Power to the people? A co-produced critical review of service user involvement in mental health professions education

Meaningful service user involvement in health professions education requires integrating knowledge held by "lay" people affected by health challenges into professional theories and practices. Involving service users redefines whose knowledge "counts" and implies a shift in power. Such a shift is especially significant in the mental health field, where power imbalances between health professionals and service users are magnified. However, reviews of the literature on service user involvement in mental health professional education do little to explore how power manifests in this work. Meanwhile critical and Mad studies scholars have highlighted that without real shifts in power, inclusion practices can lead to harmful consequences. We conducted a critical review to explore how power is addressed in the literature that describes service user involvement in mental health professions education. Our team used a co-produced approach and critical theories to identify how power implicitly and explicitly operates in this work to unearth the inequities and power structures that service user involvement may inadvertently perpetuate. We demonstrate that power permeates service user involvement in mental health professional education but is rarely made visible. We also argue that by missing the opportunity to locate power, the literature contributes to a series of epistemic injustices that reveal the contours of legitimate knowledge in mental health professions education and its neoliberal underpinnings. Ultimately, we call for a critical turn that foregrounds power relations to unlock the social justice-oriented transformative potential of service user involvement in mental health professions education and health professions education more broadly.

Correction to: Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment

A Correction to this paper has been published: 10.1007/s40596-021-01471-6

Co-producing Psychiatric Education with Service User Educators: a Collective Autobiographical Case Study of the Meaning, Ethics, and Importance of Payment

OBJECTIVE

Co-production involves service providers and service users collaborating to design and deliver services together and is gaining attention as a means to improve provision of care. Aiming to extend this model to an educational context, the authors assembled a diverse group to develop co-produced education for psychiatry residents and medical students at the University of Toronto over several years. The authors describe the dynamics involved in co-producing psychiatric education as experienced in their work.

METHODS

A collaborative autobiographical case study approach provides a snapshot of the collective experiences of working to write a manuscript about paying service users for their contributions to co-produced education. Data were collected from two in-person meetings, personal communications, emails, and online comments to capture the fullest possible range of perspectives from the group about payment.

RESULTS

The juxtaposition of the vision for an inclusive process against the budgetary constraints that the authors faced led them to reflect deeply on the many meanings of paying service user educators for their contributions to academic initiatives. These reflections revealed that payment had implications at personal, organizational, and social levels.

CONCLUSION

Paying mental health service user educators for their contributions is an ethical imperative for the authors. However, unless payment is accompanied by other forms of demonstrating respect, it aligns with organizational structures and practices, and it is connected to a larger goal of achieving social justice, the role of service users as legitimate knowers and educators and ultimately their impact on learners will be limited.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

The value of traditional cognitive variables for predicting performance in graduate speech-language pathology programs

BACKGROUND

Student performance on the Praxis examination and in clinical settings is considered indicative of university graduate program quality. Utilization of admission variables most predictive of graduate school performance in speech-language pathology is therefore critical. This study evaluated the relationship between cognitive variables (GRE scores, undergraduate GPA, and course-specific grades) and performance on the Praxis and between the cognitive variables and first-year clinical performance.

METHODS

Admissions data for 230 students from four graduate programs in two states were analyzed. Participants were assigned to three groups based on Praxis scores (high performance, moderate performance, low performance/fail) and two groups based on clinical performance (low need supervision, high need supervision).

RESULTS

Statistically significant relationships were found between all independent variables and the dependent variables (Praxis scores and first-year clinical performance). Participants' pass-fail status on the Praxis was predicted with a high degree of accuracy based on speech-hearing science grades, physical science grades, and the GRE-Total (GRE-T) scores alone. The low need supervision group for clinical performance demonstrated statistically higher group means for GRE-T and GRE-Quantitative (GRE-Q) scores compared to the high need supervision group.

CONCLUSIONS

The use of the GRE and American Speech-Language-Hearing Association-required science course grades in graduate admissions is warranted.

Porcine circovirus as a possible cause of postweaning wasting in pigs in Switzerland

Postweaning wasting is a major worldwide problem in pig production, particularly with respect to the disease termed postweaning multisystemic wasting syndrome (PMWS). In addition to wasting, PMWS symptoms include respiratory distress, diarrhoea, pallor and occasional cases of jaundice. The causative agent is porcine circovirus type 2 (PCV-2). The objective of the present study was to determine the significance of PMWS and similar conditions in Switzerland. A total of 72 weaned piglets from 26 farms showing wasting were examined for the presence of PCV-2 by immunohistochemical and histological analysis and 57 piglets from 21 farms were examined serologically. Possible causes for wasting other than PCV-2 were investigated by macroscopic, histological and bacteriological methods. PCV-2 antigen was identified immunohistochemically in the lymphatic organs in 11 of these 72 piglets. However, only 4 animals showed histological changes typical of PMWS. PCV-2 antibodies were found in 70% of the piglets. Piglets with wasting syndrome not associated with PCV-2 infection suffered from conditions including porcine proliferative enteropathy, gastric ulcers, polyserositis and polyarthritis. The most frequent condition was chronic enteritis not associated to circovirus infection. The results from the serological analyses indicate a wide distribution of PCV-2 in the Swiss pig population. However, confirmed cases of PMWS were rare in the investigated piglets.

Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis

BACKGROUND

Chronic kidney disease (CKD) is a long-term condition and has been described as the gradual loss of kidney function over time. Early in the disease process, people with CKD often experience no symptoms. For a long time, CKD has been an underdiagnosed condition. Even in the absence of symptoms, CKD appears to add significantly to the burden of cardiovascular disease and death and, for an important minority, can progress to kidney failure.

OBJECTIVE

To systematically review the evidence of the clinical effectiveness and cost-effectiveness of early referral strategies for management of people with markers of renal disease.

DATA SOURCES

Electronic searches of 12 major databases (such as MEDLINE, EMBASE, CINAHL, etc.) were conducted for the time period of 1990 to April 2008 to identify studies comparing early referral to other care options for people with CKD. Additional searching was performed in the NHS Economic Evaluation Database to support the cost-effectiveness literature review.

REVIEW METHODS

Two authors reviewed all titles, abstracts and full papers to select relevant literature. A Markov model was constructed to represent the natural history of CKD. The model allowed cohorts to be tracked according to estimated glomerular filtration rate (eGFR) status and the presence of other complications known to influence CKD progression and the incidence of cardiovascular events.

RESULTS

From 36 relevant natural history studies, CKD was found to be, despite marked heterogeneity between studies, a marker of increased risk of mortality, renal progression and end-stage renal disease. Mortality was generally high and increased with stage of CKD. After adjustment for comorbidities, the relative risk of mortality among those with CKD identified from the general population increased with stage. For clinical populations, the relative risk was higher. All three outcomes increased as eGFR fell. Only seven studies, and no randomised controlled trials, were identified as relevant to assessing the clinical effectiveness of early referral strategies for CKD. In the five retrospective studies constructed from cohorts starting on renal replacement therapy (RRT), mortality was reduced in the early referral group (more than 12 months prior to RRT) even as late as 5 years after initiation of RRT. Only two studies included predialysis participants. One study, in people screened for diabetic nephropathy, reported a reduction in the decline in renal function associated with early referral to nephrology specialists (eGFR decline 3.4 ml/min/1.73 m(2)) when compared with a similar group that had no access to nephrology services until dialysis was required (eGFR decline 12.0 ml/min/1.73 m(2)). The second study, among a group of veterans with two creatinine levels of at least 140 mg/dl, reported that a composite end point of death or progression was lower in the group receiving nephrology follow-up than in those receiving only primary care follow-up. The greatest effect was observed in those with stage 3 or worse disease after adjustment for comorbidities, age, race, smoking and proteinuria {stage 3: hazard ratio (HR) 0.8 [95% confidence interval (CI) 0.61 to 0.9)]; stage 4: HR 0.75 (95% CI 0.45 to 0.89)}. In the base-case analysis, all early referral strategies produced more quality-adjusted life-years (QALYs) than referral upon transit to stage 5 CKD (eGFR 15 ml/min/1.73 m(2)). Referral for everyone with an eGFR below 60 ml/min/1.73 m(2) (stage 3a CKD) generated the most QALYs and, compared with referral for stage 4 CKD (eGFR < 30 ml/min/1.73 m(2)), had an incremental cost-effectiveness ratio of approximately 3806 pounds per QALY.

LIMITATIONS

Because of a lack of data on the natural history of CKD in individuals without diabetes, and a lack of evidence on the costs and effects of early referral, the Markov model relied on many assumptions. The findings were particularly sensitive to changes in eGFR decline rates and the relative effect of early referral on CKD progression and cardiovascular events; the latter parameter being derived from a single non-randomised study.

CONCLUSIONS

Despite substantial focus on the early identification and proactive management of CKD in the last few years, we have identified significant evidence gaps about how best to manage people with CKD. There was some evidence to suggest that the care of people with CKD could be improved and, because these people are at risk from both renal and cardiovascular outcomes, strategies to improve the management of people with CKD have the potential to offer an efficient use of health service resources. Given the number of people now being recognised as having markers of kidney impairment, there is an urgent need for further research to support service change.

Utility of clinical swallowing examination measures for detecting aspiration post-stroke

The purpose of this investigation was to determine the utility of clinical swallowing examination (CSE) measures for detecting aspiration as defined by videofluoroscopic swallowing examination (VFSE). This study, involving 165 participants, is a follow-up to a previously published investigation of 60 participants. Findings are compared with that investigation as well as with other research on CSEs. The results suggest that clinicians can make an accurate judgment of the occurrence of aspiration in most post-stroke patients. However, ruling out aspiration when it is absent appears more problematic. More work needs to be done if data collected from non-instrumented examinations are to be strongly predictive of the presence and absence of aspiration on VFSE. At present, there are no data to suggest that CSEs can be used to quantify aspiration or make adequate recommendations regarding patient care.

PMWS: an emerging disease identified in archived porcine tissues

Postweaning multisystemic wasting syndrome (PMWS) is a disease caused by porcine circovirus type 2 (PCV-2). The disease was present as early as 1986 in Spain, 1989 in Japan and 1993 in Thailand. In view of this, we considered it possible that the disease may also have been present in Switzerland prior to its first description in 2001. A retrospective investigation was performed on paraffin-embedded lymphoid organs and ileum from 496 pigs aged 5-13 weeks collected between 1976 and mid-2001. The sections were investigated immunohistochemically using a monoclonal antibody specific for PCV-2 capsid antigen encoded by ORF2. Virus antigen was detected in tissue samples of 39 pigs from 28 farms. The earliest positive sample originated from 1986. After 1989, positive pigs were found almost every year among the 20-40 cases investigated annually. These results indicate that PCV-2 has been present in Switzerland for some time, and at least since 1986.

PMWS: experimental model and co-infections

Porcine circovirus type 2 (PCV2) is now recognised as the causal agent of porcine multisystemic wasting syndrome (PMWS), an economically important wasting disease of young pigs [J. Vet. Diagn. Invest. 12 (2000) 3]. Gross lesions of PMWS include generalised lymphadenopathy, hepatitis, nephritis and pneumonia and typical histological lesions include lymphocytic depletion and multinucleated giant cell formation in lymph nodes, degeneration and necrosis of hepatocytes, and multifocal lymphohistocytic interstitial pneumonia. This communication will review the results of experimental infections of gnotobiotic (GN), colostrum-deprived (CD) and colostrum-fed (CF) pigs within our group, and elsewhere, with PCV2 and the conclusions that can be drawn from this work.

In vitro studies on the infection and replication of porcine circovirus type 2 in cells of the porcine immune system

Porcine circovirus type 2 (PCV2) nucleic acid and/or antigens are consistently observed in cells of monocytic morphology in lesions of pigs affected by post-weaning multisystemic wasting syndrome (PMWS). In this study, PCV2 antigen was detected in the cytoplasm of monocytes, pulmonary macrophages (PMs) and monocyte-derived macrophages exposed to the virus in vitro, by immunofluorescence analysis (IFA) and the phenotype of these cells confirmed by detection of monocytic cell surface markers using flow cytometry. Viral antigen was not observed in lymphocytic cells. Replication of the virus in PMs was investigated further by comparison to that observed in the continuous pig kidney cell line (PK15A) using quantitative virus titration, quantitative PCR and by the detection of double stranded DNA intermediates of viral replication by Southern blotting analyses. Although increases in viral DNA and levels of infectious virus progeny and the presence of replicative intermediates, indicative of viral replication, were observed in PK15A cells, no such changes were observed in PMs in spite of the fact that infectious virus, viral antigen and viral DNA persisted in the cells for at least the duration of the experiment. These results suggest that in vivo, monocytic cells may not represent the primary target for PCV2 replication.

Body mass index and mortality in 'healthier' as compared with 'sicker' haemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

BACKGROUND

Haemodialysis (HD) patients with lower body mass index (BMI) have a higher relative mortality risk (RR), irrespective of race. However, only Asian Americans treated with HD have been found to have an elevated RR with higher BMI. Asian Americans on HD are 'healthier' than other race groups (i.e. have better overall survival). We hypothesized that an increased mortality risk might be associated with high BMI in a variety of other 'healthier' subgroups of HD patients.

METHODS

The prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) provided baseline demographic, comorbidity and BMI data on 9714 HD patients in the US and Europe (France, Germany, Italy, Spain, and the UK) from 1996-2000. Using multivariate survival analyses, we evaluated BMI-mortality relationships in HD subpopulations defined by continent, race (black and white), gender, tertiles of severity of illness (based on a score derived from comorbid conditions and serum albumin concentration), age (<45, 45-64, >or=65), smoking, and diabetic status.

RESULTS

Relative mortality risk decreased with increasing BMI. This was statistically significant (P<0.007) except for the smallest subgroup of patients who were <45 years old and were also in the healthiest tertile of comorbidity. All else equal, BMI <20 was consistently associated with the highest relative mortality risk. Overall a lower relative mortality risk (RR) as compared with BMI 23-24.9, was found for overweight (BMI 25-29.9; RR 0.84, P=0.008), for mild obesity (BMI 30-34.9; RR 0.73, P=0.0003), and for moderate obesity (BMI 35-39.9; RR 0.76, P=0.02).

CONCLUSION

In a wide variety of HD patient subgroups, differing with respect to their baseline health status, increasing body size correlates with a decreased mortality risk. This contrasts with the association between BMI and mortality in the general population, and deserves further study.

Summary of workshop findings for porcine myelomonocytic markers

About 65 monoclonal antibodies (mAb) including 17 internal controls were analyzed for their ability to recognize and bind to various cells of the myelomonocytic lineage. Flow cytometry (FCM) utilizing both single and double staining, and immunoprecipitation (IP) assays were used in the analysis. About 38 of the mAb were reactive with myelomonocytic cells, resulting in nine clusters of interest. Although the exact identity of many of the molecules on the cells bound by the mAb remains undetermined, information obtained about the mAb analyzed in this workshop should be helpful in further identifying various populations of myelomonocytic cells and their stages of differentiation. Out of 12 mAbs with potential CD11 specificity, seven were assigned to three different swine specific alpha chains of the CD11/CD18 integrin heterodimer, the assignment of the remaining four was tentative. One antibody had a binding specificity consistent with SWC3 and one with SWC8. CD14 expression on pig cells was characterized with a panel of CD14-positive antibodies, two of these antibodies were assigned to swine CD14. Two antibodies were assigned to CD163. Further work is required to determine the antigens recognized by many of the other mAb.

Workshop studies on monoclonal antibodies in the myeloid panel with CD11 specificity

Several putative anti-human and swine CD11-specific monoclonal antibodies (mAbs) were included in the myeloid section of the Third International Swine CD Workshop. Failure of clustering analysis to group these mAbs together prompted additional analyses to define the specificities of these mAb. Combination of one and two-color flow cytometry (FCM) and immunoprecipitation (IP) allowed the definition of the mAb into three CD11 groups. Cellular distribution of the molecules recognized by anti-human CD11b and c mAbs on swine cells proved to be significantly different from that found in humans.

[Potency testing of veterinary vaccines, rabies vaccines as an example]

Vaccines which are produced commercially should be controlled with respect to their efficacy (potency) and their "harmlessness" to the recipient animal. The basis for any potency test is the protection test in the target animal species. When a vaccine has been shown to be capable of protecting a particular species from a certain disease, alternative methods for potency testing often can be developed. The justification of the latter is that experiments which analyze the protection are cost-intensive, require a large number of animals and give only a moderate degree of reproducibility. Methods such as protection experiments in laboratory animals, the induction of the substances responsible for protection (such as antibodies) in target or laboratory animals as well as with in vitro tissue culture systems, or the quantitative determination of the immunogens (the components of a vaccine which should be responsible for protection) may be used only if their results correlate with those obtained from protection experiments in the target animal species. Rabies glycoprotein has been implicated as the main agent responsible for the induction of protection against rabies. The higher the content of glycoprotein in a rabies vaccine, the greater will be the potential of the vaccine to induce protection against the disease. Analyses of the rabies glycoprotein content in vaccines can make use of a number of methods which have proven acceptable (the immunodiffusion test, the antibody binding assay and the ELISA). However, in veterinary medicine most vaccines are associated with an adjuvant - a substance which should amplify the immune response of an animal against a vaccine. Since the adjuvants and vaccines in such preparations are inseparable, the presence of an adjuvant in a vaccine reduces the applicability of many in vitro methods. Thus, the above mentioned methods and possibilities for their adaptation to the analysis of adjuvanted vaccines will be discussed.

Predicting death from ruptured abdominal aortic aneurysms

BACKGROUND

We have previously reported preoperative and immediate postoperative formulae to estimate mortality in patients with ruptured abdominal aortic aneurysms (rAAA). In this study, we prospectively compared these formulae in patients with rAAA with their actual outcomes.

METHODS

Information was collected on 134 patients from two centers over a 3-year period. Preoperative mortality risk was estimated using coefficients for age, level of consciousness, and cardiac arrest. Mortality risk in the immediate postoperative state was based on the presence of coagulopathy, ischemic colitis, prolonged requirement for inotropes, time from arrival at hospital to surgery, patient age, perioperative myocardial infarction, renal failure, and pre-operative hemoglobin level.

RESULTS

The average age was 73 years (range 30 to 92 y) and 20 of 134 (15%) patients were women. Sixty-three patients (47%) survived. For patients with a calculated preoperative mortality risk of >90%, the sensitivity, specificity, and positive and negative predictive values were 25%, 98%, 95%, and 54%, respectively. For a mortality risk >80%, these values were 37%, 94%, 87%, and 57%, respectively. For patients with an estimated immediate postoperative mortality risk > or = 90%, the sensitivity, specificity, and positive and negative predictive values were 17%, 87%, 60%, and 49%, respectively. For a predicted mortality > or = 80%, these values were 22%, 84%, 60%, and 50%, respectively.

CONCLUSIONS

Our formula for predicting mortality for preoperative rAAA patients may be useful for patients with an estimated mortality risk >/=90%, based on the high positive predictive value. The formula for immediate postoperative rAAA patients was not useful in predicting death.

Interspecies major histocompatibility complex-restricted Th cell epitope on foot-and-mouth disease virus capsid protein VP4

T-cell epitopes within viral polypeptide VP4 of the capsid protein of foot-and-mouth disease virus were analyzed using 15-mer peptides and peripheral blood mononuclear cells (PBMC) from vaccinated outbred pigs. An immunodominant region between VP4 residues 16 and 35 was identified, with peptide residues 20 to 34 (VP4-0) and 21 to 35 (VP4-5) particularly immunostimulatory for PBMC from all of the vaccinated pigs. CD25 upregulation on peptide-stimulated CD4(+) CD8(+) cells-dominated by Th memory cells in the pig-and inhibition using anti-major histocompatibility complex class II monoclonal antibodies indicated recognition by Th lymphocytes. VP4-0 immunogenicity was retained in a tandem peptide with the VP1 residue 137 to 156 sequential B-cell epitope. This B-cell site also retained immunogenicity, but evidence is presented that specific antibody induction in vitro required both this and the T-cell site. Heterotypic recognition of the residue 20 to 35 region was also noted. Consequently, the VP4 residue 20 to 35 region is a promiscuous, immunodominant and heterotypic T-cell antigenic site for pigs that is capable of providing help for a B-cell epitope when in tandem, thus extending the possible immunogenic repertoire of peptide vaccines.

Delta opioid binding selectivity of 3-ether analogs of naltrindole

Masking of the 3-phenol of naltrindole as a range of ethers caused a decrease in binding affinity at all three opiate receptors (mu, kappa, delta), however for the methyl ether, the reduction in affinity at both mu and kappa was greater than at delta, thereby increasing delta binding selectivity.

Synthesis and biological activity of 3-substituted 3-desoxynaltrindole derivatives

The 3-unsubstituted and substituted analogs of naltrindole (NTI) were synthesized using palladium-catalyzed transformations, and their binding affinity to opioid receptors was determined. Although the 3-desoxy analog showed comparable delta selectivity with that of NTI, all of the novel compounds possessed low affinity for delta receptors indicating the important role of the 3-oxygen atom of NTI for interaction with delta-opioid receptors.

Porcine myelomonocytic markers: summary of the Second International Swine CD Workshop

Forty five mAbs submitted to the Second International Swine CD workshop were analyzed by six different laboratories for their possible reactivity with porcine myelomonocytic cells using flow cytometry and immunohistochemistry. As a result of these analyses, a new swine workshop cluster, SWC9, composed of two mAbs that recognize an antigen selectively expressed on mature macrophages, was defined. In addition, several mAbs were identified, allowing the differentiation of granulocytes from monocytes/macrophages, or monocytes from macrophages. Further work is required to identify the antigen recognized by these mAbs. Nevertheless, they should already prove useful for the identification of different stages in the macrophage maturation/differentiation, and will certainly aid analyses on the complexity of the mononuclear phagocyte system in the pig. Finally, the cross-reactivity of three anti-human CD14 mAbs with porcine myelomonocytic cells was established in this workshop.

Summary of the first round analyses of the Second International Swine CD Workshop

The reactivity of 176 monoclonal antibodies (mAb) submitted to the Second International Swine CD Workshop, together with 19 internal standards, was analyzed by flow cytometry on 16 different cell types as a means of establishing the proper cell subset for later detailed clustering analyses. The exact CD subset reactivity of the 19 internal standard mAb had been characterized in the First International Swine CD Workshop. The flow cytometric analyses resulted in 40 data sets which were then subjected to statistical clustering using the Leukocyte Typing Database IV (LTDB4) software. As result of this work, 22 clusters were defined. After review of these results, panels of mAb from the defined first round clusters were assigned to cell subsets. The respective mAb in those first round clusters were then distributed to subset group researchers for further examination during the second round of the workshop.

Workshop studies with monoclonal antibodies identifying a novel porcine differentiation antigen, SWC9

Two monoclonal antibodies (mAb) within cluster M4 of the myeloid section of the Second International Swine CD Workshop, C4 (No. 144) and PM18-7 (No. 192), showed reactivity with thymocytes and among cells of myelomonocytic origin with mature macrophages but not with monocytes and granulocytes. Both mAb recognize a protein showing two bands of 205 kDa and 130 kDa under both reducing and non-reducing conditions. Although epitope mapping with these mAb could not be performed, this cluster received the SWC9 designation.

The efficacy of intra-articular morphine for postoperative knee arthroscopy analgesia

This article describes two prospective, randomized, double-blind clinical trials designed to investigate this. Trial 1 compared a conventional local anaesthetic agent (100 mg bupivacaine) injected intra-articularly (i.a.) with a control (normal saline) and 1 mg of i.a. morphine. No significant difference was noted in the first 4 hours between the groups with respect to visual analogue pain (VAS) scores. However, at 6 and 24 hours, the group of patients who received 1 mg i.a. morphine recorded lower pain scores and required less supplementary analgesia. Trial 2 assessed the dose response relationship for i.a. morphine comparing 5 mg intravenous (i.v.) morphine (control) with 1 mg and 5 mg i.a. morphine. At early time points (1, 2, and 4 hours) similar VAS pain scores were recorded for both 5 mg i.v. morphine and 5 mg i.a. morphine, both significantly lower than the group receiving 1 mg i.a. morphine. At 6 and 24 hours, 5 mg of i.a. morphine produced significantly lower pain scores, less analgesic requirement, and less sleep disturbance on the first postoperative night than the other groups. It can be concluded from these two studies that 5 mg i.a. was the most effective analgesic following knee arthroscopy.

Peptide binding to MHC class I is determined by individual pockets in the binding groove

H-2Kb and HLA-A2 are MHC4 class I molecules with a similar overall structure. Important differences between these two class I molecules reside in the structure of the individual pockets in the antigenic-peptide-binding groove. H-2Kb, which has a deep C pocket, binds specifically peptides with a tyrosine or a phenylalanine at position 5. In contrast, HLA-A2 has a shallow C pocket, which cannot accommodate large side chains at position 5. Site-directed mutagenesis was used to generate a chimera between the murine H-2Kb and the human HLA-A2 [H-2Kb/HLA-A2(C')]. The structure of this chimera is similar to H-2Kb except for the region around the deep C pocket, where residues at positions 9, 97 and 99 were substituted with those bulkier residues from HLA-A2. Peptide binding between this chimera and H-2Kb-binding peptides [VSV (52-59), OVA (257-264), and MCMV pp89 (168-176)], revealed that the deep C pocket of H-2Kb was crucial for high-affinity binding. While a peptide, VSV (52-59), was found to bind with severalfold lower 'affinity' to H-2Kb/HLA-A2(C') than to the wild-type H-2Kb, a VSV analogue with the tyrosine in position 5 (Tyr5) substituted with an alanine was found to bind with a similar 'affinity' to both MHC class I molecules. Computer-aided modelling of the H-2Kb/HLA-A2(C') complex indicates that the VSV (52-59) peptide probably binds to the chimeric MHC molecule with the peptide side chain of anchor residue Tyr5 pointing away from the groove. These results confirm a role of the individual pockets in determining peptide-binding affinity and specificity and suggest that this may be accomplished by changes in side-chain orientation.

Injuries to the ulnar carpometacarpal region: are they being underdiagnosed?

Thirteen cases with radiographic evidence of injury to the ulnar side of the hand are reviewed. These injuries included intraarticular fractures and/or dislocations of the fourth and fifth carpometacarpal joints and associated bones collectively discussed here as the ulnar carpometacarpal region. In nine the extent of the injury was not appreciated on first presentation. Injuries to this region are often difficult to assess clinically and radiographically even in experienced hands. In our experience computerized tomography (CT) scans in the longitudinal and longitudinal oblique axis best display the ulnar carpometacarpal joint surfaces and their relationship to each other. We recommend CT of the ulnar carpometacarpal region where clinical evidence of an injury to this region is not in keeping with the plain radiographic findings, and when planning surgery on a complex injury in this region.

The antibody MY4 recognizes CD14 on porcine monocytes and macrophages

Several monoclonal antibodies directed against the human CD14 antigen have been established. We now report that the antibody My4, but not LeuM3, reacts with porcine monocytes. Among porcine peripheral blood mononuclear cells (PBMC), 14.6% of the cells stain with the CD14 antibody My4, which is similar to the percentage obtained with the antiporcine monocyte antibody 74-22-15. Two-colour immunofluorescence reveals that My4 and 74-22-15 antigens are coexpressed on the same cells, and cell sorter-purified My4+ cells exhibit the morphology of monocytes. Whole blood analysis (which also shows staining of granulocytes) reveals that the average percentage of My4+ monocytes amongst all leucocytes is 5.8% with 580 cells/microliters. Furthermore, porcine peritoneal macrophages (PM) and alveolar macrophages (AM), both stain for My4, with a four-fold lower level on AM. Treatment of cells with phosphatidylinositol-specific phospholipase C decreases My4 staining, but does not affect staining with antibody 74-22-15. Immunoprecipitation with the My4 antibody from surface labelled pig mononuclear cells demonstrates a 54 kDa band similar to human CD14, and Western blotting with pig serum demonstrates two bands similar to the alpha and beta forms of human soluble CD14. Finally, the My4 antibody is capable of blocking lipopolysaccharide- (LPS)-induced interleukin-6 production in isolated PBMC. These data show that the My4 antibody recognizes genuine CD14 on porcine monocytes and macrophages.

The enhancement of lymphocyte localization in skin sites of sheep by tumor necrosis factor alpha

Using radiolabelled lymphocytes, we have demonstrated that recombinant bovine TNF alpha is potent in its ability to recruit lymphocytes from the blood into TNF alpha injected skin sites. Furthermore, TNF alpha mediates this observed increase in lymphocyte accumulation in a clear dose-response manner, and may play an important role in the mediation of DTH reactions in the skin.

Recombinant bovine interferon-gamma enhances expression of class I and class II bovine lymphocyte antigens

Recombinant bovine interferon-gamma augments expression of class I and class II histocompatibility antigens on the surface membrane of bovine lymphocytes. Immunofluorescence techniques using a series of monoclonal anti-HLA antibodies demonstrate that this enhancement is detectable as early as 24 h after incubation with rBoIFN, while maximum surface expression is obtained within 3-5 days. A concentration as low as 10 units of rBoIFN is effective. Such results may be useful for characterizing the BoLA gene products.

Effects of acute and chronic acyclovir on canine renal function

Acyclovir-associated renal dysfunction is difficult to study in humans because it occurs in patient populations who are generally receiving multiple medicines concurrently and dysfunctions occur infrequently. We studied the effects of two regimens of acyclovir treatment, a short-term high dose (210 mg/kg/day for 43 hr) via constant infusion and a chronic lower dose by intermittent infusion (15 mg/kg, 3 times/day for 28 days), on selected renal functions in dogs. Urine concentrating capacity as compared to base-line and controls declined during both the short-term (40% decline) and chronic treatments (36% decline). The persistence of the concentrating deficit in the presence of stimulation with vasopressin suggested that the defect resided in the renal response to vasopressin. Glomerular filtration rates significantly decreased during the acute high-dose treatment (from 104 +/- 15 to 87 +/- 11 ml/min) but not during the chronic low-dose treatment. Both acyclovir treatments were associated with a small but significant decline (approximately 10% for both studies) in the plasma potassium concentrations although an increase in urine potassium clearance could not be demonstrated. We conclude that acyclovir can cause renal dysfunction in healthy animals at plasma concentrations higher but comparable to those achieved clinically. Although both treatment regimens decreased renal function, the shorter high-dose regimen which maintained acyclovir plasma concentrations was more detrimental than the longer exposure to a lower dose of the drug given intermittently. The data suggest that renal dysfunction is not related to a rare sensitivity, as all acyclovir-treated animals showed subtle decrements in renal function.

Antiviral and antigenic properties of recombinant porcine interferon gamma

Recombinant porcine interferon gamma (rPoIFN gamma) induced a dose-dependent inhibition of the cytopathic effect produced by vesicular stomatitis virus (VSV) challenge of both homologous and heterologous (bovine) cell lines. In addition, an antiviral effect of rPoIFN gamma was demonstrable against the coronavirus transmissible gastroenteritis virus (TGEV) infection of porcine epithelial cells and of pulmonary macrophages. A rabbit anti-PoIFN gamma antiserum was prepared and shown to specifically neutralize the antiviral effects of natural and recombinant porcine IFN gamma preparations. This antiserum could also neutralize recombinant bovine IFN gamma but not recombinant human IFN gamma. These results suggest antigenic homology of porcine and bovine IFN gamma but antigenic differences between these molecules and human IFN gamma.

Recombinant bovine interferon-alpha I 1 inhibits the migration of lymphocytes from lymph nodes but not into lymph nodes

Recombinant bovine interferon-alpha I 1 (IFN-alpha) was tested for effects on lymphocyte migration into and out of the lymph nodes of sheep. Chronic lymph drainage methods were used to monitor the efferent lymph of single lymph nodes of unanaesthetized animals. When IFN-alpha was injected into the drainage area of the lymph node, infused directly via an afferent lymphatic, or injected intravenously, a marked decrease in cell output was observed. Nanogram quantities of IFN-alpha produced an effect that lasted several hours. To test whether this effect was specific for lymphocytes, we first stimulated a lymph node with Staphylococcus aureus so that large numbers of neutrophils and lymphocytes were present in efferent lymph. When IFN-alpha was then injected, the lymphocytes disappeared from efferent lymph but the neutrophils did not. Normal efferent lymph cells were labeled with radioisotopes and injected intravenously during the IFN-alpha induced effect. The entry of lymphocytes from the blood was significantly enhanced at a time coinciding with the suppressed cell exit in the efferent lymph. Recovery data indicated that the lymphocytes were retained temporarily in the lymph node but were not destroyed. Furthermore, the bovine IFN-alpha does not appear to be conspicuously antigenic in sheep. It is not yet certain whether IFN-alpha enhances the interactions of cells within the lymph node thereby potentiating immunologic reactions.

Non-invasive assessment of left internal mammary-coronary bypass patency using the external Doppler probe

Non-directional blood velocity of left internal mammary bypass grafts was non-invasively studied with the Doppler ultrasonic probe. Thirteen of 14 subjects had angiographic evidence of bypass graft patency and their Doppler signals demonstrated high amplitude phasic blood velocities. A single patient with proximal left internal mammary arterial graft occlusion manifested marked attenuation of Doppler blood velocity signals. It is concluded that this technic offers a potential for ambulatory and in-office screening of internal mammary artery bypass graft function.