Specialist public health capacity in England: working in the new primary care organizations

OBJECTIVES

To determine the capacity and development needs, in relation to key areas of competency and skills, of the specialist public health workforce based in primary care organizations following the 2001 restructuring of the UK National Health Service.

STUDY DESIGN

Questionnaire survey to all consultants and specialists in public health (including directors of public health) based in primary care trusts (PCTs) and strategic health authorities (SHAs) in England.

RESULTS

Participants reported a high degree of competency. However, skill gaps were evident in some areas of public health practice, most notably "developing quality and risk management" and in relation to media communication, computing, management and leadership. In general, medically qualified individuals were weaker on community development than non-medically qualified specialists, and non-medically qualified specialists were less able to perform tasks that require epidemiological or clinical expertise than medically qualified specialists. Less than 50% of specialists felt that their links to external organizations, including public health networks, were strong. Twenty-nine percent of respondents felt professionally isolated and 22% reported inadequate team working within their PCT or SHA. Approximately 21% of respondents expressed concerns that they did not have access to enough expertise to fulfil their tasks and that their skills were not being adequately utilized.

CONCLUSIONS

Some important skill gaps are evident among the specialist public health workforce although, in general, a high degree of competency was reported. This suggests that the capacity deficit is a problem of numbers of specialists rather than an overall lack of appropriate skills. Professional isolation must be addressed by encouraging greater partnership working across teams.

Use of anaesthetic rooms in obstetric anaesthesia; a postal survey of obstetric anaesthetists and departments in the United Kingdom

BACKGROUND

Use of anaesthetic rooms has been much discussed in the UK in recent years, but attitudes and practices of obstetric anaesthetists regarding their use for caesarean section have never been sought.

METHOD

A postal survey was conducted to discover the extent of use of anaesthetic rooms versus operating theatre for induction of anaesthesia and reasons for using or not using them. Questionnaires regarding individual practices were sent to 400 randomly selected members of the Obstetric Anaesthetists' Association ( approximately 25% of UK membership). Questionnaires regarding departmental policies were sent to 100 "clinicians responsible for surveys" (approximately 38% of departments providing obstetric anaesthesia in the UK).

RESULTS

For elective caesarean section, 70% of individual clinicians never used an anaesthetic room, 9% rarely, 5% usually, 9% for all regional anaesthetics and 6% always. For emergency caesarean section the corresponding figures were 83%, 5%, 5%, 3% and 2% respectively. Use of the anaesthetic room was independent of the seniority of anaesthetists. In 68% of departments it was standard practice or policy to induce all anaesthetics for caesarean section in the operating room. Conversely, only 1% of departments had a policy to induce all anaesthetics in the anaesthetic room. Patient safety was the usual reason given for anaesthetising in the operating room.

CONCLUSION

The majority of obstetric anaesthetists have abandoned the use of anaesthetic induction rooms, the main reason being patient safety. For the same reason, two-thirds of departments providing obstetric anaesthesia consider induction of anaesthesia in the operating room their standard practice.

Altered endothelin-1 levels in acute lower limb ischemia and reperfusion

Tourniquet-induced ischemia is often used in orthopedic and reconstructive procedures. This is associated with muscle damage and dysfunction, which limits tourniquet application time. Endothelin-1 (ET-1) is a potent vasoconstrictor, which has been implicated in ischemic conditions and ischemia-reperfusion injury. This study aimed to investigate the role of ET-1 in human skeletal muscle subjected to tourniquet-induced acute ischemia and reperfusion. Thirteen patients undergoing total knee replacement were studied. Plasma and muscle ET-1 concentrations were measured at the start of surgery, after an hour of acute ischemia, and 15 minutes following reperfusion. ET-1 receptor binding was also studied by use of autoradiography, and ET-1 mRNA expression investigated by use of real-time polymerase chain reaction (RT-PCR). Tissue ET-1 increased following the period of acute ischemia and persisted during reperfusion. ET-1 was associated with microvessels and macrophages in the muscle. No changes in circulating ET-1 levels, ET-1 mRNA expression, or ET-1 receptor binding were found. It is concluded that the ET-1 pathway is involved in acute ischemia and reperfusion and it may contribute to the muscle injury that occurs during surgical procedures.

A novel mutation in CD83 results in the development of a unique population of CD4+ T cells

Using a mouse mutagenesis screen, we have identified CD83 as being critical for the development of CD4(+) T cells and for their function postactivation. CD11c(+) dendritic cells develop and function normally in mice with a mutated CD83 gene but CD4(+) T cell development is substantially reduced. Additionally, we now show that those CD4(+) cells that develop in a CD83 mutant animal fail to respond normally following allogeneic stimulation. This is at least in part due to an altered cytokine expression pattern characterized by an increased production of IL-4 and IL-10 and diminished IL-2 production. Thus, in addition to its role in selection of CD4(+) T cells, absence of CD83 results in the generation of cells with an altered activation and cytokine profile.

Suprachoroidal haemorrhage complicating cataract surgery in the UK: a case control study of risk factors

AIMS

To study the risk factors for suprachoroidal haemorrhage (SCH) complicating cataract surgery in the United Kingdom.

METHODS

109 cases of SCH complicating cataract surgery prospectively collected through the British Ophthalmological Surveillance Unit were compared with 449 controls that underwent cataract extraction from 13 "control centres" throughout UK in a case control study. 40 systemic, ophthalmic, and operative variables were examined.

RESULTS

Statistically significant risk factors for SCH in univariate analysis included: older age (p<0.001), taking at least one cardiovascular medication (p<0.001), peripheral vascular disease (p = 0.014), hyperlipidaemia (p = 0.005), glaucoma (p<0.001), elevated preoperative intraocular pressure (p<0.001), sub-Tenon's local anaesthesia (LA) (p<0.001), topical LA (p<0.001), the lack of orbital compression following LA (p<0.001), posterior capsule (PC) rupture before SCH (p<0.001), elective extracapsular cataract extraction (ECCE) (p = 0.038), and phacoemulsification conversion (p<0.001). Logistic regression analysis identified the following significant independent risk factors: older age, taking at least one cardiovascular medication, glaucoma, elevated preoperative intraocular pressure, the lack of orbital compression, PC rupture before SCH, elective ECCE, and phacoemulsification conversion.

CONCLUSION

The results allow identification of patients at risk of SCH. Attention to the various modifiable preoperative and intraoperative risk factors is recommended in order to minimise the risk of SCH.

Suprachoroidal haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features, management, and outcomes

AIMS

To study the incidence, management, and outcomes of suprachoroidal haemorrhage (SCH) complicating cataract surgery in the United Kingdom.

METHODS

Cases were prospectively collected by active surveillance through the British Ophthalmological Surveillance Unit. Details were obtained using an incident questionnaire with follow up at 6 months.

RESULTS

118 cases were reported in 1 year. The estimated incidence of SCH was 0.04% (95% confidence interval 0.034% to 0.050%). Cataract extractions were by phacoemulsification in 76.2%, extracapsular cataract extraction (ECCE) in 11.0%, and phacoemulsification conversion in 12.8%. SCH was "limited" (1 to 2 quadrants) in 48.7%, "full blown" (3 to 4 quadrants) in 43.1%. SCH in phacoemulsification was more likely to be limited (63.2%), compared with ECCE (11.1%) and phacoemulsification conversion (23.1%) (p<0.001, chi(2) test). Visual acuity (VA) was better than 6/60 in 57 of 95 (60%) cases after a median follow up interval of 185 days. 33 of 34 cases (97.1%) with secondary anterior segment revision had VA better than 6/60. VA was worse than 6/60 in 7 of 8 (87.5%) cases that had intraoperative sclerostomy, and in all 6 (100%) cases that had secondary posterior segment intervention.

CONCLUSION

SCH is a rare but serious complication of cataract surgery. Poor prognostic factors included full blown SCH, ECCE, phacoemulsification conversion, retinal apposition, and retinal detachment.

Presbyopic phacovitrectomy

AIM

To review the results and complications of combined phacoemulsification and vitrectomy in presbyopic patients.

METHODS

Retrospective review of 90 consecutive presbyopic patients who underwent phacoemulsification and vitrectomy for primary rhegmatogenous retinal detachment (RRD) (21), redo-RRD (seven), stages 2 and 3 full thickness macular holes (FTMH) (38), stage 4 FTMH (six), idiopathic epiretinal membrane (ERM) (11), proliferative diabetic retinopathy (PDR) (three) and vitreous haemorrhage secondary to branch retinal vein occlusion (BVO) (four).

RESULTS

Lens opacity was absent or mild in 84.5% of patients. Reattachment rates for primary RRD and redo-RRD after one procedure were 90.5% and 71.4% and final reattachment rates were 95.2% and 100%, respectively. Macular hole closure rate was 89.5% for stage 2 and 3 FTMH and 83.3% for stage 4 FTMH. There was significant improvement in the median logMAR visual acuity from 1.00 preoperatively to 0.48 postoperatively for the whole cohort (p<0.001, Wilcoxon test). Postoperative complications included fibrinous uveitis (13.3%), iris bombe (2.2%), IOL/iris capture secondary to gas overfill (1.1%), and posterior capsule opacification (51.1%).

CONCLUSION

Combined phacoemulsification and vitrectomy is a safe and desirable option in the management of phakic, presbyopic patients with vitreoretinal pathologies that warrant vitreous surgery, even in the absence of significant lens opacity.

Evidence for the involvement of endothelin-1 but not urotensin-II in chronic lower limb ischaemia in man

BACKGROUND

endogenous vasoconstrictor peptides may play a role in the pathophysiology of critical limb ischaemia (CLI). This study investigated endothelin-1 (ET-1) and urotensin-II (U-II) mRNA expression, peptide distribution and ET receptor subtype binding in chronically ischaemic muscle.

METHODS

open muscle biopsies were taken from patients undergoing amputations for CLI and from patients undergoing coronary artery bypass surgery (controls). ET-1 and U-II mRNA expression in muscle biopsies was studied using real-time quantitative reverse transcription-polymerase chain reaction (RT-PCR). ET-1 and U-II immunohistochemistry was performed on muscle sections and ET receptor binding studied using in vitro autoradiography.

RESULTS

ET-1 mRNA expression was significantly increased in CLI compared to controls (p<0.05) whilst no significant change in U-II expression occurred. ET-1 immunoreactivity was also increased in CLI with no difference in U-II immunostaining observed. ET(B) receptor binding was significantly increased in CLI (median 4, range 1-8 vs 2, range 1-3, dpm x 10(3)/mm(2), p=0.01, Mann-Whitney test) whilst ET(A) receptor binding was not significantly raised. Binding was associated with microvessels and macrophages.

CONCLUSIONS

in CLI, the ET-1 pathway is upregulated but U-II is unaffected. ET-1 may vasoconstrict microvessels and mediate inflammation in chronically ischaemic muscle. ET-1 binding to ET(B) receptors in particular may play an important role in the pathophysiology of CLI underscoring the therapeutic potential of ET(B) receptor antagonists in the management of CLI.

Routine patch testing with frullanolide mix: an European Environmental and Contact Dermatitis Research Group multicentre study

Contact sensitivity to plants containing 1 or more sesquiterpene lactones (SLs) is difficult to diagnose. The mixture of SLs (SL mix) has been shown to detect only about 60% of sensitized individuals. In order to improve the diagnosis of sensitization to plants containing SLs, we have tested a mixture of frullanolides contained in Frullania dilatata and Frullania tamarisci at 3 different concentrations (0.01%, 0.033% and 0.1% in petrolatum). 8605 consecutive eczema patients in 1 North American and 15 European dermatology departments were tested with this mix, and 0.35% of positive cases to the different concentrations were found. Routine use of this mix permitted detection of only a small percentage of extra cases and did not improve the SL mix score. The frullanolide mix should therefore be restricted to investigations in particular geographical zones and/or in particular occupations.

Diagnosis and eradication of Helicobacter pylori in patients with duodenal ulceration in the community

OBJECTIVE

To determine the value of Helicobacter pylori (Hp) serology in diagnosis of active Hp infection in patients with documented duodenal ulcer (DU) and to directly compare the efficacy and side-effects profiles of metronidazole or tinidazole in a triple therapy regimen to eradicate active Hp infection.

DESIGN OF STUDY

Prospective, single-blinded, randomised trial.

METHODS

One hundred patients from General Practice with documented DU and Hp seropositivity had a C14 Urea Breath Test (UBT). Those who tested positive were randomised to receive one-week, twice daily omeprazole 20 mgs and clarithromycin 250 mgs in combination with metronidazole 400 mgs (OCM) or tinidazole 500 mgs (OCT). Eradication was confirmed by a repeat UBT.

RESULTS

Eighty five sero-positive patients had a positive pre-treatment UBT. On intention to treat basis, OCT (100%) had a significantly better eradication rate than OCM (87.8%), p = 0.023. There was no difference in side effects.

CONCLUSION

(1) Positive Hp serology in patients with DU does not always mean active infection and (2) for patients in the community with active Hp and DU disease OCT is significantly better than OCM for eradicating Hp.

The British standard series of contact dermatitis allergens: validation in clinical practice and value for clinical governance

BACKGROUND

All centres use an empirically determined set of 'standard' test allergens for patch testing that contain the commoner environmental sensitizers. Objectives To assess the validity of the British standard series of 12 allergens used in addition to the 23 already in the European standard series.

PATIENTS AND METHODS

Results for 3062 consecutive patients patch tested in seven centres across the United Kingdom during the year 2000 were analysed.

RESULTS

The additional allergens from the British series and positive rates were: methyl dibromoglutaronitrile 2.4%, carba mix 1.6%, tixocortol pivalate 1.5%, ethylenediamine 1.3%, cetearyl alcohol 0.8%, 2-bromo-2-nitropane-1,3-diol 0.8%, diazolidinyl urea 0.7%, chlorocresol 0.6%, budesonide 0.6%, fusidic acid 0.5%, imidazolidinyl urea 0.5%, and chloroxylenol 0.4%. The allergens with the lowest positive rate in the European standard series were primin at 0.6% and isopropyl-phenyl-para-phenylenediamine at 0.4%.

CONCLUSIONS

The 12 allergens in the British series should continue being tested as a standard addition to the European series within the U.K. The collection of data in this manner to allow comparisons between centres shows differences that reflect selection criteria and interpretation of results, and offers a useful tool for audit and clinical governance. Testing fewer than 1 : 2150 population may indicate underprovision of service. Similarly, rates of sensitization for nickel contact allergy above 26% and for fragrance mix above 16% (the upper 95% confidence intervals) should stimulate inquiry into the reasons behind this.

Angiotensin-converting enzyme inhibitor therapy prevents upregulation of endothelin-converting enzyme-1 in failing human myocardium

In this study, we investigated the role of the renin-angiotensin system in expression of the endothelin system in atrial myocardium of patients with congestive heart failure. Atrial myocardium of control patients without angiotensin-converting enzyme (ACE) inhibitor therapy and heart failure patients without or with ACE inhibitor therapy undergoing aorto-coronary bypass surgery was studied. Endothelin-converting enzyme-1 (ECE-1) expression and endothelin-1 peptide level was upregulated in myocardium of heart failure patients without ACE inhibition. ACE inhibitor therapy prevented upregulation of ECE-1 and endothelin-1 in failing myocardium. Prepro-endothelin-1 and endothelin receptor A expression were not affected by heart failure. Endothelin receptor B was downregulated in heart failure patients. Our data demonstrate an upregulation of ECE-1 mRNA expression in failing human myocardium. Inhibition of the renin-angiotensin system by ACE inhibitor treatment prevents upregulation of ECE-1, suggesting that angiotensin II regulates ECE-1 expression in vivo.

Type-IV hypersensitivity to betamethasone valerate and clobetasol propionate: results of a multicentre study

BACKGROUND

Most studies investigating steroid allergy have been performed with tixocortol pivalate, hydrocortisone butyrate and budesonide. Betnovate and Dermovate are widely prescribed in the U.K. but little is known about the frequency of sensitization to them.

OBJECTIVES

To determine the optimum method to detect contact allergy to betamethasone valerate (BV) and clobetasol propionate (CP).

METHODS

Seven centres tested consecutive patients attending for investigation of suspected allergic contact dermatitis to these steroids at a range of concentrations in different vehicles.

RESULTS

Of 1562 patients tested, 16 (1%) reacted to either BV or CP. Ten patients (0.7%) reacted to BV and 13 (0.8%) to CP. Two patients of a further centre were included in analysis of dilutions and vehicles. Sixteen of a total of 25 reactions (64%) were identified with a 1% dilution in ethanol.

CONCLUSIONS

Consideration should be given to adding BV and CP to a standard allergy series, given that both are frequently used in the treatment of eczema and that most patients sensitized to them are not identified with currently used markers of steroid allergy. If patch tests to BV and CP are initially negative, but an allergy is suspected, the patient should be further investigated. Further studies are required to identify the ideal patch test material.

Potential role of endothelin 1 in ischaemia-induced angiogenesis in critical leg ischaemia

BACKGROUND

Ischaemia-induced angiogenesis occurs in critical leg ischaemia (CLI) and endothelin (ET) 1 may be involved in this process. The aim of this study was to quantify microvessels and study ET receptor expression and distribution in critically ischaemic leg muscle.

METHODS

Leg muscle biopsies were taken from 12 patients with CLI and 12 patients with no leg ischaemia. Microvessels were identified immunohistochemically on muscle sections, and the number of immunopositive cells was quantified. ETA and ETB receptor messenger RNA (mRNA) expression was studied using real-time quantitative reverse transcriptase-polymerase chain reaction, and receptor binding was localized and assessed by in vitro autoradiography.

RESULTS

The number of microvessels in CLI muscle biopsies was 2.6 times higher than that in controls (P < 0.01). ETB receptor mRNA expression and binding were significantly increased in CLI tissue (P < 0.05), while ETA receptor levels were not significantly raised. High-resolution autoradiography showed that ET receptor binding was associated with microvessels.

CONCLUSION

Angiogenesis occurs in CLI and raised ETB receptors within the muscle were associated with microvessels, suggesting that ET-1 may mediate angiogenesis via these receptors in critically ischaemic muscle.

Monitoring levels of preservative sensitivity in Europe. A 10-year overview (1991-2000)

A 10-year multicentre analysis of the frequency of sensitivity to common preservatives collected in 16 centres in 11 countries has shown stable but persisting high levels of sensitivity to formaldehyde and 5-chloro-2-methyl-4-isothiazolin-3-one + 2-methyl-4-isothiazolin-3-one (MCI/MI). It has also revealed a significant increase in the level of reactivity to methyldibromoglutaronitrile (MDBGN) from 0.7% in 1991 to 3.5% in 2000. The current high level of sensitivity to MDBGN requires an urgent safety re-evaluation and risk assessment update along with consideration of immediate lowering of use concentrations, especially in leave-on products.

Use of ultramolecular potencies of allergen to treat asthmatic people allergic to house dust mite: double blind randomised controlled clinical trial

OBJECTIVE

To evaluate the efficacy of homoeopathic immunotherapy on lung function and respiratory symptoms in asthmatic people allergic to house dust mite.

DESIGN

Double blind randomised controlled trial.

SETTING

38 general practices in Hampshire and Dorset.

PARTICIPANTS

242 people with asthma and positive results to skin prick test for house dust mite; 202 completed clinic based assessments, and 186 completed diary based assessments.

INTERVENTION

After a four week baseline assessment, participants were randomised to receive oral homoeopathic immunotherapy or placebo and then assessed over 16 weeks with three clinic visits and diary assessments every other week.

OUTCOME MEASURE

Clinic based assessments: forced expiratory volume in one second (FEV(1)), quality of life, and mood. DIARY BASED ASSESSMENTS: morning and evening peak expiratory flow, visual analogue scale of severity of asthma, quality of life, and daily mood.

RESULTS

There was no difference in most outcomes between placebo and homoeopathic immunotherapy. There was a different pattern of change over the trial for three of the diary assessments: morning peak expiratory flow (P=0.025), visual analogue scale (P=0.017), and mood (P=0.035). At week three there was significant deterioration for visual analogue scale (P=0.047) and mood (P=0.013) in the homoeopathic immunotherapy group compared with the placebo group. Any improvement in participants' asthma was independent of belief in complementary medicine.

CONCLUSION

Homoeopathic immunotherapy is not effective in the treatment of patients with asthma. The different patterns of change between homoeopathic immunotherapy and placebo over the course of the study are unexplained.

CD antigens 2001

The most recent Human Leucocyte Differentiation Antigen Workshop ("HLDA7") took place in 2000 in Harrogate, UK and the proceedings are about to be published (Leucocyte Typing VII). New Sections were introduced in this Workship (Dendritic cells, Stem/progenitor cells, Erythroid cells and Carbohydrate Structures) and monoclonal antibodies were selected for which at least some molecular data were already available (to avoid "blind" screening of reagents against known specificities). A total of more than 80 new CD specificities were established (previously the average was less than 30 new CD specificities per Workshop) and these are listed in this article. There is already evidence for the existence of many new leucocyte surface molecules for study at the next HLDA Workshop (in Adelaide in 2004), and we have listed in this article a number of such potential CD candidates (identified following the production of monoclonal antibodies or via gene cloning). There are also today an increasing number of lineage- and/or stage-restricted leucocyte-associated molecules localised within the cell cytoplasm (or nucleus): they will certainly prove of intense in the future for many laboratories studying human haematopoietic cells (regardless of whether a new "intracellular CD" categorisation scheme is devised for such molecules).

CD antigens 2001

This paper reviews the Seventh Human Leucocyte Differentiation Antigen (HLDA7) workshop. Due to the limitations of "blind" antibody screening, which had been evident at the previous meeting in 1996, participants at HLDA7 adopted a more selective approach to the choice of antibodies by identifying new CD specificities. This resulted in the addition of more than 80 new CD specificities. Plans for the eighth and subsequent workshops are also previewed.

Influence of aldosterone vs. endothelin receptor antagonism on renovascular function in liquorice-induced hypertension

BACKGROUND

The enzyme 11beta-hydroxysteroid dehydrogenase type 2 (11beta-HSD2) provides mineralocorticoid receptor specificity for aldosterone by metabolizing glucocorticoids to their receptor inactive 11-dehydro derivatives. Inhibition of 11beta-HSD2 by liquorice-derived glycyrrhizic acid (GA) therefore results in sodium retention and hypertension. The present study investigated the effect of the aldosterone receptor antagonist spironolactone in comparison with the endothelin ET(A) receptor antagonist darusentan on renovascular endothelial function in liquorice-induced hypertension.

METHODS

GA, a recognized inhibitor of 11beta-HSD2 was supplemented to the drinking water (3 g/l) of Wistar Kyoto rats over a period of 21 days. From day 8 to 21, spironolactone (5.8+/-0.6 mg/kg/day), darusentan (45.2+/-6.5 mg/kg/day), or placebo was added to chow (n=7 per group). After the animals were killed, vascular function of isolated renal artery segments was assessed by isometric tension recording.

RESULTS

Relaxation of pre-constricted renal artery segments in response to acetylcholine (10(-10) to 10(-5) mol/l) was impaired by GA as compared with controls (12+/-4% vs 98+/-5% of norepinephrine 3x10(-7) mol/l), whereas endothelium independent relaxations were unaffected. Endothelin receptor antagonism improved renovascular endothelium-dependent relaxation (32+/-4%, P<0.05 vs placebo) whereas endothelium-dependent relaxation was completely normalized by aldosterone receptor antagonism (85+/-4%, P<0.01 vs placebo).

CONCLUSIONS

In GA-induced hypertension, both aldosterone receptor antagonism and endothelin receptor antagonism normalize blood pressure and improve renovascular function and, thus, may represent a new therapeutic approach in cardiovascular disease associated with impaired 11beta-HSD2 activity.

Spatial and molecular organization of lymph node T cell cortex: a labyrinthine cavity bounded by an epithelium-like monolayer of fibroblastic reticular cells anchored to basement membrane-like extracellular matrix

Naive T cells encounter antigen-presenting cells within the cortex of lymph nodes to initiate primary immune responses. Within this T cell cortex is the reticular network (RN)--a system of collagen fibers and extracellular matrix (ECM) wrapped by fibroblastic reticular cells (FRC). We have investigated the distribution of various molecules, including ECM proteins and proteoglycans, in the T cell cortex of both human and rodent lymph node. We confirm and extend reports of matrix elements in the RN. In addition, we find that staining for the laminin-alpha3 chain and for tenascin reveals a 'hollow' reticular pattern, consistent with localization to the basement membrane-like covering of reticular fibers. In contrast, keratan sulfate is observed in a fine linear pattern within the RN, suggesting it is localized to the core of the fibers. Staining with the marker ER-TR7 indicates that FRC cover all identifiable ECM surfaces of the T cell cortex. Based on these findings and previous reports, we conclude that cortical lymphocytes migrate within a 'labyrinthine cavity' free of fibrillar ECM, distinguishing the T cell cortex from other loose connective tissues, and that the FRC lining of the cavity constitutes an epithelium-like boundary. We propose that this spatial organization facilitates ameboid leukocyte crawling along preformed paths of least resistance and that the basement membrane-like ECM of the FRC may facilitate fluid transport within the RN by limiting leakage from the fiber.

Percutaneous balloon mitral valvuloplasty

Mitral stenosis is commonly encountered in the elderly and among immigrant communities. Percutaneous balloon mitral valvuloplasty provides effective treatment. The present article provides a brief overview of the principles of patient selection, technical details of the procedure itself and information concerning complications and follow-up.

Rigidity of circulating lymphocytes is primarily conferred by vimentin intermediate filaments

Lymphocytes need rigidity while in circulation, but must abruptly become deformable to undergo transmigration into tissue. Previously, the control of leukocyte deformability has been attributed to microfilaments or microtubules, but the present studies demonstrate the greater importance of vimentin intermediate filaments (IFs). In circulating T lymphocytes, IFs form a distinctive spherical cage that undergoes a rapid condensation into a juxtanuclear aggregate during chemokine-induced polarization. Measurements of the resistance of peripheral blood T lymphocytes to global deformation demonstrate that their rigidity is primarily dependent on intact vimentin filaments. Microtubules, in contrast, are not sufficient to maintain rigidity. Thus, vimentin IFs are a primary source of structural support in circulating human lymphocytes, and their regulated collapse is likely to be an essential element in chemokine-induced transendothelial migration.

Sensitive skin: an epidemiological study

BACKGROUND

There is a growing awareness that some individuals exhibit heightened skin sensitivity, particularly on the face, and have a high incidence of adverse reactions to cosmetics and toiletries.

OBJECTIVES

To carry out an epidemiological study to assess the prevalence of sensitive skin and cosmetic-related adverse events in a U.K. population, and to examine possible factors that may be associated with sensitive skin.

METHODS

Self-assessment questionnaires were sent out to 3300 women and 500 men, randomly selected, who were over the age of 18 years and lived within a 10-mile radius of High Wycombe (Bucks.). Fifty non-responder women were also questioned by telephone to ensure that the postal responders were representative of the population as a whole.

RESULTS

The response rates were 62% for women and 52% for men, with the incidence of self-reported skin sensitivity being 51.4% and 38.2%, respectively. Ten per cent of women and 5.8% of men described themselves as having very sensitive skin. Fifty-seven per cent of women and 31.4% of men had experienced an adverse reaction to a personal product at some stage in their lives, with 23% of women and 13.8% of men having had a problem in the last 12 months. Among the women, symptoms of cosmetic-induced subjective sensory skin discomfort (burning, stinging, itching etc.) occurred more commonly in the sensitive skin cohort (53%) than in those who regarded themselves as non-sensitive (17%). An atopic diathesis in women did not appear to be a predictive factor for sensitive skin, the incidence of self-perceived sensitive skin being equivalent for atopics (49%) and non-atopics (51%). Furthermore, some 34% of atopic women described themselves as being non-sensitive. Nevertheless, the incidence of atopy was higher among the women in the sensitive skin group (49%) than among those in the non-sensitive group (27%). Dry skin and a predilection for blushing/flushing were associated factors for sensitive skin.

CONCLUSIONS

Our survey indicates that sensitive facial skin is a common problem for women and men in the U.K. and points to the need for the development of personal products designed for this skin phenotype.

Bud8p and Bud9p, proteins that may mark the sites for bipolar budding in yeast

The bipolar budding pattern of a/alpha Saccharomyces cerevisiae cells appears to depend on persistent spatial markers in the cell cortex at the two poles of the cell. Previous analysis of mutants with specific defects in bipolar budding identified BUD8 and BUD9 as potentially encoding components of the markers at the poles distal and proximal to the birth scar, respectively. Further genetic analysis reported here supports this hypothesis. Mutants deleted for BUD8 or BUD9 grow normally but bud exclusively from the proximal and distal poles, respectively, and the double-mutant phenotype suggests that the bipolar budding pathway has been totally disabled. Moreover, overexpression of these genes can cause either an increased bias for budding at the distal (BUD8) or proximal (BUD9) pole or a randomization of bud position, depending on the level of expression. The structures and localizations of Bud8p and Bud9p are also consistent with their postulated roles as cortical markers. Both proteins appear to be integral membrane proteins of the plasma membrane, and they have very similar overall structures, with long N-terminal domains that are both N- and O-glycosylated followed by a pair of putative transmembrane domains surrounding a short hydrophilic domain that is presumably cytoplasmic. The putative transmembrane and cytoplasmic domains of the two proteins are very similar in sequence. When Bud8p and Bud9p were localized by immunofluorescence and tagging with GFP, each protein was found predominantly in the expected location, with Bud8p at presumptive bud sites, bud tips, and the distal poles of daughter cells and Bud9p at the necks of large-budded cells and the proximal poles of daughter cells. Bud8p localized approximately normally in several mutants in which daughter cells are competent to form their first buds at the distal pole, but it was not detected in a bni1 mutant, in which such distal-pole budding is lost. Surprisingly, Bud8p localization to the presumptive bud site and bud tip also depends on actin but is independent of the septins.

Cutting edge: integration of human T lymphocyte cytoskeleton by the cytolinker plectin

Chemokine-induced polarization of lymphocytes involves the rapid collapse of vimentin intermediate filaments (IFs) into an aggregate within the uropod. Little is known about the interactions of lymphocyte vimentin with other cytoskeletal elements. We demonstrate that human peripheral blood T lymphocytes express plectin, an IF-binding, cytoskeletal cross-linking protein. Plectin associates with a complex of structural proteins including vimentin, actin, fodrin, moesin, and lamin B in resting peripheral blood T lymphocytes. During chemokine-induced polarization, plectin redistributes to the uropod associated with vimentin and fodrin; their spatial distribution indicates that this vimentin-plectin-fodrin complex provides a continuous linkage from the nucleus (lamin B) to the cortical cytoskeleton. Overexpression of the plectin IF-binding domain in the T cell line Jurkat induces the perinuclear aggregation of vimentin IFs. Plectin is therefore likely to serve as an important organizer of the lymphocyte cytoskeleton and may regulate changes of lymphocyte cytoarchitecture during polarization and extravasation.

Chronic vasopeptidase inhibition restores endothelin-converting enzyme activity and normalizes endothelin levels in salt-induced hypertension

BACKGROUND

Vasopeptidase inhibition (VPI) represents a new therapeutic principle including both inhibition of angiotensin-converting enzyme (ACE) and neutral endopeptidase (NEP). The present study investigated the effect of the vasopeptidase inhibitor omapatrilat on endothelin-1 (ET-1)-mediated vascular function in salt-induced hypertension.

METHODS

Dahl salt-sensitive rats (n=6/group) on standard or salt-enriched (4% NaCl) chow were treated for 8 weeks with either omapatrilat (36+/-4 mg/kg/day), captopril (94+/-2 mg/kg/day) or placebo. Aortic and renal artery segments were isolated and suspended in organ chambers for isometric tension recording. Functional endothelin-converting enzyme (ECE) activity was assessed in native segments and after preincubation with omapatrilat. Furthermore, vascular ECE protein levels as well as plasma and tissue ET-1 levels were determined.

RESULTS

The increase in systolic blood pressure of salt-fed rats was prevented by omapatrilat and captopril to a comparable degree. In salt-induced hypertension, functional ECE activity (calculated as the ratio of the contraction to big ET-1 divided by the contraction to ET-1) in renal arteries (0.46+/-0.05) and in aorta (0.68+/-0.05) was reduced as compared with control animals (0.9+/-0.05 and 0.99+/-0.04, respectively; P<0.05). While omapatrilat in vitro blunted the response to big endothelin-1 (big ET-1) and diminished ECE activity further (P<0.01 vs native segments), chronic treatment with omapatrilat in vivo restored contractions to ET-1 (120+/-6%) and big ET-1 (98+/-9%) in renal arteries, and therefore normalized renovascular ECE activity. In addition, omapatrilat normalized plasma ET-1 concentrations (12.9+/-1.2 vs 16.6+/-1.4 pg/ml on high salt diet; P<0.05) and renovascular ECE protein levels.

CONCLUSIONS

In salt-induced hypertension, vasopeptidase inhibition restores alterations in the endothelin system, such as renovascular ECE activity and responsiveness to ET-1 and big ET-1 with chronic but not acute in vitro application. Thus, the beneficial effects of vasopeptidase inhibition may reflect a resetting of cardiovascular control systems and therefore may be particularly suited to treat hypertension and heart failure.

Fragrance contact dermatitis: a worldwide multicenter investigation (Part II)

The purpose of this study was to determine the frequency of responses to selected fragrance materials in patients who were fragrance sensitive. 178 patients were evaluated in 8 centers worldwide with a fragrance mix (FM) and 20 other fragrance materials. Reaction to the fragrance mixture (FM) occurred in 78.7% of the subjects. Substances reacting at a rate of 2% or higher included jasmine absolute, geranium oil bourbon, l-citronellol, spearmint oil, 1,3,4,6,7,8-hexahydro-4,6,6,7,8,8-hexamethylcyclopenta-gamma-2-benzopyran, omega-6-hexadecenlactone, dimethyltetrahydrobenzaldehyde (isomer mixture), and alpha-amylcinnamaldehyde. These chemicals should be furthur evaluated to corroborate their allergenicity. We are constantly looking for new fragrance allergens to extend the diagnostic capability of the fragrance mix (FM).

Protein kinase C theta is expressed in mast cells and is functionally involved in Fcepsilon receptor I signaling

We investigated possible expression and function in mast cells of protein kinase C (PKC) theta, a member of the PKC family with demonstrated function in a limited range of cell types. We found that PKC theta is expressed in bone marrow-derived mast cells and in the RBL-2H3 mast cell line. PKC theta underwent translocation to the membrane in response to Fcepsilon receptor I (FcepsilonR I) activation. Receptor activation induced phosphorylation of PKC theta. The tyrosine phosphorylation of PKC theta is delayed relative to PKC delta and coincides temporally with PKC theta association with c-src family members Lyn and SRC: Studies of RBL-2H3 cells transduced with PKC theta constructs indicated a role for PKC theta in receptor-induced activation of extracellular regulated kinases, interleukin-3 gene transcription, and degranulation in response to antigen stimulation. These studies extend the known functions of PKCtheta to another important immune cell type and indicate the concurrent participation of multiple PKCs in the FcepsilonR I-mediated response of mast cells.

The human genome: an immuno-centric view of evolutionary strategies

A hallmark of modern biology is the realization of the fundamental unity of biological processes in all life forms. Consequently, the complete genome sequencing of various bacteria, yeast (Saccharomyces cerevisiae), fly (Drosophila melanogaster) and worm (Caenorhabditis elegans) over the past five years has already had an impact on all of biology. "Model organisms" have contributed a great deal to immunology; for example, the Toll receptors of the fly provided the impetus for the investigation of Toll-like receptors, which proved to be fundamental elements in the mammalian innate immune system. The recent release of a draft sequence of the human genome provides the first panoramic view of the 30000-35000 human genes in the human genetic blueprint and provides a plethora of new details, the significance of which will take some time to appreciate. The over-riding concepts that emerge from these studies relate primarily to general evolutionary processes that are equally as relevant to immunology as they are to other disciplines of biology.

Vasopeptidase inhibition exhibits endothelial protection in salt-induced hypertension

Omapatrilat represents a new class of drugs capable of inhibiting both ACE and neutral endopeptidase 24.11, the so-called vasopeptidase inhibitors. It therefore contributes to neurohumoral modulation, which might improve endothelial function in cardiovascular diseases. This study investigated the effect of omapatrilat in comparison to the ACE inhibitor captopril on systolic blood pressure and endothelial function in salt-induced hypertension. Dahl salt-sensitive rats (n=6/group) on standard or salt-enriched (4% NaCl) chow were treated for 8 weeks with either omapatrilat (36+/-4 mg/kg per day), captopril (94+/-2 mg/kg per day), or placebo. Aortic rings were then isolated and suspended in organ chambers for isometric tension recording. Systolic blood pressure of salt-fed, placebo-treated animals increased to 196+/-6 mm Hg, which was prevented by omapatrilat (162+/-5 mm Hg, P<0.05) and captopril (164+/-7 mm Hg, P<0.05) to a comparable degree. In control rats, acetylcholine (10(-10) to 10(-5) mol/L) induced endothelium-dependent relaxation (97+/-4%), which was reduced by high-salt diet to 30+/-5% (P<0.005; n=6). Omapatrilat improved relaxation to a greater extent (86+/-5%) than did captopril (57+/-6%; P<0.05). eNOS protein expression and aortic nitrite/nitrate content were reduced in hypertensive rats and improved by both omapatrilat and captopril. Aortic endothelin-1 levels were increased in salt-fed animals and unaffected by omapatrilat or captopril. These data suggest that despite comparable blood pressure, omapatrilat is superior to captopril in improving endothelium-dependent relaxation in salt-sensitive hypertension.