The effects of diabetes clubs on peer-support, disclosure of diabetes status, and sources of information regarding diabetes management: results of a pilot-intervention in rural Vietnam

OBJECTIVES

To measure the effects of diabetes clubs on peer support, disclosure of diabetes status, and the source of information regarding the management of diabetes among persons living with type-2 diabetes (T2D) in rural Vietnam.

STUDY DESIGN

A pre- and post-pilot intervention study was carried out in Thai Binh Province, Vietnam (n = 222).

RESULTS

Post-intervention, 57.7 % reported using experiences shared by other persons with T2D during the diabetes club sessions. Compared to pre-intervention, there was an increase in the proportion of persons with T2D who disclosed their diabetes status to friends and/or community members (an increase of 15.3 and 13.8 percentage points, respectively). The proportion of persons who reported gathering their own information regarding diabetes management without any support from others decreased from 15.7 % to 6.3 %. Those who reported a relative inside their home or a relative outside their household as their primary source of T2D-relevant information increased from 10.8 % to 18.6 % and from 2.7 % to 9.5 %, respectively. Persons who mentioned that they did not have a need for further support for their diabetes care increased from 18.5 % to 32.0 %. Specific support regarding diabetes-related knowledge received from family members, friends, and/or community members increased from 27.5 % to 62.2 % CONCLUSIONS: These findings suggest a promising potential for the implementation of diabetes clubs to enhance diabetes-relevant knowledge and the quality of self-management among persons living with T2D diabetes in rural areas of Vietnam.

GPs' prescription patterns, experience, and attitudes towards medicinal cannabis-a nationwide survey at the early stage of the Danish test scheme

BACKGROUND

On 1 January 2018 a four-year test scheme concerning use of medicinal cannabis (MC) was enacted. It has recently been extended for four more years by the Danish Parliament permitting all Danish physicians to prescribe MC to their patients. Previous studies have shown that general practitioners (GPs) have varying prescription experience, little knowledge, and mixed attitudes about MC. However, the present evidence is still limited, and no studies exist about Danish GPs' prescription experience, knowledge, and attitudes towards MC. Therefore, our aim was to examine Danish GPs' prescription experience, knowledge, and attitudes towards MC.

METHODS

A national online survey-based study addressing Danish GPs was performed from September 2018 to July 2019. We performed separate multivariable logistic regression analyses including GPs' prescription experience, knowledge, and attitudes towards MC as outcome variables.

RESULTS

A total of 427 (38.4%) of 1112 GPs completed the questionnaire. Of these, 37 (8.7%) had experience in prescribing MC. The majority had little or no knowledge about MC (80.6%) as well as a negative view on prescription of MC (71.4%) to patients. Factors associated with prescribing MC to patients were: Single-handed practices (OR = 1.6, 95% CI 1.1;1.8) and perception of having quite some knowledge about MC (OR = 4.8, 95% CI 2.2;10.4). Factors associated with having quite some knowledge about MC were: having a positive attitude towards prescribing MC (OR = 5.2, 95% CI 1.9;14.0), being male (OR = 1.7, 95% CI 1.4;1.8), and being at least 60 years of age (OR = 2.8, 95% CI 1.3;6.0). Factors associated with having a positive attitude towards prescribing MC were: having quite some knowledge about MC (OR = 5.2, 95% CI 2.2;12.5) and GPs being male (OR = 1.7, 95% CI 1.1;1.9).

CONCLUSION

In this first study on prescription experience, knowledge, and attitudes about MC among Danish GPs, conducted one year after the Danish test scheme was enacted, we find a very low proportion of prescribers, little knowledge, and an overall negative attitude towards MC. Among the prescribing GPs, four in ten have little to no knowledge and a negative attitude towards MC. We stress that prescribing patterns, knowledge, and attitudes may change throughout the remaining time of the test scheme.

Assessing and addressing vulnerability in pregnancy: General practitioners perceived barriers and facilitators - a qualitative interview study

Background

Vulnerability due to low psychosocial resources increases among women in the fertile age. Undetected vulnerability in pregnancy is a major contributor to inequality in maternal and perinatal health and constitutes a risk of maternal depression, adverse birth outcomes,—i.e. preterm birth, low birth weight, and adverse outcomes in childhood such as attachment disorders. General practitioners (GPs) have a broad understanding of indicators of vulnerability in pregnancy. However, less than 25% of pregnant women with severe vulnerability are identified in Danish general practice. The aim was to explore GPs’ perceived barriers and facilitators for assessing and addressing vulnerability among pregnant women.

Methods

A qualitative study with semi-structured focus group interviews with twenty GPs from urban and rural areas throughout the Region of Southern Denmark. A mixed inductive and deductive analytic strategy was applied, structured according to the Theoretical Domains Framework (TDF).

Results

Five themes emerged covering twelve TDF domains: (I)knowledge and attention, (II)professional confidence, (III)incentives, (IV)working conditions and (V)behavioral regulations. Prominent barriers to assessment were lack of continuity of care and trust in the doctor-patient relation. Other barriers were inattention to indicators of vulnerability, time limits, unavailable information on patients’ social support needs from cross-sectoral collaborators, and lack of reimbursement for the use of extra time. Fear of damaging the doctor-patient relation, ethical dilemmas and time limits were barriers to addressing vulnerability. Facilitators were increased attention on vulnerability, professionalism and a strong and trustful doctor-patient relation. Behavioral regulations ensuring continuity of care and extra time for history taking enabled assessing and addressing vulnerability, especially when a strong doctor-patient relation was absent.

Conclusions

The TDF disclosed several barriers, especially in the absence of a strong doctor-patient relation. A behavior change intervention of restructuring the organization of antenatal care in general practice might reduce the GPs’ barriers to assessing and addressing vulnerability in pregnancy. The findings may serve as a guide for commissioners and policymakers of antenatal care on the GPs’ support needs when providing antenatal care to vulnerable pregnant women.

Chronic opioid use before and after exercise therapy and patient education among patients with knee or hip osteoarthritis

OBJECTIVE

To investigate changes in opioid use after supervised exercise therapy and patient education among knee or hip osteoarthritis patients with chronic opioid use.

METHOD

In this cohort study, we linked data from the Good Life with osteoArthritis in Denmark register (GLA:D®; standardised treatment program for osteoarthritis; January 2013 to November 2018) with national health registries. Among 35,549 patients, 1,262 were classified as chronic opioid users based on amount and temporal distribution of dispensed opioids the year before the intervention. We investigated changes in opioid use, measured as mg oral morphine equivalents (OMEQs), from the year before the intervention to the year after using generalized estimating equations.

RESULTS

We found a 10% decrease in mg OMEQs from the year before to the year after the intervention (incidence rate ratio [IRR]: 0.90, 95% confidence interval [CI]: 0.86, 0.94). Additional analyses suggested this decrease to be mainly attributable to regulatory actions targeting opioid prescribing during the study period (IRR among patients participating in the intervention before: 0.98 [95% CI: 0.89, 1.07] vs after: 0.83 [0.74, 0.93] regulatory actions). In a random general population sample of matched chronic opioid users, a similar opioid use pattern was observed over time, further supporting the impact of regulatory actions on the opioid use in the study population.

CONCLUSION

Among patients with knee or hip osteoarthritis and chronic opioid use, a standardised treatment program did not change opioid use when regulatory changes in opioid prescribing were taken into account.

Danish Feasibility Study of a New Innovation for Screening and Brief Intervention for Alcohol Problems in Primary Care: The 15-method

Introduction

The 15-method: a new brief intervention tool for alcohol problems in primary care, has shown promising results in Sweden for mild to moderate alcohol use disorders.

Objectives

To evaluate the 15-method’s usability, organizational integration, and overall implementation feasibility in Danish general practice (GP) in preparation for a large-scale evaluation of the method’s effectiveness in identifying and treating alcohol problems in GP.

Methods

In the Central and Southern Region of Denmark, five general practices participated: seven doctors and eight nurses. Participants received half a day of training in the 15-method. Testing of implementation strategies and overall applicability ran for two months. A focus group interview, two individual interviews with the participating doctors, and five individual patient interviews concluded the study phase.

Results

indicate that implementation of the 15-method is feasible in Danish general practice. The healthcare professionals and patients were optimistic about the method and its possibilities. The method was considered a new patient-centred treatment offer and provided structure to a challenging topic. An interdisciplinary approach was much welcomed. Results indicate that the method is ready for large-scale assessment.

Conclusions

Implementation of the 15-method is considered feasible in Danish general practice, and large-scale evaluation is currently being planned. The results from the present feasibility study, and an overview of the large-scale evaluation, will be presented at the conference.

Disclosure

No significant relationships.

General practitioners' perceived indicators of vulnerability in pregnancy- A qualitative interview study

Objective

To explore general practitioners’ (GPs’) perceived indicators of vulnerability among pregnant women in primary care.

Design

A qualitative study with semi-structured in-depth focus group interviews.

Setting

General practices located in a mixture of urban, semi-urban and rural practices throughout the Region of Southern Denmark

Subjects

Twenty GPs.

Main outcome measures

Through qualitative analysis with systematic text condensation of the interview data, the following themes emerged: (1) obvious indicators of vulnerability—i.e. somatic or psychological illnesses, or complex social problems and 2) intangible indicators of vulnerability – i.e. identification depended on the GPs’ gut-feeling.

From the GPs’ perspective, the concept of vulnerability in pregnancy were perceived as the net result of risk factors and available individual and social resources, with a psychosocial etiology as the dominant framework.

Conclusions

The GPs demonstrated a broad variety of perceived indicators of vulnerability in pregnancy; most importantly, the GPs were aware of a group of pregnant women with intangible vulnerability mainly representing low resilience. Despite not fitting into the GPs' perceived concept of vulnerability, the GPs had a strong gut feeling that these women might be vulnerable. Misjudging the resources of pregnant women due to their physical appearance could delay the GPs’ identification of vulnerability. Future studies should explore the challenges GPs experiences when assessing vulnerability among pregnant women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01439-3.

Development in Danish medical students' empathy: study protocol of a cross-sectional and longitudinal mixed-methods study

BACKGROUND

Clinical empathy has been associated with positive outcomes for both physicians and patients such as: more accurate diagnosis and treatment, increased patient satisfaction and compliance, and lower levels of burnout and stress among physicians. International studies show mixed results regarding the development of empathy among future physicians associating medical education with decline, stability or increase in empathy levels. These mixed results are due to several study limitations. In Denmark, no investigation of Danish medical students' empathy trajectory has yet been conducted wherefore such a study is needed that optimizes the study design of earlier studies.

METHODS

The aim of the study is to examine and analyze empathy levels and empathy changes among Danish medical students from the four medical faculties in Denmark, employing a cross-sectional and longitudinal mixed-methods design including a control group of non-medical students. By supplementing cross-sectional and longitudinal questionnaire studies with a focus group interview study it is the aim to identify and analyze factors (including educational) that are perceived by medical students to influence the development of empathy and its expression in clinical care.

DISCUSSION

The results of the study will provide insight into the trajectory of medical students' empathy and in undergraduate and graduate students' experiences with and perceptions of empathy development. In addition, the study will provide evidence to support further research on how targeted educational programmes can best be designed to educate empathic and patient-centered physicians.

Primary health care: an opportunity for early identification of people living with undiagnosed HIV infection

OBJECTIVES

We aimed to determine the fraction of HIV-diagnosed individuals who had primary health care (PHC) contacts 3 years prior to HIV diagnosis and whether the risk of HIV diagnosis and degree of immunodeficiency were associated with the frequency of visits or procedures performed.

METHODS

We used data from national registries to conduct a population-based nested case-control study. Cases were individuals diagnosed with HIV infection in Denmark from 1998 to 2016. Population controls were extracted from the general population matched 13:1 on gender and age. We used conditional logistic regression. As there was a statistically significant interaction, analyses were further stratified by gender and Danish/non-Danish origin.

RESULTS

We identified 2784 cases and 36 192 controls. Ninety-three per cent of cases and 88% of controls attended PHC at least once in the 3 years prior to diagnosis, with a higher median number of visits to PHC (NVPC) for cases. We found a statistically significant positive association between NVPC and risk of subsequent HIV diagnosis in men and non-Danish women. A U-shaped association between NVPC and risk of HIV diagnosis among Danish women. No substantial association between NVPC and degree of immunodeficiency was found. Risk of HIV diagnosis and degree of immunodeficiency were weakly associated with type of procedures performed.

CONCLUSIONS

For most HIV-infected individuals, there seem to be many opportunities for earlier diagnosis in PHC. In men and non-Danish women, the risk of HIV diagnosis but not the degree of immunodeficiency was related to NVPC. The results suggest that the type of medical procedure performed cannot not be used as a guide by the primary physician to indicate which patients to test.

Reliability and consistency of a validated sun exposure questionnaire in a population-based Danish sample

An important feature of questionnaire validation is reliability. To be able to measure a given concept by questionnaire validly, the reliability needs to be high.

The objectives of this study were to examine reliability of attitude and knowledge and behavioral consistency of sunburn in a developed questionnaire for monitoring and evaluating population sun-related behavior.

Sun related behavior, attitude and knowledge was measured weekly by a questionnaire in the summer of 2013 among 664 Danes. Reliability was tested in a test-retest design. Consistency of behavioral information was tested similarly in a questionnaire adapted to measure behavior throughout the summer.

The response rates for questionnaire 1, 2 and 3 were high and the drop out was not dependent on demographic characteristic. There was at least 73% agreement between sunburns in the measurement week and the entire summer, and a possible sunburn underestimation in questionnaires summarizing the entire summer. The participants underestimated their outdoor exposure in the evaluation covering the entire summer as compared to the measurement week. The reliability of scales measuring attitude and knowledge was high for majority of scales, while consistency in protection behavior was low.

To our knowledge, this is the first study to report reliability for a completely validated questionnaire on sun-related behavior in a national random population based sample. Further, we show that attitude and knowledge questions confirmed their validity with good reliability, while consistency of protection behavior in general and in a week's measurement was low.

•

Objectively validated questionnaires tested for reliability/behavioral consistency.

•

Strong reliability of the knowledge and attitude items was shown.

•

Knowledge about behavioral consistency between questionnaire measurement periods

•

A recommendable design for short term evaluation of skin cancer prevention campaigns

Early-onset type 2 diabetes: Age gradient in clinical and behavioural risk factors in 5115 persons with newly diagnosed type 2 diabetes-Results from the DD2 study

AIM

To examine the association between early onset of type 2 diabetes mellitus (DM) and clinical and behavioural risk factors for later complications of diabetes.

METHODS

We conducted a cross-sectional study of 5115 persons with incident type 2 DM enrolled during 2010-2015 in the Danish Centre for Strategic Research in Type 2 Diabetes-cohort. We compared risk factors at time of diagnosis among those diagnosed at ≤45 years (early onset) with diagnosis age 46 to 55, 56 to 65 (average onset = reference), 66 to 75, and >75 years (late onset). Prevalence ratios (PRs) were computed by using Poisson regression.

RESULTS

Poor glucose control, ie, HbA1c ≥ 75 mmol/mol (≥9.0%) in the early-, average-, and late-onset groups was observed in 12%, 7%, and 1%, respectively (PR 1.70 [95% confidence intervals (CI) 1.27, 2.28] and PR 0.17 [95% CI 0.06, 0.45]). A similar age gradient was observed for severe obesity (body mass index > 40 kg/m² : 19% vs. 8% vs. 2%; PR 2.41 [95% CI 1.83, 3.18] and 0.21 (95% CI 0.08, 0.57]), dyslipidemia (90% vs. 79% vs. 68%; PR 1.14 [95% CI 1.10, 1.19] and 0.86 [95% CI 0.79, 0.93]), and low-grade inflammation (C-reactive protein > 3.0 mg/L: 53% vs. 38% vs. 26%; PR 1.41 [95% CI 1.12, 1.78] and 0.68 [95% CI 0.42, 1.11]). Daily smoking was more frequent and meeting physical activity recommendations less likely in persons with early-onset type 2 DM.

CONCLUSIONS

We found a clear age gradient, with increasing prevalence of clinical and behavioural risk factors the younger the onset age of type 2 DM. Younger persons with early-onset type 2 DM need clinical awareness and support.

One year effectiveness of neuromuscular exercise compared with instruction in analgesic use on knee function in patients with early knee osteoarthritis: the EXERPHARMA randomized trial

OBJECTIVE

To test long-term effectiveness of neuromuscular exercise (NEMEX) with instructions in optimized pharmacological treatment (PHARMA) on activities of daily living (ADL) in patients with early knee osteoarthritis.

DESIGN

12-months follow-up from a randomized controlled trial. Participants with mild-to-moderate medial tibiofemoral knee osteoarthritis were randomly allocated to 8 weeks NEMEX or PHARMA. The primary outcome measure was the ADL-subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS). Secondary outcome measures included the other four KOOS-subscales, the University of California Activity Score (UCLA) and the European Quality of Life-5 Dimensions.

RESULTS

Ninety-three patients (57% women, 58 ± 8 years, body mass index 27 ± 4 kg/m²) were randomized to NEMEX (n = 47) or PHARMA group (n = 46) with data from 85% being available at 12-months follow-up. Good compliance was achieved for 49% of the participants in NEMEX (≥12 sessions) and 7% in PHARMA (half the daily dose of acetaminophen/NSAIDs ≥ 28 days). Within-group improvements in NEMEX were considered to be clinically relevant (≥10 points) for all KOOS-subscales, except Sport/Rec whereas, no between-groups difference in the primary outcome KOOS ADL (3.6 [-2.1 to 9.2]; P = 0.216) was observed. For KOOS Symptoms, a statistically significant difference of 7.6 points (2.6-12.7; P = 0.004) was observed in favor of NEMEX with 47% improving ≥10 points.

CONCLUSIONS

No difference in improvement in difficulty with ADL was observed. NEMEX improved knee symptoms to a greater extent with half of patients reporting clinically relevant improvements. CLINICALTRIALS.

GOV IDENTIFIER

NCT01638962 (July 3, 2012).

ETHICAL COMMITTEE

S-20110153.

The effect of instruction in analgesic use compared with neuromuscular exercise on knee-joint load in patients with knee osteoarthritis: a randomized, single-blind, controlled trial

OBJECTIVE

To investigate the effect of a neuro-muscular exercise (NEMEX) therapy program compared with instructions in optimized analgesics and anti-inflammatory drug use (PHARMA), on measures of knee-joint load in people with mild to moderate knee osteoarthritis (OA). We hypothesized that knee joint loading during walking would be reduced by NEMEX and potentially increased by PHARMA.

DESIGN

Single-blind, randomized controlled trial (RCT) comparing NEMEX therapy twice a week with PHARMA. Participants with mild-to-moderate medial tibiofemoral knee OA were randomly allocated (1:1) to one of two 8-week treatments. Primary outcome was change in knee load during walking (Knee Index, a composite score from all three planes based on 3D movement analysis) after 8 weeks of intervention. Secondary outcomes were frontal plane peak knee adduction moment (KAM), Knee Injury and Osteoarthritis Outcome Scores (KOOS) and functional performance tests.

RESULTS

Ninety three participants (57% women, 58 ± 8 years with a body mass index [BMI] of 27 ± 4 kg/m² (mean ± standard deviation [SD])) were randomized to NEMEX group (n = 47) or PHARMA (n = 46); data from 44 (94%) and 41 (89%) participants respectively, were available at follow-up. 49% of the participants in NEMEX and only 7% in PHARMA demonstrated good compliance. We found no difference in the primary outcome as evaluated by the Knee Index -0.07 [-0.17; 0.04] Nm/%BW HT. Secondary outcomes largely supported this finding.

CONCLUSIONS

We found no difference in the primary outcome; knee joint load change during walking from a NEMEX program vs information on the recommended use of analgesics and anti-inflammatory drugs. ClinicalTrials.gov Identifier: NCT01638962 (July 3, 2012). Ethical Committee: S-20110153.

Faith Moves Mountains-Mountains Move Faith: Two Opposite Epidemiological Forces in Research on Religion and Health

Research suggests opposite epidemiological forces in religion and health: (1). Faith seems to move mountains in the sense that religion is associated with positive health outcomes. (2). Mountains of bad health seem to move faith. We reflected on these forces in a population of 3000 young Danish twins in which all religiosity measures were associated with severe disease. We believe the reason for this novel finding is that the sample presents as a particularly secular population-based study and that the second epidemiological force has gained the upper hand in this sample. We suggest that all cross-sectional research on religion and health should be interpreted in light of such opposite epidemiological forces potentially diluting each other.

The validated sun exposure questionnaire: association of objective and subjective measures of sun exposure in a Danish population-based sample

BACKGROUND

Few questionnaires used in monitoring sun-related behaviour have been tested for validity.

OBJECTIVES

We established the criteria validity of a questionnaire developed for monitoring population sun-related behaviour.

METHODS

During May-August 2013, 664 Danes wore a personal electronic ultraviolet radiation (UVR) dosimeter for 1 week that measured their outdoor time and dose of erythemal UVR exposure. In the following week, they answered a questionnaire on their sun-related behaviour in the measurement week.

RESULTS

Outdoor time measured by dosimetry correlated strongly with both outdoor time and the developed exposure scale measured in the questionnaire. Exposure measured in standard erythema dose (SED) by dosimetry correlated strongly with the exposure scale. In a linear regression model of UVR (SED) received, 41% of the variation was explained by skin type, age, week of participation and exposure scale, with exposure scale as the main contributor. The weekly sunburn fraction correlated strongly with the number of ambient sun hours (r = 0·73, P < 0·001).

CONCLUSIONS

This criteria-validated questionnaire provides evidence of the exposure that the questionnaire aimed to measure. The evidence provided showed a strong link between the objectively measured behaviour and the behaviour measured by this survey construct. The questionnaire is the first validated tool to measure the UVR exposure in a national population-based sample.

A biological modeling based comparison of two strategies for adaptive radiotherapy of urinary bladder cancer

Background Adaptive radiotherapy is introduced in the management of urinary bladder cancer to account for day-to-day anatomical changes. The purpose of this study was to determine whether an adaptive plan selection strategy using either the first four cone beam computed tomography scans (CBCT-based strategy) for plan creation, or the interpolation of bladder volumes on pretreatment CT scans (CT-based strategy), is better in terms of tumor control probability (TCP) and normal tissue sparing while taking the clinically applied fractionation schedules also into account. Material and methods With the CT-based strategy, a library of five plans was created. Patients received 55 Gy to the bladder tumor and 40 Gy to the non-involved bladder and lymph nodes, in 20 fractions. With the CBCT-based strategy, a library of three plans was created, and patients received 70 Gy to the tumor, 60 Gy to the bladder and 48 Gy to the lymph nodes, in 30-35 fractions. Ten patients were analyzed for each adaptive plan selection strategy. TCP was calculated applying the clinically used fractionation schedules, as well as a rescaling of the dose from 55 to 70 Gy for the CT-based strategy. For rectum and bowel, equivalent doses in 2 Gy fractions (EQD2) were calculated. Results The CBCT-based strategy resulted in a median TCP of 75%, compared to 49% for the CT-based strategy, the latter improving to 72% upon rescaling the dose to 70 Gy. A median rectum V30Gy (EQD2) of 26% [interquartile range (IQR): 8-52%] was found for the CT-based strategy, compared to 58% (IQR: 55-73%) for the CBCT-based strategy. Also the bowel doses were lower with the CT-based strategy. Conclusions Whereas the higher total bladder TCP for the CBCT-based strategy is due to prescription differences, the adaptive strategy based on CT scans results in the lowest rectum and bowel cavity doses.

Medical and non-medical predictors of initiating long-term use of proton pump inhibitors: a nationwide cohort study of first-time users during a 10-year period

BACKGROUND

Studies of the increasing use of proton pump inhibitors (PPIs) have mainly focused on prevalent long-term use and associations with gastrointestinal morbidity and comedication. Little is known about non-medical characteristics of first-time users of PPI, and predictors of initiating long-term use of PPIs.

AIMS

To describe medical and non-medical characteristics of first-time PPI users during a 10-year period and to analyse predictors of initiation of long-term use (>60 defined daily doses (DDDs) within 6 months) of PPIs.

METHODS

A nationwide cohort study of first-time users of PPI. Data were collected from Danish national registers. Individuals redeeming their first prescription for a PPI (omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole) in 2001 and 2011 were identified. Redemption of more than 60 DDDs of PPI within 6 months defined long-term use. Logistic regression models were used to determine the associations between previous diagnoses, comedication and socio-economic characteristics and initiation of long-term use of PPIs in 2011.

RESULTS

From 2001 to 2011 incidence of first-time users increased with an incidence rate ratio of 1.53 and mean quantity of PPI redeemed at first prescription increased by 44.6%. In 2011 a total of 37.6% redeemed >60 DDDs within 6 months, and 96% of the long-term users did not have a diagnosis registered which indicated treatment. New onset long-term use was significantly associated with low income and low educational level when adjusting for other predisposing variables.

CONCLUSIONS

Proton pump inhibitor treatment is increasingly initiated with larger quantities prescribed for indications that are unidentifiable from the registers. Morbidity and comedication seem to be the strongest predictors of new onset long-term use of PPIs. However, there is also an independent social gradient.

General practice variation when initiating long-term prescribing of proton pump inhibitors: a nationwide cohort study

Background

Suggestions of overprescribing of proton pump inhibitors (PPIs) for long-term treatment in primary care have been raised. This study aims to analyse associations between general practice characteristics and initiating long-term treatment with PPIs.

Methods

A nationwide register-based cohort study of patients over 18 years redeeming first-time prescription for PPI issued by a general practitioner in Denmark in 2011. Patients redeeming more than 60 defined daily doses (DDDs) of PPI within six months were defined first-time long-term users. Detailed information on diagnoses, concomitant drug use and sociodemography of the cohort was extracted. Practice characteristics such as age and gender of the general practitioner (GP), number of GPs, number of patients per GP, geographical location and training practice status were linked to each PPI user. Logistic regression analysis was used to determine associations between practice characteristics and initiating long-term prescribing of PPIs.

Results

We identified 90 556 first-time users of PPI. A total of 30 963 (34.2 %) met criteria for long-term use at six months follow-up. GPs over 65 years had significantly higher odds of long-term prescribing (OR 1.32, CI 1.16-1.50), when compared to younger GPs (<45 years). Furthermore, female GPs were significantly less likely to prescribe long-term treatment with PPIs (OR 0.87, CI 0.81-0.93) compared to male GPs.

Conclusions

Practice characteristics such as GP age and gender could explain some of the observed variation in prescribing patterns for PPIs. This variation may indicate a potential for enhancing rational prescribing of PPIs.

Socio-economic inequalities in first-time use of antidepressants: a population-based study

OBJECTIVE

To analyse whether first-time use of antidepressants (incidence) and selection of TCAs (tricyclic antidepressants) versus new-generation drugs are associated with socio-economic status and psychiatric history.

METHOD

We conducted a population-based cohort study using registry data covering Funen County, Denmark. A total of 305,953 adult residents without antidepressant prescriptions 5 years prior to the study period (1998) were included.

RESULTS

The 1-year incidence rate of antidepressant prescription (1.7%) increased with age. It was higher in people who were female, less educated, unemployed, those receiving old-age or disability pension, low-income groups, and singles. The proportion prescribed new-generation antidepressants (82%) showed no difference according to socio-economic variables (education, annual income and socio-economic group), but was higher among the young and single. Admission to psychiatric hospital within 4 years prior to the study period was associated with high-incidence rate of antidepressant prescription and overall a preference for the new-generation antidepressants.

CONCLUSION

Socio-economic status did not seem to influence the selection of TCAs versus new-generation antidepressants. Compatible with the general epidemiology of depression, low socio-economic status was associated with a high number of first-time users of antidepressants in the population, and the incidence rate increased with age.

Rainbow trout offspring with different resistance to viral haemorrhagic septicaemia

To study immunological and immunogenetical parameters related to resistance against viral haemorrhagic septicaemia (VHS), attempts to make gynogenetic strains of rainbow trout selected for high and low resistance to VHS were initiated in 1988. The first gynogenetic generation of inbreeding resulted in the more resistant offspring E8 and the low resistance offspring K3; the K3 offspring having the same high mortality as the susceptible reference strain of outbred trout in infection trials. A second gynogenetic generation derived from the E8 strain resulted in some low resistance offspring, and two gynogenetic families in which all, or nearly all, fish survived challenge with VHS virus. In this study, an attempt to associate the distribution of different MHC class II genotypes with low and high resistance gynogenetic offspring was performed. Two different MHC haplotypes could be distinguished, and in both low and high resistance families all three genotypes were found, which could be explained by the fact that the mother fish carried the heterozygous genotype. Although no significant differences in MHC II genotypes were found between the high and low resistance offspring, a significantly different distribution of haplotypes in the low resistance offspring was observed, that could not be explained by a one- or two-locus model.

Incidence and prognostic significance of skin disease in patients with HIV/AIDS: a 5-year observational study

Mucocutaneous diseases are common in HIV-infected patients. The aim of the present study was to determine the observed frequency of skin diseases and their prognostic significance for the progression of HIV infection. In a cohort of 150 HIV-infected patients diagnosed from 1986 to 1987 the number of mucocutaneous diseases, the CD4+ cell count, time to development of AIDS and survival time were registered for a period of 5 years. Eight patients were lost for follow-up. In the remaining 142 patients the number of mucocutaneous findings increased markedly during the observation period. The most frequent registered diseases and these with the highest increase were oral candidiasis, hairy leukoplakia, seborrhoeic dermatitis and herpes simplex. On average, 5.2 different diagnoses were registered per patient at the end of the follow-up period. The study showed that the total number of mucocutaneous diseases and the CD4+ cell count were significantly correlated to survival time and time to development of AIDS. The number of mucocutaneous diseases, like the CD4+ count, is an indicator of the immune system and the prognosis of HIV infection.

A new isolate of the nematophagous fungus Duddingtonia flagrans a biological control agent against free-living larvae of horse strongyles

An experiment was carried out in 1997 to test the efficacy of an isolate of the microfungus Duddingtonia flagrans against free-living stages of horse strongyles under conditions in the field and to assess the eventual effect of the fungus on the normal degradation of faeces. Faecal pats were made from faeces of a naturally strongyle infected horse, which had been fed fungal material at a dose level of 106 fungal unit/kg bwt. Control pats without fungi were made from faeces collected from the same animal just before being fed fungi. Faecal cultures set up for both groups of faeces to monitor the activity of the fungus under laboratory conditions showed that the fungus significantly reduced the number of infective third-stage larvae (L3) by an average of 98.4%. Five faecal pats from each batch of faeces were deposited on pasture plots at 3 times during spring-summer. The herbage around each pat was sampled fortnightly to recover L3 transmitted from faeces. The results showed that the herbage infectivity around fungus-treated pats was reduced by 85.8-99.4%. The remaining faecal material at the end of each sampling period was collected, and the surviving L3 were extracted. Significantly fewer larvae were recovered from the fungus-treated pats. Analysis of wet and dry weight of the collected pats, as well as their organic matter content, were performed to compare the degradation of faeces of both groups. The results indicated that the presence of the fungus did not alter the degradation of the faeces.

[Stab and cut lesions among general practitioners in the county of Funen]

In a questionnaire sent out to general practitioners (GP) in the County of Funen they reported a yearly incidence of lesions penetrating the skin of 1.2 per practitioner. Approximately half of these lesions were potentially infectious. Sixty percent of the lesions were due to accidents involving needles. Only 52% of the GPs with the risk of a potentially infectious lesion tried to prevent infection. We estimate that the risk of becoming infected with HIV or Hepatitis-B infection is very low. It is necessary to get GPs to change procedures in an attempt to minimize the risk.

Keratosis lichenoides chronica

Keratosis lichenoides chronica is a rare dermatosis characterized by a distinctive seborrheic dermatitis-like facial eruption, together with violaceous, papular, and nodular lesions on the extremities and trunk typically arranged in a linear and reticulate pattern. We describe a patient with KLC who had the typical features of this disease and responded partially to treatment with oral isotretinoin.

Oral terbinafine in toenail dermatophytosis. A double-blind, placebo-controlled multicenter study with 12 months' follow-up

The treatment of onychomycosis has previously often been protracted and unsuccessful. Terbinafine has been shown to be effective in short-term regimens. In this double-blind, placebo-controlled study, 148 patients with toenail dermatophytosis were randomized to treatment with either 250 mg terbinafine daily or placebo for 3 months. An additional treatment was given for 3 months to patients whose infection had not responded. The patients were followed clinically and mycologically through 12 months. After 3 months 82% of the terbinafine-treated group, versus 5% of the placebo group, showed significant improvement, i.e. negative culture and growth of unaffected nail more than 2 mm (p = < 0.0001). After 12 months clinical and mycological cure was seen in 40% of the patients treated with terbinafine for 3 or 6 months, while 67-81% were clinically cured, but with positive microscopy. Side-effects occurred in 13.5% of the terbinafine group, versus 5.4% of the placebo group, and were mild. 250 mg terbinafine daily for 3 months was significantly more effective than placebo. The efficacy did not appear to improve with additional treatment for 3 months.

Ethnic and geographic differences and similarities of HIV/AIDS-related mucocutaneous diseases. Danida Study Groups

BACKGROUND

A study on HIV/AIDS-related mucocutaneous manifestations has been carried out in three different ethnic and geographic areas, namely Brazil, Denmark, and Thailand.

METHODS

The Brazil cohort comprised 110 patients, the Danish cohort 150, and the Thai cohort 206 patients. The majority of the Brazil and Thai cohort patients belonged to groups III and IV according to the CDC clinical staging system, whereas the patients in Denmark called their doctors earlier and only 8% were classified in groups III and IV.

RESULTS

In all three areas the number of mucocutaneous diseases correlated well with the progression of the HIV disease. Ethnic differences were not identified, whereas geographic differences related to skin infections were marked. In the Asian cohort a generalized fungal infection was detected with characteristic mucocutaneous symptoms caused by Penicillium marneffei.

CONCLUSIONS

Teaching efforts about mucocutaneous signs as markers of HIV infection may be of value, particularly in developing areas, to allow earlier diagnosis. In future guidelines for classification of HIV/AIDS-related mucocutaneous diseases geographic considerations should be included.

Age-related diurnal changes of dermal oedema: evaluation by high-frequency ultrasound

Using high-frequency ultrasound, we measured the influence of gravitational stress on skin echogenicity in 22 young (age range 17-27; median 19) and 22 elderly (age range 75-100; median 87) healthy adults. B-mode ultrasound images were obtained from the medial malleolus, lateral calf, anterior thigh, volar forearm and the medial aspect of the arm three times daily: in the morning, immediately before rising, and 2 and 12 h later. The echogenicity was measured by counting the number of low echogenic pixels in the image. Pronounced changes of low echogenic pixel numbers were seen in the areas exposed to high gravitational stress, i.e. the ankle and calf. In the young age-group echogenicity of the skin increased steadily during the day, whereas in the elderly population echogenicity decreased 2 h after getting up in the morning, and subsequently returned to the baseline level. In a control group of 10 people (aged 17-83; median 18), who remained in the supine position throughout the day, the echogenicity of the skin remained unchanged. As the echogenicity of the dermis is inversely related to the amount of fluid it contains, our results indicate that young skin responds to gravitational stress by fluid depletion. In the skin of the elderly, the mechanism of fluid removal appears to be defective. The impaired protection against the development of intradermal oedema in the elderly may predispose to the development of lipodermatosclerosis and leg ulceration.

The use of cutaneous microdialysis to measure substance P-induced histamine release in intact human skin in vivo

BACKGROUND

The purpose of this study was to introduce a microdialysis technique, which makes it possible to measure the release of small inflammatory mediators into the extracellular water space in intact human skin in vivo. Using this technique, we have studied the histamine releasing properties of substance P, a putative skin mast cell releasing agent.

METHODS

Small hollow fibers were inserted into the upper dermis of nine healthy subjects. Each fiber was perfused with Kreb's Ringer bicarbonate buffer at a rate of 3.0 microliters/min. After establishment of a baseline, each fiber was challenged intracutaneously with substance P (0 to 4 mumol/L). Samples were collected at 2-minute intervals for 18 minutes. Histamine was measured by a fluorometric method, which correlated with an enzyme immunoassay (r = 0.96).

RESULTS

Baseline dialysate histamine concentration was 1.7 +/- 0.3 ng/ml. Peak histamine release after injection of vehicle, 0.5, 1, 2, and 4 mumol/L substance P was 0.0, 1.0, 6.0, 44.5, and 88.5 ng/ml, respectively (p = 0.00002). Statistically significant histamine release was demonstrated with 1.0 mumol/L substance P and greater. Most peak values were seen 2 to 4 minutes after injection. The histamine elimination showed a monoexponential decline; dialysate histamine half-life was 3.81 +/- 0.28 minutes.

CONCLUSIONS

This study showed that substance P releases histamine in a dose-dependent manner from intact human skin in normal subjects. We suggest that microdialysis may be a promising technique for the evaluation of mediator levels in intact human skin after intradermal injection of an inflammatory or allergenic stimulus.

Efficacy and safety of the 20-epi-vitamin D3 analogue KH 1060 in the topical therapy of psoriasis: results of a dose-ranging study

KH 1060 is a 20-epi-vitamin D3 analogue, structurally related to 1,25-dihydroxyvitamin D3 (1,25(OH)2D3). In vitro, KH 1060 is much more potent than 1,25(OH)2D3 in regulating cell growth and T lymphocyte mediated immune responses, despite a similar calcemic activity in vivo. Therefore, KH 1060 is of potential interest in the treatment of psoriasis and other diseases characterized by accelerated cell growth and T lymphocyte activation. In a multicenter, prospective, randomized, double-blind, vehicle-controlled right/left comparative study, patients with plaque-type psoriasis vulgaris were randomly assigned to one of the following treatment groups: (I) KH 1060 ointment 0.2 microgram/g versus placebo ointment, (II) KH 1060 ointment 0.2 microgram/g versus KH 1060 ointment 0.04 microgram/g, and (III) KH 1060 ointment 0.2 microgram/g versus KH 1060 ointment 1 microgram/g. All treatments were given twice daily for 6 weeks. Sixty-four of the 70 randomized patients completed the study. At the end of treatment, no difference was demonstrated between KH 1060 0.04 microgram/g and vehicle, whereas significantly increasing improvement was found for the doses KH 1060 0.2 microgram/g and KH 1060 1 microgram/g. According to the investigator's overall assessments at the end of treatment, KH 1060 1.0 microgram/g and KH 1060 0.2 microgram/g produced a marked or moderate improvement in most patients. Mild lesional irritation was observed after treatment with KH 1060 as well as with placebo. One patient was withdrawn because of an eczematous reaction, where KH 1060 1.0 microgram/g was applied.(ABSTRACT TRUNCATED AT 250 WORDS)

Impairment of the postural venoarteriolar reflex in aged individuals

The venoarteriolar vasoconstriction reflex plays a major role in the prevention of leg oedema in the upright position in man. We studied the venoarteriolar vasoconstriction reflex with laser Doppler flowmetry in young (21 subjects, age 17-27) and very old (20 subjects, age 75-100) healthy volunteers. In the group of young volunteers, after lowering of the lower extremity 50 cm below the heart level, cutaneous blood flux decreased to 16.6% of the baseline, whereas in the group of old persons the venoarteriolar reflex was impaired and the flux decreased only to 29.2%. The difference between the two groups was statistically significant (p < 0.001). These results may explain the increased prevalence of postural oedema in old people.

Microvascular reactions to postural changes in patients with sickle cell anaemia

Normal microcirculation of the lower extremity is characterized by the venoarteriolar vasoconstriction reflex and the disappearance of vasomotion in the dependent position. Patients with sickle cell disease are prone to develop ischemic leg ulcers at an early age. Dysfunction of the microcirculation might promote the development of leg ulcers in patients with sickle cell disease. Using laser Doppler equipment we have studied the changes of blood flux in the skin overlying the medial malleolus after leg lowering. Contrary to the normal physiological situation seen in our control persons, the venoarteriolar reflex was abolished and vasomotion preserved in the dependent position of the leg in both patients. We conclude that this may represent an adaptation to the dependent position in sickle cell disease.

Skin mechanical properties present adaptation to man's upright position. In vivo studies of young and aged individuals

In tall animals dependent tissues are stiffer to prevent oedema formation in the upright posture, but whether the same adaptation is operating in man is not known. Skin elasticity and distensibility were measured in vivo in 18 young and 15 aged individuals in the morning before getting up (baseline) and 12 h later. In young individuals skin was stiffer (less distensible) and less elastic in the acral parts of the extremities (ankle, forearm). In the evening distensibility and elasticity of the skin increased. In aged individuals skin was less elastic and no diurnal variability in elasticity and distensibility was detected. We propose that these unique mechanical properties of the acral skin reflect a major role of the integument in the protection against the gravitational stress and the development of the postural oedema. Altered skin mechanical properties may contribute to the poor compensation for gravitational stress in elderly.

[A short discharge letter with a copy to the patient--satisfactory for patients and practitioners]

This study evaluated the introduction of a new type of discharge letter (DL). The new DL is hand-written by the discharging doctor on a form, and a copy is both given to the patient and sent immediately to the general practitioner (GP). Questionnaires were sent both to the receiving patients and GPs. One hundred and thirty-four patients (55%) and 157 GPs (87%) replied to the questionnaires. Half of the responding patients stated that the DL had helped them to understand what had happened during their hospital stay, as well as future plans for treatment. A majority of the responding GPs found the hospital stay, the patient's status at discharge and the planned after treatment to be satisfactorily described in the new DLs. Almost all GPs (90%) were pleased with the promptness with which they received the new DL. Compared to the traditional DL, 40% of the responding GPs found the new DL to be better and 29% found it to be worse.

Ultrasound structure and digital image analysis of the subepidermal low echogenic band in aged human skin: diurnal changes and interindividual variability

Subepidermal low-echogenic band is a consistent echostructural finding in aged and photodamaged skin. The thickness of subepidermal low-echogenic band is considered to closely reflect the degree of cutaneous aging and its use for the monitoring of the severity of photoaging and the efficacy of drugs is rapidly expanding. We investigated subepidermal low-echogenic band structure in 23 old healthy volunteers (ages 75-100) with a high-frequency ultrasound scanner (B-mode, 20 MHz). Images were collected from the volar fore-arm twice daily: in the morning before getting up and 12 h later. To assess the severity of subepidermal low-echogenic band, echogenicity of the subepidermal region was determined by the image analysis and compared with visual scoring and subepidermal low-echogenic band thickness. All three methods gave consistent results, image analysis being the most sensitive, reliable, and bias-free. Significant interindividual variability of subepidermal low-echogenic band echostructure was revealed. Moreover, circadian variability of subepidermal low-echogenic band echogenicity was observed. These major interindividual and diurnal variations of subepidermal low-echogenic band suggest that this band does not only represent an irreversible structural change but also a redistribution of fluid in the aged dermis. Diurnal variations in the subepidermal low-echogenic band would limit the use of this parameter in studies of skin aging, photoaging, and efficiency of medication.

Polymorphonuclear neutrophil granulocyte chemotactic hyperresponsiveness in a case of canine acromegaly

Growth hormone (GH) has recently been shown to affect polymorphonuclear neutrophil granulocyte (PMN) function and to be secreted by mononuclear cells, indicating that the hormone may be active in an immunophysiologic network, acting as an endo- or paracrine priming agent. The purpose of the present study was to evaluate the chemotactic responsiveness of canine peripheral PMN in a dog with acromegaly, caused by spontaneous, progesterone-induced hypersecretion of GH and, secondary to this, a seven-fold increase in insulin-like growth factor I (IGF-I). The chemotactic responsiveness towards zymosan-activated serum (ZAS) and leukotriene B4 (LTB4) was evaluated at a time when the dog suffered from acromegaly and again 57 days after corrective surgery (ovariohysterectomy). The experiments showed that PMN from the patient exhibited enhanced chemotactic migration that appeared to be associated with the hypersomatotropic condition as judged from the reversibility of the phenomenon. The glucose intolerance and elevated serum alkaline phosphatase that were observed in the acromegalic dog were also shown to be reversible following surgery.

[Syphilis meets AIDS. Syphilis seen in relation to the AIDS epidemic--a review]

The incidence of syphilis in Denmark has changed within the last ten years. From being a relatively common disease at the end of the 1970's and beginning of the 1980's, the incidence has fallen considerably. It is assumed that the change is connected with the emergence of AIDS and the resulting increase in information and attention to sexually transmitted diseases. In the USA, after a fall in the beginning of the 1980's, the incidence of syphilis has risen markedly, particularly among heterosexual coloured people in large cities. Recently, there have been some reports claiming atypical syphilis in patients with HIV-infection. To date there are no controlled investigations to corroborate this notion. Seronegative syphilis or delayed seropositivity has been reported in certain immunosuppressed AIDS patients. Otherwise the syphilis serology of HIV-infected patients does not seem to differ essentially from HIV-negative patients. All patients with HIV infection should be counselled about syphilis and offered a test for syphilis, just as patients with syphilis should be encouraged to be tested for HIV antibody after informed consent.

[Contact tracing in HIV infection]

The results of contact tracing in two male and one female HIV antibody positive index cases are described. Altogether 19 sexual partners were reported, of whom 13 were traced. In one case previously unknown HIV infection was diagnosed. Contact tracing for HIV infection in Denmark depends solely upon the cooperation of the index case and upon the willingness of notified partners to appear for counselling and testing. The efficacy of partner notification for HIV infection in Denmark based on the current strategy should be further evaluated.

Histamine release in immediate-type hypersensitivity reactions in intact human skin measured by microdialysis. A preliminary study

The purpose of this study was to evaluate the application of a microdialysis technique for measurement of interstitial histamine levels in intact human skin. Three allergic subjects were investigated. Single dialysis fibers were glued to nylon tubings and inserted in forearm skin by means of a fine cannula. Dialysis fibers were inserted in triplicate and perfused with isotonic saline at a rate of 3 microliters/min. After a period of 2 h a 60-microliters base-line period was established. Then the patients were skin prick tested (SPT) with allergen in duplicate and a single saline control. Dialysate was collected in consecutive 30 microliters fractions. Histamine concentration in the dialysate was analyzed with a glass fiber fluorescence assay. Median base-line histamine level was 4 (range 4-7) ng/ml. Following allergen SPT, dialysate histamine concentration increased to 81 ng/ml (74-128), with maximum values 10-20 min after SPT. Intraindividual coefficient of variation on peak histamine levels was 18.9%. No histamine increase was seen following saline SPT. We consider microdialysis to be a valuable method for assessment of allergic mechanisms in intact human skin.

Ceftriaxone/metronidazole is more effective than ampicillin/netilmicin/metronidazole in the treatment of bacterial peritonitis

In a prospective, open, controlled clinical study, 190 consecutive patients who were thought to have bacterial peritonitis before operation, were randomised to antibiotic treatment during and after operation with either ceftriaxone 1 g plus metronidazole 1.5 g once daily (n = 94) or ampicillin 2 g plus netilmicin 150 mg twice daily plus metronidazole 1.5 g once daily (n = 96). Incisional and deep surgical wound infections, postoperative pneumonia and urinary tract infection as well as deaths caused by infection were recorded. Ceftriaxone-metronidazole was significantly more effective than ampicillin-netilmicin-metronidazole, 6/94 wound related infections (6%) compared to 18/96 (19%) (p = 0.02). In patients with peritonitis caused by a perforated colon or appendix the rates of clinical failure were 6% and 28%, respectively. We consider ceftriaxone plus metronidazole an efficient and easily administered antibiotic regimen in patients with bacterial peritonitis, and both the wide range of activity against Gram-negative aerobic rods and the long half life of ceftriaxone seem to be beneficial.

Leukotriene B4 in atopic dermatitis: increased skin levels and altered sensitivity of peripheral blood T-cells

Employing a radioimmunoassay, de-proteinated suction blister fluid from 12 patients with active atopic dermatitis appeared to contain higher levels of the pro-inflammatory and immunomodulatory mediator leukotriene B4 (LTB4) than suction blister fluid from 12 non-atopic individuals. Indirect support for the identity of the mediator was obtained by HPLC of pooled samples. Nylon wool enriched T cells from six patients with atopic dermatitis and six non-atopic people preincubated with LTB4 (10(-10) M - 10(-8) M) expressed no statistically significant suppression in co-culture with mitogen stimulated autologous mononuclear cells, and there was no difference between atopic and non-atopic T cells in this respect. In contrast, LTB4 induced a dose-dependent reduction in the percentage of phenotypic Leu 2a (suppressor) cells leading to an increased helper/suppressor ratio in five atopic patients that was not observed in five non-atopics. Elevated skin levels of LTB4 may initiate or amplify dermal inflammation, and abnormal T cell response to the mediator may account for the increased helper/suppressor ratio characteristic of patients with atopic dermatitis.

Reduced neutrophil production of leukotriene B4 associated with AIDS

Neutrophils from 10 homosexual men with evidence of HIV infection and 10 healthy controls were tested for their capacity to generate leukotriene B4. Neutrophils from patients with AIDS produced less leukotriene immunoreactivity when appropriately stimulated than neutrophils from healthy controls, whereas no significant difference could be detected between HIV-antibody-positive individuals without AIDS and healthy controls. This observation may be pertinent to the recurrence of some of the opportunistic infections associated with AIDS but more importantly, if reflecting a general defect in leukotriene production, it may provide further understanding of the mechanism which leads to reduced natural killer-cell activity, interleukin-2 and interferon-gamma production in AIDS.

AIDS related changes in pattern of sexually transmitted disease (STD) in an STD clinic in Copenhagen

Testing for antibodies against human immunodeficiency virus (HIV) was introduced in 1984 in this major sexually transmitted disease (STD) clinic in Copenhagen, which is attended by about 10,000 new patients each year. From 1984 to 1987 the proportion of patients examined for antibodies to HIV rose from 6% to 32%. The overall incidence of HIV antibody positivity decreased from 30% in 1984 to 3% in 1987, the combined result of decreased positivity in high risk patients tested and increased screening in low risk patients. HIV antibody positivity has been confined largely to homosexual men and drug addicts. Since 1985, however, 21 out of 2623 (0.8%) heterosexuals who were not drug addicts were found to be HIV antibody positive. During 1984-6 the incidence of STDs most often encountered in high risk groups (syphilis and gonorrhoea) decreased by 64% and 41% respectively, whereas the incidence of diseases most often diagnosed in low risk groups (condylomata acuminata and genital herpes) increased by 70% and 34% respectively in the same period. The addition of HIV infection to the list of STDs requires the allocation of more resources to the STD clinics to enable these clinics to handle this new problem. Screening for all patients attending an STD clinic for antibodies to HIV must be considered, and in our area it would be cost effective.

Lactoferrin, myeloperoxidase, lysozyme and eosinophil cationic protein in exudate in delayed type hypersensitivity

A skin window technique was used to study the morphology of leucocytes in upper dermis and exudate during nickel challenge in patients with contact allergy to nickel. Contact allergic patients and healthy volunteers tested with a skin widow without addition of nickel to the chamber medium served as controls. The morphology of the leucocytes in dermis was studied in biopsies taken 8, 24, or 48 h after skin window application, and in a parallel test the morphology of the exudate was examined by sequential collection of the chamber medium during a 48 h period. The infiltrate in dermis of contact allergic patients with nickel challenge in the chamber medium showed a time-dependent increase of mononuclear cells, eosinophils and basophils and a concomitant decrease of polymorphonuclear granulocytes, characteristic of a combined specific and unspecific inflammation. The morphology of the exudate in contact allergic patients exposed to nickel showed a dominance of polymorphonuclear granulocytes throughout the study period, while mononuclear cells, eosinophils and basophils were detected at a much lower quantity and with a considerable delay. Further, we studied the kinetics of the leucocyte granule proteins: lactoferrin, myeloperoxidase, lysozyme and eosinophil cationic protein in exudate fluid in a parallel test. A significant higher flux was found for all during the second day of allergen exposure compared to contact allergic patients without allergen challenge as well as normal volunteers. The increased protein fluxes were not accompanied by an increased flux of polymorphonuclear granulocytes in the exudate.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemotactic activity of LTB4 in man

An improved skin window chamber technique has been developed and used for a quantitative study of the chemotactic effect of leukotriene B4 (LTB4). LTB4 (0.5 microM) was exposed to a skin window on the forearm of eight healthy volunteers, while phosphate buffered saline served as control in a skin window on the other forearm. Skin window exudates and samples of blood draining the skin window areas were collected after 1, 2, 4, 8, and 24 h. The samples were quantitated for the different types of leukocytes as well as the intra- and extracellular concentration of the eosinophilic cationic protein and lactoferrin as markers of eosinophil and neutrophil granulocytes. A significantly increased migration of neutrophil granulocytes into the skin window chamber containing LTB4 was found from the 2nd to the 8th hour after the initial LTB4 exposure. The eosinophils reached a significant peak at the 4th hour. The rise in the actual number of eosinophil cells did not reach significance, whereas measurements of the eosinophilic cationic protein in the cellular fraction of the exudate exhibited a significant increase as a reflection of the number of eosinophils. This highlights the potential clinical value of eosinophilic cationic protein measurements to reveal eosinophilia instead of the traditional eosinophil counts. Extracellular eosinophilic cationic protein and lactoferrin did not change significantly in the LTB4-exposed skin window, implying that LTB4 does not activate the eosinophils and neutrophils to exocytosis of their enzymes. The present in vivo results support the concept of LTB4 being a potent chemoattractant to neutrophil and less so to eosinophil granulocytes in humans, a chemoattractant that recruits the leukocytes but does not seem to activate them.

Eicosanoids in skin UV inflammation

Several studies have implicated the eicosanoids as mediator substances in different types of UV inflammation. In human UV erythema, various arachidonic acid metabolites--mainly cyclooxygenase products--have been detected, particularly in skin exudates. The concentration and the sequence of release of the various eicosanoids vary in relation to the time course and the various types of UV-induced erythema. UVB, UVC but not UVA erythema at its maximum was only to some extent inhibited by indomethacin despite almost complete inhibition of the synthesis of prostaglandins E2 and F2 alpha. A major issue cannot, as yet, be answered satisfactorily: are one or a number of eicosanoids per se causing the erythema or are they only passive bystanders released by damage to cellular structures? Until further evidence has been provided, the causative role of E and F prostaglandins in relation to development of UV erythema is doubtful. By contrast, PGI2 is a more likely candidate in this respect, being synthesized and released close to the events occurring in the vessel walls. The lipoxygenase pathway is still too unexplored for proper evaluation with regard to a role in the pathogenesis, but the pharmacological properties of leukotrienes and hydroxy-fatty acids may qualify them as potential candidates alone or in a concert of mediator events occurring during the developments of UV inflammation.

Refractory condylomata acuminata: a controlled clinical trial of carbon dioxide laser versus conventional surgical treatment

Uncontrolled trials indicate that treatment of condylomata acuminata with the carbon dioxide laser is effective and probably superior to conventional surgical treatment. We performed a controlled study of refractory condylomata acuminata to clarify whether this is the case. In this randomised trial 21 patients were treated with the carbon dioxide laser and 22 by conventional surgery after having been treated with podophyllin for an average of 33 and 35 weeks respectively. Five and seven patients respectively had previously required additional treatment, such as an operation. The treatment schedule was equally effective for both groups of patients. No difference between the two groups was seen in numbers of recurrences, postoperative pain, healing time, and rate of scar formation (p greater than 0.1-0.2). Treatment of recalcitrant condylomata acuminata with the carbon dioxide laser did not offer any advantages over traditional surgery, including electrocautery.