Cytokine release assays for the prediction of therapeutic mAb safety in first-in man trials--Whole blood cytokine release assays are poorly predictive for TGN1412 cytokine storm.

The therapeutic monoclonal antibody (mAb) TGN1412 (anti-CD28 superagonist) caused near-fatal cytokine release syndrome (CRS) in all six volunteers during a phase-I clinical trial. Several cytokine release assays (CRAs) with reported predictivity for TGN1412-induced CRS have since been developed for the preclinical safety testing of new therapeutic mAbs. The whole blood (WB) CRA is the most widely used, but its sensitivity for TGN1412-like cytokine release was recently criticized. In a comparative study, using group size required for 90% power with 5% significance as a measure of sensitivity, we found that WB and 10% (v/v) WB CRAs were the least sensitive for TGN1412 as these required the largest group sizes (n = 52 and 79, respectively). In contrast, the peripheral blood mononuclear cell (PBMC) solid phase (SP) CRA was the most sensitive for TGN1412 as it required the smallest group size (n = 4). Similarly, the PBMC SP CRA was more sensitive than the WB CRA for muromonab-CD3 (anti-CD3) which stimulates TGN1412-like cytokine release (n = 4 and 4519, respectively). Conversely, the WB CRA was far more sensitive than the PBMC SP CRA for alemtuzumab (anti-CD52) which stimulates FcγRI-mediated cytokine release (n = 8 and 180, respectively). Investigation of potential factors contributing to the different sensitivities revealed that removal of red blood cells (RBCs) from WB permitted PBMC-like TGN1412 responses in a SP CRA, which in turn could be inhibited by the addition of the RBC membrane protein glycophorin A (GYPA); this observation likely underlies, at least in part, the poor sensitivity of WB CRA for TGN1412. The use of PBMC SP CRA for the detection of TGN1412-like cytokine release is recommended in conjunction with adequately powered group sizes for dependable preclinical safety testing of new therapeutic mAbs.

Thyrotropin receptor/thyroglobulin messenger ribonucleic acid in peripheral blood and fine-needle aspiration cytology: diagnostic synergy for detecting thyroid cancer.

RT-PCR for thyroglobulin (Tg) and TSH receptor (TSHR) mRNA has been used to detect circulating thyroid cancer cells. Little is known, however, regarding the preoperative sensitivity of this test to detect cancer. Seventy-two patients with thyroid disease (36 with malignancy and 36 with benign disease) were evaluated preoperatively. TSHR and Tg mRNA transcripts were detected by RT-PCR assays, previously determined to be specific for cancer cells. There was 100% concordance between TSHR and Tg mRNA RT-PCR results. Of 36 cancer patients, 11 had recurrent disease, and all were positive by RT-PCR. Among 25 patients with no prior thyroid surgery, 18 tested positive preoperatively (sensitivity 72%). Seven of 36 patients with benign disease tested positive (specificity 80%). The overall preoperative diagnostic accuracy was 77%. Preoperative fine-needle aspiration (FNA) biopsy was performed on 46 of 61 patients with no prior thyroid surgery. FNA was diagnostic in 28 (61%) patients. Preoperative cytology was adequate but not diagnostic in 18 (39%) patients. RT-PCR correctly classified 14 of these 18 patients with indeterminate FNA, and the test detected three of four cancer patients as positive (75% sensitive) and 11 of 14 patients (78% specific) with benign disease as negative. The combined diagnostic performance characteristics for RT-PCR and FNA cytology were sensitivity = 95%, specificity = 83%, and diagnostic accuracy = 89%, with positive and negative predictive values of 84 and 95%, respectively. Our results suggest that the molecular detection of circulating thyroid cancer cells by RT-PCR for TSHR/Tg mRNA complements FNA cytology in the preoperative differentiation of benign from malignant thyroid disease and their combined use may save unnecessary surgeries.

Insulin-receptor gene and its expression in patients with insulin resistance.

We studied the structure of the insulin-receptor gene in normal individuals and in four unrelated patients with leprechaunism (Minn-1, Ark-1, Ark-2, Can-1) and four unrelated patients with the type A syndrome of insulin resistance, both disorders associated with genetic alterations in affinity, binding capacity, and kinase activity of the insulin receptor. Genomic cloning and Southern blot analysis indicate that the normal human insulin-receptor gene is greater than or equal to 150 kilobases long and consists of a minimum of 17 exons, 6 in the genomic region of the alpha-subunit and 11 in the region of the beta-subunit. Three of the patients, one with leprechaunism and two with type A syndrome, have decreases in insulin-receptor mRNA but on genomic blot analysis have no obvious abnormalities in the insulin-receptor gene. No distinctive pattern of restriction-fragment-length polymorphisms or evidence for major insertion or deletion mutations of the insulin-receptor gene was found in any of the patients. These data indicate that the insulin-receptor gene is greater than 35 times larger than coding regions and has a complex structure. Although leprechaunism and type A syndrome are most likely due to defects in the structure and expression of the insulin-receptor gene, they are likely to be associated with specific point mutations rather than major changes in gene structure.

Communicating through satisfied adopters of female sterilization.

Communication patterns between 127 satisfied adopters of female sterilization (agents) and 257 potential adopters of family planning (recipients) were examined in this study conducted in a rural community in southern India. The influence of satisfied adopters relative to other family planning communication agents was evaluated. Satisfied adopters were identified as the most important source of family planning information by 55 percent of agents and 74 percent of recipients. Communication usually occurred between persons of similar caste, occupation, education, and income.

Satisfied adopters for diffusion of family planning: a study on strategy for improving programme.

PIP: A quasi-experimental study using satisfied adopters of contraceptive sterilization as information diffusers to eligible women was conducted in the Madari district in India from Oct. 1973-Nov. 1976. Planned interactions between adopters and nonadopters were carried out in villages where at least two adopters were present. There were 2 blocks set up for this test. In 1 block, called the experimental block, group meetings under the aegis of family planning personnel workers were set up between adopters and eligible women. In the control block, adopters were given identity cards with their addresses on them; these were to be distributed to any eligible woman they wished. Communication between eligible women and acceptors promoted the development of a favorable attitude towards sterilization and even adoption of that method. In fact, the number of adopters doubled in the experimental block for this time period. Other forms of information diffusion, such as mass media, proved of negligible influence. Husband/wife communication on family planning increased in the experimental block. Acceptor characteristics showed that younger, educated women were more likely to adopt. Results from the study point to the importance of providing an environment for satisfied adopters and publicizing their experiences in order to increase the number of adopters.^ieng

Report on the pilot study of multi-purpose health workers (male) in Athoor Block, Madurai District.

PIP: This study in the Institute's intensive field practice demonstration area in India attempted to determine if male health workers at the rate of 1/5000 population can carry out the various activities now being carried out by unipurpose health workers employed by the national malaria, smallpox, family planning, leprosy, and tuberculosis programs. 2 patterns were tried: 1) the workers to carry out all the activities of the various programs simultaneously through house visits at the rate of 40 a day for 6 working days a week, and 2) to do all activities except smallpox vaccination and family planning for 4 days a week with 1 day reserved for smallpox vaccination and 1 day for family planning activities. 23 workers were employed and trained. 9 were assigned to Plan 1, covering 40% of the population of 120,000; 14 under Plan 2 covered the remaining 60%. Survey design is detailed along with job descriptions. In the 1st round the multipurpose workers discovered as many fever cases as the single-purpose malaria workers and in the 2nd round, their performance improved. Performance was slightly better under Plan 2. Smallpox vaccination coverage was slightly better under Plan 1 but the time spent per worker was about double that of Plan 2 and wastage of lymph was nearly 3 times as great as when a separate day was set aside for vaccination. Family planning performance was much better under Plan 1 with 44.5% of high priority couples contacted on round 1 and 33.3% on round 2 compared with 28.2% and 36.4% under Plan 2. It was found that the worker gained effectiveness after he had developed rapport through other health services. There was demand for treatment of side effects and complications resulting from contraceptive use and for treatment of minor ailments among other household members. Quantities of Nirodh condoms distributed was higher under Plan 2. The multipurpose workers were not as effective as single-purpose workers in detecting tuberculosis or leprosy but they can refer suspected cases. It was pointed out that under Plan 2 group meetings could be held and more couples reached but that people were shy about attending group discussions and treatment of minor ailments helped in talking about family planning.^ieng