Significance of interleukin-16, macrophage-derived chemokine, eosinophil cationic protein and soluble E-selectin in reflecting disease activity of atopic dermatitis--from laboratory parameters to clinical scores

BACKGROUND

The search for the ideal clinical score reflecting atopic dermatitis (AD) severity has developed in parallel with unveiling key events in disease pathogenesis and finding laboratory parameters for monitoring disease activity. A major difficulty in assessing the relevance of reported serum markers of AD severity is the use of nonvalidated referent tools, which compromises comparison of results across studies.

OBJECTIVES

The aim of our study was to compare the significance of serum levels of interleukin (IL)-16, macrophage-derived chemokine (MDC), soluble E-selectin (sE-selectin) and eosinophil cationic protein (ECP) in reflecting AD severity and identify the most relevant parameter for monitoring the course of disease. Serum levels were tested against the same referent severity score in the same time frame and group of patients.

METHODS

The Severity Scoring of Atopic Dermatitis (SCORAD) index was used for assessment of disease severity in 21 adult patients in acute stage of AD and after complete resolution of clinical findings. Serum levels of IL-16, MDC, ECP and sE-selectin were measured at the same time points in 18 patients and compared with healthy nonatopic controls. The correlation between SCORAD and each laboratory parameter was tested for significance and compared.

RESULTS

Serum levels of IL-16, MDC, ECP and sE-selectin were significantly higher in patients in acute stage of AD compared with controls and decreased significantly after treatment, in parallel with clinical improvement. All monitored parameters reflected disease severity assessed by the clinical score. We found the highest significance level of correlation with SCORAD for IL-16 (r = 0.68, P =0.0019), followed by ECP (r = 0.65, P = 0.0032) and MDC (r = 0.55, P =0.0326). There was significant correlation between serum levels of IL-16 and MDC (r = 0.53, P = 0.0443) and ECP and sE-selectin (r = 0.48, P = 0.0427).

CONCLUSIONS

The study established a significant correlation between serum levels of IL-16 and SCORAD in adult AD patients. We report a significant correlation between IL-16 and MDC, both T-helper 2 activation markers. Our data suggested that IL-16 reflects most convincingly disease severity and may be used as a marker in clinical studies preferentially in combination with a clinical activity score.

[Microcirculatory monitoring of sepsis]

Microcirculatory dysfunctions play a central role in the pathophysiology of sepsis and shock. Modern methods enable microvascular monitoring in man and offer the possibility to test the effect of novel therapeutical strategies for sepsis. Furthermore, these techniques may be future tools for the monitoring of critically ill patients. In this review, we will describe four microvascular monitoring devices and give an overview of the microcirculatory changes observed during the course of sepsis. Laser Doppler fluxmetry is an easy to use noninvasive technique to measure tissue perfusion enabling monitoring of the effect of different catecholamines on the gastric perfusion during sepsis. Increased microvascular permeability and altered blood flow in septic patients can be quantified by venous congestion plethysmography. Alterations in sublingual microvascular blood flow are detected by intravital microscopy in septic patients and were identified as an outcome predictor. Furthermore, the role of gastrointestinal pCO2-tonometry for microcirculatory monitoring of the perfusion of splanchnic organs during sepsis is discussed. The true clinical value of these techniques has yet to be established and will depend on larger clinical trials showing an impact on diagnostics and patient management.

Monitoring long-term court order psychiatric hospitalization: a pilot project in Israel

BACKGROUND

In Israel, the rules of compulsory psychiatric hospitalization, including hospitalization under a court order, are set out in the Israel Mental Health Act, 1991 (MHA). The MHA does not specifically define the time limits of hospitalization by Court Order, though every patient, by law has to be brought before the Regional Psychiatric Board (RPB) once every six months for reevaluation. The Supreme Court recently addressed this issue and suggested that by having no specific time span, the way lies open for infringement of individual rights (Criminal Appeals 3854\02). Consequently the Supreme Court suggested that some court committed patients should be moved from the criminal to the civil track which inflicts less severe infringement of the mentally ill patient's rights. This ruling generated rethinking at the ministerial level aimed at improving the monitoring of the care of long-term psychiatric hospitalization in criminal cases. The Ministry of Health initiated a project designed to study this issue.

OBJECTIVES

The main objective of this project, which is described below, is to monitor the type and incidence of forensic mental patients hospitalized in Israel for more than 10 years, and to propose alternatives to replace this untenable situation.

METHODS

All the 12 psychiatric hospitals in Israel which hospitalize forensic patients were sent written requests for data on criminal patients hospitalized under court orders, including demographic data, diagnosis and type of offense. We identified in all 65 such patients. The data received were compared with the National Psychiatric Register databank of the Ministry of Health and divided in subgroups according to diagnosis, type of offence, demographic variables and length of hospitalization.

RESULTS

Most of the subjects of the sample (89%) suffered from psychotic disorder mainly schizophrenia of the paranoid type. 95.5% were male. The most prominent type of offense was assault against family members (37%), which is in keeping with statistics reported in the relevant literature. The profile of the typical patient of this sample is: male, aged 45-65, unmarried, with 8 years of education and suffering from paranoid schizophrenia.

DISCUSSION

No correlation between type and severity of offense and length of involuntary forensic hospitalization was found. We suggest some possible alternatives to improve the current handling of the group of long term hospitalized forensic patients. We also feel that a further study should be carried out on forensic patients hospitalized for a period of five to ten years.

[Efficiency potential in the pacemaker/implantable cardioverter defibrillator outpatient clinic]

The aim of the present study was to elucidate whether the duration of a technical follow-up (FU) of a pacemaker (PM)/implantable cardioverter defibrillator (ICD) has an impact on cost-effectiveness in the outpatient clinic. We determined the time required for a complete FU of devices from three different manufacturers. In 130 patients (70 VVI/DDD-PM, 60 VVI/DDD-ICD) with either a PM (Phylos, Chorum/Talent, Kappa, EnPulse) or an ICD (Belos, Alto or GEM) the time was recorded for a complete FU including determination of lead impedance, sensing and pacing threshold. The time for activation of individual menue buttons was excluded. On the basis of time required for FU, cost-units (CU) were calculated for 2000 FU/year and for a presumed device longevity (PM 7 years, ICD 5 years). For VVI-PM, the duration of FU was almost identical for devices from different manufacturers (105+/-11 s to 125+/-8 s; p=n.s.). However, analysis of DDD-PM revealed marked differences (140+/-25 s vs 282+/-23 s, p<0.05). Time for FU of ICDs varied between 108+/-5 s and 207+/-21 s (p<0.05) in VVI-ICDs and between 129+/-8 ms and 225+/-23 s (p<0.05) in DDD-ICDs. The total savings could be 55 000 CU in VVI- and 53 333 CU in DDD-ICDs. For full automatic DDD-pacemakers (EnPulse) time for FU could be reduced to 58+/-3 s (p<0.05). Differences in FU times were caused by problems with telemetry, delay during booting of the programmer, interrogation at the beginning and at the end of FU and for sensing tests. Improving not only programmers and devices but also test automaticity could significantly increase cost-efficiency in the outpatient clinic.

Neurodermitis

Squamous cell conjunctival carcinomas (SCCC) are rare. We report on a 34-year-old patient with neurodermatitis and chronic conjunctivitis who presented with a therapy-resistant corneal ulcer induced by mechanical irritation diagnosed as SCCC. Chronic blepharoconjunctivitis seems to sustain the development of SCCC in patients with neurodermatitis because of their insufficient immune response.

The objective severity assessment of atopic dermatitis (OSAAD) score: validity, reliability and sensitivity in adult patients with atopic dermatitis

BACKGROUND

The Objective Severity Assessment of Atopic Dermatitis (OSAAD) score is a recently developed scale for evaluation of severity of atopic dermatitis, constructed from the assessment of epidermal barrier function, and properties using noninvasive bioengineering methods and computer-assisted estimates of disease extent. The method has been validated for use in infants and children with atopic dermatitis and compared with a referent scoring system.

OBJECTIVES

The aim of the present study was to test the validity, reliability and sensitivity of the OSAAD score as an objective tool for the assessment of the severity of atopic dermatitis in adult patients.

METHODS

Thirty-two adult patients with atopic dermatitis were included in the study. To assess the validity of the OSAAD score we tested it against the Severity Scoring of Atopic Dermatitis (SCORAD) index of the European Task Force on Atopic Dermatitis as a referent clinical severity scale, and the serum levels of interleukin (IL)-16 as a laboratory variable for monitoring the activity of atopic dermatitis. Responsiveness to change was assessed in a longitudinal study comparing OSAAD, SCORAD and serum levels of IL-16 before and after treatment. To test the reliability of the OSAAD score we studied the interobserver variability of the score recorded by three independent board-certified dermatologists in 16 patients and compared it with SCORAD.

RESULTS

We report a significant correlation between the OSAAD and the SCORAD index as an acknowledged referent severity scale. The OSAAD score correlated significantly with the serum levels of IL-16 in the acute stage of atopic dermatitis. In a longitudinal study, the OSAAD score decreased significantly, parallel with improvement of the skin findings and a significant decrease in the SCORAD score and IL-16 serum levels. We report improved interobserver variability for the OSAAD score compared with SCORAD.

CONCLUSIONS

This is the first study validating the OSAAD score as a sensitive and reliable tool for the assessment of the severity of atopic dermatitis in adult patients.

[Coxitis fugax--the beginning of Perthes' disease?]

We present the clinical case of a decennial boy with acute leftsided hip pain without appropriate trauma. The initial diagnosis of coxitis fugax was verified in this case with inconspicuous blood parameters and X-ray by a sonographically proven intraarticular effusion. An immediate magnet resonance imaging (MRI) study of the affected hip joint was done. Here, a complete "necrosis" of the proximal femur epiphysis was verified. With knowledge of these results, an immediate operation of the hip joint with a ventral capsule incision and consecutive intraarticular decompression was performed. A complete reperfusion of the femur head was evident in the MRI scan seven days postoperatively. In accordance with this clinical case report, we would like to point out the necessity for the immediate diagnosis of indifferent hip pain by means of MRI, especially for patients in the atypical "critical age" (> or = 8 years) for coxitis fugax. This is discussed under consideration of the possible aetiopathogenesis and the current literature.

Regional differences in the dynamics of refractoriness in intact and hypertrophied in situ canine hearts

OBJECTIVES

Functional re-entry is thought to represent the predominant mechanism underlying ventricular arrhythmias. Functional conduction block may be caused by regional dispersion of refractoriness (ERP). Dispersion of ERP may not be evident at baseline, but may occur with sudden changes in heart rate, as ventricular arrhythmias are commonly induced by short-long-short cycles.

METHODS

We examined the dynamics of local ERPs at two left ventricular (LV) sites in dogs with either no structural heart disease or biventricular hypertrophy (BVH). ERPs were determined at each of four bipoles of two adjacent needle electrodes in the LV apex and the lateral wall. The stimulation protocol included two different basic cycle lengths, one or two longer cycles after a train of 6 or 5 shorter cycles, and one shorter cycle after a train of 6 longer cycles.

RESULTS

In normal dogs, a significant apicolateral ERP gradient was only evident with the longer basic cycle length. One shorter cycle was sufficient to dissolve that gradient. One longer cycle was enough to create a regional ERP gradient. Dynamic regional gradients occurred because the apex responded more markedly and more readily to abrupt changes in cycle length. BVH led to an increase in ERP at both LV sites and to an aggravation of regional ERP gradients.

CONCLUSIONS

Dynamic ERP behavior seems to depend on topography and underlying pathology. Abrupt changes in heart rate might induce dynamic refractory gradients between various regions of the normal heart, but also between adjacent regions inhomogenously affected by hypertrophy.

Transepidermal Water Loss Dynamics of Human Vulvar and Thigh Skin

Refinement in procedures to assess skin surface water loss (SSWL) dynamics of the vulvar skin on a large sample of subjects (60) is described and compared to another semi-occluded skin site, the inner thigh. Vulvar SSWL significantly decreased over a 30-min period from 46.2 +/- 2.6 (SE) to 24.7 +/- 1.6 g m(-2) h (p < 0.001). The inner thigh, another semi-occluded region, showed no similar pattern for SSWL (6.2 +/- 0.3 to 6.6 +/- 0.5 g m(-2) h), and the values were significantly less than those for vulvar skin. There was no significant effect of age, body mass index or atopic status on vulvar SSWL.

Electronic structure and dynamics of quantum-well states in thin Yb metal films

Quantum-well states above the Fermi energy in thin Yb(111) metal films deposited on a W(110) single crystal were studied by low-temperature scanning tunneling spectroscopy. These states are laterally highly localized and give rise to sharp peaks in the tunneling spectra. A quantitative analysis of the spectra yields the bulk-band dispersion in the Gamma-L direction as well as quasiparticle lifetimes. The quadratic energy dependence of the lifetimes is in quantitative agreement with Fermi-liquid theory.

Quantitative patch and repeated open application testing in methyldibromo glutaronitrile-sensitive patients

Contact allergy to methyldibromo glutaronitrile (MDBGN), often combined with phenoxyethanol (PE) (e.g., Euxyl K 400), increased throughout the 1990s in Europe. Consequently, in 2003, the European Commission banned its use in leave-on products, where its use concentration was considered too high and the non-sensitizing use concentration as yet unknown. The 2 objectives of the study are (a) to find a maximum non-eliciting concentration in a leave-on product in MDBGN/PE-sensitized patients, which could possibly also be considered safe regarding induction and (b) to find the best patch test concentration for MDBGN. We, therefore, performed a use-related test (ROAT) in patients sensitized to MDBGN/PE (n = 39) with 3 concentrations of MDBGN/PE (50, 100 and 250 p.p.m. MDBGN, respectively). A subset of these patients (n = 24) was later patch-tested with various concentrations (0.1, 0.2, 0.3 and 0.5% MDBGN, respectively). 15 patients (38%, 95% confidence interval (CI) = 23-55%) had a negative and 24 (62%; 95% CI = 45-77%) a positive overall repeated open application test (ROAT) result. 13 reacted to the lowest (50 p.p.m.), 8 to the middle (100 p.p.m.) and 3 to the highest concentration (250 p.p.m.) only. In those 13 reacting to the lowest ROAT concentration, dermatitis developed within a few days (1-7). The strength of the initial and the confirmatory patch test result, respectively, and the outcome of the ROAT were positively associated. Of the 24 patients with a use and confirmatory patch test, 15 reacted to 0.1% MDBGN, 16 to 0.2%, 17 to 0.3% and 22 to 0.5%. With the patch test concentration of 0.5%, the number of ROAT-negative patients but patch-test-positive patients increases considerably, particularly due to + reactions. A maximum sensitivity of 94% (95% CI = 70-100%) is reached with a patch test concentration of 0.2%, and is not further improved by increasing the concentration. However, the specificity decreases dramatically from 88 (95% CI = 47-100%) with 0.2% to a mere 12.5% (95% CI = 0-53%) with 0.5%. It can be concluded (a) that for MDBGN 0.2% is very likely the best patch test concentration and (b) that 50 p.p.m. in a leave-on product can elicit contact dermatitis in sensitized persons. We were, therefore, unable to find a safe, still microbicidal, concentration for leave-on products. By contrast, with other contact allergens, dose-response use tests may be able to identify a non-eliciting concentration, which could give valuable clues to a non-inducing (i.e., safe) concentration in products.

Vulvar Dermatoses – Irritant and Allergic Contact Dermatitis of the Vulva

Irritant and allergic contact dermatitis are commonly seen in patients complaining about itching, burning and irritation in the vulvar area. Irritation often precedes allergic sensitization. Clinically, irritant and allergic contact dermatitis can be difficult to distinguish. Diagnosis is made by history, clinical investigation and patch testing. Recommended patch test series are the standard series, a medicament series, the patient's own topical medicaments, popular remedies and other suspected products. A skin biopsy may be useful to establish the diagnosis of contact dermatitis, but it is usually not helpful for the differential diagnosis between irritant and allergic dermatitis.

Vasculitic purpura with antineutrophil cytoplasmic antibody-positive acute renal failure in a patient with Streptococcus bovis case and Neisseria subflava bacteremia and subacute endocarditis

Subacute bacterial endocarditis is frequently associated with extracardiac manifestations and renal failure. Clinical variety of endocarditis manifestation is wide and has the potential to mimic vasculitis. Whereas Streptococcus bovis is often isolated and associated with colonic tumors, Neisseriaceae are rarely found. An association of subacute bacterial endocarditis and antineutrophil cytoplasmic antibodies has been described. We report on a 62-year-old man who was admitted to our hospital with acute oliguric renal failure and a nonpruritic purpural rush without fever. Antineutrophil cytoplasmic antibody diagnostic revealed perinuclear staining with a titre of 1 : 512 and antiproteinase-3 specificity. Immune complex-mediated glomerulonephritis without extracapillary proliferation was diagnosed in renal biopsy. Finally, blood cultures became positive for Streptococcus bovis and Neisseria flava. Echocardiography showed mobile vegetations on tricuspid valve. Under treatment with penicillin G and gentamicin, skin efflorescences and renal function recovered, but vegetations increased. A colonic tumor could be excluded, a disastrous dental status may have been a predisposal factor. When classical findings of subacute bacterial endocarditis are less clear, the presence of renal failure and antineutrophil cytoplasmic antibodies in absence of fever may lead to misdiagnosis and deleterious immunosuppressive therapy. Neisseria subflava, an upper respiratory tract commensal, may cause subacute bacterial endocarditis without typical symptoms.