Isolation and characterization of human monoclonal autoantibodies to glutamic acid decarboxylase

Production of human monoclonal autoantibodies to glutamic acid decarboxylase M(r) 65,000 (GAD65), characterization of their isotype, binding affinity, V region sequences and competition with autoantibodies in patients' sera is described. Lymphocytes from a patient with Addison's disease who had GAD65 autoantibodies without diabetes were immortalised and fused to a mouse/human hybridoma. In addition, mouse monoclonal antibodies to GAD65 were produced using standard techniques. F(ab')2S from our monoclonals and the GAD6 mouse monoclonal were used in competition with intact monoclonals and sera from diabetic patients for binding to 125I-labelled GAD65 (amino acids 46-586). Reactivities of the human monoclonals with GAD 65,000/67,000 M(r) chimeras were also studied. Variable region genes of human monoclonals were sequenced and analysed. The human monoclonals (n = 3) had affinity constants for GAD65 of 2.2 x 10(9), 5.8 x 10(9), 1.3 x 10(10) mol/l(-1); affinities of the mouse monoclonals (n = 5) ranged from 1.1 x 10(8) to 5.4 x 10(10) mol/l(-1). The binding of each of the human monoclonals was inhibited by GAD6 F(ab')2 and the binding of GAD6 antibody was inhibited by the human monoclonal F(ab')2S suggesting that the epitopes for these antibodies were overlapping. Studies with GAD65/GAD67 chimeras indicated that the human monoclonals reacted with C-terminal epitopes. The human monoclonals, GAD6 and 3/5 mouse monoclonals inhibited serum autoantibody binding to 125I-labelled GAD65. Overall, the human monoclonals were of high affinity, reacted with C-terminal epitopes and showed evidence of antigen driven maturation; they represented only a proportion of the repertoire of autoantibodies to GAD65 in the donor's serum and in the sera of patients with type-1 diabetes.

Impact of angiotensin converting enzyme inhibition on post-coronary artery bypass interleukin 6 release

BACKGROUND

Angiotensin 1 converting enzyme (ACE) inhibitors reduce morbidity and mortality after coronary artery bypass graft surgery (CABG). This benefit may result from an anti-inflammatory action.

OBJECTIVE

To examine the effect of ACE inhibition on interleukin 6 (IL-6) concentrations after CABG.

PATIENTS AND METHODS

161 patients undergoing elective first time CABG were recruited, of whom 41 (25%) were receiving ACE inhibitor treatment; 21 patients with confounding postoperative complications were excluded. After these exclusions there were 33 patients (24%) on ACE inhibitor treatment. Plasma IL-6 was measured preoperatively and again six hours after CABG.

RESULTS

Baseline IL-6 concentrations (geometric mean (SEM)) were non-significantly lower among the patients receiving ACE inhibitors (3.7 (0.1) v 4.3 (0.1) pg/ml, p = 0.12). Overall, post-CABG IL-6 concentrations increased significantly (mean rise 177 (12) pg/ml, p < 0.0005). This response was blunted among ACE inhibitor treated patients. Median increases in IL-6 concentrations were 117 v 193 pg/ml, for treated v non-treated patients, respectively (Kruskal-Wallis, p = 0.02), with peak postoperative IL-6 concentrations lower among the subjects receiving ACE inhibitors than in untreated subjects (142 (19) v 196 (13) pg/ml, p = 0.02). The effect of ACE inhibitors remained significant after multivariate analysis (p = 0.018).

CONCLUSIONS

ACE inhibitor treatment is associated with a reduction in IL-6 response to CABG. The data suggest that this class of drug may have a direct anti-inflammatory effect, which could explain some of its clinical benefit.

X-ray crystal structure of a monoclonal antibody that binds to a major autoantigenic epitope on thyroid peroxidase

Thyroid peroxidase (TPO) catalyzes the production of thyroid hormones and is a major autoantigen in autoimmune thyroid disease (AITD). It is believed that the majority of TPO autoantibodies bind to an immunodominant region consisting of two overlapping domains. Precise location of these domains would help our understanding of the interaction between TPO and TPO autoantibodies. 4F5 is a mouse monoclonal antibody (IgG1, kappa) that reacts with high affinity (2.6 x 10(10) mol/L(-1)) with one of the major autoantigenic regions on TPO. Heavy chain genes of 4F5 were from the VH1 germline gene family, germline genes for the D region could not be assigned and the J region was from the JH2 germline. Light chain genes were from Vkappa4/5 and Jkappa2, germline gene families. The Fab fragment of 4F5 was prepared by papain digestion, purified, crystallized, and the structure solved to 1.9 A using molecular replacement. The refined structure had an R factor of 19.5% and a free R factor of 23.9%. Deduced amino acid sequence and amino acid sequence obtained from diffraction analysis were compared and used to finalize the 4F5 Fab model. Structural analysis indicated that the structure of 4F5 is that of a standard Fab and its combining site is flat and is rich in tyrosine residues. Comparison of the structure of 4F5 with that of a TPO autoantibody Fab, TR1.9 suggests that the two antibodies are unlikely to recognise the same structures on TPO.

Parathyroid hormone stimulates translocation of protein kinase C isozymes in UMR-106 osteoblastic osteosarcoma cells

Studies with antagonists have provided evidence that protein kinase C (PKC) is involved in several of the actions of parathyroid hormone (PTH) on bone. PTH increases total PKC activity in bone and bone cells. The current studies investigated whether PTH can activate specific PKC isozymes, as demonstrated by translocation of these isozymes from cytosolic to membrane fractions. The isozymes selected for study, alpha, betaI, delta, epsilon, and zeta, were shown previously by us to be present in normal osteoblasts and several osteosarcoma-derived osteoblastic cells. UMR-106 cells, a widely used osteoblastic cell line, were selected for the current study. PKC isozymes in whole cell lysates and cell fractions were visualized by western blotting; isozyme distribution was also visualized by immunofluorescence. The total amounts of the isozymes and their relative distribution between membrane and cytosolic fractions in untreated cells were stable over a range of passages (5-20 from initial plating). In untreated cells, the concentrations of PKC alpha, betaI, and zeta were higher in the cytosol, and PKC delta and epsilon were higher in the membrane fraction. Treatment with 1 or 10 nmol/L PTH for 1 or 5 min stimulated translocation of PKC alpha and betaI, with variable effects on the other isozymes. Treatment with phorbol-12,13-dibutyrate (PDBu), 1 micromol/L for 5 min, elicited similar effects to those of PTH on PKC alpha and betaI. Treatment with PDBu for 48 h resulted in a downregulation of PKC alpha, whereas a 48 h treatment with PTH did not cause downregulation. The results indicate that PTH can affect specific PKC isozymes, providing a mechanism for differential regulation of cellular actions through this pathway.

Interleukin-6 gene -174g>c and -572g>c promoter polymorphisms are strong predictors of plasma interleukin-6 levels after coronary artery bypass surgery

Interleukin-6 (IL-6) synthesized in response to diverse stimuli may play an important role in bridging the inflammatory and atherosclerotic processes. The acute-phase response after coronary artery bypass graft surgery (CABG) is associated with the induction and release of cytokines, such as IL-6. We have examined the effect of common polymorphisms in the IL-6 gene promoter (-174G>C, -572G>C, and -597G>A) on IL-6 levels after elective CABG. DNA extracted from the peripheral blood of 127 patients was amplified by polymerase chain reaction. IL-6 genotypes were resolved by gel electrophoresis after restriction enzyme digestion. Serum IL-6 was measured before surgery and in serial samples at 6, 24, 48, and 72 hours after CABG. Genotype distribution was as expected for a population in Hardy-Weinberg equilibrium for all polymorphisms. Rare allele frequencies (+/-95% CIs) were similar to those reported previously: -597A 0.36 (0.30 to 0.42), -572C 0.07 (0.04 to 0.10), and -174C 0.37 (0.31 to 0.43). The -174G>C and -597G>A genotypes were in strong allelic association (Delta=0.97, P<0.001). Baseline IL-6 levels did not significantly differ between patients with different genotypes for any polymorphism. However, 6 hours after CABG, peak IL-6 levels were significantly higher (P=0.03) in carriers of the -572C allele than in those of the -572GG genotype (355+/-67 versus 216+/-13 pg/mL, respectively) and in those with genotype -174CC compared with -174G allele carriers (287+/-31 versus 227+/-15 pg/mL, respectively; P=0.04). These effects remained statistically significant after adjusting for possible confounders, including age, sex, smoking, duration of cardiopulmonary bypass, aortic cross-clamp time, and total duration of surgery. These data demonstrate that IL-6 promoter polymorphisms influence peak IL-6 production after CABG, suggesting that these polymorphisms, which are functional in vitro, are also functional in vivo, suggesting a genetic influence on IL-6 levels after acute severe injury.

Efficacy of perioperative halo-gravity traction in the treatment of severe scoliosis in children

SUMMARY

Perioperative halo traction was used in the treatment of severe scoliosis in 19 children. Diagnoses included neuromuscular, idiopathic, and congenital scoliosis. Traction was transferable between the bed and a walker or wheelchair. Thirteen patients had prior spinal surgery, and most required osteotomy. Traction was used for 6 to 21 weeks. All patients underwent spinal fusion surgery after traction, with instrumentation used in 15 patients. Improvement was achieved in all patients. The Cobb angle improved 35% from an average 84 degrees before traction (range 63 degrees -100 degrees ) to 55 degrees preceding fusion. Trunk decompensation improved in all patients. Trunk height increased 5.3 cm in traction. Response to traction did not correlate with diagnosis, patient age, or prior surgery. There were no neurologic complications. Perioperative halo-gravity traction improves trunk balance and frontal and sagittal alignment in children with severe spinal deformity. Surgical fusion was enhanced by the improved alignment, and neurologic injury was avoided.

Cyclophosphamide and antithymocyte globulin to condition patients with aplastic anemia for allogeneic marrow transplantations: the experience in four centers

This report summarizes the experience with a conditioning regimen of cyclophosphamide and antithymocyte globulin in patients with severe aplastic anemia given HLA-matched related marrow grafts at 4 transplantation centers. Enrolled were 94 consecutive patients, of whom 87 had received multiple transfusions and 38 had failed immunosuppressive therapy. Their ages ranged from 2 to 59 years. After transplantation, 89 patients received a methotrexate/cyclosporine regimen for graft-versus-host disease (GVHD) prevention. Cyclosporine with or without prednisone was given in 4 patients, and no immunosuppression was given in 1 patient. Ninety-six percent of patients had sustained grafts, whereas 4% rejected grafts between 2 and 7 months after transplantation. Of the 4 rejecting patients, 3 are alive with successful second engraftments. Acute grade II GVHD was seen in 21% of patients, grade III in 7%, and grade IV in 1% of patients. Chronic GVHD was seen in 32% of patients, most of whom responded completely to immunosuppressive therapy. With a median follow-up of 6.0 years (range, 0.5-11.6 years), the survival rate was 88%. No unusual long-term side effects have been seen with the regimen. We conclude that the cyclophosphamide/antithymocyte globulin regimen combined with methotrexate/cyclosporine after transplantation is well tolerated and effective in heavily pretreated patients with aplastic anemia.

Quantification of growth hormone receptor extra- and intracellular domain gene expression in chicken liver by quantitative competitive RT-PCR

The very sensitive competitive reverse transcription-polymerase chain reaction (RT-PCR) was used to investigate the expression of the extracellular (GHRe) and intracellular (GHRi) parts of the growth hormone receptor (GHR) in the liver tissue of chickens. Two competitors (internal standards), pGHRi MUT and pGHRe MUT, specific to the GHRi and GHRe genes, respectively, were constructed by site-specific mutagenesis. The internal standards defined PCR products of 394 bp for the pGHRi MUT and 330 bp for the GHRe MUT. These were used as competitors to the wild-type GHRi or GHRe which defined PCR products of 382 and 328 bp, respectively. Coamplification, under standardized conditions, of the native RNA in competition with serial dilutions of the mutant RNA in the same PCR reaction followed by enzymatic digestion produced the expected sizes of internal standard cDNA and predicted target cDNA. Expression levels of GHRe and GHRi were determined from standard curves generated. The method was sensitive enough to detect expressions down to picogram levels. Applying this method, the effect of GH and T(3) injection on GHRe and GHRi mRNA expression was determined in the liver of adult female Hisex birds and 1-day-old normal and dwarf chickens. Intravenous GH injection (25 microg/kg body weight) increased plasma levels of GH in Hisex birds after 10 min but rapidly decreased at 60 min followed by an increase in T(3). GH injection significantly increased the expression of the GHRe 60 min after injection but not at 10 min, when the GH level in plasma was high. In the liver of saline-treated dwarf (dw) and nondwarf (Dw) chicks, the level of expression of GHRe was similar in both strains despite disparate levels of basal GH and T(3). However, the level of GHRi was higher in Dw than in dw chicks. Although GH levels increased in both strains after intravenous GH injection (250 microg/kg body wt), the expression of GHRe in both strains was unaffected. However, the mRNA for the GHRi was significantly depressed by injection in the Dw but unaffected in dw chicks. Intravenous injection of T(3) (0.5 and 5 microg/kg body wt) increased plasma levels in both strains but caused depression of GHRi in Dw but not in dw chicks. T(3) injections had no effect on GHRe in either Dw or dw chicks. It is concluded that the expression of the GHRe in adult chickens is GH regulated either directly or indirectly. In contrast, in 1-day-old chicks, GH or T(3) had no effects on the GHRe but regulated the expression of GHRi in Dw chicks, whereas in dwarf chicks both had no effect on GHRe or GHRi expression. It is postulated that GHRe and GHRi gene expression may be regulated by different agonists/antagonists in different strains and depending on the age of the chicken.

Reactivity of thyrotropin receptor autoantibodies with the thyrotropin receptor on western blots

Affinity purified recombinant human thyrotropin receptor (TSHR) was run on sodium dodecyl sulfate (SDS) gels and subjected to a renaturing and blotting procedure. Twenty sera from thyrotropin receptor autoantibodies (TRAb)-positive patients with a history of hyperthyroidism and 20 sera with high levels of TSH blocking activity were analyzed. Four of 20 sera with blocking-type of TRAb (i.e., TSH antagonist activity) were able to recognize the mature, fully glycosylated 120-kd form of the receptor on blots of gels run under reducing conditions. No sera recognized the 100-kd high mannose precursor form of the TSHR. Three of the four recognized a 74-kd band and 2 of the 4 recognized a 50-kd band. These bands are probably proteolytic cleavage fragments of the mature 120-kd TSHR. In the absence of reducing agent the same 4 of 20 sera described above together with a further serum sample (i.e., 5/20 in total) reacted with the 120-kd form of the receptor. No specific reaction with the TSHR was observed on Western blots with the remaining 15 sera with TSH blocking activity, nor with 20 sera from patients with a history of hyperthyroidism, nor with sera from 10 healthy blood donors, 10 Hashimoto sera (negative for TRAb) and 10 systemic lupus erythematosus sera. No clear differences were observed in the TRAb positive sera that were reactive and nonreactive on Western blots in terms of their ability to inhibit TSH binding or to immunoprecipitate 125I-labeled TSHR. Overall, our results indicate that the mature 120-kd form of the TSHR that is principally responsible for binding TSH is also responsible for binding TRAb (when this binding can be detected). These observations together with immunoprecipitation and TSH binding inhibition studies, emphasize the close relationship between the receptor's binding sites for TSH and TRAb.

Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization

BACKGROUND

Ratings by an expert panel of the appropriateness of treatments may offer better guidance for clinical practice than the variable decisions of individual clinicians, yet there have been no prospective studies of clinical outcomes. We compared the clinical outcomes of patients treated medically after angiography with those of patients who underwent revascularization, within groups defined by ratings of the degree of appropriateness of revascularization in varying clinical circumstances.

METHODS

This was a prospective study of consecutive patients undergoing coronary angiography at three London hospitals. Before patients were recruited, a nine-member expert panel rated the appropriateness of percutaneous transluminal coronary angioplasty (PTCA) and coronary-artery bypass grafting (CABG) on a nine-point scale (with 1 denoting highly inappropriate and 9 denoting highly appropriate) for specific clinical indications. These ratings were then applied to a population of patients with coronary artery disease. However, the patients were treated without regard to the ratings. A total of 2552 patients were followed for a median of 30 months after angiography.

RESULTS

Of 908 patients with indications for which PTCA was rated appropriate (score, 7 to 9), 34 percent were treated medically; these patients were more likely to have angina at follow-up than those who underwent PTCA (odds ratio, 1.97; 95 percent confidence interval, 1.29 to 3.00). Of 1353 patients with indications for which CABG was considered appropriate, 26 percent were treated medically; they were more likely than those who underwent CABG to die or have a nonfatal myocardial infarction--the composite primary outcome (hazard ratio, 4.08; 95 percent confidence interval, 2.82 to 5.93)--and to have angina (odds ratio, 3.03; 95 percent confidence interval, 2.08 to 4.42). Furthermore, there was a graded relation between rating and outcome over the entire scale of appropriateness (P for linear trend=0.002).

CONCLUSIONS

On the basis of the ratings of the expert panel, we identified substantial underuse of coronary revascularization among patients who were considered appropriate candidates for these procedures. Underuse was associated with adverse clinical outcomes.

A comparison of allogeneic bone marrow transplantation, autologous bone marrow transplantation, and aggressive chemotherapy in children with acute myeloid leukemia in remission

Intensive, myelosuppressive therapy is necessary to maximize outcomes for patients with acute myeloid leukemia (AML). A comparison was made of 3 aggressive postremission approaches for children and adolescents with AML in a randomized trial, CCG-2891. A total of 652 children and adolescents with AML who achieved remission on 2 induction regimens using identical drugs and doses (standard and intensive timing) were eligible for allocation to allogeneic bone marrow transplantation (BMT) based on matched related donor status (n = 181) or randomization to autologous BMT (n = 177) or to aggressive high-dose cytarabine-based chemotherapy (n = 179). Only 115 patients (18%) refused to participate in the postremission phase of this study. Overall compliance with the 3 allocated regimens was 90%. At 8 years actuarial, 54% +/- 4% (95% confidence interval) of all remission patients remain alive. Survival by assigned regimen ("intent to treat") is as follows: allogeneic BMT, 60% +/- 9%; autologous BMT, 48% +/- 8%; and chemotherapy, 53% +/- 8%. Survival in the allogeneic BMT group is significantly superior to autologous BMT (P =.002) and chemotherapy (P =.05); differences between chemotherapy and autologous BMT are not significant (P =.21). No potential confounding factors affected results. Patients receiving intensive-timing induction therapy had superior long-term survival irrespective of postremission regimen received (allogeneic BMT, 70% +/- 9%; autologous BMT, 54% +/- 9%; chemotherapy, 57% +/- 10%). Allogeneic BMT remains the treatment of choice for children and adolescents with AML in remission, when a matched related donor is available. For all others, there is no advantage to autologous BMT; hence, aggressive nonablative chemotherapy should be used.

The buck stops where? Contracting, service delivery and the challenge to provide responsive services

This paper discusses the impact of contract-based purchasing on the delivery of social and health services to families in New Zealand. The paper arose out of research conducted by the authors into the effectiveness of certain human service interventions. It begins with an outline of the agency in which the research took place. It presents a brief overview of the development of contracting and then considers four key issues raised by this development from both the international literature and from the authors' experience of researching a social service agency. These issues are: defining what is to be purchased, accountability mechanisms, specificity/fragmentation and partial funding. The paper identifies that central components of the first two issues are informational, the third is about control and the fourth is about reducing government spending and extending state control over the activities of the not-for-profit sector.

Epitope analysis of the human thyrotropin (TSH) receptor using monoclonal antibodies

A panel of thyrotropin (TSH) receptor (TSHR) monoclonal antibodies (mAbs), produced using highly purified Chinese hamster ovary (CHO) cell-produced TSHR, has been used to study TSHR structure. All 41 mAbs recognized full-length TSHR containing complex carbohydrate (120 kDa), and 40 mAbs recognized full-length precursor-containing high mannose sugars (100 kDa). The mAbs also recognized TSHR cleavage products with three types of reactivity: type 1 mAbs reacting with bands at 70 kDa and 58 kDa, type 2 with bands at 70 kDa and 52 kDa, and type 3 with bands at 52 kDa and 40 kDa. Deglycosylation studies showed that the 70-kDa and 58-kDa bands contained complex carbohydrate, whereas the 52-kDa and 40-kDa bands were unglycosylated. These results are consistent with TSHR cleavage occurring at two sites. Cleavage at both sites gives rise to glycosylated A subunit (58 kDa) corresponding to the extracellular domain of the receptor and nonglycosylated B subunit (40 kDa) corresponding to the C-terminal transmembrane domain. Cleavage only at site 1 gives rise to the 58-kDa A subunit and a large B subunit (52 kDa). Cleavage only at site 2 gives rise to a large A subunit (70 kDa) and the B subunit (40 kDa). Four of the mAbs inhibited 125I-labeled TSH binding to solubilized full-length TSHR. TSH binding was inhibited by (a) two type 3 mAbs reactive with the N-terminal region of the B subunit (epitopes between amino acids 381 and 385 and between 380 and 418, respectively) and (b) two type 2 mAbs reactive with epitopes on the A subunit (between amino acids 246 and 260). These results together with previous studies on the direct binding of TSH to the TSHR A subunit suggest that at least two distinct regions of the TSHR sequence, including one region on the A subunit and one region on the B subunit, fold together to form part of a complex TSH binding site.

Getting to the heart of the matter: making meaning--three challenges for family researchers

This article explores three of the challenges that qualitative researchers face when working in the family health and well-being field. It is based on the authors' experiences of an ongoing research program that involves research in a human services organization and a family-focused community study. The authors discuss three challenges in the context of this experience and highlight the ways in which they have resolved them within this research program. The first challenge centers on forming research questions. The second challenge concerns access and reciprocity. The final challenge involves research partnerships and teams. Partnerships can take many different forms and hold much potential in qualitative research. Participants can become research partners, or they can maintain more traditional roles as providers of information. Deciding which role participants should have and how to manage the resultant relationships become important tasks in qualitative research because of the intense levels of involvement that often characterize these sorts of research programs.

A randomised controlled trial of flexibility in routine antenatal care

OBJECTIVE

To assess changes in satisfaction associated with a flexible approach to antenatal care schedules offered to women at low obstetric risk.

DESIGN

Randomised controlled trial.

SETTING

Eleven primary care centres providing midwifery care in Avon.

PARTICIPANTS

Six hundred and nine women at low risk of obstetric complications presenting for antenatal care.

METHODS

A standard antenatal care schedule ('traditional care') was compared with a schedule based on a minimum number of visits and additional visits with timing agreed between women and midwives ('flexible care').

MAIN OUTCOME MEASURES

Women's attitudes to pregnancy and motherhood using a subscale of the Maternal Adjustment and Maternal Attitudes scale, satisfaction with antenatal care, and perception of the speed of recognition of antenatal complications.

RESULTS

There was no difference between the two groups in terms of attitudes to pregnancy and motherhood (mean difference on Maternal Adjustment and Maternal Attitudes scale -0.64, 95% CI -1.39 to 0.11, P = 0.068) and no difference in the proportions of women reporting antenatal problems as soon as possible (traditional group 74.5%, flexible group 76.4%, difference -2%, 95% CI -12.1 to 8.2, P = 0.70). Women receiving traditional care reported higher levels of satisfaction for the care provided by community midwives (P < 0.01). Women receiving flexible care were more likely to report having a choice over the number and timing of their antenatal visits (P < 0.001), but were also more likely to report that they would like to have been seen more often (P < 0.01). There was no difference between the groups in rates of obstetric complications.

CONCLUSIONS

An imposed reduction in antenatal visits has been reported to increase dissatisfaction in other studies. In this study, encouraging women to adopt a flexible approach to antenatal care resulted in a similar finding. Successful implementation of such approaches may depend on more careful selection of women who welcome such an approach, more encouragement to pregnant women to express their own needs and greater feelings of commitment on the part of the care providers.

Distributive and procedural justice in seven nations

The paper examines the impact of distributive justice and procedural justice variables on judgments in seven countries (Bulgaria, France, Hungary, Poland, Russia, Spain, and the United States). Subjects were presented with each of two experimental vignettes: one in which the actor unsuccessfully appeals being fired from his job and one in which the actor unsuccessfully goes to an employment agency to seek a job; they were asked to rate the justness of the outcome and how fairly the actor had been treated. The vignettes manipulated deservingness and need of the actor (distributive justice factors) and impartiality and voice in the hearing (procedural justice factors). Four hypotheses were tested: first, a distributive justice hypothesis that deservingness would be more important than need in these settings; second, a procedural justice hypothesis that the importance of voice and impartiality vary depending on the nature of the encounter and the forum in which it is resolved; third, because of their recent socialist experience, Central and Eastern European respondents make greater use of need information and less use of deservingness information than Western respondents; and fourth, that distributive justice and procedural justice factors interact. The distributive justice hypothesis is supported in both vignettes. The procedural justice hypothesis receives some support. Impartiality is more important in the first vignette and voice is more important in the second vignette. The interaction hypothesis was not supported in the first vignette, but does receive some support in the second vignette. The cultural hypothesis is not supported in either vignette. The implications for distributive and procedural justice research are discussed.

The views and anticipated needs of women in early pregnancy

OBJECTIVE

To assess the expectations of antenatal care of pregnant women at the outset of pregnancy.

DESIGN

Questionnaire study within a randomised controlled trial, comparing traditional antenatal care with a more flexible schedule.

SETTING

Eleven primary care centres providing midwifery care in Avon.

POPULATION

Five hundred and ninety-three pregnant women at low risk of obstetric complications presenting for antenatal care.

METHODS

A questionnaire was completed by women who agreed to participate in the trial shortly after antenatal booking. The questionnaire explored women's views on their attitudes to pregnancy and antenatal care, the locus of control related to pregnancy, the planning of the pregnancy and expectations of care.

MAIN OUTCOME MEASURES

Comparisons between nulliparous and multiparous women in terms of their views of antenatal care, and their stated preference for a particular package of care.

RESULTS

There was no difference in their views of pregnancy as an event entailing risk. On a locus of control scale that measured women's perceptions of factors which might affect their babies' health, nulliparous women rated antenatal care higher than multiparous women (P = 0.0001). However, this was not associated with any difference between the two groups in their stated preference for traditional or flexible care. Approximately half of the women expressed no preference, and of those who did 61% would opt for traditional care. Almost one-fifth of the whole sample welcomed the idea of flexible care.

DISCUSSION

These data support the evidence of previous studies that there remains a strong desire among pregnant women to receive a 'traditional' pattern of care, even among those who have previously experienced normal pregnancy. However, a minority can be identified at the outset of pregnancy who may welcome a change to a more flexible pattern of care.

Regulation of secretion of PTHrP by Ca(2+)-sensing receptor in human astrocytes, astrocytomas, and meningiomas

Parathyroid hormone-related protein (PTHrP) is the major mediator of the humoral hypercalcemia of malignancy and of malignant osteolysis associated with skeletal metastases of common epithelial cancers. PTHrP secretion is regulated by the extracellular calcium concentration ([Ca(2+)](o)) in several types of normal and malignant cells. Because the [Ca(2+)](o)-sensing receptor (CaR) is a key mediator of [Ca(2+)](o)-regulated hormone secretion [e.g., of parathyroid hormone (PTH) by parathyroid chief cells], we investigated the expression of the CaR and PTHrP in normal and neoplastic glial cells and studied the effects of [Ca(2+)](o) on PTHrP secretion. Our results show that primary embryonic human astrocytes (HPA) express CaR mRNA and protein as detected by RT-PCR and Western analysis, respectively. Furthermore, astrocytomas and meningiomas also express the CaR at similar levels as assessed by RT-PCR and Northern and Western blot analyses. HPA and astrocytomas express transcripts encoding all three known isoforms of PTHrP [PTHrP(139), PTHrP(141), and PTHrP(173), comprising 139, 141, and 173 predicted amino acid residues, respectively] as assessed by RT-PCR, whereas meningiomas express only the first two of these. Finally, elevated levels of [Ca(2+)](o) and other polycationic CaR agonists dose dependently stimulate PTHrP secretion from HPA, astrocytomas, and meningiomas, although both basal and high [Ca(2+)](o)-stimulated rates of PTHrP secretion are approximately 2. 5-fold higher in HPA than in the glial tumors studied here. Therefore, our results show that HPA, astrocytomas, and meningiomas express both the CaR and PTHrP and that CaR agonists stimulate PTHrP secretion.

Management of tuberculosis. Choosing an effective regimen and ensuring compliance

Management of active TB requires a team approach. All patients newly diagnosed with TB should be tested for HIV infection. Currently available anti-TB drug regimens are well tolerated and highly effective. Directly observed therapy has shown improved survival and decline in the rate of new cases of active TB. In suspected or proven drug-resistant TB, the regimen should be individualized in consultation with a specialist experienced in MDR TB. Primary care physicians play a pivotal role in reducing morbidity and emergence of drug resistance through early diagnosis and prompt initiation of an effective regimen under directly observed therapy.

Concordance of the toxicity of pharmaceuticals in humans and in animals

This report summarizes the results of a multinational pharmaceutical company survey and the outcome of an International Life Sciences Institute (ILSI) Workshop (April 1999), which served to better understand concordance of the toxicity of pharmaceuticals observed in humans with that observed in experimental animals. The Workshop included representatives from academia, the multinational pharmaceutical industry, and international regulatory scientists. The main aim of this project was to examine the strengths and weaknesses of animal studies to predict human toxicity (HT). The database was developed from a survey which covered only those compounds where HTs were identified during clinical development of new pharmaceuticals, determining whether animal toxicity studies identified concordant target organ toxicities in humans. Data collected included codified compounds, therapeutic category, the HT organ system affected, and the species and duration of studies in which the corresponding HT was either first identified or not observed. This survey includes input from 12 pharmaceutical companies with data compiled from 150 compounds with 221 HT events reported. Multiple HTs were reported in 47 cases. The results showed the true positive HT concordance rate of 71% for rodent and nonrodent species, with nonrodents alone being predictive for 63% of HTs and rodents alone for 43%. The highest incidence of overall concordance was seen in hematological, gastrointestinal, and cardiovascular HTs, and the least was seen in cutaneous HT. Where animal models, in one or more species, identified concordant HT, 94% were first observed in studies of 1 month or less in duration. These survey results support the value of in vivo toxicology studies to predict for many significant HTs associated with pharmaceuticals and have helped to identify HT categories that may benefit from improved methods.

Domiciliary midwifery support in high-risk pregnancy incorporating telephonic fetal heart rate monitoring: a health technology randomized assessment

We conducted a health technology assessment of the care of women with high-risk pregnancies in the South Wales valleys. Women in the control arm were intended to receive conventional care with standard midwifery visits. Women in the intervention arm received additional or longer visits and domiciliary fetal heart rate telemonitoring. Eighty-one mothers were randomized. There were significant differences in midwifery intervention resources between domiciliary and control groups, with the former receiving a mean of 3.7 visits lasting 33.5 min, compared with 1.4 visits lasting 12.8 min for the latter. There were slightly more spontaneous labours and fewer Caesarean sections in the domiciliary group. Maternal satisfaction and anxiety were high in both groups. Domiciliary care increased the service costs by 21.02 Pounds per woman in terms of extra midwife travel and visiting time, and by a further 18.38 Pounds per woman in home monitoring equipment costs. This, however, was more than offset by health service savings from fewer clinic visits (35.60 Pounds) and fewer clinic ultrasound scans (9.01 Pounds). Adding the reductions in lost productivity to women and their partners (34.51 Pounds) suggests that domiciliary care was cheaper than conventional care, even if it did not greatly reduce inpatient days (a reduction nonetheless saving 184.24 Pounds). While clinical processes were similar in both groups, there were useful practical advantages and savings for patients and the health service from the domiciliary intervention.

Treatment of chronic myelomonocytic leukaemia by allogeneic marrow transplantation

We evaluated the outcome of allogeneic bone marrow transplantation (BMT) in 21 patients with chronic myelomonocytic leukaemia (CMML) who were treated at the Fred Hutchinson Cancer Research Center between 1990 and 1998. There were 11 male and 10 female patients with a median age of 47.4 years (range 1.0-62.9). Patients were conditioned either with total body irradiation (TBI) and chemotherapy, with or without antithymocyte globulin (n = 19), or with chemotherapy alone (n = 2). The marrow donor was an HLA-identical sibling in 12 patients, an HLA-non-identical related donor in three patients and an unrelated volunteer donor in six patients. All evaluable patients achieved sustained engraftment. Fifteen patients developed grades II-IV acute graft-versus-host disease (GVHD). Nine patients (43.0%) are surviving disease free at 0.7-8.1 years (median 6.9) after transplantation. Five patients relapsed 75-660 d after transplant and all died. Five patients died with organ failure and two died with GVHD and associated infections. The Kaplan-Meier estimates of disease-free survival and relapse at 3 years were 39% and 25% respectively. The probability of survival was improved in patients with shorter disease duration compared with those with a long interval from diagnosis to BMT. Thus, as with other myeloproliferative diseases or myelodysplastic syndromes, BMT offers curative therapy for a proportion of patients with CMML. We suggest that patients with CMML who have a suitable donor should be considered for transplantation, probably early in their disease course. However, it will be important to develop new regimens with enhanced antileukaemic efficacy without further increasing regimen-related toxicity and mortality.