A systematic review of treatments for atopic dermatitis

Atopic dermatitis is a very common inflammatory skin disease, particularly in children. A systematic review of randomised controlled trials of treatments for atopic dermatitis (AD) was carried out to assess how many trials exist, what they cover, what they do not cover, the research gaps, provide a 'blue print' for future Cochrane Reviews and assist those making treatment recommendations by summarising the available RCT evidence, using descriptive statistics. The Cochrane Collaboration systematic review process formed the basis of the methodology, from which over 4000 studies were located via electronic database searches and hand searching of journals. A total of 292 trials were finally included covering 9 treatment groups and over 48 individual treatments. There are lots of trials covering lots of interventions but gaps are evident. However, there is evidence of a benefit in the treatment of atopic dermatitis with topical corticosteroids, psychological approaches, UV light, ascomycin derivatives, topical tacrolimus and oral cyclosporin. Treatments that show limited evidence of a benefit include non-sedatory antihistamines, topical doxepin, the oral antibiotic Cefadroxil on clinically infected AD, the topical antibacterial Mupirocin on clinically uninfected AD, Chinese herbs, hypnotherapy and biofeedback, massage therapy, dietary manipulation, house dust mite reduction, patient education, emollients, allergen antibody complexes of house dust mite and thymic extracts. Treatments that show no evidence of benefit include sedatory antihistamines, oral sodium cromoglycate, oral antibiotics on clinically uninfected AD, topical antibacterials, topical antifungals, aromatherapy essential oils, borage oil, fish oil, evening primrose oil, enzyme-free clothes detergent, cotton clothing, house dust mite hyposensitisation, salt baths, topical coal tar, topical cyclosporin and platelet-activating-factor antagonist. When interpreting the conclusions of this thesis it is important to understand that lack of evidence does not equal lack of efficacy, particularly considering the interventions that are commonly in use today to treat atopic dermatitis that have not been subjected to RCTs, such as occlusive dressings, water softening devices and stress management among many others.

Studies of the metabolism and the toxicity of N-Methylformamide and related amides

The hepatotoxicity of the industrial solvent and investigational anti-tumour agent N-methylformamide (NMF, HOCNHCH3) and several structural analogues was assessed in mice. NMF and its ethyl analogue (NEF) were equipotent hepatotoxins causing extensive centrilobular necrosis and damage to the gall bladder. Pretreatment of mice with SKF525A did not influence the toxicity of these N-alkylformamides. Replacement of the formyl hydrogen of NMF with deuterium or methyl significantly reduced its hepatotoxicity. An in vitro model for the study of the toxicity and metabolism of N-alkylformamides was developed using isolated mouse hepatocytes. The cytotoxicity of NMF in vitro was concentration-dependent with maximal toxicity being achieved at concentrations of 5mM or above. The cytotoxic potential of related amides correlated well with their in vivo hepatotoxic potential. Pretreatment of mice with buthionine sulphoximine (BSO), which depleted hepatocytic levels of glutathione to 15% of control values, exacerbated the cytotoxicity of NMF towards the hepatocytes. NMF (1mM or above), incubated with isolated mouse hepatocytes, depleted intracellular glutathione levels to 26% of control values within 4h. Depletion of glutathione was quantitatively matched by the formation of a carbamoylating metabolite. Metabolism was dependent on the concentration of NMF and was drastically reduced in incubations of hepatocytes isolated from mice pretreated with BSO. The carbamoylating metabolite, S-(N-methylcarbamoyl)-glutathione (SMG), was identified in vitro using FAB-MS. The generation of SMG was subject to a large primary H/D kinetic isotope effect when the formyl hydrogen was replaced with deuterium. Likewise, glutathione depletion and metabolite formation were reduced or abolished by the deuteration or methylation of the formyl moiety of NMF. NEF, like NMF, depleted hepatocytic glutathione levels and was metabolised to a carbamoylating metabolite. Radioactivity derived from 14C-NMF and 14C-NEF, labelled in the alkyl moieties, was found to be irreversibly associated with microsomal protein on incubation in vitro. Binding was dependent on the presence of NADPH and was mostly abolished in the presence of reduced glutathione. SKF525A failed to influence the binding.

Sensing and control of adipocyte function

Obesity has become a global epidemic. Approximately 15% of the world population is either overweight or obese. This figure rises to 75% in many westernised countries including the United Kingdom. Health costs in the UK to treat obesity and associated disease are conservatively estimated at 6% of the National Health Service (NHS) budget equating to 3.33 billion Euros. Excess adiposity, especially in visceral depots, increases the risk of type 2 diabetes, cardiovascular disease, gall stones, hypertension and cancer. Type 2 diabetes mellitus accounts for >90% of all cases of diabetes of which the majority can be attributed to increased adiposity, and approximately 70% of cardiovascular disease has been attributed to obesity in the US. Weight loss reduces risk of these complications and in some cases can eliminate the condition. However, weight loss by conventional non-medicated methods is often unsuccessful or promptly followed by weight regain. This thesis has investigated adipocytes development and adipokine signalling with a view to enhance the understanding of tissue functionality and to identify possible targets or pathways for therapeutic intervention. Adipocyte isolation from human tissue samples was undertaken for these investigative studies, and the methodology was optimised. The resulting isolates of pre-adipocytes and mature adipocytes were characterised and evaluated. Major findings from these studies indicate that mature adipocytes undergo cell division post terminal differentiation. Gene studies indicated that subcutaneous adipose tissue exuded greater concentrations and fluctuations of adipokine levels than visceral adipose tissue, indicating an important adiposensing role of subcutaneous adipose tissue. It was subsequently postulated that the subcutaneous depot may provide the major focus for control of overall energy balance and by extension weight control. One potential therapeutic target, 11ß-hydrosteroid dehydrogenase (11ß-HSD1) was investigated, and prospective inhibitors of its action were considered (BVT1, BVT2 and AZ121). Selective reduction of adiposity of the visceral depot was desired due to its correlation with the detrimental effects of obesity. However, studies indicated that although the visceral depot tissue was not unaffected, the subcutaneous depot was more susceptible to therapeutic inhibition by these compounds. This was determined to be a potentially valuable therapeutic intervention in light of previous postulations regarding long-term energy control via the subcutaneous tissue depot.