Using a qualitative co-design approach to identify recommendations for improving access to medication reviews for people from ethnic minority communities

Introduction

Reviews of medication are vital to support medicine effectiveness and optimise person-centred care outcomes. However, inequalities negatively impact ethnic minority populations when accessing medicine review services.1 It is important to identify opportunities to improve access for these communities. Previous studies have demonstrated the significance of overcoming accessibility barriers, but specific detail about how best to achieve this is lacking.2,3 Through co-design workshops, this study seeks to integrate the voices of those people from ethnic minority populations to gain better insight into improving access to medicines review services for ethnic minority communities.

Aim

This qualitative, person-centred co-design study sought to build greater knowledge and understanding by involving representatives from communities whose needs may remain unmet. When considering the value that medication reviews can offer in optimising a person’s medication, this study aimed to: (i) better understand existing barriers that may impact those from ethnic minority communities when accessing services and to (ii) identify measures that may facilitate improved service accessibility for these groups.

Methods

A series of co-design workshops, with four groups of patient-stakeholders, were conducted between September-November 2021; they took place in-person or via video call whilst adhering to COVID-19 restrictions. Existing evidence-based perceptions affecting access to medicines services were critiqued and recommendations were generated to improve access for ethnic minority patients. The workshops were audio-recorded and transcribed verbatim to enable thematic analysis. QSR NVivo (Version 12) facilitated data analysis. The Health Research Authority granted ethical approval (ref: 21/HRA/1426).

Results

Twelve participants were recruited: including 8 UK citizens, 2 asylum seekers and 2 participants in receipt of residency visas. In total, 4 different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and co-create recommendations. Three recommendations were developed and centred on: (i) delivering culturally competent medicines review services; (ii) building awareness of medicines review services and how to access them; and (iii) enabling better discussions with patients from ethnic minority communities.

Discussion/Conclusion

The results have important implications for overcoming ethnic inequalities in access to medicines reviews. The data highlighted the significance of raising awareness of the medicine review services and understanding each person’s lived experiences in order to address barriers that currently affect access. Delivering medication review services with cultural competency is vital; steps should be taken to address potential language barriers and build patient-provider relationships through in-person medication reviews. Collaborative co-production approaches could enable better design, implementation and delivery of medication services that are accessible and culturally competent, in order to best meet the needs of ethnic minority communities. Steps should be taken to address knowledge gaps around cultural competence training to enable the creation of pharmacies as inclusive, person-centred healthcare settings. Methods for improving person-centred communication within pharmacies should be further explored. Close, collaborative working with individual populations could enable specific tailoring of medicines review services that best meet the needs of the community. The National Institute for Health Research Applied Research Collaboration (NIHR ARC) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualisation. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and the findings were reported, with cultural competence and sensitivity.

References

1. Robinson A, et al. A qualitative exploration of the barriers and facilitators affecting ethnic minority patient groups when accessing medicine review services: perspectives of healthcare professionals. Health Expectations, 2021. DOI: 10.1111/hex.13410.

2. Robinson A, et al. “He or she maybe doesn’t know there is such a thing as a review”: a qualitative investigation exploring barriers and facilitators to accessing medication reviews from the perspective of people from ethnic minority communities. Health Expectations, 2022. DOI: 10.1111/hex.13482.

3. Latif A, et al. A qualitative exploration to understand access to pharmacy medication reviews: views from marginalized patient groups. Pharmacy, 2020. DOI: 10.3390/pharmacy8020073.

Recommendations for community pharmacy to improve access to medication advice for people from ethnic minority communities: A qualitative person-centred codesign study

INTRODUCTION

Medicines-centred consultations are vital to support medicine effectiveness and optimize health outcomes for patients. However, inequalities negatively impact ethnic minority populations when accessing medicines advice. It is important to identify opportunities to improve access for these communities however, knowledge of how best to achieve this is lacking; this study will generate recommendations to improve access to medicines advice from community pharmacies for people from ethnic minority communities.

METHODS

A series of codesign workshops, with four groups of patient-stakeholders, were conducted between September-November 2021; they took place in-person or via video call (adhering to COVID-19 restrictions). Existing evidence-based perceptions affecting access to medicines advice were critiqued and recommendations were generated, by use of reflexive thematic analysis, to improve access for ethnic minority patients. The workshops were audio-recorded and transcribed verbatim. QSR NVivo (Version 12) facilitated data analysis.

RESULTS

Twelve participants were recruited using purposive sampling; including eight UK citizens, two asylum seekers and two participants in receipt of residency visas. In total, four different ethnic minority groups were represented. Each participant took part in a first and second workshop to share and cocreate recommendations to improve access to medicines advice in community pharmacies. Three recommendations were developed and centred on: (i) delivering and providing culturally competent medicines advice; (ii) building awareness of accessing medicines advice from community pharmacies; and (iii) enabling better discussions with patients from ethnic minority communities.

CONCLUSIONS

These recommendations have the potential to support community pharmacy services to overcome ethnic inequalities affecting medicines advice; service commissioners should consider these findings to best meet the needs of ethnic minority patients. Cultural competence training for community pharmacy staff could support the creation of pharmacies as inclusive healthcare settings. Collaborative working with ethnic minority communities could enable specific tailoring of medicines-centred services to best meet their needs.

PATIENT OR PUBLIC CONTRIBUTION

The National Institute for Health Research (NIHR) and Newcastle University Patient and Public Involvement and Engagement group had extensive input in the study design and conceptualization. Seven patient champions were appointed to the steering group to ensure that the research was conducted, and findings were reported, with cultural competence.

TRIAL REGISTRATION

Not applicable.

'He or she maybe doesn't know there is such a thing as a review': A qualitative investigation exploring barriers and facilitators to accessing medication reviews from the perspective of people from ethnic minority communities

Introduction

Regular reviews of medications, including prescription reviews and adherence reviews, are vital to support pharmacological effectiveness and optimize health outcomes for patients. Despite being more likely to report a long‐term illness that requires medication when compared to their white counterparts, individuals from ethnic minority communities are less likely to engage with regular medication reviews, with inequalities negatively affecting their access. It is important to understand what barriers may exist that impact the access of those from ethnic minority communities and to identify measures that may act to facilitate improved service accessibility for these groups.

Methods

Semi‐structured interviews were conducted between June and August 2021 using the following formats as permitted by governmental COVID‐19 restrictions: in person, over the telephone or via video call. Perspectives on service accessibility and any associated barriers and facilitators were discussed. Interviews were audio‐recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes. QSR NVivo (Version 12) facilitated data management. Ethical approval was obtained from the Health Research Authority (ref: 21/HRA/1426).

Results

In total 20 participants from ethnic minority communities were interviewed; these participants included 16 UK citizens, 2 refugees and 2 asylum seekers, and represented a total of 5 different ethnic groups. Three themes were developed from the data regarding the perceived barriers and facilitators affecting access to medication reviews and identified approaches to improve the accessibility of such services for ethnic minority patients. These centred on (1) building knowledge and understanding about medication reviews; (2) delivering medication review services; and (3) appreciating the lived experience of patients.

Conclusion

The results of this study have important implications for addressing inequalities that affect ethnic minority communities. Involving patients and practitioners to work collaboratively in coproduction approaches could enable better design, implementation and delivery of accessible medication review services that are culturally competent.

Patient or Public Contribution

The National Institute for Health Research Applied Research Collaboration and Patient and Public Involvement and Engagement group at Newcastle University supported the study design and conceptualization. Seven patient champions inputted to ensure that the research was conducted, and the findings were reported, with cultural sensitivity.

Improving the identification of patients with a genetic diagnosis of familial hypercholesterolaemia in primary care: A strategy to achieve the NHS long term plan

BACKGROUND AND AIMS

We aimed to validate a nurse-led process using electronic health records to identify those at risk of familial hypercholesterolaemia (FH) for genetic diagnosis in primary care.

METHODS

Those at risk of FH were identified using searches developed and refined locally and implemented in primary care by a trained nurse; they were invited for further assessment and genetic testing if indicated. Family members at risk of FH were identified and invited for cascade testing.

RESULTS

In total 94,444 patient records were screened (expected prevalence of FH (1 in 250); 377). Of 176 records which already had a diagnostic for FH, 15 had been genetically confirmed and one was undergoing DNA testing. A further 572 (0.61%) were identified as high risk of FH. After desktop screening, 113 (15%) were invited for further assessment. Of these, 73 individuals attended the primary care clinic (64%) of whom 61 (54%) underwent proband genetic testing. Pathogenic variants were detected in 22 cases (36%) and variants of unknown significance in a further 4 cases; a total of 26 probands (43%) were therefore referred for family cascade testing.

CONCLUSIONS

An optimised FH identification pathway, based on the NICE CG71 recommendations for systematic searching of primary care electronic health records, can be deployed successfully in primary care settings.

Community infrastructure to boost social relations: a systematic review

Background

‘Boosting social relations’ in communities has been identified as a priority UK policy-related topic. An earlier scoping review identified evidence gaps in social relations & community infrastructure. We undertook a mixed method systematic review on this topic, which has potential for immediate practical impact.

Methods

A comprehensive search included 11 databases (1997-2017), grey literature and citation checking. Studies of interventions to improve or make alternative use of community or neighbourhood places, reporting outcomes of social relations, community wellbeing & related concepts were included. Established validity checklists. Qualitative data was synthesised thematically and a narrative synthesis was produced. GRADE and CERQual approaches were used to rate the overall strength of evidence for each outcome.

Results

51 included studies, mostly of poor to moderate quality, and mostly qualitative, provided moderate evidence that: Community hubs may promote social cohesion, increase social capital and build trust, widen social networks, increase interaction, and increase knowledge or skills;Changes to neighbourhood design may positively affect sense of belonging and pride in a community;Green and blue space interventions that provide the opportunity to participate in activities or meetings may improve social interactions, increase social networks, bonding and bridging social capital, physical activity and healthy eating, and improve people’s skills and knowledge.

There were also common themes relating to facilitators and barriers to successful interventions.

Conclusions

There is moderate evidence that a range of intervention approaches to community infrastructure can boost social relations and community wellbeing. Future research should prioritise high quality evaluations using repeated measures and validated tools, and robust and credible qualitative evidence.

Key messages

There is moderate evidence that a range of intervention approaches to community infrastructure can boost social relations and community wellbeing. Community hubs may promote social cohesion, increase social capital and build trust, widen social networks, increase interaction, and increase knowledge or skills.

Corrigendum: Clinical effectiveness and cost-effectiveness of first-line chemotherapy for adult patients with locally advanced or metastatic non-small cell lung cancer: a systematic review and economic evaluation

Table 96 has been removed as it includes incorrect hazard ratios caused by a reversal of the hazard ratio calculations. However, this does not impact on any of the clinical or economic results reported.

Clinical effectiveness and cost-effectiveness of first-line chemotherapy for adult patients with locally advanced or metastatic non-small cell lung cancer: a systematic review and economic evaluation

BACKGROUND

The National Institute for Health and Care Excellence (NICE) has issued multiple guidance for the first-line management of patients with lung cancer and recommends different combinations of chemotherapy treatments. This review provides a synthesis of clinical effectiveness and cost-effectiveness evidence supporting current guidance.

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of first-line chemotherapy currently licensed in Europe and recommended by NICE, for adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC).

DATA SOURCES

Three electronic databases (MEDLINE, EMBASE and The Cochrane Library) were searched from 2001 to August 2010.

REVIEW METHODS

Trials that compared first-line chemotherapy currently licensed in Europe and recommended by NICE in chemotherapy-naive adult patients with locally advanced or metastatic NSCLC were included. Data on key outcomes including, but not limited to, overall survival (OS), progression-free survival (PFS) and adverse events (AEs) were extracted. For the assessment of cost-effectiveness, outcomes included incremental cost per quality-adjusted life-year (QALY) gained. Analyses were performed for three NSCLC subpopulations: patients with predominantly squamous disease, patients with predominantly non-squamous disease and patients with epidermal growth factor receptor (EGFR) mutation-positive (M+) status. Meta-analysis and mixed-treatment comparison methodology were conducted where appropriate.

RESULTS

Twenty-three trials involving > 11,000 patients in total met the inclusion criteria. The quality of the trials was poor. In the case of patients with squamous disease, there were no statistically significant differences in OS between treatment regimes. The mixed-treatment comparison demonstrated that, in patients with non-squamous disease, pemetrexed (Alimta®, Eli Lilly and Company; PEM) + platinum (PLAT) increases OS statistically significantly compared with gemcitabine (Gemzar®, Eli Lilly and Company; GEM) + PLAT [hazard ratio (HR) = 0.85; 95% confidence interval (CI) 0.74 to 0.98] and that paclitaxel (Abraxane®, Celgene Corporation; PAX) + PLAT increases OS statistically significantly compared with docetaxel (Taxotere®, Sanofi-aventis; DOC) + PLAT (HR = 0.79, 95% CI 0.66 to 0.93). None of the comparisons found any statistically significant differences in OS among patients with EGFR M+ status. Direct meta-analysis showed a statistically significant improvement in PFS with gefitinib (Iressa®, AstraZeneca; GEF) compared with DOC + PLAT and PAX + PLAT (HR = 0.49; 95% CI 0.33 to 0.73; and HR = 0.38; 95% CI 0.24 to 0.60, respectively). No papers related to UK decision-making were identified. A de novo economic model was developed. Using list prices (British National Formulary), cisplatin (CIS) doublets are preferable to carboplatin doublets, but this is reversed if electronic market information tool prices are used, in which case drug administration costs then become more important than drug acquisition costs. For patients with both squamous and non-squamous disease, moving from low to moderate willingness-to-pay thresholds, the preferred drugs are PAX → GEM → DOC. However, in patients with non-squamous disease, PEM + CIS resulted in increased OS and would be considered cost-effective up to £35,000 per QALY gained. For patients with EGFR M+, use of GEF compared with PAX or DOC yields very high incremental cost-effectiveness ratios. Vinorelbine (Navelbine®, Pierre Fabre Pharmaceutical Inc.) was not shown to be cost-effective in any comparison.

LIMITATIONS

Poor trial quality and a lack of evidence for all drug comparisons complicated and limited the data analysis. Outcomes and adverse effects are not consistently combined across the trials. Few trials reported quality-of-life data despite their relevance to patients and clinicians.

CONCLUSIONS

The results of this comprehensive review are unique to NSCLC and will assist clinicians to make decisions regarding the treatment of patients with advanced NSCLC. The design of future lung cancer trials needs to reflect the influence of factors such as histology, genetics and the new prognostic biomarkers that are currently being identified. In addition, trials will need to be adequately powered so as to be able to test for statistically significant clinical effectiveness differences within patient populations. New initiatives are in place to record detailed information on the precise chemotherapy (and targeted chemotherapy) regimens being used, together with data on age, cell type, stage of disease and performance status, allowing for very detailed observational audits of management and outcomes at a population level. It would be useful if these initiatives could be expanded to include the collection of health economics data.

FUNDING

The National Institute for Health Research Health Technology Assessment.

Clinical effectiveness of first-line chemoradiation for adult patients with locally advanced non-small cell lung cancer: a systematic review

BACKGROUND

The National Institute for Health and Clinical Excellence has issued guidelines on the treatment of non-small cell lung cancer (NSCLC) and recommends that patients with stage IIIA-IIIB disease who are not amenable to surgery be treated with potentially curative chemoradiation (CTX-RT). This review was conducted as part of a larger systematic review of all first-line chemotherapy (CTX) and CTX-RT treatments for patients with locally advanced or metastatic NSCLC. However, it was considered that patients with potentially curable disease (e.g. stage IIIA) are different from those with advanced disease, who are suitable for palliative treatment only, and therefore the results should be reported separately.

OBJECTIVE

To evaluate the clinical effectiveness of first-line CTX in addition to radiotherapy (RT) (CTX-RT vs CTX-RT) for adult patients with locally advanced NSCLC who are suitable for potentially curative treatment.

DATA SOURCES

Three electronic databases (MEDLINE, EMBASE and The Cochrane Library) were searched from January 1990 to September 2010.

REVIEW METHODS

Inclusion criteria comprised adult patients with locally advanced NSCLC, trials that compared any first-line CTX-RT therapy (induction, sequential, concurrent and consolidation) and outcomes of overall survival (OS) and/or progression-free survival (PFS). The results of clinical data extraction and quality assessment were summarised in tables and with narrative description. Direct meta-analyses using OS data were undertaken where possible: sequential CTX-RT compared with concurrent CTX-RT; sequential CTX-RT compared with concurrent/consolidation CTX-RT; and sequential CTX-RT compared with concurrent CTX-RT with or without consolidation. There were not sufficient data to perform meta-analysis on PFS.

RESULTS

Of the 240 potentially relevant studies that were published post 2000, 19 met the inclusion criteria and compared CTX-RT with CTX-RT. The results from the OS meta-analysis comparing sequential CTX-RT with concurrent CTX-RT appear to show an OS advantage for concurrent CTX-RT arms over sequential arms; this result is not statistically significant [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.50 to 1.25)]. The results from the OS meta-analysis comparing sequential CTX-RT with concurrent/consolidation CTX-RT appear to show a statistically significant OS advantage for concurrent/consolidation CTX-RT treatment over sequential treatment (HR 0.68; 95% CI 0.55 to 0.83). The results from the OS meta-analysis comparing sequential CTX-RT with concurrent CTX-RT with or without consolidation appear to show a statistically significant OS advantage for concurrent CTX-RT with or without consolidation over sequential treatment (HR 0.72; 95% CI 0.61 to 0.84).

LIMITATIONS

This report provides a summary and critical appraisal of a comprehensive evidence base of CTX-RT trials; however, it is possible that additional trials have been reported since our last literature search. It is disappointing that the quality of the research in this area does not meet the accepted quality standards regarding trial design and reporting.

CONCLUSIONS

This review identified that the research conducted in the area of CTX-RT was generally of poor quality and suffered from a lack of reporting of all important clinical findings, including OS. The 19 trials included in the systematic review were too disparate to form any conclusions as to the effectiveness of individual CTX agents or types of RT. The focus of primary research should be good methodological quality; appropriate allocation of concealment and randomisation, and comprehensive reporting of key outcomes, will enable meaningful synthesis and conclusions to be drawn.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Synergism between growth-factors in the control of glioma cell-proliferation, migration and invasion in-vitro

Gliomas constitute more than 50% of primary brain tumours in man. Perhaps the most important hallmark of these tumours is their diffuse invasion of the normal brain structures. The biological factors involved in the control of both their proliferation and invasion are, however, not well known. We studied the expression of receptors for epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), platelet derived growth factor (PDGF), and transforming growth factor beta-1 (TGF-beta 1) in low grade astrocytoma (IPNT-H)-, grade III astrocytoma (IPSB-18)-, and glioblastoma (IPRM-5)- derived cell lines. The effects of EGF, bFGF, PDGF, and TGF-beta 1 on proliferation, migration, and invasion in vitro were also investigated. When tested individually, EGF, bFGF and PDGF, were found to differentially stimulate proliferation, motility and invasion of the cell lines examined. When combined, these three growth factors acted synergistically to stimulate these biological properties. In addition, TGF-beta 1 exhibited positive and negative effects on the mitogenic action of the other growth factors in IPNT-H cells but inhibited their activity in IPSB-18 and IPRM-5 cells. Moreover, TGF-beta 1 was found to modulate negatively and positively the migration and invasion promoting action of the other growth factors in IPNT-H and IPSB-18 cells, while it strongly potentiated this action in IPRM-5 cells. These results suggest that all the growth factors examined may play key roles in the control of the biological properties of human glioma cells in vitro. Together with our findings that TGF-beta 1 is overexpressed in human glioblastoma in vivo, these results also suggest that co-operation between growth factors and TGF-beta 1 may be of central importance in tumour progression of gliomas.

Vascular endothelial growth-factor production is stimulated in response to growth-factors in human glioma-cells

Neovascularization is essential for tumour growth and is mediated by physiological substances produced by tumours. Vascular endothelial growth factor (VEGF) is one such potent angiogenic factor. Human gliomas, the most important class of intrinsic brain tumours, express VEGF both in vivo and in vitro. Factors involved in the control of VEGF production by glioma cells are not well known. In this study, we investigated the role of basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and platelet derived growth factors (PDGF) on VEGF production by four different glioma cell lines in vitro. With the exception of PDGF A/A and B/B in one cell line, all growth factors differentially stimulated VEGF production in all cell lines investigated. These data suggest that VEGF production in human glioma may be regulated by other growth factors which are also known to be expressed in such tumours.

Improved antigen binding by a CD20-specific single-chain antibody fragment with a mutation in CDRH1

We have prepared single-chain immunoglobulin Fv fragments from the CD20-specific hybridoma HB13d. One scFv clone demonstrated strong binding to a CD20-derived peptide by ELISA and to CD20-positive cells by flow cytometry, a second had reduced binding, and a third clone did not bind the target antigen. Sequence analysis showed that all three constructs contained shared and unique amino acid changes when compared to the nearest germline match. Molecular modelling of the scFv variants revealed that several of the mutations are located in regions predicted to contact antigen, including a mutation in the heavy chain CDR1 of the strongest binding scFv construct. No similar mutation is present in the highly conserved protein sequences of a number of CD20-specific monoclonal antibodies. BIACORE analysis demonstrated that the mutated scFv had approximately three-fold greater antigen-binding activity than another clone. Competition studies showed that the scFv is able to compete with intact CD20 monoclonal antibody for binding to the target antigen. The improved antigen binding of this scFv will permit the construction of novel CD20-specific reagents for the therapy of lymphomas.

Increased tissue factor expression predicts development of cardiac allograft vasculopathy

BACKGROUND

Cardiac allograft vasculopathy (CAV) limits the long-term success of cardiac transplantation. The incidence of CAV is increased in patients with elevated plasma levels of oxidized lipids or fibrin deposition within right heart biopsy (RHB) specimens. The present study investigated whether tissue factor (TF), the expression of which is regulated by oxidized lipids, is upregulated in patients with CAV.

METHODS AND RESULTS

A TF score was developed to quantify TF expression in RHB specimens from 63 consecutive patients undergoing routine annual posttransplantation RHB and coronary angiography. In patients >2 years (3.0+/-0.8 years) posttransplantation (n=35), a high TF score was observed with greater frequency (75% versus 26%, P<0.004) in patients with CAV than those without CAV. In patients <2 years (0.87+/-0.48 years) posttransplantation (n=28) without evidence of CAV, the TF score was determined and patients were followed up prospectively. A high TF score had a positive predictive value of 78.6% for the development of CAV, and a low TF score had a negative predictive value of 100%.

CONCLUSIONS

These data demonstrate that early TF expression predicts subsequent development of CAV. Increased TF expression could link the elevated levels of oxidized LDL and fibrin deposition known to precede CAV. These findings suggest that TF may play a role in the pathophysiology of CAV and could offer a potential prognostic tool and a novel target for the prevention of CAV, possibly with antioxidants or inhibitors of the TF pathway.

Antibody against CD20 in patients with B cell malignancy

Cancer patients may make antibodies against antigens on the surface of their malignant cells due either to the expression of unique antigens or to dysregulated responses to self antigens. Patients with B cell malignancy frequently produce autoantibodies and may therefore be a source of immunoglobulin genes for the production of phage display antibody libraries directed against tumour-associated antigens. Patients with autoimmune disease have circulating antibodies against lymphocyte surface antigens, and may also provide a good starting point for the production of a library of lymphocyte-reactive antibody structures. In this study, plasma and serum samples from patients with B cell malignancy or Sjogren's syndrome and from healthy controls were screened for antibodies against the B cell membrane antigens CD20. While the majority of samples showed very low reactivity, some individuals did show significant and reproducible binding to CD20. To identify a good donor for library construction, it would be advisable to screen donors for antibody against the antigens of interest.

Evidence against potassium as an endothelium-derived hyperpolarizing factor in rat mesenteric small arteries

1. Endothelium-derived hyperpolarizing factor (EDHF) has recently been identified as potassium released from endothelial cells into the myo-endothelial space. The present study was designed to test this hypothesis. 2. In rat small mesenteric arteries, mounted in a wire myograph, relaxation to acetylcholine or potassium was not significantly changed following incubation with oxadiazolo-quinoxalin-1-one (ODQ, 4 microM) and indomethacin (10 microM, n = 9). 3. Maximal relaxations to acetylcholine occurred in all arteries, were maintained and were significantly greater (P < 0.01, n = 9) than the transient relaxations to potassium, which only occurred in 30-40% of vessels. 4. Removal of the vascular endothelium abolished relaxant responses both to potassium and acetylcholine (P < 0.005, n = 9). 5. Compared with responses in 5.5 mM potassium PSS, relaxation responses to added potassium in arteries maintained in 1.5 mM potassium PSS were more marked and were not dependent on the presence of an intact endothelium (n = 8). 6. Incubation with BaCl2 (50 microM) significantly inhibited the maximal relaxant response to potassium in the presence of an intact endothelium in 5.5 mM potassium PSS (P < 0.05, n = 4), but had no effect on relaxation of de-endothelialized preparations in 1.5 mM potassium PSS (n = 5). 7. Treatment with ouabain (0.1 mM) abolished the relaxant response to potassium in 1.5 mM potassium PSS (P < 0.001, n = 9), but only partly inhibited the maximal relaxant response to acetylcholine in 5.5 mM potassium PSS (P < 0.01, n = 5). 8. These data show that at physiological concentrations of potassium an intact endothelium is necessary for potassium-induced relaxation in rat mesenteric arteries. Furthermore, the response to potassium is clearly different to that from acetylcholine, indicating that potassium does not mimic EDHF released by acetylcholine in these arteries.

Hyaluronic acid modulates glioma cell proliferation through its interaction with CD44H in vitro

In a recent study we showed that hyaluronic acid (HA) induces cell detachment and promotes migration and invasion of glioma cells in vitro through its interaction with the cell surface molecule CD44H. In this study, the role of HA in proliferation in eight human glioma-derived cell Lines was investigated. We demonstrate that HA exerts a dose dependent proliferative and anti-proliferative effect on glioma cells. This effect was found to be partially counteracted by a CD44H monoclonal antibody, suggesting the involvement of its high affinity receptor, CD44H and other HA receptors in this process.

Expression of vascular endothelial growth-factor in the cyst fluid of human cerebral gliomas

Vascular endothelial growth factor (VEGF) or vascular permeability factor (VPF) has been shown to play a key role in angiogenesis in several solid tumours including human brain neoplasms. Its expression has also been found to be correlated to malignancy in the major class of these tumours, gliomas. Moreover, it has been suggested that cyst fluids (CFs) associated with human gliomas may contain a permeability factor responsible for the formation of brain edema and disruption of the blood-brain barrier generally observed in these tumours. We demonstrate that VEGF is present in low and high grade gliomas of seven patients. We also show that VEGF concentration increases with increasing malignancy of the tumours. Although further cases should be investigated, these results suggest that the amount of CF-VEGF may be of value in the diagnosis of human gliomas.

Peripheral blood lymphocyte surface antigen expression and prognosis in myeloma: Australian Leukaemia Study Group Study

The Australian Leukaemia Study Group myeloma study (MM1) aimed to determine the prognostic significance of clinical and immunophenotypic markers in patients with multiple myeloma. All patients were treated with standard dose melphalan and prednisone. Seventy-four patients were entered and the median survival was 27 months. Serum beta 2-microglobulin (beta 2M) and albumin levels were the only significant clinical factors influencing survival (p = 0.007 and p = 0.008, respectively). Patients with raised levels of CD38+ lymphocytes at presentation had a significantly shorter survival than patients with normal levels (p = 0.01, logrank test, median 19 months vs 33 months). CD38 antigen expression was independent of beta 2M but patients with raised levels of CD38 had significantly lower levels of albumin than patients with normal levels (p = 0.001) which may explain their poorer survival. Salmon and Durie stage was not associated with antigen expression. No other B-cell antigens (CD10, CD19, CD20, CD21, CD22, CD23, FMC1 or FMC7) or plasma cell antigens tested (PCA-1) were found to be associated with prognosis. Patients who achieved plateau phase had a better prognosis than those who did not (p = 0.04 in a landmark analysis). Patients who achieved plateau phase following an objective response appeared to have a better prognosis than those who were in plateau phase at presentation (p = 0.09 in a landmark analysis). Light chain isotype suppression (LCIS) was not associated with a significant survival advantage and did not correlate with any known prognostic indicator.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of immunological surface antigens with survival in diffuse large cell lymphoma

The prognostic value of immunophenotyping lymphomas with a panel of monoclonal antibodies (Mab) to various lymphoid antigens was assessed by studying 47 cases of diffuse large cell lymphoma. Cell suspensions were analysed by flow cytometry after labelling by indirect immunofluorescence. Thirty-eight cases were demonstrated to be of B cell and nine of T cell phenotype. Univariate analysis demonstrated that survival was significantly longer in patients expressing higher levels of HLA-DR (p = 0.01) and normal levels of CD8 (p = 0.04) but was not significantly associated with any of the other antigens. Our results support the possible value of HLA-DR in determining the prognosis of patients with diffuse large cell lymphoma.

Hybrid biphenotypic acute leukemia with extreme hypodiploidy

A patient diagnosed as having acute lymphoblastic leukemia (L2) relapsed 4 months later and was found to have morphologic and immunologic evidence of a biphenotypic hybrid acute leukemia. Chromosome analysis at relapse showed two abnormal clones, one with marked hypodiploidy and the other with exactly double the hypodiploid clone. It is considered that this is an example of a hybrid lymphoblastic/nonlymphoblastic leukemia with unique karyotype.

Blastic transformation of chronic lymphocytic leukemia

A case is described of a patient with chronic lymphocytic leukemia whose disease underwent blastic transformation. The transformed cells had the same immunoglobulin types (mu and kappa) as the original chronic lymphocytic leukemia cells. Immunoperoxidase staining technique demonstrated that, in the transformed cells of the bone marrow, much of the immunoglobulin was intracellular. In the peripheral blood the transformed cells had dense surface immunoglobulin and features of primitive T-cells. These findings suggest that transformation to an immunoblastic type of leukemia had occurred.

Rabbit antisera to cell lines RC2a and U937: antigens expressed on human leukaemic cells of myeloid, monocyte and T-lymphocyte lineage

Rabbit antisera have been produced to an acute myelomonocytic leukaemia (AMML)-derived cell line (RC2a) and a histiocytic lymphoma derived cell line (U937) having macrophage characteristics. The antisera were screened by complement-mediated cytotoxicity and immunofluorescence (cytofluorograph analysis) against separated leukaemic (122 patients plus 13 cell lines) and normal haematologic cell populations (60 preparations from 20 donors plus 10 B-lymphoblastoid cell lines). The sera were absorbed with pooled B-lymphoblastoid cell lines including the autologous B-lymphoblastoid cell line to RC2a (CESS-B) or alternatively with B-CLL and T-CLL cells. All leukaemic cell populations were confirmed using the markers SIg, E-rosette receptor, cALL antigen, alpha-naphthyl butyrate esterase and myeloperoxidase. Rabbit anti-RC2a (Adherent cells) (RARC2a(Ad) ) and rabbit anti-U937 (RAU937) recognised antigens common to immature myeloid monocyte and T-lymphocyte lineage but did not react by cytotoxicity, absorption or cytofluorographic analysis with cells of B-lymphocyte lineage (B-lymphoblastoid or B-CLL) and reacted only occasionally with cALL patients' cells (includes pre B phenotype). These sera reacted with peripheral blood monocytes but not with other mature blood leucocytes. RAU937 reacted with a major mononuclear population from normal marrow and with more differentiated myeloid leukaemia cells. RARC2a(Ad) and RAU937 detected overlapping subgroups of myeloid leukaemia (AMoL, AMML, AML and CML) patients and Null-ALL and T-ALL patients. These subgroups are now being examined for prognostic significance.

Cell lines derived from a human myelomonocytic leukaemia

Two cell lines have been isolated from separate samples, taken at the same time, from the peripheral blood of a case of myelomonocytic leukaemia. One of these (CESS-B) is a typical B cell line obtained after treatment of the peripheral blood white cells with Epstein-Barr virus (EBV). The second line (RC-2) is a monocyte-macrophage type, originally isolated by 5 months continuous culture in the presence of colony stimulating factor (CSF). Subsequently, after further culture, this line has become autonomous (RC-2A), no longer requiring CSF for maintenance of proliferation, whilst retaining the characteristics of the original line.