Tackling child health inequalities due to deprivation: using health equity audit to improve and monitor access to a community paediatric service

BACKGROUND

Deprived children constitute a large population with high levels of ill health, and difficulty with access to healthcare contributes to their poor health outcomes. There is debate on how best to engage deprived families and the literature on differential access to paediatric care based on deprivation is limited.

AIMS

To demonstrate that community paediatrics can contribute to reduction of health inequalities by providing services that are accessible to and preferentially used by children whose health is likely to be affected by deprivation. To provide a template for others to improve and monitor equity in their services.

METHOD

Long-term service reconfiguration and health equity audit. We used routinely collected activity data and the Indices of Multiple Deprivation to construct equity profiles of the children using our service, and compared these with the profile of the population aged 0-16 years in the geographical area covered by the service.

RESULTS

The new patient contact rate for the most deprived children in the population was more than three times that of the least deprived [odds ratio (OR) 3.29, 95% confidence interval (CI) 2.76-3.93]. Deprived children were more than twice as likely to require multi-agency meetings as part of their medical care (OR 2.28, 95% CI 1.94-2.69). Seventy per cent (3693/5312) of our total contacts were with children in the two most deprived quintiles. There was a marked socio-economic gradient in all types of contact.

CONCLUSIONS

The model of care used by our community paediatric service successfully engages deprived families, thereby reducing health inequalities due to poor access. Key features are multi-agency working, removing barriers to access, raising staff awareness and use of health equity audit. Our findings provide support for tackling health inequalities via health services that are available to all, but capable of responding proportionately according to level of need, a model recently described as proportionate universalism.

Myeloid-derived suppressor cells impair the quality of dendritic cell vaccines

Myeloid-derived suppressor cells (MDSC) are important regulators of the immune system and key players in tumor-induced suppression of T-cell responses. CD14+HLA-DR-/low MDSC have been detected in a great number of malignancies, including melanoma. MDSC are known to be impaired in their ability to differentiate along the myeloid lineage, e.g., into dendritic cells (DC). This is a concern for utilization of monocyte-derived DC for vaccination of patients with melanoma or other cancers exhibiting accumulation of CD14+ MDSC. When producing DC according to standard operating procedures of two currently ongoing clinical trials, we found that MDSC co-purified with monocytes isolated by elutriation. MDSC frequencies did not affect yield or viability of the produced DC, but induced a dose-dependent decrease in DC maturation, ability to take up antigen, migrate and induce T-cell IFNγ production. Changes in DC characteristics were most notable when 'pathological' frequencies of >50% CD14+HLA-DR- cells were present in the starting culture. The impaired DC quality could not be explained by altered cytokine production or increased oxidative stress in the cultures. Tracking of HLA-DR- cells throughout the culture period revealed that the observed changes were partially due to the impaired maturation and functionality of the originally HLA-DR- population, but also to their negative effects on HLA-DR+ cells. In conclusion, MDSC could be induced to differentiate into DC but, due to the impairment of overall DC vaccine quality when >50% HLA-DR- cells were present in the starting culture, their removal could be advisable.

Development of a dendritic cell-based vaccine for chronic lymphocytic leukemia

Evidence for the existence of CLL-specific antigens recognized by the immune system can be gathered from the observation that many patients display monoclonal or oligoclonal expansions and skewed repertoire of T cells. In vitro functional studies have shown that tumor-specific T-cells are able to lyse the leukemic cells. Antileukemic cellular immunity may be boosted in vivo using dendritic cell-based immunotherapy. Our preclinical studies provide evidence that DC that had endocytosed apoptotic CLL cells (Apo-DC) were superior to fusion hybrids, tumor lysate or RNA in eliciting antileukemic T-cell responses in vitro. We have validated a method for enriching the small number of monocyte precursors present in the peripheral blood of CLL patients and utilize them for generating individualized, Apo-DC cellular vaccines. In most cases, a minimum of 50 x 10(6) Apo-DC could be generated, beginning with immunomagnetically enriched monocytes from a single leukapheresis product containing at least 1% CD14+ cells. Cryopreservation and thawing did not affect the phenotype or the T cell stimulatory function of Apo-DC. A phase I/II, open label clinical trial examining the feasibility, safety and immunogenicity of Apo-DC vaccination has been initiated. CLL patients receive 10(7) Apo-DC for at least five immunizations and monitored clinically and immunologically for 52 weeks. Three cohorts are accrued stepwise. Cohort I receives Apo-DC alone; Cohort II: Apo-DC+ repeated doses of low-dose GM-CSF; Cohort III: low-dose cyclophosphamide followed by Apo-DC + GM-CSF.

Early mother-infant reciprocity

By three weeks of age, the human neonate demonstrates behaviours which are quite different with an object and with a human interactant. He also demonstrates an expectancy for interaction with his caregiver which has clearly defined limits, as demonstrated behaviourally. In microanalysis of videotape, we saw regularly a set of interactive behaviours which were demonstrable in optimal face-to-face interaction between infants and their mothers. All parts of the infant's body move in smooth circular patterns as he attends to her. His face-to-face attention to her is rhythmic with approach-withdrawal cycling of extremities. The attention phase and build-up to her cues are followed by turning away and a recovery phase in a rhythm of attention-non-attention which seems to define a cyclical homeostatic curve of attention, averaging several cycles per minute. When she violates his expectancy for rhythmic interaction by presenting a still, unresponsive face to him, he becomes visibly concerned, his movements become jerky, he averts his face, then attempts to draw her into interaction. When repeated attempts fail, he finally withdraws into an attitude of helplessness, face averted, body curled up and motionless. If she returns to her usual interactive responses, he comes alive after an initial puzzled period, and returns to his rhythmic cyclical behaviour which has previously characterized their ongoing face-to-face interaction. This attentional cycling may be diagnostic of optimal mother-infant interactions and seems not to be present in more disturbed interactions.

Generation of DC-based vaccine for therapy of B-CLL patients. Comparison of two methods for enriching monocytic precursors

BACKGROUND

The generation of Ag-loaded DC under good manufacturing practice (GMP) conditions is logistically challenging and further compounded when the starting precursors need to be purified from B-CLL patients who have overwhelming numbers of circulating B-CLL cells and decreased numbers of monocytes.

METHODS

We have previously demonstrated that DC with endocytosed B-CLL apoptotic bodies are powerful stimulators of anti-leukemic T cells. In this study we compared counterflow elutriation and immunomagnetic separation for enriching monocyte precursors, and evaluated the feasibility of generating DC from B-CLL patients and the effects of cryopreservation.

RESULTS

Monocyte yield from a single leukapheresis product of a B-CLL patient varied from 1 x 108 to 10 x 108 total cells, from which 40-200 x 106 mature DC could be produced. Adequate numbers of monocytes could not be enriched from one patient with 0.2% monocytes in the leukapheresis product, and the target of 50 x 106 DC was barely achieved in another patient with 0.9% monocytes in the pheresed cells. These results suggested that successful production of DC is dependent on a minimum frequency of 1% CD14(+) monocytes in the leukapheresis product. Cryopreservation of tumor cell-loaded DC yielded a recovery rate of 86+/-4.4% upon thawing, with a total viability of 90+/-2.8%. Most importantly, cryopreserved Ag-loaded DC retained their morphology, phenotype and function.

DISCUSSION

The results demonstrate that adequate numbers of functional DC required for clinical therapy can be generated from patients who have >1% of CD14(+) monocytes in the leukapheresis product. Moreover, Ag-loaded DC can be cryopreserved and recovered without significant change in phenotype or function.

Effects of human plasma proteins on maturation of monocyte-derived dendritic cells

Dendritic cells (DC) are a promising tool for vaccine therapy due to their unique properties as antigen presenting cells and their ability to prime naïve T cells. Increasing evidence suggests that maturation stage of DC critically influences the fate of the immune response. Generation of monocyte-derived DC for clinically applicable immunotherapy requires the use of well-defined components and stringent culture conditions. An alternative strategy is to use human autologous serum. However, its constituents are not stable and reflect the inflammatory condition of the donor. In order to investigate whether DC properties are influenced by proteins present in the plasma, we matured human monocyte-derived DC with four main plasma components: fibrinogen, fibronectin, plasminogen or C-reactive protein. These purified proteins were added at various concentrations on day 6 after the initial differentiation induced by IL-4 and GM-CSF. The maturation was assessed by phenotyping of maturation-associated marker (CD83) and co-stimulatory molecule CD86 as well as IL-12 production. Functional properties of DC were assessed by endocytic activity and mixed leukocyte culture. Our results indicate that fibrinogen had DC-maturation effect comparable to poly-I:C, TNF-alpha and PGE(2) as a positive control, but it failed to induce IL-12 production. The other plasma proteins had no effect on DC maturation. CRP at high concentration had rather inhibitory effect on DC induced lymphocyte function. We conclude that none of the tested plasma components and acute phase proteins sufficiently induce fully competent mature DC. This finding is important for the preparation of human DC-based vaccines supplemented by autologous sera.

Mucosal and systemic anti-HIV responses in rhesus macaques following combinations of intranasal and parenteral immunizations

There is an urgent need to develop vaccines that can elicit immunological memory responses against HIV. Using the rhesus macaque model and a combination of intranasal (IN) and parenteral immunizations with DNA or protein adsorbed to microparticles or mixed with mucosal adjuvants we sought to induce anti-HIV memory-type immune responses in both the mucosal and systemic compartments. Prime/boost immunizations were performed through five IN immunizations alone with HIV-env oligomeric gp140 (Ogp140) or HIV-gag-p24 mixed with Escherichia coli heat labile-derived mutant adjuvants or two parenteral immunizations with DNA encoding HIV-env or -gag adsorbed to microparticles followed by three IN immunizations with p24 gag protein and the mutant adjuvants. Both modes of immunizations induced anti-gp140 plasma and vaginal IgG and IgA as well as interferon (IFN)-gamma secreting peripheral blood mononuclear cells (PBMC) after HIV-env and -gag peptide restimulation. After a resting period of 4 months, when the levels of humoral and cellular responses had decreased, intramuscular (IM) booster immunizations with p55-gag protein adsorbed to microparticles and Ogp140 in MF59 oil in water emulsion significantly enhanced anti-HIV plasma and vaginal antibody, as well as peripheral blood IFN-gamma responses in all groups of vaccinated macaques. Importantly, plasma neutralization activity against both homologous and heterologous HIV strains was observed in all groups following the IM booster immunizations with protein. These findings show that IN priming alone or combinations of parenteral and IN immunizations followed by IM booster immunizations hold promise to significantly enhance mucosal and systemic memory-type immune responses against HIV-1 antigens.

Domestic violence screening and intervention programmes for adults with dental or facial injury

BACKGROUND

Domestic violence exists in all communities across the world. Healthcare services have a pivotal role in the identification, assessment and response to domestic violence. As the face is a common target in assault, dentists and oral and maxillofacial surgeons are in a unique position to screen for domestic violence in the context of presentation of dental and facial injury. Owing to lack of training, dentists and oral and maxillofacial surgeons may not be the best persons to give advice to someone experiencing domestic violence. Improper advice such as encouragement to leave an abusive relationship may escalate the frequency of violence. It may be more appropriate to refer to specialist agencies for intervention and support. It would, therefore be useful to know whether screening and intervention programmes are effective.

OBJECTIVES

(1) To assess the benefits and harms of intervention programmes employed to reduce and or prevent domestic violence in adults with dental and/or facial injuries.(2) To assess the benefits and harms of screening and the use of different screening tools in the detection of the proportion of adult victims of domestic violence who present with dental and/or facial injury.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO and Lilacs databases. No language restrictions were applied. Personal contacts were used and international domestic violence organisations were contacted to identify any unpublished trials. Last search was done February 2004.

SELECTION CRITERIA

Randomised controlled trials involving adults aged 16 years and over presenting with dental and/or facial injury relating to domestic violence in any healthcare setting.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies was conducted in duplicate and independently by two reviewers. Results were to be expressed as random effects models using weighted mean differences for continuous outcomes and relative risk for dichotomous outcomes with 95% confidence interval. Heterogeneity was to be investigated including both clinical and methodological factors.

MAIN RESULTS

No eligible randomised controlled trials (RCTs) were identified.

REVIEWERS' CONCLUSIONS

There is no evidence to support or refute that screening for domestic violence in adults with dental or facial injury is beneficial nor that it causes harm. Screening tools to detect domestic violence exist but no RCTs have specifically evaluated their effectiveness for patients presenting with facial and or dental injuries. There is also lack of evidence that intervention programmes are effective at reducing frequency of physical assaults and at reducing the severity of facial injuries.

Development of a technology platform for large-scale clinical grade production of DC

BACKGROUND

Clinical studies require protocols where a sufficient number of well-characterized highly immunogenic DC are produced according to good manufacturing practice (GMP) guidelines.

METHODS

In the present study, using leukapheresis products from 10 cancer patients, we validated an elutriation technology for large-scale clinical grade production of monocyte-derived DC.

RESULTS

The elutriation method gave a very high purity (mean+/-SD) (86+/-5.3%) and recovery (66+/-10.4%) of monocytes. Specifically for the two monocyte-rich fractions (3 and 4,) the recovery was 42+/-13% of viable cells that could be further differentiated into immature DC in hydrophobic culture bags using GM-CSF and IL-4. The immature DC exhibited<1% CD83+ expression and >98% phagocytic activity. Maturation with TNF-alpha or poly I:C resulted in DC with expression of CD80+, CD86+ and HLA-DR+ (>99%) and CD83+ (80+/-11.9%), as well as producing IL-12p70 and lacking phagocytic activity (<5%). This cell product can be cryopreserved with cell viability >85% and cell recovery >80% after thawing.

DISCUSSION

The elutriation procedure, when optimized and if the monocyte content of the starting material exceeds 5%, does not require further selection or depletion using affinity approaches.

Insulin-like growth factor type 1 upregulates uncoupling protein 3

In this study the expression of uncoupling protein 3 (UCP3) and its regulation by insulin-like growth factor 1 (IGF-I) and insulin in human neuroblastoma SH-SY5Y cells were characterized. Reverse transcriptase-PCR, Western blot, and immunofluorescence analysis showed that SH-SY5Y cells express UCP3 natively. IGF-I induced a time- and concentration-dependent induction of UCP3 protein reaching a twofold expression after 72 h with 10 nM IGF-I. Extremely high insulin concentrations (860 nM) and 10 nM trIGF-I, a truncated form of IGF-I with the same affinity for the IGF-I receptor as the full-length IGF-I, but with lower activity on the insulin receptor, also upregulated UCP3. We conclude that SH-SY5Y cells express UCP3 natively and that the expression is regulated by IGF-I via the IGF-I receptor.

The Illawarra Coordinated Care Trial: better outcomes with existing resources?

The Illawarra Coordinated Care Trial was one of nine Australian trials undertaken to see whether different models of coordinated care could improve the health of people with multiple service needs within existing resources. This paper summarises the findings of an extensive local evaluation and discusses the impact of the trial on clients and service providers. It examines the main findings related to the principal trial hypothesis and points to lessons that might inform the next round of trials.

Altered fetal pituitary-adrenal function in the ovine fetus treated with RU486 and meloxicam, an inhibitor of prostaglandin synthase-II

Term and preterm labor are associated with increased fetal hypothalamic-pituitary-adrenal (HPA) activation and synthesis of prostaglandins (PGs) generated through the increased expression of prostaglandin H synthase-II (PGHS-II) in the placenta. Inhibition of PGHS-II has been advocated as a means of producing uterine tocolysis, but the effects of such treatment on fetal endocrine functions have not been thoroughly examined. Because PGE(2) is known to activate the fetal HPA axis, we hypothesized that administration of meloxicam, a PGHS-II inhibitor, to sheep in induced labor would suppress fetal HPA function. Chronically catheterized pregnant ewes were treated with RU486, a progesterone receptor antagonist, to produce active labor, and then treated with either high-maintenance-dose meloxicam, graded-maintenance-dose meloxicam, or a saline infusion. Maternal uterine contraction frequency increased 24 h after the RU486 injection and the animals were in active labor by 48 +/- 4 h. RU486 injection led to increased concentrations of PGE(2), ACTH, and cortisol in the fetal circulation, and increased concentrations of 13,14 dihydro 15-ketoprostaglandin F(2 alpha) (PGFM) in the maternal circulation. Uterine activity was inhibited within 12 h of beginning meloxicam infusion at both infusion regimes. During meloxicam infusion there were significant decreases in fetal plasma PGE(2), ACTH, and cortisol concentrations, and PGFM concentrations in maternal plasma. In control animals, frequency of uterine contractions, maternal plasma PGFM, fetal plasma PGE(2), ACTH, and cortisol concentrations increased after RU486 administration, and continued to rise during saline infusion until delivery occurred. We conclude that RU486-provoked labor in sheep is associated with activation of fetal HPA function, and that this is attenuated during meloxicam treatment to a level considered compatible with pregnancy maintenance.

Effectiveness of the National Death Index for establishing the vital status of older women in the Australian Longitudinal Study on Women's Health

OBJECTIVE

To assess the effectiveness of the National Death Index (NDI) in identifying participants in the oldest cohort of the Australian Longitudinal Study on Women's Health (ALSWH) who had died between 1996 and 1998.

METHODS

Identifying information for each woman was matched with the NDI using a probabilistic algorithm and clerical review. Differences in full name, date of birth, State of residence and date of last contact were used to assess the probability of a true match.

RESULTS

NDI identified 410 matches of death records for 409 women; 386 were categorised as true matches and 23 were doubtful matches. Responses to the follow-up survey confirmed that for six of the doubtful matches the women had died, 16 were alive and the vital status of one woman remained unconfirmed at 30 June 1998. Twelve deaths, known to have occurred before July 1998, were not identified through NDI. The sensitivity of the NDI for identifying known deaths was 95%. Detailed identifying information, particularly the middle name, was important for accurate identification of the vital status.

CONCLUSIONS

Using surname, all given names, gender, date of birth, State of residence and age at last contact as matching variables, the NDI was an effective tool for identifying women who had died.

IMPLICATIONS

Routinely collected mortality data in the NDI are useful for the practice of epidemiology.

Adolescent identity--a qualitative approach: self-concept, existential questions and adult contacts

In-depth interviews were performed with 12 adolescents (Swedish students, 16-19 years). Three questions were probed; what do adolescents say on the subjects of (a) themselves, (b) their existential questions, and (c) their adult contacts. The first two questions were aimed at elucidating the process of identity development, the last one at factors that may be influencing this process. The results showed that (a) balancing and controlling one's own needs and wishes in relation to others' was a central issue, (b) existential questions mainly concerned the personal future, (c) adult contacts outside the family were scarce and (d) all respondents expressed a need for adult contacts as sources of knowledge and experience. The conclusions are that identity formation during late adolescence consists of integrative issues where adults play a specific and important role.

General practitioner screening for melanoma: sensitivity, specificity, and effect of training

OBJECTIVE

To measure the performance of trained and untrained general practitioners (GPs) in screening men and women aged 50 or more for melanomas.

METHODS

GPs trained in melanoma diagnosis, untrained GPs, and skin cancer specialists examined groups of volunteers, each of which included a small number of subjects with prediagnosed suspicious pigmented lesions (SPLs) that were subsequently excised for histopathological examination.

RESULTS

Trained and untrained GPs achieved mean sensitivities of 0.73 and 0.71, and mean predictive values of 0.40 and 0.37, respectively, for the detection of prediagnosed SPLs. When the SPLs had been excised and examined histopathologically, reanalysis showed mean sensitivities of 0.98 and 0.95, mean specificities of 0.52 and 0.49, and mean positive predictive values of 0.24 and 0.22 for the detection of subjects with melanomas by trained and untrained GPs respectively. Trained GPs were significantly better than untrained GPs at diagnosing as melanomas SPLs that subsequently proved to be melanomas (p = 0.04).

CONCLUSIONS

GPs in this study achieved high sensitivities in screening older Australian men and women for melanomas, but at the cost of low specificities and positive predictive values. Training in melanoma diagnosis had no significant effect on sensitivity, specificity, and positive predictive value for screening. Data from the study were tested in a model of population screening for melanomas, and costs per life year saved for men aged 50-70 ranged from $A11,852 to $A40,259 depending upon the screening interval and whether the GPs excised the SPLs diagnosed, or referred all patients to skin cancer specialists; this would be as cost effective as cervical cancer screening.

The research and educational priorities of rural occupational therapists

The aim of this pilot research project was to identify the research and educational priorities of occupational therapists practising in rural New South Wales. Eight participants were recruited in the south-western region of the State. The Delphi technique was used to obtain the most reliable consensus of the research participants. Priorities emerged in four designated areas: (1) research that would be of value to clients; (2) research that would be of value in providing community care for clients; (3) research that would be of value in facilitating health promotion and disease prevention; and (4) research that would be of value to professional and educational needs. In the final phase of the study, 23 high priorities were identified. The findings of the study suggest directions for research and continuing education in occupational therapy which may benefit rural practitioners and their clients.

Self-concept and questions of life: identity development during late adolescence

The purpose of the present study was to explore identity development in late adolescent (18-20) years. Three areas were examined: (a) self-concept, (b) existential questions; content and communication patterns, and (c), connections between (a) and (b). The population consisted of 44 Swedish college students. Three methods were used: a questionnaire, the writing of a short essay and a self-evaluation test, Structural Analysis of Social Behavior (SASB). The results demonstrated a positive and stable self-concept for the majority of the group, and that questions of life mainly concerned questions of future. The quality of the self-concept (positive vs. negative) was significantly related to how subjects experienced adults' interest in their existential questions. Several issues are discussed: the importance of the social environment for identity development not only during early childhood but also during adolescence, the use of the SASB method in this age group and the need for placing processes of integration into focus in research concerning late adolescence.

The accuracy of self-report of smoking status in pregnant women

Little is known about the accuracy of usual-care providers' detection of pregnant smokers. This study explored the proportion of pregnant women misclassified as nonsmokers by midwives in a public antenatal clinic. A sample of 204 women whom midwives classified as nonsmokers were asked to complete a self-administered questionnaire and to provide a urine specimen for cotinine analysis. Results indicate that midwives failed to detect a significant proportion of smokers. The conservative estimate of the proportion of midwife-identified nonsmokers who could be reclassified as smokers on the basis of the questionnaire and urinalysis procedures was 7.4% (95% CI 3.8-10.9%), the medium estimate was 8.8% (95% CI 4.9-12.7%) and the worst-case estimate was 15.2% (95% CI 10.3-20.1%). To increase the coverage achieved by smoking-cessation programs, antenatal clinics should consider incorporating biochemical measurements into routine screening procedures. Future studies examining smoking status in pregnancy should detail the methods used to classify subjects and document response rates in relation to each self-report and biochemical measurement.

Crying in !Kung San infants: a test of the cultural specificity hypothesis

The pattern of crying and fretting behavior during the first two years is described for 46 !Kung San infants from a hunter-gatherer society in northwestern Botswana. Despite markedly different caretaking practices predisposing to quieter infants, crying and fretting were significantly greater during the first three months, and a peak pattern was present. Measurement of crying 'intensity' indicated that it was predominantly short and fretful. The results support the concept that the early peak pattern is not specific to infants in western industrialized societies, and may represent a behavior universal to the human species. The caretaking differences between societies primarily appear to affect crying duration rather than its frequency and pattern in early infancy.

Characterization of two genome types of adenovirus type 31 isolated in Stockholm during 1987

The authors isolated during 1987 seven adenovirus type 31 (Ad31) within a 9-month period. The isolates were obtained from urine, throat, and feces, implying a systemic spread of the infection. Most patients displayed gastrointestinal symptoms, but some had respiratory symptoms and fever. All of the strains differed by restriction endonuclease analysis from the prototype strain (1315) by an additional Bgl II restriction site. Ad31 isolates 1-6 could be divided into two groups by the enzymes Bam HI, Msp I, and Xho I. Each enzyme gave rise to the same group distribution: isolates 1-3 and 4-6, respectively. Digestion with Bst EII, Hind III, Kpn I, and Sma I resulted in identical patterns for isolates 1-6. Isolate 7, however, demonstrated a DNA deletion of approximately 0.8 kbp, but it was otherwise identical to isolates 4-6. In conclusion, two separate genome types of Ad31 were isolated, one of which included a DNA deletion mutant. The increased isolation rate may reflect an epidemiological situation, as the same isolation procedure had been used both before and after this period.

Fibrinogen Aarhus and factor XIII induced polymerization and gel formation

Fibrinogen Aarhus is an abnormal fibrinogen for which the clotting time with thrombin is greatly prolonged both in plasma and in the isolated fibrinogen. The whole blood clotting time is only slightly prolonged. The patient with this fibrinogen has no bleeding tendency. In this report we have investigated fibrinogen Aarhus in two alternative, thrombin independent polymerization and gelation pathways. These pathways are the factor XIII dependent oligomerization and gelation of fibrinogen, and heteropolymer (fibrinogen-fibronectin) formation which also is catalysed by factor XIII. Both of these reactions are qualitatively the same in fibrinogen Aarhus as in normal fibrinogen, but the rate of oligomerization is somewhat slower in fibrinogen Aarhus. This may depend on impaired association between factor XIII and fibrinogen Aarhus.

Application of an enzyme-linked immunosorbent assay (ELISA) to von Willebrand factor (vWF) and its derivatives

Sandwich ELISA systems were developed to measure human von Willebrand factor (vWF). In one system the microtitre plates were coated with goat F(ab')2 to vWF. The F(ab')2 different molecular forms in the soluble phase. VWF antigen bound by the F(ab')2 antibody was subsequently determined by using horse-radish peroxidase labeled goat Fab' to vWF. In plasma 3 X 10(-4) units of vWF per ml could be detected with this system. In a different approach the antigen bound by the F(ab')2 antibody was probed by monoclonal antibodies to multimeric as well as to the reduced and carboxymethylated (RCM) form of vWF. Using these monoclonals and RCM-as well as native plasma as antigen, the total antigen and the relative proportion of multimeric forms in the sample were estimated.

Factor XIII catalyzed formation of fibrinogen-fibronectin oligomers--a thiol enhanced process

Fibrinogen and plasma fibronectin were shown to interact in the presence of factor XIIIa. The reaction was enhanced by dithiothreitol and was accompanied by an increase in the turbidity of the solution and the formation of particulate matter and gel structures. At a constant concentration of fibrinogen the turbidity increase was dependent on the fibronectin concentration and at a constant concentration of fibronectin, on the fibrinogen concentration. Kinetic experiments showed that an initial step in the reaction between fibrinogen and fibronectin was the formation of a transient intermediate containing 1 mole of fibrinogen and 1 mole of fibronectin. Transient intermediates of larger molecular weight and containing both fibrinogen and fibronectin were also formed. These heterooligomers eventually reached huge molecular sizes and at early times formed particulate matter that sedimented on centrifugation. The predominant molecular species formed in an equimolar mixture of fibrinogen and fibronectin were heteropolymers. Small amounts of homopolymers composed of fibrinogen and possibly also homopolymers of fibronectin were detected. The results are discussed in terms of reaction mechanism and potential importance of this novel oligomerization pathway in haemostasis, thrombosis and tissue repair.

FXIII induced gelation of human fibrinogen--an alternative thiol enhanced, thrombin independent pathway

Factor XIII induced gelation of human fibrinogen in the presence of calcium ions. At the end of this reaction between 95 and 100% of the fibrinogen was incorporated into the gel matrix. The gelation was dramatically enhanced by DTT. Cysteine and beta-mercaptoethanol also enhanced the reaction, but less efficiently. Thrombin activated factor XIII led to shortened gelation time and increased the rate of gelation. The reaction was inhibited by p-chloromercuribenzoate and iodoacetamide. Neither fibrinopeptide A, nor fibrinopeptide B were released during gelation, while quantitative release of FPA by thrombin was demonstrated from preformed gel matrices. SDS-PAGE showed the presence of gamma-dimers and alpha-polymers in the gel matrix. In the clot supernatants gamma-dimers were observed already before the gel point. We also observed that the clotting of fibrinogen by thrombin was perturbed by DTT. Preincubation of fibrinogen with calcium ions prevented this effect of DTT.

Effect of intravenous glucose injection on human maternal and fetal heart rate at term

The effects of maternal intravenous glucose administration (25 gm) on maternal heart rate, fetal heart rate, gross fetal body movements, and fetal heart rate accelerations was measured in 11 healthy pregnant women at 38 to 40 weeks' gestational age. Mean maternal heart rate increased from 78.3 +/- 0.8 bpm during the control period to 82.7 +/- 0.5 bpm at 30 to 85 minutes following glucose injections (p less than 0.01). Mean fetal heart rate rose from 137.8 +/- 0.4 bpm to 142.4 +/- 0.3 bpm at 50 to 95 minutes following injections (p less than 0.001). The incidence of gross fetal body movements and the number, duration, and amplitude of fetal heart rate accelerations did not change following glucose injection. We conclude that maternal glucose administration near term results in a small but significant increase in the mean maternal heart rate and fetal heart rate and no change in the incidence of gross fetal body movements or in fetal heart rate accelerations.

Effects of intravenous glucose injections on human fetal breathing movements and gross fetal body movements at 38 to 40 weeks' gestational age

Fetal breathing movements and gross fetal body movements were studied subsequent to the intravenous injection of either 25 gm of glucose or an equal volume of normal saline solution in 10 healthy women with uncomplicated pregnancies at 38 to 40 weeks' gestation. The incidence of fetal breathing increased from 17.5% during the control period to 54.9% after glucose injection. Neither glucose nor saline solution had any effect on the incidence of gross fetal body movements. All fetuses made some breathing movements during any 15-minute interval between 30 and 75 minutes after glucose injection. These data suggest a useful strategy for clinical measurement of fetal breathing activity near term.

The behavior of the full-term but underweight newborn infant

Ten underweight full-term newborns were compared with 10 full-weight newborns on the Brazelton Neonatal Behavioral Assessment Scale. The Brazelton examination differentiated the two groups clearly on the reflexes of walking, crawling and passive movements of arms and legs, and on rooting and sucking. More importantly, it differentiated the two groups on behaviors which are important for the caretaker of the baby: these are attractiveness, need for stimulation, interactive processes and motor processes. The 10 underweight infants were followed up at a later date during the first year. They showed temperamental organizational difficulties and some indication of psychosomatic reaction to stress. It is possible that the underweight newborn's fragile organization elicits anxiety in the caretaker which makes interaction difficult.

Regional obstetric anesthesia and newborn behavior: effect over the first ten days of life

This study examined the effects of carefully controlled amounts of analgesic premedications and anesthetics administered to mothers during delivery on the behavior of the newborn over the first ten days of life. The subjects were selected to minimize the synergistic effects of medication and other stress factors, such as abnormalities of pregnancy, labor, or delivery. The effects of these drugs on the behavior of these infants was small. The data provide a picture of the behavioral recovery of a group of minimally stressed newborns.

Nitrazepam: lastingly effective but trouble on withdrawal

The sleep of 10 volunteers with an average age of 57 years was recorded electrophysiologically before, during, and after nitrazepam 5 mg nightly for 10 weeks. Sleep was longer and less broken on the drug and no tolerance was obvious after two months' use. Withdrawal of the drug, however, caused sleep to be temporarily worse than before the drug had been taken. Slow-wave sleep was reduced by nitrazepam, but the accompanying secretion of growth hormone was not impaired.

Do placebos alter sleep?

Deliberate suggestion that an inert capsule was a sleeping pill was found not to influence subjective ratings of sleep quality or anxiety or the electrophysiologically recorded features of sleep in 10 volunteers aged 41-62 years.