Serum cytokine biomarker panels for discriminating pancreatic cancer from benign pancreatic disease.

BACKGROUND: We investigated whether combinations of serum cytokines, used with logistic disease predictor models, could facilitate the detection of pancreatic ductal adenocarcinoma (PDAC). METHODS: The serum levels of 27 cytokines were measured in 241 subjects, 127 with PDAC, 49 with chronic pancreatitis, 20 with benign biliary obstruction and 45 healthy controls. Samples were split randomly into independent training and test sets. Cytokine biomarker panels were selected by identifying the top performing cytokines in best fit logistic regression models during multiple rounds of resampling from the training dataset. Disease prediction by logistic models, built using the resulting cytokine panels, was evaluated with training and test sets and further examined using resampled performance evaluation. RESULTS: For the discrimination of PDAC patients from patients with benign disease, a panel of IP-10, IL-6, PDGF plus CA19-9 offered improved diagnostic performance over CA19-9 alone in the training (AUC 0.838 vs. 0.678) and independent test set (AUC 0.884 vs. 0.798). For the discrimination of PDAC from CP, a panel of IL-8, CA19-9, IL-6 and IP-10 offered improved diagnostic performance over CA19-9 alone with the training (AUC 0.880 vs. 0.758) and test set (AUC 0.912 vs. 0.848). Finally, for the discrimination of PDAC in the presence of jaundice from benign controls with jaundice, a panel of IP-10, IL-8, IL-1b and PDGF demonstrated improvement over CA19-9 in the training (AUC 0.810 vs. 0.614) and test set (AUC 0.857 vs. 0.659). CONCLUSIONS: These findings support the potential role for cytokine panels in the discrimination of PDAC from patients with benign pancreatic diseases and warrant additional study.

Longitudinal, mixed method study to look at the experiences and knowledge of non melanoma skin cancer from diagnosis to one year.

BACKGROUND: Skin cancer is the most common type of cancer in humans and the incidence is increasing worldwide. Our objective was to understanding the needs, experiences and knowledge of individuals with Non Melanoma Skin Cancer (NMSC) from diagnosis up until one year. METHODS: Patients with NMSC completed questionnaires at diagnosis, treatment, 8 weeks post treatment and 12 months post diagnosis. Body image, psychological morbidity and Quality of Life (QOL) were assessed at each time point, with the exception of QOL that was not assessed at diagnosis. Knowledge of NMSC was assessed at baseline and 8 weeks. A sub-sample of participants was also interviewed to allow a more in-depth exploration of patients' experiences. RESULTS: 76 participants completed the initial questionnaire, of which 15 were interviewed. Patients were anxious about a diagnosis of skin cancer, however they were no more depressed or anxious than the general population. QOL significantly improved from diagnosis to 8 weeks and from diagnosis to one year. Knowledge of NMSC was poor and did not improve after treatment. Hairdressers were highlighted as playing an important role in raising awareness and encouraging individuals to seek medical help. Most participants were aware of the need to check their skin for suspicious lesions but were not sure what to look for. At one year participants had forgotten their experience and were not overly concerned about skin cancer. CONCLUSION: There is a need to raise awareness of the signs and symptoms of NMSC. Information on skin cancer needs to be tailored to the individual both at the start of treatment and during the follow up months, ensuring that participants' needs and expectations are met. Targeting education at individuals in the community who regularly come into contact with skin should help in early identification of NMSC. This is important since skin cancer caught early is easily treatable and delay in presentation leads to larger and more complex lesions which impacts in terms of increased morbidity and increased health care costs.

An exploration of student experiences of using biology podcasts in nursing training.

BACKGROUND: Students regard biological science as one of the most difficult components of the nursing curriculum. However, a good understanding of this area is essential for effective nursing practice. The aim of this study was to explore nursing students' perceptions of the usefulness of supplementary biology podcasts for their learning. METHODS: Biological science podcasts (n=9) were made available to first-year nursing students (n=189) as supplementary learning tools. On completion of their first year, students were asked to complete a survey which investigated the frequency of their podcast use, reasons for use and their perception of the usefulness of podcasts as a learning tool. 153 of these students participated in the survey study (80.9%). Two focus groups were conducted with students (n=6) to gain a detailed understanding of student experiences of the usefulness of the podcasts for their learning. RESULTS: Survey data demonstrated that most students (71%) accessed at least one podcast. The majority of students who reported accessing podcasts agreed that they were useful as learning tools (83%), revision aids (83%) and that they helped promote understanding of course materials (72%). Focus group participants discussed how they found podcasts especially useful in terms of revision. Students valued being able to repeatedly access the lecture materials, and appreciated having access to podcasts from a range of lecturers. Focus group members discussed the benefits of live recordings, in terms of valuing the information gleaned from questions asked during the lecture sessions, although there were concerns about the level of background noise in live recordings. Lack of awareness of the availability of podcasts was an issue raised by participants in both the survey component and the focus groups and this negatively impacted on podcast use. CONCLUSIONS: Nursing students found the availability of biology podcasts helpful for their learning. Successful implementation of these tools to support learning requires teaching staff to understand and promote the importance of these tools.

Dietary supplements for established atopic eczema.

BACKGROUND: Many people with atopic eczema are reluctant to use the most commonly recommended treatments because they fear the long-term health effects. As a result, many turn to dietary supplements as a possible treatment approach, often with the belief that some essential ingredient is 'missing' in their diet. Various supplements have been proposed, but it is unclear whether any of these interventions are effective. OBJECTIVES: To evaluate dietary supplements for treating established atopic eczema/dermatitis.Evening primrose oil, borage oil, and probiotics are covered in other Cochrane reviews. SEARCH METHODS: We searched the following databases up to July 2010: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE (from 2005), EMBASE (from 2007), PsycINFO (from 1806), AMED (from 1985), LILACS (from 1982), ISI Web of Science, GREAT (Global Resource of EczemA Trials) database, and reference lists of articles. We searched ongoing trials registers up to April 2011. SELECTION CRITERIA: Randomised controlled trials (RCTs) of dietary supplements for the treatment of those with established atopic eczema/dermatitis. DATA COLLECTION AND ANALYSIS: Two authors independently screened the titles and abstracts, read the full text of the publications, extracted data, and assessed the risk of bias. MAIN RESULTS: We included 11 studies with a total of 596 participants. Two studies assessed fish oil versus olive oil or corn oil placebo. The following were all looked at in single studies: oral zinc sulphate compared to placebo, selenium versus selenium plus vitamin E versus placebo, vitamin D versus placebo, vitamin D versus vitamin E versus vitamins D plus vitamin E together versus placebo, pyridoxine versus placebo, sea buckthorn seed oil versus sea buckthorn pulp oil versus placebo, hempseed oil versus placebo, sunflower oil (linoleic acid) versus fish oil versus placebo, and DHA versus control (saturated fatty acids of the same energy value). Two small studies on fish oil suggest a possible modest benefit, but many outcomes were explored. A convincingly positive result from a much larger study with a publicly-registered protocol is needed before clinical practice can be influenced. AUTHORS' CONCLUSIONS: There is no convincing evidence of the benefit of dietary supplements in eczema, and they cannot be recommended for the public or for clinical practice at present. Whilst some may argue that at least supplements do not do any harm, high doses of vitamin D may give rise to serious medical problems, and the cost of long-term supplements may also mount up.

Blood levels of adiponectin and IL-1Ra distinguish type 3c from type 2 diabetes: Implications for earlier pancreatic cancer detection in new-onset diabetes.

BACKGROUND: Screening for pancreatic ductal adenocarcinoma (PDAC) in populations at high risk is recommended. Individuals with new-onset type 2 diabetes mellitus (NOD) are the largest high-risk group for PDAC. To facilitate screening, we sought biomarkers capable of stratifying NOD subjects into those with type 2 diabetes mellitus (T2DM) and those with the less prevalent PDAC-related diabetes (PDAC-DM), a form of type 3c DM commonly misdiagnosed as T2DM. METHODS: Using mass spectrometry- and immunoassay-based methodologies in a multi-stage analysis of independent sample sets (n=443 samples), blood levels of 264 proteins were considered using Ingenuity Pathway Analysis, literature review and targeted training and validation. FINDINGS: Of 30 candidate biomarkers evaluated in up to four independent patient sets, 12 showed statistically significant differences in levels between PDAC-DM and T2DM. The combination of adiponectin and interleukin-1 receptor antagonist (IL-1Ra) showed strong diagnostic potential, (AUC of 0.91; 95% CI: 0.84-0.99) for the distinction of T3cDM from T2DM. INTERPRETATION: Adiponectin and IL-1Ra warrant further consideration for use in screening for PDAC in individuals newly-diagnosed with T2DM. FUNDING: North West Cancer Research, UK, Cancer Research UK, Pancreatic Cancer Action, UK.

Intracellular accumulation of efavirenz and nevirapine is independent of P-glycoprotein activity in cultured CD4 T cells and primary human lymphocytes.

BACKGROUND: Interaction of antiretrovirals with drug transporters such as P-glycoprotein (P-gp), multidrug resistance-associated protein (MRP), breast cancer resistance protein (BCRP) and solute carrier organic anion transporter (SLCO) may influence the emergence of viral mutants by altering intracellular drug concentrations. Here we characterize the effect of transporter expression in a variety of cell types such as control CEM, CEM(VBL) (P-gp-overexpressing), CEM(E1000) (MRP1-overexpressing), MT4, control MDCKII, MDCKII(MDR1) (P-gp-overexpressing) and peripheral blood mononuclear cells (PBMCs) on the uptake of [(14)C]efavirenz and [(3)H]nevirapine. We also investigated the lipophilicity of [(14)C]efavirenz and [(3)H]nevirapine. METHODS: The expression of P-gp, MRP1, MRP2, SLCO1A2, 1B1, 1B3, 2B1, 3A1 and 4A1 was assessed by PCR. Inhibitors of P-gp (XR9576, GF120918, dipyridamole) and MRP (MK571, frusemide, dipyridamole), and SLCO substrate or inhibitor (estrone-3-sulphate or montelukast, respectively) were used to study the role of drug transporters in the accumulation of [(14)C]efavirenz and [(3)H]nevirapine. Lipophilicity was measured by the octanol/saline partition coefficient. RESULTS: CEM cells, MT4 cells and PBMCs express various SLCO isoforms, with SLCO3A1 detected in all of the cells. XR9576, dipyridamole and GF120918 had no effects on the accumulation of [(14)C]efavirenz, while MK571 and frusemide produced variable effects in the cells. The accumulation of [(14)C]efavirenz was significantly decreased in all the cells by montelukast and estrone-3-sulphate. CONCLUSIONS: P-gp expression had no effect on the accumulation of [(14)C]efavirenz and [(3)H]nevirapine. MRP1/2 expression, lipophilicity and SLCO-like transporters (possibly SLCO3A1) may have greater influence on the accumulation of [(14)C]efavirenz than [(3)H]nevirapine.

Comparing cost-utility estimates: does the choice of EQ-5D or SF-6D matter?

BACKGROUND: A number of different measures can be used within cost-utility analyses, we compared results according to both the EQ-5D and SF-6D. METHODS: A randomized trial was conducted to compare 4 options for people with knee pain. Over the 2 year trial period, the change in cost to health-service was estimated, and both the EQ-5D and SF-6D were used to estimate the change in quality-adjusted life years (QALYs). Using a complete case analysis, the cost-utility (incremental cost-effectiveness ratio [ICER]) of each option, according to both the EQ-5D and SF-6D, was calculated and assessed in relation to the cost-effectiveness threshold of pound20,000 per QALY. RESULTS: Of the 389 participants, 247 had complete cost, EQ-5D and SF-6D data. According to the EQ-5D, option 1 had an estimated ICER of pound10,815 (compared with option 4), option 2 was dominated by option 1, and option 3 was subject to extended dominance. Conversely, according to the SF-6D, option 3 had an ICER of pound9999 (compared with option 4), option 2 had an ICER of pound36,883 (compared with option 3), and option 1 was subject to extended dominance. CONCLUSION: The EQ-5D and SF-6D estimated that different options (1 and 3, respectively) were cost-effective at the pound20,000 per QALY threshold, demonstrating that the choice of measure does matter.

A mechanistic investigation into the irreversible protein binding and antigenicity of p-phenylenediamine.

Exposure to the skin sensitizer p-phenylenediamine (PPD) is associated with allergic contact dermatitis; however, the ability of PPD to modify protein has not been fully investigated. The aims of this study were to characterize the reactions of PPD and the structurally related chemical 2,5-dimethyl-1,4-benzoquinonediamine with model nucleophiles, a synthetic peptide (DS3) containing each of the naturally occurring amino acids and His-tagged glutathione-S-transferase pi (GSTP), and to explore the effect of dimethyl substitution on PPD-specific T-cell responses using lymphocytes from allergic patients. The reductive soft nucleophiles N-acetyl cysteine and glutathione prevented PPD self-conjugation reactions and Bandrowski's base formation, but no adducts were detected. N-Acetyl lysine, a hard nucleophile, did not alter the rate of PPD degradation or form PPD adducts. With PPD and 2,5-dimethyl-1,4-benzoquinonediamine, only cysteine was targeted in the DS3 peptide. PPD and 2,5-dimethyl-1,4-benzoquinonediamine were also found to selectively modify the reactive Cys 47 residue of GSTP, which has a pK(a) of 3.5-4.2 and therefore exists in a largely protonated form. Glutathione formed mixed disulfides with the DS3 peptide, reducing levels of PPD binding. Lymphocytes from PPD allergic patients proliferated in the presence of PPD but not with 2,5-dimethyl-1,4-benzoquinonediamine. These results reveal that PPD and 2,5-dimethyl-1,4-benzoquinonediamine bind selectively to specific cysteine residues in peptides and proteins. Lymphocytes from PPD allergic patients were capable of discriminating between the different haptenic structures, suggesting that the hapten, but not the peptide moiety associated with MHC, is an important determinant for T-cell recognition.

Comparing the performance of the EQ-5D and SF-6D when measuring the benefits of alleviating knee pain.

OBJECTIVE: To assess the practicality, validity and responsiveness of using each of two utility measures (the EQ-5D and SF-6D) to measure the benefits of alleviating knee pain. METHODS: Participants in a randomised controlled trial, which was designed to compare four different interventions for people with self-reported knee pain, were asked to complete the EQ-5D, SF-6D, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at both pre- and post-intervention. For both utility measures, we assessed their practicality (completion rate), construct validity (ability to discriminate between baseline WOMAC severity levels), and responsiveness (ability to discriminate between three groups: those whose total WOMAC score, i) did not improve, ii) improved by <20%, and iii) improved by > or = 20%). RESULTS: The EQ-5D was completed by 97.7% of the 389 participants, compared to 93.3% for the SF-6D. Both the EQ-5D and SF-6D were able to discriminate between participants with different levels of WOMAC severity (p < 0.001). The mean EQ-5D change was -0.036 for group i), 0.091 for group ii), and 0.127 for group iii), compared to 0.021, 0.023 and 0.053 on the SF-6D. These change scores were significantly different according to the EQ-5D (p < 0.001), but not the SF-6D. CONCLUSION: The EQ-5D and SF-6D had largely comparable practicality and construct validity. However, in contrast to the EQ-5D, the SF-6D could not discriminate between those who improved post-intervention, and those who did not. This suggests that it is more appropriate to use the EQ-5D in future cost-effectiveness analyses of interventions which are designed to alleviate knee pain.

Investigation of the immunogenicity of p-phenylenediamine and Bandrowski's base in the mouse.

p-Phenylenediamine (PPD) exposure is associated with T-cell mediated contact dermatitis. T-cells from allergic patients proliferate following exposure to PPD and the oxido-conjugation product Bandrowski's base (BB). Both compounds are classified as sensitizers in the local lymph node assay; however, because of their instability the nature of the antigenic determinant remains ill-defined. The aim of this study was to explore the immunogenic potential of PPD and BB in mice. Spleen cell proliferation and cytokine secretion was measured ex vivo following antigen recall with soluble PPD or BB and either irradiated or glutaraldehyde fixed, antigen pulsed dendritic cells from syngeneic mice. Glutathione was added to certain incubations. LC-MS analysis and solvent extraction were used to monitor the fate of [(14)C]BB in culture and the extent of BB binding, respectively. Spleen cells from BB exposed, but not PPD- or vehicle-exposed, mice proliferated when stimulated with BB. Proliferating cells secreted high levels of IFN-gamma, GM-CSF and IL-2. Stimulation with PPD instigated low levels of proliferation. Irradiated, but not fixed, dendritic cells pulsed with BB stimulated proliferation signifying a classical hapten mechanism involving irreversible BB binding to protein and processing. BB bound preferentially to serum protein when incubated together with cells and serum. Degradation of BB in the presence of glutathione was associated with a stronger stimulation of specific T-cells at higher BB concentrations. These data demonstrate that BB is a potent immunogen in the mouse.

Do estimates of cost-utility based on the EQ-5D differ from those based on the mapping of utility scores?

BACKGROUND: Mapping has been used to convert scores from condition-specific measures into utility scores, and to produce estimates of cost-effectiveness. We sought to compare the QALY gains, and incremental cost per QALY estimates, predicted on the basis of mapping to those based on actual EQ-5D scores. METHODS: In order to compare 4 different interventions 389 individuals were asked to complete both the EQ-5D and the Western Ontartio and McMaster Universities Osteoarthritis Index (WOMAC) at baseline, 6, 12, and 24 months post-intervention. Using baseline data various mapping models were developed, where WOMAC scores were used to predict the EQ-5D scores. The performance of these models was tested by predicting the EQ-5D post-intervention scores. The preferred model (that with the lowest mean absolute error (MAE)) was used to predict the EQ-5D scores, at all time points, for individuals who had complete WOMAC and EQ-5D data. The mean QALY gain associated with each intervention was calculated, using both actual and predicted EQ-5D scores. These QALY gains, along with previously estimated changes in cost, were also used to estimate the actual and predicted incremental cost per QALY associated with each of the four interventions. RESULTS: The EQ-5D and the WOMAC were completed at baseline by 348 individuals, and at all time points by 259 individuals. The MAE in the preferred model was 0.129, and the mean QALY gains for each of the four interventions was predicted to be 0.006, 0.058, 0.058, and 0.136 respectively, compared to the actual mean QALY gains of 0.087, 0.081, 0.120, and 0.149. The most effective intervention was estimated to be associated with an incremental cost per QALY of pound6,068, according to our preferred model, compared to pound13,154 when actual data was used. CONCLUSION: We found that actual QALY gains, and incremental cost per QALY estimates, differed from those predicted on the basis of mapping. This suggests that though mapping may be of value in predicting the cost-effectiveness of interventions which have not been evaluated using a utility measure, future studies should be encouraged to include a method of actual utility measurement. TRIAL REGISTRATION: Current Controlled Trials ISRCTN93206785.

An assessment of the discriminative ability of the EQ-5Dindex, SF-6D, and EQ VAS, using sociodemographic factors and clinical conditions.

OBJECTIVE: To assess whether three health-related quality-of-life (HRQL) measures (the EQ-5Dindex, SF-6D, and EQ VAS) can discriminate between the HRQL of different groups of individuals. METHODS: In one UK general practice a cross-sectional survey requested information on six sociodemographic factors, 10 clinical conditions, and the three HRQL measures. Regression analyses were used to assess whether there was a significant difference in HRQL between groups with different sociodemographic factors and those with and without clinical conditions. RESULTS: One thousand eight hundred and sixty-five questionnaires were returned. There was a significant difference between the HRQL of the majority of different groups according to each HRQL measure. However, not all of the measures could discriminate between groups of different ethnicity, gender, or smoking status, or those with and without asthma, stroke, cancer or diabetes. CONCLUSION: The HRQL of the majority of different groups could be discriminated between by the EQ-5Dindex, SF-6D, and EQ VAS.

Decreased Serum Thrombospondin-1 Levels in Pancreatic Cancer Patients Up to 24 Months Prior to Clinical Diagnosis: Association with Diabetes Mellitus.

PURPOSE: Identification of serum biomarkers enabling earlier diagnosis of pancreatic ductal adenocarcinoma (PDAC) could improve outcome. Serum protein profiles in patients with preclinical disease and at diagnosis were investigated. EXPERIMENTAL DESIGN: Serum from cases up to 4 years prior to PDAC diagnosis and controls (UKCTOCS,n= 174) were studied, alongside samples from patients diagnosed with PDAC, chronic pancreatitis, benign biliary disease, type 2 diabetes mellitus, and healthy subjects (n= 298). Isobaric tags for relative and absolute quantification (iTRAQ) enabled comparisons of pooled serum from a test set (n= 150). Validation was undertaken using multiple reaction monitoring (MRM) and/or Western blotting in all 472 human samples and samples from a KPC mouse model. RESULTS: iTRAQ identified thrombospondin-1 (TSP-1) as reduced preclinically and in diagnosed samples. MRM confirmed significant reduction in levels of TSP-1 up to 24 months prior to diagnosis. A combination of TSP-1 and CA19-9 gave an AUC of 0.86, significantly outperforming both markers alone (0.69 and 0.77, respectively;P< 0.01). TSP-1 was also decreased in PDAC patients compared with healthy controls (P< 0.05) and patients with benign biliary obstruction (P< 0.01). Low levels of TSP-1 correlated with poorer survival, preclinically (P< 0.05) and at clinical diagnosis (P< 0.02). In PDAC patients, reduced TSP-1 levels were more frequently observed in those with confirmed diabetes mellitus (P< 0.01). Significantly lower levels were also observed in PDAC patients with diabetes compared with individuals with type 2 diabetes mellitus (P= 0.01). CONCLUSIONS: Circulating TSP-1 levels decrease up to 24 months prior to diagnosis of PDAC and significantly enhance the diagnostic performance of CA19-9. The influence of diabetes mellitus on biomarker behavior should be considered in future studies.

Biomarkers for early diagnosis of pancreatic cancer.

Pancreatic ductal adenocarcinoma is an aggressive malignancy with a 5-year survival rate of approximately 5%. The lack of established strategies for early detection contributes to this poor prognosis. Although several novel candidate biomarkers have been proposed for earlier diagnosis, none have been adopted into routine clinical use. In this review, the authors examine the challenges associated with finding new pancreatic cancer diagnostic biomarkers and explore why translation of biomarker research for patient benefit has thus far failed. The authors also review recent progress and highlight advances in the understanding of the biology of pancreatic cancer that may lead to improvements in biomarker detection and implementation.

Serum CA19-9 is significantly upregulated up to 2 years before diagnosis with pancreatic cancer: implications for early disease detection.

PURPOSE: Biomarkers for the early detection of pancreatic cancer are urgently needed. The primary objective of this study was to evaluate whether increased levels of serum CA19-9, CA125, CEACAM1, and REG3A are present before clinical presentation of pancreatic cancer and to assess the performance of combined markers for early detection and prognosis. EXPERIMENTAL DESIGN: This nested case-control study within the UKCTOCS included 118 single and 143 serial serum samples from 154 postmenopausal women who were subsequently diagnosed with pancreatic cancer and 304 matched noncancer controls. Samples were split randomly into independent training and test sets. CA19-9, CA125, CEACAM1, and REG3A were measured using ELISA and/or CLIA. Performance of markers to detect cancers at different times before diagnosis and for prognosis was evaluated. RESULTS: At 95% specificity, CA19-9 (>37 U/mL) had a sensitivity of 68% up to 1 year, and 53% up to 2 years before diagnosis. Combining CA19-9 and CA125 improved sensitivity as CA125 was elevated (>30 U/mL) in approximately 20% of CA19-9-negative cases. CEACAM1 and REG3A were late markers adding little in combined models. Average lead times of 20 to 23 months were estimated for test-positive cases. Prediagnostic levels of CA19-9 and CA125 were associated with poor overall survival (HR, 2.69 and 3.15, respectively). CONCLUSIONS: CA19-9 and CA125 have encouraging sensitivity for detecting preclinical pancreatic cancer, and both markers can be used as prognostic tools. This work challenges the prevailing view that CA19-9 is upregulated late in the course of pancreatic cancer development.

Characterization of p-phenylenediamine-albumin binding sites and T-cell responses to hapten-modified protein.

Exposure to p-phenylenediamine (PPD) is associated with the development of T-cell-mediated allergic contact dermatitis. The purpose of this study was to define the nature of the interaction of PPD with the protein and the antigenic determinant that stimulates T cells. Mass spectrometry was employed to show that PPD oxidation products bind irreversibly to cysteine (Cys, position 34) in human serum albumin (HSA). A modified tryptic peptide was characterized with an increase in mass of 106 Da, corresponding to the addition of PPD and not to the secondary products of self conjugation. Lymphocytes from 10 PPD-allergic patients, but not tolerant/naive individuals, were stimulated with PPD and PPD-modified HSA. A total of 70 PPD-specific and 10 PPD-HSA-specific CD4+, CD8+, and CD4+CD8+, Th2-secreting T-cell clones were generated from three allergic patients. In total, 40 clones were stimulated with both PPD and PPD-modified HSA. PPD-modified HSA triggered T-cell responses through a classical hapten mechanism involving processing. Presentation of PPD to several clones was dependent on protein complex formation (42 out of 48) and processing (32 out of 68); however, 12% of clones were triggered with PPD directly. These data identify Cys as the single target for PPD-HSA binding, and show that PPD protein adducts are antigenic determinants in patients with contact dermatitis.

Measurement of CD4+ and CD8+ T-lymphocyte cytokine secretion and gene expression changes in p-phenylenediamine allergic patients and tolerant individuals.

Factors predisposing to individual susceptibility to contact allergic dermatitis are ill defined. This study was designed to characterize the response of allergic and tolerant individuals' T-lymphocytes after exposure to p-phenylenediamine (PPD). Peripheral blood mononuclear cells (PBMCs) from allergic patients proliferated when treated with PPD and Bandrowski's base (BB) and secreted IL-1alpha, -1beta, -4, -5, -6, -8, -10, and -13; IFN-gamma; tumor necrosis factor-alpha; MIP-1alpha/beta; MCP-1 (monocyte chemotactic protein-1); and RANTES. PBMCs from tolerant individuals were stimulated to proliferate only with BB, and they secreted significantly lower levels of Th2 cytokines. Principal component analysis showed that genes are differentially expressed between the patient groups. A network-based analysis of microarray data showed upregulation of T helper type 2 (Th2) gene pathways, including IL-9, in allergic patients, but a regulatory gene profile in tolerant individuals. Real-time PCR confirmed the observed increase in Th2 cytokine gene transcription in allergic patients. Purified CD4+ and CD8+ T cells from allergic patients were stimulated to proliferate and secrete Th2 cytokines following antigen exposure. Only CD4+ T cells from tolerant individuals were stimulated by BB, and levels of Th2 cytokines were 80% lower. The nature of the antigenic determinant stimulating PBMCs and levels of Th2 cytokines, including IL-9, was confirmed in a validation cohort. These studies show increased activity of Th2 cytokines in CD4+ and CD8+ T cells from individuals with allergic contact dermatitis.

Lifestyle interventions for knee pain in overweight and obese adults aged > or = 45: economic evaluation of randomised controlled trial.

OBJECTIVE: To estimate the cost effectiveness of four different lifestyle interventions for knee pain. DESIGN: Cost utility analysis of randomised controlled trial. SETTING: Five general practices in the United Kingdom. PARTICIPANTS: 389 adults aged > or = 45 with self reported knee pain and body mass index (BMI) > or = 28. INTERVENTIONS: Dietary intervention plus quadriceps strengthening exercises, dietary intervention, quadriceps strengthening exercises, and leaflet provision. Participants received home visits over a two year period. MAIN OUTCOME MEASURE: Incremental cost per quality adjusted life year (QALY) gained over two years from a health service perspective. RESULTS: Advice leaflet was associated with a mean change in cost of -31 pounds sterling, and a mean QALY gain of 0.085. Both strengthening exercises and dietary intervention were more effective (0.090 and 0.133 mean QALY gain, respectively) but were not cost effective. Dietary intervention plus strengthening exercises had a mean cost of 647 pounds sterling and a mean QALY gain of 0.147 and was estimated to have an incremental cost of 10,469 pounds sterling per QALY gain (relative to leaflet provision), and a 23.1% probability of being cost effective at a 20,000 pounds sterling/QALY threshold. CONCLUSION: Dietary intervention plus strengthening exercises was estimated to be cost effective for individuals with knee pain, but with a large level of uncertainty. TRIAL REGISTRATION: ISRCTN93206785.

Effects of dietary intervention and quadriceps strengthening exercises on pain and function in overweight people with knee pain: randomised controlled trial.

OBJECTIVE: To determine whether dietary intervention or knee strengthening exercise, or both, can reduce knee pain and improve knee function in overweight and obese adults in the community. DESIGN: Pragmatic factorial randomised controlled trial. SETTING: Five general practices in Nottingham. PARTICIPANTS: 389 men and women aged 45 and over with a body mass index (BMI) of > or = 28.0 and self reported knee pain. INTERVENTIONS: Participants were randomised to dietary intervention plus quadriceps strengthening exercises; dietary intervention alone; quadriceps strengthening exercises alone; advice leaflet only (control group). Dietary intervention consisted of individualised healthy eating advice that would reduce normal intake by 2.5 MJ (600 kcal) a day. Interventions were delivered at home visits over a two year period. MAIN OUTCOME MEASURES: The primary outcome was severity of knee pain scored with the Western Ontario McMaster (WOMAC) osteoarthritis index at 6, 12, and 24 months. Secondary outcomes (all at 24 months) included WOMAC knee physical function and stiffness scores and selected domains on the SF-36 and the hospital anxiety and depression index. RESULTS: 289 (74%) participants completed the trial. There was a significant reduction in knee pain in the knee exercise groups compared with those in the non-exercise groups at 24 months (percentage risk difference 11.61, 95% confidence interval 1.81% to 21.41%). The absolute effect size (0.25) was moderate. The number needed to treat to benefit from a > or = 30% improvement in knee pain at 24 months was 9 (5 to 55). In those randomised to knee exercise improvement in function was evident at 24 months (mean difference -3.64, -6.01 to -1.27). The mean difference in weight loss at 24 months in the dietary intervention group compared with no dietary intervention was 2.95 kg (1.44 to 4.46); for exercise versus no exercise the difference was 0.43 kg (-0.82 to 1.68). This difference in weight loss was not associated with improvement in knee pain or function but was associated with a reduction in depression (absolute effect size 0.19). CONCLUSIONS: A home based, self managed programme of simple knee strengthening exercises over a two year period can significantly reduce knee pain and improve knee function in overweight and obese people with knee pain. A moderate sustained weight loss is achievable with dietary intervention and is associated with reduced depression but is without apparent influence on pain or function. TRIAL REGISTRATION: Current Controlled Trials ISRCTN93206785.

A comparison of the performance of the EQ-5D and SF-6D for individuals aged >or= 45 years.

We sought to compare the performance of the EQ-5D and SF-6D with regard to the criteria of practicality, convergent validity, and construct validity, the level of agreement between the two measures was also assessed. Responses from 1865 individuals aged >or= 45 years in one general practice were analysed. Of these, 93.1% completed the EQ-5D, compared with 86.4% for the SF-6D, where individuals who were older, female, of a lower occupational skill level, from an area of lower deprivation, or used prescribed medication were significantly less likely to complete the SF-6D. The performance of both measures was comparable with regard to both convergent and construct validities, as both the EQ-5D and SF-6D scores were closely related to scores on the EuroQol visual analogue scale (VAS) (p<0.001) and able to discriminate between people who did and did not take: (i) analgesics and (ii) other prescribed medication. Despite EQ-5D and SF-6D scores being highly correlated (p<0.001), individuals who were healthier (according to the VAS) had higher mean scores on the EQ-5D (p<0.001), whereas less healthy individuals had higher mean scores on the SF-6D (individuals with knee pain, osteoarthritis, back pain, rheumatoid arthritis, and hip pain had significantly lower mean scores on the EQ-5D, p<0.001).