Position statement: The need for EU legislation to require disclosure and labelling of the composition of medical devices.

BACKGROUND: In recent years, skin reactions secondary to the use of medical devices (MD), such as allergic contact dermatitis have increasingly been observed (e.g. to continuous blood sugar monitoring systems, insulin pumps, wound dressings, medical gloves, etc.): this is regarded as a developing epidemic. Lack of labelling of the composition of MD, as well as frequent lack of cooperation of manufacturers to disclose this relevant information, even when contacted by the clinician for the individual case of an established adverse reaction, significantly impede patient care. OBJECTIVES: To advocate for full ingredient labelling in the implementation of EU regulation for MD. METHODS: This position paper reviews the scientific literature, the current regulatory framework adopted for MD to date, and the likely impact, including some costs data in case of the absence of such labelling. RESULTS: Efforts made by several scientific teams, who are trying to identify the culprit of such adverse effects, either via asking for cooperation from companies, or using costly chemical analyses of MD, can only partly, and with considerable delay, compensate for the absence of meaningful information on the composition of MD; hence, patient management is compromised. Indeed, without knowing the chemical substances present, physicians are unable to inform patients about which substances they should avoid, and which alternative MD may be suitable/tolerated. CONCLUSION: There is an urgent need for full and accurate labelling of the chemical composition of MD in contact with the human body.

The epidemic of methylisothiazolinone contact allergy in Europe: follow-up on changing exposures.

BACKGROUND: Methylisothiazolinone (MI) has caused an unprecedented epidemic of contact allergy in Europe and elsewhere. Subsequently, regulatory action has been taken, at least in Europe, aiming at reducing risk of MI sensitization. OBJECTIVE: To follow-up on the prevalence of contact allergy to MI in consecutively patch tested patients and assess the spectrum of products containing MI or methylchloroisothiazolinone (MCI)/MI in patients positive to MI which elicited current allergic contact dermatitis. METHODS: A cross-sectional survey was performed in 2016 and 2017, including all adult patients patch tested with the baseline series (including MI 0.2% aq.) between 1 May and 31 October at 14 centres in 11 European countries. Patients with positive reactions (+ to +++) to MI were further examined regarding history, clinical characteristics and eliciting products, which were categorized into 34 types and 4 classes (leave-on, rinse-off, household, occupational). The results were compared with the reference year 2015. RESULTS: A total of 317 patients, n = 202 of 4278 tested in 2016 (4.72%) and n = 115 of 3879 tested in 2017 (2.96%), had positive reactions to MI; the previous result from 2015 was 5.97% (P < 0.0001). The share of currently relevant contact allergy among all positive reactions declined significantly as well (P = 0.0032). Concerning product classes, a relative decline of leave-on and a relative increase of rinse-off and household products was noted. CONCLUSION: The prevalence of MI contact allergy decreased by 50% from 2015 to 2017. As a consequence of regulation, the share of cosmetics products (leave-on in particular) eliciting allergic contact dermatitis is decreasing. The chosen method of analysing causative products in sensitized patients has proven useful to monitor effects of intervention.

Factors associated with combined hand and foot eczema.

BACKGROUND: As for hand eczema, the aetiology of foot eczema is multifactorial and not very well understood. The aim of the present study was to identify factors associated with foot eczema in a cohort of hand eczema patients being classified into different subgroups. METHODS: Associations between foot and hand eczema were studied in a cross-sectional design in a cohort of hand eczema patients. Consecutive patients were recruited from nine different European Centres during the period October 2011-September 2012. Data on demographic factors, presence of foot eczema, hand eczema duration and severity, and whether the hand eczema was work-related or not were available, as well as patch-test results. RESULTS: Of a total of 427 hand eczema patients identified, information on foot eczema was available in 419 patients who were included in the present study. A total of 125 patients (29.8%) had concomitant foot and hand eczema. It was found more often in association with hyperkeratotic hand eczema (P = 0.007) and was less often associated with irritant hand eczema (P < 0.001). However, foot eczema was nevertheless found in 18% of patient with irritant hand eczema and in 25% of patients with occupational hand eczema. Combined foot and hand eczema was associated with more severe and long-standing hand eczema (P < 0.001 and P = 0.004, respectively). Contact allergy was found in 51.8% with no difference between patients with combined foot and hand eczema and patients with hand eczema only. CONCLUSION: Occurrence of combined foot and hand eczema is a common finding and not restricted to endogenous hand eczema.

Occupational skin diseases: actual state analysis of patient management pathways in 28 European countries.

BACKGROUND: Work-related skin diseases (WSD) are caused or worsened by a professional activity. Occupational skin diseases (OSD) need to fulfil additional legal criteria which differ from country to country. OSD range amongst the five most frequently notified occupational diseases (musculoskeletal diseases, neurologic diseases, lung diseases, diseases of the sensory organs, skin diseases) in Europe. OBJECTIVE: To retrieve information and compare the current state of national frameworks and pathways to manage patients with occupational skin disease with regard to prevention, diagnosis, treatment and rehabilitation in different European countries. METHODS: A questionnaire-based survey of the current situation regarding OSD patient management pathways was carried out with experts on occupational dermatology and/or occupational medicine from 28 European countries contributing to the European Cooperation in Science and Technology (COST) Action TD 1206 (StanDerm) (www.standerm.eu). RESULTS: Besides a national health service or a statutory health insurance, most European member states implemented a second insurance scheme specifically geared at occupational diseases [insurance against occupational risks (synonyms: insurance against work accidents and occupational injuries; statutory social accident insurance)]. Legal standards for the assessment of occupationally triggered diseases with a genetic background differ between different countries, however, in most European member states recognition as OSD is possible. In one-third of the countries UV light-induced tumours can be recognized as OSD under specific conditions. CONCLUSION: OSD definitions vary between European countries and are not directly comparable, which hampers comparisons between statistics collected in different countries. Awareness of this fact and further efforts for standardization are necessary.

Classification of hand eczema.

BACKGROUND: Classification of hand eczema (HE) is mandatory in epidemiological and clinical studies, and also important in clinical work. OBJECTIVES: The aim was to test a recently proposed classification system of HE in clinical practice in a prospective multicentre study. METHODS: Patients were recruited from nine different tertiary referral centres. All patients underwent examination by specialists in dermatology and were checked using relevant allergy testing. Patients were classified into one of the six diagnostic subgroups of HE: allergic contact dermatitis, irritant contact dermatitis, atopic HE, protein contact dermatitis/contact urticaria, hyperkeratotic endogenous eczema and vesicular endogenous eczema, respectively. An additional diagnosis was given if symptoms indicated that factors additional to the main diagnosis were of importance for the disease. RESULTS: Four hundred and twenty-seven patients were included, 379 (89%) of the patients could be classified directly into one of the six diagnostic subgroups, with irritant and allergic contact dermatitis comprising 249 patients (58%). For 32 (7%) more than one of the six diagnostic subgroups had been formulated as a main diagnosis, and 16 (4%) could not be classified. 38% had one additional diagnosis and 26% had two or more additional diagnoses. Eczema on feet was found in 30% of the patients, statistically significantly more frequently associated with hyperkeratotic and vesicular endogenous eczema. CONCLUSION: We find that the classification system investigated in the present study was useful, being able to give an appropriate main diagnosis for 89% of HE patients, and for another 7% when using two main diagnoses. The fact that more than half of the patients had one or more additional diagnoses illustrates that HE is a multifactorial disease.

The innovative osmotic membrane bioreactor (OMBR) for reuse of wastewater.

An innovative osmotic membrane bioreactor (OMBR) is currently under development for the reclamation of wastewater, which combines activated sludge treatment and forward osmosis (FO) membrane separation with a RO post-treatment. The research focus is FO membrane fouling and performance using different activated sludge investigated both at laboratory scale (membrane area of 112cm2) and at on-site bench scale (flat sheet membrane area of 0.1 m2). FO performance on laboratory-scale (i) increased with temperature due to a decrease in viscosity and (ii) was independent of the type of activated sludge. Draw solution leakage increased with temperature and varied for different activated sludge. FO performance on bench-scale (i) increased with osmotic driving force, (ii) depended on the membrane orientation due to internal concentration polarization and (iii) was invariant to feed flow decrease and air injection at the feed and draw side. Draw solution leakage could not be evaluated on bench-scale due to experimental limitation. Membrane fouling was not found on laboratory scale and bench-scale, however, partially reversible fouling was found on laboratory scale for FO membranes facing the draw solution. Economic assessment indicated a minimum flux of 15L.m-2 h-1 at 0.5M NaCl for OMBR-RO to be cost effective, depending on the FO membrane price.

Long-term follow-up study of occupational hand eczema.

BACKGROUND: Long-term follow-up studies on the prognosis and consequences of occupational hand eczema (OHE) and the prognostic risk factors for persistent OHE are sparse. OBJECTIVES: To determine the medical and occupational outcome after a follow-up of 7-14 years in 605 patients diagnosed with OHE and to identify the prognostic risk factors for the continuation of hand eczema. METHODS: Patients examined at the Finnish Institute of Occupational Health in 1994-2001 completed a follow-up questionnaire 7-14 years after diagnosis. RESULTS: The hand eczema had healed (no eczema during the last year) in 40% of patients with OHE. The duration of hand eczema before diagnosis was strongly associated with the continuation of eczema. Age, sex and diagnosis (allergic or irritant contact dermatitis) were not associated with the prognosis, but skin atopy, and especially respiratory atopy, were correlated with the continuation of hand eczema. Contact allergies in general were not risk factors for persistent OHE, but the presence of a work-related chromate allergy was associated with poor healing. A total of 34% of patients had changed their occupation due to OHE, and their long-term prognosis was better than those who had not. The hand eczema of patients originally in food-related occupations continued on an unfavourable course. CONCLUSIONS: In the logistic model, risk factors for the continuation of OHE were a long duration of hand eczema before diagnosis, respiratory atopy, skin atopy, and continuation in the same occupation. Those who ended up changing occupation due to their OHE had a better medical and economic prognosis.

Metabolism of arachidonic acid and prostanoids in human endometrial stromal cells in monolayer culture.

In the present investigation, we compared the metabolism of arachidonic acid in human endometrial stromal cells maintained in monolayer culture with that in human decidual tissues. By gas-chromatographic analysis, the distribution of arachidonic acid in glycerophospholipids and in the neutral lipids of decidual tissues and stromal cells in culture was similar. After the addition of [14C]arachidonic acid to the culture medium, steady-state conditions with respect to radioactive labeling of the lipids of the cells were attained after 24 h, except for phosphatidylethanolamine and neutral lipids. The percentage distribution of [14C]arachidonic acid in the lipids of the cells in culture was as follows: phosphatidylcholine, 41%; phosphatidylserine, 5%; phosphatidylinositol, 19%; phosphatidylethanolamine, 22%; neutral lipids, 11%. This distribution of arachidonic acid among the lipids is similar to that in decidual tissue, except for that in phosphatidylethanolamine. The amount of radioactivity in phosphatidylethanolamine continued to increase up to 72 h whereas that in neutral lipids declined after a maximum amount was present at 4 h. In the cells in monolayer culture, [14C]prostaglandin E2 and [14C]prostaglandin F2 alpha were produced from [14C]arachidonic acid, as is true in superfused decidual tissue. The similarities in arachidonic acid metabolism in these cells to that in decidual tissue are supportive of the proposition that endometrial stromal cells in monolayer culture are an appropriate model for the study of the regulation of arachidonic acid release and prostaglandin formation by endometrium and decidua vera.

[Prostate biopsy: Procedure in the clinical routine]. / Prostatabiopsie : Durchführung im klinischen Alltag.

Over the last decade there has been a 25% decrease in the mortality rates for prostate cancer. The reasons for this significant decrease are most likely associated with the application of urological screening tests. The main tools for early detection are currently increased public awareness of the disease, prostate-specific antigen (PSA) tests and transrectal ultrasound (TRUS) guided topographically assignable biopsy sampling. Together with the histopathological results these features provide essential information for risk stratification, diagnostics and therapy decisions. The evolution of prostate biopsy techniques as well as the use of PSA testing has led to an increased identification of asymptomatic men, where further clarification is necessary. Significant efforts and increased clinical research focus on determining the appropriate indications for a prostate biopsy and the optimal technique to achieve better detection rates. The most widely used imaging modality for the prostate is TRUS; however, there are no clearly defined standards for the clinical approach for each individual biopsy procedure, dealing with continuous technical optimization and in particular the developments in imaging. In this review the current principles, techniques, new approaches and instrumentation of prostate biopsy imaging control are presented within the framework of the structured educational approach.

Steroidogenesis in dispersed cells of human fetal adrenal.

Steroidogenesis in dispersed fetal zone cells of midtrimester human fetal adrenal was stimulated acutely by ACTH. Polypeptide hormones such as hCG, alpha MSH, ovine PRL, and LH did not produce a similar stimulation of steroidogenesis. The principal steroid products of ACTH-stimulated fetal adrenal cells were dehydroisoandrosterone sulfate, pregnenolone, pregnenolone sulfate, and 17 alpha-hydroxypregnenolone. Only minimal production of the delta 4-3-ketosteroids, cortisol, corticosterone, and progesterone, was observed. Cyanoketone (2 alpha-cyano-4,4,17 alpha-trimethyl-17 beta-hydroxyandrost-5-en-3-one; an inhibitor of 3 beta-hydroxysteroid dehydrogenase activity) treatment of the cells caused only a minor increase in 3 beta-hydroxysteroid formation, confirming that 3 beta-hydroxysteroid formation is the principal steroidogenic fate of cholesterol in these cells. SU-10603 [7-chloro-3,4-dihydro-2-(3-pyridyl)naphthalen-1-(2H)one; a steroid 17 alpha-hydroxylase inhibitor] treatment of the cells caused a marked accumulation of pregnenolone sulfate, indicating that the C-19 steroids are produced from C-21 steroids in this tissue and possibly that dehydroisoandrosterone sulfate is synthesized directly from pregnenolone sulfate. ACTH-stimulated pregnenolone synthesis was inhibited by AY-9944 [trans-1,4-bis-(2-chlorobenzylaminomethyl) cyclohexane dihydrochloride; an inhibitor of cholesterol biosynthesis]. Thus, cholesterol synthesized de novo was the likely steroidogenic precursor in the acute hormonally stimulated fetal adrenal cells.

Sterol sulfate metabolism in the adrenals of the human fetus, anencephalic newborn, and adult.

The sulfurylation of pregnenolone (delta 5P), dehydroepiandrosterone (D) and cholesterol in subcellular fractions of the separated zones of normal human fetal adrenals as well as the mitochondrial sterol desmolase activities are investigated. The values obtained are compared to those found in adrenal tissues of anencephalics and adults. The 3 beta-hydroxysteroid sulfotransferase activity is localized principally in the cytosolic fraction of the tissues assayed. The highest rate of sulfurylation of delta 5P and D is found in the cytosol of the fetal zone (5 nmol min-1 mg protein-1). The corresponding activities in fetal neocortex, anencephalic, and adult adrenocortical tissues are one tenth of that in the fetal zone. Cholesterol sulfurylation is not detectable under similar assay conditions. The specific activities of cholesterol and cholesteryl sulfate desmolases are 3- 4-fold greater in the fetal zone than in the neocortex. Cholesterol desmolase activity, but not cholesteryl sulfate desmolase activity, is found in adrenal tissues of the anencephalic newborn and adult adrenal cortex. It is concluded that the high levels of delta 5P sulfate and D sulfate found in human fetal plasma arise not only as a consequence of the high capacity of the human fetal adrenal fetal zone to sulfurylate the unconjugated compounds, but also as a result of the conversion of cholesteryl sulfate to delta 5P sulfate and thence to D sulfate.

Purification of prostaglandin E2-9-oxoreductase from human decidua vera.

Prostaglandin E2-9- oxoreductase (PGE2-9-OR), the enzyme which converts prostaglandin E2 (PGE2) to prostaglandin F2 alpha (PGF2 alpha), has been detected in human decidua vera. A 105-fold purification was achieved when the centrifuged homogenate was fractionated sequentially by DEAE-Trisacryl, hydroxyapatite-agarose gel, ultrogel AcA 44 and Matrex gel blue A gel chromatographies. The following kinetic constants for PGE2-9-OR have been obtained. The equilibrium constant with respect to PGE2 is 83 microM, the Michaelis constant, Km, for PGE2 is 80 microM, for NADPH 1.6 microM. The maximal velocity for the forward reaction is V1 = .203 pmol/min. The enzyme was inhibited by progesterone, oestradiol-17 beta, cortisol and pharmaceutical drugs. An activating effect could be demonstrated with Ca2+ and oxytocin. The occurrence of PGE2-9-OR in the decidua vera suggests that this enzyme may be responsible for the transformation of PGE2 to PGF2 alpha in these tissues. This may be an important mechanism for the initiation and maintenance of uterine contractions.

Cardio-facio-cutaneous syndrome: three additional cases and review of the literature.

We report on 3 patients with the cardio-facio-cutaneous (CFC) syndrome. Each of them was a sporadic case in the family. The severity of the psychomotor retardation varied from mild to severe. Skin manifestations were often minimal, but each patient had abnormally curly and brittle hair. A skin biopsy from one of the patients showed vellus hair cysts filled with keratin, and the hair follicles were surrounded by unusually thick fibrotic sheaths.

Thrombocytopenia in the HELLP syndrome is not due to platelet-associated IgG (PAIgG).

The presence of membrane-bound and circulating platelet-associated IgG (PAIgG) in nine pregnant women with hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome) was investigated. The reference group consisted of 21 patients with chronic idiopathic thrombocytopenic purpura (ITP). In the majority of patients with ITP, thrombocytopenia results from the binding of PAIgG to the platelet membrane with subsequent platelet destruction. In none of the patients with HELLP syndrome membrane-bound or circulating PAIgG was found. By contrast, membrane-bound and circulating PAIgG was detected in 15 of the 21 cases of chronic ITP (71.4%). These findings suggest that platelet destruction in patients with HELLP syndrome does not result from the binding of PAIgG to the platelet membrane. Therefore, the treatment of thrombocytopenia in this syndrome with immunosuppressants (e.g., corticosteroids), as in chronic ITP, does not seem appropriate.

Vanadate, epidermal growth factor and prostaglandin E2 production in human amnion cells.

We have investigated the effects of vanadate (VAN) and mouse epidermal growth factor (mEGF) on prostaglandin (PG) E2 production in human amnion cells in monolayer culture that served as a model system. The secretion of PGE2 into the culture medium was quantified by radioimmunoassay. The rate of conversion of [14C] arachidonic acid to [14C] PGE2 (PGE2 synthase) was determined in cell sonicates under optimal in vitro conditions. After a treatment period of 4 h we observed an increase in PGE2 production in the presence of mEGF (4.7-fold), VAN (1.8-fold) or both agents (6.8-fold) over control samples. Similarly, the specific activity of PGE2 synthase was stimulated maximally after 4 h with mEGF (2.1-fold), VAN (1.7-fold) or with both (4.8-fold) compared with untreated tissue samples. In the presence of cycloheximide those effects were abolished. We suggest, that VAN and mEGF act by a mechanism(s) that involves de novo protein synthesis or that alters the phosphorylation state of enzymes that are requisite for the conversion of arachidonic acid to PGE2.

The effects of vanadate and epidermal growth factor on the specific activities of phospholipase A2 and phosphatidylinositol-specific phospholipase C in human amnion cells.

We have evaluated the specific activity of phospholipase A2 (PLA2) and phosphatidylinositol-specific phospholipase C (PLC) in human amnion cells in monolayer culture that had not (CTL) or that had been treated with vanadate (VAN) and/or mouse epidermal growth factor (mEGF) for 4 h. It is known that both agents stimulate prostaglandin (PG) E2 synthesis in these cells. Phospholipase enzyme activities were determined in the 750 x g supernatant fraction of amnion cell homogenates under optimal in vitro conditions. The specific activity of PLA2 ranged from 1.1 to 1.25 nmol/mg protein/0.5 h and that of phosphatidylinositol-specific PLC from 1.04 to 1.2 mumol/mg protein/h. Treatment of amnion cell cultures with VAN and/or mEGF had no statistically significant effect on the specific activities of either phospholipases. Thus, we conclude that the stimulation of PGE2 production by VAN and mEGF is not due to an increase in the release of arachidonic acid from glycerophospholipid storage forms in human amnion cells.

The effect of vanadate of arachidonic acid metabolism in human amnion cells.

This investigation was designed to investigate the effects of vanadate on arachidonic acid metabolism in human amnion cell in primary monolayer culture that served as a model system. The secretion of prostaglandin E2 (PGE2) into the culture medium was quantified by radioimmunoassay. The rate of conversion of [14C] arachidonic acid to [14C] PGE2 (PGE2 synthase) was determined in cell sonicates under optimal in vitro conditions. A maximal stimulation of PGE2 production and PGE2 synthase activity was determined with vanadate at a concentration of 32 microM) was effective maximally after 4 h of treatment, i.e., the production of PGE2 was stimulated 2,3-fold, and the specific activity of PGE2 synthase 2,1-fold compared with control incubations, respectively. We suggest that vanadate acts to increase the rate of conversion of arachidonic acid to PGE2 by a mechanism that involves de novo protein synthesis or that alters the phosphorylation state of enzymes that are requisite for the conversion of arachidonic acid to PGE2.

Feasibility of the BIOFIX-process for treatment of municipal wastewater.

The feasibility of the so-called BIOFIX-process to treat municipal wastewater was investigated in a pilot-plant. The innovative element of this process is that carrier material to which a biofilm is attached is recirculated between a sorption reactor to take up COD from the wastewater and a reactor where this COD is used for (post-) denitrification. In between the sorption and denitrification reactor the wastewater passes two subsequent reactors for removal of the remaining COD and for nitrification, respectively. The results showed that COD uptake by the biofilm in the sorption reactor with a maximum of 34% of the influent load was far below expectations and did not meet the COD requirement for denitrification (50-60% uptake). Also, 9-21% of the influent load of ammonia was taken up by the biofilm. In the denitrification reactor this ammonia was released to the bulk and in this manner discharged with the effluent without having passed the nitrification reactor. Nitrification was inhibited by the presence of high concentrations of suspended solids (50-60 mgl-1) discharged from a COD removal reactor. Together these bottle-necks caused effluent concentrations which were well above the effluent demands and it therefore can be concluded that the BIOFIX-process is not a feasible process to treat domestic wastewater.

Cardiovascular protection by postmenopausal estrogen replacement therapy: possible mechanisms of the estrogen action.

Estrogen replacement therapy reduces the cardiovascular risk in postmenopausal women, but the mechanism has yet to be evaluated. There is growing evidence that estradiol administration results in direct vasodilatory effects on vessel walls. The biochemical mechanisms have been investigated in human arteries and veins with respect to different mediators and cell systems. Whereas estradiol had no direct effect on the prostaglandin system we found a endothelin-mediated stimulation of prostacyclin production in endothelial cell cultures. In experiments with the NO/cGMP-system estradiol activity could be demonstrated. In addition estradiol provoked an increase in the intracellular Ca2+ concentration. These results indicate that several mechanisms may be involved in the vasodilating effect of estradiol.

Eicosanoid production in human umbilical cord vessels: effect of 17 beta-estradiol.

This study was designed to investigate the effects of 17 beta-estradiol on prostanoid formation from exogenous arachidonic acid in homogenates of human umbilical cord vessels. The veins produced more prostanoids than the arteries and predominantly 6-keto-PGF1 alpha. 17 beta-estradiol had no effect on the rate of production of prostanoids in either vessels. Thus, at least in our in vitro system, the regulation of the vascular tone by prostanoids seems not to be altered by the addition of 17 beta-estradiol.