Gerontodermatology: the fragility of the epidermis in older adults.

The proportion of adults over 60 years of age is rapidly increasing and is estimated to reach approximately one-sixth of the global population by 2030. An ageing population is a real challenge for healthcare resources, including dermatologists and geriatricians, as age-related changes in skin integrity and barrier function make older adults more susceptible to developing skin pathologies such as pruritus, dermatitis and infections. Fragile skin arises from several interlinked causes, including age-related changes in skin barrier integrity, previous and current lifestyle choices, skin pathologies and medical interventions. Dermo-cosmetics can play a key role in enhancing skin care regimens and preventing pathologies in this age group. In vitro studies, clinical, and in-daily clinical practice studies of dermo-cosmetics have shown them to be effective in many skin conditions in older adults, like xerosis and pruritus. Incontinence-associated dermatitis (IAD), a common condition arising from contact with irritants such as urine and faeces which can significantly impact the quality of life of sufferers, can also be improved with a barrier cream in incontinent patients aged 70 years and older. This supplement focuses on the increased fragility of older skin, the development of common skin pathologies and the efficacy and tolerance of dermo-cosmetic products in older adults.

A new hair follicle-derived human epidermal model for the evaluation of sunscreen genoprotection.

Induction of skin cancer is the most deleterious effect of excessive exposure to sunlight. Accurate evaluation of sunscreens to protect the genome is thus of major importance. In particular, the ability of suncare products to prevent the formation of DNA damage should be evaluated more directly since the Sun Protection Factor is only related to erythema induction. For this purpose, we developed an in vitro approach using a recently characterized reconstituted human epidermis (RHE) model engineered from hair follicle. The relevance of this skin substitute in terms of UV-induced genotoxicity was compared to ex vivo explants exposed to solar-simulated radiation (SSR). The yield of bipyrimidine photoproducts, their rate of repair, and the induction of apoptosis were very similar in both types of skin samples. In order to evaluate the protection afforded by sunscreen against DNA damage, bipyrimidine photoproducts were quantified in tissue models following SSR exposure in the presence or absence of a SPF50+ formula. A rather high DNA protection factor of approximately 20 was found in RHE, very similar to that determined for explants. Thus, RHE is a good surrogate to human skin, and also a convenient and useful tool for investigation of the genoprotection of sunscreens.

A genome scan for type 2 diabetes susceptibility loci in a genetically isolated population.

A total of 896 individuals of Ashkenazi Jewish descent were ascertained in Israel from 267 multiplex families, including 472 sib-pairs affected with type 2 diabetes. A genome-wide scan with average marker spacing of 9.5 cM revealed five regions on four chromosomes (4q, 8q, 14q, and 20q) that exhibited nominal evidence for linkage (P < 0.05). The highest observed nonparametric linkage Z score was 2.41 (equivalent to a logarithm of odds score of 1.26) at marker D4S1501. A maximal signal, with a Z score of 2.05, was observed on chromosome 20 near marker D20S195, and another on 20p near marker D20S103 (Z 1.80). A single marker on chromosome 8 (D8S593) and two adjacent markers on chromosome 14 (D14S749 and D14S605) also attained evidence of linkage. To explore the hypothesis that the signals on chromosomes 4 and 20 are differentially attributable to variation in BMI or age of onset, an ordered subset analysis was conducted. This analysis revealed that only when the families were ranked by BMI (in increasing order) did a subset attain nominal significance, and only for chromosome 4. The findings reported here lend credence to the hypothesis, now supported by four studies of Caucasian populations and most recently by a combined analysis of 1,852 pedigrees, that a type 2 diabetes susceptibility locus resides on chromosome 20q. This population, because of its unique genetic attributes, may facilitate identification of this and other genes contributing to type 2 diabetes.

Identification and functional analysis of novel human melanocortin-4 receptor variants.

Inactivation of the melanocortin-4 receptor (MC4-R) by gene-targeting results in mice that develop maturity-onset obesity, hyperinsulinemia, and hyperglycemia. These phenotypes resemble common forms of human obesity, which are late-onset and frequently accompanied by NIDDM. It is not clear whether sequence variation of the MC4-R gene contributes to obesity in humans. Therefore, we examined the human MC4-R gene polymorphism in 190 individuals ascertained on obesity status. Three allelic variants were identified, including two novel ones, Thr112Met and Ile137Thr. To analyze possible functional alterations, the variants were cloned and expressed in vitro and compared with the wild-type receptor. One of the novel variants, Ile137Thr, identified in an extremely obese proband (BMI 57), was found to be severely impaired in ligand binding and signaling, raising the possibility that it may contribute to development of obesity. Furthermore, our results also suggest that sequence polymorphism in the MC4-R coding region is unlikely to be a common cause of obesity in the population studied, given the low frequency of functionally significant mutations.

Mapping of the human insulin receptor substrate-2 gene, identification of a linked polymorphic marker and linkage analysis in families with Type II diabetes: no evidence for a major susceptibility role.

Insulin receptor substrate 2 (IRS-2) is a substrate of the insulin receptor and mediates the action of the insulin. Disruption of the IRS-2 gene in mice results in peripheral insulin resistance and relative insulin deficiency. It is therefore possible that defects in the IRS-2 gene contribute to Type II (non-insulin-dependent) diabetes mellitus. We have examined the gene for evidence of linkage to Type II diabetes in Ashkenazi Jewish families. Radiation hybrid panel mapping was used to refine the map position of the IRS-2 gene and, in the absence of polymorphic markers within the gene, to identify nearby markers. The IRS-2 gene was placed 23cR from the marker D13S1265 on chromosome 13q34. 200 affected sib-pairs were genotyped for three markers across the region. Nonparametric linkage analysis (GENEHUNTER) used with this data found no evidence of excess allele sharing in the IRS-2 gene region. We therefore concluded that variation in the IRS-2 gene is unlikely to contribute to Type II diabetes in this discrete Caucasian population.

Measurement challenges and other practical concerns when studying massively obese individuals.

OBJECTIVE: To describe the measurement challenges faced and to evaluate the measurement quality obtained with massively obese individuals. METHOD: A cross-sectional analysis of 107 individuals with body mass indices (kg/m2) > or = 50 was conducted. Individuals had their body fat measured via bioimpedance analysis (BIA), their serum leptin levels measured via radioimmunoassay (RIA), and height and weight measured via both laboratory scales and self-report. RESULTS: Serum leptin appeared to be measured accurately, provided the serum was diluted prior to conducting the RIA. Difficulties remained, however, in evaluating what was an unusual or expected value of leptin among individuals this large. Measures of impedance appeared to provide reasonable ordinal indications of body fatness. However, currently available equations for converting measures of impedance to estimates of percent body fat were highly inaccurate. Self-reported height and weight were reasonably good proxies of measured height and weight among individuals who reported their height and weight. However, a substantial proportion were unable to provide estimates. DISCUSSION: The above results suggest there are substantial challenges when trying to obtain meaningful measurements regarding obesity-related variables among massively obese individuals. Other logistic challenges also are discussed. It is hoped future research is directed at overcoming some of these challenges.

The effects of health care reforms on job satisfaction and voluntary turnover among hospital-based nurses.

OBJECTIVES: Among the consequences of downsizing and cost containment in hospitals are major changes in the work life of nurses. As hospitals become smaller, patient acuity rises, and the job of nursing becomes more technical and difficult. This article examines the effects of changes in the hospital environment on nurses' job satisfaction and voluntary turnover between 1993 and 1994. METHODS: Data were collected in a longitudinal survey of 736 hospital nurses in one hospital to examine correlates of change in aspects of job satisfaction and predictors of leaving among nurses who terminated in that period. RESULTS: Unadjusted results showed decline in most aspects of satisfaction as measured by Hinshaw and Atwood's and Price and Mueller's scales. Multivariate analysis indicated that the most important determinants of low satisfaction were poor instrumental communication within the organization and too great a workload. Intent to leave was predicted by the perception of little promotional opportunity, high routinization, low decision latitude, and poor communication. Predictors of turnover were fewer years on the job, expressed intent to leave, and not enough time to do the job well. CONCLUSIONS: The authors conclude that although many aspects of job satisfaction are diminished, some factors predicting low satisfaction and turnover may be amenable to change by hospital administrators.

Enhancing support for the graduate nurse.

The authors describe how their new Clinical Entry Nurse Residency Program has helped beginning nurses advance along Benner's path toward expertise.

Establishing an interdisciplinary patient care team: collaboration at the bedside and beyond.

The authors describe how an interdisciplinary team used skills in communication and collaboration to improve patient care on a busy surgical service. A major goal was to establish and maintain continuity of care in the face of decreasing lengths of stay and increasing patient acuity. The authors share their insight about designing and supporting a successful interdisciplinary patient care team and discuss how their experiences relate to concepts such as case management and career development.

Caring for people with human immunodeficiency virus. Incorporating the patient's perspective.

The interdisciplinary HIV work team meets to improve care for people with the human immunodeficiency virus (HIV). Through its efforts, including patient and provider focus groups, the team identified what is done well in caring for patients with HIV, the obstacles that patients encounter in accessing care, and how to prepare for the future. The work team has been instrumental in developing ideas and implementing changes by serving as a vehicle for communication and enhancing a spirit of collaboration.