- Email: [email protected]
Three-quarters true
907
Trends in hospice
care
"It is better to die living than to live dying." Mitchell’s personal view that the needs of the dying are very much those of the living1 closely reflects the philosophy of the hospice movement-that terminally ill patients should be able to live fully and with dignity and comfort until death. The idea is that a hospice should cater for the social, physical, emotional, and spiritual needs of patients and their families in a relaxed atmosphere. But is this what hospices actually do? In a survey by postal questionnaire of 111 hospices in the British Isles, Johnson and colleagues2 found, from the 98 replies, that all 17 National Health Service hospices had either full-time or part-time consultants, whereas in 12 of the 81 independent hospices senior medical cover was provided by local general practitioners. Ways in which patients were cared for varied so much that, say Johnson et al, the title of hospice was the only factor these units seemed to have in common. For example, throughput varied from 17 to 31-8 deaths and discharges per bed per year, and discharge rates ranged from 1 to 76%. Nevertheless, the median values for these measures indicate that many patients are discharged from a hospice, thus dispelling the misconception of the public and some health professionals that the sole purpose of such an institution is to provide "tender loving care" in the last few days of life. Johnson et al also found that many patients were managed with a range of investigations and procedures usually associated with acute hospital care; whether such procedures were done seemed to be associated with type of medical input. For example, in units with a full-time consultant or medical director, throughput was greater, invasive procedures were more likely to be done, and patients were more likely to be referred for palliative surgery and organ donation. Moreover, there was a trend for units with such medical support to describe themselves in technical terms ("a specialist medical/ nursing unit") rather than the non-technical terms ("a peaceful haven", "home from home") favoured by units without such
support. Johnson and colleagues conclude that these differences are likely to increase with the appointment of more consultants fully trained in palliative medicine following the Royal College of Physicians’ recognition of palliative medicine as a new specialty. dying: local government services. Br Med J 1973; i: 39-40. Johnson IS, Rogers C, Biswas B, Ahmedzai S. What do hospices do? A survey of hospices in the United Kingdom and Republic of Ireland. Br Med J 1990; 300:
1. Mitchell W. Care of the
2.
791-93.
Acres of antibodies Ever thought of growing antibodies in your own back garden? The idea may not be as far-fetched as it seems, for genetically engineered antibodies may one day be harvested by the acre, rather than by the gram in the laboratory, if experiments with tobacco plants can successfully be turned to large-scale production. Indeed, a product review in Nature speculates that agricultural production could provide virtually unlimited quantities of any mammalian antibody.1 Last year Hiatt et al reported the expression of immunoglobulins derived from a mouse hybridoma in transgenic tobacco plants, using a soil bacterium Agrobacterium tumefaciens as vector.2 Transformed tobacco leaf segments expressing single gamma or kappa immunoglobulin chains were regenerated to maturity, and the adult plants were then crossed to yield progeny in which both chains were expressed. In some of the progeny functional antibody accounted for 1-3% of the total leaf protein, and the yield, says Hiatt, could probably be increased by using promoters to enhance transcription. Tobacco is not the only candidate plant-alfalfa, soybean, tomato, and potato would probably do just as well. One untested antibodies is their feature of plant-derived immunogenicity in man. The terminal residues of the carbohydrate on the heavy chain will be different from those of mammals. How these changes in carbohydrate composition would affect the antibody’s biodistribution and serum clearance has yet to be determined. The main advantage of producing antibodies in plants is the low cost-perhaps as little as US$100 per kilogram for one grown in soybeans, according to Hiatt. Genetically stable seed stocks from antibody-producing plants could be stored indefinitely and converted into a bumper crop of immunoglobulin in one growing
season. The antibody harvested could easily be purified from homogenised leaves. The therapeutic and diagnostic potential of antibody agriculture is obvious, but the impermeability of plant cell walls to large molecules suggests a further possible application of plant-produced antibodies-as biofilters to clean up the atmosphere. The feasibility of using antibodies locked inside the cells of growing plants to absorb environmental pollutants of smaller molecular weight is now being explored. ’
1. Hiatt A. Antibodies produced in plants. Nature 1990; 344: 469-70. 2. Hiatt A, Cafferkey R, Bowdish K. Production of antibodies in transgenic Nature 1990; 342: 76-78.
plants.
Three-quarters true Unlike many other US agencies, the Center for the Absorption of Federal Funds "has never failed to deliver its promised work". Who says so? None other than the Center’s near-legendary director, Grant Swinger, recipient of numerous honours including the Segmentation Prize (awarded annually for the most publications from a single piece of research) and originator of the Swinger index (numbers of papers produced, miles travelled, and conferences attended). For the uninitiated we can reveal that Dr Swinger is the alter ego of our Washington correspondent, Dan Greenberg, to whom he regularly imparts the choicest snippets from the federal scene in general and the Center’s activities in particular. The first hometruths from Dr Swinger’s prodigious output appeared in 1983 and, as Greenberg comments, should have served as a stem warning against "naive faith in the skills and disinterest of heavily credentialed ’experts’, especially that thriving new breed of press conference virtuosos who clamor for our attention". Grant Swinger now returns with an expanded second edition; the collected wisdom encompasses the earlier material plus five interviews recorded from 1983 to 1989. Dr Swinger must be heartened by the fact that the intervening years have witnessed the further "spread of the Swinger spirit in the culture of science". As Greenberg himself also admits, "Never did I expect that high bodies within the scientific community would corroborate the substantial existence of the Swingerian style within their profession. But so they have, in a succession of doleful reports, issuing from committees assigned to study the debris after one ethical crash or another in the affairs of science". Dr Swinger’s Center has flourished by a combination of foresight and nimbleness. He astutely identified the key ingredients for surviving the troughs and peaks of federal funding: the need, always, for further study; the cyclical rediscovery of discarded issues such as poverty, malnutrition, and unemployment ; and due deference to the federal research agency ethos "never move without surveys, literature surveys, conferences, and workshops, which lead to published proceedings, and followup conferences and workshops". In 1982 he triumphed with the 200 lb all light meat megachicken, developed for the fast-food industry but sufficiently aggressive for the Defense department, with an eye to new anti-Soviet weapons, to award a grant for helmets and body armour. In 1987 he was despairing about American scientific illiteracy "a majority think a mammogram is a Mother’s Day greeting ... and reverse transcriptase is a Japanese method of shorthand". But let the great man speak on his favourite theme: "We have a solid base of ongoing activities at the Center. Overhead and Underhand: The Grant S’winger Guide to Academic Finance is now in its third edition. We also prepare material on various issues: For and against the Super Collider, on the justice and the injustice of the peer-review system-take your choice. We’ve got papers saying the big universities are shortchanged on federal research money, and we’ve got papers saying they get too much. On scientific fraud, we’ve got papers that argue that the problem happens one in a million,
though, of course, we have no idea how position is that even idiotic notions merit conference, and a report." 1.
happens. Our respectful hearing, a
often it a
DS. The Grant Swinger papers. 2nd ed. Published by Science and Government Report, 3736 Kanawha Street Northwest, Washington, DC 20015, USA. Pp 40. $8.95 (add $2.00) for overseas airmail).
Greenberg
Trends in hospice
care
"It is better to die living than to live dying." Mitchell’s personal view that the needs of the dying are very much those of the living1 closely reflects the philosophy of the hospice movement-that terminally ill patients should be able to live fully and with dignity and comfort until death. The idea is that a hospice should cater for the social, physical, emotional, and spiritual needs of patients and their families in a relaxed atmosphere. But is this what hospices actually do? In a survey by postal questionnaire of 111 hospices in the British Isles, Johnson and colleagues2 found, from the 98 replies, that all 17 National Health Service hospices had either full-time or part-time consultants, whereas in 12 of the 81 independent hospices senior medical cover was provided by local general practitioners. Ways in which patients were cared for varied so much that, say Johnson et al, the title of hospice was the only factor these units seemed to have in common. For example, throughput varied from 17 to 31-8 deaths and discharges per bed per year, and discharge rates ranged from 1 to 76%. Nevertheless, the median values for these measures indicate that many patients are discharged from a hospice, thus dispelling the misconception of the public and some health professionals that the sole purpose of such an institution is to provide "tender loving care" in the last few days of life. Johnson et al also found that many patients were managed with a range of investigations and procedures usually associated with acute hospital care; whether such procedures were done seemed to be associated with type of medical input. For example, in units with a full-time consultant or medical director, throughput was greater, invasive procedures were more likely to be done, and patients were more likely to be referred for palliative surgery and organ donation. Moreover, there was a trend for units with such medical support to describe themselves in technical terms ("a specialist medical/ nursing unit") rather than the non-technical terms ("a peaceful haven", "home from home") favoured by units without such
support. Johnson and colleagues conclude that these differences are likely to increase with the appointment of more consultants fully trained in palliative medicine following the Royal College of Physicians’ recognition of palliative medicine as a new specialty. dying: local government services. Br Med J 1973; i: 39-40. Johnson IS, Rogers C, Biswas B, Ahmedzai S. What do hospices do? A survey of hospices in the United Kingdom and Republic of Ireland. Br Med J 1990; 300:
1. Mitchell W. Care of the
2.
791-93.
Acres of antibodies Ever thought of growing antibodies in your own back garden? The idea may not be as far-fetched as it seems, for genetically engineered antibodies may one day be harvested by the acre, rather than by the gram in the laboratory, if experiments with tobacco plants can successfully be turned to large-scale production. Indeed, a product review in Nature speculates that agricultural production could provide virtually unlimited quantities of any mammalian antibody.1 Last year Hiatt et al reported the expression of immunoglobulins derived from a mouse hybridoma in transgenic tobacco plants, using a soil bacterium Agrobacterium tumefaciens as vector.2 Transformed tobacco leaf segments expressing single gamma or kappa immunoglobulin chains were regenerated to maturity, and the adult plants were then crossed to yield progeny in which both chains were expressed. In some of the progeny functional antibody accounted for 1-3% of the total leaf protein, and the yield, says Hiatt, could probably be increased by using promoters to enhance transcription. Tobacco is not the only candidate plant-alfalfa, soybean, tomato, and potato would probably do just as well. One untested antibodies is their feature of plant-derived immunogenicity in man. The terminal residues of the carbohydrate on the heavy chain will be different from those of mammals. How these changes in carbohydrate composition would affect the antibody’s biodistribution and serum clearance has yet to be determined. The main advantage of producing antibodies in plants is the low cost-perhaps as little as US$100 per kilogram for one grown in soybeans, according to Hiatt. Genetically stable seed stocks from antibody-producing plants could be stored indefinitely and converted into a bumper crop of immunoglobulin in one growing
season. The antibody harvested could easily be purified from homogenised leaves. The therapeutic and diagnostic potential of antibody agriculture is obvious, but the impermeability of plant cell walls to large molecules suggests a further possible application of plant-produced antibodies-as biofilters to clean up the atmosphere. The feasibility of using antibodies locked inside the cells of growing plants to absorb environmental pollutants of smaller molecular weight is now being explored. ’
1. Hiatt A. Antibodies produced in plants. Nature 1990; 344: 469-70. 2. Hiatt A, Cafferkey R, Bowdish K. Production of antibodies in transgenic Nature 1990; 342: 76-78.
plants.
Three-quarters true Unlike many other US agencies, the Center for the Absorption of Federal Funds "has never failed to deliver its promised work". Who says so? None other than the Center’s near-legendary director, Grant Swinger, recipient of numerous honours including the Segmentation Prize (awarded annually for the most publications from a single piece of research) and originator of the Swinger index (numbers of papers produced, miles travelled, and conferences attended). For the uninitiated we can reveal that Dr Swinger is the alter ego of our Washington correspondent, Dan Greenberg, to whom he regularly imparts the choicest snippets from the federal scene in general and the Center’s activities in particular. The first hometruths from Dr Swinger’s prodigious output appeared in 1983 and, as Greenberg comments, should have served as a stem warning against "naive faith in the skills and disinterest of heavily credentialed ’experts’, especially that thriving new breed of press conference virtuosos who clamor for our attention". Grant Swinger now returns with an expanded second edition; the collected wisdom encompasses the earlier material plus five interviews recorded from 1983 to 1989. Dr Swinger must be heartened by the fact that the intervening years have witnessed the further "spread of the Swinger spirit in the culture of science". As Greenberg himself also admits, "Never did I expect that high bodies within the scientific community would corroborate the substantial existence of the Swingerian style within their profession. But so they have, in a succession of doleful reports, issuing from committees assigned to study the debris after one ethical crash or another in the affairs of science". Dr Swinger’s Center has flourished by a combination of foresight and nimbleness. He astutely identified the key ingredients for surviving the troughs and peaks of federal funding: the need, always, for further study; the cyclical rediscovery of discarded issues such as poverty, malnutrition, and unemployment ; and due deference to the federal research agency ethos "never move without surveys, literature surveys, conferences, and workshops, which lead to published proceedings, and followup conferences and workshops". In 1982 he triumphed with the 200 lb all light meat megachicken, developed for the fast-food industry but sufficiently aggressive for the Defense department, with an eye to new anti-Soviet weapons, to award a grant for helmets and body armour. In 1987 he was despairing about American scientific illiteracy "a majority think a mammogram is a Mother’s Day greeting ... and reverse transcriptase is a Japanese method of shorthand". But let the great man speak on his favourite theme: "We have a solid base of ongoing activities at the Center. Overhead and Underhand: The Grant S’winger Guide to Academic Finance is now in its third edition. We also prepare material on various issues: For and against the Super Collider, on the justice and the injustice of the peer-review system-take your choice. We’ve got papers saying the big universities are shortchanged on federal research money, and we’ve got papers saying they get too much. On scientific fraud, we’ve got papers that argue that the problem happens one in a million,
though, of course, we have no idea how position is that even idiotic notions merit conference, and a report." 1.
happens. Our respectful hearing, a
often it a
DS. The Grant Swinger papers. 2nd ed. Published by Science and Government Report, 3736 Kanawha Street Northwest, Washington, DC 20015, USA. Pp 40. $8.95 (add $2.00) for overseas airmail).
Greenberg