[Extranodal B-cell lymphoma in the distal femur with pre-existing CRMO]

CRMO is a rare form of nonbacterial osteomyelitis, which is mainly found in children. The diagnosis is complex because bone tumors or lymphoma must also be excluded. The case report describes the development of a solitary femoral lymphoma on the basis of a known CRMO disease as well as the differential diagnostic pitfalls.

Diagnostic utility of cerebrospinal fluid analysis in dogs with suspected idiopathic epilepsy

BACKGROUND

Idiopathic epilepsy (IE) is the most common cause of repeated seizures in dogs. The International Veterinary Epilepsy Task Force consensus guidelines recommend performing magnetic resonance imaging (MRI) of the brain and cerebrospinal fluid (CSF) analysis as part of a tier II diagnosis of IE, and these procedures have documented risks. The aim of this retrospective study was to identify how often dogs with suspected IE have abnormalities on CSF analysis.

METHODS

Dogs aged between 6 months and 6 years that were presented with a history of two or more seizures with at least 24 h between seizure episodes, a normal neurologic examination, no evidence of toxic or metabolic causes, a normal MRI scan (including contrast administration) and CSF analysis were included.

RESULTS

Eighty-two dogs were included. Of these, nine dogs (10.9%) had abnormalities on CSF analysis: five of nine dogs (55.5%) had albuminocytologic dissociation, three of nine dogs (33.3%) had mild increases in total nucleated cell count (TNCC), and one of nine dogs (11.1%) had mild increase in both total protein and TNCC. Cytology in dogs with elevated TNCC revealed a mononuclear pleocytosis. One of the nine dogs with abnormal CSF had a seizure within the 24 h before investigations, and six of nine dogs had a seizure within 1 month before investigation.

CONCLUSION

CSF analysis can play an important role in the diagnostic investigation of the underlying causes of repeated seizures. However, in dogs with a normal inter-ictal neurological examination and MRI scan, it rarely reveals significant abnormalities, and the risk of performing a CSF tap may outweigh the potential diagnostic gain.

C7 vertebra homeotic transformation in domestic dogs - are Pug dogs breaking mammalian evolutionary constraints?

The number of cervical vertebrae in mammals is almost constant at seven, regardless of their neck length, implying that there is selection against variation in this number. Homebox (Hox) genes are involved in this evolutionary mammalian conservation, and homeotic transformation of cervical into thoracic vertebrae (cervical ribs) is a common phenotypic abnormality when Hox gene expression is altered. This relatively benign phenotypic change can be associated with fatal traits in humans. Mutations in genes upstream of Hox, inbreeding and stressors during organogenesis can also cause cervical ribs. The aim of this study was to describe the prevalence of cervical ribs in a large group of domestic dogs of different breeds, and explore a possible relation with other congenital vertebral malformations (CVMs) in the breed with the highest prevalence of cervical ribs. By phenotyping we hoped to give clues as to the underlying genetic causes. Twenty computed tomography studies from at least two breeds belonging to each of the nine groups recognized by the Federation Cynologique Internationale, including all the brachycephalic 'screw-tailed' breeds that are known to be overrepresented for CVMs, were reviewed. The Pug dog was more affected by cervical ribs than any other breed (46%; P < 0.001), and was selected for further analysis. No association was found between the presence of cervical ribs and vertebral body formation defect, bifid spinous process, caudal articular process hypoplasia/aplasia and an abnormal sacrum, which may infer they have a different aetiopathogenesis. However, Pug dogs with cervical ribs were more likely to have a transitional thoraco-lumbar vertebra (P = 0.041) and a pre-sacral vertebral count of 26 (P < 0.001). Higher C7/T1 dorsal spinous processes ratios were associated with the presence of cervical ribs (P < 0.001), supporting this is a true homeotic transformation. Relaxation of the stabilizing selection has likely occurred, and the Pug dog appears to be a good naturally occurring model to further investigate the aetiology of cervical ribs, other congenital vertebral anomalies and numerical alterations.

Pregnancy-Related Immune Adaptation Promotes the Emergence of Highly Virulent H1N1 Influenza Virus Strains in Allogenically Pregnant Mice

Pregnant women are at high risk for severe influenza disease outcomes, yet insights into the underlying mechanisms are limited. Here, we present models of H1N1 infection in syngenic and allogenic pregnant mice; infection in the latter mirrors the severe course of 2009 pandemic influenza in pregnant women. We found that the anti-viral immune response in the pregnant host was significantly restricted as compared to the non-pregnant host. This included a reduced type I interferon response as well as impaired migration of CD8⁺ T cells into the lung. The multi-faceted failure to mount an anti-viral response in allogenic pregnant mice resulted in a less stringent selective environment that promoted the emergence of 2009 H1N1 virus variants that specifically counteract type I interferon response and mediate increased viral pathogenicity. These insights underscore the importance of influenza vaccination compliance in pregnant women and may open novel therapeutic avenues.

H7N9 Influenza A Virus Exhibits Importin-α7-Mediated Replication in the Mammalian Respiratory Tract

The acute respiratory distress syndrome (ARDS) is the leading cause of death in influenza A virus (IAV)-infected patients. Hereby, the cellular importin-α7 gene plays a major role. It promotes viral replication in the lung, thereby increasing the risk for the development of pneumonia complicated by ARDS. Herein, we analyzed whether the recently emerged H7N9 avian IAV has already adapted to human importin-α7 use, which is associated with high-level virus replication in the mammalian lung. Using a cell-based viral polymerase activity assay, we could detect a decreased H7N9 IAV polymerase activity when importin-α7 was silenced by siRNA. Moreover, virus replication was diminished in the murine cells lacking the importin-α7 gene. Consistently, importin-α7 knockout mice presented reduced pulmonary virus titers and lung lesions as well as enhanced survival rates compared to wild-type mice. In summary, our results show that H7N9 IAV have acquired distinct features of adaptation to human host factors that enable enhanced virulence in mammals. In particular, adaptation to human importin-α7 mediates elevated virus replication in the mammalian lung, which might have contributed to ARDS observed in H7N9-infected patients.

Interval cancers after skin cancer screening: incidence, tumour characteristics and risk factors for cutaneous melanoma

BACKGROUND

The rate of interval cancers is an established indicator for the performance of a cancer-screening programme.

METHODS

We examined the incidence, tumour characteristics and risk factors of melanoma interval cancers that occurred in participants of the SCREEN project, which was carried out 2003/2004 in Schleswig-Holstein, Germany. Data from 350 306 SCREEN participants, who had been screened negative for melanoma, were linked to data of the state cancer registry. Melanoma interval cancers were defined as melanomas diagnosed within 4-24 months after SCREEN examination. Results were compared with melanomas of the pre-SCREEN era (1999-2002), extracted from the cancer registry.

RESULTS

The overall relative incidence of melanoma interval cancers in terms of observed/expected ratio was 0.93 (95% CI: 0.82-1.05; in situ: 1.61 (1.32-1.95), invasive: 0.71 (0.60-0.84)). Compared with melanomas of the pre-SCREEN era, the interval melanomas were thinner and had a slightly greater proportion of lentigo maligna melanomas whereas nodular melanomas were less frequent.

INTERPRETATION

The results indicate a moderate performance of the SCREEN intervention with an excess of in situ melanomas. In part, the findings might be due to specifics of the SCREEN project, in particular a short-term follow-up of patients at high risk for melanoma.

[Coronary atherosclerosis and progression to unstable plaques : Histomorphological and molecular aspects]

Atherosclerosis causes clinical symptoms through luminal narrowing by stenosis or by precipitating thrombi that obstruct blood flow to the myocardium (coronary artery disease), central nervous system (ischemic stroke) or lower extremities (peripheral vascular disease). The most common of these manifestations of atherosclerosis is coronary artery disease, clinically presenting as either stable angina or acute coronary syndromes. Atherosclerosis is a mainly lipoprotein-driven disease, which is associated with the formation of atherosclerotic plaques at specific sites of the vascular system through inflammation, necrosis, fibrosis and calcification. In most cases, plaque rupture of a so-called thin-cap fibroatheroma leads to contact of the necrotic core material of the underlying atherosclerotic plaque with blood, resulting in the formation of a thrombus with acute occlusion of the affected (coronary) artery. The atherosclerotic lesions that can cause acute coronary syndromes by formation of a thrombotic occlusion encompass (1) thin-cap fibroatheroma, (2) plaque erosion and (3) so-called calcified nodules in calcified and tortuous arteries of aged individuals. The underlying pathomechanisms remain incompletely understood so far. In this review, the mechanisms of atherosclerotic plaque initiation and progression are discussed.

Analysis of Ebola Virus Entry Into Macrophages

Ebolaviruses constitute a public health threat, particularly in Central and Western Africa. Host cell factors required for spread of ebolaviruses may serve as targets for antiviral intervention. Lectins, TAM receptor tyrosine kinases (Tyro3, Axl, Mer), T cell immunoglobulin and mucin domain (TIM) proteins, integrins, and Niemann-Pick C1 (NPC1) have been reported to promote entry of ebolaviruses into certain cellular systems. However, the factors used by ebolaviruses to invade macrophages, major viral targets, are poorly defined. Here, we show that mannose-specific lectins, TIM-1 and Axl augment entry into certain cell lines but do not contribute to Ebola virus (EBOV)-glycoprotein (GP)-driven transduction of macrophages. In contrast, expression of Mer, integrin αV, and NPC1 was required for efficient GP-mediated transduction and EBOV infection of macrophages. These results define cellular factors hijacked by EBOV for entry into macrophages and, considering that Mer and integrin αV promote phagocytosis of apoptotic cells, support the concept that EBOV relies on apoptotic mimicry to invade target cells.

Lack of MERS coronavirus neutralizing antibodies in humans, eastern province, Saudi Arabia

We used a lentiviral vector bearing the viral spike protein to detect neutralizing antibodies against Middle East respiratory syndrome coronavirus (MERS-CoV) in persons from the Eastern Province of Saudi Arabia. None of the 268 samples tested displayed neutralizing activity, which suggests that MERS-CoV infections in humans are infrequent in this province.

Loss of Survivin influences liver regeneration and is associated with impaired Aurora B function

The chromosomal passenger complex (CPC) acts as a key regulator of mitosis, preventing asymmetric segregation of chromosomal material into daughter cells. The CPC is composed of three non-enzymatic components termed Survivin, the inner centromere protein (INCENP) and Borealin, and an enzymatic component, Aurora B kinase. Survivin is necessary for the appropriate separation of sister chromatids during mitosis and is involved in liver regeneration, but its role in regenerative processes is incompletely elucidated. Whether Survivin, which is classified as an inhibitor of apoptosis protein (IAP) based on domain composition, also has a role in apoptosis is controversial. The present study examined the in vivo effects of Survivin ablation in the liver and during liver regeneration after 70% hepatectomy in a hepatocyte-specific knockout mouse model. The absence of Survivin caused a reduction in the number of hepatocytes in the liver, together with an increase in cell volume, macronucleation and polyploidy, but no changes in apoptosis. During liver regeneration, mitosis of hepatocytes was associated with mislocalization of the members of the CPC, which were no longer detectable at the centromere despite an unchanged protein amount. Furthermore, the loss of survivin in regenerating hepatocytes was associated with reduced levels of phosphorylated Histone H3 at serine 28 and abolished phosphorylation of CENP-A and Hec1 at serine 55, which is a consequence of decreased Aurora B kinase activity. These data indicate that Survivin expression determines hepatocyte number during liver development and liver regeneration. Lack of Survivin causes mislocalization of the CPC members in combination with reduced Aurora B activity, leading to impaired phosphorylation of its centromeric target proteins and inappropriate cytokinesis.

Influenza and SARS-coronavirus activating proteases TMPRSS2 and HAT are expressed at multiple sites in human respiratory and gastrointestinal tracts

The type II transmembrane serine proteases TMPRSS2 and HAT activate influenza viruses and the SARS-coronavirus (TMPRSS2) in cell culture and may play an important role in viral spread and pathogenesis in the infected host. However, it is at present largely unclear to what extent these proteases are expressed in viral target cells in human tissues. Here, we show that both HAT and TMPRSS2 are coexpressed with 2,6-linked sialic acids, the major receptor determinant of human influenza viruses, throughout the human respiratory tract. Similarly, coexpression of ACE2, the SARS-coronavirus receptor, and TMPRSS2 was frequently found in the upper and lower aerodigestive tract, with the exception of the vocal folds, epiglottis and trachea. Finally, activation of influenza virus was conserved between human, avian and porcine TMPRSS2, suggesting that this protease might activate influenza virus in reservoir-, intermediate- and human hosts. In sum, our results show that TMPRSS2 and HAT are expressed by important influenza and SARS-coronavirus target cells and could thus support viral spread in the human host.

The Ebola virus glycoprotein and HIV-1 Vpu employ different strategies to counteract the antiviral factor tetherin

The antiviral protein tetherin/BST2/CD317/HM1.24 restricts cellular egress of human immunodeficiency virus (HIV) and of particles mimicking the Ebola virus (EBOV), a hemorrhagic fever virus. The HIV-1 viral protein U (Vpu) and the EBOV-glycoprotein (EBOV-GP) both inhibit tetherin. Here, we compared tetherin counteraction by EBOV-GP and Vpu. We found that EBOV-GP but not Vpu counteracted tetherin from different primate species, indicating that EBOV-GP and Vpu target tetherin differentially. Tetherin interacted with the GP2 subunit of EBOV-GP, which might encode the determinants for tetherin counteraction. Vpu reduced cell surface expression of tetherin while EBOV-GP did not, suggesting that both proteins employ different mechanisms to counteract tetherin. Finally, Marburg virus (MARV)–GP also inhibited tetherin and downregulated tetherin in a cell type–dependent fashion, indicating that tetherin antagonism depends on the cellular source of tetherin. Collectively, our results indicate that EBOV-GP counteracts tetherin by a novel mechanism and that tetherin inhibition is conserved between EBOV-GP and MARV-GP.

Lateral cephalometric analysis of mandibular morphology: discrimination among subjects with and without temporomandibular joint disk displacement and osteoarthrosis

To assess whether in patients with temporomandibular joint (TMJ) arthralgia cephalometric variables of mandibular morphology may discriminate among the magnetic resonance (MR) imaging-based TMJ groups of 'bilateral presence of disk displacement without reduction (DDwoR) and osteoarthrosis (OA)' and 'bilateral absence of bilateral DDwoR and OA'. Bilateral MR imaging of the TMJ was performed in 45 consecutive TMJ arthralgia patients to identify individuals with the specific structural characteristics of bilateral TMJ DDwoR associated with OA. Linear and angular cephalometric measurements were taken from lateral cephalograms to apply selected criteria of mandibular morphology. A discriminant function analysis was used to investigate how cephalometric parameters discriminate among the TMJ groups of 'bilateral presence of DDwoR with OA' and 'bilateral absence of DDwoR and OA'. Ramus height (Ar-Go) and effective mandibular length (Ar-Pog) produced a significant discriminant function that predicted TMJ group membership (P < 0·001). This function correctly classified 80·2% of original and cross-validated grouped cases. This study supports the concept that cephalometric variables of mandibular morphology discriminate among subjects with and without bilateral TMJ DDwoR and OA.

Differential expression of microRNA-675, microRNA-139-3p and microRNA-335 in benign and malignant adrenocortical tumours

BACKGROUND

For the clinical management of adrenocortical neoplasms it is crucial to correctly distinguish between benign and malignant tumours. Even histomorphologically based scoring systems do not allow precise separation in single lesions, thus novel parameters are desired which offer a more accurate differentiation. The tremendous potential of microRNAs (miRNAs) as diagnostic biomarkers in surgical pathology has recently been shown in a broad variety of tumours.

METHODS

In order to elucidate the diagnostic impact of miRNA expression in adrenocortical neoplasms, a cohort of 20 adrenocortical specimens including normal adrenal tissue (n=4), adrenocortical adenomas (ACAs) (n=9), adrenocortical carcinomas (ACCs) (n=4) and metastases (n=3) was analysed using TaqMan low density arrays to identify specific miRNA profiles in order to distinguish between benign and malignant adrenocortical lesions. Results were validated in a validation cohort (n=16).

RESULTS

Concerning the differential diagnosis of ACAs and ACCs, 159 out of 667 miRNAs were up- and 89 were down-regulated in ACAs. Using real-time PCR analysis of three of the most significantly expressed single key miRNAs allowed separation of ACAs from ACCs. ACCs exhibited significantly lower levels of miR-139-3p (up to 8.49-fold, p<0.001), miR-675 (up to 23.25-fold, p<0.001) and miR-335 (up to 5.25-fold, p<0.001). A validation cohort of 16 specimen with known Weiss score showed up-regulation of miR-335 and miR-675 in the majority of cases with probable malignant course, although overlapping values exist.

CONCLUSION

miRNA profiling of miR-675 and miR-335 helps in discriminating ACCs from ACAs. miRNA analysis may indicate malignant behaviour in cases with indeterminate malignant potential.

Different host cell proteases activate the SARS-coronavirus spike-protein for cell-cell and virus-cell fusion

Severe acute respiratory syndrome coronavirus (SARS-CoV) poses a considerable threat to human health. Activation of the viral spike (S)-protein by host cell proteases is essential for viral infectivity. However, the cleavage sites in SARS-S and the protease(s) activating SARS-S are incompletely defined. We found that R667 was dispensable for SARS-S-driven virus–cell fusion and for SARS-S-activation by trypsin and cathepsin L in a virus–virus fusion assay. Mutation T760R, which optimizes the minimal furin consensus motif 758-RXXR-762, and furin overexpression augmented SARS-S activity, but did not result in detectable SARS-S cleavage. Finally, SARS-S-driven cell–cell fusion was independent of cathepsin L, a protease essential for virus–cell fusion. Instead, a so far unknown leupeptin-sensitive host cell protease activated cellular SARS-S for fusion with target cells expressing high levels of ACE2. Thus, different host cell proteases activate SARS-S for virus–cell and cell–cell fusion and SARS-S cleavage at R667 and 758-RXXR-762 can be dispensable for SARS-S activation.

Novel insights into proteolytic cleavage of influenza virus hemagglutinin

The influenza virus hemagglutinin (HA) mediates the first essential step in the viral life cycle, virus entry into target cells. Influenza virus HA is synthesised as a precursor protein in infected cells and requires cleavage by host cell proteases to transit into an active form. Cleavage is essential for influenza virus infectivity and the HA‐processing proteases are attractive targets for therapeutic intervention. It is well established that cleavage by ubiquitously expressed subtilisin‐like proteases is a hallmark of highly pathogenic avian influenza viruses (HPAIV). In contrast, the nature of the proteases responsible for cleavage of HA of human influenza viruses and low pathogenic avian influenza viruses (LPAIV) is not well understood. Recent studies suggest that cleavage of HA of human influenza viruses might be a cell‐associated event and might be facilitated by the type II transmembrane serine proteases (TTSPs) TMPRSS2, TMPRSS4 and human airway trypsin‐like protease (HAT). Here, we will introduce the different concepts established for proteolytic activation of influenza virus HA, with a particular focus on the role of TTSPs, and we will discuss their implications for viral tropism, pathogenicity and antiviral intervention. Copyright © 2010 John Wiley & Sons, Ltd.

Knowledge and use of alcohol and other drugs among Vietnamese-speaking migrants

A survey of the Vietnamese community in Sydney was conducted in 1992 to determine whether it was at a higher or lower risk of drug-related harm than the general community. Data was collected on knowledge, attitudes and behaviour associated with alcohol and other drug use and compared with overall NSW figures. The sample of 341 Vietnamese-speakers aged 15-65 years was obtained by face-to-face interviews conducted in private households using a cluster sampling technique. Of the sample, 72% indicated they did not speak English well or at all. Recognition of tobacco and alcohol as drugs and the specific health and social problems associated with use was much lower among the Vietnamese-speakers than the general community. Compared with the general community (1991 NCADA Household Survey), reported use of tobacco on the day of the survey among Vietnamese-speakers was higher among men (37% versus 26%) but much lower among women (4% versus 22%). Reported use of other drugs such as alcohol, analgesics, minor tranquillizers and illicit drugs was lower than in the general community. It is recommended that the low level of knowledge of the health and social problems associated with tobacco and alcohol in particular should be addressed by community-based education programmes.

Laser Doppler flow investigation of fractured permanent maxillary incisors

Laser Doppler flowmetry (LDF) is a non-invasive method to assess pulpal blood-flow (PBF). Dental injury has been associated with losses of pulpal sensibility. The purpose of this study was to assess the outcome of splint therapy on tooth fracture type-related PBF values. In 15 trauma patients, a single maxillary incisor treated by repositioning and splinting was investigated by LDF to assess local PBF values. Perfusion units were taken in four sessions, on the day of splint removel, and 12, 24 and 36 weeks after splint removal. Analysis of the tooth fracture type-related PBF measurements revealed root fractures to be associated with a significant decrease (P < 0.05) and uncomplicated crown fractures to be associated with a significant increase in PBF values (P < 0.05), while complicated crown fractures showed no significant difference between the session-related values (P > 0.05). The main findings of this study suggest splint therapy of root fractures of the central maxillary incisor to be associated with a short- and long-term decrease in PBF values. The LDF may become useful in the detection of transient ischaemic episodes and the identification of teeth at risk for adverse sequelae such as avascular necrosis and tissue loss.

Reliability and temporal variation of masseter muscle thickness measurements utilizing ultrasonography

Muscle thickness may now be measured in the clinic by ultrasonography. The purpose of this study was to test (i) whether the position of the transducer on the muscle affects muscle thickness measurements and (ii) whether measurements from identical locations vary over time. Muscle thickness of one masseter muscle side was measured in each of 30 volunteers. Measurements were recorded at five different locations on the lateral surface of each muscle. Four measurement sessions were performed, and two sets of measurements were recorded at each session. Spatial position of the transducer had a clear effect on the muscle thickness measurements (P < 0.0001). Measurements made at the most upper and middle level were less and greater (P < 0.0001), respectively, than those made at the upper, lower, and most lower levels. Measurements from various positions did not differ (P > 0.05) when made at the same level. Masseter thickness measurements recorded at a given site were consistent across all of the testing sessions (P=0.575). The data suggest that reliable interpretation of longitudinal measurements of masseter thickness obtained with ultrasonography requires accurate repositioning of the transducer. Ultrasonography may be used to investigate the effect of specific treatment modalities on masseter thickness measurements.

Temporomandibular joint internal derangement: detection with 12.5 MHz ultrasonography

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) internal derangement (ID). In 48 consecutive patients with TMJ disorders 192 TMJ positions were investigated by US to analyse the functional disc-condyle relationship (DCR). In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 0.58 and 0.75, and a specificity of 0.92 and 0.84 for disc displacement with and without reduction, the data revealed US to be marginal in detecting the presence, but sensitive in detecting the absence of the respective types of a TMJ ID. In addition, with a positive predictive value of 0.83 and 0.71, and a negative predictive value of 0.81 and 0.87 for disc displacement with and without reduction, the results indicate that US may be insufficient in establishing a correct diagnosis for the presence or absence of the respective types of TMJ ID. Regarding the diagnosis of absence or presence of TMJ ID, the results demonstrate high-resolution (HR)-US to be sensitive in detecting the absence, and reliable in predicting the presence of TMJ ID. In view of the fact that the 12.5 MHz US technique proved to be a reliable diagnostic aid for the detection of normal, and the prediction of abnormal DCR, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.

Temporomandibular joint osteoarthrosis diagnosed with high resolution ultrasonography versus magnetic resonance imaging: how reliable is high resolution ultrasonography?

The purpose of this study was to determine whether 12.5 MHz ultrasonography (US) could be used to assess the presence or absence of temporomandibular joint (TMJ) condylar osteoarthrosis. In 40 consecutive patients with TMJ disorders, 80 TMJs were investigated by US to analyse the condylar morphology. In order to compare the respective findings with those of a diagnostic method offering a high accuracy, coronal and sagittal magnetic resonance imaging was carried out immediately afterwards. With US showing a sensitivity of 87%, and a specificity of 20%, the data revealed US to be sensitive in detecting the presence, but insufficient in detecting the absence of osteoarthrosis. In addition, with a positive predictive value of 88%, and a negative predictive value of 18%, the results indicate that US may be valuable in diagnosing the presence, but insufficient in diagnosing the absence of osteoarthrosis. In view of the fact that the 12.5 MHz US technique proved to be a valuable diagnostic aid for the detection and prediction of abnormal condylar morphology, the results of this study should be of further interest and encourage research in its potential uses and diagnostic capabilities.

Risk factors for temporomandibular joint pain in patients with disc displacement without reduction - a magnetic resonance imaging study

The purpose of this study was to evaluate whether the magnetic resonance (MR) imaging variables of temporomandibular joint (TMJ) internal derangement, osteoarthrosis and/or effusion may predict the presence of pain in patients with a clinical disorder of an internal derangement type (ID)-III. The relationship between TMJ ID-III pain and TMJ internal derangement, osteoarthrosis and effusion was analysed in MR images of 84 TMJs in 42 patients with a clinical unilateral diagnosis of TMJ ID-III pain. Criteria for including a TMJ ID-III pain patient were report of orofacial pain referred to the TMJ, with the presence of unilateral TMJ pain during palpation, function and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ internal derangement, osteoarthrosis and effusion. Using chi-square analysis for pair-wise comparison, the data showed a significant relationship between the MR imaging findings of TMJ ID-III pain and those of internal derangement (P=0.01) and effusion (P=0.00). Of the MR imaging variables considered simultaneously in the multiple logistic regression analysis, osteoarthrosis (P=0.82) and effusion (P=0.08) dropped out as non-significant in the diagnostic TMJ pain group when compared with the TMJ non-pain group. The odds ratio that a TMJ with an internal derangement type of disk displacement without reduction might belong to the pain group was strong (2.7:1) and highly significant (P=0.00). Significant increases in risk of TMJ pain occurred with 'disk displacement without reduction in combination with osteoarthrosis' (5.2:1) (P=0.00) and/or 'disk displacement without reduction in combination with osteoarthrosis and effusion' (6.6:1) (P=0.00). The results suggest that TMJ pain is related to internal derangement, osteoarthrosis and effusion. However, the data re-emphasize the aspect that these MR imaging variables may not be regarded as the unique and dominant factors in defining TMJ pain instances.

Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup of degenerative joint disease

Research is needed to assess the validity of the Clinical Diagnostic Criteria for Temporomandibular Disorders (CDC/TMD). The purpose of this study was to test the reliability of the clinical diagnosis of temporomandibular joint (TMJ) degenerative joint disease (DJD) as compared with the magnetic resonance imaging (MRI) 'gold standard'. The TMJ DJD group comprised 48 joints in 24 consecutive patients who were assigned a clinical bilateral diagnosis of TMJ DJD. The TMJ non-DJD group consisted of 82 joints in 41 consecutive patients without a TMJ-related diagnosis of TMD. Bilateral sagittal and coronal MR images were obtained subsequently to establish the corresponding diagnosis of degenerative joint changes. An MRI diagnosis of osteoarthrosis (OA) was defined by the presence of flattening, subchondral sclerosis, surface irregularities, and erosion of the condyle or presence of condylar deformities associated with flattening, subchondral sclerosis, surface irregularities, erosion and osteophyte. For the CDC/TMD interpretations, the positive predictive of DJD for OA was 67%, and for the presence of degenerative joint changes 88%. The overall diagnostic agreement for DJD was 44.6% with a corresponding K-value of 0.01. Most of the disagreement was due to false-negative interpretations of asymptomatic joints. The results suggest CDC/TMD to be predictive for degenerative joint changes but insufficient for determination of OA. Patients assigned a clinical TMJ-related diagnosis of DJD may need to be supplemented by evidence from MRI to determine the presence or absence of OA.

Effect of scanning level and muscle condition on ultrasonographic cross-sectional measurements of the anterior masseter muscle

With the disadvantage of computed tomography showing cumulative biological effects and magnetic resonance imaging posing a problem in clinical availability and cost, several authors described the technique of ultrasonography to measure non-invasively local cross-sectional dimensions (LCSDs) of masseter muscle sites. However only few studies addressed the issue of 'technique-related factors for intra- and inter-observer reliability' to gain more consistent testing and diagnosis. The purpose of the present study was to determine (1) whether the scanning level and/or the muscle condition may affect LCSD measurements and (2) whether measurements made at identical levels may be reproducible. The study included 35 subjects with signs and symptoms of temporomandibular disorders. Bilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to register LCSDs of the anterior masseter muscle on three different levels. Scans were made on the relaxed and contracted muscle. Measurements were made in two sessions with a time interval of at least 5 min. Data were analysed for reproducibility by using the intra-class correlation coefficient (ICC) and the method error (ME). Scanning level and muscle condition had a significant effect on muscle measurements (P = 0.000). There was no difference in LCSD between the right and left muscle (P = 0.531). Measurements recorded at a given site were consistent across the testing sessions (P = 0.058). The scanning level with highest reproducibility was halfway between the origin and insertion (ICC = 0.92; ME = 6.2%). The data suggest that ultrasonography is a reliable method for measuring LSCDs of the anterior masseter muscle.

Cross-sectional characteristics of the masseter muscle: an ultrasonographic study

Cross-sections of the masseter muscle may now be measured non-invasively using ultrasonography. The purpose of the present study was to determine (1) whether the scanning level may affect cross-sectional measurements and (2) whether measurements made at identical levels may be reproducible. The study included 42 asymptomatic volunteers. Unilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to register cross-sections of the masseter muscle on five different levels. Scans were made on the relaxed and contracted muscle. Measurements were made in two sessions with a time interval of at least 5 min. Statistical analysis consisted of univariate analysis of variance for repeated measurements. Data were analysed for reproducibility by using the method error and measurement error. For the ultrsonographic measurements the main effects of the variables 'session' (P=0.0001), 'level' (P=0.0001), and 'condition' (P=0.0001) were significant. Analysis of simple session-within-level effects revealed a significant difference between the repeated measurements for the most upper level (P=0.022), the upper level (P=0.012), and the most lower level (P=0.0001) of the relaxed muscle. An additional significant effect was found for the most lower level of the contracted muscle (P=0.015). Cross-sections evaluated at the middle (method error=0.31 mm; measurement error=2.0%) and lower level (method error=0.32 mm; measurement error=2.4%) of the contracted muscle were the most reproducible. The conclusion is that ultrasonography is a reproducible method for measuring cross-sections at the middle and lower level of the contracted masseter muscle.

Validation of the clinical diagnostic criteria for temporomandibular disorders for the diagnostic subgroup - disc derangement with reduction

Research is needed to assess the validity of the clinical diagnostic criteria for temporomandibular disorders (CDC/TMD). The purpose of this study was to test the reliability of the clinical diagnosis of temporomandibular joint (TMJ) internal derangement type (ID)-I as compared with the magnetic resonance imaging (MRI) 'gold standard'. The study comprised 168 TMJs in 84 patients, who were assigned a clinical TMJ-related diagnosis of ID-I (disc displacement with reduction) in at least one TMJ. Bilateral sagittal and coronal MR images were obtained subsequently to establish the corresponding diagnosis of the disc-condyle relationship. For the CDC/TMD interpretations, the positive predictive value (PPV) of ID-I for disc displacement with reduction (DDR) was 44%, and for the presence of an ID 69%. The overall diagnostic agreement for ID-I was 47.6% with a corresponding K-value of 0.05. Most of the disagreement was the result of the false-positive interpretations of ID-I, and false-negative interpretations of an 'absence of ID'. The results suggest CDC/TMD for ID-I to be insufficient reliable for determination of ID and/or DDR. Patients assigned a clinical TMJ-related diagnosis of ID-I may need to be supplemented by evidence from MRI to determine the functional 'disc-condyle relationship'.

Magnetic resonance imaging findings of osteoarthrosis and effusion in patients with unilateral temporomandibular joint pain

The purpose of this study was to investigate the relationship between the presence of temporomandibular joint (TMJ) pain and the magnetic resonance (MR) imaging findings of osteoarthrosis (OA), and effusion. The study comprised 112 consecutive TMJ pain patients. Criteria for including a patient were report of unilateral pain near the TMJ, with the presence of unilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ OA, and/or effusion. Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ OA (P=0.000), and TMJ effusion (P=0.000). Further, there was a significant relationship between the MR imaging diagnosis of TMJ OA and TMJ effusion (P=0.000). Use of the Kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of TMJ OA (K=0.22), TMJ effusion (K=0.29), and TMJ 'OA and effusion' (K=0.30). The study's findings suggest that while clinical pain is correlated to TMJ-related MR imaging findings, clinical pain in and of itself, is not reliable for predicting the presence of TMJ OA and/or effusion. Validation of MR imaging diagnoses would involve the investigation of cross-sectional and longitudinal evidence to assess decisive differences in terms of prognosis and/or treatment outcome.

Ultrasonographic assessment of local cross-sectional dimensions of masseter muscle sites: a reproducible technique?

Local cross-sectional dimensions (LCSDs) of masseter muscle sites may now be measured non-invasively using ultrasonography. The purpose of the present study was to determine (i) whether the muscle site may affect LCSD measurements and (ii) whether measurements made at identical sites may be reproducible. The study included 17 patients who had signs and symptoms of temporomandibular disorders (TMD). Bilateral ultrasonographic investigation was performed with a linear (B-scan) 7.5 MHz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior, and postero-inferior sites of the masseter muscle. Measurements were made in two sessions with a time interval of at least five minutes. Data were analysed for reproducibility by using the intraclass correlation coefficient (ICC) and the method error (ME). Muscle site had no significant effect on muscle measurements (P = 0.090). Measurements from the various side-related sites did not differ significantly (P = 0.425). Measurements recorded at a given site were consistent across the testing sessions (P = 0.605). The muscle site with highest reproducibility was the medio-inferior site (ICC = 0.92; ME = 6.4%). The data suggest that ultrasonography is a reproducible method for measuring LSCDs of the masseter muscle.

Magnetic resonance imaging findings of internal derangement in temporomandibular joints without a clinical diagnosis of temporomandibular disorder

The purpose of this study was to assess the prevalences of magnetic resonance (MR) imaging findings of internal derangement (ID) in temporomandibular joints (TMJs) without a specific clinical diagnosis of temporomandibular disorder (TMD), and to investigate whether in this TMJ group the variable of pain may be linked to MR imaging findings of ID. The study comprised 109 patients, who were assigned a clinical uni- or bilateral TMJ-related diagnosis of 'absence of TMD'. Bilateral sagittal and coronal MR images were obtained subsequently to establish the prevalence of TMJ ID. An MR imaging diagnosis of ID was found in 99 (55.9%) of the 177 TMJs investigated. About 30.3% of the closed mouth-related TMJ positions characterized by disc displacement presented with anterior disc displacement, while 27.3% had anterolateral and 25.3% anteromedial disc displacement. Analysis of the data revealed the presence of TMJ pain to be associated with significantly more MR imaging diagnoses of disc displacement without reduction than disc displacement with reduction (P < 0.05), while there was no significant difference in the prevalences of ID and those of absence of ID (P > 0.05). Using chi-square analysis, no significant relationship was found between the presence of TMJ pain and the MR imaging diagnosis of TMJ ID (P=0.93). Use of the kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of ID (kappa=0.01). The results suggest TMJs with a clinical diagnosis of 'absence of TMD' to be associated with a high rate of IDs, while in these instances the clinical variable of TMJ pain may have no effect on prevalences of MR imaging diagnoses TMJ ID. The data confirm the aspect of clinical diagnostic criteria as an unreliable instrument in predicting MR imaging diagnoses of TMJ ID.

Effect of stabilization-type splints on the asymmetry of masseter muscle sites during maximal clenching

Patients with temporomandibular disorders may present with a cluster of joint and muscle disorders characterized primarily by pain, joint sounds and irregular or deviating jaw function. Maxillary stabilization-type splints represent the best standard therapy, so the purpose of this study was to evaluate changes in local maximal clenching-related asymmetry patterns of masseter muscle sites associated with the immediate 'application of splint therapy' using the diagnostic approach of high-resolution gray-scale ultrasonography. The study included 24 patients who had signs and symptoms of temporomandibular disorders. Ultrasonographic investigation was performed with a linear (B-scan) 7.5 Mhz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior, and postero-inferior sites of the masseter muscle. To assess local maximal clenching-related muscle asymmetry patterns and to evaluate the respective effect of occluding splints, the 'absolute asymmetry index' was used, with the mean maximum muscle diameter of the respective right and left sides calculated from three consecutive measurements before and after splint insertion. Comparing the values assessed before splint insertion with those after splint insertion revealed a significant decrease in local maximal clenching-related muscle asymmetry values for the antero-inferior masseter muscle site (P < 0.05). The results of this study suggest stabilization-type splints to have a site-specific effect in the immediate reduction of local maximal clenching-related muscle asymmetries. Further studies are warranted to evaluate muscle-site specific effects in patient and non-patient groups and to relate these effects to pre-treatment variables like bite force, preferred chewing side, facial morphology and occlusion.

The short-term effect of stabilization-type splints on the local asymmetry of masseter muscle sites

Patients with temporomandibular disorders (TMD) may present with a cluster of joint and muscle disorders characterized primarily by pain, joint sounds and irregular or deviating jaw function. Maxillary stabilization-type splints represent the best standard therapy, so the purpose of this study was to evaluate changes in local cross-sectional dimensions (LCSD) of masseter muscle sites associated with short-term application of 'splint therapy' using the diagnostic approach of high-resolution gray-scale ultrasonography. The study included 29 patients who had signs and symptoms of temporomandibular disorders. Ultrasonographic investigation was performed with a linear (B-scan) 7.5 MHz small-part transducer to visualize the antero-superior, antero-inferior, medio-superior, medio-inferior, postero-superior and postero-inferior sites of the masseter muscle. To assess local muscle asymmetry patterns and to evaluate the respective effect of occluding splints, the 'absolute asymmetry index (AAI)' was used, with the mean maximum muscle diameter of the respective right and left sides calculated from three consecutive measurements before and after splint therapy. Comparing the pre-treatment with the 2-month follow-up values revealed a significant decrease in the overall mean asymmetry indices at the anterior (P < 0.01), medial (P < 0.05) and posterior (P < 0.05) muscle sites. There was no significant change in LCSDs at the various muscle sites (P > 0.05). The results of this study suggest stabilization-type splints to be effective in reducing local muscle asymmetries. Further studies are warranted to evaluate muscle-site specific effects in patient and non-patient groups and to relate these effects to pre-treatment variables like bite force, preferred chewing side, facial morphology and occlusion.

Magnetic resonance imaging findings of internal derangement and effusion in patients with unilateral temporomandibular joint pain

OBJECTIVES

The purpose of this study was to investigate the relationship between the presence of temporomandibular joint (TMJ) pain and the magnetic resonance (MR) imaging findings of internal derangement (ID) and effusion.

STUDY DESIGN

The study was comprised of 41 consecutive patients with TMJ pain. Criteria for including a patient were report of unilateral pain near the TMJ, with the presence of unilateral TMJ pain during palpation, function, and/or unassisted or assisted mandibular opening, and the absence of a specific clinical TMJ-related diagnosis of disk displacement with or without reduction. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ ID or effusion, or both.

RESULTS

Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ pain and the MR imaging diagnoses of TMJ ID (P =.001), and TMJ effusion (P =.004). Furthermore, there was a significant relationship between the MR imaging diagnosis of TMJ ID and TMJ effusion (P =.000). Use of the kappa statistic test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of TMJ ID (kappa = 0.34), TMJ effusion (kappa = 0.32), and TMJ ID and effusion (kappa = 0.27).

CONCLUSIONS

The study's findings suggest that although clinical pain is correlated with TMJ-related MR imaging findings, clinical pain in and of itself is not reliable for predicting the presence of TMJ ID or effusion, or both. Therefore, MR imaging appears to be a warranted and necessary supplement to the clinical findings.

Temporomandibular joint internal derangement type III: relationship to magnetic resonance imaging findings of internal derangement and osteoarthrosis. An intraindividual approach

The purpose of this study was to investigate whether in patients with a clinical unilateral temporomandibular joint (TMJ)-related finding of internal derangement type (ID)-III (disk displacement without reduction) in combination with TMJ-related pain, the intraindividual variable of 'unilateral TMJ ID-III pain' may be linked to subject-related magnetic resonance (MR) imaging findings of TMJ ID, and TMJ osteoarthrosis (OA). The study comprised 48 consecutive TMJ pain patients, who were assigned a clinical unilateral TMJ pain side-related diagnosis of ID-III. Bilateral sagittal and coronal MR images were obtained to establish the presence or absence of TMJ ID and/or OA. Comparison of the TMJ side-related data showed a significant relationship between the clinical finding of TMJ ID-III pain and the MR imaging diagnoses of TMJ ID (P=0.000) and TMJ ID type (P=0.000). There was no correlation between the clinical finding of TMJ ID-III pain and the MR imaging diagnosis of TMJ OA (P=0.217), nor between the MR imaging diagnosis of TMJ OA and that of TMJ ID (P=0.350). Regarding the diagnostic subgroups of TMJ ID, a significant relationship was found between the presence of TMJ OA and the MR imaging diagnoses of TMJ ID type(P=0.002). Use of the Kappa statistical test indicated a fair diagnostic agreement between the presence of TMJ ID-III pain and the MR imaging diagnosis of disk displacement without reduction (DDNR) (K=0.42). The results suggest that TMJ ID-III pain is related to TMJ-related MR imaging diagnoses of ID. Further, the data confirm the biological concept of 'DDNR and OA' as an underlying mechanism in the etiology of TMJ-related pain and dysfunction.

Efficacy and tolerability of escin/diethylamine salicylate combination gels in patients with blunt injuries of the extremities

The aim of this confirmative, monocentre, double-blind, controlled clinical trial was to investigate whether different escin combinations show differences in comparison to placebo with regard to pain reactions in the topical treatment of sports injuries. A total of 126 patients with blunt injuries of the extremities were randomly allocated to four parallel groups: Reparil-Gel N (n = 32), Reparil-Gel (n = 31), Reparil-Sportgel (n = 32) and a placebo gel (n = 31). All patients were evaluated for efficacy (intention to treat) and tolerability. A per-protocol analysis was also carried out, in which 12 of the 126 patients were excluded due to protocol violations. The intention-to-treat and per-protocol analyses produced similar results. The patients had suffered contusions while participating in soccer, hockey, karate, tae-kwon-do, handball, American football, rugby or tennis. The measured variable was the pressure required at the centre of the lesion to elicit the first pain reaction (tenderness reaction) at measuring time 0 (baseline) and then 1, 2, 3, 4, 6 and 24 h after the injury. The primary variable was the area under the curve (AUC) for tenderness over a six-hour period. The mean AUC differed significantly in the four groups (Kruskal-Wallis test p = 0.0001). Then six pairwise comparisons of two treatment groups each were carried out using the Mann-Whitney test. To control the multiple significance level of 5%, the adjusted p-values according to the Holm-Shaffer method were used in these tests. The three active gels were significantly superior to the placebo gel (Mann-Whitney test, p = 0.0004 in each case) in terms of the AUC. There were no significant differences between the active test substances in terms of the primary variable. The intensity of the pain was also measured on a visual analogue scale (VAS). The pain diminished more rapidly with the Reparil gels than with the placebo. The tolerability of all test substances was good. No adverse events were observed in any of the 126 patients. Escin combination gels are more effective than a placebo and are also well tolerated. Therefore, they can be recommended for the treatment of blunt injuries caused during sports and leisure activities.

The patient's perspective of irritable bowel syndrome

OBJECTIVE

The researchers wanted to understand how irritable bowel syndrome (IBS) affects patients' lives and their interactions with physicians and the health care system.

STUDY DESIGN

A qualitative study was performed using focus groups of people with physician-diagnosed IBS. Immersion/crystallization was used to identify overriding themes.

POPULATION

Adult volunteers with a previous physician diagnosis of IBS were included.

OUTCOMES MEASURED

The outcomes were patient-reported symptoms, episode triggers, treatments, lifestyle changes, and interactions with their physicians that were related to IBS, and overriding themes identified from the focus groups.

RESULTS

The subjects described IBS as a chronic episodic illness that affects their daily lives. Interaction with the medical community seldom clarified understanding of the condition or improved its management. Three overriding themes emerged from the groups: a sense of frustration, a sense of isolation, and a search for a niche in the health/sick role continuum. Frustration was evident in the perceived inability to control symptoms, prevent episodes, identify episode triggers, and obtain medical validation of the condition. The constant anticipation of the next IBS episode, the need for immediate access to toilet facilities, and the nature of the bowel symptoms often required withdrawal from social activities and resultant isolation.

CONCLUSIONS

IBS is perceived as a chronic condition resulting in frustration and social isolation, and physicians are perceived to be providing inadequate medical information or support to patients with IBS.

Diagnosing TMJ internal derangement and osteoarthritis with magnetic resonance imaging

BACKGROUND

The authors conducted a study to investigate the relationship between the presence of temporomandibular joint, or TMJ, pain and magnetic resonance imaging, or MRI, findings of internal derangement, or ID, and arthritis, or OA.

METHODS

The authors studied 131 consecutively seen TMJ pain patients. Their criteria for including a patient in the study were report of unilateral orofacial pain referred to TMJ and the presence of unilateral TMJ pain during palpation, function, and unassisted or assisted mandibular opening. The authors took bilateral sagittal and coronal MRIs to establish the presence or absence of TMJ ID, OA or both.

RESULTS

When the authors compared TMJ side-related data from all subjects, they found a significant relationship between the clinical findings of TMJ pain and the MRI diagnoses of TMJ ID (P = .000) and TMJ OA (P = .013). They also found a significant relationship between the MRI diagnosis of TMJ ID type and that of TMJ OA (P = .000). The authors used the kappa statistical test and found poor diagnostic agreement between the presence of TMJ pain and the MRI diagnosis of TMJ ID (kappa = 0.21), TMJ OA (kappa = 0.15), and TMJ ID and OA combined (kappa = 0.18).

CONCLUSIONS

The study's findings suggest that while clinical pain is related to TMJ-related MRI findings, the presence of clinical pain is not a reliable predictor of TMJ ID, OA or both.

CLINICAL IMPLICATIONS

Using MRI to supplement clinical findings of TMJ pain appears warranted and necessary to establish the presence or absence of TMJ ID.

Relationship between temporomandibular joint pain and magnetic resonance imaging findings of internal derangement

In terms of clinical decision-making in instances of temporomandibular disorders (TMD) and orofacial pain, there is controversy in the literature over the diagnostic significance of the temporomandibular joint (TMJ)-related variable disk-condyle relationship (DCR). The purpose of this study was to investigate whether in patients with TMJ-related pain, the variable of TMJ pain may be linked to magnetic resonance (MR) imaging findings of internal derangement (ID). The study comprised 163 consecutive TMJ pain patients. Criteria for including a patient were report of orofacial pain referred to the TMJ, and the presence of uni- or bilateral TMJ pain during palpation, during function, and/or during unassisted or assisted mandibular opening. Bilateral sagittal and coronal MR images were obtained to establish the prevalence of TMJ ID types. Analysis of the data revealed the presence of TMJ pain to be associated with significantly more MR imaging diagnoses of ID than an absence of ID (P<0.001), and disk displacement without reduction than disk displacement with reduction (P<0.001). Using chi-square analysis, the results showed a significant relationship between the presence of TMJ-related pain and the MR imaging diagnosis of TMJ ID (P=0.001), and TMJ ID type (P=0.000). Use of the Kappa statistical test indicated poor diagnostic agreement between the presence of TMJ pain and the MR imaging diagnosis of ID (K=0.16). The results suggest that the clinical variable of TMJ pain may have a significant effect on the prevalences of MR imaging diagnoses of TMJ ID. The data confirm the biological concept of DCR as a diagnostic approach in patients with signs and symptoms of TMJ-related pain.

Anxiety sensitivity, state and trait anxiety, and perception of change in sympathetic nervous system arousal

The psychological models of panic disorder predict that persons with this condition may demonstrate enhanced acuity for somatic stimuli, but research to date has produced conflicting results. Most studies have investigated acuity for cardiovascular responses such as heart rate. which may represent an inadequate test of this hypothesis because they would be unlikely to detect persons who respond maximally to panic through other physiological systems. The present study investigated the detection of changes in pulse transit time (PTT), as a reliable and omnibus measure of sympathetic nervous system activity, with 36 healthy volunteers. We found that accurate perception of changes in PTT was consistently related to higher levels of trait anxiety and anxiety sensitivity, both of which are risk factors for the development of anxiety disorders in general. and panic disorder in particular. served.

Idiopathic maxillary pain: prevalence of maxillary sinus hyperreactivity in relation to allergy, chronic mucosal inflammation, and eosinophilia

OBJECTIVE

In patients with chronic orofacial pain, an underlying sinus hyperreactivity may contribute to the clinical symptoms of a diagnosis of atypical odontalgia, trigeminal neuralgia, or temporomandibular disorders. The purpose of this study was to assess the prevalence of histamine-related maxillary sinus hyperreactivity in patients manifesting signs and symptoms of idiopathic maxillary pain and to correlate the respective findings with the presence or absence of chronic maxillary sinusitis-related diagnoses such as allergy, chronic mucosal inflammation, and eosinophilia.

STUDY DESIGN

Fifty patients who had been assigned a diagnosis of idiopathic maxillary pain underwent skin allergy tests, maxillary sinus histamine provocation tests, and maxillary sinus mucosa biopsy. Histamine challenge to a selected area was performed during transoral sinuscopy of the maxillary sinus; a positive test result was defined as the development of a significant local mucosa response such as reddening and swelling.

RESULTS

Comparison of the data showed most patients (38%) to have an absence of chronic maxillary sinusitis-related diagnoses, whereas the most common multiple diagnosis was found to be chronic mucosal inflammation in combination with eosinophilia (22%). Regarding the prevalence rates of positive histamine provocation test outcomes, a significant difference was found between the diagnostic subgroup "absence of chronic maxillary sinusitis-related diagnoses" (36.9%) and the diagnostic subgroups "chronic mucosal inflammation" (20%; P< .05), "chronic mucosal inflammation in combination with eosinophilia" (18.2%; P< .05), and "chronic mucosal inflammation in combination with eosinophilia and allergy" (14.3%; P < .01). An analysis of the distribution of chronic maxillary sinusitis-related diagnoses revealed absence of chronic mucosal inflammation-related diagnoses to be significantly more frequently associated with positive histamine provocation test outcomes than with negative histamine provocation test outcomes (41.2% vs 19.7%; P< .01), whereas chronic maxillary sinusitis (41.0% vs 29.4%), eosinophilia (26.2% vs 17.6%), and allergy (13.1% vs 11.8%) were found to be more prevalent in patients with negative histamine provocation test outcomes.

CONCLUSIONS

The findings of this study suggest patients with idiopathic maxillary pain to be associated with a low rate of sinus hyperreactivity, whereas a positive test outcome with histamine provocation may not be linked to the presence of chronic maxillary sinusitis-related diagnoses such as allergy, chronic mucosal inflammation, and eosinophilia. Further investigations using a larger sample size of patients with idiopathic maxillary pain and nonidiopathic maxillary pain are necessary to demonstrate the presence or absence of an idiopathic maxillary pain-specific prevalence of maxillary sinus hyperreactivity.