Performance of a hybrid central venous catheter utilized for both peripheral blood stem cell harvest and transplant support of patients undergoing autologous peripheral blood stem cell transplantation.

Patients undergoing autologous peripheral blood stem cell transplantation (PBSC) frequently require the sequential insertion of two central venous catheters, one for leukapheresis and one for transplant support. Hybrid catheters suitable for leukapheresis and long-term use have been increasingly used, but there is limited information regarding their performance and complication rate. The purpose of this study was to determine the performance of the Pheres-Flow hybrid catheter when utilized for both leukapheresis and transplant support, with particular emphasis on the incidence of infectious and occlusive complications. We prospectively analyzed the performance of 92 catheters in 82 consecutive patients who underwent autologous peripheral blood stem cell (PBSC) transplantation. Occlusion was the most frequent complication of this catheter with 29% of the patients experiencing difficulty drawing blood or infusing fluids. Infection was another frequent complication. Twenty-two percent of patients developed catheter-related bloodstream infections and 15 catheters had to be removed because of proven or suspected infection that did not respond to antibiotic therapy. Nevertheless, 77% of patients were able to complete leukapheresis and transplant support with only one catheter. We conclude that the utilization of the Pheres-Flow catheter for both leukapheresis and transplant support is feasible, but that new strategies need to be developed to decrease the incidence of occlusive and infectious complications of hybrid catheters.

Mobilization of dendritic cells and NK cells in non-Hodgkin's lymphoma patients mobilized with different growth factors.

Conflicting results have been reported regarding the effect of various growth factors on the mobilization of natural killer (NK) cells and dendritic cells in patients undergoing stem cell mobilization for autotransplantation. We compared the extent of mobilization of NK cells and dendritic cells in non-Hodgkin's (NHL) patients undergoing mobilization with granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage (GM)-CSF, or GM-CSF followed by G-CSF. Overall, 35 patients were studied. NK cells and dendritic were quantitated by flow cytometry. NK cells were defined as the sum of CD56(+) cells and CD56/CD16(+) cells. Dendritic cells were defined as the sum of CD80(+) and CD80(+)/CD14(+) cells. NK activity was determined by by microcytotoxicity assay. NK activity correlated well with the total amount of CD56(+) cells mobilized to the peripheral blood. Patients in the three arms of the study mobilized similar amounts of NK cells and NK activity, and patients who lacked NK activity in the peripheral blood, before mobilization, lacked NK activity in their apheresis collections. In contrast to NK cell mobilization, mobilization of dendritic cells/kg was three- to five-fold higher in patients mobilized with GM-CSF-containing regimens compared to patients mobilized with G-CSF alone. We conclude that GM-CSF-containing mobilization regimens are superior for dendritic cell mobilization but similar in the mobilization of NK cells. Therefore, we recommend using GM-CSF-containing regimens for patients undergoing ex vivo or in vivo manipulation of dendritic cells.

Peripheral blood stem cell mobilization with cyclophosphamide in combination with G-CSF, GM-CSF, or sequential GM-CSF/G-CSF in non-Hodgkin's lymphoma patients: a randomized prospective study.

We designed a randomized, prospective three-arm mobilization study to determine the kinetics of peripheral blood stem cell (PBSC) mobilization in 60 non-Hodgkin's lymphoma (NHL) patients primed with cyclophosphamide (CTX) in combination with granulocyte colony-stimulating factor (G-CSF) (arm A), granulocyte-macrophage (GM)-CSF (arm B) or GM-CSF/G-CSF (arm C). We also compared mobilization and transplant-related toxicities, pre- and post-transplant support and the probability of survival among the three arms. To date, 35 patients have been enrolled in the study; 13 patients have been enrolled in arm A, 10 patients in arm B, and 13 patients in arm C. Successful collection of the target of > or = 2 X 10(6) CD34+ cells/kg in one to four apheresis collections was 10/13, 6/10, and 7/12 in arms A, B, and C, respectively. The differences between arms were not statistically significant. The median time to achieve the target CD34+ cells in patients who successfully mobilized the target CD34+ cells was 3 days, 2 days, and 1 day, in patients in arms A, B, and C, respectively. The time for neutrophil engraftment was 11, 10, and 10 days in arms A, B, and C, respectively. The time for platelet engraftment was 11 days for patients in all arms of the study. Most importantly, no significant differences were observed among the three arms in the duration of neutropenic fever, the extent of mucositis, diarrhea, and nausea/vomiting, or in the number of units of platelets or red cells transfused after transplantation. Risk factors associated with poor mobilization were > or = 3 regimens of chemotherapy prior to mobilization, older age, and disease histology (follicular versus diffuse). Therefore, we conclude that the type of growth factor used for mobilization did not play a major role in the outcome of mobilization and recommend mobilizing NHL patients before they receive multiple regimens of chemotherapy.

Successful PBSC mobilization with high-dose G-CSF for patients failing a first round of mobilization.

PBSC are the preferred source of stem cells for autologous transplantation. However, regardless of the mobilization procedure used, 10%-20% of patients fail to collect an adequate number to ensure prompt engraftment. There is as yet no standard mobilization procedure for patients who fail a first mobilization attempt. Here, we describe a highly efficient strategy to obtain an adequate number of stem cells for patients who failed a first mobilization attempt. Seventy-four patients with various hematologic malignancies underwent initial mobilization with various regimens including hematopoietic growth factors with or without chemotherapy. In 72% of patients, > or =2 x 10(6) CD34+ stem cells/kg were collected in the initial mobilization attempt, and patients engrafted in a median of 10 days for neutrophils and 12 days for platelets. Eighteen patients failed to mobilize adequate numbers of stem cells, defined as the inability to collect 0.2 x 10(6) CD34+ stem cells/kg/day in the first 2-3 days. These patients had their apheresis halted. Patients were immediately given G-CSF (32 microg/kg/day) for 4 days as a second attempt at mobilization. Eighty-eight percent of these patients achieved the target of > or =2 x 10(6) CD34+ cells/kg, with a median duration of apheresis of 5 days (including the first and second mobilizations). The mean CD34+ cells/kg/day increased after administration of high-dose G-CSF from 0.16 after the first mobilization attempt to 0.61 (p = 0.0002) after the second mobilization. All patients engrafted in a median of 11 and 13 days for neutrophils and platelets, respectively. We conclude that patients whose apheresis yield is <0.4 x 10(6) CD34+ cells/kg after the first two apheresis collections can be successfully mobilized if high-dose G-CSF is administered immediately and continued until achieving > or =2 x 10(6) CD34+ stem cells/kg.

Ability of a computerized geriatric assessment to predict need for change in living status among elderly living at home.

The objective of this study was to determine the ability of a software program used in a primary care physician's office to predict the need for alternate living arrangement in a cohort of community-dwelling elderly. An analysis was conducted involving 124 consecutive patients between February 10, 1990, and December 20, 1991, in my private medical practice. These patients, all older than 65 years, underwent a computer-assisted geriatric assessment. Two scales--the Geriatric Functional Rating Scale (GFRS) and the Functional Assessment Screening Questionnaire (FASQ)--were compared for their accuracy at predicting change in living status during the 12- to 24-month period following the assessment. Similar analysis of the Tinetti gait and balance test was also performed. Ten and one-half percent of subjects (n = 13) required a change in living status during the study period. Ten went to nursing homes and three joined relatives' households. The GFRS was 62% accurate (8/13) and the FASQ was 54% (7/13) accurate in predicting this change. Abnormality in both gait and balance was predictive 77% (10/13) of the time. Combining all three parameters raised the successful prediction rate to 85% (11/13). Neither GFRS, FASQ, nor gait/balance testing was predictive of death. A computer software program designed to facilitate performance of geriatric assessments in primary care physicians' offices has a high rate of predictive capability relative to future need for change in living status among community-dwelling elderly. Further studies comparing this software program with traditional geriatric assessment protocols are suggested.

A computerized geriatric assessment designed for use in primary care physicians' offices.

Comprehensive geriatric assessments have generally been recognized as beneficial for frail elderly patients. However, the complexity of these evaluations has usually required that they be performed in a multidisciplinary setting. Staffing requirements, time commitment, new skill requirements, and reimbursement problems serve as impediments for primary care physicians performing these examinations. Computer technology may be the solution to these problems. A software program has been developed which allows primary care physicians to perform a sophisticated functional assessment on an outpatient basis without the use of a multidisciplinary team. Problems are identified by the computer-assisted protocol and patients are referred for appropriate management. Thus, the physician maintains a primary role in case management. The program is cost effective because it does not require additional staff to operate it and it effectively uses CPT and ICD9 coding.

Assessment of nutritional status and obesity in elderly patients as seen in general medical practice.

Overweight and obesity are generally considered to have a negative impact on longevity because of their association with many diseases, including hypertension, diabetes, coronary artery disease, osteoarthritis, and certain types of cancer. Nevertheless, some authors, notably Ancel Keys, have concluded that being overweight improves one's chances for longevity. I studied 122 consecutive patients who had comprehensive geriatric assessment with regard to their body mass index, responses to Wolinsky's Nutritional Risk Index, and serum albumin levels. There was a high prevalence of overweight (60% of men and 45.6% of women). This fact, coupled with the observed low prevalence of underweight subjects, tends to support Keys' statement concerning the benefit of being overweight. However, the relative absence of significant obesity supports the impression that significantly obesity reduces prospects for longevity. Although serum albumin measurements were obtained for only 38 subjects, the fact that the value was low in only one instance--in the case of a person who was seriously ill--suggests that obtaining routine serum albumin measurements in ambulatory, community-dwelling elderly people is not cost-effective.

Selection of dental hygiene as a career: associate degree students compared with baccalaureate students.

One of the most significant issues in the dental hygiene profession is the recruitment of qualified applicants. Throughout the decade of the 80s, a dramatic decline in enrollment has occurred in dental hygiene programs across the nation. According to recent demographic reports, there are fewer individuals in the age group where dental hygiene students are traditionally recruited and no significant change is expected. Therefore, in order to maintain and improve the pool of students preparing for a career in dental hygiene, it is critical that an attempt be made to understand the forces which lead students to choose the health care profession. A study was conducted using baccalaureate alumni and three classes in the baccalaureate degree dental hygiene program at The Ohio State University in order to determine why they had chosen the career of dental hygiene. This study was subsequently expanded to include students enrolled in eight associate degree dental hygiene programs in Ohio. The results from the survey indicate that career decisions are made at varying points in the educational process. Dentists and dental hygienists account for half of the influence in the decision process with high school guidance counselors having negligible influence. Nearly all respondents chose working with people as the top career benefit. Those findings point to the importance of involving dental and dental hygiene professionals in the recruitment process and the necessity to provide appropriate information to others who may provide career counseling.

Prevalence of olfactory dysfunction, hearing deficit, and cognitive dysfunction among elderly patients in a suburban family practice.

Olfactory and hearing senses diminish with age, and cognitive dysfunction increases. The association between sensory deficits and cognitive dysfunction has not been well studied. This paper presents the results of testing a group of 50 community-dwelling patients of a family physician who developed a computer-assisted comprehensive geriatric assessment program. Olfactory dysfunction was present in 39% of subjects, with 18% being unable to detect smoke. There was no correlation between olfactory dysfunction and cognitive dysfunction. Hearing deficit, however, was found in 10% of subjects, all of whom also had either an associated olfactory or cognitive dysfunction. This study demonstrates the high prevalence of olfactory and auditory dysfunction in an ambulatory geriatric population, with a possible association between hearing deficit and cognitive dysfunction. The problem of multiple sensory deficits should be addressed in any long-term management decisions regarding elderly patients.

Computer-assisted comprehensive geriatric assessment in a family physician's office.

Family physicians and other medical care providers are beginning to realize the importance of a comprehensive assessment examination for elderly patients. The components of such an examination are well documented, and include not only the standard history and physical examination, but also evaluation of mental health, functional status, and socioeconomic status of the person. A major impediment to a family physician doing such an extensive evaluation is that most offices lack the team approach commonly used in tertiary care medical facilities. In this paper I report the implementation of a computer-assisted program that was developed for use in a private physician's office. The first 22 patients examined using this protocol are discussed. A new diagnosis was uncovered in all but three of the subjects. This finding suggests that performing comprehensive geriatric assessments in a family practice setting might create an immediate benefit in terms of patient management.

Academic affiliation with a nursing home. Impact on patient outcome.

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.

Exercise Testing of Obese Subjects.

Obese patients especlally need the boost that exerclse can glve thelr dletlng programs. Dr. DeVore dlscusses the role of stress testlng ln exerclse prescription for obese patients.