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Graft-versus-host disease (GVHD) remains a source of significant morbidity and mortality in the setting of allogeneic stem cell transplantation. Improving outcomes in stem cell transplant recipients will require additional therapeutic modalities for GVHD, especially for those patients who fail to respond to initial therapy with steroids. This article provides an introduction to accompanying articles in this issue of Biology of Blood and Marrow Transplantation concerning the current state of GVHD management with an emphasis on the role of extracorporeal photopheresis as a therapeutic modality. Topics discussed include challenges associated with the design of clinical studies of GVHD therapies, the efficacy of and proposed mechanisms of photopheresis in the setting of GVHD, and our emerging understanding of regulatory T cell biology as it relates to allogeneic stem cell transplantation.

BACKGROUND

Umbilical cord blood (CB) is a promising source of hematopoietic stem cells for allogeneic transplantation. However, delayed engraftment and impaired immune reconstitution remain major limitations. Enrichment of donor grafts with CB T cells expanded ex vivo might facilitate improved T-cell immune reconstitution post-transplant. We hypothesized that CB T cells could be expanded using paramagnetic microbeads covalently linked to anti-CD3 and anti-CD28 Ab.

METHODS

CB units were divided into three fractions: (1) cells cultured without beads, (2) cells cultured with beads and (3) cells cultured with beads following CD3+ magnetic enrichment. All fractions were cultured for 14 days in the presence of IL-2 (200 IU/mL).

RESULTS

A mean 100-fold expansion (range 49-154) of total nucleated cells was observed in the CD3+ magnetically enriched fraction. Following expansion, CB T cells retained a naive and/or central memory phenotype and contained a polyclonal TCR diversity demonstrated by spectratyping.

DISCUSSION

Our data provide evidence that naive and diverse CB T cells may be expanded ex vivo and warrant additional studies in the setting of human CB transplantation.

BACKGROUND

The generation of AML-specific T-lymphocyte responses by leukemia-derived DC has been documented by multiple investigators and is being pursued clinically. An obstacle to widespread use of this strategy is that it has not been possible to generate leukemic DC from all patients, and an alternative approach is needed if the majority of leukemia patients are to receive therapeutic vaccination in conjunction with other treatment protocols.

METHODS

In the present study, we generated DC from CD14-selected monocytes isolated from healthy donor PBPC and loaded them with a total cell lysate from AML patient blasts.

RESULTS

Immature in vitro-derived DC exhibited robust phagocytic activity, and mature DC demonstrated high expression of CD80, CD83, CD86 and the chemokine receptor CCR7, important for DC migration to local lymph nodes. Mature, Ag-loaded DC were used as APC for leukemia-specific cytotoxic T-lymphocyte (CTL) induction and demonstrated cytotoxic activity against leukemic targets. CTL lysis was Ag-specific, with killing of both allogeneic leukemic blasts and autologous DC loaded with allogeneic AML lysate. HLA-matched controls were not lysed in our system.

DISCUSSION

These data support further research into the use of this strategy as an alternative approach to leukemia-derived DC vaccination.

OBJECTIVE

To investigate the effect of ultralow-dose transdermal estradiol on postmenopausal symptoms and side effects in a cohort of largely asymptomatic postmenopausal women aged 60 to 80 years.

DESIGN

This secondary analysis used data from the UltraLow-dose Transdermal estRogen Assessment trial, a randomized, placebo-controlled, double-blind trial in postmenopausal women to determine the skeletal effects and safety of ultralow-dose transdermal estradiol. Four hundred seventeen postmenopausal women, aged 60 to 80 years, were randomly assigned to receive either unopposed transdermal estradiol at 0.014 mg/d (n = 208) or placebo (n = 209). Participants were queried at each clinic visit about postmenopausal symptoms and side effects purported to be associated with estrogen therapy using a standardized questionnaire.

RESULTS

At baseline, 16% of women reported hot flashes, 32% reported vaginal dryness, and 35% reported trouble sleeping. Women who received ultralow-dose estradiol were no more likely to report improvement of hot flashes, vaginal dryness, or sleep difficulties than those who received placebo. Treatment with ultralow-dose estradiol did not cause breast tenderness, uterine bleeding, or other symptoms often attributed to estrogen, but vaginal discharge was more common in women who received estradiol compared with those who received placebo.

CONCLUSION

In this population of older, largely asymptomatic women, ultralow-dose transdermal estradiol did not improve postmenopausal symptoms and did not cause side effects other than vaginal discharge. Further study is needed to determine whether this dose of transdermal estradiol is effective in treating symptoms of postmenopause in younger, more symptomatic women.

Though previous data indicate a positive association between depression and coronary heart disease, the mechanisms mediating these associations remain unclear. These prospective analyses assessed the association between history of Center for Epidemiologic Studies Depression Scale depression and possible mediators of cardiovascular risk at Year 15 of follow-up in African Americans (AA) and Caucasians (C) in the Coronary Artery Risk Development in Young Adults Study. Physiological assessments included plasma levels of low-density-lipoprotein cholestrol (LDL), high-density-lipoprotein cholestrol (HDL), total cholesterol, triglycerides and fasting glucose, diabetes and blood pressure. Behavioral risk factors included alcohol consumption, smoking, physical activity, and body mass index (BMI). AA's showed significant associations between history of depression and diabetes that did not exist in Cs and AA women had significantly more episodes of depression than any other group. However, associations of depression with smoking, BMI, and physical activity were consistent across groups in the expected direction. HDL-cholesterol was positively and LDL-cholesterol inversely associated with depression in Cs, which was unexpected. These data indicate that in this still healthy cohort, there are already associations between depression and factors that predispose to cardiovascular risk.

To exclude bacteria- or animal-derived factors from cultured fabrication of transplantable epithelial cell sheets, primary human oral mucosal epithelial cells were seeded on temperature-responsive culture inserts having submicron-scale pores. Supplying culture medium containing human autologous serum to both apical and basal sides of human epithelial cells allows these cells to grow to confluence. These proliferating cells created stratified epithelial layers even when 3T3 feeder layers and fetal bovine serum were eliminated from culture. Normal keratin expression profiles were obtained with these cells, and basal and midlayer cells expressed p63, a putative stem/progenitor marker. These results suggest that temperature-responsive culture inserts can be useful in clinical settings that require the exclusion of xenogeneic factors.

Cell-based therapies have now generated significant interest as novel drug delivery systems, with various adult cell types used in treating a wide range of diseases. To overcome the limits that restrict treatments for corneal surface dysfunction, corneal epithelial stem cells expanded ex vivo have been applied as an alternative approach. While previous studies used various carrier substrates, we present a novel method using cell sheet engineering with temperature-responsive culture dishes to create carrier-free corneal epithelial stem cell sheets that can be transplanted without sutures. Results from clinical trials reveal successful transplantation with the recovery of lost visual acuity in all cases. Cell sheet engineering, therefore, presents a novel method for the delivery of corneal epithelial stem cells, and can also be applied for other approaches of cellular therapeutics.

Brief symptom instruments are designed to assess symptoms while maintaining low respondent burden, but they may omit important information. Our objective was to determine whether a representative brief symptom instrument effectively captures the full symptom experience of older adults with advanced diseases. In this cross-sectional study, we interviewed 90 community-dwelling adults with cancer, congestive heart failure, or chronic obstructive pulmonary disease regarding the presence of symptoms in the prior 24 hours. Participants rated the intensity and bothersome nature of 15 symptoms--10 symptoms were included in the Edmonton Symptom Assessment Scale (ESAS) plus 5 supplemental symptoms. Participants reported similar proportions of ESAS and supplemental symptoms. Intensity and "bothersomeness" ratings frequently differed. Brief symptom instruments only provide a limited assessment of the respondent's symptom experience. The benefit obtained from incorporating both the intensity and bothersome nature of a longer list of symptoms may outweigh the potential increase in respondent burden.