The first clinical trial of an antiblast monoclonal antibody, CBL1, in the treatment of kidney allograft rejection is described. The theory that this antibody might destroy active clones of cells without major side effects was given validity by a previously described study showing prolongation of skin allograft survival in rhesus monkeys. CBL1 was used to treat kidney allograft rejections in 11 patients with a one-haplotype-identical related-donor graft who had been prestimulated with donor-specific transfusions and 8 patients with cadaver grafts who had been prestimulated with multiple transfusions. 15 of the rejections were steroid-resistant. Although CBL1 had no effect on the peripheral blood lymphocyte counts, rejections were reversed in 17 of 19 patients. There was 1 graft loss in the 11 recipients of related-donor grafts and 3 in patients with cadaver-donor grafts. Side effects associated with administration of antilymphocyte serum--ie, chills, fever, and thrombocytopenia--did not develop in any of the patients treated with CBL1. It is postulated that administration of an antiblast monoclonal antibody during rejection of a kidney kills only those cells that are reacting against the graft. This could result in the maintenance of normal lymphocyte numbers and immunological functions against other antigens.

A double-blind randomised trial was carried out in 60 infants with a birth-weight of less than 1500 g or a gestational age below 31 weeks. 30 infants received phenobarbitone (20 mg/kg) within 4 h of birth and 30 infants received a placebo. The two groups of infants were similar in birth-weight, gestational age, frequency of vaginal delivery, sex, Apgar scores, ventilator dependence before the injection, pneumothorax, hypercapnia, and acidosis. Cranial ultrasound scans were carried out daily for 14 days. 12 out of 30 phenobarbitone-treated infants and 11 out of 30 placebo-treated infants had PVH, with parenchymal haemorrhages in 2 of the placebo group. Plasma phenobarbitone was over 15 micrograms/ml in 28 out of 30 of the phenobarbitone-treated infants during the first 72 h. 7 out of 17 spontaneously breathing infants became ventilator-dependent within 12 h of the phenobarbitone injection, whereas only 1 of 18 spontaneously breathing placebo-treated infants became ventilator-dependent within 12 h of injection. Although the possibility of protection against parenchymal haemorrhages may justify further investigation, there is no justification for administration of 20 mg/kg of phenobarbitone to all infants below 1500 g.

A randomised blind controlled trial of hepatitis B immune globulin (HBIG) plus hepatitis B vaccine for the prevention of the perinatally transmitted HBsAg carrier state was conducted in Taipei. Infants of e-antigen-positive HBsAg carrier mothers were given HBIG immediately after birth, and then one of three schedules of vaccination. There was no difference in efficacy between the three schedules; the combined efficacy was 94%, compared with that of HBIG alone (71%) or of vaccination alone (75%). Persistent HBs antigenaemia developed in only 9 (6%) of the 159 infants receiving prophylaxis, but in 88% of the controls. Antibodies developed in all those who did not become antigenaemic and presumably will provide long-term protection from hepatitis B virus infection. HBIG should be given as soon as possible after birth and need not be given again if the infant is subsequently vaccinated. With HBIG coverage from birth, the timing of the start of vaccination does not seem to be of importance within the first month of life, but to maximise compliance and minimise costs hepatitis B vaccination should be initiated during the confinement.

An intravenous infusion of desferrioxamine (3 g) was given to 17 chronic renal failure patients stabilised on standard haemodialysis. Aluminium clearance 48 h after desferrioxamine was 65.3 +/- 11.0 ml/min for 'Dialaid 4000' with 70 g coated charcoal haemoperfusion system; 44.6 +/- 13.7 ml/min for 'Rhondial 75' with polyacrylonitrate membrane; 35.8 +/- 11.0 ml/min for 'Monitral' with polyacrylonitrate membrane; and 4.0 +/- 17.8 ml/min for haemodialysers with a 'Cupraphane' membrane. None of these 4 systems removed any aluminium in the absence of desferrioxamine in the same patients. Even at a desferrioxamine concentration of 40 mg/dl, coated activated charcoal (CAC) was not saturated. CAC did not absorb ferric ions in vitro. But when 40 mg/dl of desferrioxamine was present CAC absorbed increasing concentrations of ferric ions in a linear fashion.

101 patients with Clostridium-difficile-associated diarrhoea or colitis were prospectively randomised to 10-day oral courses of metronidazole, 250 mg four times a day, or vancomycin, 500 mg four times a day. 7 did not complete the protocol and were dropped from analysis. Pseudomembranous colitis (PMC) was diagnosed after endoscopy in 33 patients. Of the remaining patients without PMC, 38 had both C difficile culture and cytotoxin and 23 had only culture evidence of C difficile. 52 evaluable patients received vancomycin and 42 received metronidazole. There were two treatment failures with metronidazole and none with vancomycin (p = 0.20); and two relapses with metronidazole versus six with vancomycin (p = 0.17). Treatment in 1 patient in each group was discontinued because of drug intolerance. Response and relapse rates of the 33 patients with PMC were no different from those of the remaining patients. Pharmacy cost for the dosage used was $387.48 to $520.00 for vancomycin and $11.84 for metronidazole. Metronidazole and vancomycin have equivalent efficacy and relapse rates and are tolerated to a similar extent by patients with C-difficile-related diarrhoea and colitis, but metronidazole is considerably more economical.

To compare the penetrability of methylprednisolone into lung tissue with that of prednisone, blood and bronchoalveolar lavage (BAL) fluid levels of methylprednisolone and prednisone were measured in 17 patients with a variety of lung diseases. To correct for variations in the quantity of lung fluid obtained by BAL, steroid levels were expressed in relation to creatinine concentrations. The level of methylprednisolone penetration in the pulmonary parenchyma, expressed by the slope of the relation between blood and BAL fluid, was 0.5 (r = 0.8; p less than 0.03). By contrast, despite serum levels of between 59 and 219 ng/ml, prednisone could not be detected in the BAL fluid in 3 patients; the overall correlation between blood and BAL fluid for all patients was r = 0.5 (slope = 0.3; p less than 0.1). Thus methylprednisolone is better able than prednisone to penetrate lung acini.

The effectiveness of two rubella vaccines (RA 27/3 and Cendehill) in women vaccinated post partum was compared. Significantly more women who received RA 27/3 gave satisfactory seroconversion responses than women who received Cendehill (97.6% vs 82.2%). This difference was reflected in the geometric mean titres (43.6 vs 17.0). More women who received RA 27/3 had minor side-effects, but the difference was not significant. The serological response to both vaccines was not affected by the concurrent administration of anti-D immunoglobulin. In view of these findings, the replacement of Cendehill vaccine with RA 27/3 vaccine for women vaccinated post partum should be considered.

In a multicentre trial conducted in eight European centres, 232 recipients of cadaveric renal allografts were randomly allocated to receive either cyclosporin (117 patients) or azathioprine and steroids (115 patients) for immunosuppression. All patients have now been followed up for at least a year. 1-year graft survival was 72% in the cyclosporin group and 52% in the control group. 24 of the 84 patients in the cyclosporin group with functioning grafts at 1 year had been changed to azathioprine and steroids, and 1 patient had had prednisolone added to cyclosporin therapy; the other 59 patients were receiving cyclosporin as their sole immunosuppressive agent. 16 patients on cyclosporin treatment never received steroids. 1-year patient survival was 94% in the cyclosporin group and 92% in the control group. There was no difference between the two treatment groups in the prevalence of infection. Lymphoma did not develop in any patient. At 1 year post-transplantation, renal function was poorer in patients on cyclosporin than in those on conventional therapy. Thus the 1-year graft-survival rate is higher with cyclosporin alone as a first-line immunosuppressive agent than with azathioprine and steroids.

34 very low birthweight babies (mean 1143 g) in incubators were randomly assigned to be continuously nursed on lambswool (n = 17) or ordinary cotton sheets (n = 17). The weight gain for the periods when babies were well was significantly larger for the wool group, 22.7 g/day vs 18.6 g/day for cotton control (p less than 0.02). The overall weight gain (which included weight change during periods of illness) revealed a similar picture in favour of the wool group, 21.5 g/day vs 18.2 g/day (p less than 0.05). Movement patterns for the two groups showed no differences, but for all babies a strong correlation was noted between moving and lying suspine (p less than 0.001), having eyes open (p less than 0.001), a cooler incubator (p less than 0.01), and faster weight gain (p less than 0.01). Lambswool seems to have advantages over cotton sheets as a bedding material for very low birth weight babies.