Association of tumour necrosis factor alpha and interleukin 6 levels with cytomegalovirus DNA detection and disease after renal transplantation

Cytokines such as tumour necrosis factor alpha (TNF-alpha) and interleukin 6 (IL-6) are thought to be important in the pathogenesis of post-transplant cytomegalovirus (CMV) disease. CMV infection increases the production of TNF-alpha and IL-6. Conversely, TNF-alpha switches on the replication of CMV. To study the association of these two cytokines with CMV activity and disease, TNF-alpha and IL-6 levels were assayed in plasma samples taken serially from three groups of renal transplant recipients. Group A (n = 12) had CMV disease and syndrome; Group B (n = 11) had detectable CMV DNA in plasma or peripheral blood leucocytes without disease, i.e., presumed asymptomatic CMV infection, and Group C (n = 11) had no detectable CMV DNA nor disease. The median peak TNF-alpha levels in patients with CMV disease (Group A) were significantly higher than that in Group B or Group C (P < 0.02) whereas the median peak IL-6 levels in group C patients were significantly lower than that in group A (P < 0.04) or group B (P < 0.03). A TNF-alpha level of above 100 pg/ml was significantly associated with CMV disease and high plasma CMV load (> 10,000 copies/ml). IL-6 levels above 15 pg/ml were significantly associated with CMV DNA detection, but not with CMV disease or elevated CMV load. High levels of TNF-alpha or IL-6 were not associated with CMV donor/recipient serostatus, HHV-6 or HHV-7 DNA detection, immunosuppressive regimen or rejection episodes. The role of TNF-alpha in the pathogenesis of CMV disease deserves further investigation.

Systematic review of treatments for atopic eczema

BACKGROUND

Atopic eczema is the commonest inflammatory skin disease of childhood, affecting 15-20% of children in the UK at any one time. Adults make up about one-third of all community cases. Moderate-to-severe atopic eczema can have a profound effect on the quality of life for both sufferers and their families. In addition to the effects of intractable itching, skin damage, soreness, sleep loss and the social stigma of a visible skin disease, other factors such as frequent visits to doctors, special clothing and¿the need to constantly apply messy topical applications all add to the burden of disease. The cause of atopic eczema is unknown, though a genetic pre-disposition and a combination of allergic and non-allergic factors appear to be important in determining disease expression. Treatment of atopic eczema in the UK is characterised by a profusion of treatments aimed at disease control. The evidential basis of these treatments is often unclear. Most people with atopic eczema are managed in primary care where the least research has been done.

OBJECTIVES

The objectives of this scoping review are two-fold. To produce an up-to-date coverage 'map' of randomised controlled trials (RCTs) of treatments of atopic eczema. To assist in making treatment recommendations by summarising the available RCT evidence using qualitative and quantitative methods.

METHODS

DATA SOURCES

Data sources included electronic searching of MEDLINE, EMBASE, the Cochrane Controlled Clinical Trials Register, the Cochrane Skin Group specialised register of trials, hand-searching of atopic eczema conference proceedings, follow-up of references in retrieved articles, contact with leading researchers and requests to relevant pharmaceutical companies.

INCLUSION/EXCLUSION CRITERIA

Only RCTs of therapeutic agents used in the prevention and treatment of people with atopic eczema of any age were considered for inclusion. Only studies where a physician diagnosed atopic eczema or atopic dermatitis were included.

DATA EXTRACTION

Data extraction was conducted by two observers onto abstraction forms, with discrepancies resolved by discussion.

QUALITY ASSESSMENT

The quality assessment of retrieved RCTs included an assessment of: a clear description of method and concealment of allocation of randomisation, the degree to which assessors and participants were blinded to the study interventions, and whether all those originally randomised were included in the final main analysis.

DATA SYNTHESIS

Where possible, quantitative pooling of similar RCTs was conducted using the Cochrane Collaboration's methods. Where statistical heterogeneity was found, sources of heterogeneity in terms of study participants, formulation or posology of intervention, and use of co-treatments were explored. Where pooling was not deemed to be appropriate, detailed descriptions of the study characteristics and main reported results were presented along with comments on study quality.

RESULTS

A total of 1165 possible RCTs were retrieved in hard copy form for further scrutiny. Of these, 893 were excluded from further analysis because of lack of appropriate data. The 272 remaining RCTs of atopic eczema covered at least 47 different interventions, which could be broadly categorised into ten main groups. Quality of reporting was generally poor, and limited statistical pooling was possible only for oral cyclosporin, and only then after considerable data transformation. There was reasonable RCT evidence to support the use of oral cyclosporin, topical corticosteroids, psychological approaches and ultraviolet light therapy. There was insufficient evidence to make recommendations on maternal allergen avoidance for disease prevention, oral antihistamines, Chinese herbs, dietary restriction in established atopic eczema, homeopathy, house dust mite reduction, massage therapy, hypnotherapy, evening primrose oil, emollients, topical coal tar and topical doxepin. (ABSTRACT TRUNCATED)

Clinical standards for inpatient specialist rehabilitation services in the UK

OBJECTIVE

To develop a set of clinical standards for specialist inpatient rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services.

DESIGN

The proposed set of standards was developed by group consensus followed by an iterative consultation process. A postal survey was conducted on behalf of the British Society for Rehabilitation Medicine (BSRM) amongst its consultant members in the UK (n = 163), who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability.

RESULTS

The response rate was 61%, of which 81 respondents ran an inpatient rehabilitation service. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Specific suggestions were incorporated into the revised standards. Further work is required to establish agreed outcomes that are systematically measured and recorded: only half the respondents (50%) routinely recorded a standardized outcome measure, and only a quarter (26%) routinely reviewed patients to record long-term outcome.

CONCLUSIONS

Clinical standards have been developed for specialist inpatient rehabilitation services in the UK. The BSRM proposes to adopt these standards for a test period of 2-3 years in the first instance. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Fatal antidepressant overdose among drug abusers and non-drug abusers

OBJECTIVE

This study examined the predictors, extent and pattern of fatal antidepressant overdose (FAO) in all psychoactive drug-related deaths and compared these in drug abusers and non-drug abusers.

METHOD

Inquest data on 491 psychoactive drug-related cases in England and Wales were analysed. We examined predictors of FAO relative to other drug-related deaths in drug abusers and non-abusers using logistic regression, and compared the relative fatality of different antidepressant classes using the Proportionate Fatality Index (PFI).

RESULTS

The overall FAO prevalence ratio was 10% (male = 7.1%, female = 18.5%). FAO was twice as likely to occur among cases aged 45 years and over than in younger cases (MOR = 2.6, 95% CI = 1.4-4.9), and eight times more likely to occur in cases with no history of drug abuse (MOR = 8.2, 95% CI = 4.0-18.4). Ingestion of prescribed antidepressants is the only common predictor of FAO among drug abusers and non-abusers, and co-ingestion of a combination of antidepressants of two different classes is a potent risk for FAO in the cases studied.

CONCLUSION

The results highlight the need to develop appropriate therapeutic strategies for managing treatment-resistant depression.

Hypothyroidism and aging: the Rosses' survey

An earlier impression of a high prevalence of hypothyroidism in a general practice (4,190 patients including 1,544 adult females aged 18 years or more with 544 aged 50 years or more) in the Rosses, a coastal area in the northwest of Ireland was confirmed by this study. The accumulated prevalence of overt spontaneous primary hypothyroidism was 8.6% in 544 females aged 50 years or more but only 0.9% in the 1,000 females between 18 and 50 years of age. This prevalence was approximately twice that of an Irish National general practice population sample of 4,314 females aged 50 years or more (8.6% vs. 4.6%) p < 0.001. The reasons for this difference are unclear but may reflect the high level of opportunistic screening carried out in West Donegal. Thyroid peroxidase antibodies measured by radioimmunoassay were found in 75.6% of hypothyroid patients compared to 18.6% of practice controls (p < 0.01). Neither HLA-DRB1, DQA1, and DQB1 phenotype frequencies nor dietary iodine intake (median urinary iodine excretion 104 microg/L) appeared to be contributory factors. The finding of an 8.6% accumulated prevalence of hypothyroidism in females greater than 50 years of age when a population is aggressively investigated demonstrates the relative importance of its contribution to total morbidity and suggests that the disorder may be underdiagnosed, thus supporting the concept of targeted screening in this age group.

Differences in the calcium-handling response of isolated rat and guinea-pig cardiomyocytes to metabolic inhibition: implications for cell damage

Species differences in response to hypoxic damage have been observed in studies using whole hearts. The aims of this study were to determine whether (i) species differences in response to simulated hypoxia could be detected at the level of the single myocyte, and (ii) there were any interspecies differences in the Ca2+ handling properties of the cells. Ventricular myocytes were isolated from hearts of adult rats and guinea-pigs and electrically stimulated on the stage of a fluorescence microscope. Cell length was measured using an edge-tracking device, and total intracellular [Ca2+] ([Ca2+]i) determined using indo-1. Cells were exposed to metabolic inhibition (MI) (2.5 mM NaCN and no glucose) to simulate hypoxia followed by washout of CN and re-addition of glucose ('reperfusion'). Following exposure to MI, rat cells underwent rigor contracture in 18.8+/-0.8 min (n = 80 cells), whereas the time was longer for guinea-pig cells (32.9+/-1.2 min, n = 83) (P<0.001). If cells were reperfused after 1-5 min in rigor, then rat cells showed improved morphological recovery compared with guinea-pig cells (P< 0.05); thereafter recovery decreased with increasing time spent in rigor, and was similar in both groups. In indo-1 loaded cells, [Ca2+]i was significantly increased in cells from both species at the end of MI; however, the actual increase was much higher in guinea-pig cells. Upon reperfusion, [Ca2+]i recovered fully in rat cells, but in guinea-pig cells there was no significant decrease. The restoration of [Ca2+]i to normal levels in rat cells following MI was associated with improved contractile recovery compared with guinea-pig cells. We conclude that rat cells are more resistant to effects of MI than are guinea-pig cells; this may be related to species differences in Ca2+ handling during and following exposure to MI.

Association of human herpesvirus 7 with cytomegalovirus disease in renal transplant recipients

BACKGROUND

Recent studies have linked human herpesviruses 6 (HHV-6) and 7 (HHV-7) with posttransplant cytomegalovirus (CMV) disease.

METHODS

Thirty-seven renal transplant recipients were monitored weekly for CMV, HHV-6, and HHV-7 DNA and serological responses for 12 weeks after transplantation. Plasma CMV load and the occurrence of CMV disease was related to HHV-6 and -7 detection.

RESULTS

CMV disease was identified in 12 patients. In a logistic regression analysis, factors significantly associated with CMV disease were the detection of HHV-7 DNA in peripheral blood leucocytes and donorrecipient CMV serostatus. Patients with detectable HHV-7 DNA had significantly higher peak plasma CMV loads (P=0.01).

CONCLUSIONS

An association was found between HHV-7, but not HHV-6, DNA detection and CMV disease, suggesting a possible role of HHV-7 in its pathogenesis.

Urban-rural mortality differentials: controlling for material deprivation

This paper investigates the relationship between premature mortality and material deprivation, and the differences in this relationship between urban and rural areas. We examine, given comparable measures of affluence or deprivation, whether residual differences exist between urban and rural areas for all-causes of death and, separately, for cancers, circulatory and respiratory diseases. Using 1990-92 mortality data for the 908 wards of Wales we apply statistical analyses based on tabular data and parametric Poisson regression models. Contrasts are sought between six urban and rural categories defined in terms of settlement sizes and the employment structure of rural areas. Inequalities in all-cause premature mortality are widest in the cities, narrowest in the deeper rural areas, and of intermediate and comparable value in other areas of Wales. This is largely a reflection of the different distributions of material deprivation in these areas. After controlling for differences in socio-economic characteristics, using deprivation measures, the tendency for lower mortality in deeper rural areas is substantially reduced. Residual mortality differences between urban and rural areas are shown to be dependent on the way deprivation is measured and the disease group under study. For cancers there are no residual mortality differences, while for respiratory and circulatory diseases some of the residual variation can be accounted for by employment variables, particularly previous employment in the coal mining industry.

Outcome measures of disease severity in atopic eczema

BACKGROUND

An essential component of evidence-based medicine is the use of valid and reliable outcome measures in clinical trials. There is much confusion in the field of atopic eczema regarding how to best measure disease severity objectively.

OBJECTIVE

To establish the extent to which existing objective clinical scales for atopic eczema have been tested for validity, reliability, sensitivity to change, and acceptability.

DESIGN

An electronic bibliographic search was performed for published data on all currently available named atopic eczema scales.

RESULTS

Thirteen scales were identified in total. Data on construct or criterion validity were available for 10 scales. Only 5 scales had been tested for reliability (interobserver variability, intraobserver variability, or internal consistency). Data on responsiveness to change were available for 8 scales. An estimated time to administer the measure had been given for 3 scales. The only severity scale for which published data could be found on validity, reliability, sensitivity, and acceptability testing was the Severity Scoring of Atopic Dermatitis index, although problems occurred with interobserver variation of the index.

CONCLUSION

The rapidly increasing number of severity scales for atopic eczema, many of which have been inadequately tested, has made the interpretation of patient outcomes confusing, and comparison of results between studies almost impossible. Consensus among clinicians and researchers on the use of severity scales for atopic eczema should be based on evidence of adequate validity), reliability, sensitivity to change, and ease of use.

The inhibitory effect of interleukin-10 on mouse osteoclast formation involves novel tyrosine-phosphorylated proteins

Interleukin-10 (IL-10) inhibits osteoclast (OC) formation in rat and mouse systems. However, little is known concerning the mechanism of this inhibitory effect. Using a coculture system of mouse bone marrow cells and primary osteoblastic cells (POB), we evaluated the potential target cells for IL-10 and components of the IL-10 activating pathway. In the coculture system, IL-10 treatment abolished OC differentiation in a dose-dependent manner. This inhibitory effect occurred regardless of the stage of cellular proliferation and differentiation, suggesting that IL-10 may act on a variety of genes participating in OC formation. IL-10 specifically abrogated the production of IL-6 by enriched bone marrow-derived mononuclear cells (BMM) but not by osteoblastic cells. IL-10 treatment also stimulated the binding of a protein in the BMM to an IL-10 response element, whereas no such activation was induced in osteoblastic cells. In contrast, interferon gamma (IFN-gamma), another inhibitory factor, stimulated tyrosine-phosphorylated proteins to bind to an IL-10 response element in both monocytes and osteoblastic cells. These data suggest that the BMM are the direct target of IL-10 action. Importantly, oligonucleotide-specific precipitation confirmed that IL-10 treatment strongly augmented 88, 85, and 70 kDa tyrosine-phosphorylated proteins in BMM. Taken together, these data show that IL-10 inhibits mouse OC formation by acting directly on hemopoietic OC precursor, through a novel signal transduction and activation pathway.

Is paediatric day case tonsillectomy desirable? The parents' perspective

Tonsillectomy is the most commonly performed otolaryngological procedure in most units. There is considerable financial pressure to perform paediatric tonsillectomy as a day case. Responding to concern that day case tonsillectomy might not be welcomed by parents or felt to be in the best interests of the patients, we carried out an audit of paediatric tonsillectomy, by means of a questionnaire for parents and nursing staff to complete while 32 consecutive patients underwent tonsillectomy as inpatients. Although eight parents (25%) felt that day surgery should be an option, none of those surveyed felt that on this occasion their child was well enough to be discharged home six hours postoperatively. Furthermore, no child in the audit fulfilled all the essential discharge criteria at six hours. In this area, at least, it appears parents do not uniformly welcome paediatric day case tonsillectomy.

APOE epsilon 4 influences the manifestation of Alzheimer's disease in adults with Down's syndrome

BACKGROUND

Recent studies of the relationship between the apolipoprotein E (APOE) gene and Alzheimer's disease in adults with Down's syndrome have revealed inconsistent results.

AIMS

To assess the role of the APOE gene in the manifestation of Alzheimer's disease in adults with Down's syndrome.

METHOD

We studied the APOE genotypes of 24 adults with dementia and 33 non-demented adults with Down's syndrome over 35 years of age, and an additional group of 164 non-learning disabled adults. We also carried out a meta-analysis of all previously published studies of association between APOE and Down's syndrome, incorporating the current data.

RESULTS

We observed a non-significant excess of APOE epsilon 4 and a reduction of epsilon 2 in adults with dementia compared with non-demented adults with Down's syndrome in our sample. However, meta-analysis showed a significantly higher frequency of epsilon 4 in adults with dementia compared with non-demented adults with Down's syndrome (odds ratio = 2.02, 95% CI 1.33-3.07, P = 0.001), but no significant reduction in the frequency of epsilon 2.

CONCLUSIONS

The APOE epsilon 4 allele acts as a risk factor for the age-specific manifestation of Alzheimer's disease in people with Down's syndrome.

Use of the atypical antipsychotics Olanzapine and Risperidone in adults with intellectual disability

The present study was designed to monitor the use of atypical antipsychotics in adults with intellectual disability and to evaluate the clinical effectiveness of these drugs. Twenty-one patients were commenced on an atypical antipsychotic: 12 on Olanzapine and nine on Risperidone. The ICD-10 diagnoses of the subjects were mild (13 cases) or moderate (8 cases) mental retardation, and psychiatric disorders (17 cases) with significant impairment of behaviour in 10 cases. Tolerability was good for 15 patients experiencing minimum or no side-effects, and medication was only stopped as a result of side-effects in one case. Clinical global outcome was rated as minimally improved or better for 16 cases. The present findings suggest that the atypical antipsychotics Olanzapine and Risperidone are well tolerated by patients with intellectual disability and psychiatric disorders, and are broadly effective against target symptoms.

Prediction and diagnosis of cytomegalovirus disease in renal transplant recipients using qualitative and quantitative polymerase chain reaction

BACKGROUND

Preemptive antiviral therapy against cytomegalovirus (CMV) disease after transplantation requires information from suitable laboratory markers. We examined the use of qualitative and quantitative polymerase chain reaction (PCR) to monitor renal transplant recipients.

METHODS

A cohort of 77 renal transplant recipients was monitored using an in-house and a commercial (Amplicor; Roche Diagnostic, Basel, Switzerland) PCR on leukocytes and plasma. Quantitative plasma viral load was determined using a commercial PCR kit (CMV Monitor; Roche Diagnostic). Patients were analyzed according to their pretransplantation CMV serological status (R- or R+).

RESULTS

Seventeen patients developed CMV disease after transplantation. Qualitative leukocyte PCRs had the best overall sensitivity (54-69%) and specificity (75-87%) in identifying R- recipients with CMV disease before onset. The specificities of qualitative PCRs for R+ recipients were poor and, if used, could result in unnecessary preemptive treatment in up to 50% of patients. Symptomatic and asymptomatic R+, but not R-, recipients could be distinguished using a plasma viral load of 25,000 copies/ml. An increase in viral load of >0.7 log (fivefold) per week also distinguished between symptomatic and asymptomatic R+ recipients with high sensitivity (100%) and specificity (95%).

CONCLUSIONS

Qualitative leukocyte PCRs were the best assays to predict CMV disease for R- recipients who received R+ kidneys. None of the qualitative assays could be used to guide preemptive therapy of R+ recipients, but plasma viral load and its incremental rate could be used as diagnostic tools in R+ recipients.

Comparison of two commercial methods for measurement of cytomegalovirus load in blood samples after renal transplantation

A cohort of 77 renal transplant recipients was prospectively studied for comparison of two commercially available cytomegalovirus (CMV) load assays, i.e., the COBAS AMPLICOR CMV Monitor test (Amplicor), using plasma samples, and the Murex Hybrid Capture System (HCS), using whole blood. The manufacturer of the HCS assay changed the version of the test from 1.0 (HCS-1) to 2.0 (HCS-2) after the first 37 patients had been tested. Despite the differences in principle and type of specimen used, the Amplicor and HCS assays gave comparable results. The regression line correlating the HCS-1 assay to the Amplicor assay was similar to that correlating the HCS-2 assay to the Amplicor assay. The HCS results could be converted to Amplicor-equivalent units by using linear-regression equations [log(10) HCS-1 result = 0.49 (log(10) Amplicor result) + 2.58, and log(10) HCS-2 result = 0.61 (log(10) Amplicor result) + 2.18]. The HCS-2 assay appeared to have the lowest detection limit, followed by the Amplicor assay and then the HCS-1 assay. When a sliding scale of cutoff values in Amplicor-equivalent units (>1,000, >2,500, >6,000, >16,000, >40,000, and >100,000 copies/ml) was applied to diagnose CMV disease, similar patterns of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were observed with the Amplicor and HCS assays. A cutoff value of >40,000 copies/ml has a low sensitivity (Amplicor, 29.4%; HCS, 41.2%) but is specific (Amplicor, 96.7%; HCS, 93.3%) and can be used for the differential diagnosis of CMV disease (PPV, 71.4% [Amplicor] or 63. 6% [HCS]; NPV, 82.9% [Amplicor] or 84.8% [HCS]). A lower cutoff value of >1,000 copies/ml improves the sensitivity (Amplicor, 76.5%; HCS, 82.4%) and has a high NPV (Amplicor, 91.8%; HCS, 94.2%) but, due to the low PPV (Amplicor, 46.2%; HCS, 56%), is useful only for exclusion of CMV disease.

How well are randomized controlled trials reported in the dermatology literature?

OBJECTIVE

To assess the methodological quality of the design and reporting of randomized controlled trials published in one major dermatology specialty journal.

DESIGN AND DATA SOURCES

In a survey of all published parallel group randomized controlled trials, we found 73 reports with allocation described as randomized from all issues of Clinical and Experimental Dermatology from its inception in 1976 through 1997.

MAIN OUTCOME MEASURES

Direct and indirect measures of the adequacy of randomization, trial sample size, baseline comparisons, and intention-to-treat analysis.

RESULTS

Hand searching identified 73 randomized controlled trials, but only 31 of these were found by searching MEDLINE for the publication type clinical trials. Of the 73 randomized controlled trials, 68 contained sufficient information to include in the analysis. Only 1 study (1%) reported the method of random sequence generation, and only 5 studies (7%) reported adequate concealment of allocation. Among 38 trials that used simple randomization, the sample sizes in the comparison groups were identical in 22 occasions, raising the possibility that simple randomization might not have been adequately generated or concealed. Most trials (88%) excluded some randomized participants from their analysis. The median sample size was 23 per trial. Only 1 trial reported sample size and statistical power considerations and had an a priori main hypothesis.

CONCLUSIONS

Hand searching is important for locating all relevant trials. There is the need for higher methodological quality in clinical trial reporting in dermatology journals. The adoption of the CONSORT (Consolidated Standards of Reporting Trials) statement and checklist for the reporting of trials should enhance the validity of and strengthen the evidence from clinical trials reports.