Analysis of the expenses linked to hospital stays: how to detect outliers.

When hospital financing depends on a budget which in turn depends on the pathologies being treated, it is necessary to detect hospital stays which show discrepancies between the resources they consume and the medical characteristics they present. Deterministic nonparametric frontier models are used to rank hospital stays according to their expenses taking into account the severity of the patients' conditions. As these models are very sensitive to the extreme stays, a robust frontier model, the order-m frontier is used. The too-efficient stays are highlighted and described. The mean expenses are estimated after excluding too-efficient and inefficient stays. This mean is higher than the mean estimated by using classical trimming rules.

Human follicular dendritic cells in vitro and follicular dendritic-cell-like cells.

Human follicular dendritic cell (FDC)-like cells (FLC) have been utilized for the in vitro analysis of germinal center reactions. However, there is no consensus whether FLC represent FDC in vitro. The purpose of the present study has therefore been to determine distinguishing features of FDC and FLC in vitro. The expression of CD40, CD54, CD49d, cytokine (gamma-IFN and IL-4)-dependent MHC-class II, and CD106 was observed to be specific for the determination of FDC in long-term culture. The cytokine-dependent emperipolesis of germinal center B cells was establised as another discriminating property for FDC in vitro. In 2 out of 72 long-term cultures of FDC, we encountered dividing cells among the non-dividing population of FDC. The dividing cells expressed accessory molecules similar to those of FDC but showed emperipolesis only for the initial few days of their growth. FDC did not enhance the CD40-dependent proliferation of germinal center B cells; in contrast, FLC augumented it. Both types of cells produced a significant amount of cytokine-dependent IL-6. Further studies are needed to determine whether FLC originate from FDC in vitro.

Chemotaxis-promoting and adhesion properties of human tonsillar follicular dendritic cell clusters.

Lymph follicles are globular and compact due to aggregation of lymphoid cells on follicular dendritic cells (FDC). To probe the mechanisms underlying this accumulation of cells, we analyse here the role played by FDCs in attracting and binding cells. FDCs prepared from human tonsils by mild separation techniques appeared in the form of clusters (FDC clusters), where, via cytoplasmic extensions, they enveloped lymphoid cells. Using Boyden's chambers, we demonstrated that these FDC clusters produced one or more chemoattractants capable of inducing chemotaxis of lymphoid cells. Supernatants of FDC cluster cultures also exerted a chemotaxis-promoting effect. FDC clusters induced true chemotaxis, not merely chemokinesis due to cell activation. They secreted a substance or substances that stuck to the substrate (a cellulose filter) and thus induced haptotaxis. B as well as T cells were attracted, but B cells apparently required the presence of T cells to respond fully to the chemoattractant(s). Subtypes of B cells (IgD+ and IgD-) and T cells (CD4+, CD8+, CD57+ AND CD57-) were tested and all were attracted. Since purified lymphoid cells did not induce these phenomena, FDCs were suspected to do so. FDCs have been shown to establish contact with lymphoid cells. Here we have determined that CD4+ T cells adhere in greater number to FDC clusters than do CD8+ T cells. We thus propose that FDCs specifically contribute to construction of lymph follicles by attracting and determining their cell composition.

In vitro and in vivo stimulation of the murine immune system by AGM-1470, a potent angiogenesis inhibitor.

AGM-1470, a potent angiogenesis inhibitor, is already engaged in phase I clinical trials because of its effectiveness to restrain tumor growth and its lack of major side effects. Recently, we showed that AGM-1470 stimulates in vitro human B lymphocyte proliferation through T lymphocytes. These data prompted us to explore the in vivo effects of AGM-1470 on the immune system in a mouse model. In this study, we showed that AGM-1470, in synergy with phytohemagglutinin, stimulates the proliferation of murine lymphocytes isolated from lymph nodes. This effect was similar to the one observed with human lymphocytes. When injected subcutaneously or intraperitoneally into mice at pharmacological doses, AGM-1470 induced a significant increase of axillary and mesenteric lymph nodes, respectively. Histological and morphological analyses showed that this phenomenon is mostly due to a hyperplasia of the germinal centers. On average, the area of the germinal center of lymph nodes from AGM-1470-treated mice were three times larger than in lymph nodes from control mice. Interestingly, no effect was observed when AGM-1470 was injected subcutaneously into T-deficient nude mice. Our data demonstrate that AGM-1470 stimulates B cell proliferation in vivo as suggested by the in vitro experiments. This effect should be taken into account in the follow-up of patients treated with this molecule and calls for additional studies to determine the biological consequences of such a stimulation on the host immune system.

The influence of follicular dendritic cells on B-cell proliferation depends on the activation of B cells and the mitogen used.

Follicular dendritic cells (FDC) are unique non-lymphoid cells found only in lymph follicles. They play a part in the survival, proliferation and differentiation of B cells. To analyse the influence of FDC on B-lymphocyte proliferation, we isolated them from human tonsils on albumin gradients and treated them with mitomycin C to prevent the multiplication of lymphoid cells harboured in their cytoplasmic evaginations. FDC cultured for 12-16 h remained attached to the substrate; non-adherent cells were carefully eliminated by washing. Purified B cells cultured alone or with contaminant-cleared FDC were maintained for 2 days in the presence or absence of various stimulants, after which tritiated thymidine uptake by these cells was measured. In the absence of activators, FDC did not induce B-cell multiplication. B cells cultured in the presence of FDC exhibited increased 3H-TdR uptake when activated with anti-CD40 MoAb, anti-immunoglobulin MoAb or transferrin, but not when stimulated with Staphylococcus aureus strain Cowan I (SAC) at a given concentration. In the latter case, B-cell proliferation clearly decreased. In control cocultures where mitomycin-C-treated non-adherent cells were used instead of FDC in the presence of the different stimulants, no increase in B-cell proliferation was observed. The results suggest that, inside the germinal centres, FDC modulation of B-cell proliferation depends on the activation state of the B cells and on the stimulant encountered.

The potent angioinhibin AGM-1470 stimulates normal but not human tumoral lymphocytes.

BACKGROUND: AGM-1470 is a newly synthesized molecule developed as an analog of the potent anti-angiogenic fumagillin. Its efficacy in restraining tumor growth in vivo and the absence of major side effects have already led to phase I clinical trials in patients with solid cancers. However, neither the exact mechanisms of action of AGM-1470 nor its effects on the host of normal cells have been extensively studied. Recently, we showed that AGM-1470 enhanced the proliferation of B lymphocytes in the presence of T cells. Since AGM-1470 could potentially be used in patients with lymphoma, it was urgent to test the effect of the molecule on the proliferation of tumor lymphocytes. METHODS: The possible effect of AGM-1470 on the proliferation of normal or tumor lymphocytes was evaluated by thymidine-incorporated assays. Normal T and B lymphocytes were purified from human tonsils. The tumor lymphocytes used in the study were Molt 3, Molt 4 and Jurkatt cell lines for the T lineage and Daudi and Radji cell lines for the B lineage. RESULTS: As shown previously, AGM-1470 stimulates the proliferation of normal B lymphocytes through an action on normal T cells. THe angioinhibin was ineffective ont eh proliferation of both T and B transformed cells. Moreover, in the presence of the drug, tumor T cells co-cultured with normal B lymphocytes did not induce any increase in B cell proliferation, as previously observed with normal T lymphocytes. Inversely, tumor B cells co-cultured with normal T lymphocytes were insensitive to the drug. CONCLUSIONS: Our results demonstrate that AGM-1470 is ineffective on lymphoid tumor cell proliferation and could potentially be safely administered to lymphoma patients.

Human germinal center CD4+CD57+ T cells act differently on B cells than do classical T-helper cells.

We have isolated two subtypes of helper T cells from human tonsils: CD4+CD57+ cells, mostly located in the germinal center (GC), and CD4+CD57- cells, distributed through the interfollicular areas but also present in the GC. In a functional study, we have compared the capacities of these T-cell subtypes to stimulate B cells in cocultures. In order to block T-cell proliferation while maintaining their activation level, we pretreated isolated T cells with mitomycin C prior to culture in the presence of B cells and added polyclonal activators such as PHA and Con A, combined or not with IL-2. Contrary to CD4+ CD57- cells, CD4+CD57+ cells did not markedly enhance B-cell proliferation. Even when sIgD.B cells typical of germinal center cells were tested, the CD4+CD57+ cells had no significant effect. This is in accordance with the location of these cells: They mainly occupy the light zones of the GC where few B cells divide. Even when added to preactivated, actively proliferating cells, CD4+CD57 cells failed to modulate B-cell multiplication. On the supernatants of B-cell-T-cell cocultures, we examined by the ELISA technique the effect of T cells on Ig synthesis. Contrary to CD57+ T cells, whose effect was strong, CD57- T cells weakly stimulated Ig synthesis. More IgM than IgG was generally found. Because CD57 antigen is a typical marker of natural killer cells, we tested the cytolytic activity of tonsillar CD4+CD57+ cells on K562 target cells. Unlike NK cells, neither CD4+CD57+ nor CD4+CD57- cells exhibit any cytotoxicity. Thus, germinal center CD4+CD57+ cells are not cytolytic and do not strongly stimulate either B-cell proliferation or Ig secretion. CD4+CD57- cells, however, enhance B-cell proliferation and differentiation, thus acting like the classical helper cells of the T-dependent areas.

Moabs MAS516 and 5B5, two fibroblast markers, recognize human follicular dendritic cells.

Follicular dendritic cells (FDC) are only located within follicles of secondary lymphoid tissues. The origin of this peculiar cell type is not clearly defined. To contribute to this study, we applied two monoclonal antibodies (MAS516 and 5B5) considered as specific for fibroblasts to tonsil cryosections and to isolated follicular dendritic cells. On the basis of an enzyme cocktail digestion of human tonsils and a fractionation procedure on albumin gradients, FDC can be prepared in the form of cell aggregates with associated lymphoid cells. MAS516 reacts with surface membrane molecules expressed by human fibroblasts, tissue macrophages and peripheral blood monocytes. With immunoperoxidase assays on tonsil cryosections connective tissue cells and macrophages are stained. Inside germinal centres, heavy labelling of the light zone was found. The MAS516 staining pattern is very similar to that of specific FDC markers DRC-1 or BU10. All isolated FDC reacted with MAS516 antibody. 5B5, considered as a typical fibroblast marker, reacts with human prolyl-4-hydroxylase which is an intracellular enzyme related to collagen biosynthesis. In cryosections, interfollicular and capsular areas showed 5B5 positive connective tissue fibroblasts. In germinal centres, some cells presenting features of FDC were 5B5 positive. After cell separation, 25%-50% of the isolated FDC were labelled with this antibody. This positivity of some FDC for 5B5 antibody may support the idea of their fibroblastic origin. The combination of observations realized in situ and after cell purification ensured an unequivocal recognition and identification of FDC.(ABSTRACT TRUNCATED AT 250 WORDS)

AGM-1470, a potent angiogenesis inhibitor, prevents the entry of normal but not transformed endothelial cells into the G1 phase of the cell cycle.

AGM-1470 is a potent angiogenesis inhibitor that is very effective in inhibiting endothelial cell proliferation in both in vitro and in vivo models and that prevents tumor growth in vivo. Although this molecule appears to be a most promising anticancer drug, its mechanism of action has not yet been elucidated. In this study, we examined the effects of AGM-1470 on the cell cycle of normal and transformed endothelial cells. We showed that AGM-1470, at picomolar concentrations, specifically inhibits the proliferation of both bovine aortic endothelial cells and human umbilical vein endothelial cells. AGM-1470 was ineffective in significantly inhibiting the proliferation of Ea.hy926 cells, a hybrid cell line obtained by the fusion of human umbilical vein endothelial cells with a human carcinoma cell line, or cEnd.1 cells, a polyoma middle T oncogene-transformed endothelioma cell line derived from mouse embryo. Using a double labeling technique with anti-Ki67 antibodies and propidium iodide, we demonstrated, with flow cytometry analysis, that AGM-1470 specifically prevents the entry of endothelial cells into the G1 phase of the cell cycle. We also showed that AGM-1470 was ineffective in inhibiting endothelial cell migration toward laminin or capillary-like tube formation inside a type I collagen matrix induced by phorbol esters. Our data strongly suggest that AGM-1470 is a molecule that specifically inhibits a cell cycle control pathway active in normal cells but which could be bypassed or altered in transformed cells.

Ultrastructure of CD57+ cells isolated from human tonsils or blood.

The presence of CD4+, CD57+ T cells in the germinal centers has been reported by several authors. The CD57 antigen is also expressed by natural killer (NK) cells. We purified CD57+ cells from human tonsils and blood by microdissection, rosetting with sheep red blood cells and magnetic cell sorting (MACS) and examined the ultrastructural morphology of these cells. Clear differences were found in cell aspect: blood NK contained large granules which were not found in the tonsillar CD57+ cells. These latter appeared medium-sized and not fully activated. After immunolabeling, the tonsillar CD57+ cells were mainly found in the light zone of the germinal centers.