Obstacles and solutions to screening psoriasis patients for cardiovascular risk factors.

BACKGROUND: Psoriasis has been linked with cardiovascular risk factors (CVRFs), including the metabolic syndrome, yet many patients with psoriasis remain unscreened. OBJECTIVE: To assess the reasons for lack of screening for CVRFs in psoriasis patients, and the impact of an education programme targeting these deficiencies. METHODS: All patients with psoriasis, regardless of severity, and all dermatologists working at the National Skin Centre (NSC) in Singapore were surveyed over a 2-month period on their attitudes and knowledge regarding psoriasis and cardiovascular risk. This was followed by a targeted programme which was implemented over 2 months to address these identified deficiencies. Patients and doctors were surveyed a second time to assess the effects of the intervention. RESULTS: Obstacles to screening included lack of patient knowledge, patients not considering screening important, and lack of time during the clinic consultation. After the intervention, there was a significant increase in the proportion of patients who were aware of increased cardiovascular risk in psoriasis (33.0% to 62%), with more patients attending screening (39.1% to 63.2%). While the level of doctors' knowledge did not significantly increase, there was an increase in the proportion of patients who were screened post-intervention (37.1% to 66.2%), and more doctors reported that they were more likely to screen psoriatic patients from an earlier age (30.2% to 58.1%). CONCLUSIONS: The obstacles in implementing universal screening for CVRFs in psoriasis patients stem from patient, doctor and system factors. A comprehensive programme targeting all aspects of this ecosystem helps to achieve holistic care for patients with psoriasis.

Human HLA-A0201-restricted cytotoxic T lymphocyte recognition of influenza A is dominated by T cells bearing the V beta 17 gene segment.

The major histocompatibility complex class I-restricted cytotoxic T lymphocyte (CTL) response is important in the clearance of viral infections in humans. After influenza A infection, a peptide from the matrix protein, M58-66, is presented in the context of the MHC allele HLA-A0201 and the resulting CTL response is detectable in most HLA-A0201 subjects. An initial study suggested that M58-66-specific CTL clones show conserved T cell receptor (TCR) alpha and beta gene segments. We have addressed the significance of this observation by determining the expression of V beta 17 during the development of M58-66-specific CTL lines in 21 unrelated HLA-A0201 subjects, and analyzing TCR usage by M58-66-specific CTL clones. TCR V beta 17 was the dominant V beta segment used and CD8 V beta 17 expansion correlated with M58-66-specific lysis. Limiting dilution analysis from five subjects showed the M58-66 CTL precursor frequency to vary between 1/54,000 and less than 1/250,000, and that up to 85% of the matrix peptide (M58-66)-specific CTL used the V beta 17 gene segment. The M58-66 specific CTL response was dependent on previous viral exposure and specific V beta 17 expansion, as it was not found in cord blood, despite a readily expandable V beta 17+ CD8+ T cell subpopulation. Sequence analysis of 38 M58-66-specific V beta 17 transcripts from 13 subjects revealed extensive conservation in the CDR3 region including conservation of an arginine-serine motif. To test the dependence of this CTL response on the V beta 17 gene segment, peripheral blood lymphocytes were depleted of CD8+ TCR V beta 17+ cells, before the generation of M58-66-specific CTL. In most cases such depletion blocked or severely reduced the generation of the M58-66-specific response, and under limiting dilution conditions could abolish M58-66-specific CTL precursors. These studies reveal the dependence of this natural human immune response on a particular TCR gene segment.

Microfluidic assisted synthesis of multi-functional polycaprolactone microcapsules: incorporation of CdTe quantum dots, Fe3O4 superparamagnetic nanoparticles and tamoxifen anticancer drugs.

This paper demonstrates a proof-of-concept approach for encapsulating the anticancer drug tamoxifen, Fe3O4 nanoparticles (NPs) and CdTe quantum dots (QDs) into size-controlled polycaprolactone (PCL) microcapsules utilizing microfluidic emulsification, which combined magnetic targeting, fluorescence imaging and drug controlled release properties into one drug delivery system. Cross-linking the composite PCL microcapsules with poly(vinyl alcohol) (PVA) tailored their size, morphology, optical and magnetic properties and drug release behaviors. The flow conditions of the two immiscible solutions were adjusted in order to successfully generate various sizes of polymer droplets. The result showed superparamagnetic and fluorescent properties, and was used as a controlled drug release vehicle. The composite magnetic and fluorescent PCL microcapsules are potential candidates for a smart drug delivery system.

Barbiturate therapy for patients with refractory intracranial hypertension following severe traumatic brain injury: its effects on tissue oxygenation, brain temperature and autoregulation.

The aim of this study was to explore the effects of barbiturate coma on cerebral tissue oxygen tension and cerebrovascular pressure reactivity (PRx), as an index of cerebral autoregulation in severe head injury patients. This was a prospective observational clinical study of 12 patients with severe traumatic brain injury, carried out at a tertiary-level neurosurgical intensive care unit between April 2002 and May 2005. All patients received standard neurosurgical intensive care and monitoring. Probes for intracranial pressure (ICP), brain temperature (BT) and brain tissue oxygenation (PTiO2) were inserted into (noncontused) normal-looking white matter. Cerebrovascular PRx was measured as a moving correlation between ICP and arterial blood pressure. Barbiturate coma was instituted when ICP became refractory (ICP>20 mmHg). All data from the multimodal monitoring were digitally extracted and statistically analysed. The mean ICP decreased with barbiturate coma in eight of the 12 patients (75% of the patients), but only four achieved a value below 20 mmHg. Of eight patients with prebarbiturate PTiO2 levels above 10 mmHg, six had a further improvement in oxygenation. Thus, concordant favourable changes in ICP, PRx and PTiO2 with barbiturate coma were seen in those who survived. Effective response to barbiturates can be detected by improved PTiO2 and autoregulation (PRx) in severe head injury patients.

DR3 regulates negative selection during thymocyte development.

DR3 (Ws1, Apo3, LARD, TRAMP, TNFSFR12) is a member of the death domain-containing tumor necrosis factor receptor (TNFR) superfamily, members of which mediate a variety of developmental events including the regulation of cell proliferation, differentiation, and apoptosis. We have investigated the in vivo role(s) of DR3 by generating mice congenitally deficient in the expression of the DR3 gene. We show that negative selection and anti-CD3-induced apoptosis are significantly impaired in DR3-null mice. In contrast, both superantigen-induced negative selection and positive selection are normal. The pre-T-cell receptor-mediated checkpoint, which is dependent on TNFR signaling, is also unaffected in DR3-deficient mice. These data reveal a nonredundant in vivo role for this TNF receptor family member in the removal of self-reactive T cells in the thymus.

The measurement of stress-related immune dysfunction in psychoneuroimmunology.

In recent years there has been a dramatic increase in research dedicated to the psycho-behavioural modulation of immune function, i.e. the field of Psychoneuroimmunology (PNI). This has led, necessarily, to the use of several in vitro and in vivo techniques in attempts to delineate the relationship between these two phenomena. However, since the field's inception, considerable uncertainty has existed over the significance of the immune outcomes detected and this has been compounded by the equivocal nature of some of the published data. A great deal of this uncertainty could, however, be overcome if a clearer understanding was achieved on the advantages and limitations conferred by the manifold immune assays described in the literature. This would, in turn, encourage their more appropriate use within PNI. Hence, in this review we describe the rationale behind, and offer an evaluation of, some of the more frequently used in vitro and in vivo immunological and virological techniques. We hope that a clear understanding of the rationale behind such assays and their inherent advantages and limitations will inform the discussion of the significance of stress-related immune impairment.

Consequences of live poliovirus vaccine administration in chronic fatigue syndrome.

The effect of live oral polio virus vaccination on chronic fatigue syndrome (CFS) patients was examined in a double-blind study. CFS patients were allocated randomly to placebo (N = 7) or vaccine (N = 7) conditions. All controls subjects received the vaccine (9). Vaccine administration was not associated with clinical exacerbation of CFS. However, objective responses to the vaccine revealed differences between patients and controls: increased poliovirus isolation, earlier peak proliferative responses, lower T-cell subsets on certain days post vaccination and a trend for reduced gamma-interferon in the CFS-vaccine group. Polio vaccination was not found to be clinically contraindicated in CFS patients, however, there was evidence of altered immune reactivity and virus clearance.

5-Benzylbarbituric acid derivatives, potent and specific inhibitors of uridine phosphorylase.

5-Benzylbarbituric acid derivatives were synthesized as a series of new, specific, and potent inhibitors of uridine phosphorylase. Among these, 5-(m-benzyloxy)benzyl-1-[(2-hydroxyethoxy)methyl] barbituric acid (5-benzyloxybenzylbarbituric acid acyclonucleoside, BBBA) was found to be the most potent with Ki values of 1.1 +/- 0.2 and 2.6 +/- 0.3 nM with uridine phosphorylase from human and mouse livers, respectively. BBBA exhibited competitive inhibition with uridine phosphorylase from both human and mouse livers. The 5-benzylbarbituric acid derivatives are specific inhibitors of uridine phosphorylase, as they had no effect on thymidine phosphorylase (EC 2.4.2.4), thymidine kinase (EC 2.7.1.21), uridine-cytidine kinase (EC 2.7.1.48), orotate phosphoribosyltransferase (EC 2.4.2.10), orotidine 5'-monophosphate decarboxylase (EC 4.1.2.23), and dihydrouracil dehydrogenase (EC 1.3.1.2). These compounds are more potent, easier to synthesize, and have better water solubility than their uracil counterparts as inhibitors of uridine phosphorylase. Furthermore, the 5-benzylbarbituric acids were found to be better inhibitors of human uridine phosphorylase than the murine enzyme, whereas the reverse holds true for the 5-benzyluracil derivatives. The 5-benzylbarbituric acid derivatives have potential usefulness in the therapy of cancer and AIDS, as well as other pathological and physiological disorders.

Cell sorting using immunomagnetic beads.

Immunomagnetic beads are uniform, polymer particles coated with a polystyrene shell that provides both a smooth hydrophobic surface to facilitate physical absorption of molecules, such as antibodies, and surface hydroxyl groups that allow covalent chemical binding of other bioreactive molecules, such as streptavidin, lectins, and peptides. Iron (III) oxide (Fe(2)O(3)) deposited in the core gives the beads superparamagnetic properties that lead to consistent and reproducible reactions to a magnetic field without permanent magnetization of the particles. These are the two qualities on which immunomagnetic separation (IMS) depends.

Cell sorting using immunomagnetic beads.

Immunomagnetic beads are uniform, polymer particles coated with a polystyrene shell that provides both a smooth hydrophobic surface to facilitate physical absorption of molecules, such as antibodies, and surface hydroxyl groups that allow covalent chemical binding of other bioreactive molecules, such as streptavidin, lectins, and peptides. Iron (III) oxide (Fe(2)O(3)) deposited in the core gives the beads superparamagnetic properties that lead to consistent and reproducible reactions to a magnetic field without permanent magnetization of the particles. These are the two qualities on which immunomagnetic separation (IMS) depends.

Applying epidemiology-based outcomes research to clinical decision-making. A hypothetical model of biotechnology therapy in gram-negative sepsis.

OBJECTIVE: Sepsis occurs in a heterogeneous population. A prospective nationwide surveillance study found that populations stratified by infection type had significant differences in the incidence of sepsis syndrome, rate of complications and mortality. The objective of this study was to explore whether successful identification of population-specific risk factors for disease-associated morbidity and mortality may allow for more accurate assessment of the cost effectiveness of treatment strategies. DESIGN: A decision analytic model was developed using outcomes data on incidence and resolution of major complications in sepsis syndrome. Healthcare resource utilisation data were based on length of hospital stay, intensive care unit stay versus hospital ward stay, and cost of treating sepsis-related complications. SETTING: This modelling study, conducted from the perspective of the healthcare institution, used actual outcomes data on 2 infection-specific patient populations. PATIENTS AND PARTICIPANTS: The 2 populations studied were patients with nosocomial respiratory tract infection or community-acquired urinary tract infection who subsequently developed sepsis syndrome. INTERVENTIONS: Treatment options modelled were standard therapy plus biotechnology therapy versus standard therapy alone in the treatment of gram-negative sepsis complications. MAIN OUTCOME MEASURES AND RESULTS: The incremental cost-effectiveness ratios differed between the 2 study populations, due to differences in the incidence and rate of resolution of major sepsis-associated complications. The use of biotechnology therapy is always more cost effective in the respiratory tract infection population. CONCLUSIONS: Cost-effectiveness results for a therapy may change when the epidemiology of the disease state is known and incorporated into the decision analytic model. An infection-specific approach is important in the treatment of sepsis.

Methodology standards associated with quality reporting in clinical studies in pediatric surgery journals.

BACKGROUND/PURPOSE: Reports of clinical trials often lack adequate descriptions of design and analysis; recent attention has focused on improving this omission so readers can properly assess the strength of the findings and draw their own conclusions. Similar analysis of study design and methodologic standards associated with quality reporting has not been carried out for pediatric surgery journals. METHODS: All studies (n = 642) published in 1998 in Journal of Pediatric Surgery (JPS) and Pediatric Surgery International (PSI), were reviewed for demographic data and study design. The frequency of reporting of 11 basic elements of design and analysis was evaluated in randomized clinical trials (RCT), nonrandomized clinical trials (NRCT), and retrospective cohorts (RC) from JPS by consensus of 2 assessors. RESULTS: Of the 642 studies, 17% of articles (111 of 642) were classified as clinical studies. Sixty-three were comparative studies and consisted of RC (n = 48), NRCT (n = 12), and RCT (n = 3). Two-thirds of articles published were either case reports or case series (431 of 642), and 16% were basic science articles. Demographic analysis showed a wide range of topics addressed, 4 authors per article, and multiple country of origin of authors. More than 66% of all RCT in JPS reported on eligibility criteria, admission before allocation, random allocation, method of randomization, patients' blindness to treatment, treatment complications, statistical analyses, statistical methods, loss to follow-up, and statistical methods; 2 elements of design and analysis, however, were poorly reported: blind assessment of outcome (33%) and power (17%). CONCLUSIONS: There were few randomized, controlled trials in pediatric surgery journals, and further attention should be given to evaluate the causal factors. Nine elements of quality reporting were well reported; however, 2 others were poorly reported; this may improve if editors of pediatric surgical journals provide authors with guidelines on how to report clinical trial design and analysis.

Methadone treatment during pregnancy.

OBJECTIVE: To review the literature on methadone use by pregnant women. DATA SOURCES: A search was conducted on CINAHL, MEDLINE, and PSYCHINFO under "pregnancy" and "methadone." STUDY SELECTION: Articles published between 1988-1998 were reviewed and chosen based upon relevance to the objective. DATA EXTRACTION: Data were extracted and organized under the following headings: effects of methadone on pregnancy outcome, management of the pregnant woman on methadone, and implications of social and political policies for pregnant women who use opiates. DATA SYNTHESIS: Methadone treatment is most effective for pregnant women who receive care in a comprehensive service center. Few systematic investigations exist concerning methadone maintenance during pregnancy, thus no formal guidelines for management exist. Changes in federal policies for drug treatment and welfare regulations will challenge health care professionals who provide treatment for opiate-dependent pregnant women. CONCLUSIONS: Treatment with methadone is the standard of care for the opiate-using pregnant woman, despite findings challenging its benefits and efficacy in women who continue to use illicit drugs.

Traumatic posterior fossa extradural haematomas (PFEDH).

OBJECTIVES: While posterior fossa extradural haematomas (PFEDH) may lead to rapid neurological deterioration and death because of brainstem compression, prompt treatment often leads to a good outcome. The non-specific clinical signs and the rarity of this lesion in craniocerebral trauma adds to the difficulty in diagnosis. The aim of this study was to identify features which could lead to an early diagnosis. METHODS: Seventeen patients with posterior fossa extradural haematomas were operated on over 4 1/2 years, accounting for 7.5% of the 226 surgically operated extradural haematomas in the Department of Neurosurgery, Tan Tock Seng Hospital, Singapore. Four patients were excluded from this study due to non-availability of the case records. The remaining 13 patients formed the study group in this retrospective analysis. RESULTS: The majority of cases (77%) presented acutely within 24 hours. The mechanism of injury varied from a fall in 7 cases, a road traffic accident in 4 cases and assault in 2. Nine patients had evidence of external injury to the occiput, 8 patients had skull fractures, and diastasis of the lambdoid suture was seen in 2 cases. Presence of aerocele was noted in the CT scan of 4 cases. All 9 cases admitted with a high GCS score of more than 8 had a very good outcome. CONCLUSION: An early CT scan head is recommended if a combination of the following features is present: occipital soft tissue injury, drowsiness, occipital fracture or diastasis of the lambdoid suture.

CD200 expression suppresses natural killer cell function and directly inhibits patient anti-tumor response in acute myeloid leukemia.

Upregulation of the immunosuppressive cell surface glycoprotein, CD200, is a common feature of acute myeloid leukemia (AML) and is associated with poor patient outcome. We investigated whether CD200 overexpression on AML cells could specifically compromise patient natural killer (NK) cell anti-tumor responses. We found that CD200(hi) patients showed a 50% reduction in the frequency of activated NK cells (CD56(dim)CD16(+)) compared with CD200(lo) patients. Additionally, NK receptor expression (NKp44 and NKp46) on these cells was also significantly downregulated in CD200(hi) patients. To assess whether NK cell activity was directly influenced by CD200 expression, we examined the effect of ectopic expression of CD200. These assays revealed that both NK cell cytolytic activity and interferon-γ response were significantly reduced toward CD200(+) leukemic targets and that these targets showed increased survival compared with CD200(-) cells. Similarly, NK cells isolated from AML patients were less functionally active toward CD200(hi) autologous blasts from both cytolytic and immunoregulatory perspectives. Finally, blocking CD200 alone was sufficient to recover a significant proportion of NK cell cytolytic activity. Together, these findings provide the first evidence that CD200 has a direct and significant suppressive influence on NK cell activity in AML patients and may contribute to the increased relapse rate in CD200(+) patients.

Sustained TL1A expression modulates effector and regulatory T-cell responses and drives intestinal goblet cell hyperplasia.

The tumor necrosis factor (TNF) superfamily protein TNF-like 1A (TL1A) is the ligand for death receptor 3 (DR3). TL1A is induced on activated dendritic cells (DCs) and its expression has been linked to human inflammatory bowel disease. To address how TL1A might influence intestinal inflammation, we generated transgenic mice that constitutively express TL1A on DCs. TL1A transgenic mice developed striking goblet cell hyperplasia in the ileum that was associated with elevated interleukin (IL)-13 levels in the small intestine. IL-13- and IL-17-producing small intestinal lamina propria T cells were increased in TL1A transgenic mice. TL1A also enhanced regulatory T (Treg) cell turnover in vivo and directly stimulated Treg cell proliferation in vitro. The presence of TL1A attenuated the ability of Treg cells to suppress conventional T cells, an effect that required DR3 signaling in either conventional T cells or Treg cells. Our findings identify mechanisms by which chronic DR3 signaling could promote pathogenesis in inflammatory bowel disease.