Granulocyte-colony stimulating factor in the prevention of postoperative infectious complications and sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). Protocol of a controlled clinical trial developed by consensus of an international study group. Part three: individual patient, complication algorithm and quality manage.

GENERAL DESIGN: Presentation of a new type of a study protocol for evaluation of the effectiveness of an immune modifier (rhG-CSF, filgrastim): prevention of postoperative infectious complications and of sub-optimal recovery from operation in patients with colorectal cancer and increased preoperative risk (ASA 3 and 4). A randomised, placebo controlled, double-blinded, single-centre study is performed at an University Hospital (n = 40 patients for each group). This part presents the course of the individual patient and a complication algorithm for the management of anastomotic leakage and quality management. OBJECTIVE: In part three of the protocol, the three major sections include: The course of the individual patient using a comprehensive graphic display, including the perioperative period, hospital stay and post discharge outcome. A center based clinical practice guideline for the management of the most important postoperative complication--anastomotic leakage--including evidence based support for each step of the algorithm. Data management, ethics and organisational structure. CONCLUSIONS: Future studies with immune modifiers will also fail if not better structured (reduction of variance) to achieve uniform patient management in a complex clinical scenario. This new type of a single-centre trial aims to reduce the gap between animal experiments and clinical trials or--if it fails--at least demonstrates new ways for explaining the failures.

Granulocyte colony-stimulating factor (G-CSF) transiently suppresses mitogen-stimulated T-cell proliferative response.

Granulocyte colony-stimulation factor (G-CSF) is a cytokine that selectively promotes growth and maturation of neutrophils and may modulate the cytokine response to inflammatory stimuli. The purpose of this study was to examine the effect of G-CSF on ex vivo peripheral blood mononuclear cell (PBMC) functions. Ten patients with breast cancer were included in a clinical trial in which r-metHuG-CSF was administered daily for 5 days to mobilize peripheral blood stem cells. Ten healthy women were also included as controls. Our data show that G-CSF treatment induces an increase in peripheral blood leucocyte, neutrophil, lymphocyte and monocyte counts. We have found a modulation in the percentages of CD19+, CD45+ CD14+, CD4+ CD45RA+ and CD4+ CD45RO+ cells in PBMC fractions during G-CSF treatment. We have also found a significant reduction in the proliferative response of PBMC to mitogenic stimulation that reverted 14 days after the fifth and the last dose of G-CSF. Furthermore, it was not associated with significant changes in the pattern of cytokine production. The mechanism of this immunoregulatory effect is probably indirect since G-CSF receptor has not been found in T lymphocytes. This mechanism and its potential clinical applications remain to be elucidated.

Ly-1 B cells and disease activity in (New Zealand black x New Zealand white)F1 mice. Effect of total lymphoid irradiation.

The treatment of female (New Zealand black x New Zealand white)F1 mice with total lymphoid irradiation resulted in a prolonged remission of autoimmune disease activity. Total lymphoid irradiation-treated mice also showed a marked reduction of Ly-1 B cells, which lasted up to 3 months. The subsequent return of Ly-1 B cells to preirradiation levels was not associated with a simultaneous return of disease when measured by parameters such as IgG anti-DNA antibodies and spontaneous secretion of IgG by splenic cells. In cell sorting experiments, most of the cells spontaneously secreting IgG were found within the Ly-1- (CD5-) splenic B cell population.

Recognition of self class II major histocompatibility complex antigens by CD8+ T cell clones derived from rheumatoid arthritis synovial membrane.

T cells from rheumatoid synovium have been expanded in vitro as lines and clones using autologous Epstein-Barr virus-transformed stimulator cells. Both lines and clones recognized autologous class II MHC antigens in the absence of defined exogenous antigens i.e. the equivalent of the autologous mixed lymphocyte response. Surprisingly, despite their MHC specificity, several clones expressed CD8 rather than CD4, but were not cytotoxic. The function of CD8+ T cells within synovium has not previously been defined; in view of their unusual phenotype, they may exert an immuno-modulating role upon the inflammatory response within the joint, by responding to the high density of class II MHC antigens expressed in the rheumatoid synovium.

Changes in B lymphocyte function in rheumatoid arthritis and lupus nephritis after total lymphoid irradiation.

Patients with rheumatoid arthritis and patients with lupus nephritis underwent total lymphoid irradiation (TLI). Peripheral blood mononuclear cells from these patients showed a decrease in pokeweed mitogen-induced immunoglobulin secretion after TLI. A defect in non-T cells contributed to the decreased response. No defect in the response of non-T cells to T cell-independent activators of B cells, Staphylococcus aureus Cowan 1 and Epstein-Barr virus, was observed after TLI. We conclude that TLI induces a selective deficit in B cells, which respond to T cell-dependent mitogen stimulation.

Treatment of lupus nephritis with total lymphoid irradiation. Observations during a 12-79-month followup.

Seventeen patients with intractable lupus nephritis and nephrotic syndrome were treated with total lymphoid irradiation. Statistically significant improvement in mean renal disease and serologic activity parameters occurred within 3 months and persisted for at least 3 years. Although there was a marked reduction of T helper cell numbers and function after total lymphoid irradiation, recovery of these parameters was not associated with a return of disease activity. Risks of sterility, severe infections, and hematologic malignancy appeared to be lower than with alkylating agents.

Dissection of the mechanisms of immune injury in rheumatoid arthritis, using total lymphoid irradiation.

Eleven patients with intractable rheumatoid arthritis were treated with total lymphoid irradiation. After radiotherapy, there was a marked decrease in the number and function of peripheral blood helper/inducer (Leu-3+) T lymphocytes, in the spontaneous secretion of interleukin-1 by synovial biopsy specimens, and in the activity of the joint disease. In contrast, levels of IgM, IgA, and IgG rheumatoid factors and C3 concentrations in blood and synovial fluid samples did not change significantly after therapy with total lymphoid irradiation.

Inhibition of human natural killer (NK) activity by calcium channel modulators and a calmodulin antagonist.

The presence of calcium (Ca2+) in the culture medium is a requirement for the NK cytotoxic reaction. To further explore the role of Ca2+ and calmodulin (a cytoplasmic protein that mediates most of the biological effects of Ca2+) in this process, we evaluated the effects of nifedipine (a Ca2+ channel antagonist), BAY-K-8644 (a Ca2+ channel agonist), and haloperidol (an inhibitor of calmodulin) on the NK activity of human peripheral blood mononuclear cells (PBMC), and the augmentation of this activity by recombinant interleukin 2 (r-IL 2) and interferon-gamma (r-gamma-IFN). We found that all of these drugs inhibit NK activity in a dose-dependent fashion. This appears to result from interference with the programming for lysis stage of the lytic process. In contrast, the presence of these agents during the incubation of PBMC with r-IL 2 or r-gamma-IFN did not induce any change in the enhancement of NK activity. These data suggest that Ca2+ exerts its effect at the intracellular level during the NK cytotoxic process, and that the augmentation of NK activity by lymphokines is independent of the calcium-calmodulin system.