Abstract OT1-13-02: Molecular testing for minority patients with or at high risk for cancer

PURPOSE: Meharry Medical College is a participant in eMERGE (Electronic Medical Records and Genomics); a multicenter network sponsored by NHGRI/NIMHD with the primary goal to develop, disseminate, and apply approaches to research that combine biorepositories with electronic medical records (EMR) for genomic discovery and medicine implementation research. The consortium also focuses on ethical issues involving privacy, confidentiality, and interaction with the broader community. Individual institutions created protocols around research questions individualized to their populations.

METHODS: We enrolled 500 African Americans with or at high-risk for the four most common cancers (prostate, colorectal, breast, lung) to examine possible genetic and proteomic differences to account for health disparities in this population. We will perform DNA, RNA, and proteomics analyses pertinent to these cancers and obtain corresponding clinical history from the EMR with planned long-term follow up.

RESULTS: 500 subjects (211 female) were enrolled over 11 months from Nashville General Hospital including the following cancer/at-risk participants (Breast 59/37; Colorectal 17/128; prostate 31/136; lung 16/76). Most individuals stated that they participated for potential benefit to themselves, family members, or humankind and only 11 percent of potential participants declined. Little concern has been voiced for providing samples for genetic analysis. A genetic counselor will meet with the participants that are found to have pathogenic or likely pathogenic mutations while study investigators will share results with those that are not found to have mutations. Participants will be queried regarding understanding of the genetic testing results and followed for one year to evaluate if they underwent recommended testing and to follow for cancer outcomes.

CONCLUSION: The inclusion of diverse groups in genomic research is critical to identify possible reasons for health disparities and to study the understanding of genetic testing and ethical issues surrounding this topic. In this study, African-Americans are participating willingly in clinical research to examine possible genetic and/or social bases for cancer disparities.

ACKNOWLEDGEMENT: NIMHD (U54MD007593) to the Meharry Translational Research Center (MeTRC); National Human Genome Research Institute (NHGRI); National Institute of Allergy and Infectious Disease (NIAID).

Citation Format: Singh R, Bayan MA, Kadari S, Nganteh MN, Jacksonm M, Woodson LM, Shamsuddin AS, Lemus BY, Pratap S, Murray JJ, Adunyah SE, Lammers PE. Molecular testing for minority patients with or at high risk for cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-13-02.

An Evaluation of the Role and Clinical Contribution of New Cross Dental Therapists

The first dental therapists (previously called dental auxiliaries), started their training in 1960 and, by the end of 1976, 792 women had qualified after a two-year course. In the present study the role of all dental therapists was investigated by means of a postal survey. The clinical contribution made by these ancillaries was assessed by means of a retrospective analysis of clinic day sheets recorded by 55 dental therapists employed in the community dental services. It was found that dental therapists, in terms of their working pattern and family profile, are typical of women of their age and level of qualification in Britain. The return to work by therapists, after a break from practice because of family commitments, will depend mainly on the availability of posts, particularly part-time posts. Dental therapists provide treatment predominantly for younger children. Compared with previous studies, a noticeable increase in the clinical preventive care provided by therapists was observed.

Forty years of national surveys: An overview of children's dental health from 1973-2013

INTRODUCTION

The first national survey of children's dental health in England and Wales was carried out in 1973. Subsequent surveys, in 1983, 1993 and 2003, included all United Kingdom health departments. The 2013 survey involved England, Wales and Northern Ireland.

AIM

To consider all five surveys, from 1973 to 2013, so as to summarise trends in the dental health of children in the UK over the last 40 years.

MATERIALS AND METHOD

The 2013 survey was commissioned by the Health &Social Care Information Centre and all surveys used data collected during dental examinations conducted in schools on a random sample of children by NHS dentists, together with a questionnaire to parents of those children. In 2013, a pupil questionnaire for 12- and 15-year-olds was introduced, to complement information received from parents and carers.

RESULTS

A total of 69,318 children, aged 5-15 years, were involved, from 1973-2013. Caries prevalence has reduced from 72% to 41% in 5-year-olds, and from 97% to 46% in 15-year-olds in 40 years. Changes in periodontal disease, orthodontic treatment, accidental damage to anterior teeth, tooth surface loss and enamel defects, are also summarised. Behavioural and attitudinal characteristics observed in the 2013 report are listed.

CONCLUSIONS

Caries is now concentrated in a minority of children. The prevalence of gingivitis has not changed a great deal in 40 years. About half of those children assessed 'in orthodontic need' receive treatment.

Adult Dental Health Survey 2009: transformations in British oral health 1968-2009

This series of four papers reports and interprets the findings of the Adult Dental Health Survey (ADHS), 2009, published in early 2011. This is the fifth in a series of surveys repeated every decade since 1968. The evolution of the surveys and the way the supporting methodology has changed to meet the changing needs and circumstances over the last 40 years is described. In 1968, 37% of adults in England and Wales were edentate. By 2009, only 6% of the combined population of England, Wales and Northern Ireland were edentate. Among the dentate in 1968, there were a mean of 21.9 teeth. By 2009, not only had the dentate increased by 30 percentage points as a fraction of the population, but the number of teeth in this group had also increased by nearly four teeth on average to 25.7. There were significant variations in oral health according to geography and social variables and smaller differences according to sex. The retention of 21 or more teeth is widely used as a way of defining a minimum functional dentition. The proportion of adults with 21+ teeth increased from 73% in 1978 to 86% in 2009. Further huge improvements are projected as younger generations age, assuming future tooth loss continues at current low rates. We might expect that over 90% of those aged 35-44 in 2009 have a realistic prospect of retaining a functional natural dentition of 21 or more teeth by age 80.

Adult dental health surveys: 40 years on

A comparison of the results of the Adult Dental Health Surveys in England and Wales in 1968 and England, Wales and Northern Ireland in 2009 shows marked improvements in many aspects of oral health. Edentulousness in adults aged 16 years and over has reduced from 37% to 6%. Dentate adults today have 9 to 10 more sound teeth in all age groups up to 44 years, than was the case 40 years ago. The number of decayed or unsound teeth has halved in every age group between 1968 and 2009.

The Council of Heads and Deans of Dental Schools: 75 years

For three quarters of a century the Council of Heads and Deans of Dental Schools (CHDDS) has met to discuss issues relating to the UK and Irish dental schools. In this, the 75(th) anniversary year, it seems timely to review the work of the Council to date.

Comparison of once-daily mometasone furoate versus once-daily budesonide in patients with moderate persistent asthma

We conducted this study to compare the efficacy and safety of once-daily mometasone furoate (MF) administered by dry powder inhaler (DPI) with once-daily budesonide (BUD)-DPI and placebo in patients with moderate persistent asthma previously using twice-daily inhaled corticosteroids. A total of 262 patients (> or = 12 years of age) with moderate persistent asthma were randomised to once-daily morning treatment with MF-DPI 440 microg (metered dose), BUD-DPI 400 microg (metered dose), or placebo in an eight-week, multicentre, placebo-controlled, double-blind, double-dummy study. The primary efficacy variable was percent change in FEV1 from baseline to endpoint (last evaluable visit). At endpoint, the percent change in FEV1 was significantly greater (p < 0.01) following treatment with MF-DPI 440 microg (8.9%) than with both BUD-DPI 400 microg (2.1%) and placebo (-3.9%). Secondary efficacy variables, including morning and evening peak expiratory flow rates, albuterol use, percentage of asthma symptom-free days, and physician-evaluated response to therapy were also significantly improved at endpoint in the MF-DPI group compared with both the placebo and BUD-DPI groups (p < 0.05). Both active treatments were well tolerated. In conclusion, once-daily treatment in the morning with MF-DPI 440 microg significantly improved pulmonary function and asthma control compared with morning administration of BUD-DPI 400 microg and placebo.

Pressures on dental education--a personal view

Dental schools and hospitals currently find themselves in the awkward position of being expected to be more productive whilst suffering a shortage of resources. In essence, they are expected to provide both education and NHS healthcare, yet scant attention is paid to the urgent issue of the resources required to achieve this. The same is true in medicine where the Government has promised 2000 more medical school places by 2005, a rise of almost 60%, to guarantee a decade of unprecedented expansion in doctor numbers in the NHS. However, the country's ability to train doctors is compromised by a shortage of academics available to teach them.

Better opportunities for women dentists: a review of the contribution of women dentists to the workforce

In June 2000 the Department of Health commissioned a review to examine the need for improvements to the employment opportunities for women dentists in the National Health Service (NHS) across England. Dame Margaret Seward carried out the review, which was published in September 2001. The review was considered necessary for four main reasons. Firstly, workforce panning, because now more than 50% of new entrants to dental undergraduate courses in the UK are female and by 2020 over 50% of all practising dentists will be female. Secondly, evidence that 50% of women in dentistry work for no more than two days per week for the NHS. Thirdly, most women work either as associates in general dental practice (GDP) or in the Community Dental Service (CDS). Lastly, the perception that women find it difficult to return to dentistry after taking a career break.

Using quality of life scores to help determine treatment: is restoring bowel continuity better than an ostomy?

OBJECTIVE: In colorectal surgery, evaluation of heath-related quality of life (HRQL) has been relatively minimal when compared to other medical specialties. Would the performance of such HRQL evaluations change our decision-making in patient care? In familial adenomatous polyposis (FAP), procedures that restore bowel continuity (i.e. Ileorectal anastomosis or ileal pouch anal anastomosis) are routinely preferred to ileostomy because of the perceived, but unproven, better HRQL. This study evaluates FAP patients who underwent prophylactic colectomy with either permanent ileostomy or 'restored bowel continuity' reconstruction. The functional outcomes of both groups are reported, and the HRQL assessments are compared. METHODS: All FAP patients who underwent (procto) colectomy resection with reconstruction, either restored bowel continuity (BC) or permanent ileostomy (OST), between 1980 and 1998 were studied. Functional data were obtained by questionnaire and medical record review. HRQL was assessed by 2 validated instruments - the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey - which measure physical summary (PSF) and mental summary functioning (MSF) as well as eight separate health quality dimensions including health perception (HP), physical (PF) and social functioning (SF), physical (PR) and emotional role limitations (ER), mental health (MH), bodily pain (BP), and energy level (E). RESULTS: Results were obtained in 54 patients; bowel continuity (44), ileostomy (10). Mean patient age was 39 years, mean follow up time was 10.5 years. Mean patient age at operation was 28 years. Functional results for BC included number of bowel movements/day (6.7), leakage (30%), having to wear a pad (11%), perianal skin problems (25%), food avoidance (68%), and inability to distinguish gas (27%). Functional results for OST were routinely excellent. Results of the HRQL surveys reveal no significant differences for BC vs OST (HP: 67 +/- 28 vs 79 +/- 39; PF: 91 +/- 14 vs 90 +/- 17; SF: 86 +/- 23 vs 97 +/- 5; PR: 79 +/- 34 vs 83 +/- 40; ER: 86 +/- 28 vs 88 +/- 27; MH: 77 +/- 19 vs 82 +/- 14; BP: 78 +/- 24 vs 71 +/- 32; E 60 +/- 21 vs 58 +/- 18, respectively). CONCLUSION: Although the perceived quality of life for ileostomy patients is generally worse than the 'restored bowel continuity' group, the measured HRQL is the same for both groups. These results suggest that a permanent ileostomy should be included as a viable and appropriate first line treatment option for FAP patients after resection. This study also suggests that HRQL should play a greater role in the evaluation of care and treatment in colorectal surgery.

Prevalence of dental trauma in 5-6- and 12-14-year-old boys in Riyadh, Saudi Arabia

This study involved 354 boys aged 5-6 years and 862 boys aged 12-14 years, attending 40 schools in Riyadh. All children were examined at school by a single dental examiner, using criteria similar to those employed in the survey of children's dental health in the United Kingdom. The prevalence of dental trauma in 354 Saudi boys aged 5-6 years was 33%. The most common type of dental trauma was fracture of enamel (71%) followed by loss of tooth due to trauma (13%), fracture into enamel and dentine (7%), discolouration (5%), pulp involvement (4%). No relationship between the degree of overjet and the occurrence of dental trauma in the primary dentition was observed. The prevalence of dental trauma in 862 12-14-year-old boys was 34%. The commonest dental trauma was fracture of enamel (74%) followed by fracture into enamel and dentine (15%), fracture into enamel-dentine and pulp (5%), loss of tooth due to trauma (3%), and discolouration (0.4%). A significant relationship (P=0.02) between the increased overjet (> or = 6 mm) and the occurrence of dental trauma in the permanent dentition was reported. The present study found no evidence of dental care provided for traumatised primary incisors in 5-6-year-old boys. The treatment of dental trauma in 12-14-year-old boys was negligible (2.4%). The present Saudi Arabian study showed higher prevalence of dental trauma in 5-6- and 12-14-year-old boys than the reported results of the United Kingdom Children's Dental Health Survey of the same age groups.

Salmeterol powder provides significantly better benefit than montelukast in asthmatic patients receiving concomitant inhaled corticosteroid therapy

STUDY OBJECTIVES

Comparison of inhaled salmeterol powder vs oral montelukast treatment in patients with persistent asthma who remained symptomatic while receiving inhaled corticosteroids.

DESIGN

Randomized, double-blind, double-dummy, parallel-group, multicenter trials of 12-week duration.

SETTING

Outpatients in private and university-affiliated clinics.

PATIENTS

Male and female patients > or = 15 years of age with a diagnosis of asthma (baseline FEV(1) of 50 to 80% of predicted) and symptomatic despite receiving inhaled corticosteroids.

INTERVENTIONS

Inhaled salmeterol xinafoate powder, 50 microg bid, or oral montelukast, 10 mg qd.

MEASUREMENTS AND RESULTS

Treatment with salmeterol powder resulted in significantly greater improvements from baseline compared with montelukast for most efficacy measurements, including morning peak expiratory flow (35.0 L/min vs 21.7 L/min; p < 0.001), percentage of symptom-free days (24% vs 16%; p < 0.001), and the percentage of rescue-free days (27% vs 20%; p = 0.002). Total supplemental albuterol use was decreased significantly more in the salmeterol group compared with the montelukast group (- 1.90 puffs per day vs - 1.66 puffs per day; p = 0.004) and nighttime awakenings per week decreased significantly more with salmeterol than with montelukast (- 1.42 vs - 1.32; p = 0.015). Patients treated with inhaled salmeterol were significantly more satisfied with their treatment regimen and how well, how fast, and how long it worked than were patients who were treated with oral montelukast. The safety profiles for the two treatments were similar.

CONCLUSION

In patients with persistent asthma who remain symptomatic while receiving inhaled corticosteroids, adding inhaled salmeterol powder provided significantly greater improvement in lung function and asthma symptoms and was preferred by patients over oral montelukast.

Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan

OBJECTIVES

We designed a prospective study to determine whether there is a correlation between the severity of sinus symptoms and the severity of computed tomography (CT) scan evidence of rhinosinusitis.

METHODS

Acute and chronic rhinosinusitis patients rated their symptoms and had a CT scan of the sinuses taken the same day. A Likert severity scale and standardized CT scoring system were used. Data were analyzed by nonparametric methods with Kendall's rank correlation coefficient.

RESULTS

The severity of 5 symptoms correlated with severity of disease on CT scan. Headache and facial pain or pressure had no correlation.

CONCLUSION

The certainty of a clinical diagnosis of rhinosinusitis requiring treatment is enhanced in patients with high symptom severity scores for fatigue, sleep disturbance, nasal discharge, nasal blockage, or decreased sense of smell. Isolated headache and facial pain or pressure are less reliable predictors of CT scan findings supporting the diagnosis rhinosinusitis.

Long-term outcomes of the ileal pouch anal anastomosis: the association of bowel function and quality of life 5 years after surgery

INTRODUCTION

Previous studies have reported that mean health related quality of life (HRQL) levels generally attain normalcy following construction of an ileal pouch anal anastomosis (IPAA). It appears inconsistent, however, that these normal HRQL levels are achieved while bowel function (BF) scores generally remain statistically worse than "normal" (e.g., 4-8 stools/day, possible anal leakage, diaper usage). To investigate this inconsistency, the current study attempts to determine if any statistical associations are present between HRQL and BF, specifically in the long term. Multivariate regression analyses are performed using each of 8 individual HRQL domains against the full model of BF characteristics.

METHODS

All patients more than 5 years status post an ileal pouch anal anastomosis (IPAA) procedure for familial adenomatous polyposis (FAP) at a single institution were studied. FAP was chosen because patients are routinely asymptomatic preoperatively. BF (e.g., stool frequency, anal leakage) and HRQL (using the 8 health domains of the SF-36) were assessed by patient interview. Student's t tests and full model multivariate regression analyses were used to analyze associations between BF and HRQL.

RESULTS

The sample included 25 patients (14 male). Mean age was 39 years, mean follow-up time was 11 years. Although mean scores for the 8 individual HRQL domains were not statistically different from the general United States population, regression analyses of the different domains did demonstrate significant associations with varying levels of BF. While controlling for age and gender, the analyses show that the physical function domain is improved with the ability to pass flatus independent of stool, and physical role and mental health domains are improved with decreased stool frequency. The social function domain is improved with increased stool retention time, while the perception of general health is improved with less diaper usage and less sexual dysfunction.

CONCLUSIONS

This study shows that a statistically significant association between HRQL levels and BF is present. Of the numerous BF characteristics tested, five appear to be of greater importance with regard to certain HRQL domains. This finding may have clinical implications concerning pouch construction and surgical technique. Methodologically, this study demonstrates that merely using mean levels to describe HRQL may not elucidate meaningful relationships between important clinical outcomes, such as function and HRQL.

Cyclosporine pharmacokinetics and pharmacodynamics in African American and white subjects

BACKGROUND

Renal allograft survival is lower in African American patients compared with white patients. Interethnic differences in cyclosporine (INN, ciclosporin) pharmacokinetics in renal transplant recipients have been described but have not been well characterized. Pharmacodynamic responses to cyclosporine have not been compared among ethnic groups.

METHODS

Healthy men were studied after 5 days on a controlled diet. Cyclosporine concentrations were determined in whole blood drawn at intervals over 24 hours after administration of a microemulsion cyclosporine formulation (4 mg/kg; 9 African American subjects and 9 white subjects) and after a standard cyclosporine formulation (4 mg/kg; 10 African American subjects and 10 white subjects). Inhibition of phytohemagglutinin-P-stimulated interleukin-2 production in whole blood drawn 4 hours after cyclosporine was used as a pharmacodynamic measure to compare the effect of cyclosporine in African American and white subjects.

RESULTS

The microemulsion cyclosporine formulation (area under the cyclosporine concentration-time curve, 7432 +/- 560 ng. h/mL in African American subjects and 7043 +/- 454 ng. h/mL in white subjects) was more bioavailable than the standard formulation (area under the cyclosporine concentration-time curve, 4828 +/- 319 ng. h/mL in African American subjects and 4538 +/- 301 ng. h/mL in white subjects); this resulted in an approximately 50% greater area under the cyclosporine concentration-time curve (P < .001 in both ethnic groups). There were no differences between African American subjects and white subjects in any pharmacokinetic measurement, with both the standard and the microemulsion cyclosporine formulations. Inhibition of phytohemagglutinin-P-stimulated interleukin-2 production 4 hours after the administration of cyclosporine was similar in African American subjects (70% +/- 5% inhibition) and white subjects (64% +/- 7% inhibition; P = .5).

CONCLUSIONS

The pharmacokinetics and pharmacodynamics of cyclosporine were similar in a matched group of African American and white subjects studied under controlled conditions. Environmental factors may contribute more than genetic variability to the lower bioavailability of cyclosporine reported in African American renal transplant recipients.

Assessment of oxidant stress in allergic asthma by measurement of the major urinary metabolite of F2-isoprostane, 15-F2t-IsoP (8-iso-PGF2alpha)

Asthma is a chronic inflammatory disease of the airways which may involve an oxidant injury to the lung. Assessment of oxidant stress is difficult in vivo, but measurement of F2-isoprostanes (F2-IsoPs), free radical-catalysed products of arachidonic acid, appears to offer a reliable approach for quantitative measurement of oxidative stress status in vivo. We have recently developed a mass spectrometric assay for 2,3-dinor-5,6-dihydro-15-F2t-IsoP (15-F2t-IsoP-M), the major urinary metabolite of the F2-IsoP, 15-F2t-IsoP (8-iso-PGF2a). Measurement of the urinary excretion of this metabolite offers a reliable index of oxidative stress status in vivo that has advantages over measuring unmetabolized F2-IsoPs in urine and plasma. To assess the occurrence of oxidative stress in patients with atopic asthma following allergen exposure in vivo by measuring the urinary excretion of 15-F2t-IsoP-M. Analysis of 15-F2t-IsoP-M by GC-NICI-MS in nine mild atopic asthmatics following inhaled allergen provocation and four asthmatic subjects after inhaled challenge with methacholine. Urinary excretion of 15-F2t-IsoP-M increased at 2 h after allergen challenge and remained significantly elevated in all urine collections during the subsequent 8-h period of the study compared to the baseline value (ANOVA, and Student-Newman-Keuls multiple comparisons test). No increase in the urinary excretion of 15-F2t-IsoP-M occurred after inhalation of methacholine. Allergen challenge causes an oxidant injury in human atopic asthmatics. 15-F2t-IsoP-M is a valuable marker of oxidant stress in vivo.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 4: outcome comparisons, training, and conclusions

OBJECTIVE

A critical appraisal of cleft care in the United Kingdom.

DESIGN

Retrospective comparative study.

SETTING

All National Health Service cleft centers in the United Kingdom.

PATIENTS/PARTICIPANTS

Children born with unilateral complete clefts of the lip and palate between April 1, 1982, and March 31, 1984 (12-year-olds), and April 1, 1989, and March 31, 1991 (5-year-olds). Newly appointed and senior cleft clinicians.

MAIN OUTCOME MEASURES

Skeletal pattern, dental arch relationship, success of alveolar bone grafting, dental health, facial appearance, oral health status, patient/parent satisfaction.

CONCLUSIONS

This paper highlights the poor outcomes for the fragmented cleft care in the United Kingdom, compared with European centers. There is an urgent need for a review of structure, organization, and training.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 1: background and methodology

OBJECTIVE

To review the history of cleft care in the United Kingdom and the rationale and methodology of a national study.

DESIGN

Descriptive overview to introduce this series of papers.

SETTING

Fifty National Health Service cleft teams.

PATIENTS/PARTICIPANTS

Two age cohorts, 5-year-olds and 12-year-olds, with nonsyndromic complete unilateral cleft lip and palate and their parents.

MAIN OUTCOME MEASURES

Facial development and appearance, quality of bone grafts, speech, oral health and patient/parent satisfaction.

CONCLUSIONS

The case for a national assessment of cleft care is made. The methodology of the cross-sectional outcome study is described, together with a survey of training for recently appointed clinicians.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 2: dentofacial outcomes and patient satisfaction

OBJECTIVE

To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom.

DESIGN

Cross-sectional outcome study.

SETTING

Fifty National Health Service cleft centers.

PARTICIPANTS

Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received.

MAIN OUTCOME MEASURES

Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction.

RESULTS

Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds had not received an alveolar bone graft, and only 58% of bone grafts that had been undertaken were successful. Twenty percent of 12-year-olds and 40% of 5-year-olds had untreated dental caries. Less than one-third of subjects had a good facial appearance as judged by a panel of experts. Levels of patient and parent satisfaction were generally high.

CONCLUSION

A rigorous evaluation of cleft care in the United Kingdom reveals disappointing outcomes.

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 3: speech outcomes

OBJECTIVE

To summarize speech outcomes in children born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom.

DESIGN

Prospective descriptive study on a cross-sectional sample of children.

PATIENTS/PARTICIPANTS

Data were collected for 238 5-year-olds (born between April 1, 1989, and March 31, 1991) and 218 12-year-olds (born between April 1, 1982, and March 31, 1984) with complete UCLP.

MAIN OUTCOMES

Ratings of intelligibility, nasality, "speech cleft type characteristics" and speech therapy intervention.

CONCLUSIONS

Nineteen percent of 5-year-olds and 4% of 12-year-olds were judged to be impossible to understand or just intelligible to strangers. Thirty-four percent of 5-year-olds and 17% of 12-year-olds had at least one serious error of consonant production. Eighteen percent of 5-year-olds and 12-year-olds had consistent hypernasality of mild, moderate, or severe degree. Approximately two-thirds of both age groups had undergone speech therapy.

Phase III, randomized, double-blind study of clarithromycin extended-release and immediate-release formulations in the treatment of adult patients with acute maxillary sinusitis

BACKGROUND

Clarithromycin has an established bacteriologic efficacy and safety profile in the treatment of respiratory tract infections.

OBJECTIVE

This study compares the efficacy and tolerability of extended-release and immediate-release formulations of clarithromycin in patients with acute maxillary sinusitis.

METHODS

Fourteen days' treatment with once-daily clarithromycin was compared with the immediate-release, twice-daily formulation in a phase III, randomized, double-blind, parallel-group, multicenter study. Patients aged > or =12 years with signs, symptoms, and a radiologically confirmed diagnosis of acute maxillary sinusitis were eligible. Patients were assessed before treatment, within 48 hours after treatment, on study days 16 to 18, and at the test-of-cure visit on study days 24 to 31. Patients who received > or =1 dose of study drug were included in the safety analysis.

RESULTS

Of 283 patients treated, 245 were included in the efficacy analysis (122 in the extended-release group, 123 in the immediate-release group). Treatment groups were well matched with respect to demographic characteristics and medical condition and history. At the test-of-cure visit, 85% of patients in the clarithromycin extended-release group and 79% in the immediate-release group were deemed clinical cures; 89% and 91% in the extended-release and immediate-release groups, respectively, demonstrated radiographic success. Overall incidences of study drug-related adverse events were similar in the 2 treatment groups (32% in the extended-release group and 28% in the immediate-release group); however, significantly fewer patients receiving extended-release clarithromycin (2/142 11%]), compared with those receiving the immediate-release formulation (10/141 [7%]: P = 0.02) discontinued therapy because of drug-related gastrointestinal symptoms or abnormal taste. No clinically meaningful changes in laboratory values or vital signs were observed during the study.

CONCLUSION

Although the efficacy of the 2 formulations was comparable, once-daily clarithromycin extended-release was better tolerated than the twice-daily immediate-release formulation by patients with acute maxillary sinusitis.

A retrospective study of treatment provided in the primary and secondary care services for children attending a dental hospital following complicated crown fracture in the permanent dentition

OBJECTIVES

To investigate treatment provision in primary and secondary dental care following complicated crown fracture of permanent teeth.

DESIGN AND METHODS

Retrospective observational survey of dental records of all patients attending a dental hospital trauma clinic during a 2-year period with complicated crown fracture.

RESULTS

Eighty children (70% male) aged 6-16 years (mean age 10.3 years) with 98 complicated crown fractures were identified. Of these children, 54% were seen for emergency treatment on the day of their injury, 75% within 48 h. Of the 98 injured teeth, 60% were seen initially in general dental practice but only 56% of these 59 cases were provided with emergency treatment in practice, the others being referred immediately to the trauma clinic for treatment. The main cause of fractures was transport, in particular, bicycles. Radiographs were available for 96 teeth; for the 43 open apex teeth, the definitive treatment was pulp capping (44% of cases) and pulpotomy (30%), with vitality maintained in five cases up to 4.8 years after trauma. The 53 closed apex cases were treated definitively with pulp capping (38%) and pulpectomy (36%) and six teeth had maintained their vitality up to 4.3 years after trauma. Sixty-seven per cent of the pulp caps and 47% of the 19 pulpotomies provided relied on a doubtful coronal seal. This was primarily due to the extensive use of a conventional glass ionomer cement as an emergency bandage. The use of an etched or bonded material at initial presentation extended the Median Survival Time for vitality in open apex teeth from 188 to 377 days and in closed apex teeth from 15 to 64 days.

CONCLUSIONS

Emergency treatment of complicated crown fractures, particularly in primary care services is often inappropriate or inadequate with regard to emergency management of the exposed pulp and provision of a hermetic coronal seal.

Mometasone furoate administered once daily is as effective as twice-daily administration for treatment of mild-to-moderate persistent asthma

BACKGROUND

Despite current recommendations, many patients with persistent asthma are still treated with bronchodilators alone.

OBJECTIVE

The safety and efficacy of two once daily dosing regimens (200 microg and 400 microg) of mometasone furoate (MF) administered in the morning by using a dry-powder inhaler (DPI) were compared with those of a twice daily dosing regimen (200 microg administered twice daily) in patients with mild-to-moderate persistent asthma previously taking only inhaled beta(2)-adrenergic agonists.

METHODS

All patients (306 patients; age range, 12-70 years) were given a diagnosis of asthma for at least 6 months before enrollment in this 12-week, placebo-controlled, double-blind, randomized study. The primary efficacy variable was change in FEV(1) from baseline to endpoint (last evaluable visit).

RESULTS

At endpoint, FEV(1) was significantly improved (P < or =.02) after MF-DPI 400 microg once daily morning treatment and MF-DPI 200 microg twice daily treatment (16.0% and 16.1%, respectively) compared with placebo (5.5%). The improvement seen with MF-DPI 200 microg once daily morning treatment (10.4%) was not significantly different from that with placebo. Secondary efficacy variables also showed significant improvement for the MF-DPI 400 microg once daily morning treatment group and the MF-DPI 200 microg twice daily treatment group compared with the placebo group. All doses of MF administered by means of a DPI were well tolerated.

CONCLUSION

This is the first study to demonstrate that a total daily dose of 400 microg of MF administered by means of a DPI is an effective treatment for patients with mild-to-moderate persistent asthma previously taking only inhaled beta(2)-adrenergic agonists. This treatment was equally effective when administered either as a once daily or twice daily regimen.

Prostaglandin E(2) decreases allergen-stimulated release of prostaglandin D(2) in airways of subjects with asthma

Prostaglandin E(2) (PGE(2)) inhibits the early and late bronchoconstrictor response to inhaled allergen. The mechanisms of action, however, are not understood. We investigated the effect of inhaled PGE(2) on the release of prostaglandin D(2) (PGD(2)), preformed mast cell mediators, and other products of arachidonic acid metabolism. We compared inhaled PGE(2) (100 microgram) to placebo in a randomized double-blind crossover study. Ten atopic asthmatics underwent bronchoscopy immediately after inhalation of PGE(2) or placebo. Bronchoalveolar lavage (BAL) was performed at baseline, and in a separate segment 4 min after allergen instillation. Nebulized PGE(2) was well tolerated. PGE(2) concentrations in baseline lavage fluid were significantly greater after PGE(2) inhalation than after placebo. PGD(2) concentrations after allergen challenge were significantly reduced in those subjects receiving nebulized PGE(2) compared with control subjects. We conclude that PGE(2) can be safely delivered by inhalation. Nebulized PGE(2) administered before to segmental allergen challenge reduced PGD(2) in BAL fluid (BALF). PGE(2) also decreased the production of other mediators of the arachidonic acid pathway, although not significantly. The reduction of PGD(2) may be part of the mechanism by which PGE(2) blocks the early asthmatic response.

Clinical evaluation of paired compomer and glass ionomer restorations in primary molars: final results after 42 months

OBJECTIVES

To undertake a clinical trial comparing the efficiency of a compomer restoration with a glass ionomer restoration in the management of caries in primary molar teeth.

DESIGN

Subjects were admitted to the trial if they required at least one pair of restorations in primary molar teeth.

SETTING

Department of Child Dental Health, Newcastle Dental Hospital and School.

SUBJECT

Twenty nine children, aged 4-9 years, had 56 pairs of restorations placed between January 1995 and November 1997.

METHOD

The durability of the restorations was assessed during a 42-month follow-up period using modified United States Public Health Service criteria. Survival analysis and the McNemar paired test were used to compare the performance of the two restorative materials.

RESULTS

The compomer restorations had a higher mean survival time (42 months, SE 1.40) compared with 37 months (SE 1.90) for the glass ionomer restorations and this was significant at the 5% level. The compomer also performed significantly better in terms of anatomical form, marginal integrity, cavo surface discoloration and maintenance of interproximal contact.

CONCLUSIONS

The present trial demonstrated that Dyract compomer performed significantly better than Chemfil Superior a glass ionomer cement for all modified United States Public Health Service criteria over a period of 42 months.

Does better functional result equate with better quality of life? Implications for surgical treatment in familial adenomatous polyposis

PURPOSE

The main impetus for a patient with familial adenomatous polyposis to choose colectomy with ileorectal anastomosis over ileal pouch-anal anastomosis is the better functional result. However, does better functional result necessarily translate into better overall quality of life? Previous studies of other diseases have demonstrated no such correlation. This study was performed to determine whether any relationship exists between functional result and quality of life in patients with familial adenomatous polyposis after ileorectal anastomosis and ileal pouch-anal anastomosis.

METHODS

All patients with familial adenomatous polyposis who underwent colectomy with ileorectal anastomosis or proctocolectomy with ileal pouch-anal anastomosis from 1980 to 1998 were studied. Functional data were obtained by questionnaire. Health-related quality of life was assessed by two validated instruments, the SF-36 Physical and Mental Health Summary Scales and the SF-36 Health Survey, which measure physical and mental functioning and eight separate health-quality dimensions, including health perception, physical and social functioning, physical and emotional role limitations, mental health, bodily pain, and energy or fatigue.

RESULTS

Data were obtained in 44 of 68 patients, 14 with ileorectal anastomosis and 30 with ileal pouch-anal anastomosis. No differences were demonstrated between the two groups for patient age, mean follow-up time, and mean patient age at operation. Functional results were worse for the ileal pouch-anal anastomosis group vs. the ileorectal anastomosis group in number of bowel movements per day (7.5 vs. 5.2; P < 0.05), leakage (43 vs. 0 percent; P < 0.01), pad usage (17 vs. 0 percent; P < 0.01), perianal skin problems (33 vs. 7 percent; P < 0.01), food avoidance (80 vs. 43 percent; P < 0.01), and inability to distinguish gas (37 vs. 7 percent; P < 0.01). Results of the health-related quality-of-life surveys, however, demonstrated no difference between the ileal pouch-anal anastomosis and ileorectal anastomosis groups. The Physical and Mental summary scales for the ileal pouch-anal anastomosis and ileorectal anastomosis groups were not significantly different (Physical Health Scale, 50.3 vs. 50.9; Mental Health Scale, 51.7 vs. 49.6), and none of the eight dimensions of the SF-36 health survey demonstrated statistical differences between the ileal pouch-anal anastomosis and ileorectal anastomosis groups.

CONCLUSION

Better functional results were not equated with better quality of life in this pilot study. Although patients with the ileorectal anastomosis have better functional results than those with ileal pouch-anal anastomosis, the measured health-related quality of life as determined by a validated generic health-related quality-of-life instrument is the same for both groups. These results suggest that all patients with familial adenomatous polyposis might be optimally treated with an ileal pouch-anal anastomosis. More importantly, this study suggests that health-related quality of life should play a greater role in the evaluation of care and treatment in colon rectal surgery.

Sustained reduction in myocardial reperfusion injury with an adenosine receptor antagonist: possible role of the neutrophil chemoattractant response

Recent studies have demonstrated that three membrane-permeant A(1) receptor antagonists reduced infarct size in a model of ischemia followed by brief reperfusion. However, it was not determined whether cardioprotection was mediated by nonspecific intracellular effects of these highly lipophilic drugs and whether the antagonists only delayed myocardial necrosis without affecting the ultimate infarct size. In the present study, closed-chest dogs were subjected to 90 min of left anterior descending coronary artery occlusion and 72 h of reperfusion and received either a nonmembrane-permeant adenosine receptor blocker that is devoid of direct intracellular effects and is 6-fold selective for the A(1) receptor [1, 3-dipropyl-8-p-sulfophenylxanthine (DPSPX); n = 11] or vehicle (n = 12). DPSPX was administered as three 200-mg boluses 60 min before and 30 and 120 min after reperfusion. The area of necrosis was determined histologically and expressed as a percentage of the area at risk. Baseline predictors of infarct size were similar in the two groups. The ratio of the area of necrosis to the area at risk was less in the DPSPX group (17.8 +/- 4.3% versus 35.0 +/- 1.9%; P =. 012), and DPSPX improved regional ventricular function. Under both basal and stimulated (formyl-Met-Leu-Phe) conditions, suspensions of human neutrophils generated extracellular adenosine levels (approximately 50 nM) sufficient to activate A(1) receptors. Moreover, both DPSPX and 1,3-dipropyl-8-cyclopentylxanthine, a selective A(1) receptor antagonist, significantly reduced the chemoattractant response of neutrophils to formyl-Met-Leu-Phe. We conclude that blockade of A(1) adenosine receptors attenuates myocardial ischemic/reperfusion injury, possibly in part by decreasing the chemoattractant response of neutrophils.

Ethanol increases superoxide anion production stimulated with 4beta-phorbol 12-myristate 13-acetate in human polymorphonuclear leukocytes. Involvement of protein kinase C

Stimulation of human polymorphonuclear leukocytes (PMNs) with PMA initiates a cascade of events leading to the production and release of superoxide anion (O-2), a major component in anti-bacterial defense. Generation of O-2 by PMA-stimulated PMNs occurs through the translocation and activation of protein kinase C (PKC). In this study, using freshly isolated PMNs, we examined the effect of ethanol on this response to PMA. Our results show that the basal production of O-2 was not affected by ethanol. In contrast, the response induced by PMA was potentiated by ethanol. This potentiation was observed even at high doses of PMA (200 nM) which alone had stimulated the O-2 response maximally. This enhanced response was not due to an increase of PMA uptake by PMNs. The maximal effect was obtained when the cells were preincubated with 80 mM of ethanol before PMA stimulation. Measurement of PKC activity in the cytosolic and membrane fractions showed that pretreatment of PMNs with ethanol increased twofold the PMA-stimulated PKC activity in the membrane fraction. Furthermore, Western blot analysis verified that this increase in PKC activity in the membrane fraction was linked to an increase in the translocation of PKC-alpha and -beta isoforms to the membrane. These results suggest that ethanol potentiates PMA-induced O-2 production through increasing PKC translocation and activity in PMNs.

Allergen-induced synthesis of F(2)-isoprostanes in atopic asthmatics. Evidence for oxidant stress

It is thought that reactive oxygen species (ROS) participate in the inflammation which characterizes asthma, but the evidence supporting this contention is incomplete. F(2)-isoprostanes (F(2)-IsoPs) are arachidonate products formed on membrane phospholipids by the action of ROS and thereby represent a quantitative measure of oxidant stress in vivo. Using a mass spectrometric assay we measured urinary release of F(2)-IsoPs in 11 patients with mild atopic asthma after inhaled allergen challenge. The excretion of F(2)-IsoPs increased at 2 h after allergen (1.5 +/- 0.2 versus 2.6 +/- 0.3 ng/mg creatinine) and remained significantly elevated in all urine collections for the 8-h period of the study (analysis of variance [ANOVA]). The measured compounds were of noncyclooxygenase origin because neither aspirin nor indomethacin given before challenge suppressed them. Urinary F(2)-IsoPs remained unchanged after inhaled methacholine challenge. In nine atopic asthmatics, F(2)-IsoPs were quantified in bronchoalveolar lavage fluid (BALF) at baseline values and in a separate segment 24 h after allergen instillation. F(2)-IsoPs were elevated late in the BALF (0.9 +/- 0.2 versus 11.4 +/- 3.0 pg /ml, baseline versus allergen, respectively, p = 0.007). The increase was inhibited by pretreatment of the subjects with inhaled corticosteroids. These findings provide a new evidence for a role for ROS and lipid peroxidation in allergen-induced airway inflammation.

Partial dentures as an independent indicator of root caries risk in a group of older adults

OBJECTIVES

To estimate the independent association between the wearing of removable partial dentures (RPD) and the presence of root caries in a population of older adults.

DESIGN

Multivariate logistic regression modeling of root caries prevalence using different measures of root caries as dependent variables. The model included measures of disease history as indicators of historical risk.

SETTING

Data collected in the field from three areas of England.

SUBJECTS

Random sample of adults aged 60 years and over, drawn from lists of patients registered with general medical practitioners.

INTERVENTION

Field measurements of a range of oral health variables including oral disease, disease history, oral status and various social and demographic measures.

MAIN OUTCOME MEASURES

The presence of root caries, unsound and sound root restorations.

RESULTS

Of the five different models of root caries prevalence which were used, RPDs featured as an independent risk indicator for root surface caries in the three which were related to the presence of untreated disease. The odds ratios for the contribution made by RPDs were all over 1.6, and when considered alone was in excess of 2 in one model. These models were generally well fitting. RPDs did not feature as a risk indicator in the two models which related only to the presence of root surface restorations.

CONCLUSIONS

In this study, where RPDs were present, the odds of untreated disease being present increased substantially.

Safety and efficacy of NeuroBloc (botulinum toxin type B) in type A-responsive cervical dystonia

OBJECTIVE

To determine the safety and efficacy of botulinum toxin type B (BoNT/B) in patients with cervical dystonia (CD).

BACKGROUND

BoNT/B is a form of chemodenervation therapy for the treatment of patients with CD.

METHODS

The authors performed a 16-week, randomized, multicenter, double-blind, placebo-controlled trial of BoNT/B in patients with CD who continue to respond to botulinum toxin type A. Placebo, or 5,000 U or 10,000 U of BoNT/B was administered in two to four muscles involved clinically in CD. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)-Total score at week 4 was the primary efficacy measure. Clinical assessments and adverse events were recorded for treatment day 1 and at weeks 2, 4, 8, 12, and 16.

RESULTS

A total of 109 patients were enrolled randomly across all three treatment groups. The mean improvement in the TWSTRS-Total scores in each group at week 4 was 4.3 (placebo), 9.3 (5,000 U), and 11.7 (10,000 U). For the prospectively defined primary contrast (10,000 U versus placebo), highly significant differences were noted for the primary (TWSTRS-Total, baseline to week 4, p = 0.0004) and supportive secondary (Patient Global Assessment, baseline to week 4, p = 0.0001) outcome measures. Improvement in pain, disability, and severity of CD occurred for patients who were treated with BoNT/B when compared with placebo-treated patients. Overall, improvements associated with BoNT/B treatment were greatest for patients who received the 10,000-U dose. The duration of treatment effect for BoNT/B was 12 to 16 weeks for both doses.

CONCLUSION

Botulinum toxin type B (NeuroBloc) is safe and efficacious at 5,000 U and 10,000 U for the management of patients with cervical dystonia.