No Association between Clinical Periodontal Conditions and Microbiological Findings on Driveline of Patients with Left-Ventricular Assist Devices (LVAD)

The aim of this retrospective study was to investigate whether there would be an association between periodontal disease parameters and positive bacterial findings at the driveline of patients with a left ventricular assist device (LVAD). Patients with an LVAD, who underwent a full oral and microbiological examination between 2016 and 2018, were included. During oral examination, periodontitis severity (stage and grade) and the periodontal inflamed surface area (PISA) were evaluated. A microbiological analysis was performed from swabs of the driveline, whereby different bacterial species were cultivated and analyzed. A total of 73 patients were included in the current study. The majority of participants (80.8%) had at least one positive bacterial finding during the study period. Most patients had a periodontitis stage of III-IV (80.9%). The determined PISA of the total group was 284.78 ± 352.29 mm². No associations were found between the periodontal disease parameters and the bacterial findings in general, the bacterial findings on the day of oral examination or the bacterial findings 12 months prior to/after the oral examination (p > 0.05). Periodontitis is not associated with cultivated microbiological findings at the driveline of patients with an LVAD and thus appears not to be a risk indicator for driveline colonization. Nevertheless, the high periodontal burden in LVAD patients underlines the need for their improved periodontal care.

Comparison of periodontal parameters between patients with ischemic and dilative cardiomyopathy

Background

This cross-sectional study aimed in the comparison of periodontal parameters, number of remaining teeth and oral behaviour between patients with ischemic- (ICM) and non-ischemic dilative cardiomyopathy (DCM).

Methods

Patients with HF from the Department for Cardiac Surgery at the Heart Center Leipzig were included. The two groups (ICM and DCM) were composed by matching according to age, gender and smoking habits. All participants received a comprehensive periodontal examination, including a periodontal probing on six measurement points of each tooth.

Results

A total of 226 patients (n = 113 each group) was included. Patients in DCM group used interdental cleaning significantly more often than ICM (23.9% vs. 12.5%, p = 0.04). The majority of patients in both groups (ICM: 83.6%, DCM: 84.6%, p = 0.23) were diagnosed with stage III–IV periodontitis. Periodontal parameters were comparable between groups (p > 0.05). Variance analysis revealed no influence of the group (ICM vs. DCM) on the number of remaining teeth (p = 0.16), periodontitis stage (p = 0.27) or the periodontal inflamed surface area (p = 0.62).

Conclusions

Patients with severe HF show high periodontal burden, without any differences between ICM and DCM group. Therefore, increased attention should be payed to periodontal health of patients with severe heart disease, irrespective of their underlying disease.

Oral health-related quality of life in patients with heart failure and left ventricular assist devices-results of a cross-sectional study

Objectives

The aim of this cross-sectional study was to compare oral health-related quality of life (OHRQoL) of patients with left ventricular assist device (LVAD) and heart failure (HF).

Material and methods

Seventy-four patients with LVAD were recruited from University Department for Cardiac Surgery, Leipzig Heart Center, Germany. A group of 72 patients with HF was composed by matching (age, gender, smoking). The German short form of oral health impact profile (OHIP G14) was applied. Health-related quality of life (HRQoL) was measured by short form 36 survey (SF-36). Dental conditions (decayed-, missing- and filled-teeth [DMF-T]), remaining teeth and periodontal findings were assessed. Statistics: t-test, Mann-Whitney U test, Kruskal-Wallis test, chi-square or Fisher test, linear regression.

Results

Age, gender, smoking, underlying disease, co-morbidities and oral findings were comparable between groups (p > 0.05). OHIP G14 sum score was 3.53 ± 6.82 (LVAD) and 2.92 ± 5.35 (HF; p = 0.70), respectively. The scales SF-36 physical functioning (p = 0.05) and SF-36 social functioning (p < 0.01) were worse in LVAD. In the LVAD group, the DMF-T and remaining teeth negatively correlated with OHIP G14 sum score (p < 0.01). In HF patients, positive correlations were found between OHIP G14 and D-T (p < 0.01) and remaining teeth (p = 0.04). Moreover, DMF-T (p = 0.03) and remaining molars/premolars (p = 0.02) were negatively correlated with SF-36 scales in HF.

Conclusions

Oral health and OHRQoL was comparable between LVAD and HF; thereby, OHRQoL reflected the clinical oral status.

Clinical relevance

Dental care, with beginning in early stage of HF, should be fostered to preserve teeth and support quality of life before and after LVAD implantation.

Oral health-related quality of life of patients after heart transplantation and those with heart failure is associated with general health-related quality of life: a cross-sectional study

PURPOSE

The aim of this cross-sectional study was to examine the oral health-related quality of life (OHRQoL) in patients after heart transplantation (HTx) and those with heart failure (HF).

METHODS

In total, 186 participants (HTx: 104, HF: 82) were recruited from the University Department for Cardiac Surgery, Leipzig Heart Centre, Germany. OHRQoL was assessed with the German short form of the oral health impact profile (OHIP-G14). Health-related quality of life (HRQoL) was evaluated using the short form 36 survey (SF-36). Furthermore, the dental and periodontal treatment need was recorded.

RESULTS

With an OHIP-G14 sum score of 6.58 ± 6.40 [5; 2.5-8] in the HTx group and 5.54 ± 5.47 [5; 2-7] in the HF group, no clinically relevant or statistically significant difference was apparent (p = 0.39). The SF-36 scales for physical functioning, role-physical, general health and vitality were significantly worse in the HF group compared with the HTx group (pi < 0.01). A worse SF-36 physical component summary was significantly associated with a higher OHIP-G14 sum score (HTx: p < 0.01, HF: p = 0.04). In the HTx group, a significant association was also observed for the mental component summary (p < 0.01). Multiple regression analysis revealed physical component summary (p = 0.04) and mental component summary (p < 0.01) in HTx, and physical component summary (p = 0.02), mental component summary (p = 0.02) and smoking (p < 0.01) as significant predictors for OHIP G14 in HF.

CONCLUSION

The OHRQoL in HF and HTx patients appears to be mainly associated with general HRQoL. Therefore, multidisciplinary dental care concepts may be recommended to improve oral health conditions in these patients.

Oral health and dental behaviour of patients with left ventricular assist device: a cross-sectional study

Aims

The aim of this cross‐sectional study was the assessment of dental behaviour, oral health, as well as oral health‐related quality of life of patients with left ventricular assist device (LVAD).

Methods and results

Patients (128) with LVAD were recruited from the University Department for Cardiac Surgery at Heart Center, Leipzig, Germany. A healthy control group (HC, n = 113) was included. Dental behaviour was assessed with a standardized questionnaire, and to evaluate oral health‐related quality of life, the German short form of oral health impact profile was applied. The presence of decayed, missing, and filled teeth; dental treatment need; periodontitis severity; and periodontal treatment need were assessed. These findings were correlated to disease‐related and device‐related factors. The minority of patients used aids for interdental hygiene (16.4%). For the LVAD patients, a German short form of oral health impact profile sum score of 4.96 ± 8.67 [0.5; 0–6] was assessed. The LVAD group suffered from more missing teeth (11.91 ± 9.13 vs. 3.70 ± 3.77; P < 0.01) than HC. More severe periodontitis was found in LVAD group (LVAD = 41.4% and HC = 27.4%; P < 0.01). Periodontal treatment need was high in both groups, without a significant difference (LVAD = 84.4% vs. HC = 86.7%; P = 0.71). LVAD therapy as bridge to transplantation was correlated with periodontal treatment need (odds ratio = 11.48 [1.27; 103.86]; P = 0.03). Further correlations between treatment need and disease specific factors were not detected.

Conclusions

Patients with LVAD suffer from a high periodontal treatment need and a lack in oral behaviour. Interdisciplinary special care concepts appear recommendable to improve oral health in LVAD patients.

Lack in Periodontal Care of Patients Suffering from Severe Heart Diseases-Results after 12 Months Follow-Up

BACKGROUND

To assess whether the standardized recommendation of patients with heart failure (HF), left-ventricular assist device (LVAD) and heart transplantation (HTx) to visit their dentist leads to improved oral conditions after 12 months.

METHODS

Patients from the Department of Cardiothoracic Surgery, Leipzig Heart Centre, Germany were examined at baseline and after 12 months. A dental (decayed-, missing-, and filled-teeth index (DMF-T)) and periodontal examination (periodontal probing depth, clinical attachment loss) was performed. At baseline, patients received a standardized recommendation to visit their dentist. At follow-up, a standardized questionnaire regarding the dental consultation was applied.

RESULTS

Eighty-eight participants (HTx: 31, LVAD: 43, HF: 14) were included. The majority of patients (79.5%) followed the recommendation to visit their dentist. Within the total cohort, periodontal treatment need was significantly reduced from 91% (baseline) to 75% (follow-up; p < 0.01). Only 10% of total cohort stated that they received periodontal treatment. The outcome in periodontal and dental treatment need at follow-up appointment revealed no statistically significant associations to the questionnaire regarding dentist consultation (p > 0.05). Conclusions: The simple recommendation to visit the dentist appears not enough to obtain sufficient dental and periodontal conditions in patients with severe heart diseases. Thereby, a lack in periodontal treatment of patients with HF, HTx and LVAD was identified, making interdisciplinary dental special care programs recommendable.

Technique for visualization of epidermal glandular structures in plants

The distribution of microscopic glandular structures (hairs, capsules, nodules) on a leaf or other plant part can be recorded visually by pressing the plant part against an indicator surface (filter paper, thin-layer chromatography plate) soaked in Tollens' reagent. The glandular sites are revealed instantly on the test surface as dark spots.

Ultraviolet patterns on rear of flowers: basis of disparity of buds and blossoms

Flowers of Jasminium primulinum and Hypericum spp. have ultraviolet patterns on the reverse surface of the corolla. Those areas of the surface that are exposed to the outside in the bud are ultraviolet absorbent, whereas the portions that come into view at maturity in the open blossom are ultraviolet reflectant. Buds and blossoms, as a result, appear different in color to insects sensitive to ultraviolet light. Experimental evidence indicates that the ultraviolet-absorbent quality of the outer surface of the bud is a consequence of exposure itself, attributable possibly to a "sun tanning" effect.

Predictors of mortality in acute lung injury during the era of lung protective ventilation

BACKGROUND

Lung protective ventilation has been widely adopted for the management of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Consequently, ventilator associated lung injury and mortality have decreased. It is not known if this ventilation strategy changes the prognostic value of previously identified demographic and pulmonary predictors of mortality, such as respiratory compliance and the arterial oxygen tension to inspired oxygen fraction ratio (Pao(2)/Fio(2)).

METHODS

Demographic, clinical, laboratory and pulmonary variables were recorded in 149 patients with ALI/ARDS. Significant predictors of mortality were identified in bivariate analysis and these were entered into multivariate analysis to identify independent predictors of mortality.

RESULTS

Hospital mortality was 41%. In the bivariate analysis, 17 variables were significantly correlated with mortality, including age, APACHE II score and the presence of cirrhosis. Pulmonary parameters associated with death included Pao(2)/Fio(2) and oxygenation index ((mean airway pressurexFio(2)x100)/Pao(2)). In unadjusted analysis, the odds ratio (OR) of death for Pao(2)/Fio(2) was 1.57 (CI 1.12 to 3.04) per standard deviation decrease. However, in adjusted analysis, Pao(2)/Fio(2) was not a statistically significant predictor of death, with an OR of 1.29 (CI 0.82 to 2.02). In contrast, oxygenation index (OI) was a statistically significant predictor of death in both unadjusted analysis (OR 1.89 (CI 1.28 to 2.78)) and in adjusted analysis (OR 1.84 (CI 1.13 to 2.99)).

CONCLUSIONS

In this cohort of patients with ALI/ARDS, OI was an independent predictor of mortality, whereas Pao(2)/Fio(2) was not. OI may be a superior predictor because it integrates both airway pressure and oxygenation into a single variable.

The neuromelanin of human substantia nigra and its interaction with metals

Neuromelanin (NM) is a peculiar biochemical component of several neurons in the Substantia Nigra (SN), the target area of the degenerative process in Parkinson Disease (PD). SN NM has peculiarities as to its composition and an impressive capacity of chelating metals, iron in particular, but not exclusively. Gaining insights into the structural and functional characteristics of NM should help understanding the reasons of selective vulnerability of nigral neurons in many parkinsonian conditions. From the present data a protective role of NM can be postulated until the buffering capability toward heavy metals are exhausted. The overloading of NM with iron and other metals in neurons may trigger inflammatory and degenerative processes aggravating the underlying pathological condition.

A national study of medical care expenditures for respiratory conditions

This study was undertaken to estimate the magnitude of medical care expenditures among persons with respiratory conditions in the USA in 1996, and the increment in expenditures attributable to these conditions. The study data were derived from the 1996 Medical Expenditure Panel Survey, a national sample of 21,571 persons. Of the 21,571, 1,027 reported one or more respiratory condition. After weighting, the individuals may represent about 12.1 million persons in the USA. All medical care expenditures of these individuals were tabulated, stratified by comorbidity status, and then compared to those among persons with nonrespiratory conditions or with no conditions. Regression techniques were then used to estimate the increment of healthcare expenditures attributable to the respiratory conditions. From a national total of $45.3 billion, medical care expenditures averaged $3,753 among persons with respiratory conditions. Hospital stays comprised the largest component (45%). The per capita increment in total expenditures attributable to respiratory conditions ranged from $1,003-2,588, from a national total ranging from $12.1-31.3 billion. The total medical care expenditure of persons with respiratory conditions was estimated to be $45.3 billion, of which $12.1-31.3 billion represents an increment in expenditures associated with the conditions themselves.

Attractive and defensive functions of the ultraviolet pigments of a flower (Hypericum calycinum)

The flower of Hypericum calycinum, which appears uniformly yellow to humans, bears a UV pattern, presumably visible to insects. Two categories of pigments, flavonoids and dearomatized isoprenylated phloroglucinols (DIPs), are responsible for the UV demarcations of this flower. Flavonoids had been shown previously to function as floral UV pigments, but DIPs had not been demonstrated to serve in that capacity. We found the DIPs to be present in high concentration in the anthers and ovarian wall of the flower, suggesting that the compounds also serve in defense. Indeed, feeding tests done with one of the DIPs (hypercalin A) showed the compound to be deterrent and toxic to a caterpillar (Utetheisa ornatrix). The possibility that floral UV pigments fulfill both a visual and a defensive function had not previously been contemplated. DIPs may also serve for protection of female reproductive structures in other plants, for example in hops (Humulus lupulus). The DIPs of hops are put to human use as bitter flavoring agents and preservatives in beer.

Production of a cyanogenic secretion by a thyridid caterpillar (Calindoea trifascialis, Thyrididae, Lepidoptera)

The thyridid caterpillar, Calindoea trifascialis, when disturbed, emits a defensive secretion from two sac-like glands that open dorsolaterally on the first abdominal segment. The larva has two arm-like protuberances that project outward from the body just in front of the gland openings. These "arms", which are wetted by secretion when the larva activates its glands, appear to function specifically for administration of the fluid. A primary component of the secretion in mandelonitrile, a cyanogenic compound, but the fluid also contains other potential deterrents, including benzaldehyde, benzoic acid, (E,E)-alpha-farnesene, and 3-methylbutyl-3-methylbutanoate. Tests done in the field in Vietnam, where the species is native, showed the secretion to be protective against ants.

The work impact of asthma and rhinitis

Asthma and rhinitis are common chronic conditions that affect adults of working age. Little is known about their relative impacts on work loss and decreased productivity. Using random digit telephone dialing, we carried out a population-survey of adults in Northern California aged 18-50 years. We interviewed 125 persons with asthma (with or without concomitant rhinitis) and 175 persons with rhinitis alone. Study eligibility was based on subject report of a physician's diagnosis of asthma and/or a rhinitis-related condition. Any adult labor force participation since condition onset was lower among those with asthma (88%) than among those with rhinitis alone (97%) (P = 0.002). In contrast, among those still employed, decreased job effectiveness was more frequently reported in the rhinitis group (43 of 121; 36%) compared to those with asthma (14 of 72; 19%) (P = 0.02). Condition-attributed lost work was common in both groups, with more than 20% reporting one or more complete or partial work days lost in the 4 weeks previous to interview. Taking into account age, gender, race, and smoking status, those with asthma were more likely to have no labor force participation after diagnosis (OR = 3.0; 95% CI 1.1-7.7) and less likely to report decreased job effectiveness among those remaining employed (OR = 0.4; 95% CI 0.2-0.9). Excluding subjects from the rhinitis group most likely to have unreported asthma based on past medication use had little impact on these associations. Both asthma and rhinitis negatively affect work productivity. Those with asthma are less likely to be employed at all, while among those remaining on the job, rhinitis is a more potent cause of decreased work effectiveness. The economic impact of asthma and rhinitis and related conditions may be under-appreciated.

Spray mechanism of the most primitive bombardier beetle (Metrius contractus)

The bombardier beetle Metrius contractus discharges its defensive secretion as a froth that clings to its body. When attacked from the rear, it allows the froth to build up over the gland openings near the abdominal tip; when attacked from the front, it conveys the secretion forwards along special elytral tracks. M. contractus has two-chambered defensive glands typical of bombardier beetles, and its secretion, like that of other bombardiers, is quinonoid and hot. Its frothing mechanism, however, is unique for bombardiers and possibly illustrative of the ancestral glandular discharge mechanism of these beetles. M. contractus, thus, could be the least derived of extant bombardiers.

Defensive use of a fecal thatch by a beetle larva (Hemisphaerota cyanea)

The larva of the tortoise beetle, Hemisphaerota cyanea (Chrysomelidae, Cassidinae), constructs a thatch from long filamentous fecal strands, beneath which it is totally concealed. The thatch is not discarded at molting but is enlarged by addition of strands as the larva grows. Thatch construction begins when the larva hatches from the egg. Pupation occurs beneath the thatch. Two predators, a coccinellid beetle larva (Cycloneda sanguinea) and a pentatomid bug (Stiretrus anchorago), were shown to be thwarted by the thatch. However, one predator, a carabid beetle (Calleida viridipennis), feeds on the larva by either forcing itself beneath the thatch or chewing its way into it. The attack behavior is stereotyped, suggesting that the beetle feeds on Hemisphaerota larvae as a matter of routine.

Chemical defense against predation in an insect egg

The larva of the green lacewing (Ceraeochrysa cubana) (Neuroptera, Chrysopidae) is a natural predator of eggs of Utetheisa ornatrix (Lepidoptera, Arctiidae), a moth that sequesters pyrrolizidine alkaloids from its larval foodplant (Fabaceae, Crotalaria spp.). Utetheisa eggs are ordinarily endowed with the alkaloid. Alkaloid-free Utetheisa eggs, produced experimentally, are pierced by the larva with its sharp tubular jaws and sucked out. Alkaloid-laden eggs, in contrast, are rejected. When attacking an Utetheisa egg cluster (numbering on average 20 eggs), the larva subjects it to an inspection process. It prods and/or pierces a small number of eggs (on average two to three) and, if these contain alkaloid, it passes "negative judgement" on the remainder of the cluster and turns away. Such generalization on the part of the larva makes sense, because the eggs within clusters differ little in alkaloid content. There is, however, considerable between-cluster variation in egg alkaloid content, so clusters in nature can be expected to range widely in palatability. To check each cluster for acceptability must therefore be adaptive for the larva, just as it must be adaptive for Utetheisa to lay its eggs in large clusters and to apportion alkaloid evenly among eggs of a cluster.

Sexually transmitted chemical defense in a moth (Utetheisa ornatrix)

The arctiid moth Utetheisa ornatrix is protected against predation by pyrrolizidine alkaloids (PA) that it sequesters as a larva from its food plant. Earlier work had shown that males transmit PA to the female with the sperm package and that the female bestows part of this gift on the eggs, protecting these against predation as a result. We now show that the female herself derives protection from the gift. Females deficient in PA are vulnerable to predation from spiders (Lycosa ceratiola and Nephila clavipes). If mated with a PA-laden male, the females become unacceptable as prey. The effect takes hold promptly and endures; females are unacceptable to spiders virtually from the moment they uncouple from the male and remain unacceptable as they age. Chemical data showed that the female allocates the received PA quickly to all body parts. We predict that other instances will be found of female insects being rendered invulnerable by receipt of sexually transmitted chemicals.

What do general practice receptionists think and feel about their work?

BACKGROUND

Although there is some published work acknowledging that the general practice receptionist's role is both important and difficult, receptionists' own views have rarely been sought.

AIM

To explore general practice receptionists' ideas and feelings about their work.

METHOD

A questionnaire was distributed to all 150 receptionists in a representative sample of 26 practices in the area covered by Leeds family health services authority. Semi-structured interviews were conducted with a representative group of 20 receptionists selected from the questionnaire sample.

RESULTS

All responders were women, 60% were over 40 years old, and about half had been in the post for more than five years; four-fifths worked part-time. They had chosen the job because it dovetailed with the rest of their lives. Responders derived satisfaction from helping patients, meeting people, having good relationships with colleagues, and doing varied work. Sources of stress included difficult patients, work pressure, problems finding appointments for patients, and feeling caught between doctors' and patients' demands. Responders' experiences and views of training were diverse. Practice managers were important in making them feel consulted and supported. All had a sense of teamwork with colleagues, but many did not perceive the whole practice as a team. Many felt doctors failed to appreciate the pressure and complexity of their work.

CONCLUSIONS

Receptionists' work is complex, demanding and intense, involving a high level of commitment to patients, colleagues, and the practice. Recommendations include improved appointment systems, a positive role for practice managers in relation to reception staff, and individual planning of receptionists' training. Effective teamwork among receptionists should be recognized and developed. General practitioners (GPs) are recommended to develop a greater understanding of receptionists' work.

X-ray absorption fine-structure spectroscopy studies of Fe sites in natural human neuromelanin and synthetic analogues

X-ray absorption fine-structure spectroscopy is used to study the local environment of the iron site in natural (human) neuromelanin extracted from substantia nigra tissue and in various synthetic neuromelanins. All the materials show Fe centered in a nearest neighbor sixfold (distorted) oxygen octahedron; the Fe-O distances, while slightly different in the natural and synthetic neuromelanin, are both approximately 2.0 A. Appreciable differences arise, however, in the second (and higher) coordination shells. In this case the synthetic melanin has the four planar oxygens bound to carbon rings with Fe-C distances of approximately 2.82 and 4.13 A; the human sample does not show the 2.82 A link but instead indicates a double shell at approximately 3.45 and 3.78 A.

Confocal microscopy with a refractive microlens-pinhole array

The stable setup of a confocal arrangement consisting of a combination of a refractive microlens and a pinhole array is presented. The focal plane of the microlenses lies at the rear surface of the substrate in the pinhole plane. By using a microscope objective one can image the stop array onto the object at a reduced size. Surface profiles of refractive and diffractive optical elements were measured with the help of this confocal microscope.

When defense backfires: detrimental effect of a plant's protective trichomes on an insect beneficial to the plant

The plant Mentzelia pumila (family Loasaceae) has leaves and stems densely covered with tiny hooked trichomes. The structures entrap and kill insects and therefore are most probably protective. But they are also maladaptive in that they incapacitate a coccinellid beetle (Hippodamia convergens) that preys upon an aphid enemy (Macrosiphum mentzeliae) of the plant. The adaptive benefit provided by the trichomes is evidently offset by a cost.

Rendering the inedible edible: circumvention of a millipede's chemical defense by a predaceous beetle larva

The larva of the phengodid beetle, Phengodes laticollis, feeds on the millipede, Floridobolus penneri, without risking exposure to the repellent benzoquinones ordinarily ejected by the millipede from its defensive glands when attacked. The phengodid subdues the millipede by piercing the millipede's integument with its hollow sickle-shaped mandibles and apparently injecting gastric fluid. The infusion abruptly paralyzes the millipede, which thereby is prevented from discharging its glands. As the phengodid then imbibes the liquefied systemic contents of the dead millipede, the millipede's benzoquinones remain harmlessly confined to the glands, prevented from diffusing into the millipede's body cavity by the glands' impervious cuticular lining. At the end of the meal only the millipede's skeletal armor and glandular sacs remain uneaten. Analysis of such discarded sacs showed these to contain benzoquinones in amounts commensurate with those present in replete glands of living millipedes.

Primary gastroduodenal prophylaxis with omeprazole for non-steroidal anti-inflammatory drug users

AIM

To investigate the efficacy of omeprazole 20 mg o.m. as primary prophylaxis against non-steroidal anti-inflammatory drug (NSAID)-associated ulcer disease or dyspeptic symptoms.

METHODS

A parallel group study compared patients randomized to receive omeprazole 20 mg o.m. or placebo as co-therapy with on-going NSAID treatment, over 6 months, in 19 specialist centres in Ireland, Hungary, France, the UK and the USA. One hundred and sixty-nine patients taking NSAIDs regularly, chronically and above defined minimum doses entered the trial. The main outcome measure was the development of gastric or duodenal ulcers detected endoscopically, the development of multiple erosions in the stomach or duodenum, or the onset of moderate or severe dyspeptic symptoms.

RESULTS

The estimated probability of remaining free of these end-points for 6 months for patients taking omeprazole was 0.78 compared to 0.53 for placebo (P = 0.004). Fourteen patients receiving placebo (16.5%) developed 15 ulcers, comprising nine gastric and six duodenal ulcers, compared to three patients (3.6%) receiving omeprazole (all gastric ulcers). Logistic regression analysis showed that older patients were less likely, whilst those with rheumatoid arthritis were more likely, to remain free of NSAID-associated problems.

CONCLUSIONS

Omeprazole is an effective agent for gastroduodenal prophylaxis in patients taking NSAIDs. Its main effect is to reduce the rate of development of gastric and duodenal ulcers.

To treat? To befriend? To prevent? Patients' and GPs' views of the doctor's role

OBJECTIVE

To examine and compare patients' and GPs' views of the doctor's role and patients' reasons for going to the doctor.

DESIGN

A cross sectional questionnaire survey.

SETTING

General practices across England.

SUBJECTS

501 patients and 68 GPs.

MAIN OUTCOME MEASURES

Beliefs about the doctors' role and beliefs about patients' reasons for going to the doctor in terms of illness treatment, a psychosocial approach and preventive health care.

RESULTS

A majority of both patients and GPs agreed that the doctor's role was primarily to treat illness. However, whereas patients showed greater endorsement for preventive health care and a belief that the doctor's role was to keep people healthy, GPs showed greater support for an emphasis on personal problems. In terms of patients' reasons for visiting their doctor, a majority of both patients and GPs agreed that illness prevention and illness treatment were important. However, more patients believed that patients visit the doctor for illness prevention than GPs, more of whom felt that patients seek help with their personal problems.

CONCLUSION

The results indicate a mismatch between patients' and GPs' beliefs, which has implications for understanding the impact of recent changes in primary care and the effects on GPs' job satisfaction.

Defensive production of formic acid (80%) by a carabid beetle (Galerita lecontei)

The carabid beetle Galerita lecontei has a pair of abdominal defensive glands that secrete a mixture of formic acid, acetic acid, and lipophilic components (long-chain hydrocarbons and esters). Formic acid, at the concentration of 80%, is the principal constituent. The beetle ejects the secretion as a spray, which it aims accurately toward parts of the body subjected to assault. At full capacity, the glands store 4.5 mg of formic acid (3% of body mass), enough for upward of six ejections. The beetle reloads the glands at a rate of 126 microg of formic acid per day. For the approximately 500 secretory cells of the glands, this means an hourly output of 10 ng of formic acid per cell, or about 5% of cell volume. Replenishing empty glands to their full formic acid load takes the beetle an estimated 37 days. Replenishing the 0.7 mg of formic acid expended in a single discharge takes 5.5 days.

Millipede defense: use of detachable bristles to entangle ants

The millipede Polyxenus fasciculatus (Diplopoda; Polyxenida) defends itself against ants by use of a pair of bristle tufts at its rear. When attacked, it wipes the tufts against the ants, thereby causing these to become encumbered by bristles that detach from the tufts. Ants contaminated with bristles desist from their assault. The bristles have grappling hooks at the tip by which they lock onto setae of the ants and barbs along their length by which they interlink. In attempting to rid themselves of bristles, ants may succeed only in further entangling themselves by causing the bristles to become enmeshed. Ants heavily contaminated may remain entangled and die. Most millipedes have chemical defenses; polyxenids, instead, have a mechanical weapon.

Chemical basis of courtship in a beetle (Neopyrochroa flabellata): Cantharidin as "nuptial gift"

The amount of cantharidin (Spanish fly) that the Neopyrochroa flabellata male presents to the female as a glandular offering during courtship represents only a small fraction of the total cantharidin the male accumulates systemically following ingestion of the compound. A major fraction of the acquired cantharidin is stored by the male in the large accessory glands of the reproductive system. At mating, the male transfers this supply, presumably as part of the sperm package, to the spermatheca of the female. The female in turn allocates the gift to the eggs. Eggs endowed with cantharidin proved relatively invulnerable to attack by a predaceous beetle larva (Coleomegilla maculata).

Chemical basis of courtship in a beetle (Neopyrochroa flabellata): cantharidin as precopulatory "enticing" agent

Male Neopyrochroa flabellata have a natural affinity for cantharidin (Spanish fly). They are attracted to cantharidin baits in the field and feed on the compound if it is offered to them in the laboratory. Males that ingest cantharidin secrete cantharidin from a cephalic gland. Females sample secretion from this gland during courtship and mate preferentially with males that had fed on cantharidin. Cantharidin-unfed males can be rendered acceptable to females if cantharidin is added to their cephalic gland.

Chemical egg defense in a green lacewing (Ceraeochrysa smithi)

The green lacewing Ceraeochrysa smithi (Neuroptera, Chrysopidae), like other members of its family, lays its eggs on stalks, but it is unusual in that it coats these stalks with droplets of an oily fluid. The liquid consists of a mixture of fatty acids, an ester, and a series of straight-chain aldehydes. Relative to the eggs of a congeneric chrysopid that lacks stalk fluid, the eggs of C. smithi proved well protected against ants. Components of the fluid, in an assay with a cockroach, proved potently irritant. Following emergence from the egg, C. smithi larvae imbibe the stalk fluid, thereby possibly deriving nutritive benefit, defensive advantage, or both.

X-ray characterization of melanins--II

Structural modeling of amorphous eumelanin has been carried out by comparing calculated data, S(q) and RDF(r), in reciprocal and real space, respectively, for limited random network models with the experimental X-ray scattering data of tyrosine melanin (Cheng et al., 1994). A basic picture of the atomic arrangements in amorphous eumelanin, which accounts for the short and intermediate range order, has been formulated. This reveals domains of a fundamental "particle" dimension of R approximately 15 A, consisting of a paracrystalline array of disordered planar networks polymerized by 4-8 DHI monomers with a graphite-like stacking spacing of approximately 3.45 A, 4-5 layers thick.

X-ray characterization of melanins--I

The intrinsic local structure characterization of natural sepia melanin and L-dopa and tyrosine synthetic melanin powder has been carried out by X-ray diffraction using synchrotron radiation. The derived structure factor, S(q), shows six significant diffuse peaks within the q-range from 0.3 A-1 to 16 A-1 in the reciprocal space (q = (4 pi sin theta)/lambda, 2 theta is the scattering angle). The Fourier transform of S(q), which yields the radial distribution function (RDF), gives us information in real space of a 1.42 A distance averaged over the C-C, C-O and C-N bond lengths as well as peaks at 2.40-2.41 A, 3.67-3.71 A and 4.67-4.70 A discrete neighbor distances. There is a great similarity in the scattering intensity profiles of the natural and synthetic melanins indicating that the synthetically prepared material may be essentially similar to "real" melanin in its local atomic arrangements. An evidence of a prepeak at q congruent to 0.45 A-1 has been confirmed which indicates a preferred length scale of approximately 13-20 A that corresponds to the initial particle size in colloidal melanin solutions.

Defensive use of an acquired substance (carminic acid) by predaceous insect larvae

Larvae of two insects, a coccinellid beetle (Hyperaspis trifurcata) and a chamaemyiid fly (Leucopis sp.), feed on cochineal insects and appropriate their prey's defensive chemical, carminic acid, for protective purposes of their own. H. trifurcata discharges the chemical with droplets of blood (hemolymph) that it emits when disturbed; Leucopis sp. ejects the compound with rectal fluid. Ants are thwarted by these defenses, which are compared with the previously-described defense of a pyralid caterpillar (Laetilia coccidivora) that disgorges carminic acid-laden crop fluid. The defensive fluid of all three larvae contains carminic acid at concentrations spanning a range (0.2-6.2%) proven deterrent to ants. Many insects are known to appropriate defensive substances from plants. Insects that acquire defensive chemicals from animal sources may be relatively rare.

The fundamental unit of synthetic melanin: a verification by tunneling microscopy of X-ray scattering results

A characteristic dimension of a melanin protomolecule synthesized from tyrosine has been investigated by scanning tunneling microscopy (STM). Identification of a melanin protomolecule of approximately approximately 20 A lateral extent and approximately 10 A height has been established. This size is in good agreement with models constructed to fit wide angle X-ray diffraction experiments on melanin. These protomolecules are believed to consist of Van der Waals interacting stacks of a basic random polymer of 5.6 indolequinone units. There is extensive pi-delocalization within the individual polymeric sheets. Structure minimization and molecular orbital techniques were employed to verify the X-ray and STM results.

[Churg-Strauss syndrome: two cases histories]

Two cases of Churg-Strauss syndrome with severe polyneuropathy have been diagnosed according to clinical and histopathologic criteria. Perforation of small intestine, successfully treated with surgery, was observed in one of two cases. The resected part of gut presented specific histologic picture of Churg-Strauss syndrome.

Chemical attraction of kleptoparasitic flies to heteropteran insects caught by orb-weaving spiders

Insects of the heteropteran families Pentatomidae (stink bugs) and Coreidae (squash bugs), when being eaten by the orb-weaving spider Nephila clavipes, attract flies of the family Milichiidae. The flies aggregate on the bugs and, as kleptoparasites, share in the spider's meal. Stink bugs and squash bugs typically eject defensive sprays when attacked; they do so when caught by Nephila, but the spray only minimally affects the spider. Evidence is presented indicating that it is the spray of the bugs that attracts milichiids to the spider's catch.

[Kallman's syndrome combined with aortic valve anomaly and epilepsy]

Kallman's syndrome is defined clinically as hypogonadotropic hypogonadism associated with anosmia and other congenital abnormalities. There is no report on Kallman's syndrome coexisting with aortic valve anomaly and epilepsy in the available literature. Therefore, the authors considered worthy presenting a case of a 36-years male [correction of female] patient with Kallmann's syndrome combined with aortic valve anomaly, epilepsy and hyperostosis frontalis. Disease history data, clinical examination, the results of hormonal tests and USG helped to establish the diagnosis. Diagnostic and therapeutical problems in such cases have also been discussed.

Endoscopic lithotripsy of biliary stones

Historically, gallstone therapy has been surgery. Gastrointestinal endoscopists and radiologists are now becoming increasingly active in the definitive management of both cholelithiasis and choledocholithiasis. Today, for uncomplicated cholelithiasis and for many cases of choledocholithiasis in patients without increased surgical risk, biliary surgery remains the recommended treatment by internists and surgeons alike. However, with an increased battery of available therapeutic modalities, management decisions and strategies are becoming more complex and the treatment of biliary stone disease in the future will be different than it was in the past.

Presenting characteristics of patients with duodenal ulcer and outcome of medical treatment in controlled clinical trials using cimetidine and diethylamine persilate to treat ulcer attack and diethylamine persilate and placebo to prevent relapses

A double-blind controlled clinical trial on the medical treatment of the acute episode of duodenal ulcer and the prevention of symptomatic relapses was performed. A total of 164 patients with active duodenal ulcer were either treated with cimetidine 1 g/day (70 patients), diethylaminepersilate (DAP) 1.5 g/day (64 patients) or DAP 2.5 g/day (30 patients). DAP is an allegedly protective agent stimulating mucosal prostaglandin synthesis. Cumulative healing rates after 4 weeks in the 3 groups were 66, 28 and 28% and after 8 weeks 94, 70 and 63%, respectively. One hundred and five patients with healed duodenal ulcer received, in a second double-blind study, either DAP 0.5 g/day or placebo. Thus, ulcer healing was more rapid with cimetidine than with DAP. DAP did not prevent relapses. No presenting characteristic was associated with slow healing. Three presenting characteristics--smoking, teetotalling and bleeding episode in the past--were associated with early symptomatic relapse. The present study was compared with a previous study performed by the same group of investigators using a similar study protocol. In both trials, an early relapse was associated with smoking. No other presenting characteristic was identified which in both trials was associated with slow healing or early symptomatic relapse. Thus, smoking appears to be the only one of the commonly available presenting characteristics which allows a prediction of the course of duodenal ulcer disease.

[Misoprostol and cimetidine in the treatment of duodenal ulcer. A multicenter Swiss double-blind study]

The efficacy and tolerance of misoprostol a synthetic prostaglandin E1 analogue-and of cimetidine were evaluated in the treatment of duodenal ulcer following a double blind multicenter design. A group of Swiss gastroenterologists recruited 119 patients with endoscopically proven acute duodenal ulcer. They were enrolled and treated according to a uniform protocol either with misoprostol 4 X 50 micrograms daily, with misoprostol 4 X 200 micrograms daily or with cimetidine 4 X 300 mg daily. Patients who were healed after 4 or 8 weeks were followed during 6 months. Cumulative healing rates at 4 weeks in groups receiving misoprostol 200 micrograms, misoprostol 800 micrograms or cimetidine 1200 mg daily were 42%, 58% and 71% respectively. Patients treated with cimetidine showed a more rapid improvement of symptoms than patients treated with misoprostol. Symptomatic recurrences after ulcer healing occurred in almost 40% of the patients within 6 months, irrespective of the type of acute ulcer treatment. Risk factors for slowed healing and increased rate of recurrence were evaluated in the present study, and the results were compared with the results of two previous trials performed according to a similar protocol. Smoking appeared to slow healing and to favor relapses. Moderate consumption of alcohol appeared to decrease the relapse rate. In the present trial, ulcer size was associated with ulcer pain but not with ulcer healing.