Relation between patients' and physicians' severity assessment of occupational hand eczema.

BACKGROUND: Severity assessment of occupational hand eczema (OHE) is important not only in clinical settings but also in research. Questionnaires with self-rated assessment of severity may be an attractive tool for assessing severity because of their cost efficiency in comparison with expensive clinical examinations. OBJECTIVES: To evaluate the relation between self-rated severity and severity assessment based on standardized medical certificates issued by dermatologists in a population of patients with OHE. METHODS: Between October 2001 and November 2002 (58 weeks) we identified all new cases of recognized OHE from the Danish National Board of Industrial Injuries (DNBII) registry. Each patient was examined by a dermatologist, who issued a standardized medical certificate. The severity assessment in the DNBII registry was based on this medical certificate, which comprised information on morphology and extent of eczema, and frequency of eruptions. All participants received a self-administered questionnaire and were asked to classify severity of their OHE on a visual analogue scale from 0 to 10. The relation between DNBII-assessed and self-rated severity was illustrated by a receiver operating characteristic analysis. RESULTS: Of 758 patients included in the study, 621 returned the questionnaire and 602 (79%) provided information on self-rated severity. The proportion of severe cases was significantly higher among patients' assessments compared with the rating by the DNBII. Almost 18% were categorized as severe cases by the DNBII while 40% of patients had assessed themselves as having severe eczema. The optimal cut-off point had a sensitivity and specificity of self-rated severity according to the DNBII assessment of 65% and 66%, respectively. The positive predictive value was 29% and the negative predictive value was 90%. CONCLUSIONS: The low positive predictive value suggests major differences in the criteria for self-rated severity vs. DNBII-rated severity. We recommend researchers to include ratings from both patients and physicians in future investigations of severity. The methods may address different aspects of OHE.

Relation between diagnoses on severity, sick leave and loss of job among patients with occupational hand eczema.

BACKGROUND: Epidemiological studies indicate that occupational hand eczema (OHE) often is associated with persistent dermatitis and prolonged sick leave, which may lead to unemployment. Previous studies suggest that OHE caused by allergic contact dermatitis and atopic dermatitis (AD) carries the worst prognosis. OBJECTIVES: To evaluate and compare the severity and consequences of recognized OHE in different diagnostic and subdiagnostic groups. METHODS: Between October 2001 and November 2002, all new cases of recognized OHE were identified from the Danish National Board of Industrial Injuries Registry (758 cases). Severity was graded from 0 to 2 depending on the intensity of skin response and the frequency of relapse. To supplement the information from the Registry, we surveyed the study population using a postal questionnaire which included questions about disease duration, sick leave, current occupation and loss of job. RESULTS: The overall response rate to the questionnaire was 82%. We observed substantially greater severity among those with occupational irritant contact dermatitis (ICD) and AD than for any other diagnoses. Age above 50 years was also associated with increased severity of OHE. Prolonged sick leave due to OHE was reported by 19.9% and was associated with AD and severe OHE. We found a higher proportion of prolonged sick leave among those in food-related occupations (27.2%) compared with those in wet occupations (20.1%) and other occupations (16.5%). Twenty-three per cent reported that they had lost their job at least once during the past 12 months due to OHE. The only strong association with loss of job was food-related occupations. CONCLUSIONS: Occupational ICD and AD appear to be strongly associated with severity of OHE. AD and severity of OHE were independently associated with prolonged sick leave. Having a food-related occupation appears to be associated with increased risk of loss of job.

Concurrent measurement of smooth muscle shortening, lumen narrowing and flow to acetylcholine in large and small porcine bronchi.

Models of airway function indicate that responsiveness (flow reduction) to bronchoconstrictor provocation depends on airway smooth muscle shortening and airway wall morphology. The contribution of these factors to the responsiveness of central and peripheral bronchi was assessed. Lumen flow was recorded in porcine perfused small (2 min i.d.) and large bronchial segments (6 mm i.d.). Lumen diameter was recorded in the same airways after inserting an endoscope. Smooth muscle shortening, relative wall area (WAr), smooth muscle and cartilage thickness and mucosal folds were measured morphometrically. The effect of acetylcholine (ACh; 10(-6)-10(-1) M) on functional measurements was determined by curve fitting. Maximum muscle shortening was 30% in small and 19% in large bronchi (p<0.01) and lumen narrowing was 49% and 39%, respectively. High doses of ACh stopped flow in small bronchi, but produced a plateau in large bronchi. Small airways were 250-times more sensitive to ACh than large airways, for all measurements. Smooth muscle and cartilage thickness and numbers of mucosal folds were greater in large than in small bronchi (p< or =0.01). Lumen narrowing and flow reduction were greater than predicted on the basis of muscle shortening and WAr (p<0.05). The structure of airways from the two groups was qualitatively similar, but responses were markedly different. Greater narrowing and flow responses of small bronchi were directly associated with smooth muscle responsiveness in situ. The results suggest that in vivo changes in airway wall shape or dimensions, or luminal secretions, exert a significant effect on airway flow, particularly in the small airways.

Influence of regional differences in ETA and ETB receptor subtype proportions on endothelin-1-induced contractions in porcine isolated trachea and bronchus.

1. Quantitative autoradiographic studies were conducted to determine the distributions and densities of ETA and ETB binding site subtypes in porcine tracheal and bronchial smooth muscle. In addition, the roles of ETA and ETB receptors in endothelin-1-mediated contraction of these tissues were assessed. 2. Quantitative autoradiographic studies revealed that both ETA and ETB binding sites for [125I]-endothelin-1 were present in both bronchial and tracheal airway smooth muscle. However, the proportions of these sites were markedly different at these two levels within the respiratory tract. In tracheal smooth muscle, the proportions of ETA and ETB sites were 30 +/- 1% and 70 +/- 1% respectively, whereas in bronchial smooth muscle, these proportions were virtually reversed, being 73 +/- 2% and 32 +/- 8% respectively. 3. Endothelin-1 induced concentration-dependent contraction of porcine tracheal and bronchial airway smooth muscle. Endothelin-1 had similar potency (concentration producing 30% of the maximum carbachol contraction, Cmax) in trachea (22 nM; 95% confidence limits (c.l.), 9-55 nM; n = 9) and bronchus (22 nM; c.l., 9-55 nM; n = 6). Endothelin-1 also produced comparable maximal contractions in trachea (59 +/- 5% Cmax; n = 9) and bronchus (65 +/- 4% Cmax, n = 6). 4. In trachea, endothelin-1 induced contractions were not significantly inhibited by either the ETA receptor-selective antagonist, BQ-123 (3 microM) or the ETB receptor-selective antagonist, BQ-788 (1 microM). However, in the combined presence of BQ-123 and BQ-788, the concentration-effect curve to endothelin-1 was shifted to the right by 3.7 fold (n = 8; P = 0.01). 5. In bronchus, concentration-effect curves to endothelin-1 were shifted to the right by BQ-123 (3 microM; 4.3 fold; P < 0.05), but not by BQ-788 (1 microM). In the presence of both antagonists, concentration-effect curves to endothelin-1 were shifted by at least 6.7 fold (n = 6; P = 0.01). 6. Sarafotoxin S6c induced contraction in both tissue types, although the maximum contraction was greater in trachea (53 +/- 7% Cmax; n = 6) than in bronchus (21 +/- 5% Cmax; n = 6). BQ-788 (1 microM) markedly reduced sarafotoxin S6c potency in both trachea and bronchus (e.g. by 50 fold in trachea; c.l., 14-180; n = 6; P < 0.05). 7. These data demonstrate that the proportions of functional endothelin receptor subtypes mediating contraction of airway smooth muscle to endothelin-1, vary significantly at different levels in the porcine respiratory tract.