Prevalence, Incidence, and Progression of Radiographic and Symptomatic Hand Osteoarthritis: The Osteoarthritis Initiative

OBJECTIVE

To describe prevalence, incidence, and progression of radiographic and symptomatic hand osteoarthritis (OA), and evaluate age, sex, race and risk factors differences.

METHODS

We assessed both radiographic and symptomatic hand OA at baseline and year 4 for incident disease. A modified poisson regression with a robust variance estimator was used to account for clustering of joints within fingers within persons to estimate the prevalence ratios and relative risk estimates associated with participant characteristics.

RESULTS

Of 3588 participants, the prevalence hand OA was 41.4% for radiographic hand OA and 12.4 % for symptomatic hand OA. The incidence of hand OA over 48 months was 5.6 % for radiographic hand OA, and 16.9 % for symptomatic hand OA. Over 48 months, 27.3 % participants exhibited OA progression. We found complex differences by age, sex and race with both men and women having increasing prevalent hand OA with age, but women peaking at age 55-65, for incident disease. Women have more symptomatic hand OA than men but only non-significantly higher rates for incident radiographic hand OA. Women have more distal interphalangeal joint disease while men have more metacarpal joint OA. Black men and women have less hand OA than whites but black men have more hand OA than black women at younger ages.

CONCLUSION

Hand OA is a heterogeneous disease with complex differences by age, sex and race, hand symptoms and patterns of specific joints. Further research investigating the mechanisms behind these differences whether mechanical, metabolic, hormonal, or constitutional is warranted.

Lay public's use of a support group for general dental problems

OBJECTIVE

To categorize and tabulate layperson inquiries made to an Internet dental health support site to identify oral conditions and associated behaviors of concern.

METHODS

A retrospective tabulation of wall postings was made from an established dental health support website hosted by WebMD over a 2-year period (April 2013-April 2015). A mixed method approach of content and thematic analysis was used. Content analysis identified content of oral health concerns, while thematic analysis using grounded theory identified themes and beliefs concerning associated behaviors.

RESULTS

The presence of non-descript growths on the tongue and swelling and/or discoloration of the lips elicited the most inquires. These were often self-diagnosed as oral candidiasis, a STD or a carcinoma, provoking high levels of self-concern. Unprotected sexual activity, excessive ingestion of soft and hard beverages, smoking and overexposure to the sun were the most frequently self-reported behaviors associated with their concerns. Many questions focused upon "normal" healing, including the amount of edema and discomfort that could occur following oral surgery or other dental procedures. Information concerning alternative treatments was often solicited, and many alluded that they had not been provided sufficient information to make informed decisions prior to dental treatment.

CONCLUSIONS

Laypersons have many oral health concerns particularly in relationship to the development of undiagnosed pathologies in conjunction with a history of volitional behaviors. The dental community should monitor these sites to provide advice and links to information about common oral health concerns and their possible association with detrimental behaviors.

Class II composite resin restorations: faster, easier, predictable

Composite resin continues to displace amalgam as the preferred direct restorative material in developed countries. Even though composite materials have evolved to include nanoparticles with high physical properties and low shrinkage stress, dentists have been challenged to efficiently create quality, long lasting, predictable restorations. Unlike amalgam, composite resin cannot be condensed making the establishment of a predictable, proper contact more difficult. In addition, composite requires an understanding of adhesives and an appreciation for their exacting application. These facts combined with the precise adaptation and light-curing of multiple layers makes placement of quality Class II composite restorations tedious and time-consuming. For private practicing dentists, it can also have an effect on economic productivity. Clinicians have always wanted an easier, efficient placement technique for posterior composite restorations that rivals that for amalgam. It appears that advances in instrumentation, materials and technology have finally delivered it.

Health risks and benefits from calcium and vitamin D supplementation: Women's Health Initiative clinical trial and cohort study

SUMMARY

The Women's Health Initiative (WHI) double-blind, placebo-controlled clinical trial randomly assigned 36,282 postmenopausal women in the U.S. to 1,000 mg elemental calcium carbonate plus 400 IU of vitamin D(3) daily or placebo, with average intervention period of 7.0 years. The trial was designed to test whether calcium plus vitamin D supplementation in a population in which the use of these supplements was widespread would reduce hip fracture, and secondarily, total fracture and colorectal cancer.

INTRODUCTION

This study further examines the health benefits and risks of calcium and vitamin D supplementation using WHI data, with emphasis on fractures, cardiovascular disease, cancer, and total mortality.

METHODS

WHI calcium and vitamin D randomized clinical trial (CT) data through the end of the intervention period were further analyzed with emphasis on treatment effects in relation to duration of supplementation, and these data were contrasted and combined with corresponding data from the WHI prospective observational study (OS).

RESULTS

Among women not taking personal calcium or vitamin D supplements at baseline, the hazard ratio [HR] for hip fracture occurrence in the CT following 5 or more years of calcium and vitamin D supplementation versus placebo was 0.62 (95 % confidence interval (CI), 0.38-1.00). In combined analyses of CT and OS data, the corresponding HR was 0.65 (95 % CI, 0.44-0.98). Supplementation effects were not apparent on the risks of myocardial infarction, coronary heart disease, total heart disease, stroke, overall cardiovascular disease, colorectal cancer, or total mortality, while evidence for a reduction in breast cancer risk and total invasive cancer risk among calcium plus vitamin D users was only suggestive.

CONCLUSION

Though based primarily on a subset analysis, long-term use of calcium and vitamin D appears to confer a reduction that may be substantial in the risk of hip fracture among postmenopausal women. Other health benefits and risks of supplementation at doses considered, including an elevation in urinary tract stone formation, appear to be modest and approximately balanced.

Cognitive function and retinal and ischemic brain changes: the Women's Health Initiative

OBJECTIVE

To examine the association between retinopathy and cognitive decline or brain lesions and volumes in older women.

METHODS

This study included 511 women aged 65 and older who were simultaneously enrolled in the Women's Health Initiative Memory Study and the Sight Examination Study. In this analysis, we examined the link between retinopathy, assessed using fundus photography (2000-2002), cognitive performance over time assessed by the modified Mini-Mental State Examination (3MSE) (1996-2007), and white matter hyperintensities and lacunar infarcts in the basal ganglia.

RESULTS

Presence of retinopathy was associated with poorer 3MSE scores (mean difference = 1.01, SE: 0.43) (p = 0.019) over a 10-year follow-up period and greater ischemic volumes in the total brain (47% larger, p = 0.04) and the parietal lobe (68% larger, p = 0.01) but not with measures of regional brain atrophy.

CONCLUSIONS

The correspondence we found between retinopathy and cognitive impairment, along with larger ischemic lesion volumes, strengthens existing evidence that retinopathy as a marker of small vessel disease is a risk factor for cerebrovascular disease that may influence cognitive performance and related brain changes. Retinopathy may be useful as a clinical tool if it can be shown to be an early marker related to neurologic outcomes.

Renal function and nonvertebral fracture risk in multiethnic women: the Women's Health Initiative (WHI)

To examine the association between renal function and fracture in multiethnic women, we studied postmenopausal women enrolled in the Women's Health Initiative. Postmenopausal White women with mild renal dysfunction were at increased risk of nonvertebral fracture; this association was at least partially explained by effects of renal dysfunction on chronic inflammation. Reduced renal function appeared to increase fracture risk among Black women, but there was little evidence to support this association among other racial/ethnic groups.

INTRODUCTION

The purpose of this study was to determine whether renal function is associated with fracture risk within racial/ethnic groups.

METHODS

A nested case-control study was conducted among 93,673 postmenopausal women; incident nonvertebral fractures were identified in 362 Black, 183 Hispanic, 110 Asian, and 45 American-Indian women. A random sample of 395 White women with incident nonvertebral fracture was chosen. One nonfracture control for each case was selected (matched on age, race/ethnicity, and blood draw date). Cystatin C levels were measured using baseline serum, and estimated glomerular filtration rate calculated (eGFR(cys-c)).

RESULTS

Each 1 SD increase in cystatin C was associated with a 1.2-fold increased risk of fracture among White women (adjusted odds ratios [OR], 1.23; 95% confidence intervals [CI], 1.04-1.46). The OR of fracture was 1.16 (95% CI, 0.85-1.58) among women with eGFR(cys-c) 60-90 mL/min/1.73 m(2) and 2.46 (95% CI, 1.16-5.21) among those with eGFR(cys-c) <60 mL/min/1.73 m(2) compared to the reference group (eGFR(cys-c) >90 mL/min/1.73 m(2)) (p trend = 0.05). The association was reduced after adjustment for cytokine TNFα soluble receptors (OR, 1.62; 95% CI, 0.59-4.46 for eGFR(cys-c) <60 mL/min/1.73 m(2)). Among Blacks, there was an association between cystatin C and fracture risk (OR per 1 SD increase, 1.15; 95% CI, 1.00-1.32); after adjustment, this association was only modestly attenuated, but no longer statistically significant. There was no evidence of significant associations among Hispanic, Asian, or American-Indian women.

CONCLUSION

Postmenopausal White women with mild renal dysfunction are at increased risk of nonvertebral fracture. Effects of renal function on chronic inflammation may mediate this association. Reduced renal function may increase fracture risk among Black women, but there was little evidence to support this association among other racial/ethnic groups.

The use of phenome-wide association studies (PheWAS) for exploration of novel genotype-phenotype relationships and pleiotropy discovery

The field of phenomics has been investigating network structure among large arrays of phenotypes, and genome-wide association studies (GWAS) have been used to investigate the relationship between genetic variation and single diseases/outcomes. A novel approach has emerged combining both the exploration of phenotypic structure and genotypic variation, known as the phenome-wide association study (PheWAS). The Population Architecture using Genomics and Epidemiology (PAGE) network is a National Human Genome Research Institute (NHGRI)-supported collaboration of four groups accessing eight extensively characterized epidemiologic studies. The primary focus of PAGE is deep characterization of well-replicated GWAS variants and their relationships to various phenotypes and traits in diverse epidemiologic studies that include European Americans, African Americans, Mexican Americans/Hispanics, Asians/Pacific Islanders, and Native Americans. The rich phenotypic resources of PAGE studies provide a unique opportunity for PheWAS as each genotyped variant can be tested for an association with the wide array of phenotypic measurements available within the studies of PAGE, including prevalent and incident status for multiple common clinical conditions and risk factors, as well as clinical parameters and intermediate biomarkers. The results of PheWAS can be used to discover novel relationships between SNPs, phenotypes, and networks of interrelated phenotypes; identify pleiotropy; provide novel mechanistic insights; and foster hypothesis generation. The PAGE network has developed infrastructure to support and perform PheWAS in a high-throughput manner. As implementing the PheWAS approach has presented several challenges, the infrastructure and methodology, as well as insights gained in this project, are presented herein to benefit the larger scientific community.

Remote detection of biological stresses in plants with infrared thermometry

Green leaves of mature sugar beets infected with Pythium aphanidermatum and cotton infected with Phymatotrichum omnivorum had midday radiant leaf temperatures 3 degrees to 5 degrees warmer than adjacent plants with no sign of disease. The temperature difference persisted under varying conditions of soil moisture and could be used to detect biological stress imposed by these soilborne root-rotting fungi.

Estimating evaporation: a technique adaptable to remote sensing

A procedure is presented for calculating 24-hour totals of evaporation from wet and drying soils. Its application requires a knowledge of the daily solar radiation and the maximum and minimum air temperatures (standard Weather Service measurements), moist surface albedo (readily estimated or obtainable from a one-time measurement), and maximum and minimum surface temperatures (obtainable from surface or airborne sensors). Tests of the technique on a bare field of Avondale loam at Phoenix, Arizona, have shown it to be independent of season.

Remote-sensing of crop yields

Our research efforts with durum wheat have led to the development of the SDD concept. Its application makes possible crop yield estimates from remotely acquired canopy temperatures and auxiliary air temperature measurements obtained during the period from head emergence to the cessation of head growth. Canopy albedo measurements appear adequate to delineate this critical period, making the technique potentially adaptable to predictions of crop yields by remote-sensing. The trifactor nomograms produced from combinations of the linear regression equations also suggest that the SDD concept may be used for scheduling irrigations by remote-sensing.

Incidence of fractures compared to cardiovascular disease and breast cancer: the Women's Health Initiative Observational Study

To compare the absolute risk of fracture to the risk of other conditions by race/ethnicity, we studied 83,724 women, aged 70-79. The projected number of fractures was similar to or exceeded the combined number of cardiovascular events and breast cancers. Osteoporosis prevention efforts should target women of all ethnicities.

INTRODUCTION

The relative risk of fracture is lower in non-white compared to white women but the absolute risk of fracture in comparison to other common chronic conditions is uncertain.

METHODS

We performed a prospective cohort study of 83,724 women, age 50-79 years. Cardiovascular disease (CVD), invasive breast cancer and all fractures were identified over an average of 7.7 +/- 2.6 years.

RESULTS

The incidence of fracture, breast cancer, stroke and CVD varied across ethnicity. The annualized (%) incidence of fracture was greatest in whites (2.4%) and American Indians (2.8%) and lowest among blacks (1.3%). The majority of hip fractures occurred in white women. The projected number of women who will experience a fracture in one year exceeded the combined number of women who would experience invasive breast cancer or a broad category of CVD events in all ethnic groups except blacks. In 10,000 black women, an estimated 153 women would experience CVD, and 35 women, breast cancer compared to 126 women expected to fracture in one year.

CONCLUSION

The annual risk of suffering a fracture is substantial in women of all ethnicities. Osteoporosis prevention efforts should target all women irrespective of their race/ethnic backgrounds.

Two year longitudinal change and test-retest-precision of knee cartilage morphology in a pilot study for the osteoarthritis initiative

OBJECTIVE

Fast low angle shot (FLASH) and double echo steady state (DESS) magnetic resonance imaging (MRI) acquisitions were recently cross-calibrated for quantification of cartilage morphology at 3T. In this pilot study for the osteoarthritis (OA) initiative we compare their test-retest-precision and sensitivity to longitudinal change.

METHOD

Nine participants with mild to moderate clinical OA were imaged twice each at baseline, year 1 (Y1) and year 2 (Y2). Coronal 1.5mm FLASH and sagittal 0.7mm DESS sequences were acquired; 1.5mm coronal multiplanar reformats (MPR) were obtained from the DESS. Patellar, femoral and tibial cartilage plates were quantified in a paired fashion, with blinding to time point.

RESULTS

In the weight-bearing femorotibial joint, average precision errors across plates were 1.8% for FLASH, 2.6% for DESS, and 3.0% for MPR-DESS. Volume loss at Y1 was not significant; at Y2 the average change across the femorotibial cartilage plates was -1.7% for FLASH, -2.8% for DESS, and -0.3% for MPR-DESS. Volume change in the lateral tibia (-5.5%; P<0.03), and in the medial (-2.9%; P<0.04) and lateral femorotibial compartments (-3.8%; P<0.03) were significant for DESS.

CONCLUSIONS

FLASH, DESS and MPR-DESS all displayed adequate test-retest precision. Although the comparison between protocols is limited by the small number of participants and by the relatively small longitudinal change in cartilage morphology in this pilot study, the data suggest that significant change can be detected with MRI in a small sample of OA subjects over 2 years.

Best Practice Smoking Cessation Intervention and Resource Needs of Prenatal Care Providers

OBJECTIVE

To describe smoking cessation interventions by prenatal care providers and to identify factors associated with best practice.

METHODS

A mailed survey assessed implementation of the "5 A's" of best practice (Ask about smoking; Advise patients to quit; Assess willingness to quit; Assist with a cessation plan; and Arrange follow-up), practice characteristics, intervention training, resources, barriers, and attitudes toward reimbursement. Each factor in association with provider type and best practice implementation was analyzed.

RESULTS

Of 1,138 eligible North Carolina health professionals, 844 responded (74%); 549 were providing prenatal care and returned completed surveys. Most asked about smoking (98%) and advised cessation (100%). Across provider type, one third (31%) consistently implemented all "5 A's" of best practice. Most providers (90%) had at least one material resource (eg, pamphlets), which correlated with nearly 10 times the adjusted odds of best practice (odds ratio [OR] 9.6, 95% confidence interval [CI] 1.3-72.9). Seventy percent had at least one counseling resource. Having a counseling resource (OR 2.5, 95% CI 1.4-4.4) and a written protocol to identify staff responsibilities (OR 2.5, 95% CI 1.5-4.3) were equally associated with best practice. More than one half of providers endorsed reimbursement as influential on best practice.

CONCLUSION

Best practice is well-established to promote prenatal smoking cessation yet implemented by only one third of prenatal care providers in North Carolina. In this study, best practice was associated with resources, practice organization, and reimbursement. Augmented use of available resources (eg, toll-free hotlines) and adequate reimbursement may promote best practice implementation.

Novel fast semi-automated software to segment cartilage for knee MR acquisitions

OBJECTIVE

Validation of a new fast software technique to segment the cartilage on knee magnetic resonance (MR) acquisitions. Large studies of knee osteoarthritis (OA) will require fast and reproducible methods to quantify cartilage changes for knee MR data. In this report we document and measure the reproducibility and reader time of a software-based technique to quantify the volume and thickness of articular cartilage on knee MR images.

METHODS

The software was tested on a set of duplicate sagittal three-dimensional (3D) dual echo steady state (DESS) acquisitions from 15 (8 OA, 7 normal) subjects. The repositioning, inter-reader, and intra-reader reproducibility of the cartilage volume (VC) and thickness (ThC) were measured independently as well as the reader time for each cartilage plate. The root-mean square coefficient of variation (RMSCoV) was used as metric to quantify the reproducibility of VC and mean ThC.

RESULTS

The repositioning RMSCoV was as follows: VC=2.0% and ThC=1.2% (femur), VC=2.9% and ThC=1.6% (medial tibial plateau), VC=5.5% and ThC=2.4% (lateral tibial plateau), and VC=4.6% and ThC=2.3% (patella). RMSCoV values were higher for the inter-reader reproducibility (VC: 2.5-8.6%) (ThC: 1.9-5.2%) and lower for the intra-reader reproducibility (VC: 1.6-2.5%) (ThC: 1.2-1.9%). The method required an average of 75.4min per knee.

CONCLUSIONS

We have documented a fast reproducible semi-automated software method to segment articular cartilage on knee MR acquisitions.

The significance of platelet counts in coagulation studies

Traditionally, the platelet count recommended for coagulation studies has been less than 10 x 10(9)/L, but the documentation for this is obscure. In the present study, platelet rich plasma (PRPs) and platelet poor plasmas (PPPs) were prepared from the same blood specimen to determine prothrombin times (PTs), International Normalized Ratios (INRs), partial thromboplastin times (PTTs), and their results compared. The measurements of all three of these parameters are not statistically or clinically significant in 100 paired comparisons. Incremented platelet count studies, selected by the number of platelets in the PRPs, showed that platelet counts of at least 199 x 10(9)/L, or perhaps even higher, did not compromise the results of PTs, INRs or PTTs. Such increased platelet counts, however, cannot be tolerated in the various studies for antiphospholipid antibodies, the Lupus Anticoagulant (LAC), or when monitoring heparin therapy with PTTs. Here, the < 10 x 10(9)/L platelet levels must be respected; otherwise the tests would be compromised by platelet-liberated phospholipid (Triplett, Brand et al., 1983) or by Platelet Factor 4, respectively.

Involving minority and underrepresented women in clinical trials: the National Centers of Excellence in Women's Health

Recent attention to reducing health disparities among population groups has focused on the need to include in clinical studies, especially clinical trials, participants who represent the diversity of the populations to which study results will be applied. While scientists generally applaud the goal of broadening the characteristics of participants in clinical trials, they are faced with multiple challenges as they seek to include historically underrepresented populations in their research. This article examines the historical and sociocultural context of participation by underrepresented groups, especially women and minorities, in clinical trials, identifies major barriers and challenges facing researchers, and suggests strategies for meeting these challenges. The article draws upon the experiences of the investigators affiliated with the National Centers of Excellence of Women's Health (CoEs).

Modified anticoagulant therapy factor and international normalized ratio in patients in an unstable coagulation state with respect to warfarin therapy

In our pilot study of 1997, an Anticoagulant Therapy Factor (ATF) was formulated, compared to the International Normalized Ratio (INR) and proposed to replace the INR. Statistically, replacement of the INR was reasonable; but many discrepancies occurred when the results of ATFs and INRs were compared for individual patients. The study was based on patients undergoing induction of warfarin anticoagulant therapy, so they were "unstable" with respect to warfarin. A 1998 follow-up study by Carroll and Jackson based on patients "stable" with respect to warfarin, having taken the drug for at least six weeks, was, therefore, undertaken. In this study, the ATF was modified to an MATF by both multiplying the ATF by the prothrombin ratio (PR) and adjusting the INR-ATF linear regression analysis line by analytic geometry, so that the slope was one and the line passed through the origin. These modifications achieved both statistical and individual patient concordance between INRs and ATFs. The purpose of the present paper is to apply the techniques of the 1998 study to the original 1997 pilot study to see if the reprocessed data on the "unstable" patients is, in fact, also concordant with respect to INRs and ATFs.

The new posterior resins and a simplified placement technique

BACKGROUND

New heavy-body (packable) composites have been developed for use in posterior direct resin restorations. These materials are promoted as having better handling characteristics and higher physical properties than previous microhybrid composites.

METHODS

The authors describe an incremental layering technique that takes advantage of the improved handling characteristics and proposed reduced shrinkage and greater depth of cure.

CLINICAL IMPLICATIONS

When this new technique is used with one-bottle adhesives and improved instrumentation, posterior heavy-body composites can be placed faster, easier and possibly more predictably than when medium-body resins and previous techniques are used.

Indirect resin inlay and onlay restorations: a comprehensive clinical overview

Advances in adhesive technology and aesthetic dental materials have permitted clinicians to perform conservative preparation of the dentition for inlay/onlay restorations. The use of adhesive indirect procedures provides numerous advantages (e.g., aesthetics, reinforcement, adequate seal) to conventional restorative techniques. This article describes the indications/contraindications and material properties of aesthetic indirect restorations. It also highlights the preparation, bonding, and finishing procedures utilized to achieve an aesthetic indirect resin restoration and demonstrates the techniques with a series of case presentations.

Dental caries diagnosis

As with any disease process, the early initiation of therapy for dental caries is often the most effective means to ensure resolution. However, for any therapy to be effective, early diagnosis is paramount to success. Unfortunately, current tools used in dental caries detection are not sensitive enough to diagnose the disease process in its early stages and, frequently, once a diagnosis is made restoration is the only effective means of treatment. Quantitative light-induced fluorescence, electrical conductance measurements, direct digital radiography, and direct fiber optic transillumination are methods that may offer promise as effective tools in diagnosing early dental caries. This article describes some of the research that has been performed to make these methods a reality.

Dental fluorosis in children residing in communities with different water fluoride levels: 33-month follow-up

PURPOSE

The purpose of these examinations was to monitor changes, in the prevalence of dental fluorosis.

METHODS

In February 1992 and December 1994, children who were residents of one of three communities with varying levels of fluoride in their communal water supply were examined for dental fluorosis. Since some children were available at both examination periods, it was also possible to determine changes in the incidence of dental fluorosis.

RESULTS

The prevalence of fluorosis increased by approximately 14%, 20%, and 6% in the negligibly, optimally, and 4X optimally fluoridated communities, respectively. In the negligibly and optimally fluoridated communities, the incidence of dental fluorosis increased by 12% and 7%, respectively. In the 4X optimally fluoridated community, all the children examined had evidence of fluorosis at both examinations.

CONCLUSION

Fluoride continues to be the primary therapeutic agent for the prevention of dental caries in adults and children. With the downward adjustment in the fluoride supplement schedule, continued monitoring of the prevalence of dental fluorosis in young children is needed to determine if any additional steps are even necessary to restrict fluoride intake during the years that enamel formation is occurring.

Diagnosis and treatment of glucocorticoid-induced osteoporosis

Glucocorticoids are a mainstay in the treatment of many diseases, including pulmonary and rheumatologic disorders. Unfortunately, as many as 90% of long-term glucocorticoid recipients lose a significant amount of bone and incur an increased risk of fractures. This paper reviews the pathophysiology, diagnosis, and treatment of glucocorticoid-induced osteoporosis.

Warfarin monitoring by an anticoagulant therapy factor (ATF)

In a pilot study (1997) using POTENS+, our coagulation instrument, we determined that: (a) an Anticoagulant Therapy Factor (ATF) was comparable to the International Normalized Ratio (INR) for monitoring warfarin anticoagulant therapy, (b) one could use any of the four thromboplastins with which the ATF was derived with comparable results, and (c) the ATF could be proposed to monitor warfarin therapy. The ATF-INR comparisons correlated well statistically; but when individual ATF-INR comparisons were later studied, there were frequent discrepancies. The pilot study (1997) was based on hospitalized patients, so almost all patients were undergoing induction of warfarin anticoagulation. Since none of them had taken warfarin for at least six weeks, none of them could be considered "stable" on warfarin. In the present study, all patients were on warfarin therapy for at least six weeks, and the ATF equation was modified by multiplying it by the prothrombin ratio (PR) to give a corrected ATF (CATF). This CATF was then further modified to achieve agreement with the INR by adjusting the linear regression line by means of analytic geometry, so that the CATF-INR regression line now had a slope of one and passed through the origin. With these changes, the modified ATFs (MATF) and INRs correlated well and were nearly equal numerically when using two of the four thromboplastins. Reason for the discrepancies with the other two thromboplastins will be discussed.

Protocol for predictable restoration of anterior teeth with composite resins

The composite resins have reached a high degree of excellence and are now used with predictable results in restoring the anterior dentition. This article discusses the development of these resins and the histologic and optical considerations (polychromatic characteristics, hue translucency and opacity, chroma, value, strength and polishability). In restorative materials, the use of universal or all-purpose restorative resins is considered: i.e. materials that combine the junctional strength necessary for the posterior regions and the high gloss polishability necessary to emulate enamel in the anterior. The restorative sequence of cervical, middle, and incisal thirds describes the materials best suited for each third, along with aids to create the intricate refinement of hue, chroma, and value. The learning objective of this article is to review the principles involved in these restorations and to provide a protocol for their clinical implementation.

Muscle atrophy is prevented in patients with acute spinal cord injury using functional electrical stimulation

Severe muscle atrophy occurs rapidly following traumatic spinal cord injury (SCI). Previous research shows that neuromuscular or 'functional' electrical stimulation (FES), particularly FES-cycle ergometry (FES-CE) can cause muscle hypertrophy in individuals with chronic SCI (> 1 year post-injury). However, the modest degree of hypertrophy in these already atrophied muscles has lessened earlier hopes that FES therapy would reduce secondary impairments of SCI. It is not known whether FES treatments are effective when used to prevent, rather than reverse, muscle atrophy in individuals with acute SCI. This study explored whether unloaded isometric FES contractions (FES-IC) or FES-CE decreased subsequent muscle atrophy in individual with acute SCI (< 3 months post-injury). Twenty-six subjects, 14-15 weeks post-traumatic SCI, were assigned to control, FES-IC, or FES-CE against progessively increasing resistance. Subjects were involved in the study for 3 or 6 months. Total body lean body mass (TB-LBM), lower limb lean body mass (LL-LBM), and gluteal lean body mass (G-LBM) were determined before the study, and at 3 and 6 months using dual energy X-ray absorptiometry (DEXA). Controls lost an average of 6.1%, 10.1%, 12.4%, after 3 months and 9.5%, 21.4%, 26.8% after 6 months in TB-LBM, LL-LBM and G-LBM respectively. Subjects in the FES-IC group consistently lost less lean body mass than controls, however, only 6 month G-LBM loss was significantly attenuated in this group relative to the controls. In the FES-CE group, LL-LBM and G-LBM loss were prevented at both 3 and 6 months, and TB-LBM loss was prevented at 6 months. In addition, FES-CE significantly increased G-LBM and LL-LBM after 6 months of training relative to pre-training levels. Within the control group, there was no significant relationship between LL-LBM loss (3 and 6 months) and the number of days between injury and baseline measurement. In summary, this study shows that FES-CE, but not FES-IC, training prevents muscle atrophy in acute SCI after 3 months of training, and causes significant hypertrophy after 6 months. The magnitude of differences in regionalized LBM between controls and FES-CE subject raises hopes that such treatment may indeed be beneficial in preventing secondary impairments of SCI if employed before extensive post-injury atrophy occurs.

Cyclical etidronate in the treatment of postmenopausal osteoporosis: efficacy and safety after seven years of treatment

PURPOSE

To determine the efficacy and safety of cyclical etidronate for up to 7 years in the treatment of postmenopausal osteoporosis and to examine the effects of discontinuing treatment after 2 or 5 years of therapy.

PATIENTS AND METHODS

Patients were randomized at entry into the original study in 1986 to blinded treatment for 2 years with either a calcium (placebo) or an intermittent cyclical etidronate regimen, which most patients continued for a third year. Following this phase of the study, patients were enrolled into an open-label, follow-up study (years 4 and 5), during which all patients received cyclical etidronate treatment. In the present double-blind study (years 6 and 7), patients were rerandomized to receive intermittent cyclical therapy with either etidronate or placebo; all patients received calcium. The treatment regimen consisted of 400 mg/day etidronate or placebo for 14 days, followed by 76 days of elemental calcium (500 mg/day); this cycle was repeated approximately 4 times in each year. Of the 193 patients who continued in years 6 and 7 of the study, 93 were randomized to receive cyclical etidronate and 100 were randomized to receive calcium only. For purposes of efficacy analyses, patients were categorized by their total years of cumulative etidronate treatment (7, 5, 4, or 2 years). There were 51, 46, 42, and 54 patients in the 7-, 5-, 4-, and 2-year groups, respectively. Annual assessments included lumbar spine bone mineral density (BMD), as measured by densitometry, and vertebral radiographs.

RESULTS

The groups receiving cyclical etidronate during this 2-year study period (7- and 4-year groups) had statistically significant mean percent increases in spinal BMD of 1.8% and 2.2%, respectively (P < 0.05) at the week 104 observation time. The 5- and 2-year groups, which did not receive etidronate during this period, had mean values of 1.4% and 0.2%, respectively (not significant) at week 104. In the 7-, 5-, 4-, and 2-year groups, the increases in spinal BMD at the end of 7 years were 7.6%, 8.6%, 8.1%, and 3.9%, respectively; these values were statistically significant for all groups compared with original baseline (year 0) (P < 0.05). BMD of the femur and wrist was maintained throughout the 7-year period. The incidence and rate of vertebral fractures were lowest in patients with the longest exposure to etidronate. Etidronate was well tolerated during the study, with low incidences of gastrointestinal side effects and nonvertebral fractures.

CONCLUSIONS

Long-term cyclical etidronate is a safe, effective, and well-tolerated treatment for postmenopausal osteoporosis. Bone mass is maintained for at least 2 years after treatment with etidronate is stopped; however, further gains in spinal bone mass are seen in patients who continue therapy.

Forestalling fracture in osteoporosis

When osteoporosis is imminent, simple clinical measures--risk reduction and preventive steps such as calcium supplementation and exercise--are in order. Estrogen replacement offers excellent protection in menopausal women. When disease is apparent, bone densitometry can confirm the diagnosis and therapy can be chosen from a widening palette that includes calcitonin and the bisphosphonates.

Warfarin monitoring independent of the international normalized ratio (INR): a pilot study

Warfarin monitoring is extended to include an anticoagulant therapy factor (ATF). ATF is shown, using four different thromboplastins (Tps), to be comparable with the International Normalized Ratio (INR) mathematically; but ATF is less cumbersome and does not have the INR's poor precision with up to 13.5% error. ATF is formulated from the prothrombin time (PT), fibrinogen transformation rate (FTR) (a representation of thrombin activity), and a consideration of the fibrinogen (FBG) content of blood plasma. Each of these three components is derived from the optical density (O.D.) changes during both the monitoring of the PT and the following FBG-fibrin conversion by a potentiophotometer (PTPH), a linear-reading spectrophotometric device. Comparison of the ATF with the INR shows correlation coefficients of 0.9474, 0.9248, 0.8116 and 0.8603 using the four respective Tps, and the difference against the mean for Bland-Altman plots averages only 0.2 units more for the ATF than the INR. The ATF is independent of the Tp used, and, although Tp affects the PTs, Tp essentially only initiates the tissue factor pathway (TFP) (extrinsic clotting system) to then obtain the PT. It has no rapid direct effect on thrombin activity. For these reasons, in ATF determination, the kind of Tp used is of no consequence. The ATF is independent of the INR, and numerically almost equal to it. The ATF is, therefore, proposed as a replacement for the INR.

Lack of effect of long-term fluoride ingestion on blood chemistry and frequency of sister chromatid exchange in human lymphocytes

Two studies were conducted to assess the potential for adverse physiologic and genotoxic effects of long-term fluoride ingestion in adults residing in three communities with varying water fluoride levels (0.2 ppm, 1.0 ppm, and 4.0 ppm). All were long-time (> or = 30 years) residents of their respective communities. Plasma and urine samples were collected for fluoride analyses. Additional plasma was collected to determine blood chemistry, and plasma lymphocytes were examined to determine the frequency of sister chromatid exchange. Significant differences in urine (P = 0.001) and plasma (P = 0.0001) fluoride levels were found in the three communities. Seven of the blood parameters were statistically different among the communities, although all were within the defined normal range of the pathology laboratory. Sister chromatid exchange frequency was statistically higher in the 4.0 ppm fluoride community as compared to the other communities. Because of the higher SCE frequency in the 4.0 ppm fluoride community, a second study was performed to determine if the increased frequency was potentially related to the fluoride level of the communal water supply. Of the 58 adults recruited; 30 had used city water and 28 had used well water (< or = 0.3 ppm fluoride) as their principal water source for 30 years. Data analyses showed that the sister chromatid exchange frequency did not differ between the groups, indicating that the increased sister chromatid exchange frequency was not related to the fluoride level of the communal water. The investigation provided evidence that the long-term ingestion of water containing 4.0 ppm fluoride did not have any clinically important physiologic or genotoxic effects in healthy adults.

Bone mass and endocrine adaptations to training in spinal cord injured individuals

To investigate whether exercise training can produce increases in bone mass in spinal cord-injured (SCI) individuals with established disuse osteopenia, nine subjects (age 28.2 years, time since injury 6.0 years, level of injury C5-T7) were recruited for a 9-month training program using functional electrical stimulation cycle ergometry (FES-CE), which produces active muscle contractions in the paralyzed limb. After training, bone mineral density (BMD, by X-ray absorptiometry) increased by 0.047 +/- 0.010 g/cm2 at the lumbar spine; changes in BMD at the femoral neck, distal femur, and proximal tibia were not significant for the group as a whole. In a subset of subjects training at > or = 18 W for at least 3 months (n = 4), BMD increased by 0.095 +/- 0.026 g/cm2 (+18%) at the distal femur. By 6 months of training, a 78% increase in serum osteocalcin was observed, indicating an increase in bone turnover. Urinary calcium and hydroxyproline, indicators of resorptive activity, did not change over the same period. Serum PTH increased 75% over baseline values (from 2.98 +/- 0.15 to 5.22 +/- 0.62 pmol/L) after 6 months' training, with several individual values in hyperparathyroid range; PTH declined toward baseline values by 9 months. These data establish the feasibility of stimulating site-specific increases in bone mass in severely osteopenic bone with muscle contractions independent of weight-bearing for those subjects able to achieve a threshold power output of 18 W with FES-CE. Calcium supplementation from the outset of training in osteopenic individuals may be advisable to prevent training-induced increases in PTH.

Longitudinal studies of the duplication form of Charcot-Marie-Tooth polyneuropathy

This study presents a longitudinal comparison of motor nerve conduction velocities (MCVs) in patients with Charcot-Marie-Tooth type 1A with proven duplication of a segment of chromosome 17p11.2p12. Results were compared for 8 CMT1A duplication patients from one family whose MCV measurements were taken 22 years apart (1967 and 1989). Measurements from a total of seven median motor and five peroneal motor MCVs were compared. Median MCVs showed a slight reduction that averaged 2.2 m/s, and peroneal MCVs showed an average decrease of 3.0 m/s. In addition, mild objective increase in limb weakness was seen in only 1 of 8 patients and subjective symptoms of gradual worsening of leg strength were noted in half the patients over the same period. In this study of a small group of CMT1A patients with proven segmental duplication of chromosome 17p11.2p12, the motor conduction velocities and clinical motor exam did not change significantly over 22 years.

Protocol for predictable restoration of anterior teeth with composite resins

The composite resins have reached a high degree of excellence and are now utilized with predictable results in restoring the anterior dentition. This article discusses the development of these resins and the histologic and optical considerations (polychromatic characteristics, hue, translucency and opacity, chroma, value, strength, and polishability). In restorative materials, the use of universal or all-purpose restorative resins is considered, ie, materials that combine the functional strength necessary for the posterior regions and the high gloss polishability necessary to emulate enamel in the anterior. The restorative sequence of cervical, middle, and incisal thirds describes the materials best suited for each third, along with aids to create the intricate refinement of hue, chroma, and value. The learning objective of this article is to review the principles involved in these restorations and to provide a protocol for their clinical implementation.

Rapid fibrinogen determination with the prothrombin time using a potentiophotometer

The potentiophotometer (PTPH) is a spectrophotometric device that embodies the electrical, analog solution to Beer's Law. The output of the instrument gives, directly and simultaneously, the concentration of the substance being measured. The PTPH has been applied to the manual determination of fibrinogen (FBG) with the same thrombopalstin injection as the prothrombin time (PT). We have now semi-automated and computerized the PTPH to constitute the coagulation instrument named POTENS+. POTENS+ determines the FBG rapidly, within approximately three to twenty seconds after the PT. With POTENS+, precision, linearity and reference range will be given for its FBG method. The accuracy of POTENS+ will be assessed by comparing it with both automated FBG methods on the MLA Electra 1000C Coagulation Timer. Of these two methods, the automated Clauss method is used as the reference method.

Dental fluorosis and caries prevalence in children residing in communities with different levels of fluoride in the water

OBJECTIVES

This study investigated the prevalence of dental fluorosis and caries in 7-14-year-old children residing in communities with negligible (NF: 0.2 ppm), optimal (OPF: 1.0 ppm), and four-times optimal (4X OPF: 4.0 ppm) naturally occurring fluoride in their water systems.

METHODS

Examinations were performed on 344 children who were lifetime residents of their communities.

RESULTS

Whether using the tooth surface index of fluorosis or Dean's index, children examined in the 4X OPF community had the highest prevalence of dental fluorosis. While the severity of fluorosis seen in the OPF and NF communities was mild in appearance, the results indicate that fluorosis does occur in optimally and negligibly fluoridated communities. Compared to the NF community, DMFT and DMFS scores in the OPF community were 9.2 percent and 21.2 percent lower, respectively.

CONCLUSIONS

The ingestion of water containing 1 ppm or less fluoride during the time of tooth development may result in dental fluorosis, albeit in its milder forms. However, in these times of numerous products containing fluoride being available, children ingesting water containing 1 ppm fluoride continue to derive caries protection compared to children ingesting water with negligible amounts of fluoride. Thus, the potential for developing a relatively minor unesthetic condition must be weighed against the potential for reducing dental disease.

Differential diagnosis of agitation following brain injury

Posttraumatic agitation is perhaps the most dramatic behavioral consequence of severe traumatic brain injury. The mechanism for this behavior remains to be determined. The development of effective management strategies has been hampered at least in part by the lack of a consensus definition for posttraumatic agitation. The diagnosis of posttraumatic agitation is a diagnosis of exclusion. Concurrent neurologic or medical decline during the recovery from an acute traumatic brain injury may precipitate delirium, which has many clinical features that overlap with posttraumatic agitation. Hence, the differential diagnosis of posttraumatic agitation includes all medical and neurologic etiologies for transient declines in consciousness and cognition.

Catecholamine response to exercise and training in individuals with spinal cord injury

It is unknown whether the catecholamine (CAT) response to acute exercise and prolonged training in humans with spinal cord injury (SCI) is similar to that of neurologically intact man. Plasma samples were collected from seven subjects with chronic SCI (level of injury C5-T7) at rest and during voluntary arm-crank ergometry (ACE) before and after 6 months of training with functional electrical stimulation cycle ergometry (FES-CE). Similar plasma collections were made during one FES-CE exercise training session after 6 months of training. Norepinephrine (NE) and epinephrine (EPI) were measured by HPLC. After FES-CE training, resting NE decreased 37% (950 +/- 150 vs 1510 +/- 350 pmol.l-1 pretraining); resting EPI decreased 80% (54 +/- 10 vs 163 +/- 32 pmol.l-1 pretraining) (P < 0.05 by paired t-tests). No significant changes were observed in group means after training for the CAT response to submaximal ACE; however, five of seven subjects exhibited greater increments in plasma NE with ACE after FES-CE training. Acute FES-CE exercise elicited a 55-844% increase in NE, and a 35-350% increase in EPI above resting values with power outputs eliciting heart rates of 90-146 bpm. These data provide evidence for a systemic CAT response in subjects with SCI during acute FES-CE and reduced resting CAT following 6 months of training with FES-CE.

A semi-micro method for fibrinogen determination essentially unaffected by turbidity

A semi-micro method (BR BLUE) is presented using Coomassie Brilliant Blue G-250 color reagent for the determination of fibrinogen on potentially turbid specimens. It is compared with the reference Clauss method using the automated MLA Electra 1000C Automatic Coagulation Timer and the semi-automated Mechrolab Clot Timer. Correlation is excellent (r = 0.97). The BR BLUE method is also seen to be reasonably precise and linear.

A conservative, aesthetic, restorative treatment of a worn dentition

Advances in adhesive technology and in materials science have combined to provide the dentist with techniques which increased the ability to achieve the ultimate restorative objective: The restoration of diseased or missing tooth structure, including its appearance, without the additional removal of healthy tooth structure. The learning objective of this article is to illustrate, using a case report, how far restorative dentistry, redefined as aesthetic, adhesive, restorative dentistry, has taken us in this endeavor.

Esthetic inlays and onlays

Advances in adhesive technology offer the dentist the potential to place tooth-reinforcing restorations with more conservative preparations. At the same time, improvements in tooth-colored restorative materials are yielding high levels of durability and esthetics. The combination of these events has led to the development and continued refinement of an entirely new class of restorations for posterior teeth, called esthetic inlays and onlays. This paper summarizes current scientific and clinical opinion regarding this class of dental restorative and presents clinical technique criteria common to all types of esthetic inlays and onlays whether performed directly or indirectly, in resin or in ceramic.

Four-year study of intermittent cyclic etidronate treatment of postmenopausal osteoporosis: three years of blinded therapy followed by one year of open therapy

PURPOSE

To determine the effect of long-term intermittent cyclic etidronate treatment on spinal bone density and vertebral fracture rates.

PATIENTS AND METHODS

Postmenopausal osteoporotic women (n = 423) were randomized initially into a 2-year, double-blind, multicenter study; it was extended to a third year of blinded treatment followed by open-label treatment: 357 patients continued treatment in Year 3 (305 receiving blinded therapy and 52 receiving calcium supplementation) and 277 in Year 4. During Years 1 through 3, patients received double-blind treatment with phosphate (1.0 g) or placebo twice daily for 3 days, etidronate (400 mg) or placebo daily for 14 days, and calcium (500 mg) daily for the remainder of each 91-day treatment cycle. During Year 4, open-label intermittent cyclic etidronate therapy (without preceding phosphate) was administered to all patients. Spinal bone density and vertebral fracture rates were the main outcome measures.

RESULTS

During Year 3, etidronate therapy maintained the significant increases in spinal bone mineral density of the first 2 years. Over the 3-year period, proximal femur bone density increased in etidronate-treated patients. Etidronate therapy for 3 years significantly decreased the vertebral fracture rate in patients at higher risk for fracture (low spinal bone density and three or more vertebral fractures at study entry), as compared with nonetidronate treatment (228 versus 412 fractures per 1,000 patient-years, respectively; p < 0.05). After 1 year of open-label treatment, patients previously treated with etidronate maintained bone mass, and vertebral fracture rates in all groups were lower than in any other study period. There were no apparent serious adverse effects.

CONCLUSIONS

Three years of intermittent cyclic etidronate therapy produced significant increases in spinal and hip bone density, with a significant reduction in vertebral fracture rates in patients at higher fracture risk. Maintenance of bone mass and low fracture rate were observed when etidronate was continued for an additional year.