Benign monoclonal gammopathy with IgG anti-DNA, anti-Sm and anti-F(ab')2 activity.

OBJECTIVE: To study anti-DNA idiotypic markers and anti-DNA activity in human monoclonal immunoglobulin proteins. METHODS: Seventy human IgG M-components intentionally selected for cationic electrophoretic characteristics were studied for F4 and 31 anti-DNA idiotypic markers and anti-DNA as well as anti-F(ab')2 antibody activity. RESULTS: Eight of 70 M-components showed significant anti-DNA activity. In two both anti-DNA and anti-F(ab')2 activity occurred together. One IgG-2 kappa M-component showed extremely high anti-ds DNA, anti-Sm, anti-F(ab')2 and anti-Sm/ RNP ELISA activity. Cross inhibition studies showed that each reactive antigen inhibited the other. N-terminal V-region sequencing showed the VH3, VK3 subgroup. Anti-idiotypic rabbit antibody produced against this M-component showed strong reactivity with affinity purified IgG anti-DNA and anti-F(ab')2 from most SLE patients and normal subjects. CONCLUSION: Monoclonal human immunoglobulins may contain multiple autoantibody specificities including anti-DNA; anti-Sm, anti-Sm/RNP, and anti-F(ab')2. Many antibodies with these specificities share common V-region antigens. Such relationships could contribute to idiotypic immune regulation and control.

Compensation to a department of medicine and its faculty members for the teaching of medical students and house staff.

BACKGROUND: Changes in the organization and financing of health care threaten to alter the prevailing system of financing the teaching of medical students and residents. Little information is available from private medical schools and teaching hospitals about the extent of teaching by faculty members or the mechanisms and levels of reimbursement for teaching. METHODS: We surveyed faculty members in the Department of Medicine at Columbia-Presbyterian Medical Center to ascertain the extent of their teaching activities. A standard number of hours was assigned to each activity, and the total number of teaching hours was calculated for each faculty member. Teaching of fellows and in continuing medical education programs was excluded. We also determined how much money the Department of Medicine received in payment for faculty members' teaching activities, and the sources of this compensation. RESULTS: In the 1992-1993 academic year, the 188 full-time faculty members spent a total of 46,086 hours teaching (mean [+/- SD], 245 +/- 178 hours per faculty member); 10,780 hours (23.4 percent) were spent teaching medical students, and 35,306 hours (76.6 percent) teaching house staff. Eighty percent of faculty members taught for 137 or more hours each. In a multivariate analysis including faculty rank, subspecialty division, years since graduation from medical school, sex, and tenure or clinical track, senior faculty members (P = 0.02), members of certain subspecialty divisions (P < 0.001), and women (P = 0.05) contributed more than the average number of teaching hours. An additional 56 non-full-time faculty members contributed a total of 5684 hours. The net reimbursement to the department for teaching totaled $965,808, or about $16 per hour of teaching by full-time faculty members, after the cost of fringe benefits was excluded. CONCLUSIONS: Faculty members of the department of medicine at a major medical center contribute a large number of hours teaching medical students and house staff. This effort is poorly compensated. Cost-containment efforts have the potential to jeopardize fragile social contracts at academic health centers whereby the faculty participates in teaching by contributing unreimbursed or underreimbursed time.

Characterization of a human monoclonal immunoglobulin M (IgM) antibody (IgMBEN) specific for Vi capsular polysaccharide of Salmonella typhi.

A search for human monoclonal antibodies to protective antigens of bacteria revealed an immunoglobulin M lambda chain [IgM(lambda); designated IgMBEN] reactive with the Vi capsular polysaccharide of Salmonella typhi. Vi, a linear homopolymer of alpha(1-->4)GalApNAc that is O acetylated at C-3, is a licensed vaccine for typhoid fever. Immunologic properties of IgMBEN were compared to those of burro globulin prepared by intravenous injections of S. typhi (B339-340). IgMBEN and B339-340 yielded identical precipitin lines with Vi by double immunodiffusion. IgMBEN and B339-340 produced similar precipitation results with Vi and its derivatives prepared by de-O-acetylation, carboxyl reduction, and removal or replacement of the N-acetyl at C-2 with O-acetyl. B339-340 yielded maximal precipitation with Vi (0.41 mg of antibody per ml with 1.4 micrograms of Vi); next was carboxyl-reduced, O-acetylated Vi, which precipitated 0.325 mg of antibody per ml with 2.5 micrograms of Vi. IgMBEN yielded maximal precipitation with de-O-acetylated, carboxyl-reduced Vi (approximately 11.0 mg of antibody per ml with approximately 1.3 micrograms of antigen); next were de-O-acetylated Vi (9.89 mg/ml) and Vi (9.19 mg/ml). The precipitin curves and equivalence points of these three antigens were similar. Pneumococcus type 1, which contains GalApNAc, did not precipitate with Vi or its derivatives. These slight differences in specificity between IgMBEN and B339-340 were related to our proposed structure of Vi. We plan to use IgMBEN as a reference for measurement of vaccine-induced Vi antibodies.

Human and mouse monoclonal antibodies to blood group A substance, which are nearly identical immunochemically, use radically different primary sequences.

A human monoclonal antibody (HuA) specific for blood group A substance with two fucose groups was found to be immunochemically almost identical with that of a previously characterized mouse monoclonal anti-A, AC-1001. The VH and VL chain cDNAs of HuA were sequenced and compared with those of AC-1001. The human and mouse antibodies used VH and Vk genes that came from different families and shared minimal nucleotide and amino acid sequence identity. Thus, two antibodies from two different species can use evolutionarily unrelated sequences to bind the same carbohydrate epitope. The cloned HuA VH and VL genes were then transfected into a mouse myeloma cell line and re-expressed, together, and each separately with an irrelevant VH or VL. Only the original HuA VH and Vk had anti-A activity, demonstrating that both the heavy and light chains contributed to specificity.

A monoclonal IgM kappa from a blood group B individual with specificity for alpha-galactosyl epitopes on partially hydrolyzed blood group B substance.

We have characterized a human monoclonal IgM kappa, designated IgMDON, from a blood group B individual. IgMDON is specific for alpha-galactosyl residues on blood group B substance; its fine specificity as defined by hemagglutination, quantitative precipitin, and inhibition ELISA assays was for the defucosylated terminal Gal(alpha 1-3)Gal epitope. Gal(alpha 1-3)Gal epitopes are also found on a variety of normal and pathogenic intestinal bacteria, and polyclonal IgG antibodies with the same specificity are found in the serum of nearly all normal individuals. The specificity of IgMDON was also quite similar to that of a human antiserum, serum 262, obtained by immunizing an individual with blood group B substance that had been subjected to mild acid hydrolysis (BP1). The possible ways whereby IgMDON might have arisen are discussed.

Women in academic medicine: perceived obstacles to advancement.

To investigate perceived obstacles to the advancement of women in academic medicine, we sent a questionnaire assessing perceptions of the fairness and supportiveness of the academic environment to the 229 female teaching and research faculty of the School of Physicians & Surgeons at Columbia University. The overall response rate was 85%. Forty-six percent believed that they had not had the same professional opportunities as their male colleagues, 52% believed that salaries were not equivalent for men and women in similar positions, and 50% believed that promotions were awarded in a biased manner. Thirty percent reported that sexist behavior was common and that sexual harassment occurred in the workplace. Eighty-one percent experienced conflicts between their professional and personal lives and most believed that the institution failed to adequately address the needs of women with children. This survey indicates that there are significant perceived obstacles to the advancement of women in academic medicine that must be addressed.

Results of conservative management of cervical intraepithelial neoplasia.

Cryotherapy and laser surgery have been the most frequently used conservative methods to treat cervical intraepithelial neoplasia (CIN) in the past decade. This report documents our experience using these modalities to treat 2773 patients between the years 1984-1989. One thousand eight hundred eleven women received laser surgery and the remaining 962 were treated with cryotherapy. In the first 2 years of the study period, only 78 patients were treated with laser surgery. Conversely, only 69 of the 979 patients treated in 1988 and 1989 had cryotherapy. As greater experience was gained with laser surgery, the success rates rose from 58.3% in 1984 to 95.5% in 1988. The success rate was similar for all grades of CIN. Overall, 11.2% of all patients were lost to follow-up. Among patients treated with laser surgery, 4.8% had postoperative bleeding that required either packing or, in two instances, sutures for hemostasis. Success with these methods appeared to be related to the size of lesion and not to the degree of histologic abnormality. The shift toward increasing use of laser surgery in our clinic was due to its precision in destroying identified lesions in the transformation zone. Our results indicate that both cryotherapy and laser surgery are simple, effective methods for the treatment of CIN.

VH gene usage in humans: biased usage of the VH6 gene in immature B lymphoid cells.

Preferential usage of JH-proximal VH genes has been demonstrated in immature murine B cell repertoires. To determine whether this phenomenon is also evident in human repertoires, we studied utilization of VH6, the most JH-proximal human VH gene. Examination of VH gene usage in a panel of precursor B cell acute lymphoblastic leukemia samples indicated that 15% of the IgH rearrangements utilized VH6. VH6 is a single-member family in a total repertoire of 100-200 VH genes; thus, if usage were purely random, one would expect VH6 rearrangement frequency to be less than 1%. Analysis of VH gene usage in normal lymphoid tissues also revealed biased usage of VH6. VH6 was preferentially utilized in 16- to 24-week-old fetal liver as compared to adult peripheral blood mononuclear cells or spleen. Possible implications of the conservation of preferential usage of JH-proximal genes in both immature murine and human repertoires are discussed.

The status of women at one academic medical center. Breaking through the glass ceiling.

Despite recent gains in admission to medical school and in obtaining junior faculty positions, women remain underrepresented at senior academic ranks and in leadership positions in medicine. This discrepancy has been interpreted as evidence of a "glass ceiling" that prevents all but a few exceptional women from gaining access to leadership positions. We analyzed data from Columbia University College of Physicians & Surgeons, New York, NY, for all faculty hired from 1969 through 1988 and found that the likelihood of promotion on the tenure track was 0.40 for women and 0.48 for men (ratio, 0.82; 95% confidence interval, 0.56 to 1.20); on the clinical track the likelihood of promotion was 0.75 for women and 0.72 for men (ratio, 1.04; 95% confidence interval, 0.56 to 1.94). Additional analysis of current faculty showed that in the academic year 1988-1989 the proportion of women at each tenure track rank at the College of Physicians & Surgeons equaled or exceeded the national proportion of women graduating from medical school, once allowance was made for the average time lag necessary to attain each rank. On the clinical track women were somewhat overrepresented, particularly at the junior rank. National data that describe medical school faculty, which combine tenure and clinical tracks, showed that in 1988 women were proportionately represented at each rank once the lead time from graduation was considered. We conclude that objective evidence shows that women can succeed and are succeeding in gaining promotions in academic medicine.

Early human IgH gene assembly in Epstein-Barr virus-transformed fetal B cell lines. Preferential utilization of the most JH-proximal D segment (DQ52) and two unusual VH-related rearrangements.

We have analyzed the phenotypic characteristics and IgH gene rearrangements in a panel of EBV-transformed B lineage cell lines from human fetal liver and bone marrow. Some lines contained only populations of immature, Ig- Be cells, while others contained mixed populations of mature and immature B cells. The majority of identifiable IgH rearrangements involved joining of the most JH-proximal D segment, DQ52, to various JH segments, implying that DQ52 is a preferred target for initial DJH rearrangements. Three other rearrangements involving VH-related sequences were also characterized. Two involved VHDJH joining using VH3 genes, although one of these had a very unusual DJH structure. The third consisted of inverted 3' signal sequences and flanking regions of a VH4 gene appended to a JH. The mechanisms by which the later rearrangement could have occurred and its potential physiological significance are discussed.

Colposcopic evaluation of abnormal Papanicolaou smears in pregnancy.

Colposcopy was used to examine 401 pregnant patients with cytologic or clinical abnormalities of the cervix to determine if routine biopsy could be safely omitted except where the colposcopic impression was one of possible invasive carcinoma. A comparison of the antepartum colposcopic impressions with the postpartum histologic diagnosis revealed agreement to within one degree in 87% of patients, with 3% of patients showing a more advanced lesion than that anticipated. Only 2% of patients showed a progression of cytologic abnormalities at postpartum examination; 39% showed marked improvement. Four of nine patients with invasive carcinoma were diagnosed at antepartum colposcopy, with an additional two patients recognized as having invasive cancer at the postpartum colposcopic examination. The omission of routine biopsy is less than ideal if only one antepartum colposcopy is performed, since a considerable period of time may elapse before the patient is seen again postpartum. Those situations in which it may be omitted, together with guidelines for the management of pregnant patients with abnormal cervical cytologic findings, are presented.

The results of cryosurgical treatment of cervical intraepithelial neoplasia at one, five, and ten years.

The results after cryosurgical treatment of cervical intraepithelial neoplasia at 1, 5, and 10 years are reported. Ninety-four percent of the 1675 patients eligible for assessment at 1 year were successfully treated, with only 5.6% lost to follow-up. After 5 years, 14% of patients were lost to follow-up, but the corrected success rate remained essentially unchanged. No major differences in success rates were noted for the various histologic grades of cervical intraepithelial neoplasia treated. A small but definite percentage of patients developed further disease over the ensuing years, indicating the need for long-term, continued surveillance of these patients.

Monoclonal anti-DNA IgM kappa in neuropathy binds to myelin and to a conformational epitope formed by phosphatidic acid and gangliosides.

Anti-DNA antibodies that cross-react with phosphorylated epitopes of other cellular constituents may be involved in the pathogenesis of autoimmune disease. An IgM monoclonal antibody from a patient with chronic lymphocytic leukemia (CLL) and neuropathy bound to denatured DNA and immunostained myelin in peripheral nerve and spinal cord. The monoclonal IgM bound to ELISA microwells coated with a mixture of phosphatidic acid and gangliosides at serum dilutions of up to 1/100,000, but binding to phosphatidic acid alone was observed at dilutions of less than 1/100 only, and there was no binding to gangliosides alone. Incubation with micelles containing phosphatidic acid and gangliosides selectively absorbed the monoclonal IgM and inhibited its binding to denatured DNA and to myelin. These observations suggest that autoantibodies may bind to conformational epitopes formed by two separate molecules, and that autoantibodies that cross-react with phosphorylated epitopes in DNA and neural tissue could be involved in autoimmune neurologic diseases.

A human monoclonal macroglobulin with specificity for alpha(2----8)-linked poly-N-acetyl neuraminic acid, the capsular polysaccharide of group B meningococci and Escherichia coli K1, which crossreacts with polynucleotides and with denatured DNA.

We have described an IgM antibody from a patient with macroglobulinemia specifically reacting with poly-alpha(2----8)N-acetyl neuraminic acid (NeuNAc) the capsular polysaccharide of two important human pathogens, group B meningococcus and E. coli K1. This antibody has a narrowly defined specificity in its interactions with polysaccharides, being unable to bind poly-alpha(2----9)NeuNAc or alternating poly-alpha(2----8)alpha(2----9)NeuNAc. However, it shows interesting crossreactivity with seemingly unrelated polynucleotides and denatured DNA, supporting the hypothesis that charged groups with a given spacing may determine the specificity of antigen-antibody interactions on otherwise dissimilar molecular structures. Despite the crossreactivity with denatured DNA and polynucleotides, the antibody does not appear to have adverse effects in the patient. The antibody protects newborn rats against E. coli K1 infection, as well as the standard horse antiserum H46, and one would expect it to prove useful in humans as an adjunct to antibiotic therapy in infections with group B meningococcus and E. coli K1. We have attempted to clone the antibody-producing cells from peripheral blood, and have shown that the relevant cells are present and can be cultured.

The role of prostaglandin F in the symptoms of endometriosis.

Prostaglandin F (PGF) levels in endometriotic tissue in vitro have been shown to be higher than the levels in healthy ovarian tissue and uterine endometrium. The results of a study of nine women with endometriosis support this finding and suggest that prostaglandins have an important role in the pathogenesis of the symptoms and infertility in such women.

Cryotherapy in the treatment of cervical intraepithelial neoplasia.

Cryotherapy was used to treat 516 patients with various degrees of dysplasia and carcinoma in situ over a 7-year period. Seventy-one percent of patients had either severe dysplasia or carcinoma in situ. In 88% of the patients treated, a single treatment session was successful in eradicating the lesion. Treatment was defined as successful when cytologic and colposcopic findings were negative 1 year after treatment. Five percent of patients were lost to follow-up. The criteria for selection of patients and possible causes of treatment failure are discussed.