Occupational asthma in teachers

BACKGROUND

Work-related asthma symptoms are common in teachers and teaching assistants, there are few studies evaluating their causes.

AIMS

To identify causes of occupational asthma in teachers and teaching assistants referred to the Birmingham Occupational Lung Disease clinic 2000-20 using evaluation of serial Peak Expiratory Flow (PEF) records.

METHODS

Teachers and teaching assistants with possible occupational asthma were asked to record PEF 2-hourly at home and work for 4 weeks. Their records were evaluated with the Oasys programme. Those with a positive score for any of the three scores (area between curves (ABC), timepoint and Oasys score from discriminant analysis) were included. Repeat records were made as indicated to help identify the cause and the effects of remedial actions.

RESULTS

Thirty-eight teachers or teaching assistants met the inclusion criteria with all three Oasys scores positive in 24, 2/3 scores in nine and 1/3 in five. The building was the likely cause in 17 (in new builds particularly acrylates from carpet adhesives and in old buildings mould and construction dust), bystander exposure to agents in the schools in 12 (cleaning agents, acrylates from photocopiers and chloramines from indoor pools) and materials used in the classroom in 9 (most commonly MDF in design and technology classes). We illustrate how the PEF records helped identify the cause.

CONCLUSIONS

Oasys analysis of PEF records is a useful method of evaluating occupational asthma in teachers and identified difficult to confirm causes where successful remediation or redeployment was achieved.

Fractional exhaled nitric oxide in the interpretation of specific inhalational challenge tests for occupational asthma

PURPOSE

Fractional exhaled nitric oxide (FENO) measurements are recommended for the assessment of eosinophilic airway inflammation in asthma. Clinically relevant increases in FENO have been reported 24 h after positive specific inhalational challenge (SIC) tests in occupational asthma. We aimed to determine whether positive SICs could be discriminated from control tests, on the basis of change in FENO.

METHODS

We reviewed all positive SICs to a variety of agents performed at our institution 2008-2012 and gathered data on age, sex, asthmatic response (immediate/dual/late), smoking status, inhaled corticosteroid usage, and FENO pre- and 24-h postcontrol and positive SIC from each worker. Changes in FENO after positive SICs were compared with control SICs from each worker, by using paired Student's t tests.

RESULTS

In 16 workers, negative control challenges were associated with mean changes in FENO of 9 % (95 % CI -1.14 to 19.01) or 1.1 ppb (95 % CI -3.59 to 5.84); 2 of 16 (13 %) workers tested showed increases in FENO that were clinically relevant based on recent guidelines. Subsequent positive SICs were associated with mean changes in FENO of 7 % (95 % CI −15.73 to 29.6) or 2.1 ppb (95 % CI -6.07 to 10.19), which were not significantly different to controls; only 2 of 16 (13 %) workers had FENO changes that were clinically relevant.

CONCLUSIONS

FENO changes above the upper confidence limits of ≥20 % or ≥6 ppb may be considered to be outside the range of normality. However, the majority of workers who had clearly positive SICs to common low molecular weight agents also had no statistically or clinically relevant increase in FENO. Therefore, change in FENO does not predict a positive SIC in this group.

Differences in serial lung function recorded on four data-logging meters

OBJECTIVE

Lung function measurements performed several times daily are useful for the diagnosis of occupational asthma. Patient fabrication of hand-recorded charts can limit confidence in the results; this is overcome using electronic meters that log time and measurement. We have compared individual and meter differences in FEV1 and PEF recorded by hand and from meter logs using expert subjects on four data-logging spirometers with different methods of measurement and different quality control software.

METHODS

Eight workers in a respiratory physiology department were asked to record FEV1 and PEF 2-hourly from waking for 7 days using four electronic meters (Easyone, Micro DL, Vitalograph Diary card 2110 and Piko-1) in random order. Subjects hand-recorded the best FEV1 and PEF from each session, this was compared with the logged data.

RESULTS

Discordant measurements from individuals were lower for FEV1 than PEF and differed from 4.4-19.1% for FEV1 (mean 9.4%, p < 0.0001) and 6-23.3% for PEF (mean 12.6, p < 0.0001). There were also significant differences between meters for both variables (p < 0.0001). The magnitude of the differences in PEF was highest for the Easyone (34l/min) and lowest for the Vitalograph Diary card 2110 (14l/min) and varied significantly between meters (mean 22l/min, p = 0.002).

CONCLUSIONS

Differences between hand-recorded and logged measurements are unlikely to be due solely to patient fabrication and can be due to quality criteria or other unclear software requirements applied after the results are shown on the meter screen; they differ between meters. Whether the differences shown affect clinical outcome will require further investigation.

Current topics in occupational asthma

The study of occupational asthma (OA) provides insights into asthma in general, as the cause is known. The relationships between the cause and response can be measured and modifying factors can be identified and their influence quantified. Developing OA has much more serious consequences for the patient than new onset asthma unrelated to work exposures, as the patient's livelihood is nearly always affected. Many healthcare professionals are more ready to accept and act on asthmatic symptoms when they are unrelated to work than when work may be the cause; antagonism can also occur in the workplace. This article reviews some of the areas where development and controversy enrich the study of OA. It makes no attempt to be comprehensive.

Concise guidance: diagnosis, management and prevention of occupational asthma

This concise guidance, prepared for physicians, summarises the British Occupational Health Research Foundation guideline for the prevention, identification and management of occupational asthma. Approximately one in six people of working age who develop asthma have work-related asthma, where work has either caused or aggravated their disease. Physicians who assess working adults with asthma need to ask the patient about their job and the materials they work with, and be aware of those that carry particular risks; they should also ask whether symptoms improve regularly on days away from work. A diagnosis of occupational asthma (ie asthma caused by work) should not be made on the basis of history alone, but be supported by immunological and physiological investigations of proven diagnostic benefit. Following a validated diagnosis of occupational asthma, physicians should recommend early avoidance of further exposure, because this offers the best chance of complete recovery. If appropriate and timely interventions are not taken, the prognosis of occupational asthma is poor, with only approximately one-third of workers achieving full symptomatic recovery.

Standards of care for occupational asthma: an update

BACKGROUND

The British Thoracic Society (BTS) Standards of Care (SoC) Committee produced a standard of care for occupational asthma (OA) in 2008, based on a systematic evidence review performed in 2004 by the British Occupational Health Research Foundation (BOHRF).

METHODS

BOHRF updated the evidence base from 2004-2009 in 2010.

RESULTS

This article summarises the changes in evidence and is aimed at physicians, nurses and other healthcare professionals in primary and secondary care, occupational health and public health and at employers, workers and their health, safety and other representatives.

CONCLUSIONS

Various recommendations and evidence ratings have changed in the management of asthma that may have an occupational cause.

Medium-density fibreboard and occupational asthma. A case series

BACKGROUND

Medium-density fibreboard (MDF) is a wood composite material, composed primarily of softwood, bonded with a synthetic formaldehyde-based resin. It is increasingly used, as it has various advantages over natural woods.

METHODS

Enquiry of the national reporting scheme data and three case reports were used to further the evidence base linking this exposure to occupational asthma (OA).

RESULTS

From 1991 to 2007, 21 cases of occupational sensitization to MDF were reported to the UK voluntary reporting scheme, Surveillance of Work Related Occupational Respiratory Disease (SWORD): 18 reported as occupational asthma (OA) and 3 as occupational rhinitis. All workers were male, with a mean age of 48 years, working in education, furniture manufacturing or joinery among other employments.

CONCLUSIONS

Whilst reporting scheme data identified relatively small numbers of cases of OA likely to be due to MDF, the evidence base supporting this link is generally lacking. The three cases presented, where OA was attributed to MDF exposure, add to this evidence.

A novel missense mutation in GJB2, p.Tyr65His, causes severe Vohwinkel syndrome

Gap junctions are intercellular channels which are permeable to ions and small molecules up to about 1 kDa in size. They are prominent in the skin, but their precise function there is largely unknown. Mutations in skin-expressed gap junction genes disrupt epidermal growth and differentiation. A relatively minor epidermal connexin, connexin 26 (Cx26), is associated with a wide variety of phenotypes, each specifically associated with a particular amino acid residue. How the different mutations in GJB2 lead to such distinctive phenotypes is poorly understood. Analysis of new GJB2 mutations can shed new light on pathogenesis and the apparently vital role of Cx26 in maintaining epidermal integrity.

Audit of dermatological content of U.K. undergraduate curricula

BACKGROUND

Recommendations for the dermatology content (learning outcomes) of the core undergraduate curriculum were sent to all U.K. medical schools in June 2006.

OBJECTIVE

To carry out an audit of the content of the core curriculum in each U.K. medical school against the recommendations for a core undergraduate dermatology curriculum (the criteria) published by the British Association of Dermatologists, to identify areas of good practice and to gather evidence for developing the learning and teaching of dermatology.

METHODS

A questionnaire was circulated to the dermatology teaching leads of all U.K. medical schools (29) and one Irish medical school. Questions which the teaching leads were unable to answer were sent to the relevant deans and responses incorporated into the results. All curricula should include the essential learning outcomes that focus on clinical skills; as this was an audit to benchmark current practice, we did not set standards for the other recommendations for a core curriculum.

RESULTS

Replies were received from teaching leads in 29 of the 30 medical schools and from 16 of the deans. Essential clinical skills such as taking a dermatological history and examining the skin were included in the curricula of most, but not all, medical schools. Areas of good practice include teaching on tumours, acne and psoriasis, but we found some surprising omissions including the diagnosis of meningococcaemia. Our data suggest that some students have little exposure to dermatology, but dermatology teaching takes place in secondary care in all medical schools. Knowledge-based assessments are used by 27 medical schools.

CONCLUSIONS

Curricula should be strengthened so that the recommended learning outcomes feature in the core curricula of all medical schools. Teaching leads in all specialties, including those in the community, should communicate so that learning and teaching are integrated horizontally and vertically. The results should provide a baseline for future audits.

Are we failing workers with symptoms suggestive of occupational asthma?

AIMS

To assess the route to secondary care for patients with possible occupational asthma, and to document the duration of workrelated symptoms and referral times.

METHODS

Consecutive patients with suspected occupational asthma were recruited to a case series from six secondary care clinics with an interest in occupational asthma. Semi-structured interviews were performed and hospital case notes were reviewed to summarise relevant investigations and diagnosis.

RESULTS

97 patients were recruited, with a mean age of 44.2 years (range 24-64), 51 of whom (53%) had occupational asthma confirmed as a diagnosis. Most (96%) had consulted their general practitioner (GP) at least once with work-related respiratory symptoms, although these had been present for a mean of 44.6 months (range 0-320 months) on presentation to secondary care. Patients experienced a mean delay for assessment in secondary care of 4 years (range 1-27 years) following presentation in primary care.

CONCLUSIONS

Significant diagnostic delay currently occurs for patients with occupational asthma in the UK.

An outbreak of extrinsic alveolitis at a car engine plant

BACKGROUND

Twelve workers from a car engine-manufacturing plant presented with extrinsic allergic alveolitis (EAA), with heterogeneous clinical, radiological and pathological findings. They were exposed to metalworking fluids (MWF) that cooled, lubricated and cleaned the machines.

METHODS

They were characterized by history, examination, lung function testing, radiology, bronchoscopic lavage, lung biopsy and serology. Sera were tested for precipitins to a crude extract of used MWF and to reference cultures of bacteria suspected to be implicated.

RESULTS

All were males and none were current smokers. All had dyspnoea, many had weight loss and cough, but only half had influenza-like symptoms. Only half had auscultatory crackles. Five had peak flow variability, four with an occupational component. There was overall restrictive spirometry, decreased lung volumes and reduced gas transfers. Ten had radiological evidence of interstitial lung disease. Seven (of eight) had lymphocytosis on bronchial lavage, including the two with inconclusive radiology. Seven (of 11) had lung biopsies showing inflammatory infiltrates, two with fibrosis and one with granulomas. Three (of 11) had strong positive precipitins to an extract of the used MWF from the plant. Molecular biological analysis of the MWF revealed Acinetobacter and Ochrobactrum. Precipitins to Acinetobacter were detected in seven of 11 workers tested (and four of 11 control workers). Precipitins to Ochrobactrum were detected in three of 11 workers tested (and three of 11 control workers).

CONCLUSION

This is the largest series reported in Europe of EAA due to an aerosol of microbiologically contaminated MWF in heavy manufacturing industry.

Occupational asthma: an assessment of diagnostic agreement between physicians

OBJECTIVES

To investigate the levels of agreement between expert respiratory physicians when making a diagnosis of occupational asthma.

METHODS

19 cases of possible occupational asthma were identified as part of a larger national observational cohort. A case summary for each case was then circulated to 12 physicians, asking for a percentage likelihood, from the supplied information, that this case represented occupational asthma. The resulting probabilities were then compared between physicians using Spearman's rank correlation and Cohen's kappa coefficients.

RESULTS

Agreement between the 12 physicians for all 19 cases was generally good as assessed by Spearman's rank correlation. For all 66 physician-physician interactions, 45 were found to correlate significantly at the 5% level. The agreement assessed by kappa analysis was more variable, with a median kappa value of 0.26, (range -0.2 to +0.76), although 7 of the physicians agreed significantly (p<0.05) with >or=5 of their colleagues. Only in one case did the responses for probability of occupational asthma all exceed the "on balance" 50% threshold, although 12 of the 19 cases had an interquartile range of probabilities not including 50%, implying "on balance" agreement. The median probability values for each physician (all assessing the identical 19 cases) varied from 20% to 70%. Factors associated with a high probability rating were the presence of a positive serial peak expiratory flow Occupation Asthma SYStem (OASYS)-2 chart, and both the presence of bronchial hyper-reactivity and significant change in reactivity between periods of work and rest.

CONCLUSIONS

Despite the importance of the diagnosis of occupational asthma and reasonable physician agreement, certain variations in diagnostic assessment were seen between UK expert centres when assessing paper cases of possible occupational asthma. Although this may in part reflect the absence of a normal clinical consultation, a more unified national approach to these patients is required.

Defining the dermatological content of the undergraduate medical curriculum: a modified Delphi study

BACKGROUND

Dermatological problems are common, but in undergraduate medical courses time for learning dermatology and teaching dermatology is limited. The Delphi technique has been used in other specialties to define undergraduate and postgraduate curricula and to reach consensus on what is important.

OBJECTIVES

To identify the core dermatological content of the undergraduate medical curriculum.

METHODS

Modified Delphi technique. A questionnaire was designed after review of previous recommendations made by dermatologists. Items were written as explicit learning outcomes. A multidisciplinary panel of 66 individuals responded. Outcomes were rated using a Likert scale (1-5).

RESULTS

Fifty-three learning outcomes were rated 'very important'. We recommend that these are included in the content of U.K. undergraduate medical core curricula.

CONCLUSIONS

A multidisciplinary panel identified dermatological learning outcomes that should be achieved by all medical graduates. Undergraduate medical curricula must provide sufficient resources for learning, teaching and assessment of dermatology so that graduates achieve these outcomes.

Patient attitudes to clinical trials: development of a questionnaire and results from asthma and cancer patients

OBJECTIVE

To develop a questionnaire to assess patients' views of clinical trials, and to report the results from the questionnaire in two patient groups: asthma and cancer.

DESIGN

A 43 item questionnaire asking patients about their views to clinical trials was developed on the basis of interviews with trialists and focus groups with patients. The questionnaire was mailed to patients with a diagnosis of either asthma or cancer. A set of items was then selected, via statistical analyses, to form the core of the questionnaire.

PARTICIPANTS

Patients with a diagnosis of cancer in one NHS Hospital Trust, and patients with a diagnosis of asthma in two NHS Hospital Trusts.

RESULTS

Completed questionnaires were received from 353 cancer patients and 578 asthma patients. Factor analyses of the data indicated that 22 items contributed to five dimensions: 'positive beliefs', 'safety', 'information needs', 'negative expectations' and 'patient involvement'. Differences between asthma and cancer patients on these dimensions were small. A regression of these dimension scores against a variable asking if patients would be willing to take part in trials found that 'safety' and 'information needs' did not contribute significantly to the model for either asthma or cancer patients.

CONCLUSIONS

A questionnaire has been developed for use in assessing patients' views towards clinical trials. Results from the surveys reported here suggest that patient views about the importance of trials and beliefs about the value of patient involvement are likely to be predictive of whether or not patients will agree to take part in a study.

Point-of-care controls for nosocomial legionellosis combined with chlorine dioxide potable water decontamination: a two-year survey at a Welsh teaching hospital

This study reports a two-year programme of attempted eradication of Legionella colonization in the potable water supply of a 1000-bed tertiary care teaching hospital in Wales. There was a simultaneous, point-of-care, sterile-water-only policy for all intensive care units (ICU) and bone marrow and renal transplant units in order to prevent acquisition of nosocomial Legionnaires' disease. The programme was initiated following a case of nosocomial pneumonia caused by Legionella pneumophila serogroup 1-Bellingham-like genotype A on the cardiac ICU. The case occurred 14 days after mitral and aortic valve replacement surgery. Clinical and epidemiological investigations implicated aspiration of hospital potable water as the mechanism of infection. Despite interventions with chlorine dioxide costing over 25000 UK pounds per annum, Legionella has remained persistently present in significant numbers (up to 20000 colony forming units/L) and with little reduction in the number of positive sites. Two further cases of nosocomial disease occurred over the following two-year period; in one case, aspiration of tap water was implicated again, and in the other case, instillation of contaminated water into the right main bronchus via a misplaced nasogastric tube was implicated. These cases arose because of inadvertent non-compliance with the sterile-water-only policy in high-risk locations. Enhanced clinical surveillance over the same two-year period detected no other cases of nosocomial disease. This study suggests that attempts at eradication of Legionella spp. from complex water systems may not be a cost-effective measure for prevention of nosocomial infections, and to the best of our knowledge is the first study from the UK to suggest that the introduction of a sterile-water-only policy for ICUs and other high-risk units may be a more cost-effective approach.

Improving the quality of peak flow measurements for the diagnosis of occupational asthma

INTRODUCTION

Serial measurements of peak expiratory flow (PEF) are recommended in the evidence-based review list as the first stage in objective confirmation of occupational asthma. Different centres have reported widely different success in obtaining records of sufficient data quantity for diagnosis. We investigated different methods of instruction and determined the return rate and quality of the resulting record for the diagnosis of occupational asthma.

METHODS

Consecutive new referrals were recruited from a specialized occupational lung disease clinic and requested to carry out serial PEFs for the assessment of suspected occupational asthma. Requests to carry out the records were either from written postal instructions or personal instruction from a PEF specialist. Record quality received from other clinicians was also analysed separating those using dedicated occupational forms, and those submitting on graph type forms.

RESULTS

The postal return rate was 56% and the personal rate 85%. The number of records fulfilling all the data quality criteria were similar in the postal and personal groups (55 and 59%, respectively). Pre-existing records from other clinics plotted from graph charts (fulfilling all criteria) were only adequate in 23%, compared with 61% adequate for pre-existing records plotted from occupational forms. Failure of the record to contain consecutive work periods of > or =3 workdays was the most common failure.

CONCLUSION

The return rate of PEFs for diagnosing occupational asthma is better when patients have been given specific instructions from a PEF specialist and the data quantity better when recorded on a dedicated form.

Heterozygous disruption of SERCA2a is not associated with impairment of cardiac performance in humans: implications for SERCA2a as a therapeutic target in heart failure

OBJECTIVE

To verify whether a deficiency in the cardiac sarcoplasmic reticulum pump SERCA2a causes cardiac dysfunction in humans.

DESIGN

Cardiac performance was measured in a serendipitous human model of primary SERCA2a deficiency, Darier's disease, an autosomal dominant skin disorder caused by mutations inactivating one copy of the ATP2A2 gene, which encodes SERCA2a.

METHODS

Systolic and diastolic function and contractility were assessed by echocardiography at rest and during exercise in patients with Darier's disease with known mutations. Fourteen patients with Darier's disease were compared with 14 normal controls and six patients with dilated cardiomyopathy with stable heart failure.

RESULTS

Resting systolic and diastolic function was normal in patients with Darier's disease and in controls. The increase in systolic function during exercise was not different between patients with Darier's disease and normal controls; neither was there a difference in contractility. As expected, patients with dilated cardiomyopathy had impaired diastolic and systolic function with depressed contractility at rest and during exercise.

CONCLUSION

Contrary to expectations, heterozygous disruption of SERCA2a is not associated with the impairment of cardiac performance in humans. Attempts to increase SERCA2a levels in heart failure, although showing promise in rodent studies, may not be addressing a critical causal pathway in humans.

Specific IgE to colophony?

BACKGROUND

Colophony (rosin) is a natural product obtained from coniferous trees. It is used in a diverse range of products such as adhesives, ink, paints and soldering fluxes. Some workers exposed to colophony during soldering can develop occupational asthma; at present, no specific IgE test is available to assess sensitization to colophony.

METHODS

Serum samples were obtained from exposed symptomatic individuals (n = 7), some with a likely diagnosis of occupational asthma, exposed asymptomatic individuals (n = 10) and unexposed individuals (n = 11). Serum was tested for specific IgE antibodies against a protein extract produced following in vitro challenge of mono-mac-6 cells with colophony extract.

RESULTS

Serum from exposed symptomatic individuals showed increased binding of specific IgE antibodies to a range of colophony-cell protein conjugates [29% (2/7) of samples tested when cut-off > 0.1 or 86% (6/7) of samples tested when cut-off > 0%] compared with both the exposed asymptomatic [0% when cut-off > 0.1, or 20% when cut-off > 0% (2/10)] and the non-exposed control populations [0% when cut-off > 0.1, or 27% when cut-off > 0% (3/11)].

CONCLUSIONS

This novel approach for the production of conjugates to assess sensitization to colophony was able to detect specific IgE in colophony-exposed workers with a likely diagnosis of occupational asthma.

Extensive Grover's-like eruption with lentiginous 'freckling': report of two cases

We have described two females with extensive freckling and scaly lesions and conclude that they have a widespread form of Grover's disease associated with lentiginous sun-induced 'freckling'. We report these cases to draw attention to an unusual pattern of Grover's disease that can simulate Darier's disease.

Mycosis fungoides responding to systemic itraconazole

Mycosis fungoides is a form of cutaneous lymphoma with a typically indolent course. We describe an unexpected, repeated response to a systemic antifungal agent, itraconazole. The mechanism of action is speculative but itraconazole has marked immunosuppressive activity on T-lymphocyte proliferation in vitro.

COPD exacerbations: definitions and classifications

Chronic obstructive pulmonary disease (COPD) is defined independently of exacerbations, which are largely a feature of moderate-to-severe disease. This article is the result of a workshop that tried to define exacerbations of COPD for use in clinical, pharmacological and epidemiological studies. The conclusions represent the consensus of those present. This review describes definitions, ascertainment, severity assessments, duration and frequency, using varying sources of data including direct patient interview, healthcare databases and symptom diaries kept by patients in studies. The best general definition of a COPD exacerbation is the following: an exacerbation of COPD is a sustained worsening of the patient's condition, from the stable state and beyond normal day-to-day variations that is acute in onset and may warrant additional treatment in a patient with underlying COPD. A more specific definition for studies where a bacteriological cause of exacerbation is being studied is included, as well as simpler definitions for retrospective identification from database sources. Prospective diary card assessments are best recorded as changes from an agreed baseline, rather than absolute symptom severities. Diary cards identify many unreported exacerbations, which on average have similar severities to reported exacerbations. A scale for exacerbation severity is proposed that incorporates in- and outpatient assessments. Exacerbation duration, which also relates to severity, is defined from diary card reports. Healthcare utilisation is not an adequate substitute for severity, depending on many unrelated social and comorbidity factors. It is an outcome in its own right.

Expression of sarco/endo-plasmic reticulum Ca2+-ATPase type 2 isoforms (SERCA2) in normal human skin and mucosa, and Darier's disease skin

BACKGROUND

The recent report that mutations in ATP2A2, which encodes the Ca2+ transporting sarco/endo-plasmic reticulum pump type 2 isoforms (SERCA2), cause Darier's disease (DD) suggests that SERCA2 plays an important role in epidermal cell adhesion and differentiation. However, no data exist regarding SERCA2 expression in normal human skin, mucosa and DD.

OBJECTIVES

We have therefore investigated SERCA2 expression in normal human skin (40 samples), oral and vaginal mucosa (13 samples) and DD lesional skin (six samples).

MATERIALS AND METHODS

These investigations were performed with a mouse monoclonal antibody specific for human SERCA2, using a standard ABC immunoperoxidase technique.

RESULTS

SERCA2 was expressed in all specimens. SERCA2 expression was pronounced in the subnuclear aspect of basal epidermal keratinocytes, with variable suprabasal expression. SERCA2 expression was also observed in the infundibulum and outer root sheath of hair follicles; germinative and mature cells of sebaceous glands; secretory coil and duct of eccrine glands; apocrine gland cells, and arrector pili muscle. Fibroblasts and blood vessels (endothelium and muscle) expressed SERCA2, whereas nerves did not. SERCA2 expression was observed throughout oral and vaginal mucosa. In DD skin, strong SERCA2 positivity was detected in the basal, suprabasal and acantholytic lesional cells. Perilesional DD skin was comparable to normal skin.

CONCLUSIONS

These findings support the hypothesis that SERCA2 is an important player in cutaneous biology, and provide baseline data that will facilitate the design and interpretation of functional studies of cutaneous SERCA2.

Should inhaled corticosteroids be used in the long term treatment of chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a progressive disease with alveolar destruction (emphysema) and bronchiolar fibrosis (obstructive bronchitis) in variable proportions. Reducing disease progression, as assessed by forced expiratory volume in I second (FEV1) decline, health-related quality of life, exacerbation rate and mortality, is a more realistic outcome than physiological improvement. This paper reviews all the published studies of at least 100 patients followed for at least 2 years. Studies have included patients with mild COPD (Copenhagen City Lung Study) to advanced symptomatic disease [Inhaled Steroids in Obstructive Lung Disease (ISOLDE)], with 2 studies of those with relatively early symptoms [European Respiratory Society Study on Chronic Obstructive Pulmonary Disease (EUROSCOP) and Lung Health-21. Exacerbation frequency, and probably severity, are reduced by high dose inhaled corticosteroids. Exacerbations are only frequent in more advanced disease, limiting the use of this outcome in EUROSCOP and Lung Health-2. Exacerbations are associated with reduced health-related quality of life. ISOLDE clearly showed a reduced rate in decline of the disease-specific St George's Respiratory Questionnaire with fluticasone propionate, partly related to the reduced exacerbations. The symptom component of the score showed the greatest difference between placebo and fluticasone propionate. None of the larger studies were able to reproduce the statistically significant reduction in the rate of decline in FEV1 suggested by the smaller, earlier studies. This might at least in part be as a result of the statistical modelling used which cannot adequately compensate for those with more rapidly progressive disease dropping out earlier. The equivalent doses of inhaled corticosteroids differed approximately fivefold between the major studies. The more positive results were obtained with higher doses. Oropharyngeal adverse effects were similar to those seen in patients with asthma; bruising was increased in one study with budesonide, otherwise adverse effects were similar to placebo. Bone loss was specifically studied in subgroups of patients in EUROSCOP and Lung Health-2. Budesonide 800 microg/day was associated with less bone loss than placebo, whereas triamcinolone 1200 microg/day was associated with excess bone loss. High dose inhaled corticosteroids have a favourable risk/benefit ratio in patients with advanced disease, particularly those with frequent exacerbations, and no benefit for those with very mild disease. It is not possible from the data to make firm recommendations for the important intermediate group where delaying progression is likely to lead to greatest benefit. I believe high dose inhaled steroids are warranted for those with intermediate severity COPD, who have frequent exacerbations or significant COPD-related symptoms.

Teaching dermatology to medical students: a survey of current practice in the U.K

BACKGROUND

In 1993, the General Medical Council recommended that all medical schools should revise their curricula for undergraduate medical education and foster more interdisciplinary collaboration in teaching. In accordance with these recommendations, new curricula have been introduced in U.K. medical schools.

OBJECTIVES

To assess the impact of changes in medical curricula on the teaching of dermatology to medical undergraduates.

METHODS

A questionnaire was sent to the dermatologists responsible for organizing the teaching of undergraduate dermatology in each of the 24 medical schools in England, Scotland, Wales and Northern Ireland.

RESULTS

Replies were received from all schools. Nineteen of the 24 schools had already introduced integrated curricula and the others were changing more slowly. Some dermatology was included in the core curriculum in all schools. Dermatologists in 14 schools contributed to the teaching of basic science and students in 18 schools were able in years 1 and 2 to see patients in primary care (14) and/or the hospital (13). In nine of these schools, students could meet dermatology patients in these early clinical sessions. Nine schools used some problem-based learning (PBL) in addition to other teaching methods, but PBL predominated in four schools and in two of these schools most students never met a dermatologist. Dermatology was a compulsory clinical attachment in 21 schools, but the length of attachments varied and was less than 5 days in four schools. Students had to pass a dermatology assessment at the end of the clinical attachment in 14 schools and there was assessment of knowledge of dermatology in final examinations in all schools. Students had an early opportunity to explore a dermatology topic in depth in 17 schools, and 20 schools offered or were planning to introduce special study modules in dermatology. Interdisciplinary teaching links were common. Resources for out-patient teaching were inadequate in 16 schools and university support poor in 10 schools. Few departments had direct access to the considerable health service funding that is paid to National Health Service Trusts to reimburse the costs of teaching medical students.

CONCLUSIONS

In general, dermatology has maintained a reasonable profile in the new undergraduate curricula, but dermatology experience is inadequate in four schools. Dermatologists should maximize opportunities for introducing dermatology into the curriculum by familiarizing themselves with the forces that are driving curriculum reform, participating in curriculum development, keeping abreast of changes in medical education and using opportunities for interdisciplinary teaching.

Pigmentary anomalies in ataxia--telangiectasia: a clue to diagnosis and an example of twin spotting

A 6-year-old girl with consanguineous parents presented with a history of progressive ataxia and patchy, segmental pigmentary changes, some reminiscent of Blaschko's lines. There was no evidence of oculocutaneous telangiectases or signs of immunodeficiency. A clinical diagnosis of ataxia--telangiectasia (AT) was suggested and confirmed by the presence of a low serum IgA, raised alpha-fetoprotein and chromosomal rearrangements of chromosomes 7 and 14. This case of AT is unique for having hypopigmentation and hyperpigmented patches adjacent to each other, which is a feature that has been described as 'cutis tricolor', and is unusual for having pigmentary skin changes, some in the lines of Blaschko without telangiectases. Clinicians should be aware that a diagnosis of AT may be made in the absence of telangiectases.

Mosaicism for ATP2A2 mutations causes segmental Darier's disease

Epidermal naevi are localized malformations of the epidermis consisting of verrucoid scaly papules and plaques following Blaschko's lines. Genetic mosaicism has been proposed to underlie the development of linear epidermal naevi. Rarely, epidermal naevi show acantholytic histology similar to Darier's disease, a dominantly inherited skin condition characterized by widespread warty papules. As patients with acantholytic dyskeratotic naevi often give a history of worsening after sun exposure and the lesions are typical of Darier's disease, numerous authors have proposed that these patients have segmental Darier's disease. The postulated relationship has not been proven, however. Recently, we identified ATP2A2, which encodes the sarco/endoplasmic reticulum Ca(2+) ATPase isoform 2 as the defective gene in Darier's disease. In this report, we investigated the involvement of ATP2A2 in acantholytic dyskeratotic naevi following Blaschko's lines in two patients. We identified a nonsense mutation (Y894X) in the first patient and a nonconservative glycine to arginine mutation at codon 769 (G769R) in the other patient. These mutations were present in affected skin, and were not detected in unaffected skin or in leukocytes. We conclude that acantholytic dyskeratotic naevi can arise from a somatic mutation in ATP2A2. These individuals are mosaics for the mutation, but the risk of transmission of generalized Darier's disease will depend on whether the germline is affected. Our findings provide further evidence that Blaschko's lines do reflect genetic mosaicism and that the term acantholytic dyskeratotic naevus might be replaced in the future by segmental Darier's disease induced by postzygotic mosaicism. J Invest Dermatol 115:1144-1147 2000

Hailey-Hailey disease is caused by mutations in ATP2C1 encoding a novel Ca(2+) pump

Hailey-Hailey disease (HHD) is an autosomal dominant skin disorder characterized by suprabasal cell separation (acantholysis) of the epidermis. Previous genetic linkage studies localized the gene to a 5 cM interval on human chromosome 3q21. After reducing the disease critical region to <1 cM, we used a positional cloning strategy to identify the gene ATP2C1, which is mutated in HHD. ATP2C1 encodes a new class of P-type Ca(2+)-transport ATPase, which is the homologue for the rat SPLA and the yeast PMR1 medial Golgi Ca(2+)pumps and is related to the sarco(endo)plasmic calcium ATPase (SERCA) and plasma membrane calcium ATPase (PCMA) families of Ca(2+)pumps. The predicted protein has the same apparent transmembrane organization and contains all of the conserved domains present in other P-type ATPases. ATP2C1 produces two alternative splice variants of approximately 4.5 kb encoding predicted proteins of 903 and 923 amino acids. We identified 13 different mutations, including nonsense, frameshift insertion and deletions, splice-site mutations, and non-conservative missense mutations. This study demonstrates that defects in ATP2C1 cause HHD and together with the recent identification of ATP2A2 as the defective gene in Darier's disease, provide further evidence of the critical role of Ca(2+)signaling in maintaining epidermal integrity.