Ischemia considerations for the development of an organ and tissue donor derived bone marrow bank.

BACKGROUND: Deceased organ donors represent an untapped source of therapeutic bone marrow (BM) that can be recovered in 3-5 times the volume of that obtained from living donors, tested for quality, cryopreserved, and banked indefinitely for future on-demand use. A challenge for a future BM banking system will be to manage the prolonged ischemia times that are inevitable when bones procured at geographically-dispersed locations are shipped to distant facilities for processing. Our objectives were to: (a) quantify, under realistic field conditions, the relationship between ischemia time and the quality of hematopoietic stem and progenitor cells (HSPCs) derived from deceased-donor BM; (b) identify ischemia-time boundaries beyond which HSPC quality is adversely affected; (c) investigate whole-body cooling as a strategy for preserving cell quality; and (d) investigate processing experience as a variable affecting quality. METHODS: Seventy-five bones from 62 donors were analyzed for CD34+ viability following their exposure to various periods of warm-ischemia time (WIT), cold-ischemia time (CIT), and body-cooling time (BCT). Regression models were developed to quantify the independent associations of WIT, CIT, and BCT, with the viability and function of recovered HSPCs. RESULTS: Results demonstrate that under "real-world" scenarios: (a) combinations of warm- and cold-ischemia times favorable to the recovery of high-quality HSPCs are achievable (e.g., CD34+ cell viabilities in the range of 80-90% were commonly observed); (b) body cooling prior to bone recovery is detrimental to cell viability (e.g., CD34+ viability < 73% with, vs. > 89% without body cooling); (c) vertebral bodies (VBs) are a superior source of HSPCs compared to ilia (IL) (e.g., %CD34+ viability > 80% when VBs were the source, vs. < 74% when IL were the source); and (d) processing experience is a critical variable affecting quality. CONCLUSIONS: Our models can be used by an emerging BM banking system to formulate ischemia-time tolerance limits and data-driven HSPC quality-acceptance standards.

Characterization and Function of Cryopreserved Bone Marrow from Deceased Organ Donors: A Potential Viable Alternative Graft Source.

Despite the readily available graft sources for allogeneic hematopoietic cell transplantation (alloHCT), a significant unmet need remains in the timely provision of suitable unrelated donor grafts. This shortage is related to the rarity of certain HLA alleles in the donor pool, nonclearance of donors owing to infectious disease or general health status, and prolonged graft procurement and processing times. An alternative hematopoietic progenitor cell (HPC) graft source obtained from the vertebral bodies (VBs) of deceased organ donors could alleviate many of the obstacles associated with using grafts from healthy living donors or umbilical cord blood (UCB). Deceased organ donor-derived bone marrow (BM) can be preemptively screened, cryogenically banked for on-demand use, and made available in adequate cell doses for HCT. We have developed a good manufacturing practice (GMP)-compliant process to recover and cryogenically bank VB-derived HPCs from deceased organ donor (OD) BM. Here we present results from an analysis of HPCs from BM obtained from 250 deceased donors to identify any substantial difference in composition or quality compared with HPCs from BM aspirated from the iliac crests of healthy living donors. BM from deceased donor VBs was processed in a central GMP facility and packaged for cryopreservation in 5% DMSO/2.5% human serum albumin. BM aspirated from living donor iliac crests was obtained and used for comparison. A portion of each specimen was analyzed before and after cryopreservation by flow cytometry and colony-forming unit potential. Bone marrow chimerism potential was assessed in irradiated immunocompromised NSG mice. Analysis of variance with Bonferroni correction for multiple comparisons was used to determine how cryopreservation affects BM cells and to evaluate indicators of successful engraftment of BM cells into irradiated murine models. The t test (with 95% confidence intervals [CIs]) was used to compare cells from deceased donors and living donors. A final dataset of complete clinical and matched laboratory data from 226 cryopreserved samples was used in linear regressions to predict outcomes of BM HPC processing. When compared before and after cryopreservation, OD-derived BM HPCs were found to be stable, with CD34+ cells maintaining high viability and function after thawing. The yield from a single donor is sufficient for transplantation of an average of 1.6 patients (range, 1.2 to 7.5). CD34+ cells from OD-derived HPCs from BM productively engrafted sublethally irradiated immunocompromised mouse BM (>44% and >67% chimerism at 8 and 16 weeks, respectively). Flow cytometry and secondary transplantation confirmed that OD HPCs from BM is composed of long-term engrafting CD34+CD38-CD45RA-CD90+CD49f+ HSCs. Linear regression identified no meaningful predictive associations between selected donor-related characteristics and OD BM HPC quality or yield. Collectively, these data demonstrate that cryopreserved BM HPCs from deceased organ donors is potent and functionally equivalent to living donor BM HPCs and is a viable on-demand graft source for clinical HCT. Prospective clinical trials will soon commence in collaboration with the Center for International Blood and Marrow Research to assess the feasibility, safety, and efficacy of Ossium HPCs from BM (ClinicalTrials.gov identifier NCT05068401).

Continuously-infused human C-reactive protein is neither proatherosclerotic nor proinflammatory in apolipoprotein E-deficient mice.

Studies of human native C-reactive protein (nCRP) in mice have shown effects ranging from proatherogenic, to antiatherogenic, to no effect. It is likely that these disparities are related to (a) the use, in some studies, of contaminated nCRP, or to (b) variation in CRP levels associated with either its episodic administration or the use of CRP-transgenic mice. In our study, 12-week-old male apolipoprotein E-deficient (apoE (-/-)) mice, maintained on a Western diet, received azide- and endotoxin-free nCRP (n = 23) or placebo (n = 23) continuously via osmotic pumps (20.4 microg/day) for 4 weeks. CRP-treated and control mice developed similar atherosclerotic lesions in whole aortas (nCRP: 10.4 +/- 4.7% vs. controls: 11.7 +/- 4.4%, P = 0.76) and aortic roots (nCRP: 65.0 +/- 7.8% vs. controls: 64.7 +/- 9.7%, P = 0.94). No differences were observed in macrophage or T-lymphocyte infiltrates and there was no meaningful change in VCAM-1 or IL-6 expression, in the levels of soluble VCAM-1, or in circulating proinflammatory (IL-1 beta, IL-6, IL-12p40, IL-12p70, TNF-alpha, and INF-gamma), or anti-inflammatory (IL-4 and IL-10) cytokines. We conclude that continuous infusion of uncontaminated nCRP in apoE (-/-) mice is not associated with increased atherosclerosis, does not alter systemic or local inflammation, and does not affect endothelial activation. These observations suggest that alternative approaches to study CRP (perhaps using different pentraxins in the mouse model or using a rabbit model instead of a mouse model) are needed to evaluate the effects of pentraxins on atherosclerosis.

Gender differences in risk factors for attempted suicide among young adults: findings from the Third National Health and Nutrition Examination Survey.

PURPOSE: To identify the significant factors associated with attempted suicide among men and women, and determine whether socioeconomic status (SES) and social support indictors, health risk factors, and lifetime history of medical and psychiatric illnesses can explain gender differences in attempted suicide. METHODS: We used data from 3357 men and 4004 women aged 17 to 39 years, who completed a mental disorder diagnostic interview as a part of the Third National Health and Nutrition Examination Survey, 1988-1994. Adjusted odds ratios (ORs) were calculated for the association between risk factors and attempted suicide. RESULTS: The prevalence of lifetime attempted suicides was 7.58% (SE, 0.66) in women and 3.69% (SE, 0.49) in men. In men, low income and smoking were associated with attempted suicide, while attempted suicide in women was associated with poor self-evaluated health, low educational attainment, and drug use. A history of medical and psychiatric illnesses was associated with attempted suicide in both genders, for cancer/pulmonary disease, OR=2.89 (95% CI, 1.25-6.67) in men and 1.94 (1.09-3.45) in women; for major depressive disorder, OR=9.86 (5.08-19.14) in men and 5.00 (3.19-7.83) in women. The significant gender difference of attempted suicide prevalence remained after being adjusted for risk factors selected. CONCLUSION: There were significant gender differences in the risk factors for attempted suicide among young adults, and the gender difference in the prevalence of lifetime attempted suicides could not be explained by differential exposure to risk factors selected.

Low HDL cholesterol is associated with suicide attempt among young healthy women: the Third National Health and Nutrition Examination Survey.

BACKGROUND: Serum cholesterol is reported to be associated with suicidality, but studies conducted among general healthy population are rare. We examined the association between serum cholesterol and suicidality in a national sample of the general population of US. METHODS: We used the data of 3237 adults aged 17 to 39 years, who completed a mental disorder diagnostic interview and had blood specimens collected after a 12-h fast, as a part of the Third National Health and Nutrition Examination Survey, 1988-1994. The serum concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were dichotomized according to the recommended levels of the National Cholesterol Education Program. A polytomous logistic regression was employed to control for covariates. RESULTS: Independent of socio-demographic variables, health risks and nutrition status, and a history of medical and psychiatric illness (including depression), a significant association between low HDL-C (< or = 40 mg/dl) and increased prevalence of suicide attempts was observed in women (OR=2.93, 95% CI=1.07-8.00). No significant evidence was found to support an association between cholesterol and suicide ideation in women. Serum cholesterol was unrelated with either suicide ideation or attempts in men. LIMITATION: The inherent limitation of cross-sectional design prevented the authors from investigating causality. CONCLUSIONS: Low HDL-C is significantly associated with suicide attempts in women. Further studies are necessary to explore the clinical application of serum cholesterol as an indicator for suicide attempts among high risk population.

Cost-benefit analysis of home blood pressure monitoring in hypertension diagnosis and treatment: an insurer perspective.

Home blood pressure (BP) monitoring has been shown to be more effective than clinic BP monitoring for diagnosing and treating hypertension. However, reimbursement of home BP monitoring is uncommon in the United States because of a lack of evidence that it is cost beneficial for insurers. We develop a decision-analytic model, which we use to conduct a cost-benefit analysis from the perspective of the insurer. Model inputs are derived from the 2008 to 2011 claims data of a private health insurer in the United States, from 2009 to 2010 National Health and the Nutrition Examination Survey data, and from published meta-analyses. The model simulates the transitions among health states from initial physician visit to hypertension diagnosis, to treatment, to hypertension-related cardiovascular diseases, and patient death or resignation from the plan. We use the model to estimate cost-benefit ratios and both short- and long-run return on investment for home BP monitoring compared with clinic BP monitoring. Our results suggest that reimbursement of home BP monitoring is cost beneficial from an insurer's perspective for diagnosing and treating hypertension. Depending on the insurance plan and age group categories considered, estimated net savings associated with the use of home BP monitoring range from $33 to $166 per member in the first year and from $415 to $1364 in the long run (10 years). Return on investment ranges from $0.85 to $3.75 per dollar invested in the first year and from $7.50 to $19.34 per dollar invested in the long run.

Early inflammatory markers are independent predictors of cardiac allograft vasculopathy in heart-transplant recipients.

BACKGROUND: Identification of risk is essential to prevent cardiac allograft vasculopathy (CAV) and graft failure due to CAV (GFDCAV) in heart transplant patients, which account for 30% of all deaths. Early CAV detection involves invasive, risky, and expensive monitoring approaches. We determined whether prediction of CAV and GFDCAV improves by adding inflammatory markers to a previously validated atherothrombotic (AT) model. METHODS AND FINDINGS: AT and inflammatory markers interleukin-6 (IL-6) and C-reactive protein (CRP) were measured in heart biopsies and sera of 172 patients followed prospectively for 8.9±5.0 years. Models were estimated for 5- and 10-year risk using (1) the first post-transplant biopsy only, or (2) all biopsies obtained within 3 months. Multivariate models were adjusted for other covariates and cross-validated by bootstrapping. After adding IL-6 and CRP to the AT models, we evaluated the significance of odds ratios (ORs) associated with the additional inflammatory variables and the degree of improvement in the area under the receiver operating characteristic curve (AUROC). When inflammatory markers were tested alone in prediction models, CRP (not IL-6) was a significant predictor of CAV and GFDCAV at 5 (CAV: p<0.0001; GFDCAV: p = 0.005) and 10 years (CAV: p<0.0001; GFDCAV: p = 0.003). Adding CRP (not IL-6) to the best AT models improved discriminatory power to identify patients destined to develop CAV (using 1st biopsy: p<0.001 and p = 0.001; using all 3-month biopsies: p<0.04 and p = 0.008 at 5- and 10-years, respectively) and GFDCAV (using 1st biopsy: 0.92 vs. 0.95 and 0.86 vs. 0.89; using all 3-month biopsies: 0.94 vs. 0.96 and 0.88 vs. 0.89 at 5- and 10-years, respectively), as indicated by an increase in AUROC. CONCLUSIONS: Early inflammatory status, measured by a patient's CRP level (a non-invasive, safe and inexpensive test), independently predicts CAV and GFDCAV. Adding CRP to a previously established AT model improves its predictive power.

Value of the first post-transplant biopsy for predicting long-term cardiac allograft vasculopathy (CAV) and graft failure in heart transplant patients.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is the principal cause of long-term graft failure following heart transplantation. Early identification of patients at risk of CAV is essential to target invasive follow-up procedures more effectively and to establish appropriate therapies. We evaluated the prognostic value of the first heart biopsy (median: 9 days post-transplant) versus all biopsies obtained within the first three months for the prediction of CAV and graft failure due to CAV. METHODS AND FINDINGS: In a prospective cohort study, we developed multivariate regression models evaluating markers of atherothrombosis (fibrin, antithrombin and tissue plasminogen activator [tPA]) and endothelial activation (intercellular adhesion molecule-1) in serial biopsies obtained during the first three months post-transplantation from 172 patients (median follow-up = 6.3 years; min = 0.37 years, max = 16.3 years). Presence of fibrin was the dominant predictor in first-biopsy models (Odds Ratio [OR] for one- and 10-year graft failure due to CAV = 38.70, p = 0.002, 95% CI = 4.00-374.77; and 3.99, p = 0.005, 95% CI = 1.53-10.40) and loss of tPA was predominant in three-month models (OR for one- and 10-year graft failure due to CAV = 1.81, p = 0.025, 95% CI = 1.08-3.03; and 1.31, p = 0.001, 95% CI = 1.12-1.55). First-biopsy and three-month models had similar predictive and discriminative accuracy and were comparable in their capacities to correctly classify patient outcomes, with the exception of 10-year graft failure due to CAV in which the three-month model was more predictive. Both models had particularly high negative predictive values (e.g., First-biopsy vs. three-month models: 99% vs. 100% at 1-year and 96% vs. 95% at 10-years). CONCLUSIONS: Patients with absence of fibrin in the first biopsy and persistence of normal tPA in subsequent biopsies rarely develop CAV or graft failure during the next 10 years and potentially could be monitored less invasively. Presence of early risk markers in the transplanted heart may be secondary to ischemia/reperfusion injury, a potentially modifiable factor.

Centile-based early warning scores derived from statistical distributions of vital signs.

AIM OF STUDY: To develop an early warning score (EWS) system based on the statistical properties of the vital signs in at-risk hospitalised patients. MATERIALS AND METHODS: A large dataset comprising 64,622 h of vital-sign data, acquired from 863 acutely ill in-hospital patients using bedside monitors, was used to investigate the statistical properties of the four main vital signs. Normalised histograms and cumulative distribution functions were plotted for each of the four variables. A centile-based alerting system was modelled using the aggregated database. RESULTS: The means and standard deviations of our population's vital signs are very similar to those published in previous studies. When compared with EWS systems based on a future outcome, the cut-off values in our system are most different for respiratory rate and systolic blood pressure. With four-hourly observations in a 12-h shift, about 1 in 8 at-risk patients would trigger our alerting system during the shift. CONCLUSIONS: A centile-based EWS system will identify patients with abnormal vital signs regardless of their eventual outcome and might therefore be more likely to generate an alert when presented with patients with redeemable morbidity or avoidable mortality. We are about to start a stepped-wedge clinical trial gradually introducing an electronic version of our EWS system on the trauma wards in a teaching hospital.