[Systemic lupus erythematosus in the county of Fynen. An epidemiologic study]

The incidence and prevalence of systemic lupus erythematosus (SLE) has never been investigated in Denmark, whereas international studies have reached divergent results. In the study patients were ascertained from diagnosis-based registers of inpatients and outpatients, notifications from physicians, and an autoimmune register. Diagnoses were validated and patients classified according to the American College of Rheumatology criteria: definite SLE (D-SLE) > or = 4 and incomplete SLE (I-SLE) < 4 criteria. The point prevalence as of Jan. 1, 1995, was 21.7/100,000 (CI 95% 17.3-26.8) for D-SLE and 5.2/ 100,000 (CI 95% 3.2-8.0) for I-SLE. The mean annual incidence in 1990-94 was 2.5/100,000 (CI 95% 1.8-3.3). Figures for annual incidence and prevalence were in accordance with recent British reports but considerably lower than Swedish and Icelandic results. Although methodological issues should be considered, the results point to a different distribution of SLE in otherwise closely related nationalities.

Population newborn screening for inherited metabolic disease: current UK perspectives

Some of the generally accepted criteria for screening programmes are inappropriate for newborn metabolic screening as they ignore the family dimension and the importance of timely genetic information. Uncritical application of such criteria creates special difficulties for screening by tandem mass spectrometry, which can detect a range diseases with widely different natural histories and responsiveness to treatment. Further difficulties arise from increasing demands for direct proof of the effects of screening on long-term morbidity and mortality. The randomized controlled trial is held to be the gold standard, but for ethical and practical reasons it will be impossible to achieve for such relatively rare diseases. This approach also oversimplifies the complex matrix of costs and benefits of newborn metabolic screening. A more workable approach could involve Bayesian synthesis, combining quantitative performance data from carefully designed prospective pilot studies of screening with existing experience of the natural history, diagnosis, and management of the individual disorders concerned.

Do people who apply sunscreens, re-apply them?

Little is known about Australians' practices regarding sunscreen re-application, yet it is routinely advised and has recently been shown to increase the protective efficacy of sunscreens. A baseline survey of sunscreen application and re-application behaviour was therefore conducted in a Queensland community using a standard self-administered questionnaire. Other sun protection methods were also assessed. Of a total of 669 adult respondents, 76% reported using sunscreen and of those, 61% reported re-applying sunscreen. Significantly more women (66%) than men (55%) reported re-applying sunscreen and re-application was inversely related to age (79% of those aged less than 45, 57% of those 45-59 years old and 46% of those over 60 years). Increased rates of re-application were reported during times of increased sun exposure, as well as by those with greater knowledge of the benefits of sunscreen re-application. A recent personal history of non-melanoma skin cancer did not lead to improved rates of sunscreen application, sunscreen re-application, or most forms of physical sun protection.

[Incidence of type 1 childhood diabetes in Hungary (1978-1997). Hungarian Committee on the Epidemiology of Childhood Diabetes]

The incidence of Type 1 diabetes in 2417 children aged 0-14 years was studied between 1978 and 1997. Statistical analysis of the data in the twenty-year period showed a steady increase in incidence of Type 1 diabetes with an average rate of 4.8% (95% CI 4.0-5.5) per annum. The incidence rate was lowest in children aged 0 to 4 years and the highest in the age group 10 to 14 years. This increase in incidence was similar for all age groups, but it was most pronounced in the 10 to 14 year-old age group. One hundred and twenty one of the 1239 families (9.7%), one of parents was also reported to have Type 1 diabetes and in 3 (0.2%) families both parents had Type 1 diabetes. Twenty two (2.3%) of the diabetic families had a sibling with Type 1 diabetes. The nearly three-fold increase in incidence during the last two decades (3.8 per 100,000 per year in 1978; 10.7 per 100,000 per year) was probably due to environmental factors, while the high degree of familial clustering emphasises the role of genetic factors in the etiology of Type 1 diabetes.

Do people who apply sunscreens, re-apply them?

Little is known about Australians' practices regarding sunscreen re-application, yet it is routinely advised and has recently been shown to increase the protective efficacy of sunscreens. A baseline survey of sunscreen application and re-application behaviour was therefore conducted in a Queensland community using a standard self-administered questionnaire. Other sun protection methods were also assessed. Of a total of 669 adult respondents, 76% reported using sunscreen and of those, 61% reported re-applying sunscreen. Significantly more women (66%) than men (55%) reported re-applying sunscreen and re-application was inversely related to age (79% of those aged less than 45, 57% of those 45-59 years old and 46% of those over 60 years). Increased rates of re-application were reported during times of increased sun exposure, as well as by those with greater knowledge of the benefits of sunscreen re-application. A recent personal history of non-melanoma skin cancer did not lead to improved rates of sunscreen application, sunscreen re-application, or most forms of physical sun protection.

Radioimmunoluminography: a tool for relating tissue antigen concentration to clinical outcome

Proteins control cell function and measurement of their concentration is crucial for understanding their roles in health and disease. However, current methods for their detection in tissue sections are not quantitative. Radioimmunoluminography (RILG) is a system for direct measurement of quantity and distribution of protein in histological sections. Histological carcinomas were reacted with antigen-saturating concentrations of 125I-antibody to carcinoembryonic antigen (CEA). Antibody distribution and concentration was mapped by phosphor imaging. Radioactivity in each pixel of the digital image was proportional to antigen concentration, calculated from a standard line generated from a nitrocellulose CEA dot-blot assay. RILG gave a linear correlation with standards of known CEA concentration (r = 0.999). Six tumour xenografts with differing CEA concentrations by radioimmunoassay (RIA) were studied by RILG and immunohistochemistry (IHC). RILG gave a linear correlation with CEA by RIA (r = 0.994) but IHC failed to do so (r = 0.42). CEA levels measured by RILG, in cryostat (n = 15) and paraffin (n = 19) sections from colorectal cancer patients showed a range of CEA concentration (38.9-594 ng g(-1) and 22.5-212.5 ng g(-1) respectively). Tumour CEA concentration by RILG was significantly correlated with dose of antibody (% injected radioactivity kg(-1)) localized in tumour (P = 0.04 and P < 0.02 respectively), in patients receiving radioimmunoguided surgery. Clinical relevance of RILG is illustrated by identifying patients with high tumour CEA, most likely to benefit from antibody targeted therapy. Knowledge of the pathophysiology of many diseases may be enhanced by quantitative estimation of antigen concentration related to tissue morphology.

Suppression of cell proliferation and telomerase activity in 4-(hydroxyphenyl)retinamide-treated mammary tumors

The detection of telomerase activity has been proposed as a biomarker of breast cancer development and progression. In this study, we used cell proliferation and telomerase in MNU (N-methyl-N-nitrosourea)-induced mammary carcinomas as targets for assessing the response of tumor cells to 4-(hydroxyphenyl)retinamide (4-HPR), a known inhibitor of mammary carcinogenesis in animal models and premenopausal women. In mammary tumors of rats treated for 1, 2, 4 or 6 weeks with 4-HPR, we observed that telomerase activity decreased progressively with the extension of 4-HPR administration. A marked reduction in telomerase activity was already observed by 2 weeks after treatment and the lowest level was found at 6 weeks after initiation of 4-HPR treatment. The changes in telomerase activity were preceded and accompanied by a significant decrease in the percentage of proliferating cells as evaluated by 5-bromodeoxyuridine (BrdU)-labeling. However, when the values of telomerase activity in the individual tumors were compared with the percentage of proliferating cells, no significant correlation was found. These data suggest that the decreased telomerase activity in the animals treated with 4-HPR is not a simple consequence of the changes in cell proliferation, but a more complex phenomenon involving different cellular mechanisms and pathways. The time-dependent and consistent decrease of telomerase activity in the tumors treated with 4-HPR suggests that, in addition to the percentage of proliferating cells, telomerase activity could also be used as an endpoint in breast cancer chemotherapy studies.

Heightened intrathecal release of proinflammatory cytokines in Creutzfeldt-Jakob disease

The authors report high intrathecal release of tumor necrosis factor alpha (TNF-alpha) and interleukin (IL)-1beta in five patients with sporadic or new-variant Creutzfeldt-Jakob disease (CJD) without activation of the humoral or lymphocytic immune responses. Increased release of TNF-alpha and IL-1beta was also detected in some patients with progressive dementias. CJD is associated with a local cerebral host response that involves the release of proinflammatory cytokines.

Health sector reform and the interpretation of policy context

Health sector reform is on the policy agenda of national governments and international agencies. This paper focuses on the policy process of health sector reform and, more specifically, the policy context. The importance of understanding policy context is emphasised and the elements of policy context are discussed. These are: demographic and epidemiological change; processes of social and economic change; economic and financial policy; politics and the political regime; ideology, public policy and the public sector. The paper then discusses the means for, and methods of, interpretation of the policy context. Particular emphasis is placed on linking policy context with an overall understanding of the policy process, the 'messiness' of policy-making, the interrelationship between the contextual factors, the contextual factors interpreted by policy actors, the use of analytical categories in the policy analysis. The paper concludes on the importance of strengthening policy analysis for effective health sector reform.

On discriminating and not discriminating between affect and representation

The topic involves two issues. They can be related either to different clinical pictures or to divergent opinions about the same clinical facts. But the above mentioned opposition can be found in Freud's work. Listening in analysis differentiates between situations where the distinction of affect and representation is blurred within the general frame of communication and others where this distinction imposes itself because of the critical or chronic character of the predominance of affect. Problems about the discrimination between affect and representation in the unconscious are elucidated in the light of their structural differences. The notion of the psychical representative of the drive announces the reference to the further notion of instinctual impulse. Later on, in Freud's theory, the notion of instinctual impulse has encompassed the distinction between affects and representation. Contemporary authors have, in their vast majority, chosen to refer preferably to object relationships. Nevertheless, the problems raised by Freud remain unanswered. It is with the clinical picture of borderline personality disorders that the lack of discrimination between affect and representation becomes evident. A detailed description is presented of the forms of transference where the irrepresentable prevails, accompanied by feelings of being overwhelmed, repetition compulsion, acting out and somatic reactions. In the countertransference, the affects of helplessness, despair and even the impossibility of grasping the meaning of the patient's communication are frequently met in the analyst. In these clinical pictures, intermediary formations, i.e. psychic organisations where primary processes structures the unconscious, are impaired. One is struck by the limitation of the capacities of representation and by the importance of phenomena related to negative hallucinations specially focused on thought processes, The communication is frequently self-contradictory, the transference oscillating between disembodiment and primitive fusion. The object has a paradoxical status; it is at the same time everything and nothing, the transference being incomprehensible and unanalysable. Different hypotheses are presented to explain the importance of destruction. Finally, the author presents a hypothesis for the deficiency of these intermediary formations because of the absence of continuing cathexis from the primary object at certain important moments of the relationship. It is the establishment of theses intermediary formations that will permit the acceptance of the separation from the object, the child now being able to rely on his own internal creations. However important the influences of the relationship to the other in the genesis of affects, the internal orientation towards the body of the psychic processes is what constitutes the core of the primordial psychic world.

Public sector hospitals and organizational change: an agenda for policy analysis

An important feature of health care systems in recent years is the change in the organizational position and relations of public sector hospitals. Health sector reforms have led to increasing heterogeneity in the organizational location and status of public sector hospitals and new organizational forms of public-private relations are being developed by and for hospitals. These changes can have important implications for health and health care. They raise issues around equity, control, accountability and performance of health care. Yet the policy process in practice may be failing to develop and implement appropriate forms of policy formulation on health sector reform. This paper focuses on the organizational position and relations of hospitals within public sector health services. It firstly outlines key elements of health sector reform and relates these to two dimensions of organizational change for hospitals: increasing heterogeneity and forms of public-private relations. The paper provides a descriptive format for classifying forms of hospital organizational change and proposes a framework of six questions for analysing these organizational forms. This may be used to assess the appropriateness of specific policies to particular country situations and to develop more open debate around hospital organizational forms.

Biochemical monitoring of treatment for galactosaemia: biological variability in metabolite concentrations

Red cell galactose 1-phosphate (Gal-1-P) concentrations and urinary galactitol excretion have been suggested as biochemical indices of dietary compliance in classical transferase-deficient galactosaemia. We report our experience of measuring both in 32 patients over 0-10.9 years (median 3.45). A total of 438 blood specimens for Gal-1-P and 383 urine specimens for galacitol assay were received; 317 pairs of specimens were collected at the same time. Concentrations of both analytes fell rapidly over the first 2-3 months following dietary intervention, to mean (geometric SD) levels of 225 (1.60) mumol/L red cells for Gal-1-P and 388 (1.19) mumol/mmol creatinine for galactitol. Concentrations then fell exponentially over the next 7-8 years, with times to half-disappearance of 6.3 years for Gal-1-P and 6.4 years for galactitol, to levels of 104 (1.58) and 193 (1.36) respectively in patients aged over 10 years. Concentrations of both analytes were independent of the presence of the common Q188R mutation. Mean intra- and inter-individual coefficients of variation (CV) across the range of values studied were 36% and 61% for Gal-1-P, and 37% and 42% for galactitol. Analytical CVs were 3.6% for Gal-1-P and 5.5% for galactitol, indicating that the major source of variability is biological. The correlation coefficient between Gal-1-P and galactitol in paired samples overall was 0.33; the regression equation being [Galactitol] = 0.84[Gal-1-P] + 176. Serial measurements of both Gal-1-P and galactitol may be valuable in monitoring galactosaemia, but high intra-individual biological variability limits their usefulness. Standardization of sample collection times may improve this. Further work is needed to assess the predictive values of both analytes for long-term outcome.

Tumor necrosis factor alpha stimulates lipolysis in adipocytes by decreasing Gi protein concentrations

Prolonged treatment (12-24 h) of adipocytes with tumor necrosis factor alpha (TNFalpha) stimulates lipolysis. We have investigated the hypothesis that TNFalpha stimulates lipolysis by blocking the action of endogenous adenosine. Adipocytes were incubated for 48 h with TNFalpha, and lipolysis was measured in the absence or presence of adenosine deaminase. Without adenosine deaminase, the rate of glycerol release was 2-3-fold higher in the TNFalpha-treated cells, but with adenosine deaminase lipolysis increased in the controls to approximately that in the TNFalpha-treated cells. This suggests that TNFalpha blocks adenosine release or prevents its antilipolytic effect. Both N6-phenylisopropyl adenosine and nicotinic acid were less potent and efficacious inhibitors of lipolysis in treated cells. A decrease in the concentration of alpha-subunits of all three Gi subtypes was detected by Western blotting without a change in Gs proteins or beta-subunits. Gi2alpha was about 50% of control, whereas Gi1alpha and Gi3alpha were about 20 and 40% of control values, respectively. The time course of Gi down-regulation correlated with the stimulation of lipolysis. Furthermore, down-regulation of Gi by an alternative approach (prolonged incubation with N6-phenylisopropyl adenosine) stimulated lipolysis. These findings indicate that TNFalpha stimulates lipolysis by blunting endogenous inhibition of lipolysis. The mechanism appears to be a Gi protein down-regulation.

CDKN2A variants in a population-based sample of Queensland families with melanoma

BACKGROUND

Mutations in the CDKN2A gene confer susceptibility to cutaneous malignant melanoma (CMM); however, the population incidence of such mutations is unknown. Polymorphisms in CDKN2A have also been described, but it is not known whether they influence melanoma risk. We investigated the association of CDKN2A mutations and polymorphisms with melanoma risk in a population-based sample of families ascertained through probands with melanoma.

METHODS

The 482 Queensland, Australia, families in our sample were characterized previously as having high, intermediate, or low family risk of CMM. Unrelated individuals (n = 200 families/individuals) drawn from the Australian Twin Registry served as control subjects. For individuals in the high-risk group, the entire CDKN2A gene coding region was screened for mutations by use of the polymerase chain reaction, agarose gel electrophoresis, allele-specific oligonucleotide (ASO) hybridization, and single-strand conformation polymorphism analysis. The intermediate- and low-risk families and control subjects were analyzed by ASO hybridization for a total of six recurring mutations as well as for polymorphisms at nucleotides (Nts) 442, 500, and 540.

RESULTS

CDKN2A mutations were found only in the high-risk families (nine [10.3%] of 87). The prevalence of the Nt500G (guanosine) polymorphism increased linearly with increasing familial risk (two-sided P = .02) and was highest in the nine (primarily Celtic) families with CDKN2A mutations. After adjustment for ethnic origin, the relationship between risk group and the frequency of the Nt500G allele was weakened (P = .25); however, there was no relationship between ethnic origin and Nt500-polymorphism frequency among the control subjects.

CONCLUSIONS

CDKN2A mutations are rare in this population (approximately 0.2% of all melanoma cases in Queensland) and appear to be associated with melanoma in only the most affected families. The Nt500G allele appears to be associated with familial risk, but this association probably reflects Celtic ancestry.

A case-control study of melanomas of the soles and palms (Australia and Scotland)

OBJECTIVES

Because the factors that influence risk of acral melanomas on the soles and palms in White populations are unknown, we investigated these in a multi-center case-control study.

METHODS

Cases of melanoma of the feet and hands diagnosed from 1987-93 in persons aged over 18 years were ascertained in eastern Australia and western Scotland. There were 275 cases of melanoma on the soles and palms matched to 496 controls (selected from the electoral roll) in Australia, and 36 cases matched to 72 controls (nominated by general practitioners) in Scotland.

RESULTS

Acral melanoma was strongly associated with high total body nevus counts (adjusted relative risk [RR] = 6.3, 95% confidence interval [CI] = 2.5-15.6), and with nevi on the soles (RR = 7.5, CI = 3.0-18.6). There were also significant positive associations with a penetrative injury of the feet or hands (RR = 5.0, CI = 3.0-8.6) and with heavy exposure to agricultural chemicals (RR = 3.6, CI = 1.5-8.3). Sun-sensitive complexions, cumulative sun exposure and a past history of nonmelanoma skin cancer were also associated with increased risk of acral melanoma. Current cigarette smoking was inversely related to acral melanoma (RR = 0.6, CI = 0.4-0.9).

CONCLUSIONS

Melanomas of the soles and palms resemble other cutaneous melanomas in their association with sun exposure, but are distinguished from them by their strong positive associations with nevi on the soles, previous penetrative injury, and exposure to agricultural chemicals, and by their inverse association with smoking.

Photobiological aspects of sunscreen re-application

A single application of a high sun protection factor (SPF) sunscreen has been shown to prevent sunburn, but the existence of a further protective effect following re-application of sunscreen has received little attention. The aim of this study was to quantify the ultraviolet radiation (UVR) protection against sunburn afforded by a re-application of sunscreen relative to a single application. The study methods were based on the Australian Standard SPF testing regimen, using human volunteers, standardized applications of sunscreen and an artificial solar simulating UVR source. Sunscreen was initially applied, followed by a suberythemal UVR dose; sunscreen was then re-applied, followed immediately by a second period of controlled UV exposure sufficient to induce mild erythema. Compared to the first application, the second sunscreen application afforded 3.1 times more protection against minimal UVR-induced erythema. The combined effect of two sunscreen applications gave on average 2.5 times better protection from UVR than a single sunscreen application. Health authorities worldwide have recommended sunscreen re-application for the prevention of sunburn for some time. This is the first quantitative study to substantiate such recommendations.

Epidemiology of type 1 (insulin-dependent) diabetes mellitus: public health implications in the Middle East

Recent estimates suggest that more than 100,000 inhabitants in the Middle East suffer from type 1 diabetes and that about 6000 subjects in the region develop the disease each year. This paper illustrates how epidemiological principles and methods may assist in a rational assessment of the public health impact of type 1 diabetes in the Middle East. Making a series of assumptions, it is estimated that the future prevalence of type 1 diabetes in the region will increase slightly, but that the increase may be more pronounced if the disease incidence is increasing and the prognosis improved. It is recommended that more valid information is established on the basic epidemiological features of type 1 diabetes in the Middle East, as this will provide the basis of more rational planning of the current and future diabetes healthcare in the region.

Hereditary haemorrhagic telangiectasia: a population-based study of prevalence and mortality in Danish patients

INTRODUCTION

Hereditary haemorrhagic telangiectasia (HHT) is a dominantly inherited disease characterized by telangiectatic lesions. The disease manifestations are variable and include epistaxis, gastrointestinal bleeding, pulmonary arteriovenous malformations and cerebral arteriovenous malformations. Early death due to these complications has been described.

DESIGN

We report a study on the prevalence and mortality of HHT in a Danish population based on two cross-sectional surveys in combination with a long-term follow-up study.

SETTINGS AND SUBJECTS

Prevalent cases of HHT as of 1 January 1974 in the County of Fyn, Denmark, were identified. In 1995-97 a follow-up study of mortality was performed of the initial patient sample, and a new point prevalence rate of HHT as of 1 January 1995 was calculated. All live patients and their families were invited to attend a detailed clinical examination.

RESULTS

The prevalence of HHT in the County of Fyn was 13.8 per 100,000 on 1 January 1974 and 15.6 per 100,000 on 1 January 1995. In the HHT group as a whole, we found a slightly increased mortality; however, amongst the HHT patients younger than 60 years at inclusion the mortality of HHT patients was twice the expected. The excess mortality could be fully explained by severe HHT symptoms.

CONCLUSION

This study suggests that HHT is more prevalent than previously believed. In young patients the disease is associated with an excess mortality which is fully attributable to HHT. Future research should aim at the identification of HHT patients at particular risk of developing severe complications.

Traumatic nerve injuries about the elbow

Although not common, nerve injuries about the elbow occur because of the proximity of the three upper extremity nerves or because of the relationship of the median, ulnar, and radial nerves to the bony and soft-tissue structures about the elbow joint. Nerve injuries at and about the elbow joint occur more frequently with fractures than with any other kind of trauma. Nerve injuries may be found with periarticular fractures, dislocations, gunshot wounds, lacerations, and other iatrogenic causes.

Heterodimerization is required for the formation of a functional GABA(B) receptor

GABA (gamma-aminobutyric acid) is the main inhibitory neurotransmitter in the mammalian central nervous system, where it exerts its effects through ionotropic (GABA(A/C)) receptors to produce fast synaptic inhibition and metabotropic (GABA(B)) receptors to produce slow, prolonged inhibitory signals. The gene encoding a GABA(B) receptor (GABA(B)R1) has been cloned; however, when expressed in mammalian cells this receptor is retained as an immature glycoprotein on intracellular membranes and exhibits low affinity for agonists compared with the endogenous receptor on brain membranes. Here we report the cloning of a complementary DNA encoding a new subtype of the GABAB receptor (GABA(B)R2), which we identified by mining expressed-sequence-tag databases. Yeast two-hybrid screening showed that this new GABA(B)R2-receptor subtype forms heterodimers with GABA(B)R1 through an interaction at their intracellular carboxy-terminal tails. Upon expression with GABA(B)R2 in HEK293T cells, GABA(B)R1 is terminally glycosylated and expressed at the cell surface. Co-expression of the two receptors produces a fully functional GABA(B) receptor at the cell surface; this receptor binds GABA with a high affinity equivalent to that of the endogenous brain receptor. These results indicate that, in vivo, functional brain GABA(B) receptors may be heterodimers composed of GABA(B)R1 and GABA(B)R2.

Buteyko breathing techniques in asthma: a blinded randomised controlled trial

OBJECTIVE

To evaluate the effect of Buteyko breathing techniques (BBT) in the management of asthma.

DESIGN

Prospective, blinded, randomised study comparing the effect of BBT with control classes in 39 subjects with asthma. The study was conducted from January 1995 to April 1995.

PARTICIPANTS AND SETTING

Subjects recruited from the community, aged 12 to 70 years, with asthma and substantial medication use.

MAIN OUTCOME MEASURES

Medication use; morning peak expiratory flow (PEF); forced expiratory volume in one second (FEV1); end-tidal (ET) CO2; resting minute volume (MV); and quality of life (QOL) score, measured at three months.

RESULTS

No change in daily PEF or FEV1 was noted in either group. At three months, the BBT group had a median reduction in daily beta 2-agonist dose of 904 micrograms (range, 29 micrograms to 3129 micrograms), whereas the control group had a median reduction of 57 micrograms (range, -2343 micrograms to 1143 micrograms) (P = 0.002). Daily inhaled steroid dose fell 49% (range, -100% to 150%) for the BBT group and 0 (range, -82% to +100%) for the control group (P = 0.06). A trend towards greater improvement in QOL score was noted for BBT subjects (P = 0.09). Initial MV was high and similar in both groups; by three months, MV was lower in the BBT group than in the control group (P = 0.004). ET CO2 was low in both groups and did not change with treatment.

CONCLUSION

Those practising BBT reduced hyperventilation and their use of beta 2-agonists. A trend toward reduced inhaled steroid use and better quality of life was observed in these patients without objective changes in measures of airway calibre.