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BACKGROUND: It has been calculated that 30% of chronic uraemic patients fail to produce antibodies to HBsAg antigen after hepatitis B (HB) vaccination. Low-dose intradermal (i.d.) inoculations and supplementary intramuscular (i.m.) injections have been reported to improve the response rate in previous non-responder chronic uraemic patients, but no cost-effectiveness evaluations have been made about this issue. METHODS: We re-vaccinated 50 chronic dialysis patients, who did not have any detectable anti-HBs antibody after a reinforced protocol of hepatitis B vaccine given by i.m. route, with hepatitis B recombinant DNA yeast vaccine (80 micrograms) by intradermal (25 patients) or intramuscular (25 patients) administration (randomly allocated). We used the same amount of HBsAg in order to exclude the confounding effect of the dose level administered on the immune response of uraemic patients. We studied, over a 20-month follow-up, the persistence of anti-HBs antibodies in our responder vaccinees. We made a comparison between the costs of our re-vaccination protocol and the other re-vaccination strategies that have been recently suggested. RESULTS: One month after completion of re-vaccination protocol, seroconversion rates (100% vs 48%, P = 0.008) and proportion of patients who elicited protective anti-HBs titres (96% vs 40%, P = 0.0001) were significantly higher in i.d. compared to i.m. patients. The levels of anti-HBs expressed as geometric mean titres and 95% confidence intervals (GMT (95% CI)), were significantly increased in i.d. than in i.m. groups, 100 (44-187) vs 26 (14-52) mUI/ml (P = 0.018). At month 12, the seroconversion rates were 57 vs 14% in i.d. and i.m. groups respectively (P = 0.158); the seroprotection rate was higher in i.d. individuals in comparison with i.m. patients, 50 vs 0%, P = 0.072. At month 20, the seroconversion rates were 54 and 0% among i.d. and i.m. patients respectively (P = 0.055); the seroprotection rate was higher in i.d. than in i.m. group (30 vs 0%, P = 0.2). At month 20, the median anti-HBs titres in i.d. patients were 21 mUI/ml, and GMT (95% CI) were 20.9 (2-54) mUI/ml. No important general or local side-effects were observed. The cost of our schedule was $92 US whereas the costs of other re-vaccination protocols ranged between 138 and $807 US. CONCLUSIONS: Our results show that the unresponsiveness to recombinant yeast-derived vaccine may be mostly reversed by repeated low-dose i.d. injections of the same agent. In spite of an equal amount of HBsAg received, i.d. hepatitis B re-vaccination shows higher immunogenicity compared to i.m. administration over a 20-month observation period. Cost-effectiveness analysis demonstrated that the intradermal administration of HB vaccine is the most clinically effective re-vaccination strategy; it is also the most unexpensive one. We strongly recommend low-dose intradermal inoculations in order to re-vaccinate chronic dialysis patients who fail to respond to hepatitis B vaccination.
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The valence photoelectron spectra of Re(CO)(5)X (X=Cl, Br, and I) are studied theoretically using symmetry-adapted cluster (SAC)/SAC-configuration interaction (SAC-CI) theory. The relativistic effects are included by the third-order Douglas-Kroll (DK3) method, and the spin-orbit coupling is also considered. Both electron correlation and relativistic effects are significant in assigning the valence photoelectron spectra of Re(CO)(5)X (X=Cl, Br, and I). DK3-SAC/SAC-CI provides values for the relative peak positions in a reasonable agreement with the observed photoelectron spectra. The sequence of ionization energies for Re(CO)(5)Cl, Re(CO)(5)Br, and Re(CO)(5)I are calculated as e(')[a(1)(Cl)]>e(')[e(Re+Cl)] approximately e(")[e(Re+Cl)]>e(")[b(2)(Re)]>e(')[e(Re-Cl)]>e(")[e(Re-Cl)], e(')[a(1)(Br)]>e(')[e(Re+Br)]>e(")[e(Re+Br)+b(2)(Re)]>e(")[b(2)(Re)+e(Re+Br)]>e(')[e(Re-Br)]>e(")[e(Re-Br)], and e(')[e(Re+I)+a(1)(I)]>e(")[b(2)(Re)+e(Re+I)] approximately e(')[a(1)(I)+e(Re+I)]>e(")[e(Re+I)+b(2)(Re)]>e(')[e(Re-I)]>e(")[e(Re-I)], respectively. These assignments are quite new and different from previous assignments.
This article discusses the recent decision of the Court of Appeal of the United Kingdom in Re B (Adult: Refusal of Medical Treatment) [2002] 2 All ER 449, which confirmed the common law right of a competent patient to refuse medical treatment, even though exercise of the right would (and later did) result in the patient's own death. Re B indicates that if a competent refusal is not respected, health professionals and hospitals face the prospect of awards of damages being made against them for unlawful trespass.
Treatment of 7-NH(2)Bu(t)-nido-7-CB(10)H(12) in tetrahydrofuran (THF) with LiBu(n)(3 equiv) and then [ReBr(CO)(3)(THF)(2)] gives the rhenacarborane dianion [1-NHBu(t)-2,2,2-(CO)(3)-closo-2,1-ReCB(10)H(10)](2-), isolated as the bis-[N(PPh(3))(2)](+) salt (4). Iodine oxidation of this Re(I) intermediate gives the Re(III) complex [1,2-mu-NHBu(t)-2,2,2-(CO)(3)-closo-2,1-ReCB(10)H(10)] 6 in which the carborane functions formally as an 8-electron (6pi+ 2sigma) donor. Reaction of with ligands L in the presence of Me(3)NO gives substituted products [1,2-mu-NHBu(t)-2,2-(CO)(2)-2-L-closo-2,1-ReCB(10)H(10)][L = PPh(3)(7a), CNXyl (7b; Xyl = C(6)H(3)Me(2)-2,6), or Bu(t)C triple bond CH (7c)]. Formation of complex 7c is unexpectedly accompanied by [1,2-mu-NHBu(t)-2,2-(CO)(2)-3,2-sigma:eta(2)-{C(=CHBu(t))-CH=CHBu(t)}-closo-2,1-ReCB(10)H(9)] 8a, in which an alkyne-derived dienyl group is bound to both the rhenium centre and to an adjacent boron vertex. Complex 8a is also obtained from 7c with Bu(t)C triple bond CH and Me(3)NO. The same reaction of 7c, using PhC triple bond CH or CNXyl instead of Bu(t)C triple bond CH, gives, respectively, [1,2-micro-NHBu(t)-2,2-(CO)(2)-3,2-sigma:eta(2)-{C(=CHBu(t))-CH=CHPh}-closo-2,1-ReCB(10)H(9)] 8b and [1,2-micro-NHBu(t)-2-Bu(t)C triple bond CH-2-CO-2-CNXyl-closo-2,1-ReCB(10)H(10)] 9. Addition of donors L to results in displacement from rhenium of the pendant dienyl moiety, yielding [1,2-mu-NHBu(t)-2,2-(CO)(2)-2-L-3-{C(=CHBu(t))-CH=CHBu(t)}-closo-2,1-ReCB(10)H(9)][L = PMe(3)(10a), CNBu(t)(10b)]. Single-crystal X-ray diffraction analyses have confirmed the novel structural features of compounds 6, 7c, 8b and 9.
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