[Therapeutic adherence among asthma patients: Variations according to age groups. How can it be improved? The potential contributions of new technologies]

While asthma patients' treatment adherence (TA) generally leaves to be desired, few data exist on TA evolution from age group to another. During the meeting of a working group of pneumo-pediatricians and adult pulmonologists, we reviewed the literature on adherence according to age group, examined explanations for poor adherence, and explored ways of improving adherence via new technologies. Asthma is a chronic disease for which TA is particularly low, especially during adolescence, but also among adults. Inhaled medications are the least effectively taken. Several explanations have been put forward: cost and complexity of treatments, difficulties using inhalation devices, poor understanding of their benefits, erroneous beliefs and underestimation of the severity of a fluctuating disease, fear of side effects, neglect, and denial (especially among teenagers). Poor TA is associated with risks of needless treatment escalation, aggravated asthma with frequent exacerbations, increased school absenteeism, degraded quality of life, and excessive mortality. Better compliance is based on satisfactory relationships between caregivers and asthmatics, improved caregiver training, and more efficient transmission to patients of relevant information. The recent evolution of innovative digital technologies opens the way for enhanced communication, via networks and dedicated applications, and thanks to connected inhalation devices, forgetfulness can be limited. Clinical research will also help to ameliorate TA. Lastly, it bears mentioning that analysis of the existing literature is hampered by differences in terms of working definitions and means of TA measurement.

[Community-acquired Staphylococcus aureus pneumonia]

We report a clinical case of a patient hospitalized for community-acquired Staphylococcus aureus pneumonia. A 26-year-old patient with no medical history went to the emergency department for fever. He quickly developed acute respiratory failure and community-acquired Staphylococcus aureus pneumonia as well as bacteremia were confirmed. This pulmonary infection is rare but can affect all age groups and occur in a variety of ways. Patients with community-acquired Staphylococcus aureus pneumonia have more severe clinical outcomes than those with community-acquired pneumonia caused by other germs. The article discusses the main characteristics of community-acquired Staphylococcus aureus pneumonia and recalls the recommendations in case of bacteremia with Staphylococcus aureus.

[Paraneoplastic neurological syndromes]

Neurological paraneoplastic syndromes are non-metastatic complications of systemic cancers, often resulting from an immune response triggered by the crossed expression of neuronal antigens by tumour cells. Several neurological syndromes such as cerebellar degeneration, sensory neuronopathy, limbic encephalitis, encephalomyelitis or the Lambert-Eaton myasthenic syndrome are most often paraneoplastic and require prompt cancer screening, particularly if the patient shows risk factors for cancer. Although there are many exceptions to this rule, a given syndrome is often associated with a particular antibody and the corresponding tumour. A prompt diagnosis of neurological paraneoplastic syndrome is of major importance as it often reveals the underlying tumour. The treatment relies on both the elimination of the neoplasia and the control of the immune response.

The molecular chaperone sigma 1 receptor mediates rescue of retinal cone photoreceptor cells via modulation of NRF2

Sigma 1 receptor (Sig1R), a putative molecular chaperone, has emerged as a novel therapeutic target for retinal degenerative disease. Earlier studies showed that activation of Sig1R via the high-affinity ligand (+)-pentazocine ((+)-PTZ) induced profound rescue of cone photoreceptor cells in the rd10 mouse model of retinitis pigmentosa; however the mechanism of rescue is unknown. Improved cone function in (+)-PTZ-treated mice was accompanied by reduced oxidative stress and normalization of levels of NRF2, a transcription factor that activates antioxidant response elements (AREs) of hundreds of cytoprotective genes. Here, we tested the hypothesis that modulation of NRF2 is central to Sig1R-mediated cone rescue. Activation of Sig1R in 661W cone cells using (+)-PTZ induced dose-dependent increases in NRF2-ARE binding activity and NRF2 gene/protein expression, whereas silencing Sig1R significantly decreased NRF2 protein levels and increased oxidative stress, although (+)-PTZ did not disrupt NRF2-KEAP1 binding. In vivo studies were conducted to investigate whether, in the absence of NRF2, activation of Sig1R rescues cones. (+)-PTZ was administered systemically for several weeks to rd10/nrf2+/+ and rd10/nrf2-/- mice. Through post-natal day 42, cone function was significant in rd10/nrf2+/+, but minimal in rd10/nrf2-/- mice as indicated by electroretinographic recordings using natural noise stimuli, optical coherence tomography and retinal histological analyses. Immunodetection of cones was limited in (+)-PTZ-treated rd10/nrf2-/-, though considerable in (+)-PTZ-treated rd10/nrf2+/+mice. The data suggest that Sig1R-mediated cone rescue requires NRF2 and provide evidence for a previously-unrecognized relationship between these proteins.

[Norovirus nosocomial outbreak : an hospital experience]

Human noroviruses (NoV) are the main pathogenic agents worldwide responsible for viral sporadic and epidemic gastroenteritis worldwide. A gastroenteritis outbreak broke out in patients hospitalized in several wards located in two different floors of a hospital in Liege, Belgium. The objective was to determine whether a same NoV strain would be involved in the two different floors, and to explore how this outbreak would have spread from a floor to the other. Stool samples from patients and healthcare workers were collected, as well as data from medical files. NoV detection, quantification and characterization were performed using molecular biology methods. A same NoV strain, from genotype GII.4, was detected in two patients hospitalized on the two different floors. This finding allowed to conclude that a same outbreak spread in the two floors, probably due to movements of common healthcare workers. A rapid NoV detection during outbreak is important in the aim to rapidly implement hygiene measures to limit the size of the outbreak.

New insights into the phenotypes of atopic dermatitis linked with allergies and asthma in children: An overview

Atopic dermatitis (AD) is a complex disease with multiple causes and complex mechanistic pathways according to age of onset, severity of the illness, ethnic modifiers, response to therapy and triggers. A group of difficult-to-manage patients characterized by early-onset AD and severe lifelong disease associated with allergic asthma and/or food allergy (FA) has been identified. In this study, we focus on these severe phenotypes, analysing their links with other atopic comorbidities, and taking into account the results from recent cohort studies and meta-analyses. The main hypothesis that is currently proposed to explain the onset of allergic diseases is an epithelial barrier defect. Thus, the atopic march could correspond to an epithelial dysfunction, self-sustained by a secondary allergenic sensitization, explaining the transition from AD to allergic asthma. Furthermore, AD severity seems to be a risk factor for associated FA. Results from population-based, birth and patient cohorts show that early-onset and severe AD, male gender, parental history of asthma, and early and multiple sensitizations are risk factors leading to the atopic march and the development of asthma. The importance of environmental factors should be recognized in these high-risk children and prevention programs adapted accordingly. Effective targeted therapies to restore both barrier function and to control inflammation are necessary; early emollient therapy is an important approach to prevent AD in high-risk children. Clinicians should also keep in mind the specific risk of atopic comorbidities in case of filaggrin loss-of-function mutations and the rare phenotypes of orphan syndromes due to heritable mutations in skin barrier components.

The measurement of patients' expectations for health care: a review and psychometric testing of a measure of patients' expectations

BACKGROUND

There is recognition of the importance of measuring patients' experiences, expectations and satisfaction.

OBJECTIVES

To assess the literature on the concept and measurement of patients' expectations for health care, and to develop and test a measure of patients' expectations, using adult patients in community, general practice and hospital outpatient departments in Greater London, Norwich and Essex, UK.

DATA SOURCES

Major electronic databases including the British Nursing Index, EMBASE, MEDLINE, PsycINFO and the Applied Social Sciences Index and Abstracts were searched between 2000 and 2009.

REVIEW METHODS

Narrative review, semi-structured exploratory study and surveys of GP patients and hospital outpatients immediately before and after their surgery/clinic visit to measure their pre-visit expectations for their health care and their post-visit experiences (expectations met and satisfaction with visit) (site specific).

RESULTS

A total of 20,439 titles and 266 abstracts were identified, of which 211 were included in the review. Most research designs were weak, with small or selected samples, and a theoretical frame of reference was rarely stated. The origin of questions about expectations was often absent, questions were frequently untested and those with reported reliability or validity data had generally mixed results. In the survey data the expectations measures met acceptability criteria for reliability; all exceeded the threshold of α = 0.70, in each mode of administration and sample type. Items and subscales also correlated at least moderately with those variables that they were expected to be associated with, supporting their validity. The item means within subscales were generally similar between samples and all-item-total correlations exceeded the acceptability threshold. Descriptive findings revealed that most patients ideally expected cleanliness, information about where to go, convenient and punctual appointments and helpful reception staff, the doctor to be knowledgeable, clear and easy to understand, to be involved in treatment decisions and to experience a reduction in symptoms/problems. Expectations least likely to be met included being seen on time and choice of hospital/doctor (items requested by the ethics committee). Other items that had low met expectations included helpfulness of reception staff, doctor being respectful and treating with dignity (hospital sample), doctor knowledgeable (hospital), being given reassurance, receiving advice about health/condition, information about cause and management of condition and information about benefits/side effects of treatment, being given an opportunity to discuss problems, and the three items on outcome expectancies. Previous consultations/experiences of health services and health-care staff/professionals most commonly influenced expectations. Overall, pre-visit realistic expectations were lower than patients' ideals or hopes. Most post-visit experiences indicated some unmet expectations (e.g. cause and management of health/condition, benefits/side effects of treatments) and some expectations that were exceeded. Generally, GP patients reported higher pre-visit expectations and post-visit met expectations. Correlations between subscale domains were strongest between the structure and process of health care, doctor-patient communication style and doctor's approach to giving information, all common indicators of the quality of health care, supporting the validity of the measures. The post-visit experiences subscale significantly predicted single-item summary ratings of overall met expectations and satisfaction. GP rather than hospital patients were also independently predictive of expectations met. Other predictors were having no/little anxiety/depression, older age (satisfaction) and fewer effects of health on quality of life (met expectations).

LIMITATIONS

The surveys in clinics were based on convenience, not random sampling methods.

CONCLUSIONS

These findings have implications for establishing the quality of health services and informing their improvement. Awareness of the patient's met and unmet expectations should enable staff to understand the patient's perspective and improve communication. This study examined the perspective of the patient only; it is not possible to examine the extent to which any expectations might have been unrealistically too high or too low. This is a challenge for future research.

FUNDING

The National Institute for Health Research Health Technology Assessment programme and the National Co-ordinating Centre for Research Methodology (NCCRM).

Evaluation of ultrasound technology for the disinfection of process water and the prevention of biofilm formation in a pilot plant

In this study, we investigated the use of ultrasound for the disinfection of process water as an alternative for more traditional techniques, like chlorination and UV-irradiation. A pilot plant was constructed to mimic circulating process water in industrial environments. The disinfection efficiency of ultrasound was assessed and compared to UV-treatment and chlorination. In addition, the operational costs for the different technologies were evaluated. Based on disinfection efficiency and operational costs, the pilot plant experiments indicate that chlorination is the method of preference to treat bacteria in suspension. In the prevention of biofilm formation, the results of UV irradiation and ultrasound are comparable, with a slightly higher energy consumption for the ultrasonic treatment. Finally, the use of ultrasound to prevent biofilms was also evaluated in an industrial environment (case study). The results obtained from the case study are in agreement with the results obtained from the pilot plant study. To our knowledge, this is the first study that evaluates the use of ultrasound technology for prevention of biofilm formation in realistic circumstances as encountered in an industrial environment.

Towards a low complexity carbon removal model for the optimal design of compact decentralised wastewater treatment systems

On-site decentralised wastewater treatment systems can provide a financially attractive alternative to a sewer connection in locations far from existing sewer networks. Operational problems and shortcomings in the design of these systems still occur frequently. The aim of this paper is to provide a low complexity (i.e. easy to calibrate) but still accurate mathematical model that can be used to optimise the operational design of compact individual wastewater treatment systems. An integrated hydraulic and biological carbon removal model of a biofilm-based compact decentralised treatment system is developed. The procedure for drafting the model is generic and can be used for similar types of wastewater treatment systems since (i) the hydraulic model is based on an N-tanks-in-series model inferred from tracer test experiments and (ii) (biofilm) respirometry experiments are exploited to determine the biodegradation kinetics of the biomass. Based on the preliminary validation results of the integrated model, the carbon removal in the system can be predicted quite accurately. While some adjustments could further improve the modelling strategy, the here presented results can already assist the manufacturers of compact treatment systems in efficiently (re)designing their systems.

A large multicentre analysis of CTGF -945 promoter polymorphism does not confirm association with systemic sclerosis susceptibility or phenotype

OBJECTIVE

To conduct a replication study to investigate whether the -945 CTGF genetic variant is associated with systemic sclerosis (SSc) susceptibility or specific SSc phenotype.

METHODS

The study population comprised 1180 patients with SSc and 1784 healthy controls from seven independent case-control sets of European ancestry (Spanish, French, Dutch, German, British, Swedish and North American). The -945 CTGF genetic variant was genotyped using a Taqman 5' allelic discrimination assay.

RESULTS

An independent association study showed in all the case-control cohorts no association of the CTGF -945 polymorphism with SSc susceptibility. These findings were confirmed by a meta-analysis giving a pooled OR = 1.12 (95% CI 0.99 to 1.25), p = 0.06. Investigation of the possible contribution of the -945 CTGF genetic variant to SSc phenotype showed that stratification according to SSc subtypes (limited or diffuse), selective autoantibodies (anti-topoisomerase I or anticentromere) or pulmonary involvement reached no statistically significant skewing.

CONCLUSION

The results do not confirm previous findings and suggest that the CTGF -945 promoter polymorphism does not play a major role in SSc susceptibility or clinical phenotype.

New autoantigens in rheumatoid arthritis (RA): screening 8268 protein arrays with sera from patients with RA

OBJECTIVE

To identify new IgG autoantibodies in sera from patients with rheumatoid arthritis (RA).

METHODS

We tested serum samples from 19 patients with RA with given human leukocyte antigen (HLA)-DR genotypes, from 7 patients with spondylarthropathy, 2 patients with lupus, 4 patients with systemic sclerosis and 10 healthy individuals on 8268 human protein arrays.

RESULTS

We identified four antigens (peptidyl arginine deiminase 4 (PAD4), protein kinase Cbeta1 (PKCbeta1), phosphatylinositol 4 phosphate 5 kinase type II gamma (PIP4K2C) and v raf murine sarcoma viral oncogene homologue B1 catalytic domain (BRAF)) that were recognised almost uniquely by sera from patients with RA on protein arrays. Using purified proteins, we confirmed that PAD4 and BRAF are recognised almost uniquely by patients with RA.

CONCLUSION

We identified PAD4 and BRAF as RA specific autoantigens.

HLA-DRB1*0404 is strongly associated with high titers of anti-cyclic citrullinated peptide antibodies in rheumatoid arthritis

OBJECTIVE

To test whether the presence of RA associated HLA-DRB1*0101, HLA-DRB1*0401 and HLA-DRB1*0404 alleles individually influences anti-cyclic citrullinated peptide antibodies (anti-CCP) production.

METHODS

The frequency of anti-CCP antibodies was calculated in the sera of 260 RA patients expressing either two (double dose genotypes SE+/SE+), one (single dose genotypes SE+/SE-) or no RA associated HLA-DR alleles (SE-/SE-). Anti-CCP antibodies titers were also determined.

RESULTS

RA associated HLA-DR alleles are not mandatory for production of anti-CCP. We found that 68% of SE-/SE- patients were anti-CCP positive. There was no significant difference in anti-CCP between SE negative patient (SE-/SE-) and patients expressing at least one SE (SE+/SE+ and SE+/SE-) (p=0.140). We observed no statistical difference in anti-CCP between RA patients expressing one or two SE (82% vs. 77%, p=0.577). Among SE+/SE-patients, HLA-DRB1*0404 was associated with anti-CCP with a statistically significant difference compared with SE negative patients (90% anti-CCP positive, p=0.02). HLA-DRB1*0404 was also associated with high titers of anti CCP with a statistically significant difference compared with HLA-DRB1*0401 and HLA-DRB1*0101 patients (p=0.025).

CONCLUSIONS

The RA-associated HLA-DRB1*0404 allele was the most strongly associated with the presence of anti-CCP in RA sera. Moreover, HLA-DRB1*0404 patients had higher titers of anti CCP than patients with other RA associated HLA-DR alleles.

Electron-spin manipulation and resonator readout in a double-quantum-dot nanoelectromechanical system

We demonstrate how magnetically coupling a nanomechanical resonator to a double quantum dot confining two electrons can enable the manipulation of a single electron spin and the readout of the resonator's natural frequency. When the Larmor frequency matches the resonator frequency, the electron spin in one of the dots can be selectively and coherently flipped by the magnetized oscillator. By simultaneously measuring the charge state of the two-electron double quantum dots, this transition can be detected thus enabling the natural frequency and displacement of the mechanical oscillator to be determined.

Value of HCV antigen-antibody combined HCV assay in hepatitis C diagnosis

Reduction of the window period of hepatitis C virus (HCV) infection represents an important goal in the transfusional and diagnostic settings. Currently, the detection of HCV infection relies on the use of immunoassays to detect viral antibodies. A new enzyme immunoassay (Monolisa HCV Ag-Ab ULTRA) designed to simultaneously detect circulating HCV antigen and anti-HCV antibodies has been developed by Bio-Rad and registered by the European Authorities. Several evaluations have been conducted in Europe to determine whether this new assay can improve early detection of HCV infection. Sensitivity studies included 130 HCV RNA positive/anti-HCV negative samples, 21 well documented seroconversion panels and 430 anti-HCV genotyped samples from France and Italy. Specificity has also been assessed in 15,302 non-selected blood donations and hospital samples. Studies have shown that Monolisa HCV Ag-Ab ULTRA assay has been able to detect 40-90 % of HCV RNA positive/anti-HCV negative samples collected in the window period, improving early detection of HCV when antibodies may be undetectable. The mean delay in detecting HCV infection between HCV-RNA and this new test was found to be 5 days, reducing the window period by an average of 37 days. All samples collected after seroconversion were detected with the HCV Ag-Ab ULTRA assay. The specificity analyzed in 15,302 random blood donations and hospital samples was estimated at 99.86 %. Although less sensitive than NAT (71 % of HCV RNA positive/anti-HCV negative in window period), this assay could be a reasonable alternative when NAT cannot be used for reasons such as cost, organization, emergency or logistic difficulties.

Knowledge, attitudes and health outcomes in HIV-infected travellers to the USA

BACKGROUND

The USA bans entry to non-citizens unless they obtain a waiver visa.

AIM

To establish how many people with HIV infection travelled to the USA, whether they were aware of the travel restriction, whether they travelled with a waiver visa and HIV inclusive medical insurance and how they managed with their antiretroviral medication (ARV).

DESIGN

Collation of data from cross-sectional studies conducted independently at three different medical centres, Manchester, Brighton and London, using a structured self-completion questionnaire.

RESULTS

The overall response rate was 66.6% (1113 respondents). 349 (31%) had travelled to the USA since testing HIV positive, of whom only 14.3% travelled with a waiver visa. 64% and 62% of the respondents at Manchester and Brighton were aware of the need of a waiver visa. 68.5% (212) were on ARV medication at the time of travel and, of these, 11.3% stopped their medication. Of those taking ARV medication, only 25% took a doctors' letter, 11.7% posted their medication in advance. Of those discontinuing treatment (n=27), 55.5% sought medical advice before stopping, 11 were on NNRTI-based regimen and one developed NNRTI-based mutation. Only 27% took up HIV inclusive medical insurance. Many patients reported negative practical and emotional experiences resulting from travel restrictions.

CONCLUSION

The majority of HIV patients travel to the USA without the waiver visa, with nearly half doing so with insufficient planning and advice. A significant minority (11.3%) stop their medication in an unplanned manner, risking the development of drug resistance.

Refocusing health promotion for syphilis prevention: results of a case-control study of men who have sex with men on England's south coast

BACKGROUND

Prevention interventions have had little impact on syphilis outbreaks among men who have sex with men (MSM) and diagnosis rates continue to rise rapidly. Detailed studies of the determinants of syphilis transmission are needed to inform new prevention interventions.

OBJECTIVE

To investigate factors associated with recent syphilis diagnosis and recommend strategies for improved prevention interventions.

METHODS

A case-control study of MSM attending genitourinary medicine (GUM) and HIV outpatient clinics. Cases were MSM testing positive for early syphilis, based on either laboratory or microscopy results, with those testing negative being controls. All participants completed the same anonymous questionnaire covering demographics, lifestyle, sexual behaviour, and sexual partnerships.

RESULTS

50 cases and 108 controls returned questionnaires. Syphilis diagnosis was significantly associated with sexually transmitted infection history, recent recreational drug use, receptive anal sex practices, but not insertive ones, higher numbers of oral sex partners, but not specific oral sex practices. Overall, there were no differences between HIV positive and HIV negative/untested men in reporting of sexual behaviours or partnership combinations. The use of public sex settings (backrooms, saunas, "cruising grounds," etc) was reported by 68% of all participants and not significantly associated with syphilis diagnosis.

CONCLUSIONS

Many key behavioural and partnership risk factors for syphilis are also risk behaviours for HIV transmission and point to the need for integrated strategies that tackle the two infections together. Simplified procedures for syphilis screening should be available in GUM clinical settings, along with targeted community outreach prevention interventions.

Using smart card technology to monitor the eating habits of children in a school cafeteria: 1. Developing and validating the methodology

OBJECTIVE

The aim of the study was to test the feasibility of using smart card technology to track the eating behaviours of nearly a thousand children in a school cafeteria.

METHODS

Within a large boys' school a smart card based system was developed that was capable of providing a full electronic audit of all the individual transactions that occurred within the cafeteria. This dataset was interfaced to an electronic version of the McCance and Widdowson composition of foods dataset. The accuracy of the smart card generated data and the influence of portion size and wastage were determined empirically during two 5-day trials.

RESULTS

The smart card system created succeeded in generating precise data on the food choices made by hundreds of children over an indefinite time period. The data was expanded to include a full nutrient analysis of all the foods chosen. The accuracy of this information was only constrained by the limitations facing all food composition research, e.g. variations in recipes, portion sizes, cooking practices, etc. Although technically possible to introduce wastage correction factors into the software, thereby providing information upon foods consumed, this was not seen as universally practical.

CONCLUSION

The study demonstrated the power of smart card technology for monitoring food/nutrient choice over limitless time in environments such as school cafeterias. The strengths, limitations and applications of such technology are discussed.

Using smart card technology to monitor the eating habits of children in a school cafeteria: 3. The nutritional significance of beverage and dessert choices

OBJECTIVE

The consumption patterns of beverages and desserts features highly in the current debate surrounding children's nutrition. The aim of this study was to continuously monitor the choice of beverages and desserts made by nearly 1000 children in a school cafeteria.

METHODS

A newly developed smart card system was used to monitor the food choices of diners (7-16-year-old boys) in a school cafeteria over 89 days. A wide variety of beverages and desserts were on offer daily.

RESULTS

Despite coming from an affluent, well-educated demographic group, the boys' choices of beverages and desserts mirrored those of children in general. Buns and cookies were over 10 times more popular than fresh fruits and yogurts. Sugary soft-drinks were over 20 times more popular than fresh fruit drinks and milk combined. Appropriate choices could, over a month, reduce intake of added sugar by over 800 g and fat by over 200 g.

CONCLUSION

The smart card system was very effective at monitoring total product choices for nearly 1000 diners. In agreement with a recent national school meal survey, where choice is extensive, children show a preference for products high in fat and/or sugar. The consequences of these preferences are discussed.

Using smart card technology to monitor the eating habits of children in a school cafeteria: 2. The nutrient contents of all meals chosen by a group of 8- to 11-year-old boys over 78 days

OBJECTIVE

The aim of the study was to test the abilities of the newly created smart card system to track the nutrient contents of foods chosen over several months by individual diners in a school cafeteria.

METHODS

From the food choice and composition of food data sets, an Access database was created encompassing 30 diners (aged 8-11 years), 78 days and eight nutrients. Data were available for a total of 1909 meals.

RESULTS

Based upon population mean values the cohort were clearly choosing meals containing higher than the recommended maximum amounts for sugar and lower than the recommended minimum amounts of fibre, iron and vitamin A. Protein and vitamin C contents of meals chosen were well above minimum requirements. Over the 1909 meals, nutrient requirements were met 41% of the time.

CONCLUSIONS

The system created was very effective at continually monitoring food choices of individual diners over limitless time. The data generated raised questions on the common practice of presenting nutrient intakes as population mean values calculated over a few days. The impact of heavily fortified foods on such studies in general is discussed.

Low-income consumers' attitudes and behaviour towards access, availability and motivation to eat fruit and vegetables

OBJECTIVE

To determine low-income consumers' attitudes and behaviour towards fruit and vegetables, in particular issues of access to, affordability of and motivation to eat fruit and vegetables.

DESIGN AND SETTING

Questionnaire survey mailed to homes owned by a large UK housing association.

PARTICIPANTS

Participants were 680 low-income men and women, aged 17-100 years.

RESULTS

Age, employment, gender, smoking and marital status all affected attitudes towards access, affordability and motivation to eat fruit and vegetables. Few (7%) participants experienced difficulty in visiting a supermarket at least once a week, despite nearly half having no access to a car for shopping. Fruit and vegetables were affordable to this low-income group in the amounts they habitually bought; purchasing additional fruits and vegetables was seen as prohibitively expensive. Less than 5% felt they had a problem with eating healthily and yet only 18% claimed to eat the recommended 5 or more portions of fruit and vegetables every day.

CONCLUSIONS

Supported by research, current UK Government policy is driven by the belief that low-income groups have difficulties in access to and affordability of fruit and vegetables. Findings from this particular group suggest that, of the three potential barriers, access and affordability were only a small part of the 'problem' surrounding low fruit and vegetable consumption. Thus, other possible determinants of greater consequence need to be identified. We suggest focusing attention on motivation to eat fruit and vegetables, since no dietary improvement can be achieved if people do not recognise there is a problem.

Perceptions of HAART among gay men who declined a treatment offer: preliminary results from an interview-based study

As part of a prospective study of treatment decision making among people with HIV infection, we explored perceptions of HAART in a cohort who declined a treatment offer. This was a qualitative study in which 26 gay men were interviewed in relation to their views about HAART soon after treatment was recommended by their HIV physician. Fifteen themes were associated with the decision to decline HAART. These were grouped under three broad categories: doubts about personal necessity for HAART, concerns about potential adverse effects of taking HAART and satisfaction with the amount of personal control over the decision. These findings provide new insights into the type of beliefs that might inform people's evaluation of their perceived need for HAART and their concerns about HAART. Initiatives to support informed decisions should take account of these perceptions.

Understanding patients' preferences for treatment: the need for innovative methodologies

Treatment selection is now much more consumer driven than in the past. However, there is a need to develop investigative methodological approaches that are sensitive to differences in patient preferences if full account is to be taken of what the patient sees as the best option in terms of different possible treatments available for a particular condition. Previous attitude research has been criticised because it does not provide insight into reasons why people hold different preferences or beliefs. A methodology is described which allows people to describe their concerns and values associated with different treatment options in their own words. This is the repertory grid method of eliciting personal constructs used in conjunction with generalised Procrustes analysis (GPA). An example of the use of this methodology is provided, drawn from research directed towards understanding people's beliefs about genetic technologies. A possible application of the method to understanding treatment preferences related to type 2 diabetes is also discussed. It is concluded that the use of innovative methodologies is essential if our understanding of patient preferences regarding treatment options is to have a significant impact on patient quality of life.

Understanding patients' preferences for treatment: the need for innovative methodologies

Treatment selection is now much more consumer driven than in the past. However, there is a need to develop investigative methodological approaches that are sensitive to differences in patient preferences if full account is to be taken of what the patient sees as the best option in terms of different possible treatments available for a particular condition. Previous attitude research has been criticised because it does not provide insight into reasons why people hold different preferences or beliefs. A methodology is described which allows people to describe their concerns and values associated with different treatment options in their own words. This is the repertory grid method of eliciting personal constructs used in conjunction with generalised Procrustes analysis (GPA). An example of the use of this methodology is provided, drawn from research directed towards understanding people's beliefs about genetic technologies. A possible application of the method to understanding treatment preferences related to type 2 diabetes is also discussed. It is concluded that the use of innovative methodologies is essential if our understanding of patient preferences regarding treatment options is to have a significant impact on patient quality of life.

In vitro metabolism and drug interaction potential of a new highly potent anti-cytomegalovirus molecule, CMV423 (2-chloro 3-pyridine 3-yl 5,6,7,8-tetrahydroindolizine I-carboxamide)

AIMS

To identify the enzymes involved in the metabolism of CMV423, a new anticytomegalovirus molecule, to evaluate its in vitro clearance and to investigate its potential involvement in drug/drug interactions that might occur in the clinic.

METHODS

The enzymes involved in and the kinetics of CMV423 biotransformation were determined using pools of human liver subcellular fractions and heterologously expressed human cytochromes P450 (CYP) and FMO. The effect of CMV423 on CYP probe activities as well as on indinavir and AZT metabolism was determined, and 26 drugs were tested for their potential to inhibit or activate CMV423 metabolism.

RESULTS

CMV423 was oxidized by CYP and not by FMO or cytosolic enzymes. The Km values for 8-hydroxylation to rac-RPR 127025, an active metabolite, and subsequent ketone formation by human liver microsomes were 44 +/- 13 microM and 47 +/- 11 microM, respectively, with corresponding Vmax/Km ratios of 14 and 4 microl min(-1) nmol(-1) P450. Inhibition with selective CYP inhibitors indicated that CYP1A2 was the main isoform involved, with some participation from CYP3A. Expressed human CYP1A1, 1A2, 2C9, 3A4 and 2C8 catalysed rac-RPR 127025 formation with Km values of < 10 microM, 50 +/- 21 microM, 55 +/- 19 microM, circa 282 +/- 61 microM and circa 1450 microM, respectively. CYP1B1, 2A6, 2B6, 2C19, 2D6, 2E1 or 3A5 did not catalyse the reaction to any detectable extent. CYP1A1 and 3A4 also catalysed ketone formation from rac-RPR 127025. In human liver microsomes, CMV423 at 1 and 10 microM inhibited CYP1A2 activity up to 31% and 63%, respectively, CYP3A4 activity up to 40% (10 microM) and CYP2C9 activity by 35% (1 and 10 microM). No effect was observed on CYP2A6, 2D6 and 2E1 activities. CMV423 had no effect on indinavir and AZT metabolism. Amongst 26 drugs tested, none inhibited CMV423 metabolism in vitro at therapeutic concentrations.

CONCLUSIONS

CMV423 is mainly metabolized by CYP1A2 and 3A4. Its metabolism should not be saturable at the targeted therapeutic concentrations range (Cmax < 1 microM). CMV423 will probably affect CYP1A2 and 1A1 activities in vivo to some extent, but no other drug-drug interactions are expected.

[Toxoplasmosis serodiagnosis: comparison of Access Toxo IgM II assay compared to Axsym Toxo IgM and Vidas Toxo IgM assays]

The Access Toxo IgM II test (Beckman Coulter Inc) was evaluated on 1,190 samples from toxoplasmosis serology requests, documented seroconversions, umbilical cord blood or venous blood from healthy newborn, and from newborns with congenital toxoplasmosis. Results were compared to those obtained with Vidas (bioMérieux) and Axsym (Abbott) assays, with Isaga as confirmatory technique. Results obtained with the Access test well correlate those with the Vidas (98.3%) and the Axsym (97.6%) assays. Less "bordeline" results are also observed with the Access test (0.22% versus 0.56% and 1.24% with Vidas and Axsym assays respectively). Results obtained from seroconverted patients prove that the Access assay is more sensitive than Vidas and Axsym assays, with respectively 2 and 4 samples detected earlier for 28 cases studied (recently seroconverted patients). Results obtained using prospective samples and with sequential sera obtained from patients with seroconversion clearly demonstrate that Access Toxo IgM II assay is perfectly adapted to toxoplasmosis diagnosis.

Founder effect for a 26-bp deletion in the RFXANK gene in North African major histocompatibility complex class II-deficient patients belonging to complementation group B

Expression of major histocompatibility complex (MHC) class II genes is controlled at the transcriptional level by at least four trans-acting genes, CIITA, RFXANK, RFX5, and RFXAP. Defects in these regulatory genes result in the absence of MHC class II molecule expression and, thereby, cause a combined immunodeficiency. MHC class II deficiency is inherited as an autosomal recessive trait. Since the first description of the disease, about 70 patients from 50 families have been reported. Forty-three of these families have been classified into four complementation groups: A, B, C, and D. In the largest group, B, the majority of patients are of North African origin. In two of these patients, the same mutation in the RFXANK gene (752delG-25) was identified. We performed a mutation analysis in 20 additional patients belonging to complementation group B and detected the 752delG-25 mutation in 17. All of these patients are of North African origin. A founder effect for this mutation was documented, since all tested patients, except one, display a common haplotype spanning the RFXANK locus.

Purification of cytosolic beta-glucosidase from pig liver and its reactivity towards flavonoid glycosides

Flavonoid glycosides are common dietary components which may have health-promoting activities. The metabolism of these compounds is thought to influence their bioactivity and uptake from the small intestine. It has been suggested that the enzyme cytosolic beta-glucosidase could deglycosylate certain flavonoid glycosides. To test this hypothesis, the enzyme was purified to homogeneity from pig liver for the first time. It was found to have a molecular weight (55 kDa) and specific activity (with p-nitrophenol glucoside) consistent with other mammalian cytosolic beta-glucosidases. The pure enzyme was indeed found to deglycosylate various flavonoid glycosides. Genistein 7-glucoside, daidzein 7-glucoside, apigenin 7-glucoside and naringenin 7-glucoside all acted as substrates, but we were unable to detect activity with naringenin 7-rhamnoglucoside. Quercetin 4'-glucoside was a substrate, but neither quercetin 3, 4'-diglucoside, quercetin 3-glucoside nor quercetin 3-rhamnoglucoside were deglycosylated. Estimates of K(m) ranged from 25 to 90 microM while those for V(max) were about 10% of that found with the standard artificial substrate p-nitrophenol glucoside. The non-substrate quercetin 3-glucoside was found to partially inhibit deglycosylation of quercetin 4'-glucoside, but it had no effect upon activity with p-nitrophenol glucoside. This study confirms that mammalian cytosolic beta-glucosidase can deglycosylate some, but not all, common dietary flavonoid glycosides. This enzyme may, therefore, be important in the metabolism of these compounds.

Chediak-Higashi syndrome associated with maternal uniparental isodisomy of chromosome 1

Chediak-Higashi syndrome (CHS) is a rare autosomal recessive disorder (incidence around 1 in 106 births), characterised by a complex immunologic defects, reduced pigmentation, and presence of giant granules in many different cell types. It most likely results from defective organellar trafficking or protein sorting. The causative gene (LYST) has recently been identified and shown to be homologous to the beige locus in the mouse. CHS has always been reported associated with premature-termination-codon mutations in both alleles of LYST. We report a unique patient with CHS, who was homozygous for a stop codon in the LYST gene on chromosome 1 and who had a normal 46,XY karyotype. The mother was found to be a carrier of the mutation, whereas the father had two normal LYST alleles. Non-paternity was excluded by the analysis of microsatellite markers from different chromosomes. The results of 13 informative microsatellite markers spanning the entire chromosome 1 revealed that the proband had a maternal isodisomy of chromosome 1 encompassing the LYST mutation. The proband's clinical presentation also confirms the absence of imprinted genes on chromosome 1.

Long-term fetal microchimerism in peripheral blood mononuclear cell subsets in healthy women and women with scleroderma

Fetal CD34(+) CD38(+) cells have recently been found to persist in maternal peripheral blood for many years after pregnancy. CD34(+) CD38(+) cells are progenitor cells that can differentiate into mature immune-competent cells. We asked whether long-term fetal microchimerism occurs in T lymphocyte, B lymphocyte, monocyte, and natural-killer cell populations of previously pregnant women. We targeted women with sons and used polymerase chain reaction for a Y-chromosome-specific sequence to test DNA extracted from peripheral blood mononuclear cells (PBMC) and from CD3, CD19, CD14, and CD56/16 sorted subsets. We also asked whether persistent microchimerism might contribute to subsequent autoimmune disease in the mother and included women with the autoimmune disease scleroderma. Scleroderma has a peak incidence in women after childbearing years and has clinical similarities to chronic graft-versus-host disease that occurs after allogeneic hematopoietic stem-cell transplantation, known to involve chimerism. Sixty-eight parous women were studied for male DNA in PBMC and 20 for PBMC subsets. Microchimerism was found in PBMC from 33% (16 of 48) of healthy women and 60% (12 of 20) women with scleroderma, P =.046. Microchimerism was found in some women in CD3, CD19, CD14, and CD56/16 subsets including up to 38 years after pregnancy. Microchimerism in PBMC subsets was not appreciably more frequent in scleroderma patients than in healthy controls. Overall, microchimerism was found in CD3, CD19, and CD14 subsets in approximately one third of women and in CD56/16 in one half of women. HLA typing of mothers and sons indicated that HLA compatibility was not a requirement for persistent microchimerism in PBMC subsets. Fetal microchimerism in the face of HLA disparity implies that specific maternal immunoregulatory pathways exist that permit persistence but prevent effector function of these cells in normal women. Although microchimerism in PBMC was more frequent in women with scleroderma than healthy controls additional studies will be necessary to determine whether microchimerism plays a role in the pathogenesis of this or other autoimmune diseases.

T cell receptor gene in synovial tissues of rheumatoid arthritis

Rheumatoid arthritis is a chronic and destructive autoimmune joint disease characterized by inflammation of synovial tissue of unknown aetiology. Studies on TCR genes expressed by infiltrating T cells in synovial tissues have attempted to identify mechanism and specificity of the recruitment. T cell infiltrate in rheumatoid arthritis appears to be an association of a polyclonal non specific infiltrate with dominant clones or clonotypes. T cell repertoire in synovial tissue is biased compared to peripheral blood but no TCR V gene can be identified as commonly over-used. Comparison of motifs found in the CDR3 region of dominant clones from different studies has currently failed to identified a commonly motif. The fact that a number of dominant clones or clonotypes is present in different joints and at different times of the disease suggests a selective expansion of T lymphocytes in rheumatoid arthritis synovial membrane. Further investigations are needed to characterize the specificity of these dominant clonotypes.