Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin

Background

COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies.

Methods

Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with “classical” HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination.

Results

All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation.

Conclusion

Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.

Evaluation of recorded video-observed therapy for anti-tuberculosis treatment

BACKGROUND: Asynchronous video directly observed therapy (VDOT) may reduce tuberculosis (TB) program costs and the burden on patients. We compared VDOT performance across three cities in the United States, each of which have TB incidence rates above the national average.METHODS: Patients aged ≥18 years who are currently receiving directly observed anti-TB treatment were invited to use VDOT for monitoring treatment. Pre- and post-treatment interviews and medical records were used to assess site differences in treatment adherence and patient characteristics and perceptions.RESULTS: Participants were enrolled in New York City, NY (n = 48), San Diego, CA (n = 52) and San Francisco, CA, USA (n = 49). Overall, the mean age was 41 years (range 18-87); 59% were male; most were Asian (45%) or Hispanic/Latino (30%); and 77% were foreign-born. The median fraction of expected doses observed (FEDO) was 88% (IQR 76-96). At follow-up, 97% thought VDOT was "very or somewhat easy to use" and 95% would recommend VDOT to other TB patients. Age, race/ethnicity, annual income, and country of birth differed by city (P < 0.05), but FEDO and VDOT perceptions did not.CONCLUSIONS: TB programs in three large US cities observed a high FEDO using VDOT while minimizing staff time and travel. Similar findings across sites support VDOT adoption by other large, urban TB programs.

A Hitherto not Described Enzyme Defect in Thrombasthenia: Glutathionreductase Deficiency

Two cases of thrombasthenia in the same family are described in which a deficiency of glutathionreductase and a reduction of reduced glutathion was found in the platelets, but no in the erythrocytes.

Digitizing Medicines for Remote Capture of Oral Medication Adherence Using Co-encapsulation

High‐resolution measurement of medication adherence is essential to personalized drug therapy. A US Food and Drug Administration (FDA)‐cleared device, using an edible ingestion sensor (IS), external wearable patch, and paired mobile device can detect and record ingestion events. Oral medications must be combined with an IS to generate precise “digitized‐medication” ingestion records. We developed a Good Manufacturing Practice protocol to repackage oral medications with the IS within certified Capsugel capsules, termed co‐encapsulation (CoE). A randomized bioequivalence study of CoE‐IS‐Rifamate (Isoniazid/Rifampin 150/300 mg) vs. native‐Rifamate was conducted in 12 patients with active Mycobacterium tuberculosis and demonstrated bioequivalence using the population method ratio test (95% confidence interval). Subsequently, CoE‐IS‐medications across all biopharmaceutical classes underwent in vitro dissolution testing utilizing USP and FDA guidelines. CoE‐IS medications tested met USP dissolution specifications and were equivalent to their native formulations. CoE combines oral medications with the IS without altering the quality of the native formulation, generating “digitized” medications for remote capture of dosing histories.

Using administrative data for primary care research: the City and East London General Practice Database Project

The City and East London General Practice Database Project was launched in 1992 to provide a framework for describing and understanding the nature of general practice in east London using routinely available administrative data from all practices in the area. It has provided an opportunity to use information on practices for research, health planning and policy, and for educational purposes. The project differs from others because it allows description in detail, clarity and depth in three distinct ways. Firstly, by covering all practices, and not just a select group, it is possible to investigate intra-health authority variability. Secondly, it has taken into account social and demographic characteristics of the practice populations, so making it possible to examine practice outputs in relation to population deprivation. Thirdly, in time, analyses using a combination of patient outcomes, morbidity information and longitudinal data become possible, making it an even more powerful information base for commissioning.

Feasibility of tuberculosis treatment monitoring by video directly observed therapy: a binational pilot study

BACKGROUND

Although directly observed therapy (DOT) is recommended worldwide for monitoring anti-tuberculosis treatment, transportation and personnel requirements limit its use.

OBJECTIVE

To evaluate the feasibility and acceptability of 'video DOT' (VDOT), which allows patients to record and transmit medication ingestion via videos watched remotely by health care providers to document adherence.

METHODS

We conducted a single-arm trial among tuberculosis (TB) patients in San Diego, California, USA, (n = 43) and Tijuana, Mexico (n = 9) to represent high- and low-resource settings. Pre-/post-treatment interviews assessed participant characteristics and experiences. Adherence was defined as the proportion of observed doses to expected doses.

RESULTS

The mean age was 37 years (range 18-86), 50% were male, and 88% were non-Caucasian. The mean duration of VDOT use was 5.5 months (range 1-11). Adherence was similar in San Diego (93%) and Tijuana (96%). Compared to time on in-person DOT, 92% preferred VDOT, 81% thought VDOT was more confidential, 89% never/rarely had problems recording videos, and 100% would recommend VDOT to others. Seven (13%) participants were returned to in-person DOT and six (12%) additional participants had their phones lost, broken or stolen.

CONCLUSIONS

VDOT was feasible and acceptable, with high adherence in both high- and low-resource settings. Efficacy and cost-effectiveness studies are needed.

Allelic heterogeneity in NCF2 associated with systemic lupus erythematosus (SLE) susceptibility across four ethnic populations

Recent reports have associated NCF2, encoding a core component of the multi-protein NADPH oxidase (NADPHO), with systemic lupus erythematosus (SLE) susceptibility in individuals of European ancestry. To identify ethnicity-specific and -robust variants within NCF2, we assessed 145 SNPs in and around the NCF2 gene in 5325 cases and 21 866 controls of European-American (EA), African-American (AA), Hispanic (HS) and Korean (KR) ancestry. Subsequent imputation, conditional, haplotype and bioinformatic analyses identified seven potentially functional SLE-predisposing variants. Association with non-synonymous rs17849502, previously reported in EA, was detected in EA, HS and AA (P(EA) = 1.01 × 10(-54), PHS = 3.68 × 10(-10), P(AA) = 0.03); synonymous rs17849501 was similarly significant. These SNPs were monomorphic in KR. Novel associations were detected with coding variants at rs35937854 in AA (PAA = 1.49 × 10(-9)), and rs13306575 in HS and KR (P(HS) = 7.04 × 10(-7), P(KR) = 3.30 × 10(-3)). In KR, a 3-SNP haplotype was significantly associated (P = 4.20 × 10(-7)), implying that SLE predisposing variants were tagged. Significant SNP-SNP interaction (P = 0.02) was detected between rs13306575 and rs17849502 in HS, and a dramatically increased risk (OR = 6.55) with a risk allele at each locus. Molecular modeling predicts that these non-synonymous mutations could disrupt NADPHO complex assembly. The risk allele of rs17849501, located in a conserved transcriptional regulatory region, increased reporter gene activity, suggesting in vivo enhancer function. Our results not only establish allelic heterogeneity within NCF2 associated with SLE, but also emphasize the utility of multi-ethnic cohorts to identify predisposing variants explaining additional phenotypic variance ('missing heritability') of complex diseases like SLE.

The lupus family registry and repository

The Lupus Family Registry and Repository (LFRR) was established with the goal of assembling and distributing materials and data from families with one or more living members diagnosed with SLE, in order to address SLE genetics. In the present article, we describe the problems and solutions of the registry design and biometric data gathering; the protocols implemented to guarantee data quality and protection of participant privacy and consent; and the establishment of a local and international network of collaborators. At the same time, we illustrate how the LFRR has enabled progress in lupus genetics research, answering old scientific questions while laying out new challenges in the elucidation of the biologic mechanisms that underlie disease pathogenesis. Trained staff ascertain SLE cases, unaffected family members and population-based controls, proceeding in compliance with the relevant laws and standards; participant consent and privacy are central to the LFRR's effort. Data, DNA, serum, plasma, peripheral blood and transformed B-cell lines are collected and stored, and subject to strict quality control and safety measures. Coded data and materials derived from the registry are available for approved scientific users. The LFRR has contributed to the discovery of most of the 37 genetic associations now known to contribute to lupus through 104 publications. The LFRR contains 2618 lupus cases from 1954 pedigrees that are being studied by 76 approved users and their collaborators. The registry includes difficult to obtain populations, such as multiplex pedigrees, minority patients and affected males, and constitutes the largest collection of lupus pedigrees in the world. The LFRR is a useful resource for the discovery and characterization of genetic associations in SLE.

A polymorphism within interleukin-21 receptor (IL21R) confers risk for systemic lupus erythematosus and is associated with malar rash in lupus patients (49.17)

Interleukin (IL) 21 is a member of the type I cytokine superfamily that exerts a variety of effects on the immune system including B cell activation, plasma cell differentiation, and immunoglobulin production. The IL21 receptor (IL21R) is expressed on B cells, T cells, NK cells, and monocyte-derived dendritic cells. The expression of IL21R is reduced in B cells from lupus patients, while IL21 serum levels are increased in both lupus patients and some lupus-murine models. We recently reported that polymorphisms within the IL21 gene are associated with increased susceptibility to lupus. Herein, we genotyped SNPs in the IL21R gene located on chromosome 16p11. We identify and confirm the association between rs3093301 and lupus in two independent European-derived and Hispanic cohorts (p=7.2X10-5). In addition, the presence of the homozygous risk genotype in rs3093301 (A/A) was associated with the development of malar rash in the European-derived female lupus patients (OR=2.83, 95% CI=1.56-5.13, p=0.00045).

C8orf13/BLK association with systemic lupus erythematosus across different ethnicities (136.28)

SLE is a complex autoimmune disease with immunological abnormalities that targets B cell functions and development. Previous genome-wide association studies identified C8orf13/BLK as a novel SLE risk factor. BLK (B lymphoid tyrosine kinase) has been shown to have potential effects on B cell develoment. The main objectives of this study are to: 1.) assess this association in independent populations and 2.) determine if BLK risk alleles correlate with alteration in peripheral blood B cell development and protein expression. We genotyped 52 SNPs within the C8orf13/BLK region in European-derived, Asian and African American populations. rs13277113 is associated with SLE in all three populations. A few novel upstream SNPs within the intergenic region demonstrate a stronger association in Asians. Flow cytometry data suggests there is a significant difference in BLK expression and T2 cells B cell numbers between high-risk and non-risk individuals based on the risk haplotype. Our results suggest that the BLK genetic polymorphisms alter immune system development and function to increase the risk for SLE development. Supported by NIH RR020143, RR015577, NIAID-DAIT-BAA-05-11, AI031584, AR053483, AR48940, AI063274, AR052125, AR043247 and OCAST # HR08-037.

Prevalence, severity, and predictors of fatigue in subjects with primary Sjögren's syndrome

OBJECTIVE

To investigate the relationship of fatigue severity to other clinical features in primary Sjögren's syndrome (SS) and to identify factors contributing to the physical and mental aspects of fatigue.

METHODS

We identified 94 subjects who met the American-European Consensus Group criteria for the classification of primary SS. Fatigue was assessed with a visual analog scale, the Fatigue Severity Scale (FSS), and the Profile of Fatigue (ProF). Associations with fatigue were compared using multivariate regression.

RESULTS

Abnormal fatigue, defined as an FSS score >or=4, was present in 67% of the subjects. Pain, helplessness, and depression were the strongest predictors of fatigue according to the FSS and the somatic fatigue domain of the ProF (ProF-S), both with and without adjustment for physiologic and serologic characteristics. Depression was associated with higher levels of fatigue; however, the majority of subjects with abnormal fatigue were not depressed. Anti-Ro/SSA-positive subjects were no more likely to report fatigue than seronegative subjects. The regression models explained 62% of the variance in FSS and 78% of the variance in ProF-S scores. Mental fatigue was correlated with depression and helplessness, but the model predicted only 54% of the variance in mental fatigue scores.

CONCLUSION

Psychosocial variables are determinants of fatigue, but only partially account for it. Although fatigue is associated with depression, depression is not the primary cause of fatigue in primary SS. Investigation of the pathophysiologic correlates of physical and mental aspects of fatigue is needed to guide the development of more effective interventions.

[Postoperative pain after ambulatory surgery]

BACKGROUND

Outpatient surgeons were surveyed about the quality of postoperative pain therapy after outpatient interventions.

PATIENTS AND METHODS

Of 2,317 outpatient surgeons who received a questionnaire by mail, 419 responded. The return rate was 18.1%. The questionnaire collected data on the operative procedures and methods of anesthesia from 2004 and the analgesics, which were applied in the immediate postoperative period and at home. Methods and contents of quality control were registered.

RESULTS

The respondents indicated that the person responsible for the pain therapy was the surgeon in 74% of the practices, the anesthesiologist in 16%, and both in 10%. The drugs used in the practice were: novaminsulfone (34%), NSAIDs (28%), and opioids (36%). The drugs used for at-home care were: NSAIDs (58%), opioids (43%), novaminsulfone (32%), and mixed analgesics (28%). No analgesics were given by 6%, and 21% prescribed a supplementary antiemetic. Routine pain measurement was performed with pain scales in only 11% of the practices; among the certified practices, 48% performed pain measurement for quality control. Ninety-five percent of the surgeons were satisfied with the pain therapy.

CONCLUSION

This survey shows that the guidelines for acute pain therapy (http://www.awmf.de ) are only partially implemented.

Detection of a rare oligo(A) repeat tract mutation (8As-->7As) in the sequence encoding the La/SS-B autoantigen

Several diseases are characterized by the presence of point mutations, which are amenable to molecular detection using a number of methods such as PCR. However, certain mutations are particularly difficult to detect due to factors such as low abundance and the presence of special (e.g., oligonucleotide repeat) sequences. The mutation 7A in the oligoA sequence of exon 7 of the gene encoding the La autoantigen is difficult to detect at the DNA level, and even at the RNA level, due to both its estimated low abundance and its differentiation from the wild-type 8A sequence. This article describes a technique in which amplification of the excess wild-type 8A La sequence is suppressed by a peptide nucleic acid (PNA) during a nested PCR step. Detection of the amplified 7A mutant form was then performed by simple electrophoresis following a final primer extension step with an infrared dye-labeled primer. This technique allowed us to detect the mutation in 3 of 7 individuals harboring serum immunoglobulin G (IgG) antibodies reactive with a neo-B cell epitope in the 7A mutant protein product. We propose that this method is a viable screening test for mutations in regions containing simple polynucleotide repeats.

Three functional variants of IFN regulatory factor 5 (IRF5) define risk and protective haplotypes for human lupus

Systematic genome-wide studies to map genomic regions associated with human diseases are becoming more practical. Increasingly, efforts will be focused on the identification of the specific functional variants responsible for the disease. The challenges of identifying causal variants include the need for complete ascertainment of genetic variants and the need to consider the possibility of multiple causal alleles. We recently reported that risk of systemic lupus erythematosus (SLE) is strongly associated with a common SNP in IFN regulatory factor 5 (IRF5), and that this variant altered spicing in a way that might provide a functional explanation for the reproducible association to SLE risk. Here, by resequencing and genotyping in patients with SLE, we find evidence for three functional alleles of IRF5: the previously described exon 1B splice site variant, a 30-bp in-frame insertion/deletion variant of exon 6 that alters a proline-, glutamic acid-, serine- and threonine-rich domain region, and a variant in a conserved polyA+ signal sequence that alters the length of the 3' UTR and stability of IRF5 mRNAs. Haplotypes of these three variants define at least three distinct levels of risk to SLE. Understanding how combinations of variants influence IRF5 function may offer etiological and therapeutic insights in SLE; more generally, IRF5 and SLE illustrates how multiple common variants of the same gene can together influence risk of common disease.

Specific combinations of HLA-DR2 and DR3 class II haplotypes contribute graded risk for disease susceptibility and autoantibodies in human SLE

The human leukocyte antigen (HLA) Class II antigen presentation alleles DR and DQ are associated with susceptibility to systemic lupus erythematosus (SLE) and the production of lupus-related autoantibodies. Here, we explore the effect of different combinations of Class II risk haplotypes in a large, multi-center collection of 780 SLE families. Haplotypes bearing the DRB1*1501/DQB1*0602 (DR2) and DRB1*0301/DQB1*0201 (DR3) alleles were present in nearly two-thirds of SLE cases and were significantly associated with disease susceptibility in both family-based and case-control study designs. DR3-containing haplotypes conferred higher risk for disease than DR2, and individual homozygous for DR3 or compound heterozygous for DR3 and DR2 showed the highest risk profile. DR2 haplotypes were also found to be associated with antibodies to the nuclear antigen Sm, and, as previously observed, DR3 genotypes were associated with Ro and La autoantibodies. Interestingly, SLE cases and unaffected family members who were DR2/DR3 compound heterozygotes showed particularly strong risk of developing antibodies to Ro, and were enriched for La and Sm. These data provide convincing evidence that particular combinations of HLA Class II DR2 and DR3 haplotypes are key determinants of autoantibody production and disease susceptibility in human SLE.

Immunological memory stabilizing autoreactivity

The etiopathologies of autoimmune diseases are complex. A broad variety of cell types and gene products are involved. However, clinical and experimental evidence suggests that the importance of an individual factor changes during the course of the disease. Factors and cell types that induce acute autoreactivity and initiate an autoimmune disease could be distinct from those that drive a chronic course of that disease. Autoreactive immunological memory, in particular B cell and plasma cell memory, contributes to chronicity through several mechanisms. Formation of autoreactive memory B cells leads to an increase in the numbers of autoreactive cells. In comparison to naive B cells, these memory B cells show a decreased threshold for activation. Additionally, a fraction of memory B cells express the chemokine receptor CXCR3, which supports their accumulation within chronically inflamed tissues. This may allow their escape from mechanisms for induction of peripheral tolerance. Within the inflamed tissue, inflammatory cytokines and autoantigens provide activation signals that promote plasma cell differentiation and survival. The autoantibodies produced locally by these plasma cells contribute to the severity of inflammation. Together, an autoreactive loop of autoantibody-induced inflammation is formed. Another integral part of immunological memory are long-lived plasma cells. These cells provide persistent humoral antibody memory. Though not all autoantibodies are produced by long-lived plasma cells, these cells have a special impact on immune pathology. Long-lived plasma cells are relatively resistant to existing therapies of immunosuppression and continuously secrete antibodies, without need for restimulation. Long-lived plasma cells provide titers of autoantibodies even during clinically quiescent phases and after immunosuppression. These persisting autoantibody titers, though often low and not causing acute clinical symptoms, are likely to maintain a low level of chronic inflammation and progressive tissue destruction, which reduces the threshold for another break of immunological tolerance.

Diagnosing melanoma patients entering American Joint Committee on Cancer stage IV, C-reactive protein in serum is superior to lactate dehydrogenase

Lactate dehydrogenase (LDH) in serum has recently been introduced into the American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma because of its prognostic value. We hypothesised LDH to be of value in discriminating melanoma patients entering AJCC stage IV from patients staying in AJCC stages I, II or III. Lactate dehydrogenase was compared to the acute phase protein C-reactive protein (CRP), which we observed to reflect the course of melanoma metastasis in a previous report. In this prospective study, we measured LDH and CRP in the serum of 91 consecutive melanoma patients progressing into AJCC stage IV in comparison to 125 patients staying in AJCC stages I, II or III. Comparing distributions of the parameters by median values and quartiles by Mann-Whitney test, LDH was not significantly elevated in patients entering AJCC stage IV melanoma (P=0.785), whereas CRP was (P<0.001). Analysing the sensitivity and the specificity jointly by the areas under the receiver operating characteristics curves (ROC-AUC), LDH did not discriminate between the defined groups of patients (AUC=0.491; 95% confidence interval, 0.410, 0.581), whereas CRP did (AUC=0.933; 95% confidence interval, 0.900, 0.966; P<0.001). Upon logistic regression analysis to calculate the ROC-AUC values upon the predictive probabilities, LDH provided no additional information to CRP. Choosing a cutoff point of 3.0 mg l(-1), CRP yielded a sensitivity of 0.769 together with a specificity of 0.904 in diagnosing AJCC stage IV entry. Altogether, for first diagnosing AJCC stage IV melanoma, CRP is the superior serum marker when compared to the conventional LDH.

Expression levels for many genes in human peripheral blood cells are highly sensitive to ex vivo incubation

Monitoring of gene and protein expression in peripheral blood cells has significant potential for improving the diagnosis and therapy of many human diseases. As genomic-scale microarray and proteomic technologies are applied to peripheral blood, it is important to consider the variables that may affect interpretation of data. Here we report experiments performed to identify genes that are particularly sensitive to ex vivo handling prior to RNA extraction for gene expression microarrays or quantitative real-time RT-PCR assays. We examined Affymetrix gene expression in samples from eight normal individuals where blood was processed for RNA either immediately after blood draw or the next day following overnight incubation. These studies identified hundreds of genes that are sensitive to ex vivo handling of blood, and suggest that this is an important variable to consider when designing and interpreting human PBMC experiments.

Social inequalities in low birth weight in England and Wales: trends and implications for future population health

STUDY OBJECTIVE

To examine social inequalities and trends in low birth weight in England and Wales.

DESIGN

Analysis of routine birth data, comparing (a) couple and sole registered births, and (b) manual and non-manual occupational groups.

SETTING

England and Wales, 1993-2000.

MAIN RESULTS

Social inequalities in low birth weight were evident throughout 1993-2000: relative to the non-manual group, there is an increased risk for the manual group (range in RR 1.22-1.35) and sole registrations (RR 1.51-1.67). An estimated 6.5% (2979 births) of low birth weight in 2000 could have been avoided if risks associated with the manual group were absent, and 2.8% (1290 births) avoided if risks associated with sole registration were absent. Between 1993 and 2000, the low birthweight rate increased significantly with an estimated overall increase of 11%. Increases were evident in all social groups (15% in manual, 11% in sole registrations and 9% in non-manual); however relative to non-manual the increase in RRs were not statistically significant for manual or sole registrations. When multiple births are excluded, the rate of low birth weight is reduced but there is still a significant increase over time and social differentials are undiminished.

CONCLUSIONS

There are social inequalities in low birth weight in England and Wales that have not narrowed over an eight year period, 1993-2000. These inequalities are likely to affect childhood and adult health inequalities in the future, hence strategies will need to address differences in low birth weight and further monitoring of trends is therefore desirable.

Successful immunotherapy in early relapse of acute myeloid leukemia after nonmyeloablative allogeneic stem cell transplantation

We report on a 35-year-old woman who underwent allogeneic stem cell transplantation (SCT) in second complete remission (CR) of acute myeloid leukemia (AML) after reduced-intensity conditioning with fludarabine and 2 Gy of total body irradiation. For graft-versus-host disease (GVHD) prophylaxis, cyclosporin A (CsA) and mycophenolate mofetil (MMF) were given. On day 27 after SCT complete hematological remission and donor chimerism was documented. However, in CD34(+) bone marrow cells 28% of recipient hematopoiesis persisted. On day +59 leukemic relapse occurred. After discontinuation of CsA and onset of GVHD, complete donor chimerism and hematological CR were achieved which has been maintained for 14 months.

Did the London Initiative Zone investment programme affect general practice structure and performance in East London? A time series analysis of cervical screening coverage and asthma prescribing

A programme of incentives was set up in the London Initiative Zones to improve primary care in inner London based on the findings of the Tomlinson Enquiry in 1992. This descriptive study is a 4-y time series analysis of changes in general practice structure in East London as the result of London Initiative Zone investment, and an exploration of the possible effect of investment on practice performance. We used routinely available administrative data for the whole analysis. General practice characteristics and two selected performance indicators: the asthma prophylaxis to bronchodilator ratio and cervical cytology screening rate, for all practices in the East London and the City Health Authority for 4 y, 1993-1996, were used. Both reflect practice efficiency, but relate to different aspects of practice performance. The prescribing indicator is more indicative of the quality of clinical practise, whereas cervical screening coverage relates more to the characteristics of the practice population and to practice organisation. Repeated measures analyses were used to identify trends and to explore the relationship between changes in practice characteristics and performance. Graphical methods were used to compare East London trends with the rest of England. There were significant improvements in practice structure as the consequence of London Initiative Zone investment. There was a positive association with improvements in practice performance, but East London still lagged some way behind national patterns. The findings suggest that while improvements in asthma prescribing follow the national trend, practices have difficulty in achieving and sustaining the 80% target for cervical cytology screening, and that an overall population coverage of 80% may be in doubt.Increased investment in practice staffing may be influential in improving some aspects of performance. However, in common with other inner cities, a greater effort and more innovative strategies may be needed to achieve a standard of performance equal to the best.

Management of tuberculosis in San Diego County: a survey of physicians' knowledge, attitudes and practices

SETTING

A survey conducted in San Diego County.

OBJECTIVE

To assess local physicians' knowledge, attitudes and practices regarding tuberculosis (TB).

METHODS

The survey consisted of questions covering diagnosis and treatment of active disease, diagnosis and treatment of latent infection, and infection control. The survey was sent to physicians who reported a TB case or suspect to the local health department in the years 1995-1997.

RESULTS

Of the 384 physicians in this group, 150 (39%) returned the survey form. The percentage of physicians whose response conformed to health department guidelines varied widely from question to question (51%-94%, median 83%). Pulmonary medicine and infectious diseases specialists, physicians educated completely in the United States (US), and physicians who treated six or more TB patients in the past 2 years were more likely to give answers in agreement with health department policies.

CONCLUSIONS

Because the response rate to the survey was low, these findings may not be completely representative of the targeted group of physicians. Nevertheless, they may indicate that health care provider education about TB management standards is needed.

Passive skin penetration enhancement and its quantification in vitro

The poor penetration of drugs into the skin (and, partially, the permeation across the stratum corneum) often limits the efficacy of topical formulations. Basically, skin penetration can be enhanced by the following strategies: (i) increasing drug diffusivity in the skin; (ii) increasing drug solubility in the skin, and/or (iii) increasing the degree of saturation of the drug in the formulation. In this article, we review the literature with respect to: (i) chemical penetration enhancers, which have been shown to influence the diffusivity and/or solubility of the drug in the skin and (ii) supersaturated formulations, in which the degree of saturation of the drug is increased compared to conventional formulations. In addition, three different in vitro methods, specifically, classic diffusion cell studies, attenuated total-reflectance-Fourier transform infrared spectroscopy, and tape stripping in conjunction with an appropriate analytical technique, are considered, emphasizing their application to obtain quantitative values for skin transport parameters and to separate the kinetic or thermodynamic effects of an enhancement strategy.

Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database

OBJECTIVE

To determine the prevalence of atrial fibrillation in England and Wales, and examine trends in its treatment with warfarin and aspirin between 1994 and 1998.

DESIGN

Analysis of data from the general practice research database.

SETTING

England and Wales.

PATIENTS

1.4 million patients registered with 211 general practices.

MAIN OUTCOME MEASURES

Age and sex specific prevalence rates of atrial fibrillation; percentage of patients with atrial fibrillation treated with oral anticoagulants or aspirin.

RESULTS

The prevalence of atrial fibrillation in 1998 was 12.1/1000 in men and 12.7/1000 in women. Prevalence increased from less than 1/1000 in under 35 year olds to over 100/1000 in those aged 85 years and over. There was a 22% increase in the age standardised prevalence of atrial fibrillation in men and a 14% increase in women between 1994 and 1998. The percentage of patients prescribed oral anticoagulants increased from 20% to 34% in men and from 17% to 25% in women. The percentage of men with atrial fibrillation prescribed aspirin increased from 26% to 36%, and the percentage of women increased from 24% to 36%. Applying the age and sex specific prevalence and treatment rates to the population gives an estimate of around 650 000 cases of atrial fibrillation in England and Wales. The greatest number of cases occurs in the 75-84 year old age group.

CONCLUSIONS

The number of patients in the community with identified atrial fibrillation is increasing. There has also been a pronounced increase in the percentage of patients with atrial fibrillation prescribed oral anticoagulants or aspirin.

Stabilization of supersaturated solutions of a lipophilic drug for dermal delivery

The stability of supersaturated solutions of a model lipophilic drug (LAP, a lavendustin derivative) in propylene glycol-water mixtures prepared using the method of mixed cosolvents was investigated. The solutions had a fixed degree of saturation (DS=4), but contained different ratios of propylene glycol-water. The absolute concentrations of LAP in these solutions varied by approximately a factor of 40, but the solutions at lower concentrations were no more stable than the more concentrated solutions. This shows that stability is primarily a question of the degree of saturation and not of the absolute drug concentration. Solutions of up to 5 degrees of saturation in 7:3 propylene glycol-water mixture were stable when stored for several hours; those at higher degrees of saturation recrystallized immediately. When the solutions were stirred, recrystallization occurred more rapidly. The influence of various polymeric additives on the stability of the supersaturated solutions showed that only sodium carboxymethyl cellulose had a stabilizing effect; however, the solution was very viscous and it is not clear whether the stabilizing effect was due to this high viscosity or to a specific interaction between drug and polymer.

Supersaturation: enhancement of skin penetration and permeation of a lipophilic drug

PURPOSE

To increase the dermal delivery of a lipophilic model compound (LAP), and to deduce the underlying mechanism of enhanced absorption.

METHODS

Penetration of LAP from mixtures of up to four degrees of saturation into the stratum corneum was evaluated using a tape-stripping method; epidermal permeation of the drug was measured in Franz diffusion cells. The relative diffusion and stratum corneum-vehicle partition coefficients of LAP were determined by fitting the results to the appropriate solutions to Fick's second law of diffusion.

RESULTS

Both the skin permeation rate and the amount of LAP in the stratum corneum increased linearly with increasing degree of saturation. The apparent diffusivity and its partition coefficient deduced from the penetration experiments were independent of the degree of saturation of the drug in the applied formulation, and consistent with corresponding parameters derived from the permeation experiments.

CONCLUSIONS

Supersaturation can increase the skin penetration and permeation of lipophilic drugs. The diffusion and partition parameters deduced for LAP indicate that supersaturation acts exclusively via increased thermodynamic activity without apparent effect on the barrier function of the skin per se.

Enhanced skin permeation of a lipophilic drug using supersaturated formulations

Supersaturation was used to enhance the permeation of a lipophilic model compound (a lavendustin derivative, LAP) through excised pig skin in vitro. The drug was dissolved in a series of liquid and semisolid vehicles (in which it had different solubilities) and which were prepared using either (i) the method of mixed cosolvents, (ii) the method of solvent evaporation, or (iii) the method of dissolving the drug with heating. Saturated formulations showed comparable permeation rates through the skin, independent of the absolute concentration of the drug in the vehicle. Supersaturated solutions at a degree of saturation of two resulted in a doubling of the drug permeation rate. These experiments show, therefore, that the percutaneous absorption of LAP may be consistently increased using supersaturated formulations, independent of the type and composition of the vehicles and independent of their method of preparation.

Inequalities in treated heart disease and mental illness in England and Wales, 1994-1998

BACKGROUND

Current government policy is directed towards reducing inequalities in health. General practice is increasingly the focus for health care provision in the United Kingdom and it is therefore important to understand the relationship between socioeconomic factors and health at the general practice level. A deprivation measure was used for the area in which the practice is located and two key priority areas were focused upon: mental health and heart disease.

AIM

To explore the relationship between area deprivation and the prevalence of treated heart disease and mental illness in England and Wales.

DESIGN OF STUDY

Analysis of data from medical records from practices contributing to the General Practice Research Database.

SETTING

A total of 211 practices located in England and Wales.

METHOD

The data from the practices were used to examine deprivation differentials in treated disease prevalence rates.

RESULTS

There are strong deprivation gradients (highest prevalence in the most deprived category) for treated depression, anxiety, schizophrenia, coronary heart disease and non-insulin-treated diabetes. In general the deprivation differentials are wider in the middle of the age range. Women aged 35 to 64 years in the most deprived areas had rates of treated coronary heart disease two to three times those in the least deprived areas. Men aged 25 to 44 years in the most deprived areas had rates of treated depression 50% higher than those in the least deprived areas.

CONCLUSIONS

This study has identified wide deprivation differentials in the prevalence of treated mental illness and heart disease. If all of England and Wales experienced the rates of the least deprived fifth of the population then the number of people being treated for depression, anxiety, and coronary heart disease would fall by 10%, 16%, and 11% respectively.

Linkage analysis of angiotensin-converting enzyme (ACE) insertion/deletion polymorphism and systemic lupus erythematosus

Previous studies have suggested an association between systemic lupus erythematosus (SLE) and an insertion/deletion polymorphism in the angiotensin-converting enzyme gene (ACE). This polymorphism consists of a 250-bp insertion/deletion of an alu repeat in the 16th intron of the ACE gene. Individuals homozygous for the deletion have a higher level of circulating enzyme. Due to the important role of this enzyme in regulating the renin--angiotensin and kallikrein--kininogen systems, it is possible that the ACE insertion/deletion may play a role in SLE, which can include vasculitis and vascular changes. Using primers flanking the insertion/deletion site, we have examined the ACE gene in lupus patients and family members using genomic DNA obtained from the Lupus Multiplex Registry and Repository (LMRR). We were unable to detect significant linkage or genetic association between the ACE gene and SLE.

Permeation enhancement of a highly lipophilic drug using supersaturated systems

The potential of supersaturation as a method for enhancing the membrane permeation of highly lipophilic compounds has been investigated using, as a model system, the transport of a lavendustin derivative (LAP, log K(o/w) = 5) through silicone membrane. Propylene glycol-water mixtures, which permitted the formulation of LAP at different levels of saturation, were prepared and tested for stability prior to conducting membrane permeation studies. The transport of LAP across silicone membrane from donor solutions containing the drug at different degrees of saturation (DS = 1-5) was evaluated by two independent experimental methods: (i) using attenuated total-reflectance Fourier transform infrared spectroscopy (ATR-FTIR) and (ii) using standard vertical diffusion cells followed by quantification with high-performance liquid chromatography (HPLC). Both methods demonstrated a linear relationship between the DS of the applied solution and the flux through the membrane, yielding similar values for the diffusion coefficients of LAP [diffusion cells, D = 1.75 ( +/- 0.16) x 10(-7) cm(2) s(-1) and ATR-FTIR, D = 1.42 ( +/- 0.26) x 10(-7) cm(2) s(-1)). In addition to the characterization of LAP permeation, ATR-FTIR spectroscopy enabled an examination of solvent transport across the membrane.