["Health 2020" - the New European Framework Strategy of WHO]. / "Gesundheit 2020" - das neue europäische Rahmenkonzept der WHO.

The WHO Regional Committee for Europe agreed in September 2012 on the new framework strategy "Health 2020". The framework has the strategic objectives of improving health for all and reducing health inequalities as well as improving leadership and participatory governance for health. The present article introduces the basic points of "Health 2020". Central elements (European Action Plan for Strengthening Public Health and Public Health Services, health and well-being, reducing health inequalities, whole-of-governance and whole-of-society approaches) are described in more detail, taking background materials into account. Critical remarks address the implementation, reporting and governance issues. They are discussed by taking into account the context of the development of "Health 2020". Even if some critical aspects exist, it can be stated that "Health 2020" delivers a framework and orientation for health policies - as well as for the heterogeneous situation in WHO Europe as well as for Germany.

[Health targets for health promotion in an area of conflict between individual freedom, state paternalism and common welfare]. / Gesundheitsziele zur Gesundheitsförderung im Spannungsfeld von individueller Freiheit, staatlichem Paternalismus und Gemeinwohl.

In Germany, a growing number of health targets has been adopted in the last years by various actors. While health targets are a useful instrument of governance, the priority setting and a respective redistribution of resources have to be legitimised in the cause of their advantages and disadvantages for population groups. The involved sciences including ethics can support decision-making, but not fully justify decisions. Therefore, decisions on health targets must be made in a transparent and participative process. In spite of a growing number of health targets, the lack of targets in health policies is to be criticised. Within the health targets, those measures assigned to curative medicine and prevention have a greater weight than health promotion. Health promotion should follow the WHO Ottawa-Charter and be embedded in the concept of "capabilities". Under these conditions, a stronger consideration of health promotion in the health target process would be desirable. However, the present actor constellations within health target processes make such a direction improbable. The struggle around capabilities and individual freedom occurs through, in and about institutions of the civil society as well as political and legal institutions. To restrict the discussion about public health and health promotions to an juxtaposition of individual freedom and state paternalism minimises societal and social restrictions of individual freedom as well as the possibility of a safeguard and enlargement of individual freedoms through political and legal institutions.

[Dissent in public health ethics. A guarantor for political credibility?]. / Der Dissens in der Public-Health-Ethik. Ein Garant für politische Glaubwürdigkeit?

Public health covers public activities linked with cure, prevention and health promotion directed to positively influence the health of populations. As far as these criteria are met, health policies are public health. Public health holds many ethical implications. Resources and health opportunities are redistributed, ends and means of public health as well as rights and duties have to be discussed, and conflicts exist between targets. Ethical policy counselling is an important complement to natural and social scientific policy counselling. However, ethical counselling cannot solve conflicts about values and norms nor does it claim to do so. There are different theories and approaches, recommended principles differ and are in conflict with each other. It must not be expected that a generally accepted frame for public health ethical policy counselling will be developed. Public health ethics can develop an ordering effect and enforce more clarity for actors about their values and norms, but in case of unresolvable dissent between experts it can also be misused to give support to the legitimation of political decisions. Orientation of consulting activities towards the "pragmatistic model" (Habermas) and a counselling of the civil society is promising to prevent such exploitation.

[Policy counselling through public health reporting?]. / Politikberatung durch Gesundheitsberichterstattung?

For about 20 years public health reporting has increasingly been developed as a resource in health policy counselling. Both with regard to its use as well as its further development it is important to reflect on the possibilities and limits of this resource. A basis for this is provided by theories, models and hypotheses derived from the discussion about scientific policy counselling. In early conceptual reflections on the organisation of health reporting a technocratic use was rejected. This is reflected by the ideas and views about the institutional embedding of health reporting activities. Against the background of diverging opinions about the political dimensions of health reporting activities, reflections were guided by the decisionistic and pragmatic model of the "scientification of politics". Public health reporting must provide the possibility for being used in a flexible way in order to add a pragmatistic component to its decisionistic and strategic uses. For action-oriented, pragmatistic and scientific policy counselling through the health reporting discipline it is important to link "information about politically relevant facts" with the "targeted processing of knowledge geared towards problems in the field of decision-making processes" (expertise).

1,25-Dihydroxyvitamin D inhibits lipopolysaccharide-induced immune activation in human endothelial cells.

In addition to its well-known role in mineral and skeletal homeostasis, 1,25-dihydroxyvitamin D3 [1,25-(OH)2, D3] regulates the differentiation, growth and function of a broad range of immune system cells, including monocytes, dendritic cells, T and B lymphocytes. Vascular endothelial cells play a major role in the innate immune activation during infections, sepsis and transplant rejection; however, currently there are no data on the effect of 1,25-(OH)2 D3 on microbial antigen-induced endothelial cell activation. Here we show that 1,25-(OH)2 D3 pretreatment of human microvessel endothelial cells (HMEC) inhibited the enteric gram-negative bacterial lipopolysaccharide (LPS) activation of transcription factor NF-kappaB and interleukin (IL)-6, IL-8 and regulated upon activation normal T cell exposed and secreted (RANTES) release. The effect of 1,25-(OH)2 D3 was not due to increased cell death or inhibition of endothelial cell proliferation. 1,25-(OH)2 D3 pretreatment of HMEC did not block MyD88-independent LPS-induced interferon (IFN)-beta promoter activation. 1,25-(OH)2 D3 pretreatment of HMEC did not modulate Toll-like receptor 4 (TLR4) or MD-2 expression. These data suggest that 1,25-(OH)2 D3 may play a role in LPS-induced immune activation of endothelial cells during gram-negative bacterial infections, and a suggest a potential role for 1,25-(OH)2 D3 and its analogues as an adjuvant in the treatment of gram-negative sepsis.

Neuronal storage of histamine in the brain and tele-methylimidazoleacetic acid excretion in portocaval shunted rats.

Rats with portocaval anastomosis (PCA), an animal model of hepatic encephalopathy (HE), have very high brain histamine concentrations. Our previous studies based on a biochemical approach indicated histamine accumulation in the neuronal compartment. In this study, immunohistochemical evidence is presented which further supports the amine localization in histaminergic neurons. These neurons become pathological in appearance with cisternae frequently seen along histaminergic fibres in many brain areas, including the hypothalamus, amygdala, substantia nigra and cerebral cortex. Such formations were not observed in sham-operated animals. The neuronal deposition is predominant, and unique for histamine. It serves as a mechanism to counterbalance excessive brain neurotransmitter formation evoked by PCA. However, there are other mechanisms. The data provided here show that there is also a significant increase in histamine catabolism in the shunted rats, as reflected by both the higher brain N-tele-methylhistamine (t-MeHA) concentration and urinary excretion of N-tele-methylimidazoleacetic acid (t-MelmAA), a major brain histamine end product. The stomach, in addition to the brain, is a site of enhanced histamine synthesis in portocavally shunted subjects. After gastrectomy or food deprivation to eliminate the contribution of the stomach, shunted rats excrete significantly more t-MelmAA, implying the role of the CNS. This last finding suggests that under strictly defined conditions, namely in parenterally fed HE patients with abnormal plasma L-histidine, the measurement of urinary t-MelmAA might provide valuable information concerning putative brain histaminergic activity.

Multiple sites of L-histidine decarboxylase expression in mouse suggest novel developmental functions for histamine.

Histamine mediates many types of physiologic signals in multicellular organisms. To clarify the developmental role of histamine, we have examined the developmental expression of L-histidine decarboxylase (HDC) mRNA and the production of histamine during mouse development. The predominant expression of HDC in mouse development was seen in mast cells. The HDC expression was evident from embryonal day 13 (Ed13) until birth, and the mast cells were seen in most peripheral tissues. Several novel sites with a prominent HDC mRNA expression were revealed. In the brain, the choroid plexus showed HDC expression at Ed14 and the raphe neurons at Ed15. Close to the parturition, at Ed19, the neurons in the tuberomammillary (TM) area and the ventricular neuroepithelia also displayed a clear HDC mRNA expression and histamine immunoreactivity (HA-ir). From Ed14 until birth, the olfactory and nasopharyngeal epithelia showed an intense HDC mRNA expression and HA-ir. In the olfactory epithelia, the olfactory receptor neurons (ORN) were shown to have very prominent histamine immunoreactivity. The bipolar nerve cells in the epithelium extended both to the epithelial surface and into the subepithelial layers to be collected into thick nerve bundles extending caudally toward the olfactory bulbs. Also, in the nasopharynx, an extensive subepithelial network of histamine-immunoreactive nerve fibers were seen. Furthermore, in the peripheral tissues, the degenerating mesonephros (Ed14) and the convoluted tubules in the developing kidneys (Ed15) showed HDC expression, as did the prostate gland (Ed15). In adult mouse brain, the HDC expression resembled the neuronal pattern observed in rat brain. The expression was restricted to the TM area in the ventral hypothalamus, with the main expression in the five TM subgroups called E1-E5. A distinct mouse HDC mRNA expression was also seen in the ependymal wall of the third ventricle, which has not been reported in the rat. The tissue- and cell-specific expression patterns of HDC and histamine presented in this work indicate that histamine could have cell guidance or regulatory roles in development.

The role of toll-like receptors (TLRs) in bacteria-induced maturation of murine dendritic cells (DCS). Peptidoglycan and lipoteichoic acid are inducers of DC maturation and require TLR2.

Toll-like receptors (TLRs) have been found to be key elements in pathogen recognition by the host immune system. Dendritic cells (DCs) are crucial for both innate immune responses and initiation of acquired immunity. Here we focus on the potential involvement of TLR ligand interaction in DC maturation. TLR2 knockout mice and mice carrying a TLR4 mutation (C3H/HeJ) were investigated for DC maturation induced by peptidoglycan (PGN), lipopolysaccharide (LPS), or lipoteichoic acids (LTAs). All stimuli induced maturation of murine bone marrow-derived DCs in control mice. TLR2(-)/- mice lacked maturation upon stimulation with PGN, as assessed by expression of major histocompatibility complex class II, CD86, cytokine, and chemokine production, fluorescein isothiocyanate-dextran uptake, and mixed lymphocyte reactions, while being completely responsive to LPS. A similar lack of maturation was observed in C3H/HeJ mice upon stimulation with LPS. DC maturation induced by LTAs from two different types of bacteria was severely impaired in TLR2(-)/-, whereas C3H/HeJ mice responded to LTAs in a manner similar to wild-type mice. We demonstrate that DC maturation is induced by stimuli from Gram-positive microorganisms, such as PGN and LTA, with similar efficiency as by LPS. Finally, we provide evidence that TLR2 and TLR4 interaction with the appropriate ligand is essential for bacteria-induced maturation of DCs.

Toll-like receptor-2 mediates Treponema glycolipid and lipoteichoic acid-induced NF-kappaB translocation.

Recently Toll-like receptors (TLRs) have been found to be involved in cellular activation by microbial products, including lipopolysaccharide, lipoproteins, and peptidoglycan. Although for these ligands the specific transmembrane signal transducers TLR-4, TLR-2, or TLR-2 and -6 have now been identified, the molecular basis of recognition of lipoteichoic acids (LTAs) and related glycolipids has not been completely understood. In order to determine the role of TLRs in immune cell activation by these stimuli, experiments involving TLR-2-negative cell lines, TLR-expression plasmids, macrophages from TLR-4-deficient C3H/HeJ-mice, and inhibitory TLR-4/MD-2 antibodies were performed. Glycolipids from Treponema maltophilum and Treponema brennaborense, as well as highly purified LTAs from Staphylococcus aureus and Bacillus subtilis exhibited TLR-2 dependence in nuclear factor kappaB activation and cytokine induction; however, T. brennaborense additionally appeared to signal via TLR-4. Fractionation of the T. brennaborense glycolipids by hydrophobic interaction chromatography and subsequent cell stimulation experiments revealed two peaks of activity, one exhibiting TLR-2-, and a second TLR-4-dependence. Furthermore, we show involvement of the signaling molecules MyD88 and NIK in cell stimulation by LTAs and glycolipids by dominant negative overexpression experiments. In summary, the results presented here indicate that TLR-2 is the main receptor for Treponema glycolipid and LTA-mediated inflammatory response.

Induction of cross-tolerance by lipopolysaccharide and highly purified lipoteichoic acid via different Toll-like receptors independent of paracrine mediators.

Exposure of macrophages to LPS induces a state of hyporesponsiveness to subsequent stimulation with LPS termed LPS desensitization or tolerance. To date, it is not known whether similar mechanisms of macrophage refractoriness are induced on contact with components of Gram-positive bacteria. In the present study, we demonstrate that pretreatment with highly purified lipoteichoic acid (LTA) results in suppression of cytokine release on restimulation with LTA in vitro and in vivo in both C3H/HeN and C3H/HeJ mice, but not in macrophages from Toll-like receptor (TLR)-2-deficient mice. Furthermore, desensitization in response to LPS or LTA exposure also inhibits responses to the other stimulus ("cross-tolerance"), suggesting that signaling pathways shared by TLR2 and TLR4 are impaired during tolerance. Finally, we show that LPS- or LTA-induced cross-tolerance is not transferred to hyporesponsive cells cocultured with LPS/LTA-responsive macrophages, showing that soluble mediators do not suffice for tolerance induction in neighboring cells.

Activation of mitogen-activated protein kinases p42/44, p38, and stress-activated protein kinases in myelo-monocytic cells by Treponema lipoteichoic acid.

We have shown previously that phenol/water extracts derived from two novel Treponema species, Treponema maltophilum, and Treponema brennaborense, resembling lipoteichoic acid (LTA), induce cytokines in mononuclear cells. This response was lipopolysaccharide binding-protein (LBP)-dependent and involved Toll-like receptors (TLRs). Here we show that secretion of tumor necrosis factor-alpha induced by Treponema culture supernatants and extracted LTA was paralleled by an LBP-dependent phosphorylation of mitogen-activated protein kinases (MAPKs) p42 and p44, and p38, as well as the stress-activated protein kinases c-Jun N-terminal kinases 1 and 2. Phosphorylation of p42/44 correlated with an increase of activity, and tumor necrosis factor-alpha levels were significantly reduced by addition of inhibitors of p42/44 and p38, PD 98059 and SB 203580, respectively. Treponeme LTA differed from bacterial lipopolysaccharide regarding time course of p42/44 phosphorylation, exhibiting a prolonged activation of MAPKs. Furthermore, MAPK activation and cytokine induction failed to be strictly correlated. Involvement of TLR-4 for phosphorylation of p42/44 was shown employing the neutralizing anti-murine TLR-4 antibody MTS 510. In TLR-2-negative U373 cells, the compounds studied differed regarding MAPK activation with T. maltophilum leading to a stronger activation. In summary, the data presented here show that treponeme LTA are able to activate the MAPK and stress-activated protein kinase pathway involving LBP and TLR-4.

Cerebral and gastric histamine system is altered after portocaval shunt.

Biochemical parameters of the histamine (HA) system were examined in both rat brain and stomach, after portocaval anastomosis (PCA). These tissues become rich in histamine after PCA. Immunocytochemistry was used for brain histamine localisation. In addition to increased HA concentrations, monoamine oxidase B activity increased in both tissues. In hypothalamus HA was 15 fold; in cerebral cortex and in stomach mucosa 2.8 and 2.5 fold of the corresponding controls, respectively. MAO B activity was increased by approximately 50% in brain and 100% in stomach. A significant, uneven increase in tele-methylhistamine concentration was only found in the brain. In stomach mucosa higher histidine decarboxylase activity was found. PCA and sham rats treated with an irreversible inhibitor of MAO B, FA-73, 0.5 mg/kg i.p., showed 24 h later greatly reduced MAO activity and doubled t-MeHA concentration in brain structures. The treatment had no effect on gastric mucosal t-MeHA concentration and urinary excretion of the t-MeHA metabolite, N-tele-methylimidazoleacetic acid. The HA rise in the stomach of PCA rats is associated with proliferation of histamine producing and storing cells (ECL cells) as demonstrated by others. However, in the brain we saw no indication for increased number of relevant cells either mast cells or neurons and our immunocytochemical findings suggest that in PCA rat brain, histamine deposits are located exclusively in neurons. The data indicate that the adaptative mechanisms to excessive histamine formation are tissue specific.

Involvement of lipopolysaccharide binding protein, CD14, and Toll-like receptors in the initiation of innate immune responses by Treponema glycolipids.

Culture supernatants from Treponema maltophilum associated with periodontitis in humans and Treponema brennaborense found in a bovine cattle disease accompanied with cachexia caused a dose-dependent TNF-alpha synthesis in human monocytes increasing with culture time. This activity could be reduced significantly by blocking the CD14-part of the LPS receptor using the My 4 mAb and by polymyxin B. In the murine macrophage cell line RAW 264.7, Treponema culture supernatants induced TNF-alpha secretion in a LPS binding protein (LBP)-dependent fashion. To enrich for active compounds, supernatants were extracted with butanol, while whole cells were extracted using a phenol/water method resulting in recovery of material exhibiting a similar activity profile. An LPS-LBP binding competition assay revealed an interaction of the treponeme phenol/water extracts with LBP, while precipitation studies implied an affinity to polymyxin B and endotoxin neutralizing protein. Macrophages obtained from C3H/HeJ mice carrying a Toll-like receptor (TLR)-4 mutation were stimulated with treponeme extracts for NO release to assess the role of TLRs in cell activation. Furthermore, NF-kappaB translocation in TLR-2-negative Chinese hamster ovary (CHO) cells was studied. We found that phenol/water-extracts of the two strains use TLRs differently with T. brennaborense-stimulating cells in a TLR-4-dependent fashion, while T. maltophilum-mediated activation apparently involved TLR-2. These results indicate the presence of a novel class of glycolipids in Treponema initiating inflammatory responses involving LBP, CD14, and TLRs.

The histaminergic system in the brain: structural characteristics and changes in hibernation.

Histaminergic neurons in adult vertebrate brain are confined to the posterior hypothalamic area, where they are comprised of scattered groups of neurons referred to as the tuberomammillary nucleus. Histamine regulates hormonal functions, sleep, food intake, thermoregulation and locomotor activity, for example. In the zebrafish, Danio rerio, histamine was detected only in the brain, where also the histamine synthesizing enzyme L-histidine decarboxylase (HDC) was expressed. It is possible that histamine has first evolved as a neurotransmitter in the central nervous system. We established sensitive quantitative in situ hybridization methods for histamine H(1) and H(2) receptors and HDC, to study the modulation of brain histaminergic system under pathophysiological conditions. A transient increase in H(1) receptor expression was seen in the dentate gyrus and striatum after a single injection of kainic acid, a glutamate analog. H(1) antagonists are known to increase duration of convulsions, and increased brain histamine is associated with reduced convulsions in animal models of epilepsy. No HDC mRNA was detected in brain vessels by in situ hybridization, which suggests lack of histamine synthesis by brain endothelial cells. This was verified by lack of HDC mRNA in a rat brain endothelial cell line, RBE4 cells. Both H(1) and H(2) receptor mRNA was found in this cell line, and the expression of both receptors was downregulated by dexamethasone. The findings are in agreement with the concept that histamine regulates blood-brain barrier permeability through H(1) and H(2) receptor mediated mechanisms. Hibernation is characterized by a drastic reduction of central functions. The activity of most transmitter systems is maintained at a very low level. Surprisingly, histamine levels and turnover were clearly elevated in hibernating ground squirrels, and the density of histamine-containing fibers was higher than in euthermic animals. It is possible that histamine actively maintains the low activity of other transmitters during the hibernation state.

[What effects does methadone maintenance treatment have on the rehabilitation of heroin addicts?]. / Hvilke effekter har vedlikeholdsbehandling med metadon på rehabilitering av heroinavhengige?

The purpose of the study was to determine the effect of methadone maintenance treatment on heroin addicts. By searching in Medline and Cochrane Library two randomized controlled trials were found where methadone was the main intervention in the rehabilitation of heroin addicts. The trials were found among more than 2,350 articles on various aspects of methadone and were the only ones that met our criteria for inclusion in the study. The two studies comprised 347 participants. Both trials showed that methadone maintenance treatment had a positive effect on continuing participation in the treatment programme. One of the trials also showed that the treatment lowered the rates of opioid and cocaine use. It is alarming that only two randomized controlled trials could be found evaluating the effect of methadone maintenance treatment on the rehabilitation of heroin addicts. No trials demonstrating the effect of the treatment on mortality, crime, prostitution or risk behaviour related to communicable diseases were found.

Metabolism of a glucuronide conjugate of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone in rats.

Besides 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), [4-(methylnitrosamino)-1-(3-pyridyl)butl-yl]-beta-O-d-glucosidu ronic acid (NNAL-Glu) is another important metabolite of the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) which has been detected in the urine of tobacco users and non-smokers heavily exposed to sidestream cigarette smoke. In order to evaluate the toxicological significance of NNAL-Glu formation and excretion, the metabolism of [5-3H]-NNAL-Glu was studied in rats. Five male F344 rats were administered 3.7 mg/kg [5-3H]-NNAL-Glu by i.v. injection and the metabolites in urine analysed by HPLC. More than 90% of the radioactivity was excreted in urine within the first 24 h. Unchanged NNAL-Glu accounted for 81.2 +/- 3.1% of the total radioactivity; the remaining part of the dose appears to be deconjugated resulting in the urinary excretion of NNAL (3.6 +/- 1.7%) and its alpha-hydroxylation (11.5 +/- 2.2%) and N-oxidation (3.6 +/- 1.6%) products. The presence of alpha-hydroxylation products of NNAL-Glu in urine suggests that this NNK metabolite may be activated in vivo to carcinogenic intermediates.

Purification and characterization of hepatic triacylglycerol lipase isolated from rainbow trout,Oncorhynchus mykiss.

Trialcylglycerol (TG) lipase was isolated and partially purified from rainbow trout liver. Triacylglycerol lipase activity was assayed by measuring(14)C-oleic acid release from(14)C-triolein.(14)C-oleic acid release was linear for up to two hours. Optimal activity occurred at pH 7.0 and 15°C. Most of the lipase activity was recovered in the cytosolic fraction. A 27,000-fold purification was achieved after Sepharose (Bio-gel A 0.5 M, 200-400 mesh) chromatography of a resuspended 20% ammonium sulfate fraction. The molecular weight of the trout hepatic lipase as determined by size-exclusion chromatography and by SDS-polyacrylamide gel electrophoresis was 40-43 kD. Lipase-mediated hydrolysis of TG resulted in the production of diacylglycerols, monoacylglycerols, and fatty acids. Kinetic analysis indicated that Vmax=0.016 nmol/h/mg protein and that Km=0.28 mM triolein. Lipolytic activity was enhanced in the presence of cAMP/ATP-Mg(2+). These results suggest that the liver of trout possesses a neutral TG lipase that is responsible for mobilizing stored TG and is catalytically activated by phosphorylation.