Ideals in action: the U.S. Schweitzer Fellows Programs.

The inclusion of formal courses in medical ethics as part of standard undergraduate medical education has not led to widespread confidence in the moral and professional development of young physicians. As important as classes on informed consent and other such topics are, alternative approaches to professional moral development are needed. One example can be found in The U.S. Schweitzer Fellows Programs, which now support over 100 health professions students annually in six locations. Fellows participate in activities designed to strengthen the ideals that originally attracted them to medicine and other health care fields. Because Dr. Schweitzer is remembered primarily for the way he translated his ideals of human service into action, the core activity of each program is a direct-service project that addresses an important unmet health need of the local community or individuals in the community, with the support of community-based and school-based mentors. Alumni of these programs report that their experiences as Schweitzer fellows have helped them integrate their own ideals into their professional and career development. Such systematic efforts to recognize and support the latent idealism of young health professionals may strengthen the moral dimensions of professional life in ways that have broad social benefits.

Human photoreceptor transplantation in retinitis pigmentosa. A safety study.

OBJECTIVE: To establish the technical feasibility and safety of photoreceptor transplantation in retinitis pigmentosa. METHODS: A sheet of human photoreceptor cells was harvested from 2 human cadaveric eyes with a vibratome and transplanted into the subretinal spaces of 2 patients with advanced retinitis pigmentosa and visual acuity of no light perception by means of submacular surgery techniques. Preoperative and postoperative electrophysiologic testing, fundus photography, fluorescein angiography, and scanning laser ophthalmoscopy were performed. RESULTS: Twelve months after photoreceptor transplantation, the visual acuity of each patient remained no light perception. The temporal edge of the retinotomy in 1 patient was folded but was not associated with a retinal detachment. The patients were not immunosuppressed, and there was no evidence of rejection of the allogeneic transplant. Cystoid macular edema, uveitis, and macular pucker were not observed. CONCLUSION: A sheet of adult human photoreceptor cells can be harvested from human cadaveric eyes and safely transplanted to the subretinal spaces of patients with retinitis pigmentosa without systemic immunosuppression.

Mapping the RP2 locus for X-linked retinitis pigmentosa on proximal Xp: a genetically defined 5-cM critical region and exclusion of candidate genes by physical mapping.

Genetic linkage studies have implicated at least two loci for X-linked retinitis pigmentosa (XLRP) on proximal Xp. We now report a defined genetic localization for the RP2 locus to a 5-cM interval in Xp11.3-11.23. Haplotype analysis of polymorphic markers in recombinant individuals from two XLRP families has enabled us to identify DXS8083 and DXS6616 as the new distal and proximal flanking markers for RP2. Using STS-content and YAC end-clone mapping, an approximately 1.2 Mb YAC contig has been established encompassing the proximal RP2 boundary and extending from T1MP1 to DXS1240 in Xp11.23. Several ESTs have been positioned and ordered on this contig, one of which is novel to the region, identified by sequence data-base match to a physically mapped YAC insert terminal STS. Integration of the genetic and physical data has placed four retinally expressed genes proximal to DXS6616, and thereby excluded them from a causitive role in RP2. This work now provides a much needed focus for positional cloning approaches to isolation of the defective gene.

Expansion of activated lymphocytes obtained from renal cell carcinoma in an automated hollow fiber bioreactor.

Immunotherapy using IL-2 alone or combined with activated lymphocytes has been promising for metastatic renal cell carcinoma. Cytotoxic lymphocytes can be isolated from tumors, expanded in vitro with IL-2, and adoptively transferred back into the tumor-bearing host. These cells can also be transduced with the genes coding for cytokines for local delivery to tumor sites. A major drawback in adoptive immunotherapy is the cumbersome and expensive culture technology associated with the growth of large numbers of cells required for their therapeutic effect. To reduce the cost, resources, and manpower, we have developed the methodology for lymphocyte activation and expansion in the automated hollow fiber bioreactor IMMUNO*STAR Cell Expander (ACT BIOMEDICAL, INC). Tumor Infiltrating Lymphocytes (TIL) isolated from human renal cell carcinoma tumor specimens were inoculated at a number of 10(8) cells in a small bioreactor of 30 ml extracapillary space volume. We have determined the medium flow rates and culture conditions to obtain a significant and repeated expansion of TIL at weekly intervals. The lymphocytes cultured in the bioreactor demonstrated the same phenotype and cytotoxic activity as those expanded in parallel in tissue culture plates. Lymphocyte expansion in the hollow fiber bioreactor required lower volumes of medium, human serum, IL-2 and minimal labor. This technology may facilitate the use of adoptive immunotherapy for the treatment of refractory malignancies.

Functional effect of IL-7-enhanced CD19 expression on human B cell precursors.

We have previously demonstrated that IL-7 can sustain the growth of normal human B cell precursors (BCP) for several weeks on bone marrow-derived stromal cells. Flow cytometric analysis of BCP recovered from IL-7 supplemented cultures revealed two- to threefold higher levels of cell surface CD19, compared with BCP maintained without IL-7. Short term culture of BCP showed that IL-7 enhancement of CD19 was dose-dependent, with increases detected by day 1 and plateauing by days 3 to 4. IL-7 increased cell-surface CD19 on small lymphoid cells, and to a greater degree on lymphoblasts, whereas cell-surface CD10 was unchanged. The CD34+/CD19+ pro-B cell population showed a greater increase in cell-surface CD19 compared with pre-B and immature B cells. IL-1, IL-3, IL-4, IL-6, and stem-cell factor had no effect on CD19. The potential functional significance of IL-7-enhanced cell-surface CD19 was examined using a F(ab')2 fragment of anti-CD19. This reagent had no effect on [3H]TdR incorporation in BCP cultured in the absence or presence of IL-7 for 5 days, but homotypic adhesion of BCP was induced at a concentration as low as 1.0 ng/ml F(ab')2 anti-CD19. IL-7 enhanced the F(ab')2 anti-CD19 induced homotypic adhesion of BCP in a dose-dependent manner. Blocking antibody studies indicated that members of the beta 1 or beta 2 integrin families did not mediate anti-CD19-induced homotypic adhesion, even though the adhesion was completely ablated by 10 mM EDTA. The pre-B and immature leukemic B cell lines NALM-6 and 1E8 expressed comparable levels of cell-surface CD19, and exhibited comparable increases after IL-7 stimulation. However, their homotypic adhesion responses to anti-CD19 were different. NALM-6 cells exhibited a strong homotypic adhesion response to anti-CD19 that was EDTA-resistant, and beta 1/beta 2 integrin independent. 1E8 cells only responded to anti-CD19 after IL-7 stimulation; this response was EDTA-sensitive and beta 1/beta 2 integrin independent. These collective results indicate that IL-7 not only acts as a growth factor for human BCP, but also regulates signal transduction through cell-surface CD19.

Expression of a chimeric helix-loop-helix gene, Id-SCL, in K562 human leukemic cells is associated with nuclear segmentation.

We have designed a chimeric gene, Id-SCL, in which the 3' helix-loop-helix encoding portion of the presumptive oncogene SCL/tal is joined to the 5' coding portion of Id, an inhibitory helix-loop-helix gene. The predicted protein product of this chimeric gene contains the helix-loop-helix dimerization domain of SCL/tal, but, lacking a basic DNA binding domain, is predicted to have the inhibitory function of the Id product. Expression of the Id-SCL fusion gene in stably transfected K562 cells reproducibly resulted in nuclear segmentation and depressed growth rates; both of these phenotypic effects demonstrated a dosage dependence on the levels of Id-SCL mRNA and protein expressed in the various clones. Electron microscopy of cells expressing high levels of Id-SCL mRNA showed a significant increase in cytoplasmic perinuclear thin filaments and diminution of marginal heterochromatin in the nuclei. No other changes in hematopoietic differentiation status were observed in association with Id-SCL expression. Expression of intact Id and SCL/tal genes, as well as deletion mutants of Id and SCL/tal, independently transfected into K562 cells, indicated that the nuclear segmentation effect is dependent on the presence of a protein possessing a helix-loop-helix domain but lacking a basic domain. Our studies suggest that the balance of transcriptional inhibitory and stimulatory helix-loop-helix proteins in cells may be important determinants of proliferation and of structural organization within cells.

Development of a bone marrow culture for maintenance and growth of normal human B cell precursors.

The absence of long term bone marrow cultures for studying the growth and differentiation of human B cell precursors (BCP) has placed restrictions on the ability to analyze the early stages of human B cell ontogeny. We now describe a bone marrow-derived adherent cell microenvironment that maintains human BCP for several weeks in vitro. The adherent cells are maintained in a serum-free tissue culture medium, and consist of a predominant population of CD10+ fibroblast-like cells and a minor population of CD10+/nonspecific esterase+ macrophages. Adherent cell cultures seeded with fresh or cryopreserved fetal bone marrow, or purified CD10+/surface IgM- cells, provide a supportive microenvironment for lymphoid cells with a predominant phenotype of CD10+/CD19+/HLA-DR+/surface IgM-. Supplementation of the adherent cell cultures with human IL-7 induces active growth of BCP during the first 14 to 21 days of culture. However, the expansion of these cells does not continue past 21 days, and the cultures undergo a steady decline in BCP. Analysis of adherent cell conditioned medium revealed the presence of an unidentified soluble factor (or factors) that acts in concert with IL-7 to promote the growth of CD10+/surface IgM- cells. This culture system will be useful in elucidating the patterns of gene expression and growth factor requirements that characterize normal human B cell ontogeny, and perturbations of normal B cell ontogeny that lead to immunodeficiency and leukemia.

The use of LIS for blood usage review. Experience in a children's hospital.

To comply with the requirements of the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and to facilitate the review process, the authors designed a program to screen for the appropriateness of packed red cell (PRC) and platelet concentrate (PLT) transfusions. The purpose of this report is to describe the methodology of the review process. A quality assurance (QA) monitor was created in the Laboratory Information System (LIS) to screen indicators: hemoglobin for PRCs and platelet count for PLTs. Numerical value limits were defined to determine acceptable ranges. Each week, the LIS compiles a list of all patients who received transfusions and for whom the QA monitor determined that the values of the screened indicators were outside the defined appropriate limits. A detailed transfusion record is generated for each patient identified. During a six-month evaluation of this program, a total of 1,788 PRC and 3,109 PLT units were transfused. Of these, 582 PRC (32.5%) and 2,219 PLT (71.4%) units were within the acceptable guidelines. Lists for the remaining 1,206 PRCs and 890 PLTs were generated. Review of the transfusion record and other laboratory values from the LIS established the appropriateness of 1,052 PRC and 782 PLT transfusions. At the conclusion of the six-month period, the medical charts for 181 (11%) PRC and 108 (4.5%) PLT transfusions required chart review. This method provided major reduction in time of the transfusion review process. Similar guidelines may be used to monitor other transfusion products such as fresh frozen plasma.

The response of splenic lymphocytes removed from hypophysectomized-orchidectomized hamsters to phytohemagglutinin correlates with somatic growth but not with circulating prolactin levels.

To examine the relationship between PRL and the mitogenic capacity of lymphocytes, we studied the relationships among circulating PRL levels, somatic growth, and the response of splenic lymphocytes to the mitogen phytohemagglutinin (PHA) in hamsters. In the first experiment, no differences were observed in the PHA responses of lymphocytes removed from intact or hypophysectomized-orchidectomized hamsters. No relationships were observed between circulating PRL levels and either the PHA responses or somatic growth. However, significant positive correlations were observed between the somatic growth of intact or hypophysectomized-orchidectomized hamsters and the PHA responses (r = 0.741; P less than 0.01 for intact hamsters; r = 0.642; P less than 0.01 for hypophysectomized-orchidectomized hamsters). In three subsequent experiments we tested the effects of placing muscle or hypophysial allografts in hypophysectomized-orchidectomized hamsters on somatic growth, the PHA responses, and circulating PRL levels. Neither type of allograft altered the somatic growth of hypophysectomized-orchidectomized hamsters. The hypophysial allografts did elevate serum PRL levels. In all experiments the responses of splenic lymphocytes to PHA showed a significant positive correlation with somatic growth, but not with serum PRL levels. These results minimize a role of PRL in this particular lymphocyte response. The results suggest that a strong correlation exists between mechanisms responsible for somatic growth in hypophysectomized-orchidectomized hamsters and the immune status, as determined by the response to PHA, of the animals. This relationship also may exist in intact hamsters.

Altering body position affects intraocular pressure and visual function.

Intraocular pressure (IOP) can be altered by changing body position. This report describes two experiments evaluating variations in IOP, as well as neural functioning of the retina and visual cortex (as measured by pattern-reversal electroretinogram and visual evoked potential), associated with whole-body, head-down tilt. The subjects, ten per experiment, were visually normal with IOP less than 19. In the first experiment, IOP elevations were induced by varying the angle of tilt in discrete steps between +90 degrees (upright) and -90 degrees (inverted). In each position IOP was measured and significant elevations (up to 3x baseline) were noted. These elevations were maintained for 1 min during which simultaneous retinal and cortical biopotentials were measured. In the second experiment, 6 degrees head-down tilt was maintained for 2 hr during which time the IOP and both biopotentials were measured repeatedly. Our findings confirm the effect of body position of IOP, while also revealing that head-down tilt produces significant reductions in neurophysiological function at both the retinal and cortical levels. The neural effect is maximized when 6 degrees head-down tilt is maintained for 20 min.

A therapeutic trial of vitamin A in patients with pigmentary retinal degenerations: a negative study.

A prospective therapeutic trial was designed to test the hypothesis that measurable improvement of retinal functions might occur in some patients with pigmentary retinal degeneration when placed on high doses of solubilized vitamin A (Aquasol A, 50,000 I.U. per day by mouth for 28 days). After a standard ophthalmic history and examination pre-trial examinations consisting of visual acuity, visual fields, color vision tests, dark adaptations and cone thresholds were obtained on two separate occasions. Electroretinography was usually performed only once. Forty-seven patients were entered into the study of which 27 had typical retinitis pigmentosa. The patients showed no significant change in visual function from pre-trial results when tested after taking the vitamin A for 28 days. Post-trial electroretinography performed on 10 patients with recordable pre-trial electroretinograms showed no change. The 10 patients retested at six and 12 months after the trial showed no significant change in visual function.