[Ratification of UE 4.4 S4 "simulated blood transfusion": inquiry and answers]. / Validation de l'UE 4.4 S4 "pose de transfusion sanguine en situation simulée:: une enquête et des réponses.

The new training reference guide related to state registered degree has been applied since 31 July 2009. Training and valuation projects developed by nurse training institutes have been amended to comply with learning concept: understanding-action-transfer. Validation of grade 4.4 S4 is part of competence 4 validation "implementation of actions related to diagnostic and therapy". The requirement for all students to ratify simulated transfusion lead teachers to update their knowledge and to be more committed to knowledge acquisition. To complete its work, the research and quality control department of the French Transfusion Company regarding the result of the national 2011 inquiry, proposes in relation with the National Transfusion Institute to provide the professional network with tools and supports making knowledge exchanges and experience sharing easier. The reference transfusional teaching guide updating intended to training institutes is being carried out and considered as a priority.

ABO blood group and related antigens, natural antibodies and transplantation.

The current success rate of transplant surgery and immunosuppression has led to a demand for organs that has outstripped the supply. This has required investigation of alternate strategies. Therefore, allotransplantation across the ABO blood group barrier has commenced, and pig-to-human xenotransplantation is under consideration. The first immunological barrier to both these types of transplantation is the prevention of the antibody-mediated rejection. This rejection is a result of natural preformed antibodies circulating in the serum of the recipient binding to either ABO (for allo) or alpha-galactose (alpha-Gal) (for xeno) antigens expressed on the donor tissue. These antibodies recognise antigens that are, in both cases, carbohydrate molecules with the characteristic feature that the nonreducing terminal carbohydrate is either a Gal or N-acetlygalactosamine residue in an alpha1,3 linkage. These epitopes are synthesised by closely related members of a single family of glycosyltransferases. This review discusses the carbohydrate antigens, the enzymes involved in their synthesis and the consequences of natural antibodies binding these antigens.

Evidence for structurally conserved recognition of the major carbohydrate xenoantigen by natural antibodies.

Natural or preformed antibodies that react with oligosaccharides bearing terminal galactose-alpha(1,3)-galactose [Gal alpha(1,3)Gal] stuctures are present in the sera of all humans. Antibodies against Gal alpha(1,3)Gal epitopes initiate hyperacute rejection of xenografts of porcine organs in human recipients. Despite the enormous clinical potential for xenotransplantation, very little is known about the 3D structural basis for natural antibody recognition of the major xenoantigen (i.e. Gal alpha(1,3)Gal). In this review, we discuss general binding patterns that have been repeatedly identified in antibody complexes with small molecules (haptens), carbohydrate and peptide ligands because similar mechanisms will almost certainly mediate recognition of the major xenoantigen by natural antibodies.

LFA-1 and ICAM-1 antibody-idarubicin conjugates separately prolong murine cardiac allograft survival.

Drug antibody conjugates can enhance the activity of monoclonal antibodies (MoAb) and idarubicin-MoAb conjugates have led to tolerance induction with antibodies which are inactive when used alone. It has been reported that, in mice, antibodies to ICAM-1 and LFA-1 have to be used together to induce tolerance to cardiac allografts; here we show that these monoclonal antibodies, conjugated to idarubicin, can lead to tolerance induction to cardiac allografts when used alone.

Tolerance in baboon kidney transplantation with total lymphoid irradiation (TLI) and anti-CD3/CD4-idarubicin conjugates.

BACKGROUND: We previously reported the induction of transplantation tolerance by a modified wide field method of pretransplant total lymphoid irradiation (TLI), cumulative dose 800 cGy, given as 80 or 100 cGy fractions twice/week, in approximately one-third of chacma baboons receiving liver or kidney allografts (1-4) and in vervet monkeys receiving baboon kidney xenografts (5). In this study, the effects of the administration of brief courses of anti-CD3 or CD4-Idarubicin conjugates on the frequency and predictability of tolerance induction by TLI were examined. METHODS: TLI was administered pretransplant in doses of 800, 600, or 400 cGy. The conjugates were administered either after transplantation in doses of 0.25 mg/kg body weight, 3 times/week for 2 weeks, or as a single dose of 1.0 mg/kg body weight 24 hr before transplantation. RESULTS: Operational tolerance, defined as normal graft function >1 year after transplantation, was obtained in one-half of six baboons receiving the single dose of 1 mg/kg of Idarubicin conjugate pretransplant after 800 cGy of TLI and also in one of four baboons treated with 400 cGy of TLI and a single dose of anti-CD3 conjugate before transplantation. By contrast, administration of the conjugated antibodies 3 times/week for 2 weeks after transplantation prevented tolerance induction in all animals, providing further evidence for the involvement of active mechanisms, capable of inhibition by immunosuppressive agents, in tolerance induction with TLI, and of relevance to our reported clinical experience with TLI (6). CONCLUSIONS: These promising findings invite further studies with a larger number of animals and additional brief regimens of irradiation and antibody dosages and specificities.

Characteristics of immunoglobulin gene usage of the xenoantibody binding to gal-alpha(1,3)gal target antigens in the gal knockout mouse.

BACKGROUND: Natural antibodies that react with galactose-alpha(1,3)galactose [galalpha(1,3)gal] carbohydrate epitopes exist in humans and Old World primates because of the inactivation of the alpha1,3-galactosyltransferase (alpha1,3GT) gene in these species and the subsequent production of antibodies to environmental microbes that express the galalpha(1,3)gal antigen. The Gal knockout (Gal o/o) mouse, produced by homologous disruption of the alpha1,3GT gene, spontaneously makes anti-galalpha(1,3)gal antibodies and can be used to study the genetic control of humoral immune responses to this carbohydrate epitope. METHODS: Six hybridomas that produce monoclonal antibodies (mAbs) to galalpha(1,3)gal were generated in Gal o/o mice. The mAbs were tested to characterize the binding activity with flow cytometry using pig aortic endothelial cells and ELISA with galalpha(1,3)gal carbohydrates. The VH and VK genes of these hybridomas were cloned, sequenced, and analyzed. RESULTS: The mAbs showed distinct patterns of antibody binding to galalpha(1,3)gal antigens. The VH genes that encode the mAb binding activity were restricted to a small number of genes expressed in their germline configuration. Four of six clones used closely related progeny of the same VH germline gene (VH441). Comparison of the mouse gene VH441 to the human gene IGHV3-11, a gene that encodes antibody activity to galalpha(1,3)gal in humans, demonstrates that these two genes share a nonrandom distribution of amino acids used at canonical binding sites within the variable regions (complimentary determining regions 1 and 2) of their immunoglobulin VH genes. CONCLUSIONS: These results demonstrate the similarity of the Gal o/o mice and humans in their immune response to galalpha(1,3)gal epitopes. Gal o/o mouse can serve as a useful model for examining the genetic control of antibody/antigen interactions associated with the humoral response to pig xenografts in humans.

The cytoplasmic tail of alpha 1,2-fucosyltransferase contains a sequence for golgi localization.

The Golgi apparatus has a central role in the glycosylation of proteins and lipids. There is a sequential addition of carbohydrates by glycosyltransferases that are distributed within the Golgi in the order in which the glycosylation occurs. The mechanism of glycosyltransferase retention is considered to involve their transmembrane domains and flanking regions, although we have shown that the cytoplasmic tail of alpha1,2-fucosyltransferase is important for its Golgi localization. Here we show that the removal of the alpha1,2-fucosyltransferase cytoplasmic tail altered its function of fucosylation and its localization site. When the tail was removed, the enzyme moved from the Golgi to the trans Golgi network, suggesting that the transmembrane is responsible for retention and that the cytoplasmic tail is responsible for localization. The cytoplasmic tail of alpha1,2-fucosyltransferase contains 8 amino acids (MWVPSRRH), and mutating these to alanine indicated a role for amino acids 3 to 7 in localization with a particular role of Ser(5). Mutagenesis of Ser(5) to amino acids containing an hydroxyl (Tyr and Thr) demonstrated that the hydroxyl at position 5 is important. Thus, the cytoplasmic tail, and especially a single amino acid, has a predominant role in the localization and thus the function of alpha1,2-fucosyltransferase.

Genetic engineering for xenotransplantation.

Xenotransplantation is being pursued vigorously to solve the shortage of allogeneic donor organs. Experimental studies of the major xenoantigen (Gal) and of complement regulation enable model xenografts to survive hyperacute rejection. When the Gal antigen is removed or reduced and complement activation is controlled, the major barriers to xenograft survival include unregulated coagulation within the graft and cellular reactions involving macrophages, neutrophils, natural killer (NK) cells, and T lymphocytes. Unlike allografts, where specific immune responses are the sole barrier to graft survival, molecular differences between xenograft and recipient that affect normal receptor-ligand interactions (largely active at the cell surface and which may not be immunogenic), are also involved in xenograft failure. Transgenic strategies provide the best options to control antigen expression, complement activation, and coagulation. Although the Gal antigen can be eliminated by gene knockout in mice, that outcome has only become a possibility in pigs due to the recent cloning of pigs after nuclear transfer. Instead, the use of transgenic glycosyl transferase enzymes and glycosidases, which generate alternative terminal carbohydrates on glycolipids and glycoproteins, has reduced antigen in experimental models. As a result, novel strategies are being tested to seek the most effective solution. Transgenic pigs expressing human complement-regulating proteins (DAF/CD55, MCP/CD46, or CD59) have revealed that disordered regulation of the coagulation system requires attention. There will undoubtedly be other molecular incompatibilities that need addressing. Xenotransplantation, however, offers hope as a therapeutic solution and provides much information about homeostatic mechanisms.

Determination of prefracture physical function in community-dwelling people who fracture their hip.

BACKGROUND: Prefracture physical function must be accurately determined to set appropriate and attainable goals for rehabilitation following hip fracture. This is especially important for people who were living independently prior to their fracture. This study determines reliability and internal consistency of a prefracture physical function questionnaire (PFPFQ) completed by both patients and knowledgeable informants (KIs). METHODS: A 20-item PFPFQ, including ambulation, transfers, balance, and self-care domains, was developed using focus groups. Community-dwelling patients with a hip fracture (N = 40, 77.9 +/- 8 years) completed the PFPFQ on two occasions during postoperative acute care. Forty KIs were identified by the patients and also completed the PFPFQ on two occasions via telephone interview. Day-to-day reliability of the patients and KIs [intraclass correlation coefficients (ICC)], and internal consistency [Kuder-Richardson coefficient (KR)] of the PFPFQ were determined. RESULTS: Intrarater reliability was high with ICCs (95% confidence interval) of 0.94 (0.89, 0.96) for patients and 0.96 (0.93, 0.98) for KIs. Interrater reliability on occasion 1 had an ICC of 0.81 (0.69, 0.88). Internal consistency of the patient responses on the first occasion was high (KR coefficient = 0.896). CONCLUSIONS: The PFPFQ is a reliable and internally consistent instrument for determining prefracture physical function in community-dwelling people who fracture their hip. In situations where patients with a hip fracture are unable to provide this necessary information, KIs can provide reliable estimates of prefracture function to assist in setting appropriate rehabilitation goals.

Fucosyl transferase (H) transgenic heart transplants to Gal-/- mice.

BACKGROUND: We have previously described the rejection of Gal+ mouse hearts by mice lacking Gala(1,3)Gal (Gal-/-) and demonstrated this to be a model of xenogeneic hyperacute rejection (HAR) which would occur in pig-to-human/primate xenotransplantation, where Gal+ antibody (Ab) and complement (C') mediate HAR. To reduce the amount of Gal present we used fucosyl transferase (H) as a transgene, H transferase competes for the same substrate as Gal transferase and reduces Gal expression by >90%. METHODS: Gal-/- mice received a heart graft from C57BL/6 Gal+ or H transgenic mice and additional Gal Ab and C' provided; HAR was monitored by direct observation for up to 90 min, or by palpation thereafter. When grafts were rejected they were examined macro- and microscopically. RESULTS: H transgenic mice were used as donors to Gal-/- mice; it was found that: 1) C57BL/6 or H transgenic hearts were not rejected by Gal-/- recipients within 90 min in the absence of additional Gal Ab. 2) If additional Gal Ab and C' were provided as fresh normal human serum (NHS), Gal+ (C57BL/6) grafts were rejected by Gal-/- mice in approximately 34 min, whereas H transgenic hearts mostly lasted up to 17 hr, but were then rejected. The histological appearances showed features of both Arthus and Shwartzmann phenomena. 3) Mice hyperimmunized with Gal with anti-Gal titers of >1:20,000, rejected Gal+ grafts in 31 min; the survival was prolonged to 75 min with the H transgenic hearts. CONCLUSION: The presence of the H transgene in donor hearts transplanted to naive Gal-/- mice delays the onset of HAR, but rejection ultimately occurs; if the mice are hyperimmune earlier rejection occurs. The expression of the H transgene alone is insufficient to avoid HAR in the Gal-/- mouse model; the presence of other transgenes and techniques will be required to give an appropriate increase in survival of pig-to-human/primate grafts.

The immune response of mice and cynomolgus monkeys to macaque mucin 1-mannan.

Mice immunised with human epithelial mucin MUC1 coupled to oxidised mannan produce MUC1 specific MHC Class 1 restricted CD8(+) cytotoxic T cells and are completely protected from the development of MUC1(+) tumours; such therapy may be applicable to humans. In this light we describe pre-clinical studies in cynomolgus monkeys (Macaca fascicularis), to test the efficacy of mannan-MUC1 in higher primates. Monkey MUC1 genomic clones were isolated from a macaque library, peptides and fusion protein synthesised and mice and monkeys immunised with macaque MUC1-mannan. In mice CTL responses were induced (as has been found with human MUC1 mannan conjugates), but in contrast monkeys produced a humoral response, with no T cell proliferative, cytotoxic responses or CTLp found. In spite of the presence of anti-MUC1 auto-antibodies, there was no toxicity or induction of autoimmunity.

Inhibition of hyperacute transplant rejection by soluble proteins with the functional domains of CD46 and FcgammaRII.

BACKGROUND: Recombinant soluble forms of complement regulatory molecules, including the human complement regulatory protein CD46 (rsCD46), have been shown to inhibit hyperacute transplant rejection (HAR) and protect against complement-mediated inflammatory tissue damage. Similarly, recombinant soluble forms of the immunoglobulin receptor FcgammaRII (rsFcgammaRII) can attenuate antibody-mediated inflammatory responses. We have produced and tested the function of novel recombinant chimeric proteins that incorporate the functional domains of both CD46 (membrane cofactor protein, MCP) and the low affinity human IgG receptor FcgammaRII (CD32). METHODS: Two recombinant soluble chimeric proteins (CD46:FcR and FcR:CD46) were designed and produced using a human cell expression system. Their ability to protect cells against complement-mediated lysis (through the CD46 domain) and bind human IgG (through the Fc receptor domain) was assessed in vitro. They were also tested in vivo in the rat reverse passive Arthus reaction and a murine model of hyperacute cardiac transplant rejection. RESULTS: In vitro, the functional domains of the chimeric proteins each retained their activity. In vivo, the serum half-life of the recombinant chimeric proteins in mice was more than either rsCD46 or rsFcgammaRII. In the rat reverse passive Arthus reaction, intradermal injection of each recombinant protein substantially reduced inflammatory skin edema (>50%) and polymorphonuclear neutrophil infiltration (>90%). In the hyperacute rejection model, i.v. treatment with FcR:CD46 prevented complement-mediated rejection, macroscopic bruising, edema, and thrombosis more effectively than rsCD46. CONCLUSIONS: CD46/FcgammaRII bifunctional proteins have an improved ability to control complement-mediated hyperacute graft rejection and have therapeutic potential in other conditions involving antibody-mediated inflammation.

Ly6d-L, a cell surface ligand for mouse Ly6d.

The mouse Ly6 gene family encodes proteins found in lymphocytes and other cells. Some are involved in cell activation; no ligands have been found. A ligand for Ly6d (ThB) was identified on lymphocytes using microspheres loaded with Ly6d and the cDNA isolated from a spleen/thymus library by panning on Ly6d. The Ly6d ligand (Ly6d-L) is a nonglycosylated protein of 9 kDa of broad distribution, rich in cysteine, with no discernable transmembrane sequence. Its N and C termini are on the cell surface, where it associates with a 30 kDa protein. Ly6d-L is homologous with an EGF repeat of Notch.

Mimics and cross reactions of relevance to tumour immunotherapy.

MUC1 has been used as a target for immunotherapy and with oxidised mannan in mice there is selective delivery into the class I pathway and the induction of a T1 response. We have also been working in pig-to-human transplantation and of particular interest is the description in humans of natural Galalpha(1,3)Gal antibodies (Abs) which react with pig tissues. A peptide mimic (DAHWESWL) to the Galalpha(1,3)Gal sugar was found in a phage display library and is also mimicked by MUC1 peptides. It was of interest to note that while mice make cytotoxic T cells (CTLs) and little Ab to MUC1, humans make the reverse immune response. It was found that the cross reaction of the natural Galalpha(1,3)Gal Abs in humans to MUC1 was likely to be responsible for the diversion. Cross reactions are therefore an important problem in tumour immunotherapy, although the problem can be overcome by in vitro immunisations.

Recent advances in xenotransplantation.

The major barrier to clinically successful pig-to-human xenotransplantation is antibody- and complement-dependent hyperacute rejection, known to be due to host anti-Galalpha(1,3)Gal antibodies. Strategies aimed at eliminating hyperacute rejection involve transgenic approaches to eliminate or reduce expression of Galalpha(1,3)Gal or to reduce complement activation; some of these are now in clinical trials in primates. Another important role of Galalpha(1,3)Gal that is becoming more evident is in antibody-dependent and -independent xenograft rejection that is mediated by natural killer cells and monocytes.