The healthcare system and the provision of oral healthcare in European Union member states. Part 7: Republic of Ireland

The Irish oral healthcare system is a hybrid model with a public/private mix of service provision, predominantly organised on the basis of fee-per-item remuneration. The system is structured around three long standing publicly funded schemes: the Public Dental Service (PDS) for all children and adults with special needs and provided by salaried dentists, the Dental Treatment Services Scheme (DTSS) for low income adults, and the Dental Treatment Benefit Scheme (DTBS) for insured persons, the latter two both provided by private independent dental practitioners. Ireland introduced systemic water fluoridation in 1963 and currently 73% of the population has access to fluoridated water. Ireland currently has a dentist density ratio of 6.1 dentists per 10,000 inhabitants and on average, 43% of the population (30% for those aged 70+ years) visit a dentist annually. In 2014, 83% of expenditure on oral healthcare was from out-of-pocket payments by patients, with less than 1% of overall government expenditure on healthcare allotted to oral healthcare. After the economic downturn of 2008 and the severe recession that followed in Ireland, substantial cutbacks in government expenditure resulted in extensive cuts to the public sector supply of dental services and to the extent of cover provided by the publicly funded schemes. The Department of Health has recognised the major post recessionary challenges facing the Irish health system, not least, significantly reduced budgets and capacity deficits, and acknowledges the need for change in Ireland's health service. In 2014, a three-year project commenced at the Department of Health, to develop a new national oral health policy for Ireland.

Targeted temperature management in cardiovascular disease complicated by cardiac arrest

PURPOSE

The majority of cardiac arrests occur due to cardiovascular etiology. Targeted temperature management (TTM) (32-34 °C) is a part of the standard post arrest care. We hypothesized that lower body temperature may lead to reduced cardiac metabolic demand and potentially have a beneficial effect on myocardial function.

METHODS

We performed a retrospective study on patients admitted to the intensive care unit following cardiac arrest secondary to cardiovascular etiology over a 9 year period. We assessed the impact of TTM on neurological and cardiac outcomes.

RESULTS

There were 57 patients in the cohort; 21 patients in the TTM group and 36 in the non-TTM group. Demographic characteristics were similar in both groups-the majority of patients (86 vs 80 %, respectively) were males in their 60s. Neurological outcomes were similar; 24 % of patients died during the ICU admission in the TTM group vs 18 % in the non-TTM group. Mean GCS on admission to the ICU was 4 vs 7, respectively, and 11 at discharge in both groups. Majority of patients recovered good neurological function (GCS ≥ 13)-57 % in the TTM group vs 64 % in the non-TTM group. The change in left ventricular function over a 6 month follow up period was significantly better in patients who received targeted temperature management-mean change of +4.4 vs -3.3 %, respectively. This proved to be statistically significant (p = 0.02).

CONCLUSIONS

The study demonstrates a possible beneficial effect of TTM on long-term cardiac function, when instituted following cardiac arrest.

Attitudes of Irish dental graduates to vocational training

INTRODUCTION

Vocational training (VT) is a mandatory 12 month period for UK dental graduates after graduation. Graduates of Irish Dental Schools are eligible to enter the general dental service in Ireland or obtain an NHS performers list number in the UK immediately after qualification. Reports would suggest that some graduates of Irish Dental Schools are choosing to take part in VT in the UK and find the experience beneficial. This study aimed to record the uptake of VT amongst recent graduates from University College Cork and to document their experiences. It was designed to compare the attitudes and experiences of graduates of Irish Dental Schools who undertook VT compared with those who entered the general dental service.

METHOD

A self-completion questionnaire was distributed by e-mail to dental graduates from University College Cork who had graduated 2001-2007. Responses were returned by e-mail or post.

RESULTS

The response rate was 68.9%. There has been an increase in the numbers of graduates taking part in VT each year since 2004. 92.5% of Vocational Dental Practitioners (VDPs) found their experience beneficial as they received a guaranteed source of income, had a supportive peer network and worked in a positive learning environment. However, some felt that they earned a lower income than their associate colleagues, others found the pace of practice slow and that the duration of the training period was excessive. Eighty-five per cent of VDPs would choose the same position again after graduation as compared with 61.8% of associates (P < 0.001). Ninety per cent of VDPs would advise current undergraduates to take part in VT as compared with 51% of associates (P < 0.001). A larger proportion of VDPs had taken part in postgraduate studies but there was no significant difference between the two groups.

CONCLUSIONS

Larger proportions of recent graduates are undertaking vocational training.--The majority of VDPs and associates find their initial employment position beneficial.--VDPs benefit from a guaranteed source of income, a supportive peer network and a positive learning environment.--Some associates suffered from a lack of support, feeling isolated and overwhelmed with patients.--The majority of previous VDPs and associates would recommend VT to current undergraduates.--Almost 40% of associates would now choose to take part in VT if given the opportunity.

Thrombostatin FM compounds: direct thrombin inhibitors - mechanism of action in vitro and in vivo

BACKGROUND

Novel pentapeptides called Thrombostatin FM compounds consisting mostly of D-isomers and unusual amino acids were prepared based upon the stable angiotensin converting enzyme breakdown product of bradykinin - RPPGF.

METHODS AND RESULTS

These peptides are direct thrombin inhibitors prolonging the thrombin clotting time, activated partial thromboplastin time, and prothrombin time at >or=0.78, 1.6, and 1.6 microm, respectively. They competitively inhibit alpha-thrombin-induced cleavage of a chromogenic substrate at 4.4-8.2 microm. They do not significantly inhibit plasma kallikrein, factor (F) XIIa, FXIa, FIXa, FVIIa-TF, FXa, plasmin or cathepsin G. One form, FM19 [rOicPaF(p-Me)], blocks alpha-thrombin-induced calcium flux in fibroblasts with an IC(50) of 6.9 +/- 1.2 microm. FM19 achieved 100% inhibition of threshold alpha- or gamma-thrombin-induced platelet aggregation at 8.4 +/- 4.7 microm and 16 +/- 4 microm, respectively. The crystal structure of thrombin in complex with FM19 shows that the N-terminal D-Arg retrobinds into the S1 pocket, its second residue Oic interacts with His-57, Tyr-60a and Trp-60d, and its C-terminal p-methyl Phe engages thrombin's aryl binding site composed of Ile-174, Trp-215, and Leu-99. When administered intraperitoneal, intraduodenal, or orally to mice, FM19 prolongs thrombin clotting times and delays carotid artery thrombosis.

CONCLUSION

FM19, a low affinity reversible direct thrombin inhibitor, might be useful as an add-on agent to address an unmet need in platelet inhibition in acute coronary syndromes in diabetics and others who with all current antiplatelet therapy still have reactive platelets.

The fraction 1 and V protein antigens of Yersinia pestis activate dendritic cells to induce primary T cell responses

The F1 and V antigens of Yersinia pestis, despite acting as virulence factors secreted by the organism during infection, also combine to produce an effective recombinant vaccine against plague, currently in clinical trial. The protective mechanisms induced by rF1 + rV probably involve interactions with dendritic cells (DC) as antigen uptake, processing and presenting cells. To study such interactions, naive ex vivo DC from bone marrow, spleen and lymph node were cultured with rF1, rV or combined antigens and demonstrated to secrete interleukin (IL)-4 and IL-12 into the culture supernatant. Cytokine production in response to pulsing was dependent on the maturity of the bone marrow-derived DC culture, so that pulsed 8-day-old cultures had accumulated significantly more intracellular IL-4 and IL-12 than unpulsed cells. DC, pulsed with rF1 + rV for 2-24 h, were able to prime naive autologous lymph node T cells to proliferate in an antigen dose-dependent manner, with an order of potency of 3d bone marrow-derived DC (BMDC) > 7d BMDC > splenic DC. Significantly, cell-free supernatants from rF1 + rV-pulsed BMDC and splenic DC were also able to induce specific primary responses effectively in naive T cells, suggesting that these supernatants contained stimulatory factor(s). This study suggests an important role for DC, or factors secreted by them, in the induction of protective immunity to plague by the rF1 and rV antigens.

Comparative Evaluation of Alternative Forages to Grass Silage in the Diet of Early Lactation Dairy Cows

Fifty-six autumn-calving Holstein-Friesian cows, blocked on the basis of days in milk (27.6 +/- 10.65 d), lactation number (3.1 +/- 2.21), and preexperimental milk yield (28.4 +/- 6.69 kg) were used to examine the effects of replacing 330 g/kg of dry matter (DM) of first-cut perennial ryegrass silage with either fermented whole-crop wheat (WCW), urea-treated processed WCW, or corn silage on subsequent feed intake, milk production, and efficiency of nitrogen utilization. The DM (g/kg), crude protein (CP, g/kg of DM) and in vitro DM digestibility (g/kg) of the forages were 204, 179, and 762 for grass silage; 389, 90, and 711 for fermented WCW; 795, 141, and 768 for urea-treated processed WCW; and 346, 93, and 783 for corn silage, respectively. Four forage treatments were evaluated as follows: 1) grass silage as the sole forage (GS); 2) a mixture of grass silage and fermented WCW silage, (F-WCW); 3) a mixture of grass silage and urea-treated processed WCW, (UP-WCW); and 4) a mixture of grass silage and corn silage (CS). In all cases, the alternative forages comprised 67% of the forage mix on a DM basis. Isonitrogenous diets were formulated by offering all cows 8 kg of concentrate as fed, formulated to different CP concentrations. Cows were offered these diets from 28 to 104 d in milk. Total DM intake and milk yield were greater on UP-WCW (20.0 and 30.2 kg/d) and CS (18.3 and 33.2 kg/d) than on GS (13.5 and 26.5 kg/d). Although DM intake was greater on F-WCW (17.1 kg/d) than on GS, milk yield was not significantly greater (+2.7 kg/d). Milk protein concentration was greater on F-WCW (30.5 g/kg), UP-WCW (31.3 g/kg), and CS (30.7 g/kg) than on GS (28.5 g/kg). However, there was no difference between treatments in milk fat or lactose concentrations. Body weight change was greater for cows offered GS (-0.27 kg/d) than for those offered UP-WCW (-0.01 kg/d) and CS (+0.05 kg/d) but not compared with those offered F-WCW (-0.06 kg/d). There was no effect of treatment on plasma glucose, nonesterified fatty acids, beta-hydroxybutyrate, urea, or total protein at d 64 +/- 17.4 and d 92 +/- 17.4 postpartum. Efficiency of N utilization was greatest for CS with 0.36 of N intake being recovered in milk compared with 0.28, 0.32, and 0.26 for GS, F-WCW, and UP-WCW, respectively. There was no effect of treatment on milk urea N concentration or the urinary allantoin N to creatinine N ratio. The results of this experiment indicate that corn silage is a more suitable supplementary forage to grass silage than fermented or urea-treated processed WCW, with advantages realized in milk production and more efficient N utilization.

Attitudes of general dental practitioners in Europe to the microbial risk associated with dental unit water systems

Dental Unit Water Systems (DUWS) are used in dental practices to provide water for cooling of dental equipment and irrigation of the oral cavity. However, they have been demonstrated to be contaminated with micro-organisms. There are currently no European Union (EU) Commission guidelines for the microbial quality of water discharged by DUWS. This study was part of an EU research programme to investigate the microbial contamination of DUWS in general dental practice (GDP) in the UK, Denmark, Germany, The Netherlands, Ireland, Greece and Spain.

OBJECTIVE

To undertake a questionnaire survey on the type of DUWS in use and determine the attitude of GDPs to the risk of microbial infection from DUWS.

MATERIALS AND METHODS

The questionnaire was written and translated into the language of each country before being posted to each participating dentist. Dentists were asked to complete the questionnaire survey and return it by post.

RESULTS AND CONCLUSIONS

The major findings were that the majority of dentists did not clean, disinfect or determine the microbial load of their DUWS, and that dentists would welcome regular monitoring and advice on maintaining their DUWS; the introduction of guidelines; and recommendations on controlling the microbial load of DUWS.

Comparison of the efficacies of disinfectants to control microbial contamination in dental unit water systems in general dental practices across the European Union

Water delivered by dental unit water systems (DUWS) in general dental practices can harbor high numbers of bacteria, including opportunistic pathogens. Biofilms on tubing within DUWS provide a reservoir for microorganisms and should be controlled. This study compared disinfection products for their ability to meet the American Dental Association's guideline of <200 CFU x ml(-1) for DUWS water. Alpron, BioBlue, Dentosept, Oxygenal, Sanosil, Sterilex Ultra, and Ster4Spray were tested in DUWS (n = 134) in Denmark, Germany, Greece, Ireland, The Netherlands, Spain, and the United Kingdom. Weekly water samples were tested for total viable counts (TVCs) on yeast extract agar, and, where possible, the effects of products on established biofilm (TVCs) were measured. A 4- to 5-week baseline measurement period was followed by 6 to 8 weeks of disinfection (intermittent or continuous product application). DUWS water TVCs before disinfection ranged from 0 to 5.41 log CFU x ml(-1). Disinfectants achieved reductions in the median water TVC ranging from 0.69 (Ster4Spray) to 3.11 (Dentosept) log CFU x ml(-1), although occasional high values (up to 4.88 log CFU x ml(-1)) occurred with all products. Before treatment, 64% of all baseline samples exceeded American Dental Association guidelines, compared to only 17% following commencement of treatment; where tested, biofilm TVCs were reduced to below detectable levels. The antimicrobial efficacies of products varied (e.g., 91% of water samples from DUWS treated with Dentosept or Oxygenal met American Dental Association guidelines, compared to 60% of those treated with Ster4Spray). Overall, the continuously applied products performed better than those applied intermittently. The most effective products were Dentosept and Oxygenal, although Dentosept gave the most consistent and sustained antimicrobial effect over time.

Use of sensorineural tests in a large volume of medico-legal compensation claims for HAVS

BACKGROUND

The Department of Trade and Industry set up a contract to examine miners and ex-miners claiming compensation for hand-arm vibration syndrome (HAVS). They had been exposed to hand-transmitted vibration. Over 100,000 have now been examined using sensorineural tests as part of that process.

AIMS

The purpose of this paper was to examine the internal consistency of the vibrotactile threshold test (VTT) and the thermal aesthesiometry test (TA).

METHODS

In 18 centres across the UK, nurses were trained to perform the measurement of VTT and TA in a controlled standardized manner. These tests were to aid the staging of the neurological component of the Stockholm Workshop Scales. The staging of this component was modified by dividing stage 2SN into 2SN (early) and 2SN (late). The test results and an automatic neurological staging were presented to the examining doctor following the clinical examination. The results of these sensorineural tests were held on a central database. The results and analysis of the first 57,000 tests are reported.

RESULTS

The correlations within the VTT and TA scores were consistent with reliable measures. However, these correlations were not of such strength as to allow reliance on the results of a single test when making an assessment of the severity of neurological damage.

CONCLUSIONS

Different end organs and nerve fibres should be tested when making an assessment of damage in the sensorineural component of HAVS. The correlations demonstrated for the VTT and TA suggest that they are of value in assessing these claimants and would be for other vibration exposed workers.

Microbiological evaluation of dental unit water systems in general dental practice in Europe

A range of opportunistic pathogens have been associated with dental unit water systems (DUWS), particularly in the biofilms that can line the tubing. This study therefore aimed to assess the microbiology of DUWS and biofilms in general dental practices across seven European countries, including the United Kingdom (UK), Ireland (IRL), Greece (GR), Spain (ES), Germany (D), Denmark (DK) and the Netherlands (NL). Water supplied by 51% of 237 dental unit water lines exceeded current American Dental Association recommendations of < or = 200 colony-forming units (CFU) ml(-1). Microbiological loading of the source waters was between 0 (Denmark, the Netherlands and Spain) and 4.67 (IRL) log CFU ml(-1); water line samples from the DUWS ranged from 1.52 (ES) to 2.79 (GR) log CFU ml(-1); and biofilm counts ranged from 1.49 (GR) to 3.22 (DK) log CFU.cm(-2). Opportunistic pathogens such as legionellae (DK and ES), including Legionella pneumophila SG1 (DK and GR), and Mycobacterium spp. (DK, NL, GR, D and ES) were recovered occasionally. Presumptive oral streptococci (ES and NL), oral anaerobes (GR), Candida spp. (UK, NL and ES) and blood (GR and IRL) were detected at relatively low frequencies, but their presence indicated a failure of the 3-in-1 antiretraction valve, leading to back siphonage of oral fluids into the water and biofilm phase. These findings confirm that a substantial proportion of DUWS have high levels of microbial contamination, irrespective of country, type of equipment and source water. The study emphasizes the need for effective mechanisms to reduce the microbial burden within DUWS, and highlights the risk of occupational exposure and cross-infection in general dental practice.

Cold provocation testing and hand-arm vibration syndrome--an audit of the results of the Department of Trade and Industry scheme for the evaluation of miners

BACKGROUND

Hand-arm vibration syndrome (HAVS) is a major industrial disease that causes considerable morbidity among workers exposed to vibration. Compensation is paid to those affected in civil claims against employers and (in the UK) in claims made under Social Security legislation rules for Prescribed Disease A11. Diagnostic tests have been proposed but most are not objective. The cold provocation test (CPT), which is objective, is often included in the evaluation of HAVS.

METHODS

A continuous audit was made of the findings recorded at the 18 HAVS test centres in the UK established to evaluate miners. The audit, and its outcome, were monitored by the Medical Reference Panel who advise the Department of Trade and Industry. This audit report constitutes the second analysis of the findings relating to the CPT.

RESULTS

The CPT, with measurement of digital rewarming times, is of no value in assessing vibration-induced damage to the hands.

CONCLUSION

In its present format, the CPT should not be used for evaluating the vascular component of HAVS.

Surface hardness of light-activated resin composites cured by two different visible-light sources: an in vitro study

OBJECTIVE

Microhardness values of upper and lower surfaces of disk specimens of 3 commercially available resin composites were compared and cured using both the traditional halogen source and a plasma arc lamp.

METHOD AND MATERIALS

Twenty samples of each of the resin composites were cured in nylon washers. Ten samples of each composite were cured using the appropriate halogen lamp protocol, and 10 samples of each were cured using the plasma lamp protocol. Surface microhardness measurements were carried out using a calibrated Vickers indenter on both top and bottom surfaces after 7 days of storage in air at 20 degrees C. Statistical analysis of the data was carried out using a commercial statistical package. The data for top and bottom surfaces were analyzed separately using a repeated measures analysis of variance (ANOVA).

RESULTS

Lamp, composite, and the interaction between lamp and composite were significant in determining the results for both top and bottom surfaces of the disk-shaped specimens. The plasma lamp yielded lower hardness values for all surfaces compared with the halogen source, but the size of the difference depended on the composite.

CONCLUSION

Caution must be exercised in the plasma irradiation of resin composites as a curing method due to the possibility of reduced surface microhardness values that may reflect a reduced percent conversion of monomer to polymer.

Sonographic examination of lateral epicondylitis

OBJECTIVE

The purpose of this study was to describe the sonographic appearance of the common extensor origin in cadavers and asymptomatic volunteers, and to relate this appearance to the findings in patients with lateral epicondylitis.

SUBJECTS AND METHODS

Seventy-two elbows in 71 patients with lateral epicondylitis were examined on sonography. Most of the patients (60/71) gave a history of repetitive microtrauma. The injuries were evaluated with respect to location and severity. Focal areas of degeneration, discrete cleavage tears, and involvement of the lateral collateral ligament were identified. Calcification and bony changes were noted. The appearance of the normal common extensor tendon was described, and cadaveric specimens were dissected. Twenty-one patients subsequently underwent surgery.

RESULTS

The normal common extensor origin is composed of longitudinal fibrils bound closely with the extensor carpi radialis brevis constituting most of the deep fibers, with the extensor digitorum making up the superficial part. The lateral collateral ligament can be identified as a discrete and separate band. The most common appearance of lateral epicondylitis is a focal hypoechoic area in the deep part of the tendon (46/72). These focal areas were identified at surgery and corresponded histologically to collagen degeneration with fibroblastic proliferation. Often discrete cleavage planes traversing the tendon were manifest as partial (18/72) and complete (2/72) tears. The lateral collateral ligament was involved in eight of 72 elbows.

CONCLUSION

Sonography of the common extensor origin can be used to confirm lateral epicondylitis in patients with lateral elbow pain and provide information about the severity of the disease.

Mice deficient in tumor necrosis factor-alpha are resistant to skin carcinogenesis

Given the associations between chronic inflammation and epithelial cancer, we studied susceptibility to skin carcinogenesis in mice deficient for the pro-inflammatory cytokine TNF-alpha (refs. 5,6). TNF-alpha(-/-) mice were resistant to development of benign and malignant skin tumors, whether induced by initiation with DMBA and promotion with TPA or by repeated dosing with DMBA. TNF-alpha(-/-) mice developed 5-10% the number of tumors developed by wild-type mice during initiation/promotion and 25% of those in wild-type mice after repeated carcinogen treatment. TNF-alpha could influence tumor and stromal cells during tumor development. The early stages of TPA promotion are characterized by keratinocyte hyperproliferation and inflammation. These were diminished in TNF-alpha(-/-) mice. TNF-alpha was extensively induced in the epidermis, but not the dermis, in TPA-treated wild-type skin, indicating that dermal inflammation is controlled by keratinocyte TNF-alpha production. Deletion of a TNF-alpha inducible chemokine also conferred some resistance to skin tumor development. TNF-alpha has little influence on later stages of carcinogenesis, as tumors in wild-type and TNF-alpha(-/-) mice had similar rates of malignant progression. These data provide evidence that a pro-inflammatory cytokine is required for de novo carcinogenesis and that TNF-alpha is important to the early stages of tumor promotion. Strategies that neutralize TNF-alpha production may be useful in cancer treatment and prevention.

Cytotoxic response of ovarian cancer cell lines to IFN-gamma is associated with sustained induction of IRF-1 and p21 mRNA

Interferon-gamma (IFN-gamma) has some anti-tumour activity in human ovarian cancer. This cytokine inhibited proliferation in three of four ovarian cancer cell lines in vitro. We then compared the action of IFN-gamma in two cell lines, one sensitive and one resistant to its growth inhibitory effects. IFN-gamma signalling appeared normal in both cell lines, with stat1 DNA binding activity detectable at 30 min. Continuous exposure to IFN-gamma for 2-3 days was necessary for an irreversible effect on cell growth and apoptosis in cells sensitive to growth inhibition. During this time there was an increase in mRNA for the CKI p21, but no alterations in mRNA levels for other members of the CKI family. Maintenance of p21 mRNA required continuous mRNA synthesis. mRNA for the transcription factor IRF-1 was also induced in growth inhibited cells with similar kinetics to those observed for p21. Maximal induction of both p21 and IRF-1 mRNA was observed after 2-3 days IFN-gamma exposure as the cells became committed to cell death. There was also a rapid increase in p21 and IRF-1 mRNA in cells resistant to the growth inhibitory effects of IFN-gamma, but this increase was not maintained. Thus, continuous interaction with the IFN-gamma receptor, together with a sustained induction of p21 and IRF-1, is associated with growth inhibitory and apoptotic effects of IFN-gamma in ovarian cancer cells.

Cytokines (IFNs, TNF-alpha, IL-2 and IL-12) and animal models of cancer

Cytokines are a complex family of mediators that influence many aspects of tumour cell biology. Whether they are used as a therapy or produced locally during the process of tumorigenesis, they are able to act on tumour cells, on the tumour stroma and on the host itself. Animal models have played key roles in optimizing doses and schedules, and have been useful in determining net effects in the tissue microenvironment. Whilst early studies used xenogeneic and syngeneic systems, more recently gene and protein delivery systems have been used to introduce ectopically expressed high and continuous levels of cytokines. This review will discuss the application of some animal model systems that have been investigated to further understand the role cytokines play in cancer, and will concentrate on those cytokines for which there are the most experimental animal model data.

Hypoxia down-regulates MCP-1 expression: implications for macrophage distribution in tumors

Monocyte chemoattractant protein 1 (MCP-1) is likely to contribute to the macrophage infiltrate in human ovarian carcinomas. Although MCP-1 is predominantly expressed by the tumor parenchyma, macrophages accumulate at highest density in necrotic regions, which are associated with low oxygen tensions. Tumor necrosis factor alpha (TNF-alpha) can stimulate MCP-1 production and is also present within ovarian carcinomas. We have investigated the effect of hypoxia both on MCP-1 expression in ovarian cancer cell lines and monocyte migration. Hypoxia down-regulated TNF-alpha-induced MCP-1 mRNA and protein production by ovarian cancer cells. The effect was mimicked by cobalt chloride and desferrioxamine, consistent with a specific oxygen-sensing mechanism. Unlike antioxidants, hypoxia did not inhibit nuclear factor KB mobilization. Monocyte migration in response to MCP-1 was also diminished under hypoxic conditions. Down-regulation of MCP-1 expression and the inhibition of monocyte migration are independent effects of hypoxia that may contribute to the distribution of macrophages within ovarian tumors.

Interferon gamma induces cell cycle arrest and apoptosis in a model of ovarian cancer: enhancement of effect by batimastat

Locoregional human IFN-gamma may have activity against refractory ovarian cancer. We investigated this further in an ovarian cancer xenograft model. Administered at clinically relevant doses, intraperitoneal IFN-gamma prolonged the survival of mice bearing multiple established peritoneal tumours, with optimal treatment giving a 3-6-fold increase in median survival time. Daily dosing, which was superior to intermittent treatment, decreased DNA synthesis and induced apoptosis in tumour cells with maximal effects after 7-21 days treatment. This was preceded by an increase in p53 protein at 48 h. The effect of IFN-gamma was not enhanced by sequential treatment with carboplatin. However, the matrix metalloprotease inhibitor, batimastat, further increased mouse survival when given after IFN-gamma. Thus IFN-gamma is cytotoxic to ovarian epithelial cells in vivo and intensive locoregional dosing over short periods is effective. Sequential administration of novel agents that perturb the host/tumour relationship may be of benefit.

Cytokines in animal models of cancer

Cytokines are a complex family of mediators that play a wide role in development, immunity, inflammation and tissue repair. Their use in therapy is still in its infancy and animal models have a key role to play in optimizing doses and schedules. Whilst xenogeneic and syngeneic transplantable systems have traditionally been used to look at the effects of cytokines in tumour models, oncogene transgenic mice prone to develop cancer, may now have a role to play. Moreover, gene therapy has allowed the investigation of ectopically expressed high and continuous levels of cytokines. We will attempt to review the literature on the effect of cytokines and their combinations in these models of cancer.

A cytokine profile of normal and malignant ovary

We defined a cytokine mRNA profile of 12 ovarian cancer biopsies, 10 normal/benign biopsies, six ovarian cancer cell lines and three ovarian cancer xenografts, using RT-PCR. The profile, based on screening for 25 cytokines and 12 receptor mRNAs, was rich in growth factors, pro-inflammatory cytokines and chemokines, but weak in lymphocyte-associated cytokines. The pattern was unique to ovarian tissue, but similar in normal, benign and malignant biopsies, with > 80% samples expressing 16 cytokines in common. Fourteen of these were also expressed by > 65% cell lines, but fewer were detected in xenografts. Potential autocrine loops existed for IL-1, IGF-1, M-CSF, GM-CSF and TNF-alpha. IL-4 and IFN-gamma receptors were expressed in absence of ligand. Chemokines RANTES, MIP-1 alpha and MIP-1 beta were expressed in biopsies, but were rarely detected in cell lines and absent from xenografts. IGF-1 and its receptor was expressed in every sample, as was IFN-gamma receptor. Another 10 cytokine mRNAs and six receptors were expressed in > 80% samples. These may contribute to key survival/growth loops. Similarities between normal and malignant biopsies suggest that analogous processes of remodelling and repair occur. RT-PCR proved a rapid, reproducible screen, but further assays are required to detect quantitative differences between normal and malignant tissues and tumour models.

Hand surgery coding and classification

The development of codes for hand surgery as part of the Read Code System is described. A lexicon of clinical terms and surgery has been developed, and will shortly be available from the National Health Service Centre for Coding and Classification in Loughborough, UK.

The detection and localization of monocyte chemoattractant protein-1 (MCP-1) in human ovarian cancer

Chemokines may control the macrophage infiltrate found in many solid tumors. In human ovarian cancer, in situ hybridization detected mRNA for the macrophage chemokine monocyte chemoattractant protein-1 (MCP-1) in 16/17 serous carcinomas, 4/4 mucinous carcinomas, 2/2 endometrioid carcinomas, and 1/3 borderline tumors. In serous tumors, mRNA expression mainly localized to the epithelial areas, as did immunoreactive MCP-1 protein. In the other tumors, both stromal and epithelial expression were seen. All tumors contained variable numbers of cells positive for the macrophage marker CD68. MCP-1 mRNA was also detected in the stroma of 5/5 normal ovaries. RT-PCR demonstrated mRNA for MCP-1 in 7/7 serous carcinomas and 6/6 ovarian cancer cell lines. MCP-1 protein was detected by ELISA in ascites from patients with ovarian cancer (mean 4.28 ng/ml) and was produced primarily by the cancer cells. Human MCP-1 protein was also detected in culture supernatants from cell lines and in ascites from human ovarian tumor xenografts which induce a peritoneal monocytosis in nude mice. We conclude that the macrophage chemoattractant MCP-1 is produced by epithelial ovarian cancer and that the tumor cells themselves are probably a major source. MCP-1 may contribute to the accumulation of tumor-associated macrophages, which may subsequently influence tumor behavior.

The role of indoleamine 2,3-dioxygenase in the anti-tumour activity of human interferon-gamma in vivo

We have studied the relationship between L-tryptophan metabolism and the response to human IFN-gamma in 3 human ovarian cancer xenografts growing in nude mice. During IFN-gamma therapy all 3 tumours showed a profound depletion in L-tryptophan and a corresponding rise in L-kynurenine. The microenvironment surrounding the tumours was also depleted of L-tryptophan. The IFN-gamma-inducible enzyme indoleamine dioxygenase, IDO, was induced in treated tumours. While there was a variability in IDO mRNA expression in the different xenografts tested, in situ hybridization showed that the gene was induced at all levels of the tumour, and not just the periphery. These results show that induction of IDO by IFN-gamma in vivo can metabolize L-tryptophan rapidly enough for it to become depleted, despite a continued supply of L-tryptophan from the host. The IDO mRNA and protein remained induced after the L-tryptophan levels had returned to normal, suggesting that the gene may be post-transcriptionally regulated and/or the IDO co-factor supply may be limited. Another IFN-gamma-inducible gene, tryptophanyl tRNA synthetase, was also induced in the tumour. It is possible that this enzyme, which is responsible for synthesizing tryptophanyl tRNA, acts in a compensatory manner by allowing protein synthesis to continue despite low free L-tryptophan concentrations. There was no correlation of the above parameters with the anti-tumour response to IFN-gamma, suggesting that other mechanisms must play a role. L-tryptophan depletion may be a contributor to a multifactorial growth inhibition of tumour cells following IFN-gamma treatment, but cannot on its own explain their growth inhibition.

The effect of cytokines on cultured mononuclear cells from patients with B cell chronic lymphocytic leukemia

In the past 5 years a number of cytokines have been identified that control B cell development, proliferation, and maturation. The role of such cytokines in the evolution, pathophysiology, and treatment of B cell malignancies is an area of great interest. The in vitro response of freshly isolated peripheral blood mononuclear cells from patients with B cell chronic lymphocytic leukemia (B-CLL) and a high white cell count, to four cytokines, IFN-alpha, IFN-gamma, IL-2 and TNF, was studied. No culture condition or cytokine resulted in a significant increase in cell number over 4 days, cells survived better in autologous serum than in heat inactivated foetal calf serum, and a small but significant increase in blast cells was seen when the cells were cultured in IL-2. There was a discrepancy between uptake of thymidine and increase in cell number which can be explained by the low labelling index of these cultures and the fact that cells can incorporate [3H]-thymidine without going into mitosis. The majority of cultures produced biologically active TNF at levels ranging from 1 to 40 pg/ml. In IFN-alpha treated cultures TNF levels were decreased. Cultures contained biologically active IL-6 at levels ranging from 2 to 2800 U/ml. IL-6 production was not influenced by other cytokines. Thirteen of 28 patients had detectable IL-6 in their serum, but in cells lysed no more than 2 h after removal from the patient, message for IL-6 could not be detected by Northern blotting. Cells also failed to express IL-1 beta mRNA but seven of eight patients had low levels of TNF message. Preliminary data using in situ hybridization techniques revealed that whilst no mRNA for IL-6 was detected, TNF and IL-1 beta mRNA were detected in a minority of mononuclear cells.

Angiolymphoid Hyperplasia with Eosinophilia in the Hand: A Case Report

Angiolymphoid hyperplasia is an uncommon condition which may give rise to difficulty in diagnosis. The case described was originally regarded as Kaposi’s sarcoma, but H.I.V. testing was negative. Excision of a further lesion established the diagnosis as angiolymphoid hyperplasia.

The cytokine network

The availability of pure recombinant cytokines and molecular probes for their genes has generated an avalanche of scientific information. These data show that cytokines have a broad and overlapping range of cell regulatory activity both in vitro and in vivo. New factors are added to the cytokine list, and new functions reported for existing cytokines, with such frequency that it is difficult to retain an overall picture. With this problem in mind, a large wallchart was designed and was displayed at the second meeting of the British Cytokine Group* whose members pooled their collective knowledge, to list the known biological activities of these cytokines. This wallchart of cytokine activity, now referenced, is reproduced for Immunology Today. It is not a final list: new information and cytokines are continually reported and space has been left for readers to make their own additions. A neutrophil-activating peptide variously named monocyte-derived neutrophil chemotactic factor (MDNCF), neutrophil-activating factor (NAF), lymphocyte-derived neutrophil-activating peptide (LYNAP), which has been suggested as a candidate for interleukin 8 (IL-8), is included.

Fractures of the hook of the hamate

Fractures of the hook of the hamate have been infrequently reported in the literature. A high index of suspicion is required if the correct diagnosis is to be established. We report three cases of fractures of the hook of the hamate and postulate a mechanism of injury in sportsmen. Once established, an excision of the hook is usually necessary to resolve the discomfort.