parameters are useful in detecting FID, irrespective of the concurrent iron storage status.

EPO, red cells, and serum transferrin receptor in continuous and intermittent hypoxia.

PURPOSE: Erythropoietic response in 10 healthy nonsmoking volunteers exposed to normobaric hypoxia continuously or intermittently 12 h daily for 7 d was evaluated in a randomized cross-over study. METHODS: An oxygen content of 15.4% corresponding to an altitude of 2500 m was created by adding nitrogen into room air in a flat. Venous blood samples for hemoglobin (Hb), hematocrit (Hct), reticulocytes, serum erythropoietin (S-EPO), red cell 2,3-diphosphoglycerate (2,3-DPG), serum ferritin (S-Ferrit), and serum soluble transferrin receptor (S-TransfR) were drawn at 8:00 a.m. RESULTS: S-EPO was increased from baseline values of 22.9+/-9.6 and 20.5+/-10.1 U x L(-1) to 40.7+/-12.9 (P < 0.05) and 35+/-14.3 U x L(-1) (P < 0.05) after the first night in continuous and intermittent hypoxia, respectively, and remained elevated throughout both exposures. Hb and Hct values did not show any significant changes. Red cell 2,3-DPG rose from baseline a value of 5.0+/-0.8 to 5.9+/-0.7 mmol x L(-1) (P < 0.05) after the first day in continuous hypoxia and from 5.2+/-0.7 mmol x L(-1) to 6.1+/-0.5 mmol x L(-1) on day 3 (P < 0.05) during intermittent hypoxia. The reticulocyte count rose significantly (P < 0.05) after 5 d in both experiments. S-transferrin receptor level rose significantly from 2.2+/-0.4 and 2.1+/-0.5 mg x L(-1) to 2.6+/-0.5 mg x L(-1) and 2.3+/-0.6 mg x L(-1) on day 5 (P < 0.05), to 2.7+/-0.5 mg x L(-1) and 2.5+/-0.6 mg x L(-1) on day 7 (P < 0.05) under continuous and intermittent hypoxia, respectively. CONCLUSIONS: We suggest that intermittent exposure to moderate normobaric hypoxia 12 h daily for 1 wk induces a similar stimulation of erythropoiesis as continuous exposure.

RT-PCR from eosinophil-depleted leukocytes without RNA extraction: cell selection using streptavidin PCR tubes.

OBJECTIVES: The major RNase activity of leukocytes has been attributed to eosinophil-derived neurotoxin EDN. Depletion of eosinophils enables RT-PCR from 10(5) leukocytes without RNA extraction. In this study we introduced streptavidin-coated PCR tube strips for the selection of eosinophil-free leukocytes for RT-PCR analysis. DESIGN AND METHODS: Polypropylene 0.2 ml PCR tube strips were coated with streptavidin and biotinylated antibodies against cell surface antigens were attached to the tubes. CD7-positive T-lymphocytes, CD19-positive B-lymphocytes and CD16-positive cells (mainly neutrophils and monocytes) were positively selected by incubating of 1-2 x 10(5) leukocytes in the antibody-coated PCR tubes for 30 min at 23 degrees C. RESULTS: The mean amount of cells bound into a tube was 31,500 (CV25%) T-cells and 8,600 (CV61%) B-cells from 12 blood samples, and 23,600 (CV22%) CD16+ cells from 17 samples. The influence of selected cell lysate on the RT-PCR analysis of Philadelphia chromosome (bcr/abl translocation) from 100 K562 cells was small: 78% (CV28%) of the leukocyte-free signal was obtained in the presence of CD16+ cells or 89% (CV15%) and 99% (CV11%) and in the presence of T-cells and B-cells, respectively. CONCLUSIONS: These results suggest that through the introduction of eosinophil-free cell population into RT-PCR a reproducible method with reasonable leukocyte yield and avoiding RNA extraction was developed.

Evaluation of iron status of Finnish blood donors using serum transferrin receptor.

The maximum allowable frequency of blood donations has been set so that donations should not cause anaemia or depletion of iron stores. However, it has not been determined precisely how often blood donations result in depletion of iron stores. In the present study we have evaluated iron status in blood donors using serum ferritin and transferrin receptor (TfR) concentrations. The elevation of serum TfR has been reported to be the most sensitive indicator of depletion of iron stores. On the basis of ferritin values, in men who donate frequently the amount of body iron is reduced to a level very close to that found in women donating blood for the first time. When an elevation of serum TfR above 4.0 mg L-1 was used as a stringent definition of complete iron depletion, it was estimated that 17% of frequently donating women had completely lost their iron stores, while the corresponding value for men was 8%. The fact that a considerable proportion of the female blood frequent donors have completely depleted their iron stores raises the question whether the iron status of female frequent blood donors should be routinely monitored using serum transferrin receptor measurements.

Serum transferrin receptor and transferrin receptor-ferritin index identify healthy subjects with subclinical iron deficits.

Despite the established utility of serum transferrin receptor (sTfR), serum ferritin, and the sTfR/log ferritin ratio (TfR-F Index) in the diagnosis of iron deficiency (ID) anemia, the numeric values of these parameters, which are indicative of subclinical ID, remain to be clearly defined. In this study, 65 apparently healthy nonanemic adults (22 men and 43 women) were treated with 3 months of oral iron supplementation to evaluate its effect on parameters reflecting iron status and to determine the prevalence of subclinical iron deficiency in apparently healthy adults. Significant supplementation-induced changes were observed in sTfR, ferritin, and TfR-F Index values in women, whereas in men, none of the studied parameters showed any significant change. Iron-deficient erythropoiesis (IDE) was not observed in men, but was found in 17 women (40%). Although individuals with a compromised iron status may be represented in substantial numbers in conventional reference populations, they can be readily identified using sTfR, ferritin, and TfR-F Index determinations.

Comparison between four and eight cycles of intensive chemotherapy in adult acute myeloid leukemia: a randomized trial of the Finnish Leukemia Group.

In acute myelogenous leukemia (AML) intensive postremission treatment is needed for an optimal result. However, it is not known how long the treatment should last and how many courses are necessary. The object of this prospective study was to compare four and eight intensive chemotherapy cycles in the treatment of adult de novo AML. In a multicenter study, 248 consecutive patients, aged from 16 to 65 years, were treated with intensive induction treatment. The patients in remission after two courses were randomized to receive either two (short arm) or six (long arm) additional intensive cycles of chemotherapy. The median follow-up time of the living patients is 68 months. Of the patients, 77% achieved complete remission, and 36% of all patients survived for 5 years. Seventy-three patients were randomized to the short arm and 66 to the long arm. There was no significant difference in the relapse-free survival (median 21 months vs 17 months) or overall survival (43 months vs 39 months) between the short and long arms, respectively. Treatment-related deaths occurred in 31 patients (13%), 11 of them in first remission. More than one-third of the patients survived for 5 years. It seems probable that the first few months after diagnosis are decisive for the prognosis if the chemotherapy is intensive, and further treatment cannot markedly influence the outcome.

Regression-based reference limits and their reliability: example on hemoglobin during the first year of life.

Calculation of reference limits by regression analysis makes it unnecessary to partition the reference data into subgroups, and age-dependent limits can be estimated within as narrow age intervals as necessary. However, the reliability of the regression-based reference limits has not been considered before. To get valid regression-based confidence intervals (CIs) for reference limits, one must evaluate the convolution of two distributions. In this study, age-dependent reference limits with corresponding CIs were produced for blood hemoglobin concentrations over the age interval from newborns to 12 months. We describe how the variance associated with the reference limits can be estimated, and present a Table from which appropriate values can be chosen for the calculation of regression-based reference limits and exact CIs. Also, an equation for the calculation of approximate CIs is given. The data were modeled by linear regression in several cumulative age groups to find the transition zone where the slope changed. After defining this cutoff point, piecewise linear regression was applied. Reference limits and their CIs calculated by conventional and piecewise linear regression methods were almost the same in older age groups but differed significantly during the period of most rapid age-dependent changes, i.e., during the 2 months after birth.

Evaluation of new immunoenzymometric assay for measuring soluble transferrin receptor to detect iron deficiency in anemic patients.

During the last few years the measurement of serum-soluble transferrin receptor (sTfR) has been introduced as a tool to detect iron deficiency and as an analyte to differentiate between anemia caused by iron deficiency (IDA) and that caused by chronic disease (ACD). Commercially available methods have emerged to make diagnostics by sTfR more readily accessible. We documented the analytical performance of a newly introduced IDeA sTfR immunoenzymometric assay (IEMA) by Orion Diagnostica. We also evaluated its clinical performance in 98 consecutive anemic patients, with information derived from bone marrow aspirate samples as the reference for iron status. The clinical usefulness of two other commercially available sTfR assays was assessed for comparison. The analytical performance and clinical applicability of the IDeA were sufficient to support reliable clinical work. We conclude that IDA and iron deficiency in the presence of inflammatory states can be differentiated efficiently from ACD with this new commercial test to measure sTfR.

High-dose chemotherapy with autologous stem cell support for the treatment of advanced ovarian cancer--initial experience in Uppsala and Turku.

BACKGROUND: With current standard-dose chemotherapy ovarian cancer is a chemosensitive but not chemocurable disease in the majority of cases. The widely used first-line chemotherapy including a platinum analogue combined with cyclophosphamide results in response rates of 60-80%. However, only 10-20% of patients with advanced disease are alive 5 years after the diagnosis. The efficacy of high-dose chemotherapy supported by autologous stem cell transplantation (ASCT) is currently under intensive investigation. METHODS: We report here our initial experiences of the use of high-dose chemotherapy supported by ASCT for patients with high-risk ovarian cancer. Two patients were treated at Uppsala University Hospital in 1992 and four patients at Turku University Central Hospital in 1994. RESULTS: The first four patients treated either after heavy previous chemotherapy or recurrent disease relapsed within 5-10 months. Two patients received high-dose therapy as part of first-line treatment. One of them had a relapse 18 months after therapy, the other one has been disease free for 28 months. No toxic deaths occurred, but the patients had neutropenic febrile episodes and moderate to severe gastrointestinal toxicity. CONCLUSIONS: Coordinated efforts in Nordic countries are indicated to evaluate the usefulness of high-dose therapy supported by ASCT in the treatment of advanced ovarian cancer.

Autologous blood cell transplantation in B-CLL: response to chemotherapy prior to mobilization predicts the stem cell yield.

Successful stem cell mobilization and collection is possible in B-CLL after a favorable response to preceding chemotherapy, and also after treatment with the new nucleoside analogues fludarabine and cladribine. A poor response, on the other hand, seemed to predict a mobilization failure. CD34+ cell selection resulted in a 2- to 3-log reduction of the CLL cells in the harvests. Engraftment with both unselected and selected progenitor cells was rapid, and need for hospitalization was short. High-dose therapy with stem cell rescue appears to be capable of inducing CRs of high quality, but so far the follow-up is too short to define whether this will be translated into prolonged disease-free survival.