A single unit transfusion policy reduces red cell transfusions in general medical in-patients.

BACKGROUND: The NICE guidelines for blood transfusion and the patient blood management recommendations state that a single unit of red cells should be the standard dose for patients with stable anaemia who are not bleeding. Studies have shown that changing clinical transfusion practice can be difficult and that many clinicians' order two units of blood as standard for patients needing a transfusion. AIM: A collaborative project between NHS Blood and Transplant and Kings College Hospital started in September 2014 to evaluate the impact of a single unit policy on blood usage. DESIGN METHODS: Training and education was undertaken for clinical staff on eight general medical wards and all staff working in the blood transfusion laboratory. We collected transfusion data for 12 months, (6 months before and after implementation). RESULTS: There was a decrease of 50% red cell unit usage between the two periods, equating to a unit cost saving of £28 670. The number of single unit transfusions, increased from 30 to 53% whilst the number of two units decreased from 65 to 43% (P < 0.001). DISCUSSION/CONCLUSION: This project has shown that transfusion practice can be changed and savings in blood usage can be achieved through the successful implementation of the single unit transfusions policy. Key to the implementation was engagement from key medical staff within the medical department in which the policy was implemented and support from the hospital transfusion team. Continued attention and training shall be needed to support these, and implement other, patient blood management recommendations.

Stabilized plasmid-lipid particles containing PEG-diacylglycerols exhibit extended circulation lifetimes and tumor selective gene expression.

Stabilized plasmid lipid particles (SPLP) consist of a single copy of DNA surrounded by a lipid bilayer. The particles are small ( approximately 100 nm), stable, monodisperse and have a low surface charge. A diffusible polyethylene glycol (PEG) coating attached to a lipid anchor is critical to the SPLP's functionality. The PEG-lipid exchanges out of the bilayer at a rate determined by the size of the lipid anchor. Here we show that SPLP can be prepared using a series of PEG-diacylglycerol lipids (PEG-S-DAGs). SPLP were prepared incorporating PEG-dimyristoylglycerol (C14), PEG-dipalmitoylglycerol (C16) or PEG-distearoylglycerol (C18) and the rate of PEG-lipid diffusion from the bi-layer determined using a FRET assay. SPLP pharmacokinetics confirm a correlation between the stability of the PEG-lipid component and circulation lifetime. PEG-S-DAGs with longer lipid anchors yield more stable SPLP particles with longer circulation half-lives yielding an increase in tumor delivery and gene expression. PEG-distearoylglycerol (C18) containing SPLP bypass so-called 'first pass' organs, including the lung, and elicit levels of gene expression in distal tumor tissue 100- to 1000-fold greater than that observed in any other tissue. The incorporation of PEG-S-DAG in SPLP confirms that small size, low surface charge and extended circulation lifetimes are prerequisite to the accumulation and tumor selective expression of plasmid DNA following systemic administration.

Molecular physiology of aquaporins in plants.

In plants, membrane channels of the major intrinsic protein (MIP) super-family exhibit a high diversity with, for instance, 35 homologues in the model species Arabidopsis thaliana. As has been found in other organisms, plant MIPs function as membrane channels permeable to water (aquaporins) and in some cases to small nonelectrolytes. The aim of the present article is to integrate into plant physiology what has been recently learned about the molecular and functional properties of aquaporins in plants. Exhaustive compilation of data in the literature shows that the numerous aquaporin isoforms of plants have specific expression patterns throughout plant development and in response to environmental stimuli. The diversity of aquaporin homologues in plants can also be explained in part by their presence in multiple subcellular compartments. In recent years, there have been numerous reports that describe the activity of water channels in purified membrane vesicles, in isolated organelles or protoplasts, and in intact plant cells or even tissues. Altogether, these data suggest that the transport of water and solutes across plant membranes concerns many facets of plant physiology. Because of the high degree of compartmentation of plant cells, aquaporins may play a critical role in cell osmoregulation. Water uptake in roots represents a typical process in which to investigate the role of aquaporins in transcellular water transport, and the mechanisms and regulations involved are discussed.

Recent developments in gene-directed enzyme prodrug therapy (GDEPT) for cancer.

Gene-directed enzyme prodrug therapy (GDEPT) is a promising two-step treatment for solid malignant tumors. In the first step, the gene for a foreign enzyme is administered and directed to the tumor, where it may be expressed using specific transcriptional elements. In the second step, prodrugs are administered and activated by the foreign enzyme expressed at the tumor. This review focuses on the progress from the end of 1997 to date. Important issues, such as viral and non-viral vectors, new enzyme/prodrug systems, new strategies, advances in the understanding of the bystander effects, the comparison of different systems used in GDEPT and clinical trials are outlined.

A general practice records audit of the process of care for people with epilepsy.

BACKGROUND: The appropriateness of epilepsy as a topic for general practice audit activity has been emphasized, but few audits have been undertaken to data and those that have are small scale. Historically, management of epilepsy has been a neglected area, and services for people with epilepsy remain generally poor. AIM: The study was designed to examine the process of care for people with epilepsy through a region-wide audit of general practitioner records. METHOD: General practitioners in 31 randomly selected general practices in one UK health region undertook a notes audit for all patients identified as having active epilepsy (patients who had had seizures in the last 2 years, or were currently seizure-free but on antiepileptic medication). A standard pro forma was used to collect information relating to diagnosis, drug treatment, and primary and secondary care contacts. RESULTS: Recording of information in the notes was generally good, but poor for some key items essential to the effective management of the condition; results suggest that a number of recommendations about provision of care for epilepsy are not being met: in particular, EEG and CT investigations often appear poorly directed; prescribed antiepileptic therapy is not always optimal; significant numbers of patients are being treated in hospital by non-neurologists; there is little evidence of any regular review being undertaken by general practitioners of their patients with epilepsy; and counselling about the non-clinical aspects of epilepsy often appears inadequate. CONCLUSIONS: Despite recommendations in a number of recent reports, gaps and inconsistencies in epilepsy care persist, both at the primary and secondary level. The means by which such shortcomings can be reduced (e.g. by specialist epilepsy nurses working across the primary-secondary care interface) should now be systematically examined. The study has highlighted a need for evidence-based guidelines which span the primary-secondary care interface and clarify the contribution of the various practitioners involved in the provision of care for people with epilepsy.

The monoclonal antibody TAL16.1 recognizes the aspartic acid residue at position 70 in DRB gene products.

A polymorphic monoclonal antibody (TAL16.1), raised against a mouse L-cell transfectant expressing the human DRB5*0101 gene from the HLA-DR15(2) Dw2 DR51 haplotype was shown to have a complex pattern of reactivity to DRB gene products. The antibody bound to a transfectant expressing the DRB5*0101 allele against which it was produced but not to a transfectant expressing the DRB1*1501 allele. These alleles of the DRB1 and DRB5 genes are usually coexpressed on DR15(2) Dw2 DR51 cells. A comparison of the HLA-DRB amino acid sequences of reactive and non-reactive cells identified an aspartic acid residue at position 70, conserved in all antibody-positive cells and absent in antibody-negative cells, which was postulated as being responsible for conferring the specificity of the antibody. The aspartic acid residue at position 70 is present in DRB5*0101 and DRB5*0102 alleles but absent in DRB5*0201 and DRB5*0202 alleles, allowing the antibody to distinguish between these splits of the DR51 serological specificity. TAL16.1 also binds to the product of the DRB1*0103 allele and discriminates between cells with a DR103 specificity and the other DR1 subtypes, DRB1*0101 and DRB1*0102. In this report the value of transfectants as immunogens for use in the production of monoclonal antibodies of predetermined specificity and as tools for the fine mapping of antibody specificity is discussed.

A microELISA assay for detection of anti-HLA activity of mouse monoclonal antibodies using an Astroscan 2100 automated plate reader.

A microenzyme-linked immunosorbent assay (microELISA) method has been developed using an Astroscan 2100 system automated plate reader which was initially designed for tissue typing by a two colour fluorescent microcytotoxicity assay. A 96-well plate ELISA used for screening mouse monoclonal antibodies raised against surface HLA antigens has been modified for use with the Astroscan plate reader and 72-well typing trays. The existing substrate 4-methylumbelliferyl-beta-D-galactoside (4MUG) has been replaced with fluorescein-di-beta-D-galactopyranoside (FDG), to provide a wavelength (530 nm) detectable by the Astroscan or other automated plate readers designed for reading microcytotoxicity assay plates. The assay volumes have also been reduced tenfold for use with Terasaki microtest plates. The assay now has the major advantage of requiring only 5 microliters of test supernatant allowing hybridomas to be screened earlier during a fusion and on a wider cell panel. The use of the large panel which includes B lymphoblastoid cell lines (B-LCL) and mouse L cell transfectants expressing HLA genes, reduces the length of time the hybridomas need to be kept in tissue culture before selection. Other advantages include the reduction in the number of target cells required, smaller volumes of reagents throughout the assay and the ability to screen cytotoxic as well as non-cytotoxic monoclonal antibodies. The sensitivity of this microELISA proved to be comparable with the original assay and so provides an efficient screening method for monoclonal antibodies.

A DR7 specific monoclonal antibody TAL13.1, raised against a transfectant detects IL-4 upregulated antigen on peripheral B-lymphocytes.

A monoclonal antibody TAL13.1 was raised against mouse L cells transfected with the human HLA-DRB1*0701 gene. This antibody was found to be polymorphic recognizing a determinant expressed by the DR7, DRB1*0701 and DRB1*0702 gene products. Four polymorphic sites unique to this specificity have been identified within the DR beta 1 domain. These are residues 11-14, 25, 30 and 71-74, one or a combination of which is postulated as being responsible for conferring the specificity of the antibody. In Western blot analysis TAL13.1 was found to react with the DR alpha beta dimer, but not with the free alpha or beta chains. However, in flow cytometry it failed to bind a DR alpha/DQ beta mixed pair transfectant confirming that it recognizes an epitope on the DR beta not the DR alpha chain. Although TAL13.1, a low affinity antibody is negative or only weakly positive on resting peripheral blood lymphocytes (PBLs), we have demonstrated that by interleukin-4 (IL-4) stimulation we can up-regulate the levels of antigen already present and gain a level of binding comparable to that found on B lymphoid cell lines (B-LCLs) where it has been found to be a valuable reagent in their characterization.

Microcytotoxicity assay using mouse L cells transfected with human MHC class II genes. A method and its application.

Modifications of the standard microcytotoxicity assay make it possible to use this technique to screen both alloantisera and monoclonal antibodies with mouse L cells transfected with Class II genes. It is necessary to maintain a protein-rich environment in order to prevent nonspecific complement lysis. Selection of the complement itself is also an important factor, the best results being achieved using a commercially available complement that had previously been absorbed with mouse cells and used at a dilution of 1/8. Using this modified method with transfectants of DW2 origin we could show that alloantisera against DRw15 recognize the DRB1*1501 gene product, whereas broad DR2 sera react only with the DRB5*0101 product. This technique can be applied successfully to study the fine specificity of polymorphic monoclonal antibodies, as shown by the reactivity of HU-30 which binds to the LDR2b transfectant and not to the LDR2a, indicating that the antibody recognizes an epitope present on the DRB1 chain and not the DRB5 chain of DR2 cell lines.

Epitope mapping of an HLA-DR-specific monoclonal antibody produced by using human-mouse transfectant cells.

A polymorphic HLA-DR mAb, TAL15.1, was produced against L cells transfected with DR alpha- and beta-chain cDNA from a cell line homozygous for HLA-DRw8. This antibody reacted with DRw8 plus all other DR types except DR3 and DRw52. DR3 and DRw52 differ uniquely from other other DR antigens at position 77 in the beta 1-domain of their beta-chains where there is asparagine instead of threonine. In Western blots the antibody reacted with DR alpha/beta-dimer but not with free alpha- or beta-chains. Two-dimensional gel analysis of a DRw11, DRw52 cell line showed that TAL15.1 immunoprecipitated the DR products. Although it also coprecipitated the DQ beta chain products, flow microfluorimetric analysis with various transfectant cell lines showed that TAL15.1 failed to bind the DQ or DP products tested. We conclude that TAL15.1 is a DR-specific polymorphic antibody whose activity correlates with a specific residue. It has already proved to be a valuable reagent for distinguishing DR3 homozygotes from DR3, DRw6 heterozygotes, which have in the past been difficult to separate.

Endogenous digoxin-like substance(s) associated with uneventful and high-risk pregnancies.

We assessed the existence of endogenous digoxin-like substance(s) (EDLS) in mother-neonate pairs using a routine radioimmunoassay for digoxin. None of those studied had been treated with cardiac glycosides during or before pregnancy. In uneventful pregnancies, cord EDLS levels (0.31 +/- 0.02 ng/ml mean +/- SEM) were significantly higher (p less than 0.001) than both antepartum and postpartum maternal levels (0.14 +/- 0.02 and 0.17 +/- 0.02 mg/ml, respectively). This observation was in contrast with findings in high-risk pregnancies. In general, EDLS levels in the high-risk group were significantly higher than in normal pregnancies (cord 0.94 +/- 0.38 ng/ml; antepartum 1.63 +/- 0.54 ng/ml; postpartum 0.89 +/- 0.73 ng/ml). In the high-risk group there was a remarkably wide range of maternal and cord EDLS concentrations. The present studies suggest that following pregnancies of high risk for a variety of reasons, EDLS determination may be commonly high in the perinatal period and may affect the determination of 'true' digoxin. Consequently, digoxin dosing based on monitoring drug concentration may be futile.

Identification of HLA-DP polymorphism with DP alpha and DP beta probes and monoclonal antibodies: correlation with primed lymphocyte typing.

Thirty-four lymphoblastoid cell lines that had been previously typed for HLA-DP antigens by primed lymphocyte typing (PLT) were tested by Southern blotting and by ELISA. Using two DP beta probes and a DP alpha probe with a series of enzymes, it is possible to identify restriction fragment length polymorphism (RFLP) patterns characteristic of DPw1, -2, -3, -4, and possibly -5. ELISA typing results, based on two polymorphic DP antibodies DP11.1 and ILR1, were compared with PLT-defined and RFLP-defined types. Thus, using a range of probes and enzymes it is possible to identify DP polymorphism. The value of monoclonal antibodies for such studies is demonstrated, and the molecular data can, in some cases, pinpoint the amino acids responsible for the specificity of the monoclonal antibodies.

Monoclonal antibodies to HLA-DP-transfected mouse L cells.

Mouse L cells transfected with human HLA-DP (DPw4) alpha and beta genes were used to make monoclonal antibodies in C3H mice. A polymorphic antibody, DP11.1, was obtained, as well as several monomorphic antibodies. In ELISAs, DP11.1 bound to DPw4 cells and, more weakly, to DPw2, but not DPw1, -3, -5, or -6, using HLA homozygous cells. It also bound to L-cell transfectants expressing either DPw2 or DPw4 products. From B lymphoblastoid cell lysates labeled with [35S]methionine, the antibody immunoprecipitated alpha and beta chains of a similar size to those precipitated by a well-characterized DP monoclonal antibody, B7/21.2. Immunoblotting indicated that the DP11.1 antibody was directed against the alpha chain. This result confirms partial sequence data that showed that the DP alpha chain, as well as DP beta, is polymorphic, and that DPw2 and -4 alpha chains are very similar, if not identical.

Significance of the endogenous digoxin-like substance in infants and mothers.

Digoxin serum concentrations were measured by a routine radioimmunoassay in 30 neonates not receiving digoxin; nonetheless, digoxin levels were between 0.17 nM and 1.64nM (means = 0.64nM +/- 0.27 nM). There was a negative correlation between gestational age and concentration of an endogenous digoxin-like substance (EDLS). Neonates less than or equal to 32 wk gestational age had higher levels of EDLS than neonates greater than 32 wk old. EDLS concentrations were compared in 22 mothers and their 24 offspring and were higher in all newborn infants (0.34nM +/- 0.09nM and 0.15nM +/- 0.08nM). EDLS was shown to inhibit Na+-K+-adenosinetriphosphatase activity by measurement of 86Rb uptake in erythrocytes exposed to sera samples from 30 infants in the study. EDLS levels greater than 0.6 ng/ml were associated with lesser 86Rb uptake. Simulation kinetics suggest that the presence of 0.6nM EDLS would lengthen the digoxin t1/2 by 64%, reduce the volume of distribution by 23%, and lower clearance by 53% if the peak "true" digoxin level were 2 ng/ml. EDLS concentrations of 1.5 ng/ml would increase the t1/2 by 207% while reducing the volume of distribution by 43% and clearance by 81%. These considerations cast serious doubts on the validity of currently accepted digoxin kinetics and dosing in preterm infants.

Are immunoassays for digoxin reliable?

The specificity of radioimmunoassay and fluorescence polarization immunoassay procedures for the measurement of digoxin has been assessed. Many steroids and lipids have been found to interfere and give false positive results for digoxin under the conditions of the study. Caution is recommended in the interpretation of digoxin measurements made by immunoassay procedures.