The role of lipopolysaccharide in the development of atopy in humans

Atopy is a highly prevalent condition and remains the single biggest risk factor for asthma. Although atopy has a heritable component, the time frame of the increase in the prevalence indicates that it is not due to genetic factors alone. The relationship between allergen exposure and sensitization is complex. Lipopolysaccharide (LPS) and its bioactive moiety endotoxin are common to all gram-negative bacteria, and have been used as a surrogate of microbial load. Endotoxin can be readily measured in dust collected from homes. Some studies have demonstrated a clear inverse dose-response relationship between exposure to endotoxin and the risk of atopy but this finding has not been reproduced in all studies. Our innate immune system recognizes LPS readily via the LPS signal transduction pathway, which has the trimolecular complex of CD14/TLR4/MD2 at the core. A common single-nucleotide polymorphism in the promoter region of CD14 rs2569190 C to T (CD14/-260 or CD14/-159) has been associated with elevated sCD14. Although early studies suggested that this variant was associated with more severe atopy, this finding was not uniformly replicated. It has now been demonstrated in four independent populations that high exposure to endotoxin in the domestic environment is protective against the development of atopy, but only among carriers of the C allele, that is, the environmental exposure is only relevant when taken in the context of the genotype. Furthermore, this interaction is biologically plausible. We propose that neither the environmental exposure nor the genotype in isolation is sufficient to cause complex diseases like asthma and atopy, but disease results from the one acting in the context of the other, of which CD14 and endotoxin is one example contributing to the risk for atopy.

Manual restraint of adult psychiatric inpatients: a literature review

Relatively little is known about the prevalence of manual restraint to manage violent or challenging behaviour in hospital psychiatric services or the circumstances of its use. This review identified 45 empirical studies of manual restraint of adult psychiatric inpatients, mostly from the UK. On average, up to five episodes per month of manual restraint might be expected on an average 20-bed ward. Episodes last around 10 min, with about half involving the restraint of patients on the floor, usually in the prone position. Manually restrained patients tend to be younger, male and detained under mental health legislation. Staff value restraint-related training, but its impact on nursing practice has not been evaluated. Research has tended to focus on official reports of violent incidents rather than manual restraint per se. Larger and more complex studies are needed to examine how manual restraint is used in response to different types of incident and in different service settings.

An unusual case of Epstein-Barr virus driven lymphoproliferative disorder of the conjunctiva which mimicked a high grade lymphoma: a sheep in wolf's clothing

Lymphoid proliferations represent 25-33% of acquired sub-epithelial conjunctival lesions which are excised or biopsied in patients over 15 years of age. These lesions are reported in association with Epstein-Barr virus (EBV). One such case of EBV associated spontaneously regressed monoclonal B cell infiltrate in conjunctiva that mimicked a large B cell lymphoma is reported.

Locked doors in acute inpatient psychiatry: a literature review

Many acute inpatient psychiatric wards in the UK are permanently locked, although this is contrary to the current Mental Health Act Code of Practice. To conduct a literature review of empirical articles concerning locked doors in acute psychiatric inpatient wards, an extensive literature search was performed in SAGE Journals Online, EBM Reviews, British Nursing Index, CINAHL, EMBASE Psychiatry, International Bibliography of the Social Sciences, Ovid MEDLINE, PsycINFO and Google, using the search terms 'open$', 'close$', '$lock$', 'door', 'ward', 'hospital', 'psychiatr', 'mental health', 'inpatient' and 'asylum'. A total of 11 empirical papers were included in the review. Both staff and patients reported advantages (e.g. preventing illegal substances from entering the ward and preventing patients from absconding and harming themselves or others) and disadvantages (e.g. making patients feel depressed, confined and creating extra work for staff) regarding locked doors. Locked wards were associated with increased patient aggression, poorer satisfaction with treatment and more severe symptoms. The limited literature available showed the urgent need for research to determine the real effects of locked doors in inpatient psychiatry.

Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway responsiveness in mid-childhood

Background:

Patterns of wheezing during early childhood may indicate differences in aetiology and prognosis of respiratory illnesses. Improved characterisation of wheezing phenotypes could lead to the identification of environmental influences on the development of asthma and airway diseases in predisposed individuals.

Methods:

Data collected on wheezing at seven time points from birth to 7 years from 6265 children in a longitudinal birth cohort (the ALSPAC study) were analysed. Latent class analysis was used to assign phenotypes based on patterns of wheezing. Measures of atopy, airway function (forced expiratory volume in 1 s (FEV₁), mid forced expiratory flow (FEF_25-75)) and bronchial responsiveness were made at 7–9 years of age.

Results:

Six phenotypes were identified. The strongest associations with atopy and airway responsiveness were found for intermediate onset (18 months) wheezing (OR for atopy 8.36, 95% CI 5.2 to 13.4; mean difference in dose response to methacholine 1.76, 95% CI 1.41 to 2.12 %FEV₁ per μmol, compared with infrequent/never wheeze phenotype). Late onset wheezing (after 42 months) was also associated with atopy (OR 6.6, 95% CI 4.7 to 9.4) and airway responsiveness (mean difference 1.61, 95% CI 1.37 to 1.85 %FEV₁ per μmol). Transient and prolonged early wheeze were not associated with atopy but were weakly associated with increased airway responsiveness and persistent wheeze had intermediate associations with these outcomes.

Conclusions:

The wheezing phenotypes most strongly associated with atopy and airway responsiveness were characterised by onset after age 18 months. This has potential implications for the timing of environmental influences on the initiation of atopic wheezing in early childhood.

The effect of anti-Rho(D) and non-specific immunoglobulins on monocyte Fc receptor function: the role of high molecular weight IgG polymers and IgG subclasses

Anti-Rho(D) immunoglobulin (anti-D) contained more high molecular weight (HMW) IgG polymers than intravenous non-specific immunoglobulin (i.v. Ig). The low-dose anti-D and high-dose i.v. Ig regimens used to treat idiopathic thrombocytopenic purpura (ITP) therefore contained similar total amounts of HMW IgG. In vitro, the HMW IgG polymers were more effective competitive inhibitors of monocyte phagocyte Fc receptors than monomeric IgG. The IgG subclass composition of anti-D and i.v. Ig were both similar to normal human plasma. We conclude that the HMW IgG content but not the IgG subclass composition of anti-D may explain its low-dose therapeutic efficacy in ITP.

Patient ethnicity and three psychiatric intensive care units compared: the Tompkins Acute Ward Study

Psychiatric care units provide care to disturbed patients in a context of higher security and staffing levels. Although such units are numerous, few systematic comparisons have been made, and there are indications that ethnic minority groups may be over-represented. The aim of this study was to compare the rates of adverse incidents and patterns of usage of three psychiatric intensive care units. The study used a triangulation or multi-method design, bringing together data from official statistics, local audit and interviews conducted with staff. Intensive care patients were more likely to be young, male and suffering a psychotic disorder, as compared with general acute ward patients. Caribbean patients were twice as likely, and Asian patients half as likely, to receive intensive care (age, gender and diagnosis controlled). There were large differences in service levels, staffing, team functioning and adverse incidents between the three units. Various aspects of physical security were important in preventing absconds. More evaluative research is required in order to define effective service levels, and to explore the nature of the interaction between ethnicity and inpatient care provision during acute illness.

Collaborative care for depression in UK primary care: a randomized controlled trial

BACKGROUND

Collaborative care is an effective intervention for depression which includes both organizational and patient-level intervention components. The effect in the UK is unknown, as is whether cluster- or patient-randomization would be the most appropriate design for a Phase III clinical trial.

METHOD

We undertook a Phase II patient-level randomized controlled trial in primary care, nested within a cluster-randomized trial. Depressed participants were randomized to 'collaborative care' - case manager-coordinated medication support and brief psychological treatment, enhanced specialist and GP communication - or a usual care control. The primary outcome was symptoms of depression (PHQ-9).

RESULTS

We recruited 114 participants, 41 to the intervention group, 38 to the patient randomized control group and 35 to the cluster-randomized control group. For the intervention compared to the cluster control the PHQ-9 effect size was 0.63 (95% CI 0.18-1.07). There was evidence of substantial contamination between intervention and patient-randomized control participants with less difference between the intervention group and patient-randomized control group (-2.99, 95% CI -7.56 to 1.58, p=0.186) than between the intervention and cluster-randomized control group (-4.64, 95% CI -7.93 to -1.35, p=0.008). The intra-class correlation coefficient for our primary outcome was 0.06 (95% CI 0.00-0.32).

CONCLUSIONS

Collaborative care is a potentially powerful organizational intervention for improving depression treatment in UK primary care, the effect of which is probably partly mediated through the organizational aspects of the intervention. A large Phase III cluster-randomized trial is required to provide the most methodologically accurate test of these initial encouraging findings.

Quantification of atopy and the probability of rhinitis in preschool children: a population-based birth cohort study

BACKGROUND

Atopy quantification using IgE levels/skin test diameter (SPT-MWD) may better predict the expression of rhinitis than using atopy as a dichotomous variable.

OBJECTIVE

To investigate the association between the presence, temporal pattern and severity of rhinitis in preschool children and specific IgE levels/SPT-MWDs.

METHODS

Children were followed prospectively to age 5 years in a whole-population birth cohort study. We administered questionnaires (n = 815), skin prick tested children (n = 717) and measured specific serum IgE (n = 478) to inhalant and food allergens. Main outcomes were current rhinitis (CR) and current rhinoconjunctivitis (CRC).

RESULTS

The prevalence of CR and CRC was 26.1% and 12.1%, respectively. The risk of CR and CRC increased significantly with increasing IgE to grass, mite and cat; CRC was also associated with increasing IgE to dog and peanut. Similarly, increasing SPT-MWDs to inhalant allergens were significantly associated with CR and CRC. This association was also shown for grass within the group of atopic children. Perennial and seasonal rhinitis were associated with increasing IgE/SPT-MWD to mite and grass, respectively. Moderate/severe rhinitis was associated with increasing IgE/SPT-MWD to grass. In a multivariate analysis, increasing levels of IgE/SPT-MWD to grass were the strongest independent predictors of both CR (for IgE: OR 1.42, 95% CI 1.23-1.64, P < 0.001) and CRC (for IgE: 1.51, 1.30-1.76, P < 0.001).

CONCLUSION

The probability of CR/CRC increases with increasing specific IgE levels or SPT-MWD. With respect to allergic rhinitis, the absolute levels of specific IgE antibody or the size of SPT wheal offer more information than just the presence/absence of sensitization.

Mental health and debt: challenges for knowledge, practice and identity

People with mental health problems (MHPs) in Britain are nearly three times more likely to report debt compared with individuals without similar conditions. With one-in-four respondents with MHPs reporting personal debt, this may be equivalent to eight or nine clients in the recommended national community mental health nurses' (CMHNs) caseload of 35. Although client debt is not a new problem for CMHNs, it can pose significant difficulties for client well-being and nursing practice. This paper reviews the published literature on debt and mental health, then considers three of the challenges that client debt can present to: (1) nursing knowledge--moving away from understandings of client debt based on crisis, and towards those focused on process and prevention; (2) nursing practice--reworking the collaborative relationship between CMHNs and external debt advice agencies; and (3) nursing identity--managing the role conflicts that engaging with client debt can bring. The paper concludes by contending that nurses should raise and monitor debt issues among clients, but cannot be expected to become proxy 'debt advisors', with CMHNs being encouraged to increasingly collaborate with debt advisors (rather than simply referring on clients).

Rhinoconjunctivitis in 5-year-old children: a population-based birth cohort study

BACKGROUND

There is a paucity of data on the prevalence, risk factors and natural history of rhinitis in early childhood.

OBJECTIVE

Within the context of a whole-population birth cohort we investigated the prevalence of and risk factors for current rhinoconjunctivitis (CRC) at age 5 years.

METHODS

Children were followed prospectively to age 5 years [questionnaires (n = 815), skin testing (n = 717), specific immunoglobulin E (n = 478), lung function (n = 711), dry air challenge (n = 556)]. Endotoxin and allergen exposures were measured in dust samples.

RESULTS

The prevalence of rhinitis ever, current rhinitis and rhinoconjunctivitis was 28.2%, 26.1%, and 12.1%, respectively. Asthma, wheeze and eczema coexisted with CRC (P < or = 0.01). In a multivariate model, maternal asthma (OR 2.38, 95% CI: 1.30-4.38, P = 0.005), paternal hay fever (1.96, 1.11-3.46, P = 0.02) and sensitization to grass (3.46, 1.86-6.42, P < 0.001) and cat (2.42, 1.14-5.18, P = 0.02) remained significant and independent associates of CRC. Whilst almost half of children with CRC were nonatopic, there was little difference in risk factors between atopic and nonatopic CRC. Amongst children with current wheeze, the presence of concurrent CRC had no effect on either severity or frequency of wheezy episodes. There was no difference in specific airway resistance, forced expiratory volume in 1 second (FEV(1)) or airway reactivity between children with and without CRC after adjustment for the presence of wheeze.

CONCLUSION

Family history of allergic disease and sensitization to inhalant allergens are risk factors for rhinoconjunctivitis in preschool children. In this age group, there is no association between the presence of rhinoconjunctivitis and severity of wheeze, increased airway reactivity and reduced lung function.

European birth cohort studies on asthma and atopic diseases: II. Comparison of outcomes and exposures--a GA2LEN initiative

BACKGROUND

The Global Allergy and Asthma European Network (GA2LEN) is a consortium of 26 leading European research centres committed to establish a European research area of excellence in the field of allergy and asthma.

AIM

One of the GA2LEN work packages was designed to identify and compare the existing European birth cohort studies on asthma and atopic diseases. The present review compares their subjective and objective outcomes as well as exposure variables.

METHODS

A common database was established to assess study characteristics of observational birth cohort studies designed to examine asthma and atopic diseases. Data were collected by visiting most of the participating research teams and interviewing all relevant study personnel. For each study, the type of objective/subjective outcome parameters and potentially influential factors were recorded precisely for every time point during follow-up.

RESULTS

Eighteen birth cohort studies on asthma and atopic diseases were identified in eight European countries. Thirteen studies collected data on specific immunoglobulin E (IgE) to various inhalant and food allergens, whereas 12 performed skin prick tests (many at several time points during follow up). Several studies measured lung function, but across the cohorts no comparable standard procedures were used. For subjective evaluation of asthma and allergic rhinitis most studies applied the ISAAC questionnaire (sometimes modified), whereas the assessment of eczema was rather heterogeneous across the studies.

CONCLUSION

This GA2LEN initiative established a unique common database of 18 European birth cohorts on asthma and atopic diseases. For selected cohorts, it seems that pooling data and performing common analyses may be possible to examine associations between certain exposure variables (e.g. pet ownership, tobacco smoke exposure and day-care) and selected outcome measures for atopy, asthma or allergic rhinitis (e.g. sensitization assessed by IgE or skin prick tests, doctor's diagnosis of asthma, parental perception regarding asthma/wheezing or hay fever symptoms).

A comparison of non-radioactive methods for assessing viability in ex vivo cultured cancellous bone: technical note

Biocompatibility studies are carried out either in two dimensional monolayer culture or in animal studies. Bone organ cultures are therefore required in order to reduce the number of animal studies performed, while at the same time ensuring a more natural environment than that provided by monolayer culture of isolated cells. Due to the three dimensional nature of bone explants, assays that determine the distribution of viable cells are required, however dense mineralised bone is not easily penetrated by soluble factors. We sought to compare a number of non-radioactive viability methods in order to assess their suitability for use with cancellous bone. Fluorescent live/dead staining, MTT activity and lactate dehydrogenase detection were all investigated on either whole bone explants (9.5 mm in diameter, 5 mm high) or on sections of explants. All these assays are routinely used in 2 dimensional cell culture systems, yet each required modifications to be suitable for use with cancellous bone. Factors such as penetration of reagent, incubation time, assay temperature and ease of determining viable cells were all compared. It was demonstrated that penetration of the reagents into whole cores was a major problem which easily led to artefacts that could be overcome by preparing 250 mum unfixed sections. Fluorescent live/dead staining had extra complications caused by the autofluorescence of the bone generating a high signal to noise ratio, making assessment of osteocyte viability impossible. MTT staining was difficult to interpret due to the punctate nature of the stain. We found that lactate dehydrogenase staining of 250 mum thick unfixed sections led to excellent viability determination of osteocytes within the mineralised matrix. It also maintained marrow structure and enabled marrow viability to be assessed as a factor of volume occupied by viable marrow. Decreasing the viscosity of the LDH assay solution used in published methods led to a greatly improved penetration into the calcified matrix. Quantification of thick sections is aided by using the autofluorescence of the bone to highlight the darkly stained osteocytes against the fluorescing bone.

Can mainstream health services provide meaningful care for people who self-harm? A critical reflection

People who self-harm currently access health care based in a wide variety of settings. These include primary care, accident and emergency departments, and specialist mental health providers. This paper considers whether meaningful care for people who self-harm can be provided within these mainstream health services. The paper begins by clarifying the meaning of self-harm and distinguishes self-harm from suicide. Four treatment models applied in clinical practice are identified: (i) psychodynamic, (ii) behavioural, (iii) biosocial and (iv) feminist. Each of these is critically considered in terms of practical utility, professional attitudes and wider organizational/policy context.

Transverse Modes and Frequencies of Beams Translating between Fixed end Supports

The effects of longitudinal steady translational motion on the vibration frequencies and modes of simple Euler beams are outlined. An example shows that the natural frequencies decrease monotonically with increasing translation velocity, while the mode shapes are complex, indicating significant phase disparities from point to point across the span. Divergence is shown to occur when the translation velocity is greater than the fundamental flexural wave propagation velocity.

More general equations of motion, governing the translating Timoshenko beam under axial loading, are derived in Appendix 1.

European birth cohort studies on asthma and atopic diseases: I. Comparison of study designs -- a GALEN initiative

BACKGROUND

The reasons for the rise in asthma and allergies remain unclear. To identify risk or protective factors, it is essential to carry out longitudinal epidemiological studies, preferably birth cohort studies. In Europe, several birth cohort studies on asthma and atopic diseases have been initiated over the last two decades.

AIM

One of the work packages within the Global Allergy and Asthma European Network (GA(2)LEN) project was designed to identify and compare European birth cohorts on asthma and atopic diseases. The present review (part I) describes their objectives, study settings, recruitment process and follow-up rates. A subsequent review (part II) will compare outcome and exposure parameters.

METHODS

For each birth cohort, we collected detailed information regarding recruitment process, study setting, baseline data (pregnancy, birth, parents/siblings) as well as follow-up rates, outcome and exposure parameters at each time point.

RESULTS

We identified and assessed 18 European birth cohorts on asthma, allergic rhinitis and eczema. Six of these studies also focused on food allergies. The birth cohorts were mostly initiated in the 1990s with predominantly urban/metropolitan settings. Many studies were able to maintain high follow-up rates, even after five or more years.

CONCLUSIONS

Due to the unique cooperation within the GA(2)LEN project a common database was established containing study characteristics of European birth cohorts on asthma and atopic diseases. This can be used as a basis for evaluating the possibility to pool data and perform meta-analyses, as well as to recommend criteria for conducting future birth cohorts.

Allergy and infection: understanding their relationship

Sensitization to indoor allergens has long been recognized as a risk factor for asthma and its associated phenotypes. Immunoglobulin E antibody quantification may be used to confirm that a particular sensitization has a role in the development of respiratory symptoms. However, in order to use quantitative information effectively, it is essential to understand the factors that contribute to the deterioration of symptoms and cause exacerbations. One such risk factor is high allergen exposure. Worsening asthma control is also associated with virus infections, in particular rhinovirus infection. Each of these factors in isolation is unlikely to have a major effect on symptoms. However, the combination of respiratory virus infection, allergen sensitization and concurrent high exposure to allergens markedly increases the risk for hospitalization. Further investigation of this synergism could help to understand the mechanisms of asthma exacerbations and lead to the development of strategies for prevention.

Failure monitoring in water distribution networks

An algorithm for the burst detection and location in water distribution networks based on the continuous monitoring of the flow rate at the entry point of the network and the pressure at a number of points within the network is presented. The approach is designed for medium to large bursts with opening times in the order of a few minutes and is suitable for networks of relatively small size, such as district metered areas (DMAs). The burst-induced increase in the inlet flow rate is detected using the modified cumulative sum (CUSUM) change detection test. Based on parameters obtained from the CUSUM test, the burst is simulated at a number of burst candidate locations. The calculated changes in pressure at the pressure monitoring points are then compared to the measured values and the location resulting in the best fit is selected as the burst location. The EPANET steady-state hydraulic solver is utilised to simulate the flows and pressures in the network. A sensitivity-based sampling design procedure is introduced to find the optimal positions for pressure monitoring points. The proposed algorithm is tested on a case study example network and shows potential for burst detection and location in real water distribution systems.

South-East Scotland trabeculectomy survey

AIM

Assessment of trabeculectomy in South-East Scotland (SESTS) with comparison to National Survey of Trabeculectomy (NST) and outcomes of consultant and trainee surgery.

METHOD

A retrospective study of 304 consecutive, primary trabeculectomies, in two Scottish centres (Edinburgh and Dunfermline) with two glaucoma specialists and higher surgical trainees, was performed. The study group had primary open angle glaucoma (65.5%), pseudoexfoliation (6.9%), normal tension glaucoma (7.6%), pigment dispersion syndrome (1.6%), and other complicated glaucoma (18.4%). All patients underwent trabeculectomy by the glaucoma specialist (57.6%) and higher surgical trainee (42.4%) with close scrubbed supervision.

RESULTS

Compared to the NST, the waiting time for surgery (<3 months) was significantly less in the SESTS (P<0.001). There was also significantly more use of intraoperative antimetabolites (P<0.01), bleb intervention (P<0.001), and a higher rate of early complications (P<0.025). There was no significant difference in outcome at intraocular pressure (IOP)<2/3 listing IOP (qualified and unqualified) between the SESTS and the NST. Significantly, more patients achieved an unqualified success of IOP<21 mmHg (P<0.01) and an unqualified success of IOP<16 mmHg in the SESTS than the NST (P<0.05). At 1 year post surgery, visual loss of greater than one Snellen line was more common in the NST (P<0.01) as was the use of anti-glaucoma medication (P<0.001). Trainee cases returned to theatre more frequently (P<0.025) and merited more bleb intervention (P<0.01) than consultant cases, but the long-term outcome was similar.

CONCLUSION

Our study highlights significant changes in the practice and outcome of trabeculectomy compared to the national survey conducted a decade ago.

Real world application of an intervention to reduce absconding

Absconding by acute psychiatric inpatients is associated with risk of harm to self and others, and creates considerable emotional as well as tangible burdens for staff. Previous research has led to the development of an effective nursing intervention to reduce absconding. In this project, that intervention was encapsulated in a self-training package, and offered freely to wards across the UK who agreed to implement it and audit the results. Fifteen wards completed this distributed audit, and achieved overall a 25.5% decrease in their absconding rates, as measured by official reports. The results support the efficacy of the intervention, and indicate that significant reductions can be made in absconding rates from unlocked or partially locked acute psychiatric wards.

Validation of direct intraabdominal pressure measurement using a continuous indwelling compartment pressure monitor

BACKGROUND

According to recommendations, intraabdominal pressure should be monitored every 8 hours for patients at high risk of abdominal compartment syndrome. Continuous intraabdominal pressure monitoring may be valuable for these patients.

METHODS

For 15 patients undergoing laparoscopic surgery, a pressure monitor was introduced after formation of pneumoperitoneum. During the procedure, the laparoscopic insufflator pressure was varied. The pressure monitor values and the time to equilibrium were recorded.

RESULTS

Altogether, 152 pressure recordings were taken for the patients studied. The measurements from the insufflator and pressure monitor were compared using a Bland-Altman plot. The mean difference between the techniques was 0.04 +/- 3.8, and 95% of the points from the pressure monitor were within two standard deviations of the mean difference. Pressure changes were essentially "real time."

CONCLUSIONS

The intracompartmental pressure monitor provides accurate, rapid, and direct measurement of intraabdominal pressure, and may be a useful tool for continuous intraabdominal pressure measurement among patients at risk of abdominal compartment syndrome.

Patients' preference for gender of urologist

The NHS Plan is for a health service designed around the patient. Several studies have investigated patients' preference for the gender of their doctor. However, within these studies, the patients have predominantly been females. The preferences of urology patients, of whom the majority are males, have not previously been investigated. The preferences for gender of urologist, from 496 consecutive patients attending urology clinic in a district general hospital, were investigated by questionnaires. The majority of patients had no preference for gender of their urologist. Of the patients who did have a preference, females were more likely to prefer the same gender urologist than males.

Inter‐ and intralaboratory variation of in vitro diffusion cell measurements: An international multicenter study using quasi‐standardized methods and materials

In vitro measurements of skin absorption are an increasingly important aspect of regulatory studies, product support claims, and formulation screening. However, such measurements are significantly affected by skin variability. The purpose of this study was to determine inter- and intralaboratory variation in diffusion cell measurements caused by factors other than skin. This was attained through the use of an artificial (silicone rubber) rate-limiting membrane and the provision of materials including a standard penetrant, methyl paraben (MP), and a minimally prescriptive protocol to each of the 18 participating laboratories. "Standardized" calculations of MP flux were determined from the data submitted by each laboratory by applying a predefined mathematical model. This was deemed necessary to eliminate any interlaboratory variation caused by different methods of flux calculations. Average fluxes of MP calculated and reported by each laboratory (60 +/- 27 microg cm(-2) h(-1), n = 25, range 27-101) were in agreement with the standardized calculations of MP flux (60 +/- 21 microg cm(-2) h(-1), range 19-120). The coefficient of variation between laboratories was approximately 35% and was manifest as a fourfold difference between the lowest and highest average flux values and a sixfold difference between the lowest and highest individual flux values. Intralaboratory variation was lower, averaging 10% for five individuals using the same equipment within a single laboratory. Further studies should be performed to clarify the exact components responsible for nonskin-related variability in diffusion cell measurements. It is clear that further developments of in vitro methodologies for measuring skin absorption are required.

The changing pattern of bloodstream infections associated with the rise in HIV prevalence in northeastern Thailand

A survey of bloodstream infections was conducted in the large regional hospital in Ubon Ratchatani, northeastern Thailand between 1989 and 1998, during the onset of the HIV epidemic. The incidence of Staphylococcus aureus, Escherichia coli, Klebsiella/Enterobacter and Pseudomonas aeruginosa bacteraemias remained constant whereas infections caused by Burkholderia pseudomallei, non-typhoid Salmonellae, Cryptococcus neoformans, Penicillum marneffei and to a lesser extent Streptococcus pneumoniae all rose. Burkholderia pseudomallei infections were unrelated to HIV, whereas the other infections were associated directly with HIV. Group D non-typhoid Salmonellae bloodstream infections (mainly Salmonella enteritidis) rose coincident with the increase in HIV seroprevalence, and preceded the increase in the other HIV-associated infections. Other non-typhoid Salmonella bacteraemias increased two years after the rise in group D infections, and invasive yeast infections increased four years later, coincident with the increase in AIDS. Increasing Group D non-typhoid Salmonella bloodstream infections are an early warning signal of an impending rise in AIDS.

Reported versus confirmed wheeze and lung function in early life

AIMS

To investigate the relation between parentally reported wheeze (unconfirmed), physician confirmed wheeze, and subsequent lung function.

METHODS

Children at risk of allergic disease (one parent atopic) were recruited antenatally and followed prospectively from birth. During the first three years of life parents were asked to contact the study team if their child was wheezy. The presence of wheeze was confirmed or not by the primary care or study physician. Respiratory questionnaire and specific airway resistance measurement (sR(aw), body plethysmograph) were completed at age 3 years.

RESULTS

A total of 454 children were followed from birth to 3 years of age. One hundred and eighty six (40.9%) of the parents reported their child wheezing in the first three years of life, and in 130 (28.6%) the wheeze was confirmed. A total of 428 children attended the three year clinic review, of whom 274 (64%) successfully carried out lung function tests. There was no significant difference in sR(aw) (kPa.s; geometric mean, 95% CI) between children who had never wheezed (n = 152; 1.03, 1.00 to 1.06) and those with a parentally reported but unconfirmed wheeze (n = 36; 1.02, 0.96 to 1.07, p = 1.00). sR(aw) was significantly higher in children with a physician confirmed wheeze (n = 86; 1.17, 1.11 to 1.22, p < 0.001) compared to those with no history of wheeze or with unconfirmed wheeze.

CONCLUSIONS

Children with physician confirmed wheeze have significantly poorer lung function compared to those with parentally reported but unconfirmed and those who have never wheezed. A proportion of parents may have little understanding of what medical professionals mean by the term "wheeze".

Stringent environmental control in pregnancy and early life: the long-term effects on mite, cat and dog allergen

BACKGROUND

As part of a primary prevention of asthma study, we measured the effect of environmental control measures on Der p 1, Fel d 1 and Can f 1 over a 3.5-year period.

METHODS

High-risk infants (both parents atopic) without pets, were randomized to the Active group (n = 142, vinyl flooring in child's room, allergen-impermeable cot mattress, hot-washable toy, mite allergen-impermeable encasings to parental bed and to child's bed when older, high filtration vacuum cleaner, hot-washing of bedding) or the Control group (n = 136, no intervention), in early pregnancy. Dust samples from the parental mattress, living room floor, child's mattress and floor at baseline (pregnancy), birth and at 3 years were analysed for Der p 1, Fel d 1 and Can f 1.

RESULTS

A total of 278 families completed the baseline visit, 259 the birth visit and 239 the 3-year visit. In the Active group at 3 years, 58% remained compliant with all measures likely to reduce the child's exposure to allergen and 77% of parents still used encasings on their bed. Levels of Der p 1, Fel d 1 and Can f 1 were significantly lower in the Active group in the child's floor and the child's mattress at 3 years compared to the Control group (P < 0.001). For the parental mattress, the levels of Der p 1 and Fel d 1 were lower in the Active group (P < 0.001) and there was a strong trend towards a lower level for Can f 1. There was no difference in the levels of any of the allergens between the groups in the living room floor. Childrens' bedrooms with no detectable mite, cat or dog allergen were significantly more common in the Active than the Control group (25 vs. 2, P < 0.001).

CONCLUSIONS

Environmental control measures are effective in substantially reducing levels of Der p 1, Fel d 1 and Can f 1 in homes without pets in the long term and are acceptable to families. The effect of this environmental manipulation on the development of sensitization and allergic disease remains to be seen.

Case management models and the care programme approach: how to make the CPA effective and credible

The care programme approach (CPA), a form of case management, is a key mental health policy in England. Yet after over 10 years, it remains poorly and unevenly implemented with few benefits for service users, carers or mental health staff. This paper reviews the wider literature on case management and identifies and considers the principal models that might have informed the development of the CPA. After discussing the evidence for each of the clinical, strengths, intensive and assertive case management models, the paper identifies the key components that appear to be central to effective case management across these models. These components are then considered in relation to the CPA. It is argued that the CPA has been undermined by a failure to incorporate and build on certain important features of the major models of case management. The paper concludes by suggesting the key developments required to make the CPA more effective and to underpin the policy with a unifying philosophy while endorsing it with much needed credibility among both clinicians and service users.

Improved prognosis of patients with intermediate- and poor-risk nonseminomatous germ cell tumours by optimizing combined treatment

OBJECTIVE

To assess whether the optimal use of combined treatment with chemotherapy and appropriately timed surgical intervention by a specialized team might improve the outcome for patients with poor- and intermediate-prognosis (International Germ Cell Consensus Classification, IGCCC) nonseminomatous germ cell tumours (NSGCTs).

PATIENTS AND METHODS

Between 1984 and 1998, 47 patients with intermediate (16) and poor prognosis (31) NSGCT were treated; 43 had a testicular and four a retroperitoneal primary.

RESULTS

Of the 47 patients only seven (15%) had a complete radiological response after primary chemotherapy; 36 (77%) required surgery after chemotherapy (29 para-aortic lymphadenectomy, 13 resection of pulmonary metastases, two each excision of supraclavicular and retrocrural lymph nodes and one resection of brain metastases; 13 required surgery at more than one site). There was no surgical mortality, with postoperative wound pain the commonest morbidity. On pathology, the resected masses were mature teratoma in 13, necrosis in 12 and malignant disease in 11 patients, the resection being complete in 30. There were microscopically positive margins in the other six patients, all but one having viable residual cancer. Of the 47 patients, 18 needed treatment for relapse, with four having surgery for growing mature teratoma, six chemotherapy plus surgery and eight salvage chemotherapy alone. Of 31 patients, 22 (71%) with a poor and 13 of 16 with an intermediate prognosis were alive at a median (range) follow-up of 94 (41-171) months; of all 47, 34 (72%) remain in complete remission. Ten patients died from disease progression. The presence of residual malignant disease at the resection margin was significantly associated with poorer survival (hazard ratio 7.21, P = 0.0016). Prognostic factors, e.g. number of involved sites, IGCCC group and viable tumour in resected masses, were not significant. The 5-year overall and relapse-free survival (95% confidence interval) was 81 (69-93)% and 57 (43-71)%, respectively.

CONCLUSION

The optimal delivery and timing of chemotherapy and surgical resection by a specialist team of oncologists, urological and cardiothoracic surgeons is critical in treating poor-risk NSGCT and might be responsible for improving the outcome of these patients. The detection of residual malignant disease after chemotherapy by positron emission tomography should be investigated to identify those who might benefit from further systemic treatment before complete surgical resection.

The effect of ultraviolet radiation exposure on the prevalence of mast cells in human skin

BACKGROUND

Dermal mast cells have been implicated as important effector cells in innate immunity, hypersensitivity responses and ultraviolet (UV)B-induced suppression of cell-mediated immune responses to contact allergens. Humans, like mouse strains, display variations in dermal mast cell prevalence. The factors determining these differences are yet to be fully elucidated. In mice, expression of the receptor for stem cell factor, c-kit, on dermal mast cells correlates with prevalence.

OBJECTIVES

To evaluate dermal mast cell prevalence and mast cell c-kit expression in non-sun-exposed and sun-exposed skin in the same donor.

METHODS

In 14 subjects, biopsies of skin (4 mm) were sampled from the skin sites of buttock, inner arm, shoulder and back of hand skin and dermal mast cell prevalence quantified. Non-sun-exposed buttock and chronically sun-exposed hand skin were evaluated for mast cell expression of c-kit and elastin content, a feature of photoageing and surrogate marker of UV exposure.

RESULTS

The prevalence of dermal mast cells was significantly higher in hand skin than in the three other anatomically different skin sites. Significant correlations were observed in hand but not buttock skin between increasing dermal mast cell densities, extent of elastin content in the papillary dermis and age of the subject. Cellular expression of c-kit correlated with mast cell prevalence in hand skin. However, no relationship was observed in hand skin between c-kit expression, elastin content and age.

CONCLUSIONS

The prevalence of mast cells in human skin is altered by factors that are intrinsic (mechanisms regulating c-kit expression) and extrinsic (chronic sun exposure), and the fact that the associations of mast cell prevalence with age is explained by the latter being a correlate of cumulative sun exposure.