Current landscape of ESMO/ASCO Global Curriculum adoption and medical oncology recognition: a global survey

Background

With the implementation of multidisciplinary treatment and development of multiple novel anticancer drugs in parallel with expanding knowledge of supportive and palliative care, a need for separate training and specialisation in medical oncology emerged. A Global Curriculum (GC) in medical oncology, developed and updated by a joint European Society for Medical Oncology/American Society of Clinical Oncology (ESMO/ASCO) GC Task Force/Working Group (GC WG), greatly contributed to the recognition of medical oncology worldwide.

Material and methods

ESMO/ASCO GC WG carried out a global survey on medical oncology recognition and GC adoption in 2019.

Results

Based on our survey, medical oncology is recognised as a separate specialty or sub-specialty in 47/62 (75%) countries participating in the survey; with a great majority of them (39/47, 83%) recognising medical oncology as a standalone specialty. Additionally, in 9 of 62 (15%) countries, medical oncology is trained together with haematology as a specialty in haemato-oncology or together with radiotherapy as a specialty in clinical oncology. As many as two-thirds of the responding countries reported that the ESMO/ASCO GC has been either fully or partially adopted or adapted in their curriculum. It has been adopted in a vast majority of countries with established training in medical oncology (28/41; 68%) and adapted in 12 countries with mixed training in haemato-oncology, clinical oncology or other specialty responsible for training on systemic anticancer treatment.

Conclusions

With 75% of participating countries reporting medical oncology as a separate specialty or sub-specialty and as high as 68% of them reporting on GC adoption, the results of our survey on global landscape are reassuring. Despite a lack of data for some regions, this survey represents the most comprehensive and up-to-date information about recognition of medical oncology and GC adoption worldwide and will allow both societies to further improve the dissemination of the GC and global recognition of medical oncology, thus contributing to better cancer care worldwide.

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ESMO/ASCO Global Curriculum (GC) supported medical oncology (MO) as a standalone specialty or sub-specialty worldwide.

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The ESMO/ASCO GC Working Group regularly updates the GC and conducted a worldwide survey on GC adoption and MO recognition.

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Based on the survey, MO is recognised as a specialty or sub-specialty in the majority (47/62; 75%) of participating countries.

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ESMO/ASCO GC has been adopted or adapted in 68% of participating countries without significant differences around the world.

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This most comprehensive information about MO recognition and GC adoption will support their further dissemination worldwide.

An 11-year review of hip fracture hospitalisations, health outcomes, and predictors of access to in-hospital rehabilitation for adults ≥ 65 years living with and without dementia: a population-based cohort study

This study examined hip fracture hospitalisation trends and predictors of access to rehabilitation for adults aged ≥ 65 years living with and without dementia. The hospitalisation rate was 2.5 times higher for adults living with dementia and adults who lived in aged care were between 4.8 and 9.3 times less likely to receive rehabilitation.

INTRODUCTION

To examine hip fracture hospitalisation temporal trends, health outcomes, and predictors of access to in-hospital rehabilitation for older adults living with and without dementia.

METHODS

A population-based retrospective cohort study of adults aged ≥ 65 years hospitalised with a hip fracture during 2007-2017 in New South Wales, Australia.

RESULTS

Of the 69,370 hip fracture hospitalisations, 27.1% were adults living with dementia. The hip fracture hospitalisation rate was 2.5 times higher for adults living with dementia compared with adults with no dementia (1186.6 vs 492.9 per 100,000 population). The rate declined by 6.1% per year (95%CI - 6.6 to - 5.5) for adults living with dementia and increased by 1.0% per year (95%CI 0.5-1.5) for adults with no dementia. Multivariable associations identified that adults living with dementia who experienced high frailty and increasing age were between 1.6 and 1.8 times less likely to receive in-hospital rehabilitation. Adults who were living in long-term aged care facilities were between 4.8 and 9.3 times less likely to receive in-hospital rehabilitation which varied by the presence of dementia or delirium.

CONCLUSION

Consistent criteria should be applied to determine rehabilitation access, and rehabilitation services designed for older adults living with dementia or in aged care are needed.

HIGHLIGHTS

• Adults living with dementia were able to make functional gains following hip fracture rehabilitation. • Need to determine consistent criteria to determine access to hip fracture rehabilitation. • Rehabilitation services specifically designed for adults living with dementia or in aged care are needed.

Future hospital service utilisation in older adults living in long-term residential aged care or the community hospitalised with a fall-related injury

This study identified group-based trajectories of hospitalisation for older adults who were living in residential aged care facilities (RACF) or the community for up to 4 years after an index fall injury hospitalisation. Greater than 3 subsequent fall injury hospitalisations and time until move to a RACF were key predictors of RACF and community-living trajectory group memberships, respectively.

INTRODUCTION

To examine hospital service use trajectories of people aged ≥ 65 years who had a fall injury hospitalisation and were either living in a residential aged care facility (RACF) or the community at the time of the index fall and to identify factors predictive of their trajectory group membership.

METHOD

A group-based trajectory analysis of hospitalisations of people aged ≥ 65 years who had a fall injury hospitalisation during 2008-2009 in New South Wales, Australia, was conducted. Linked hospitalisation and RACF data were examined for a 5-year period. Group-based trajectory models were derived based on number of subsequent hospital admissions following the index fall injury hospitalisation. Multinominal logistic regression examined predictors of trajectory group membership.

RESULTS

There were 24,729 fall injury hospitalisations; 78.8% of fallers were living in the community and 21.2% in a RACF. Five distinct trajectory groups were identified for community-living and four trajectory groups for RACF residents. Key predictors of trajectory group membership for both community-living and RACF residents were age group, number of comorbidities and dementia status. For RACF residents, depression, assistance with activities of daily living and number of subsequent fall injury admissions were also predictors of group membership, with time to move to a RACF a predictor of group membership for community living.

CONCLUSIONS

Identifying trajectories of ongoing hospital use informs targeting of strategies to reduce hospital admissions and design of services to allow community-living individuals to remain as long as possible within their own residence.

A randomized controlled trial comparing tapentadol with oxycodone in non-breastfeeding women post elective cesarean section

BACKGROUND

Tapentadol may allow greater pain relief with reduced "opioid load" compared to oxycodone. Its use has not been studied in the obstetric population. The objective of this study was to compare the efficacy and side effect profile of tapentadol with oxycodone in patients who received spinal anesthesia for elective cesarean section. The trial was registered with EU Clinical Trials Register with CT number 2016-001621-33.

METHODS

This was a multicenter, randomized controlled trial. Randomized patients (n = 68) received either 50 mg tapentadol or oxycodone 10 mg 12 hourly postoperatively. The primary endpoint was the sum of pain intensity difference over the first 48 hours of treatment (SPID₄₈). Secondary outcomes included time to rescue medications, SPID₃₆, total pain relief (TOTPAR) scores, patient satisfaction scores, sum of total pain relief and pain intensity difference (SPRID) scores, time to rescue medications and side effects experienced. An analysis of covariance model with baseline pain intensity score as a covariate was used for statistical analysis.

RESULTS

There was no significant difference in the primary endpoint of SPID₄₈ with adjusted mean difference -11.45 (95% CI -35.35, 12.45) p = .34). Oxycodone showed significantly greater SPID₃₆ scores compared to tapentadol with increased time to rescue medication. Side effects experienced were similar between groups.

CONCLUSION

Tapentadol did not provide superior pain control or improved tolerability compared to oxycodone post cesarean section. Results should be interpreted however with consideration of administration of intrathecal opioids to all patients in this study and debate over the optimal dose of tapentadol for acute pain.

Comparison of hospitalised trends, treatment cost and health outcomes of fall-related hip fracture for people aged ≥ 65 years living in residential aged care and the community

This study compared hip fracture rates and health outcomes of older people living in residential aged care facilities (RACFs) to the community. The RACF resident age-standardised hospitalisation rate was five times higher than the community rate and declining. RACF residents experience overall worse health outcomes and survival post-hip fracture.

INTRODUCTION

To compare hospitalisation trends, characteristics and health outcomes following a fall-related hip fracture of older people living in residential aged care facilities (RACFs) to older people living in the community.

METHODS

A retrospective analysis of fall-related hip fracture hospitalisations of people aged ≥ 65 years during 1 July 2008 and 30 June 2013 in New South Wales (NSW), Australia's largest populated state. Linked hospitalisation, RACF and Aged Care Assessment Appraisal data collections were examined. Negative binomial regression examined the significance of hospitalisation temporal trends.

RESULTS

There were 28,897 hip fracture hospitalisations. One-third were of older people living in RACFs. The hospitalisation rate was 2180 per 100,000 (95%CI: 2097.0-2263.7) for RACF residents and 390 per 100,000 (95%CI 384.8-395.8) for older people living in the community. The hospitalisation rate for RACF residents was estimated to decline by 2.9% annually (95%CI: - 4.3 to - 1.5). Hospital treatment cost for hip fractures was AUD$958.5 million. Compared to older people living in the community, a higher proportion of RACF residents were aged ≥ 90 years (36.1% vs 17.2%), were female (75.3% vs 71.8%), had > 1 Charlson comorbidity (37.6% vs 35.6%) and 58.2% had dementia (vs 14.4%). RACF residents had fewer in-hospital rehabilitation episodes (18.7% vs 60.9%) and a higher proportion of unplanned readmissions (10.6% vs 9.1%) and in-hospital mortality (5.9% vs 3.3%) compared to older people living in the community.

CONCLUSIONS

RACF residents are a vulnerable cohort of older people who experience worse health outcomes and survival post-hip fracture than older people living in the community. Whether access to individualised hip fracture rehabilitation for RACF residents could improve their health outcomes should be examined.

Masseter function and skeletal malocclusion

The aim of this work is to review the relationship between the function of the masseter muscle and the occurrence of malocclusions. An analysis was made of the masseter muscle samples from subjects who underwent mandibular osteotomies. The size and proportion of type-II fibers (fast) decreases as facial height increases. Patients with mandibular asymmetry have more type-II fibers on the side of their deviation. The insulin-like growth factor and myostatin are expressed differently depending on the sex and fiber diameter. These differences in the distribution of fiber types and gene expression of this growth factor may be involved in long-term postoperative stability and require additional investigations. Muscle strength and bone length are two genetically determined factors in facial growth. Myosin 1H (MYOH1) is associated with prognathia in Caucasians. As future objectives, we propose to characterize genetic variations using "Genome Wide Association Studies" data and their relationships with malocclusions.

Self-report of latex allergy by patients visiting a dental clinic

BACKGROUND

The prevalence of latex allergy among dental patients is not known, although it has been increasing in the population since 1982, when the use of gloves was expanded to prevent the transmission of infectious diseases.

METHODS

A retrospective cross-sectional study was undertaken of 1,798 electronic health records (EHRs) of new clinic patients who registered at the University of Pittsburgh School of Dental Medicine (SDM) dental clinic between January and June 2010. Data extracted from the EHRs included age, gender, and a history of a previous latex reaction, asthma, or allergy to penicillin.

RESULTS

A previous reaction to latex was reported by 59 patients (3.3%). Women were almost three times more likely to report this (4.7% versus 1.6%, P = 0.0005). Histories of asthma or penicillin allergy in women were significantly associated with latex allergy (P = 0.0005 and P = 0.0001, respectively).

CONCLUSIONS

The reported rate of a previous reaction to latex in this patient sample was higher than that of the general population. This may, in part, be related to repeated exposures to latex-containing gloves.

CLINICAL IMPLICATIONS

Practitioners are increasingly likely to encounter patients who have had a reaction to latex. Non-latex products must be available for these patients, who are more likely to be women and individuals with asthma or an allergy to penicillin.

Dentin matrix protein 1 (DMP1) signals via cell surface integrin

Dentin matrix phosphoprotein 1 (DMP1) is a non-collagenous, acidic extracellular matrix protein expressed chiefly in bone and dentin. We examined the DMP1 ability to engage cell-surface receptors and subsequently activate intracellular signaling pathways. Our data indeed show that the presence of extracellular DMP1 triggers focal adhesion point formation in human mesenchymal stem cells and osteoblast-like cells. We determine that DMP1 acts via interaction with αvβ3 integrin and stimulates phosphorylation of focal adhesion kinase. Further biochemical characterization confirms the activation of downstream effectors of the MAPK pathways, namely ERK and JNK, after DMP1 treatment. This activation is specifically inhibitable and can also be blocked by the addition of anti-αvβ3 integrin antibody. Furthermore, we show that extracellular treatment with DMP1 stimulates the translocation of phosphorylated JNK to the nucleus and a concomitant up-regulation of transcriptional activation by phosphorylated c-Jun. The evidence presented here indicates that DMP1 is specifically involved in signaling via extracellular matrix-cell surface interaction. Combined with the published DMP1-null data (Feng, J. Q., Ward, L. M., Liu, S., Lu, Y., Xie, Y., Yuan, B., Yu, X., Rauch, F., Davis, S. I., Zhang, S., Rios, H., Drezner, M. K., Quarles, L. D., Bonewald, L. F., and White, K. E. (2006) Nat. Genet. 38, 1310-1315) it can be hypothesized that DMP1 could be a key effector of ECM-osteocyte signaling.

Who will manage American patients with diabetes? Residents' career preferences and perceptions of diabetes care

OBJECTIVE

To identify the factors that encourage or discourage internal medicine and pediatric residents regarding specializing in endocrinology with a focus on diabetes.

METHODS

We conducted an electronic survey of internal medicine and pediatric residents using a $10 participation incentive. A total of 653 residents responded to the survey (estimated response rate of 9.2%)-626 from residency programs that were contacted for our survey and 27 from referrals.

RESULTS

Among internal medicine and pediatric residents surveyed, 39 respondents (6.0%) planned to specialize in endocrinology, and 27 of these (4.1% of total respondents) planned to focus on diabetes. "Intellectual satisfaction," "emotional satisfaction," and "work-life balance" were identified by respondents as the most important factors in their choice of a specialty, with ratings of 5.5, 5.4, and 5.3 on a 6-point Likert scale. Among these factors identified as most important to a medical career, endocrinology with a focus on diabetes scored poorly with regard to intellectual and emotional satisfaction but received high ranking with regard to lifestyle. With regard to other factors, endocrinology was rated negatively on "compensation," "number of procedures," and "patient adherence to prescribed treatment." Exposure to diabetes during training had no major influence on the decision to enter endocrinology.

CONCLUSION

Endocrinology with a focus on diabetes care is not an attractive specialty for most internal medicine and pediatric residents. Therefore, new strategies to attract residents to the field of diabetes care are needed.

Assessing the need for anesthesia and sedation services in Kuwaiti dental practice

The objective of this study was to examine the public health relevance of the prevalence of dental fear in Kuwait and the resultant barrier that it creates regarding access to dental care. The study analysis demonstrated a high prevalence of dental fear and anxiety in the Kuwaiti population and a perceived need for anesthesia services by dental care providers. The telephone survey of the general population showed nearly 35% of respondents reported being somewhat nervous, very nervous, or terrified about going to the dentist. In addition, about 36% of the population postponed their dental treatment because of fear. Respondents showed a preference to receive sedation and anesthesia services as a means of anxiety relief, and they were willing to go to the dentist more often when such services were available. People with high fear and anxiety preferred to receive some type of medication to relieve their anxiety. In conclusion, the significance and importance of the need for anesthesia services to enhance the public health of dental patients in Kuwait has been demonstrated, and improvements are needed in anesthesia and sedation training of Kuwaiti dental care providers.

Overcoming barriers to tobacco cessation counselling in dental students

PURPOSE

Tobacco use screening and brief intervention is recognised as an effective available preventive health service; yet, this service is still not routinely offered to dental patients by clinicians, despite dental schools generally providing some form of tobacco cessation counselling (TCC) by including it in their dental curriculum. A pilot study was therefore carried out to more clearly identify barriers that prevented the delivery of this service to tobacco-using patients at the University of Pittsburgh School of Dental Medicine and educational initiatives that might overcome these barriers.

MATERIALS AND METHODS

A survey of faculty and students asked participants to rank their knowledge, preparation and comfort levels in performing TCC as well as their belief as to the importance of such training in the dental curriculum. Six months following training and practice opportunities, surveys were again administered to participants. Each individual's pre- and post-TCC training surveys were reviewed and difference in response to each item was calculated.

RESULTS

The results of the present study show that students feel more prepared, that the time required to provide TCC was less than anticipated and that training in TCC is an important part of dental education to a greater extent after the pilot study than before.

CONCLUSIONS

TCC training and practice opportunities for clinical application were effective in this pilot study in improving students' attitudes towards cited barriers.

Complications associated with anesthesia administered for dental treatment

This assessment sought to identify and quantify complications that occur with anesthesia administration during dental treatment of consecutive patients who received care through the University of Pittsburgh School of Dental Medicine's (UPSDM) Department of Anesthesiology. This prospective study was completed by participating anesthesia caregivers at the UPSDM as a case-by-case evaluation. A standardized form delineating possible complications was used to collect data following 286 consecutive outpatient anesthetic cases administered within the UPSDM. After statistical analysis of five types of administered anesthesia, the overall complication rate was 22.4% in 286 cases. All of the complications were considered to be mild (90.6%) or moderate (9.4%); there were no reports of severe complications. The complications encountered most frequently were airway obstruction (18 reports) and occurrence of nausea/vomiting (12 reports). ASA classification, anesthetic technique, pre-existing medical findings, and the type of dental procedure performed all were variables that were found to affect the incidence of anesthesia-related complications. The overall complication rate from anesthesia administered during dental care is similar to or less than that reported within the hospital operating system environment.

Factors associated with parents? and adolescents? perceptions of oral health and need for dental treatment

OBJECTIVE

The aim of this study was to characterize the association between clinical and psychosocial factors as they related to perceptions by parents and adolescents to the adolescent's oral health status and treatment need. Additionally, the degree to which adolescent's and parent's perceptions of oral health and treatment need were related was examined.

METHODS

Data from the Pennsylvania oral health needs assessment for 530 parent-adolescent pairs were used to address the objectives of this study. Comparisons between clinical oral health measures, psychosocial factors, and the parent- and adolescent-reported perceptions of the adolescent's oral health status were made using descriptive and inferential statistics, including exploratory factor analysis and path analysis.

RESULTS

Parents and adolescents exhibited only modest concordance on ratings of the adolescent's oral health status and need for dental treatment. Furthermore, parents tended to rate their adolescent's oral health status as better than did the adolescent. The results of the path analysis showed that adolescents based their ratings of oral health status more on oral symptoms, while parents rated their adolescent's oral health more on esthetic or psychosocial factors.

CONCLUSIONS

Adolescents and parents based their perceptions of oral health status and treatment need on different underlying factors. Additionally, adolescents' perceptions of their oral health status and treatment needs did not appear to be communicated to their parents.

Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer

BACKGROUND

Segmentectomy for early-stage non-small cell lung cancer (NSCLC) remains controversial and has been previously associated with high local recurrence rates. We compared the outcomes of anatomic segmentectomy with lobectomy for stage I NSCLC and investigated the impact of surgical resection margins on recurrence.

METHODS

From 2002 to 2006, 182 anatomic segmentectomies (114 open, 68 video-assisted thoracic surgery [VATS]), were performed for stage 1A (n = 109) or IB (n = 73) NSCLC. These were compared with 246 lobectomies (1A, 114; 1B, 132). Variables analyzed included hospital course, mortality, and patterns of recurrence and survival.

RESULTS

All segmentectomy surgical margins were free of tumor (average margin, 18.2 mm). Operative time (147 versus 216 minutes; p < 0.0001) and estimated blood loss (185 versus 291 mL; p = 0.0003) were significantly reduced after segmentectomy compared with lobectomy. Thirty-day mortality (1.1% versus 3.3%), total complications, disease-free recurrence, and survival were similar between segmentectomy and lobectomy at a mean follow-up of 18.1 and 28.5 months, respectively. There were 32 recurrences after segmentectomy (17.6%) at a mean of 14.3 months (14 locoregional [7.7%], 18 distant [9.9%]), and 89% of recurrences were seen when tumor margins were 2 cm or less. Margin/tumor diameter ratios exceeding 1 were associated with a significant reduction in recurrence rates compared with ratios of less than 1 (25.0% versus 6.2%; p = 0.0014).

CONCLUSIONS

Anatomic segmentectomy can be performed safely by an open or VATS approach. Segmentectomy outcomes compare favorably with standard lobectomy for stage I NSCLC. Margin/tumor ratios of less than 1 are associated with a higher rate of recurrence. Lobectomy should be considered as primary therapy when such margins are not obtainable with segmentectomy in the good-risk patient.

Replication profile of PCDH11X and PCDH11Y, a gene pair located in the non-pseudoautosomal homologous region Xq21.3/Yp11.2

In order to investigate the replication timing properties of PCDH11X and PCDH11Y, a pair of protocadherin genes located in the hominid-specific non-pseudoautosomal homologous region Xq21.3/Yp11.2, we conducted a FISH-based comparative study in different human and non-human primate (Gorilla gorilla) cell types. The replication profiles of three genes from different regions of chromosome X (ZFX, XIST and ATRX) were used as terms of reference. Particular emphasis was given to the evaluation of allelic replication asynchrony in relation to the inactivation status of each gene. The human cell types analysed include neuronal cells and ICF syndrome cells, considered to be a model system for the study of X inactivation. PCDH11 appeared to be generally characterized by replication asynchrony in both male and female cells, and no significant differences were observed between human and gorilla, in which this gene lacks X-Y homologous status. However, in differentiated human neuroblastoma and cerebral cortical cells PCDH11X replication profile showed a significant shift towards allelic synchrony. Our data are relevant to the complex relationship between X-inactivation, as a chromosome-wide phenomenon, and asynchrony of replication and expression status of single genes on chromosome X.

Nanostructured calcium phosphates (NanoCaPs) for non-viral gene delivery: Influence of the synthesis parameters on transfection efficiency

Calcium phosphate (CaP) based approaches remain an attractive option for delivering plasmid DNA (pDNA) into cultured cells. However, despite their appeal, current synthesis methodologies typically yield lower, less consistent transfection efficiencies when compared to viral approaches. Therefore, we report here a novel method to consistently synthesize efficient, nano-sized, mono-dispersed CaP-pDNA particles; accomplished by optimizing both the stoichiometry (Ca/P ratio) of the CaP particles as well as the mode in which the calcium and phosphate precursor solutions are mixed. Our results indicate that calcium and phosphate precursors when mixed in a controlled and regulated manner reproducibly result in nano-sized particles that consistently yield higher transfection efficiencies when compared to particles synthesized via manual mixing (a two-fold increase was observed). Also, maximum transfection efficiencies in both HeLa and MC3T3-E1 cells lines were obtained when a Ca/P ratio between 100 and 300 was used. Particles synthesized within this optimum Ca/P ratio range were between 25 and 50 nm. Our data suggests that these maximized transfection efficiencies were obtained because these particles not only effectively condensed (70% efficient) but also efficiently bound (90% efficient) the pDNA. In addition, X-ray diffraction and Fourier transform infrared spectroscopy analyses confirmed that all of the synthesized CaP structures exhibited the hydroxyapatite phase.

The role of similarity in human associative learning

In 2 experiments, humans received sequences of patterns that were similar (AX-->BX, AY-->BY, AZ-->BZ) or dissimilar (CX-->DY, CY-->DZ, CZ-->DX). The patterns were portrayed as bugs that could be eliminated with 2 insecticide sprays (red or blue). Either spray eliminated bugs with Features A and C, and participants learned by trial and error to use one spray (e.g., red) to eliminate bugs with Feature B and the other spray (e.g., blue) to eliminate those with Feature D. In Experiment 1, participants' spray choice for bugs with Feature A came to match that used to eliminate bugs with Feature B, but there was no such associative transfer between Features C and D. That is, similarity promoted associative transfer of responding between paired patterns when the features used to manipulate similarity (i.e., X, Y, and Z) were irrelevant. In Experiment 2, in which X, Y, and Z were relevant to the solution of configural discrimination, similarity hindered such associative transfer. These results complement those found in pigeons (R. A. Rescorla & D. J. Gillan, 1980) and indicate that similarity should not be accorded independent status as a principle of associative learning.

Fiber-type differences in masseter muscle associated with different facial morphologies

BACKGROUND

The influence of muscle forces and associated physiologic behaviors on dental and skeletal development is well recognized but difficult to quantify because of the limited understanding of the interrelationships between physiologic and other mechanisms during growth.

METHODS

The purpose of this study was to characterize fiber-type composition of masseter muscle in 44 subjects during surgical correction of malocclusion. Four fiber types were identified after immunostaining of biopsy sections with myosin heavy chain-specific antibodies, and the average fiber diameter and percentage of muscle occupancy of the fiber types were determined in each of 6 subject groups (Class II or Class III and open bite, normal bite, or deepbite). A 2 x 3 x 4 analysis of variance was used to determine significant differences between mean areas for fiber types, vertical relationships, and sagittal relationships.

RESULTS

There were significant differences in percentage of occupancy of fiber types in masseter muscle in bite groups with different vertical dimensions. Type I fiber occupancy increased in open bites, and conversely, type II fiber occupancy increased in deepbites. The association between sagittal jaw relationships and mean fiber area was less strong, but, in the Class III group, the average fiber area was significantly different between the open bite, normal bite, and deepbite subjects. In the Class III subjects, type I and I/II hybrid fiber areas were greatly increased in subjects with deepbite.

CONCLUSIONS

Given the variation between subjects in fiber areas and fiber numbers, larger subject populations will be needed to demonstrate more significant associations between sagittal relationships and muscle composition. However, the robust influence of jaw-closing muscles on vertical dimension allowed us to conclude that vertical bite characteristics vary according to the fiber type composition of masseter muscle.

The effects of Le Fort I osteotomies on velopharyngeal and speech functions in cleft patients

PURPOSE

Orthognathic surgery alters or even worsens symptoms of velopharyngeal insufficiency in cleft patients. The goal of this study was to evaluate how advancing the maxilla would affect the speech and articulation disorders of these patients.

PATIENTS AND METHODS

This was a retrospective study in which we compiled and evaluated the speech scores of 54 cleft lip and palate patients who underwent maxillary advancement between 1981 and 2001. Although 34 individuals underwent an isolated Le Fort I advancement, 20 patients had a combined Le Fort I advancement/mandibular setback operation. The following variables were recorded from both preoperative and postoperative speech evaluations: presence of a pharyngeal flap at the time of surgery, oronasal fistulas, nasality, 7 different articulation errors, velopharyngeal function assessment, and overall speech score. Preoperative and postoperative changes in the data were analyzed using the McNemar test and paired t test.

RESULTS

A decrease in competent velopharyngeal function mechanisms was noted postoperatively (42% to 18%), increased borderline incompetence (9% to 22%), and complete velopharyngeal insufficiency (13% to 20%). Speech scores deteriorated significantly (P <.05), whereas articulation defects insignificantly (P =.146) improved after surgery (84% to 73%), with those related to the anterior dentition (P =.064) showing the greatest change (64% to 47%). The frequency of hyponasality decreased after surgery. The number of cases of mild to moderate hypernasality increased.

CONCLUSION

This study confirms previous findings that patients with clefts of the lip and palate or palate alone are predisposed to velopharyngeal function alteration after maxillary advancement, particularly with borderline function preoperatively. However, the results show that surgical correction of skeletal relationships and occlusion may translate into improvements in certain aspects of speech disorders.

Targeted deletion of 5'HS1 and 5'HS4 of the beta-globin locus control region reveals additive activity of the DNaseI hypersensitive sites

The mammalian beta-globin locus is a multigenic, developmentally regulated, tissue-specific locus from which gene expression is regulated by a distal regulatory region, the locus control region (LCR). The functional mechanism by which the beta-globin LCR stimulates transcription of the linked beta-like globin genes remains unknown. The LCR is composed of a series of 5 DNaseI hypersensitive sites (5'HSs) that form in the nucleus of erythroid precursors. These HSs are conserved among mammals, bind transcription factors that also bind to other parts of the locus, and compose the functional components of the LCR. To test the hypothesis that individual HSs have unique properties, homologous recombination was used to construct 5 lines of mice with individual deletions of each of the 5'HSs of the endogenous murine beta-globin LCR. Here it is reported that deletion of 5'HS1 reduces expression of the linked genes by up to 24%, while deletion of 5'HS4 leads to reductions of up to 27%. These deletions do not perturb the normal stage-specific expression of genes from this multigenic locus. In conjunction with previous studies of deletions of the other HSs and studies of deletion of the entire LCR, it is concluded that (1) none of the 5'HSs is essential for nearly normal expression; (2) none of the HSs is required for proper developmental expression; and (3) the HSs do not appear to synergize either structurally or functionally, but rather form independently and appear to contribute additively to the overall expression from the locus.

Duplicate mitf genes in zebrafish: complementary expression and conservation of melanogenic potential

Mutations in the zebrafish nacre/mitfa gene, expressed in all embryonic melanogenic cells, perturb only neural crest melanocytes, suggesting redundancy of mitfa with another gene in the zebrafish retinal pigment epithelium (RPE). Here, we describe a second zebrafish mitf gene, mitfb, which may fulfill this role. The proteins encoded by the two zebrafish mitf genes appear homologous to distinct isoforms generated by alternately spliced mRNAs of the single mammalian Mitf gene, suggesting specialization of the two zebrafish genes following a duplication event. Consistent with this hypothesis, expression of mitfa and mitfb is partially overlapping. mitfb is coexpressed with mitfa in the RPE at an appropriate time to compensate for loss of mitfa function in the nacre mutant but is not expressed in neural crest melanoblasts. Additionally, mitfb is expressed in the epiphysis and olfactory bulb where mitfa is not, and where Mitf expression has not previously been reported in other species. mitfb, but not a zebrafish ortholog of the closely related gene tfe3, can rescue neural crest melanophore development in nacre/mitfa mutant embryos when expressed via the mitfa promoter. These data suggest that mitfa and mitfb together may recapitulate the expression and functions of a single ancestral Mitf gene, and that mitfb may serve additional novel functions.

p27(Kip1) regulates cell cycle withdrawal of late multipotent progenitor cells in the mammalian retina

The cyclin-dependent kinase inhibitor protein, p27(Kip1), is necessary for the timing of cell cycle withdrawal that precedes terminal differentiation in oligodendrocytes of the optic nerve. Although p27(Kip1) is widely expressed in the developing central nervous system, it is not known whether this protein has a similar role in neuronal differentiation. To address this issue, we have examined the expression and function of p27(Kip1) in the developing retina, a well-characterized part of the central nervous system. p27(Kip1) is expressed in a pattern coincident with the onset of differentiation of most retinal cell types. In vitro analyses show that p27(Kip1) accumulation in retinal cells correlates with cell cycle withdrawal and differentiation, and when overexpressed, p27(Kip1) inhibits proliferation of the progenitor cells. Furthermore, the histogenesis of photoreceptors and Müller glia is extended in the retina of p27(Kip1)-deficient mice. Finally, we examined the adult retinal dysplasia in p27(Kip1)-deficient mice with cell-type-specific markers. Contrary to previous suggestions that the dysplasia is caused by excess production of photoreceptors, we suggest that the dysplasia is due to the displacement of reactive Müller glia into the layer of photoreceptor outer segments. These results demonstrate that p27(Kip1) is part of the molecular mechanism that controls the decision of multipotent central nervous system progenitors to withdraw from the cell cycle. Second, postmitotic Müller glia have a novel and intrinsic requirement for p27(Kip1) in maintaining their differentiated state.

An integrated map of human 6q22.3-q24 including a 3-Mb high-resolution BAC/PAC contig encompassing a QTL for fetal hemoglobin

Genetic studies have previously assigned a quantitative trait locus (QTL) for hemoglobin F and F cells to a region of approximately 4 Mb between the markers D6S408 and D6S292 on chromosome 6q23. An initial yeast artificial chromosome contig of 13 clones spanning this region was generated. Further linkage analysis of an extended kindred refined the candidate interval to 1-2 cM, and key recombination events now place the QTL within a region of <800 kb. We describe a high-resolution bacterial clone contig spanning 3 Mb covering this critical region. The map consists of 223 bacterial artificial chromosome (BAC) and 100 P1 artificial chromosome (PAC) clones ordered by sequence-tagged site (STS) content and restriction fragment fingerprinting with a minimum tiling path of 22 BACs and 1 PAC. A total of 194 STSs map to this interval of 3 Mb, giving an average marker resolution of approximately one per 15 kb. About half of the markers were novel and were isolated in the present study, including three CA repeats and 13 single nucleotide polymorphisms. Altogether 24 expressed sequence tags, 6 of which are unique genes, have been mapped to the contig.

Beta-globin gene switching and DNase I sensitivity of the endogenous beta-globin locus in mice do not require the locus control region

We have generated mice with a targeted deletion of the beta-globin locus control region (LCR). Mice homozygous for the deletion die early in embryogenesis but can be rescued with a YAC containing the human beta-globin locus. After germline passage, deletion of the LCR leads to a severe reduction in expression of all mouse beta-like globin genes, but no alteration in the developmental specificity of expression. Furthermore, a DNase I-sensitive "open" chromatin conformation of the locus is established and maintained. Thus, the dominant role of the LCR in the native locus is to confer high-level transcription, and elements elsewhere in the locus are sufficient to establish and maintain an open conformation and to confer developmentally regulated globin gene expression.

Prevention of falls in the elderly trial (PROFET): a randomised controlled trial

BACKGROUND

Falls in elderly people are a common presenting complaint to accident and emergency departments. Current practice commonly focuses on the injury, with little systematic assessment of the underlying cause, functional consequences, and possibilities for future prevention. We undertook a randomised controlled study to assess the benefit of a structured inderdisciplinary assessment of people who have fallen in terms of further falls.

METHODS

Eligible patients were aged 65 years and older, lived in the community, and presented to an accident and emergency department with a fall. Patients assigned to the intervention group (n=184) underwent a detailed medical and occupational-therapy assessment with referral to relevant services if indicated; those assigned to the control group (n=213) received usual care only. The analyses were by intention to treat. Follow-up data were collected every 4 months for 1 year.

FINDINGS

At 12-month follow-up, 77% of both groups remained in the study. The total reported number of falls during this period was 183 in the intervention group compared with 510 in the control group (p=0.0002). The risk of falling was significantly reduced in the intervention group (odds ratio 0.39 [95% CI 0.23-0.66]) as was the risk of recurrent falls (0.33 [0.16-0.68]). In addition, the odds of admission to hospital were lower in the intervention group (0.61 [0.35-1.05]) whereas the decline in Barthel score with time was greater in the control group (p<0.00001).

INTERPRETATION

The study shows that an interdisciplinary approach to this high-risk population can significantly decrease the risk of further falls and limit functional impairment.

Description and targeted deletion of 5' hypersensitive site 5 and 6 of the mouse beta-globin locus control region

The most upstream hypersensitive site (HS) of the beta-globin locus control region (LCR) in humans (5' HS 5) and chickens (5' HS 4) can act as an insulating element in some gain of function assays and may demarcate a beta-globin domain. We have mapped the most upstream HSs of the mouse beta-globin LCR and sequenced this region. We find that mice have a region homologous to human 5' HS 5 that is associated with a minor HS. In addition we map a unique HS upstream of 5' HS 5 and refer to this novel site as mouse 5' HS 6. We have also generated mice containing a targeted deletion of the region containing 5' HS 5 and 6. We find that after excision of the selectable marker in vivo, deletion of 5' HS 5 and 6 has a minimal effect on transcription and does not prevent formation of the remaining LCR HSs. Taken together these findings suggest that the most upstream HSs of the mouse beta-globin LCR are not necessary for maintaining the beta-globin locus in an active configuration or to protect it from a surrounding repressive chromatin environment.

The reliability of upper airway landmark identification

Research involving the upper airway has assessed linear measurements of certain structures on the assumption that the landmarks involved can be reliably identified. This study was conducted to determine the reliability of landmark identification for those structures most commonly reported in the obstructive sleep apnoea literature. Three judges were asked to identify specific landmarks on 20 randomly selected radiographs and 10 superior quality radiographs. This was repeated one week later. The results of the analysis of variance (ANOVA) indicated that the majority of the landmarks could be reliably identified, irrespective of the quality of the radiograph. However, the quality of the radiograph did affect identification of the horizontal position of the hyoid bone and the linear measure of posterior airway space although these were not clinically significant. The vertical position of the tip of the soft palate was highly unreliable, irrespective of the quality of the radiograph. This resulted in errors in the measurement of soft palate length. Future airway-related research should consider the potential inaccuracies when attempting to identify these dynamic three-dimensional structures on static two-dimensional images.

The effect of carbamide peroxide bleach on the tensile bond strength of ceramic brackets: an in vitro study

Recent advances in cosmetic dentistry have led to the development of a variety of new products and techniques including vital bleaching and ceramic brackets. Therefore this study was conducted to see whether the use of an at-home carbamide peroxide bleaching agent before bonding affected the tensile bond strength of a precoated ceramic orthodontic bracket. Sixty extracted human premolar teeth were randomly separated into three groups of 20. Group 1 was a control group that was etched and bonded in the usual manner. Group 2 was immersed in a carbamide peroxide home bleaching agent for 72 hours before pumicing and bonding. Group 3 was also bleached for 72 hours but was immersed in distilled water for 1 week before bonding. The results indicated that recently bleached teeth have significantly reduced bond strength values when compared with both groups 1 and 3. We suggest that if a patient is using a tooth whitening product, that they discontinue its use at least 1 week before the bonding of orthodontic attachments.

The validity of the prediction of Soft Tissue profile changes after LeFort I osteotomy using the dentofacial planner (computer software)

The purpose of this study was to examine the validity of the prediction of soft tissue changes after LeFort I osteotomy with the DentoFacial Planner (DFP) (computer software). The preoperative and postoperative lateral cephalograms of 21 white adult orthodontic patients (10 males and 11 females) who underwent only LeFort I osteotomy as part of their overall treatment were digitized. A coordinate system of X and Y axes were used to assess the amount and direction of movement of the maxilla. The SN + 7 degrees was the X axis, and a perpendicular to this plane from nasion was the Y axis. The sample was divided into two groups depending on the amount of forward movement of the maxilla. More than 2 mm of anterior placement of the maxilla comprised the advancement group (13 patients) and less than 2 mm comprised the impaction group (8 patients). The selection criteria for the sample were (1) before and after cephalograms taken with lips in repose and in centric occlusion; (2) all preoperative records taken almost immediately before surgery; (3) postoperative records taken at least 6 months after surgery and checked by regional superimposition of the preoperative and postoperative lateral cephalograms onto the maxilla and the mandible. No tooth movement occurred between the time the records were taken. The following soft tissue landmarks were examined: pronasale, subnasale, stomion superior, middle upper lip, stomion inferior, middle lower lip, labrale inferior, labiomental fold, and pogonion. The results indicate that for some of these landmarks the amount and direction of soft tissue changes differed between the DFP prediction and the actual surgical changes by LeFort I osteotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibiotics alter interactions of Staphylococcus aureus with collagenous substrata

The effects of sub-minimum inhibitory concentrations (sub-MICs) of three antibiotics affecting the biosynthesis of peptidoglycan on the interactions of Staphylococcus aureus strains with collagenous substrata were evaluated. In a system measuring binding of 125I-labeled collagen, growth of bacteria in the presence of one-quarter MIC of cloxacillin and vancomycin reduced the number of collagen binding sites on the surface of bacteria. Growth in the presence of cefpodoxime reduced the number of collagen binding sites in one strain and increased it in another. Cefpodoxime also increased the dissociation constant of collagen binding to bacteria, 2- to 3-fold, while the other two antibiotics did not affect the affinity of the interaction. In a system measuring adhesion of 125I-labeled bacteria to collagen-coated surfaces or cartilage, bacteria grown in the presence of cloxacillin and vancomycin attached to varying degrees depending on the strain. In contrast, compared to untreated controls as well as to bacteria treated with the other two antibiotics, growth in the presence of cefpodoxime significantly reduced adhesion of the majority of strains tested. Sub-MICs of antibiotics appear to affect staphylococcal adhesion to collagenous substrata with cefpodoxime exhibiting the strongest effect. The critical factor in reducing bacterial adhesion seems not to be the number of bacterial binding sites for collagen, but the affinity of the interaction.

Efficacy of a prebrushing rinse for orthodontic patients

The oral health benefits of a prebrushing rinse, when used in conjunction with an established twice-a-day brushing regimen, was investigated in a population of orthodontic patients. Twenty children (ages 11-18) who were undergoing orthodontic treatment that required brackets and labial wires were enrolled. This randomized, double-blind, cross-over clinical trial compared five weeks of twice-daily use of a commercial prebrushing rinse (Plax) to five weeks of a placebo rinse. Three investigators rated plaque accumulation (Simplified Oral Hygiene Index) and gingival health (modified O'Leary Index) prior to treatment and after each five week session. Because one child exited from the project and three children did not satisfactorily comply with the treatment protocol, sixteen children were used for the analysis. Although both treatment groups showed plaque and gingival improvement from pretreatment scores, no differences in plaque accumulation ratings and gingival health ratings were noted between the active and placebo rinse treatments.

Dose-responsive characteristics of meperidine sedation in preschool children

Using double-blind conditions, 60 uncooperative and fearful preschool children (24-66 months) received intramuscular injections of meperidine 0.25, 0.50, 1.00 mg/lb or placebo prior to restorative dental treatment. Behavior was assessed by the dentist and an independent observer during five specific treatment procedures. Behavioral ratings found meperidine to be an effective sedative, with 0.50 mg/lb and 1.00 mg/lb being significantly more effective than placebo (P less than 0.05, Kruskal-Wallis). Children receiving 1.0 mg/lb of meperidine had significantly more nausea and vomiting than patients receiving lower doses of the drug (P less than 0.05, Chisquare). Physiologic monitoring demonstrated that the highest dose of meperidine was associated with transient drops in arterial oxygen saturation. Meperidine sedation was found to be more effective for older children (37-66 months) and for children initially rated as being only moderately uncooperative and fearful.