The cost-effectiveness of antenatal and postnatal education and support interventions for women aimed at promoting breastfeeding in the UK

Background

Breastfeeding is associated with health benefits to mothers and babies and cost-savings to the health service. Breastfeeding rates in the UK are low for various reasons including cultural barriers, inadequate support to initiate and sustain breastfeeding, lack of information, or choice not to breastfeed. Education and support interventions have been developed aiming at promoting breastfeeding rates. The objective of this study was to assess the cost-effectiveness of such interventions for women, initiated antenatally or in the first 8 weeks postnatally, aiming at improving breastfeeding rates, in the UK.

Methods

A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of a breastfeeding intervention from the perspective of health and personal social services in England. Data on intervention effectiveness and the benefits of breastfeeding were derived from systematic reviews. Other model input parameters were obtained from published sources, supplemented by expert opinion.

Results

The incremental cost-effectiveness ratio (ICER) of the modelled intervention added on standard care versus standard care was £51,946/QALY, suggesting that the intervention is not cost-effective under National Institute for Health and Care Excellence (NICE) criteria in England. Sensitivity analysis suggested that the cost-effectiveness of the intervention improved as its effectiveness increased and intervention cost decreased. At the base-case effect (increase in breastfeeding rates 16–26 weeks after birth by 19%), the intervention was cost-effective (<£20,000/QALY) if its cost per woman receiving the intervention became ≈£40–£45. At the base-case cost (£84), the intervention was cost-effective if it increased breastfeeding rates by at least 35–40%.

Conclusions

Available breastfeeding interventions do not appear to be cost-effective under NICE criteria in England. Future breastfeeding interventions need to have higher effectiveness or lower cost compared with currently available interventions in order to become cost-effective. Public health and other societal interventions that protect, promote and support breastfeeding may be key in improving breastfeeding rates in the UK.

Comparative effects of dexmedetomidine, propofol, sevoflurane, and S-ketamine on regional cerebral glucose metabolism in humans: a positron emission tomography study

INTRODUCTION

The highly selective α₂-agonist dexmedetomidine has become a popular sedative for neurointensive care patients. However, earlier studies have raised concern that dexmedetomidine might reduce cerebral blood flow without a concomitant decrease in metabolism. Here, we compared the effects of dexmedetomidine on the regional cerebral metabolic rate of glucose (CMR_glu) with three commonly used anaesthetic drugs at equi-sedative doses.

METHODS

One hundred and sixty healthy male subjects were randomised to EC₅₀ for verbal command of dexmedetomidine (1.5 ng ml^-1; n=40), propofol (1.7 μg ml^-1; n=40), sevoflurane (0.9% end-tidal; n=40) or S-ketamine (0.75 μg ml^-1; n=20) or placebo (n=20). Anaesthetics were administered using target-controlled infusion or vapouriser with end-tidal monitoring. ¹⁸F-labelled fluorodeoxyglucose was administered 20 min after commencement of anaesthetic administration, and high-resolution positron emission tomography with arterial blood activity samples was used to quantify absolute CMR_glu for whole brain and 15 brain regions.

RESULTS

At the time of [F¹⁸]fluorodeoxyglucose injection, 55% of dexmedetomidine, 45% of propofol, 85% of sevoflurane, 45% of S-ketamine, and 0% of placebo subjects were unresponsive. Whole brain CMR_glu was 63%, 71%, 71%, and 96% of placebo in the dexmedetomidine, propofol, sevoflurane, and S-ketamine groups, respectively (P<0.001 between the groups). The lowest CMR_glu was observed in nearly all brain regions with dexmedetomidine (P<0.05 compared with all other groups). With S-ketamine, CMR_glu did not differ from placebo.

CONCLUSIONS

At equi-sedative doses in humans, potency in reducing CMR_glu was dexmedetomidine>propofol>ketamine=placebo. These findings alleviate concerns for dexmedetomidine-induced vasoconstriction and cerebral ischaemia.

CLINICAL TRIAL REGISTRATION

NCT02624401.

Prenatal early food and multiple micronutrient supplementation trial reduced infant mortality in Bangladesh, but did not influence morbidity

AIM

A previous maternal and infant nutrition intervention in rural Matlab, Bangladesh, showed that prenatal nutrient supplements improved child survival, but had no effect on size at birth. This secondary analysis examined whether prenatal multiple micronutrient supplements (MMS), on their own or combined with an early invitation to receive prenatal food supplements, affected child morbidity.

METHODS

This randomised trial enrolled 4436 pregnant women from November 2001 to October 2003 and allocated them to early or standard invitations to food supplements, in the ninth and 20th weeks of pregnancy, respectively, and supplements of either the standard 60 mg iron with 400 μg folic acid, 30 mg iron with 400 μg folic acid or MMS. Quasi-Poisson regression was used to analyse morbidity.

RESULTS

There were 3560 single live births and 3516 had morbidity data. The incidence rates of fever, diarrhoea and acute lower respiratory tract infection were 15.3, 3.6 and 2.3 episodes per person-year, respectively. The separate or combined interventions had no effect on morbidity up to 24 months.

CONCLUSION

Early invitations to prenatal food supplements or prenatal MMS had no effect on common infections in rural Bangladesh, suggesting that earlier findings on improved child survival were not mediated by an effect on child morbidity.

Renal Angiomyolipoma

The findings at ultrasonography (US), CT, and angiography in 13 patients with renal angiomyolipomas were compared with histologically determined proportions of fatty, myogenic, and vascular components. The angiomyolipoma was composed mainly of fat in 4 cases, half of fat in 2, mainly of myogenic tissue in 4, and was hemorrhagic in 3. US showed high echogenicity in 10 patients, while CT demonstrated attenuation values of fat in 3 tumors with mainly fat tissue but gave non-specific findings in the other cases. The angiographic findings were considered specific for angiomyolipoma in 2 out of 11 cases (18%). Low fat content and hemorrhagic areas caused diagnostic difficulties at both US and CT. The diagnostic algorithm for renal angiomyolipoma is discussed.

Dermal expression of laminin-332 and type IV collagen in humans with severe sepsis

BACKGROUND

An intact basement membrane at the dermal-epidermal junction is essential to the viability of the skin. The effect of sepsis on the basement membrane is unknown.

METHODS

Skin biopsies were used to study basement membrane structure in severe sepsis (Day 1). Subsequent biopsies were taken on Day 8 and at 3 months in the survivors. Immunohistochemical staining was undertaken using laminin-223 and type IV collagen. Twenty patients with severe sepsis and four control subjects were included in the analysis.

RESULTS

Intensive care unit mortality was 4/20, and total 30-day mortality was 5/20. Exactly, 7/17 of patients with severe sepsis exhibited weak or absent laminin-332 expression and 11/15 exhibited weak or absent type IV collagen expression compared with 0/4 of control subjects on Day 1 in intact skin. The proportion of sepsis patients with weak or absent laminin-332 expression was 5/11 on Day 8 and fell to 1/7 at 3 months. The proportion of sepsis patients with weak or absent type IV collagen expression was 10/11 on Day 8 and 4/7 at 3 months.

CONCLUSION

These findings suggest that basement membrane formation may be compromised in patients with severe sepsis.

Recovery of galactoglucomannan from wood hydrolysate using regenerated cellulose ultrafiltration membranes

Hemicelluloses show promise as a renewable source of raw material for various industrial processes. In this study, galactoglucomannan was recovered from pressurized hot water extract of spruce-sawdust in two steps using hydrophilic regenerated cellulose ultrafiltration membranes having different molecular weight cut-off values. The first step was concentration of galactoglucomannan (GGM) by ultrafiltration using a flat sheet unit and the second step was purification of the retained galactoglucomannan by diafiltration using reverse osmosis filtered water. The highest GGM retention (88%), purity (63%) and recovery (70%) were achieved with the UC005 membrane (cut-off value 5-kDa) at a volume reduction (VR%) of 86%. The UC010 and UC030 membranes (cut-off values 10- and 30-kDa, respectively) partly separated xylan from GGM. Generally, diafiltration did not improve the purity of the GGM due to overlapping of the GGM and lignin molar mass distributions and the fact that most of free low molar mass lignin had already been removed in the concentration filtration step. However, by diafiltration, partial removal of xylan and complete removal of monosaccharides from the GGM rich concentrate was achieved.

Industrial membrane processes in the treatment of process waters and liquors

A review on pulp and paper industrial membrane processes using a variety of modules and processes is presented. Membranes are mostly used today to purify process waters and to recover coating colours. Ultrafiltration using tubular membrane modules or cross-rotational (CR) filtration has been widely applied for the purification of process waters. The reuse of UF membrane permeate has decreased the fresh water consumption to lower than 6 m³/t of paper in some paper machines. Some industrial membrane processes also recover valuable products from different streams (e.g lignosulphonates). Membranes are also combined with biological degradation processes in some paper mills. Nanofiltration has been used to purify the effluents discharged from the activated sludge process. At least two reverse osmosis plants purify river water to be used as raw water in the mill. Furthermore, advantages of different membrane modules and the current ways to treat membrane concentrate are discussed.

Dupuytren's contracture; increased cellularity--proliferation, is there equality?

BACKGROUND

Dupuytren's disease is a chronic inflammatory process which causes contractures of the fingers by shortening and thickening the palmar fascia. During the proliferative phase, fibroblasts transform into myofibroblasts apparently under the influence of several different factors. The disease usually develops slowly, but in some patients it tends to develop aggressively. The pathogenesis of Dupuytren's disease remains unsolved. In this study, we analyzed some histological characteristics that seem to predict rapid recurrence.

MATERIAL AND METHODS

21 patients were divided into two groups. In 11 patients the disease was classified as aggressive because it had recurred within two years after an operation. In 10 cases it was non-aggressive, as no recurrence had been seen. Five control samples were taken from healthy palmar aponeurosis. The differences in cellularity, collagen, Ki-67, MSA, alpha-SMA and tenascin between the specimens were analyzed using immunohistochemistry.

RESULTS

Alpha-SMA and Ki-67 were present more often in the aggressive specimens. Immunohistochemical stainings for macrophages and lymphocytes were negative.

CONCLUSION

There may be differences in the histology and/or immunohistochemical appearance of pathological palmar connective tissue cords in aggressive and normal Dupuytren's disease. Further studies are needed to elucidate the pathogenesis of this disease.

Water circuit closure with membrane technology in the pulp and paper industry

In this study, membrane filtration as an internal purification method, "the kidney", in the pulp and paper industry is discussed. Membrane filtration is economically competitive and a very versatile process. It can be used to remove the enriched organic and/or inorganic loads either partially or totally from, for example, the mechanical pulping and paper making water circuits and it can be applied to various points within the process. With the so-called shear enhanced membrane modules very high fluxes, in ultrafiltration about 400 L/(m2h) and in nanofiltration fluxes almost 200 L/(m2h), have been obtained. Depending on the membrane, suspended solids (microfiltration), polysaccharides, extractives and high molar mass lignous substances (ultrafiltration) and multivalent salts (nanofiltration) can be removed. Ultrafiltration permeate can well be used in paper machine showers to replace fresh water. The quality of the nanofiltration permeate is significantly higher than that of ultrafiltration. The membrane processes can be enhanced by various pre-treatment techniques to produce higher permeate fluxes and to eliminate membrane fouling. Such pre-treatment methods are, e.g., chemical treatment, ozonation and biological treatment. The most cost-effective processes were chemical flocculation, pH adjustment and thermophilic aerobic biological treatment.

Smoking affects collagen synthesis and extracellular matrix turnover in human skin

BACKGROUND

Smoking is associated with premature facial wrinkling and aberrant wound healing, but the underlying mechanisms of skin injury are poorly understood.

OBJECTIVES

To compare the in vivo collagen synthesis and degradation in the skin of smokers and non-smokers.

METHODS

The study population consisted of 47 current smokers and 51 individuals who had never smoked from northern Finland. Suction blisters were induced in the sun-protected upper inner arm of the study subjects, after which suction blister fluid (SBF) was collected for analyses of the levels of aminoterminal procollagen propeptides of type I and III collagens (PINP and PIIINP, respectively), matrix metalloproteinase (MMP)-8 and tissue inhibitor of MMP (TIMP)-1. PINP, PIIINP and TIMP-1 were also determined from serum samples. The levels of active and pro MMP-1 were assessed from deep-frozen skin biopsies by Western blotting.

RESULTS

The synthesis rates of type I and III collagens were lower by 18% and 22%, respectively, in the SBF of the smokers compared with the non-smokers. The levels of MMP-8 were higher by 100% in the SBF of the smokers. The levels of MMP-1 in the skin biopsies did not differ significantly between the groups. The levels of TIMP-1 in SBF were 14% lower in the smokers than in the non-smokers, whereas the serum concentrations of TIMP-1 did not differ between the groups.

CONCLUSIONS

Smoking decreases the synthesis rates of type I and III collagens in skin in vivo and alters the balance of extracellular matrix turnover in skin.

Radiation therapy induces tenascin expression and angiogenesis in human skin

In analysing radiation-induced connective tissue changes, we studied tenascin expression, elastic fibres, angiogenesis and physio-mechanical properties in irradiated and contralateral healthy skin of radiotherapy-treated breast cancer patients. Skin biopsies were obtained from a radiotherapy-treated skin area and a corresponding non-treated skin area. Haematoxylin-eosin and Verhoeff stainings as well as immunohistochemical stainings for tenascin and factor VIII were performed. Epidermal and total skin thickness, together with the amount of elastic tissue calculated by computerized digital image analysis, were measured. Suction blisters were induced on both skin areas. Transepidermal water loss was analysed. Skin elasticity was also measured. Tenascin expression was found to be increased in irradiated human skin. In haematoxylin-eosin and factor VIlI-stained sections, an increase in the number of blood vessels was detected. Although skin stiffness measured by an elastometer was increased in irradiated skin, no marked difference in the elastic fibres could be found between treated and non-treated skin. The increased tenascin expression could be due to activation of cytokines as a result of irradiation. An increase in angiogenesis could be caused by an activation of angiogenetic factors by irradiation or due to direct radiation damage on blood vessel walls. Our findings suggest that the effects of irradiation tend to accumulate in the dermal parts of skin. The higher skin stiffness values measured by elastometer in irradiated skin could be due to an accumulation of dermal connective tissue as a result of irradiation.

Occult neurofibroma and increased S100 protein in the skin of patients with neurofibromatosis type 1: new insight to the etiopathomechanism of neurofibromas

BACKGROUND

Neurofibromas represent proliferation of the connective tissue cells of peripheral nerves and deposition of collagenous extracellular matrix. There is evidence that the appearance and growth of neurofibromas may be associated with prior or ongoing mechanical trauma in patients with neurofibromatosis type 1 (NF1).

OBJECTIVE

To study the histologic characteristics of apparently healthy skin of patients with NF1.

DESIGN

The histologic features of healthy-looking skin of patients with NF1 were analyzed.

SETTING

University hospital.

PATIENTS

Ten patients who fulfilled the criteria for NF1.

INTERVENTIONS

Punch biopsy specimens of healthy-looking skin of the forearm from 9 volunteer patients and of the upper eyelid during cosmetic operation from 1 volunteer patient were obtained.

MAIN OUTCOME MEASURES

The main outcomes were not predicted, and the hypothesis was formulated during data collection.

RESULTS

Apparently unaffected skin of 5 patients with NF1 was studied by routine histologic testing with respect to expression of S100 protein. Unexpectedly, analysis of the samples revealed the presence of a small neurofibroma tumor in one of the samples. The tumor was located in deep dermis around a hair follicle. In addition, neurofibromatous tissue not large enough to be called a tumor was found on the same anatomical location in another patient. In further studies, 10 punch biopsy specimens of apparently healthy skin from patients with NF1 were similarly sectioned and analyzed. No tumors were found in these additional samples. In 4 patients, however, abundant S100 protein-positive cells were located within collagenous extracellular matrix surrounding hair follicles.

CONCLUSIONS

The skin of patients with NF1 might be more widely affected than previously thought and occult neurofibromas are not rare.

Modulation of skin collagen metabolism by irradiation: collagen synthesis is increased in irradiated human skin

Radiation-induced fibrosis is a common side-effect of cancer treatment. The pathophysiological events leading to fibrosis are not known in detail. We analysed the effect of therapeutic irradiation on human skin collagen synthesis, skin thickness, gelatinases and their inhibitors. Twenty randomly chosen women who had been treated for breast cancer with surgery and radiation therapy participated in the study. In each patient, the irradiated skin area was compared with a corresponding non-treated skin area. Suction blister fluid (SBF) and serum samples were analysed for the aminoterminal propeptides of type I and type III procollagens (PINP and PIIINP), tissue inhibitors of matrix metalloproteinases (MMPs) 1 and 2 (TIMP-1 and TIMP-2) and MMP-9 and MMP-2/TIMP-2 complex. Skin biopsies were analysed for PINP and immunohistochemical staining was used for PIIINP. In irradiated skin, PINP, PIIINP, TIMP-1 and MMP-2/TIMP-2 complex levels in SBF and the number of PINP-positive fibroblasts in tissue sections were significantly higher in comparison with non-treated skin. The levels of TIMP-2 in irradiated and non-irradiated skin were similar. MMP-9 could not be detected in SBF with the assay used. The serum levels of MMP-9 were higher in the treated subjects than the reference values. The serum values of PINP, PIIINP, TIMP-1, TIMP-2 and MMP-2/TIMP-2 complex were not significantly affected. These results indicate increased local collagen synthesis and accumulation of connective tissue in irradiated skin. The marked upregulation of collagen synthesis as a result of irradiation offers a possibility to treat this complication with compounds such as topical steroids which downregulate collagen synthesis.

Comparison of self-reinforced poly-L-lactide and steel wire in fixation of sternotomy in rabbits

BACKGROUND AND AIMS

To investigate the healing of sternotomies fixed with biodegradable self-reinforced poly-L-lactide (SR-PLLA) wire and comparing it with steel wire fixation.

MATERIAL AND METHODS

Sixteen rabbits (15 Chinchilla and one New Zealand White rabbit) were operated on. Two parallel holes of 1.5 mm in diameter were drilled in the sternum at the level of the second and third rib and similar holes of 0.8 mm were drilled at the level of the third and fourth rib. A transverse sternotomy was created between both drill hole pairs. The sternotomy with larger drill holes was fixed with 1.1-mm thick SR-PLLA wire. The sternotomy between the smaller drill holes was fixed using 2.0 steel wire. The animals were sacrificed at 2, 7, 26 and 52 weeks postoperatively and specimens were taken, radiographed and studied by both light and scanning electron microscopy.

RESULTS

One rabbit died at four months postoperatively as a result of gastrointestinal problems. No other complications were seen. The SR-PLLA wire was slowly degraded. There was no disturbance of bone healing. The implants were surrounded by a fibrous tissue capsule, which also contained chronic inflammatory cells. Both SR-PLLA and steel wires provided sufficient fixation security. No differences in the healing of the sternotomies were observed between SR-PLLA and steel wire fixation.

CONCLUSIONS

SR-PLLA wires are biocompatible and useful for sternotomy fixation. They may be suitable for use in clinical applications.

Evaluation of self-reinforced polyglycolide membrane implanted in the subcutis of rabbits

BACKGROUND

Self-reinforced absorbable implants have been developed recently to use in hard tissue reconstructive surgery. Polyglycolide is a biocompatible polymer from which the suture Dexon is made and widely used.

AIMS

To study histologically the behaviour of self-reinforced polyglycolide membrane (SR-PGA) in rabbits' ears.

MATERIAL AND METHODS

SR-PGA membranes, 0.4 mm thick, were implanted in the subcutis of the ears of 24 New Zealand white rabbits. Sham operations were carried out on the contralateral ear of each rabbit. The rabbits were followed-up for 4, 12 and 20 weeks. Attention was directed towards external macroscopic changes in the rabbits' ears. After sacrifice, the ears were taken as specimens, inspected for any evidence of infection, sinus formation or fluid accumulation and histological examination was carried out.

RESULTS

No complications such as infection, fluid accumulation or sinus formation were observed. Histologically, the membranes induced a foreign-body reaction involving fibrous tissue encapsulation, macrophages and giant cells. Fibrous tissue and inflammatory cells were seen between the PGA fibres. The membranes underwent progressive degradation throughout the follow-up period. However, PGA material could be still seen 20 weeks postoperatively, with a small amount of fibrous tissue and macrophages and giant cells. The implant-cartilage interface comprised fibrous and fatty tissue.

CONCLUSIONS

SR-PGA membranes are biocompatible when implanted in the subcutis of the ears of rabbits.

Histological evaluation of poly(L-lactide/epsilon-caprolactone) membrane implanted subcutaneously in rats

BACKGROUND

Poly(L-lactide/epsilon-caprolactone) [P(L-LA/epsilon-CL)] 50/50 membranes is an absorbable membrane which has been developed recently for possible use in tissue engineering.

AIMS

To look at histological tissue reactions to the membrane and its behaviour upon its in vivo implantation in rats.

MATERIAL AND METHODS

P(L-LA/e-CL) 50/50 membranes, 0.4 mm thick, were implanted subcutaneously in the dorsal neck of 20 Wistar rats. The rats were followed-up for 1, 3, 6, 12 and 28 months. After sacrifice, subcutaneous tissues with implants were taken as specimens, inspected for any gross abnormality and histological examination was carried out.

RESULTS

No significant macroscopic changes were noticed except for two implants that were grossly rounded. Histologically, the membranes had undergone cracking, fragmentation and progressive degradation. Cracks appeared initially at the periphery of the implant. Large cracks progressed mainly in longitudinal planes. Cracks occurred in the middle of implants and led to membrane bending in some cases. "Neomembrane" formation, comprised of fibrous tissue and the implant, was seen. The foreign-body reaction to the membrane involved macrophages and foreign-body giant cells. In one case an acute type of polymorphonuclear cell reaction was observed and in a second case a predominantly lymphocytic reaction was seen at three months. They were thought to be the results of infection. No other adverse effects were seen.

CONCLUSIONS

P(L-LA/e-CL) 50/50 membrane was found to be biocompatible when implanted subcutaneously in rats. It was degraded to a great extent but not completely in 28 months.

Bone healing and mineralization, implant corrosion, and trace metals after nickel-titanium shape memory metal intramedullary fixation

Its shape memory effect, superelasticity, and good wear and damping properties make the NiTi shape memory alloy a material with fascinating potential for orthopedic surgery. It provides a possibility for making self-locking, self-expanding, and self-compressing implants. Problems, however, may arise because of its high nickel content. The purpose of this work was to determine the corrosion of NiTi in vivo and to evaluate the possible deleterious effects of NiTi on osteotomy healing, bone mineralization, and the remodeling response. Femoral osteotomies of 40 rats were fixed with either NiTi or stainless steel (StSt) intramedullary nails. The rats were killed at 2, 4, 8, 12, 26, and 60 weeks. Bone healing was examined with radiographs, peripheral quantitative computed tomography, (pQCT) and histologically. The corrosion of the retrieved implants was analyzed by electron microscopy (FESEM). Trace metals from several organs were determined by graphite furnace atomic absorption spectrometry (GF-AAS) or by inductively coupled plasma-atomic emission spectrometry (ICP-AES). There were more healed bone unions in the NiTi than in the StSt group at early (4 and 8 weeks) time points. Callus size was equal between the groups. The total and cortical bone mineral densities did not differ between the NiTi and StSt groups. Mineral density in both groups was lower in the osteotomy area than in the other areas along the nail. Density in the nail area was lower than in the proximal part of the operated femur or the contralateral femur. Bone contact to NiTi was close. A peri-implant lamellar bone sheet formed in the metaphyseal area after 8 weeks, indicating good tissue tolerance. The FESEM assessment showed surface corrosion changes to be more evident in the StSt implants. There were no statistically significant differences in nickel concentration between the NiTi and StSt groups in any of the organs. NiTi appears to be an appropriate material for further intramedullary use because it has good biocompatibility in bone tissue.

Duration of increased mucosal permeability of the urinary bladder after acute overdistension: an experimental study in rats

The duration of damage to the mucosal barrier of the urinary bladder after overdistension was investigated in a rat model. Overdistension was induced for 3 h in 48 female Sprague-Dawley rats by forced diuresis and balloon obstruction of the bladder neck. In 24 rats 0.5 ml of 2% solution of Trypan blue in 0.9% NaCl solution was instilled into the bladder for 1 h at 0 h, 24 h, 48 h, 7 days and 21 days after overdistension. After dyeing, full-thickness samples were taken from the wall of the bladder dome and body immediately above the ureteral orifices for histological studies. Inflammatory reaction was investigated histologically without Trypan blue dyeing in 24 rats at 0 h, 24 h, 48 h, 7 days and 21 days after overdistension. At 0, 24 and 48 h after overdistension the bladder wall was deep blue throughout. The dome and body were similar. At 7 days there was only slight staining of the bladder surface urothelium and subjacent connective tissue, while at 21 days there was no longer any dye in the bladder wall or urothelium. Oedema reached its maximum at 48 h, and large numbers of inflammatory cells were seen in the submucosa at 48 h. These changes had normalized by 7 days. After overdistension urothelial integrity is destroyed for several days, making it possible for different substances in the urine to penetrate into the bladder wall. This renders questionable the use of bladder distension in the treatment of interstitial cystitis, as it may only increase leakage of the urothelium and accelerate inflammatory reaction in the bladder wall. However, in the present study of healthy rat bladders the integrity of the urothelium had recovered to a large extent after 1 week and completely after 3 weeks.

Bone modeling and cell-material interface responses induced by nickel-titanium shape memory alloy after periosteal implantation

The purpose of this study was to evaluate the new bone formation, modeling and cell-material interface responses induced by nickel-titanium shape memory alloy after periosteal implantation. We used a regional acceleratory phenomenon (RAP) model, in which a periosteal contact stimulus provokes an adaptive modelling response. NiTi has thermal shape memory and superelasticity properties uncommon in other implant alloys. So far, there are insufficient data concerning the biocompatibility of NiTi as a bone implant. NiTi was compared to stainless steel (stst) and Ti-6Al-4V. The test implant was placed in contact with the intact femur periosteum, but it was not fixed inside the bone. Histomorphometry with digital image analysis was used to determine the bone formation and resorption parameters. The ultrastructural features of cell-material adhesion were analysed with scanning electron microscopy (FESEM). A typical peri-implant bone wall modelation was seen due to the normal RAP. The maximum new woven bone formation started earlier (2 weeks) in the Ti-6Al-4V group than in the NiTi (P < 0.01) group, but also decreased earlier, and at 8 weeks the NiTi (P < 0.05) and stst (P < 0.005) groups had greater cortical bone width. At 12 and 26 weeks no statistical differences were seen in the histomorphometric values. The histological response of the soft tissues around the NiTi implant was also clearly non-toxic and non-irritating. Cell adhesion and focal contacts were similar between the materials studied by FESEM. We conclude that NiTi had no negative effect on total new bone formation or normal RAP after periosteal implantation during a 26-week follow-up.

Matrix metalloproteinase-2 (MMP-2) immunoreactive protein--a new prognostic marker in uveal melanoma?

Uveal melanoma is the most common primary intraocular tumour. Once haematogenous metastasis has occurred, there is no cure for the disease and there is an obvious need for new biological prognostic markers to estimate the risk of metastasis. In this study, the expression of matrix metalloproteinase-2 (MMP-2) was characterized immunohistochemically in 29 human uveal melanomas. Enzyme-linked immunoassays and gelatin zymographies were assessed in order to quantify the expression of gelatinases A and B, as well as the tissue inhibitor of metalloproteinases (TIMPs), in the vitreous body. A total of 49 per cent of the uveal melanomas displayed a positive immunoreaction for MMP-2 in melanoma cells, the epithelioid cells showing the most frequent staining. There was no correlation between the positivity of MMP-2 staining and the size of the primary tumour, gender or age. The expression of MMP-2 was associated with a dismal prognosis: the 5-year overall survival rate for MMP-2-positive cases was significantly inferior to that of the MMP-2 negative cases, 49 per cent vs. 86 per cent, respectively (p=0.02). A patient group at high risk of metastatic disease was identified; only 38 per cent of patients with a MMP-2-positive non-spindle cell uveal melanoma survived for 5 years. The analyses of MMPs or TIMPs in the vitreous body had no prognostic value. Positive immunostaining for MMP-2 was observed in the retinal pigment epithelium, corneal epithelium, and fibroblasts in the ciliary body and choroid. It is concluded that immunohistochemical analysis of MMP-2 may help to predict a risk of metastasis in uveal melanoma.

Increased prevalence of vitiligo, but no evidence of premature ageing, in the skin of patients with bp 3243 mutation in mitochondrial DNA in the mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes syndrome (MELAS)

The MELAS syndrome (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes) belongs to the category of mitochondrial disorders. The most common molecular aetiology of the syndrome is a mutation at base pair (bp) 3243 in the mitochondrial genome (mtDNA). The phenotype is varied and, apart from central nervous system involvement, the patients with this mutation may present with neurosensory hearing loss, diabetes mellitus and cardiomyopathy. These phenotypes suggest that organs dependent on aerobic metabolism suffer most. We investigated the possible clinical and physiological manifestations of impaired energy metabolism in the skin of 28 patients with the bp 3243 mutation in mtDNA. Non-invasive sonography and laser Doppler flowmetry were used to measure skin thickness and the blood flow of the skin. Skin collagen synthesis was assayed from suction blister fluid. Evaporimetry was used to assess the re-epithelialization rate of suction blister wounds. Histochemistry and immunohistochemistry were used to evaluate the melanocytes and pigment in the skin. Vitiligo was found in three of the 28 patients (11%), which was markedly more than in the general population. Histological findings showed an absence of pigment, but an apparently normal distribution of melanocytes in the dermoepidermal junction. Seborrhoeic eczema and atopy were also somewhat more frequent. No features of premature ageing, such as a marked decrease in skin thickness, blood flow, collagen synthesis or re-epithelialization rate, were demonstrated.

Prognostic value of MMP-2 immunoreactive protein (72 kD type IV collagenase) in primary skin melanoma

The penetration of the subepithelial basement membrane is the first critical step in the dissemination of melanoma. In vitro studies have suggested that the 72 kD type IV collagenase (MMP-2) may be important in melanoma invasion. It has recently been demonstrated that the expression of MMP-2 immunoreactive protein increased with increasing atypia in melanocytic tumours and was associated with later haematogenous metastases in melanoma. This paper investigates the value of MMP-2 as a possible prognostic marker in melanoma. The expression of MMP-2 immunoreactive protein was studied with immunoperoxidase staining in paraffin-embedded sections of 50 cases of primary skin melanoma by using specific, affinity purified antibodies. Positive immunostaining was quantified by counting the percentage of positive cancer cells and was compared with clinical patient characteristics and survival. Sixty-four per cent of the primary melanoma cases displayed positive cytoplasmic immunostaining for MMP-2 in tumour cells. Marked overexpression of MMP-2 protein (> or = 34 per cent of melanoma cells positive) correlated with the 5-year survival of the patients when compared with patients with lower MMP-2 positivity, 55 per cent vs. 85 per cent, respectively (P < 0.05). Male patients displayed positive staining more often than females (75 per cent vs. 54 per cent, respectively). There was no correlation between MMP-2 positivity and Clark level or Breslow classification. A distinct group with unfavourable prognosis was identified. The 10-year survival for MMP-2-positive male melanoma patients was 39 per cent as opposed to 79 per cent with the other melanoma patients (P < 0.05). In the hierarchic Cox regression model for survival, MMP-2 immunoreactive protein was found to be independent of Clark level and Breslow classification. Overexpression of MMP-2 protein indicated a 4.5-fold relative risk of dying from melanoma. It is concluded that MMP-2 immunoreactive protein in melanoma cells is an independent prognostic factor for survival. High MMP-2 expression in male melanoma patients indicates an unfavourable prognosis.

In vivo biocompatibility evaluation of nickel-titanium shape memory metal alloy: muscle and perineural tissue responses and encapsule membrane thickness

Nickel-titanium shape memory alloy (Nitinol) has properties that could be very useful in surgical applications. Thermal shape memory, superelasticity, and high damping properties make such alloys behave differently compared to other implant metals. There has previously been a lack of sufficient evidence on the biocompatibility of Nitinol. The purpose of this study was to evaluate general soft tissue response and biocompatibility to Nitinol in vivo, and to clarify neural and perineural responses, previously unreported. Seventy-five rats were randomized into three groups. Test specimens were implanted into paravertebral muscle and near the sciatic nerve. A comparison was made between Nitinol, stainless steel, and Ti-6Al-4V. The animals were euthanized at 2, 4, 8, 12, and 26 weeks after implantation. General morphologic and histologic observations were made under light microscopy. Semiautomatic computerized image analysis was used to measure the encapsule membrane thickness around the implants. The muscular tissue response to Nitinol was clearly nontoxic, regardless of the time period. The overall inflammatory response to Nitinol was very similar to that of stainless steel and Ti-6Al-4V alloy. There were no necroses, granulomas, or signs of dystrophic soft tissue clacification. The immune cell response to Nitinol remained low. Only a few foreign-body giant cells were present. The detected neural and perineural responses were also clearly nontoxic and nonirritating with Nitinol. No qualitative differences in histology between the different test materials could be seen. At 8 weeks, the encapsule membrane of Nitinol was thicker than that of stainless steel (mean 62 +/- 25 microns vs. 41 +/- 8 microns). At the end of the study, the encapsule thickness was equal to all the materials tested. We concluded that Nitinol had good in vivo biocompatibility after intramuscular and perineural implantation in rats in the 26-week follow-up. Based on the results of the present study, Nitinol appears to have good potential for clinical use.

Prognostic value of MMP-2 immunoreactive protein (72 kD type IV collagenase) in primary skin melanoma

The penetration of the subepithelial basement membrane is the first critical step in the dissemination of melanoma. In vitro studies have suggested that the 72 kD type IV collagenase (MMP-2) may be important in melanoma invasion. It has recently been demonstrated that the expression of MMP-2 immunoreactive protein increased with increasing atypia in melanocytic tumours and was associated with later haematogenous metastases in melanoma. This paper investigates the value of MMP-2 as a possible prognostic marker in melanoma. The expression of MMP-2 immunoreactive protein was studied with immunoperoxidase staining in paraffin-embedded sections of 50 cases of primary skin melanoma by using specific, affinity purified antibodies. Positive immunostaining was quantified by counting the percentage of positive cancer cells and was compared with clinical patient characteristics and survival. Sixty-four per cent of the primary melanoma cases displayed positive cytoplasmic immunostaining for MMP-2 in tumour cells. Marked overexpression of MMP-2 protein (> or = 34 per cent of melanoma cells positive) correlated with the 5-year survival of the patients when compared with patients with lower MMP-2 positivity, 55 per cent vs. 85 per cent, respectively (P < 0.05). Male patients displayed positive staining more often than females (75 per cent vs. 54 per cent, respectively). There was no correlation between MMP-2 positivity and Clark level or Breslow classification. A distinct group with unfavourable prognosis was identified. The 10-year survival for MMP-2-positive male melanoma patients was 39 per cent as opposed to 79 per cent with the other melanoma patients (P < 0.05). In the hierarchic Cox regression model for survival, MMP-2 immunoreactive protein was found to be independent of Clark level and Breslow classification. Overexpression of MMP-2 protein indicated a 4.5-fold relative risk of dying from melanoma. It is concluded that MMP-2 immunoreactive protein in melanoma cells is an independent prognostic factor for survival. High MMP-2 expression in male melanoma patients indicates an unfavourable prognosis.

Skin atrophy of the eyelid induced by topical ophthalmic corticosteroids

A case of eyelid skin atrophy caused by long-term application of topical ophthalmic corticosteroids for chronic uveitis is reported. Skin punch biopsy of the uveitic eye showed moderate atrophy of both epidermis and dermis (compared to normal skin on the other eye) resulting from a reduction in the three main fibrous components of the skin, namely type I and type III collagens, and elastic fibers. To our knowledge, this is the first report of skin atrophy in this association.

Laminin-5 expression is independent of the injury and the microenvironment during reepithelialization of wounds

We examined the expression of laminin-5 and its integrin receptors during reepithelialization of human wounds. We used suction blisters of skin as a model of keratinocyte migration on a basement membrane matrix and mucosal full-thickness wounds as a model in which keratinocytes migrate in a provisional matrix. An animal model, in which human epidermal keratinocytes were injected into the back of athymic mice, was used to follow the deposition of the basement membrane components. In 4-day-old blisters, about 20-50 cells at the leading edge of the migrating tongue showed cytoplasmic laminin-5 immunostaining. Laminin-5 mRNA was detected in 15-30 cells at the leading edge of the migrating epidermis. alpha3beta1 and alpha6beta4 integrins were found in membrane projections of the migrating basal cells and also in suprabasal cell layers, suggesting their combined role in binding laminin-5. In mucosal wounds, laminin-5 was the only basement membrane zone component that was deposited between the clot and the migrating keratinocytes. In the animal model, linear deposition of laminin-5 and alpha6beta4 integrin was already seen on Day 2, whereas the other basement membrane zone components were not yet organized. The results suggest that, regardless of the injury and the microenvironment, laminin-5 plays an essential role in the interaction between wound keratinocytes and the surrounding matrix.

Consolidation of craniotomy lines after resorbable polylactide and titanium plating: a comparative experimental study in sheep

The consolidation process of craniotomy lines in a skeletally immature large mammal was studied. A traditional narrow titanium miniplate was compared with a 0.5-mm-thick, 12-mm-wide absorbable punched self-reinforced poly-L-lactide (SR-PLLA) plate, both fixed with titanium miniscrews over bilateral parietal 2.5-mm-wide stable transosseous craniotomies on nine female sheep (16 to 20 months old). After 6, 12, 20, 52, and 104 weeks, cross-sectional histology, histomorphometry, and oxytetracycline chloride fluorescence studies were done to compare the healing process of the craniotomy lines and to study the biocompatibility and the degradation process of the SR-PLLA plate. The consolidation pattern supported the principle of guided tissue regeneration: under the wide, resorbable plate osseous bridging proceeded evenly throughout the line, whereas titanium plating led to bulky, uneven growth in the bone margins. All SR-PLLA-plated osteotomy lines had healed completely by 20 weeks, whereas none of the titanium-plated lines had consolidated during a follow-up of 1 year. The nonossified gaps were filled with dense connective tissue. Histomorphometric analysis showed that osseous bridging proceeded significantly faster on the resorbable plate side compared with the titanium side (p < 0.001). The osteoid surface fraction over the total trabecular surface was highest at 6 weeks, being 63 percent on the SR-PLLA side and only 36 percent on the titanium side. The oxytetracycline chloride fluorescence studies confirmed these findings. After 52 weeks, there was no osteoid or oxytetracycline chloride fluorescence left as a sign of terminated ossification, even in the nonconsolidated titanium sides. Microscopic cracking of the plate was evident at 12 to 20 weeks, and the first signs of active resorption were present at 52 weeks. After 2 years, the plate had disappeared and tiny polylactide particles were being actively reabsorbed. The biocompatibility of SR-PLLA and titanium was good, and no adverse cellular reactions to these materials were noted, except a clinical foreign body reaction caused by loosened titanium miniscrews. A densely punched, 0.5-mm-thick self-reinforced PLLA plate seems to retain its integrity for a sufficiently long time to complete osseous healing of a 2.5-mm-wide craniotomy line in the sheep calvarial area. A thin, wide fixation plate enables superior healing, especially in osseous defects. The degradation process of the SR-PLLA plate begins within 1 year and is far advanced after 2 years. By using absorbable SR-PLLA fixation plates instead of metallic plates, a subsequent operation for the removal of the implants can be avoided. SR-PLLA devices could thus be a potential additive or even alternative to metallic implants in craniofacial surgery.

Multicellular origin of tenascin in skin tumors--an in situ hybridization study

Tenascin mRNA expression was studied by an in situ hybridization method in 27 skin tumors. Tenascin synthesis was increased in all skin tumors when compared to uninvolved skin but there was variation in the site of cellular synthesis between different types of tumors. In melanocytic nevi and precancerous keratinocyte lesions, tenascin seemed to be of epidermal or stromal origin. In basal cell carcinoma, squamous cell carcinoma and malignant melanoma, there was tenascin synthesis also in tumor cells. These findings are in concordance with earlier studies which suggest a role of tenascin as an anti-adhesive and motility-promoting factor in malignant skin tumors.

Erythema elevatum diutinum in association with coeliac disease

Erythema elevatum diutinum (EED) has been described in association with several immunological or infectious diseases. We describe a female patient who presented with clinically and histologically typical EED in whom previously undiagnosed coeliac disease was found. Appearance of EED lesions was preceded by widespread joint pains. In extensive laboratory tests, the only abnormal findings were an elevated erythrocyte sedimentation rate (ESR) and decreased haemoglobin and folic acid levels. Later, IgA and IgG type antireticulin and antigliadin antibodies were detected. Serum total IgA was elevated but no paraproteinaemia was found. In lesional skin, granular deposits of IgA and C3 were seen at the dermo-epidermal junction. A duodenal biopsy revealed total villous atrophy. Dapsone treatment was partly effective but complete healing of the EED lesions was achieved only after the introduction of a strict gluten-free diet. The patient has now remained symptom-free on the diet for 1.5 years.

Systemic therapy with estrogen or estrogen with progestin has no effect on skin collagen in postmenopausal women

OBJECTIVES

To investigate the effect of estrogen alone or combined with progestin on the amount and synthesis of skin collagen in postmenopausal women.

METHODS

Forty-three early postmenopausal women were enrolled into this open, non-randomized parallel-groups study. Fifteen women received a continuous oral dose of 2 mg of 17 beta-estradiol and 1 mg of norethisterone acetate daily and 14 women an oral dose of 2 mg estradiol valerate daily. Fourteen subjects served as controls. The histology and type I and III procollagen immunohistochemistry of the skin, skin thickness, the amount of total collagen determined by a colorimetric method and the synthesis of type I and III collagens determined by analysing procollagen propeptides in the suction blister fluid were studied before the treatment and at 6 and 12 months. The proportional area of elastic fibers and the thickness of the epidermis were assessed from the sections obtained before the treatment and at 12 months, with computerized image analysis.

RESULTS

Skin thickness, the amount and rate of collagen synthesis, the proportional area of elastic fibers and the thickness of the epidermis were not affected by either 17 beta-estradiol and 1 mg of norethisterone acetate or 2 mg of estradiol valerate. No histological or immunohistological changes were detected in the skin specimens during the 12-month treatment period compared to the baseline or to the skin specimens of the control group.

CONCLUSIONS

A 1-year treatment with systemic estrogen alone or combined with progestin does not change the amount of collagen or the rate of collagen synthesis in postmenopausal women.

Effect of topical tretinoin on non-sun-exposed human skin connective tissue: induction of tenascin but no major effect on collagen metabolism

The effects of topical tretinoin on collagen synthesis and degradation were studied in 29 volunteers. The subjects applied 0.1% tretinoin cream on their non-sun-exposed abdominal skin once a day for 1 week (n = 10) (experiment 1) or twice a day for 2 weeks (n = 8) (experiment 2) or once a day for 2 months (n = 11) (experiment 3). After the treatments, suction blisters were induced and amino-terminal propeptides of type I and III procollagens (PINP, PIIINP, respectively) (experiments 1 and 3) and carboxy-terminal propeptide of type I procollagen (PICP) (experiment 2) were assayed as an index of de novo collagen synthesis by radioimmunoassays. Matrix metalloproteases 2 (MMP-2) and 9 (MMP-9) were assayed by the zymography method in experiment 2. In experiment 3, histology, immunohistochemistry of type I and III procollagens, tenascin, mRNA levels of type I collagen alpha 1-chain [alpha 1 (I)], interstitial collagenase (MMP-1), MMP-2, MMP-9 by slot-blot analysis and the levels of alpha 1 (I) collagen mRNA by a quantitative polymerase chain reaction method were studied. The proportional area of elastic fibres visualized in Verhoeff-stained sections was analysed by computerized digital image analysis. The results indicated that treatment with topical tretinoin does not markedly induce de novo synthesis of collagen in vivo or affect matrix metalloproteases. In the immunohistochemical staining, tenascin was increased in the papillary dermis. As it has been suggested that tretinoin could counteract the atrophogenic effect of corticoids on the dermis, the effect of a combination of betamethasone-17-valerate (once a day) and tretinoin (once a day) on the propeptide levels was also studied. Betamethasone alone caused a 60% decrease in the concentrations of PINP and PIIINP, and a similar decrease was found after the combination treatment, indicating that topical tretinoin administered during short treatment periods does not counteract the inhibitory effect of a potent corticoid on collagen propeptides.

P53 accumulation, deoxyribonucleic acid ploidy and progression of bladder cancer

PURPOSE

The alterations in deoxyribonucleic acid (DNA) ploidy and p53 expression during progression of bladder cancer were determined.

MATERIALS AND METHODS

p53 Expression and DNA ploidy were studied in 51 patients with transitional cell carcinoma of the bladder (mean followup 5 years). Of 29 primarily superficial tumors (stages Ta and T1) 17 became subsequently invasive (greater than stage T2) within an average of 4 years (group 2) and 12 recurred superficially with no sign of progression during a mean followup of 10.8 years (group 1). Of the patients 22 had metastatic disease (group 3). Samples of tumors at diagnosis and recurrence or progression were analyzed by immunohistochemistry and flow cytometry.

RESULTS

p53 Accumulation was detected at diagnosis in 29 of the 51 patients (57%), including 3 of 12 (25%) in group 1, 5 of 17 (29%) in group 2 and 14 of 22 (64%) in group 3. The p values for the differences between groups 1 and 3, and 2 and 3 were 0.07 and 0.054, respectively. Abnormal DNA contents were noted in 3 of 12 (25%), 11 of 17 (65%) and 16 of 22 (73%) patients in groups 1 to 3, respectively, and the differences between groups 1 and 2, and 1 and 3 were statistically significant. Using these 2 genetic markers, we found genetic progression to be uncommon in groups 1 and 3, whereas in group 2 an initially negative p53 staining became positive at invasion into the muscle in 5 of 12 patients (42%).

CONCLUSIONS

The tumors in patients with superficial recurrences are mostly diploid and negative for p53, and those with metastasis are nondiploid and positive for p53 from the beginning, while further genetic progression is uncommon. However, p53 tends to accumulate frequently when the tumor begins to invade the muscle. There seems to be a need for caution against under staging an apparent stage T1 tumor that is positive for p53.

A homozygous nonsense mutation and a combination of two mutations of the Wilson disease gene in patients with different lysyl oxidase activities in cultured fibroblasts

Wilson disease is a rare autosomal recessive disease of copper metabolism. The gene for Wilson disease was characterized recently and has been predicted to encode a copper-transporting ATPase highly homologous to the protein encoded by the gene of Menkes disease. In this study, the genetic mutations of two Finnish patients with Wilson disease were investigated. One patient was homozygous for a novel nonsense mutation in exon 4, while the other was a compound heterozygote. Lysyl oxidase (EC 1.4.3.13) is an extracellular copper enzyme with deficient activity in Menkes disease. The levels of lysyl oxidase activity in cultured skin fibroblasts from these Wilson disease patients were also measured.