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Umbilical cord blood (UCB) is a valuable source of hematopoietic stem cells (HSCs) for use in allogeneic transplantation. Key advantages of UCB are rapid availability and less stringent requirements for HLA matching. However, UCB contains an inherently limited HSC count, which is associated with delayed time to engraftment, high graft failure rates, and early mortality. 16,16-Dimethyl prostaglandin E2 (dmPGE2) was previously identified to be a critical regulator of HSC homeostasis, and we hypothesized that brief ex vivo modulation with dmPGE2 could improve patient outcomes by increasing the "effective dose" of HSCs. Molecular profiling approaches were used to determine the optimal ex vivo modulation conditions (temperature, time, concentration, and media) for use in the clinical setting. A phase 1 trial was performed to evaluate the safety and therapeutic potential of ex vivo modulation of a single UCB unit using dmPGE2 before reduced-intensity, double UCB transplantation. Results from this study demonstrated clear safety with durable, multilineage engraftment of dmPGE2-treated UCB units. We observed encouraging trends in efficacy, with accelerated neutrophil recovery (17.5 vs 21 days, P = .045), coupled with preferential, long-term engraftment of the dmPGE2-treated UCB unit in 10 of 12 treated participants.

Objective: By using timely, high-quality information, ministries of health can identify and address priority health problems in their populations more effectively and efficiently. The Data for Decision Making (DDM) project developed a conceptual model for a data-driven health system. This model included a systematic methodology for assessing access to information to be used as a basis for improvement in national health surveillance systems., Study Design and Methods: The DDM surveillance assessment methodology was applied to six systems in five countries by staff from the US Centers for Disease Control and Prevention (CDC). Ministry of health personnel at national, regional, district and local levels were interviewed using either informal conversation or an interview guide approach, and their methods for collecting and using data were reviewed. Attributes of timeliness, accuracy, simplicity, flexibility, acceptability and usefulness were examined. Problems and their underlying causes were identified., Results: The problems preventing decision makers from having access to information are many and complex. The assessments identified no fewer than eight problem areas that impeded decision makers' access to information. The most common deficiencies were concerning the design of the system, ongoing training of personnel and dissemination of data from the system., Conclusions: To improve the availability of information to public health decision makers, it is recommended that: (a) surveillance system improvement begins with a thorough evaluation of existing systems using approaches outlined by the CDC and the Health Metric Network of the World Health Organization; (b) evaluations be designed to identify specific causes of these deficiencies; (c) interventions for improving systems be directly linked to results of the evaluations; and (d) efforts to improve surveillance systems include sustained attention to underlying issues of training and staff support. The assessment tool presented in this report can be used to facilitate this process.

As recently as 1990, there was no reservation-wide, population-based health status information about Navajo Indians. To remedy this shortcoming, the Navajo Health and Nutrition Survey was conducted from 1991 to 1992 to assess the health and nutritional status of Navajo Reservation residents using a population-based sample. Using a three-stage design, a representative sample of reservation households was selected for inclusion. All members of selected households 12 y of age and older were invited to participate. A total of 985 people in 459 households participated in the study. Survey protocols were modeled on those of previous national surveys and included a standard blood chemistry profile, complete blood count, oral glucose tolerance test, blood pressure, anthropometric measurements, a single 24-h dietary recall and a questionnaire on health behaviors. The findings from this survey, reported in the accompanying papers, inform efforts to prevent and control chronic disease among the Navajo. Lessons learned from this survey may be of interest to those conducting similar surveys in other American Indian and Alaska Native populations.

Noninsulin-dependent diabetes mellitus is a major health problem among most American Indian tribes. This is the first population-based reservation-wide study of the Navajo that has used oral glucose tolerance testing to determine diabetes status. Employing WHO criteria, we found an age-standardized prevalence of diabetes mellitus (DM) of 22.9% among persons aged 20 y and older. This prevalence is 40% higher than any previous age-standardized estimate for the Navajo and four times higher than the age-standardized U.S. estimate. More than 40% of Navajo aged 45 y and older had DM. About one third of those with DM were unaware of it, with men more likely to be unaware than women. Among persons with a medical history of DM, almost 40% had fasting plasma glucose values > or = 200 mg/dL. Persons with DM were heavier, more sedentary and more likely to have a family history of DM than were persons without DM. Persons with DM had more hypertension, lower HDL levels and higher triglyceride levels than their counterparts without DM. Insulin usage was infrequent among persons with a history of DM, and about one third of women with such a history used no medical therapy to control their diabetes. Although important measures to combat diabetes have already been undertaken by the Navajo, additional efforts are required to slow the progression of this disease and prevent its sequelae.

Coronary heart disease was uncommon among the Navajo in the past, but appears to have increased substantially over the last few decades. The 1991-1992 Navajo Health and Nutrition Survey, which included interviews and examinations of 303 men and 485 women between the ages of 20 and 91 y, is the first population-based examination of coronary heart disease risk factors in this tribe. Coronary heart disease risk characteristics were common, particularly overweight (men, 35%; women, 62%), hypertension (men, 23%; women, 14%) and diabetes mellitus (men, 17%; women, 25%). Among 20- to 39-y-olds, a large proportion of men reported that they currently smoked cigarettes (23%); use of chewing tobacco or snuff was also prevalent among these 20- to 39-y-old men (37%) and women (31%). Although serum concentrations of total cholesterol were fairly comparable to those seen in the general U.S. population, fasting serum triglyceride concentrations were high (median: men, 132 mg/dL; women, 137 mg/dL), and concentrations of HDL cholesterol were low, particularly among women (median: men, 42 mg/dL; women, 44 mg/dL). Body mass index was associated with levels of most risk factors, and, independently of the level of overweight, a truncal pattern of body fat was related to adverse lipid levels among men. A large proportion of men (20%) and women (30%) reported not having participated in physical activity during the preceding month. Lessons learned from past intervention activities among the Navajo, particularly those for diabetes, may be useful in managing these risk factors to reduce the future burden of coronary heart disease.

Cancer-screening behaviors, reproductive history, risk behaviors during pregnancy and chronic disease risk factors were examined in a representative sample of 566 Navajo women residing on the Navajo Reservation in 1991-1992. Among all women 15 y and older, 59% were overweight, 4% were current smokers, 10% currently used smokeless tobacco and 12% were anemic. Seventy-one percent of Navajo women aged 18 and older reported ever having had a Pap smear, but only 35% of women aged 50 and over reported ever having had a mammogram. Among parous women, the prevalence of having received no prenatal care for any pregnancy declined from 60% among women 60 and older to 13% among women 20-29 y of age, and the prevalence of ever having had a child born at home declined from 82 to 2%. These data suggest marked secular improvement in these pregnancy-related risk behaviors. However, data on cancer-screening behaviors indicate opportunities to improve health of Navajo women by increasing their use of mammography and Pap smear screening services.

Historically, the Navajo exhibited a low prevalence of overweight, but a number of small studies over the past few decades indicate that the prevalence is increasing. In the population-based Navajo Health and Nutrition Survey conducted in 1991-92, overweight was defined as a body mass index (BMI, kg/m2) at or above the 85th percentile (BMI > 27.8 for men, > 27.3 for women) of the Second National Health and Nutrition Examination Survey. One third of men age 20 and 39 and one half of men age 40 and 59, but fewer than 10% of men age 60 and older were overweight. Two thirds or more of women in all age groups were overweight. Nineteen percent of the participants underestimated their weight status (underweight, appropriate, overweight) relative to their BMI category and 17% overestimated their weight status. Women overestimated their weight status more often than men (P < 0.05), and participants age 20-39 overestimated their weight status more often than older participants (P < 0.001). Men and women age 60 and older preferred heavier body shape models as ideals of health more often than younger participants (P < 0.001). Nearly half of the participants, regardless of their weight status, reported that they were trying to lose weight; most reported using diet and exercise. Because overweight is an important risk factor for many chronic diseases, including diabetes mellitus, cardiovascular disease and cancer, primary prevention of overweight and weight management for adults are recommended to prevent an increase in the burden of chronic disease among the Navajo.

Diet has been implicated in the etiology of chronic diseases in many populations, including the Navajo and other American Indian tribes. This report describes the current nutrient intake of the Navajo and identifies the primary food sources of key nutrients. In the Navajo Health and Nutrition Survey, interviewers obtained single 24-h diet recalls from 946 nonpregnant participants age 12-91 between October 1991 and December 1992. Among various sex and age groups, total fat contributed 33-35% of energy and saturated fat contributed 10-11% of energy in the diets. Median fiber intake was 11-14 g/d. Median intakes of vitamin A, vitamin E, vitamin B-6, folate, calcium and magnesium were below sex- and age-specific recommended dietary allowances (RDA) for men and women of all age groups. Intake of vitamin C was below the RDA for men and women age 20 and older. Median iron intake was below the RDA for women under age 60. Fruits and vegetables were each consumed less than once per day per person, as were dairy products. Fry bread and Navajo tortillas, home-fried potatoes, mutton, bacon and sausage, soft drinks, coffee and tea provided 41% of the energy and 15-46% of the macronutrients consumed. Recommendations to increase the intake of essential micronutrients in the Navajo diet are presented.

Information about dietary behaviors, attitudes, and knowledge is important for state and local health agencies because national monitoring lacks the local representativeness and timeliness necessary to catalyze community interest and to design, target, and evaluate dietary intervention programs. Currently, however, both methods and resources are limited for surveying diet in the population of a state or community. Brief assessments are included in the Youth Risk Behavior Surveillance System for adolescents, which is conducted by state departments of education, and in the Behavioral Risk Factor Surveillance System for adults, which is operated by state departments of health. More quantitatively precise measurements are being made by a few states and communities but personnel and financial resources for such surveys are limited. Nutritionists in state and local health agencies should explore the possibility of developing public-private partnerships with food producers, retailers, and marketers to collect information about dietary determinants and behaviors in states and communities. Better standardization of dietary assessment methods is needed, as is development of better methods to identify attitudes about diet and barriers to dietary improvement. Most important, though, dietary surveillance in states and communities must be more strongly tied to intervention programs intended to improve nutrition in those populations.