Clinically orientated classification incorporating shoulder balance for the surgical treatment of adolescent idiopathic scoliosis.

PURPOSE: The achievement of shoulder balance is an important measure of successful scoliosis surgery. No previously described classification system has taken shoulder balance into account. We propose a simple classification system for AIS based on two components which include the curve type and shoulder level. METHODS: Altogether, three curve types have been defined according to the size and location of the curves, each curve pattern is subdivided into type A or B depending on the shoulder level. This classification was tested for interobserver reproducibility and intraobserver reliability. A retrospective analysis of the radiographs of 232 consecutive cases of AIS patients treated surgically between 2005 and 2009 was also performed. RESULTS: Three major types and six subtypes were identified. Type I accounted for 30 %, type II 28 % and type III 42 %. The retrospective analysis showed three patients developed a decompensation that required extension of the fusion. One case developed worsening of shoulder balance requiring further surgery. This classification was tested for interobserver and intraobserver reliability. The mean kappa coefficients for interobserver reproducibility ranged from 0.89 to 0.952, while the mean kappa value for intraobserver reliability was 0.964 indicating a good-to-excellent reliability. CONCLUSIONS: The treatment algorithm guides the spinal surgeon to achieve optimal curve correction and postoperative shoulder balance whilst fusing the smallest number of spinal segments. The high interobserver reproducibility and intraobserver reliability makes it an invaluable tool to describe scoliosis curves in everyday clinical practice.

Oesophageal hypersensitivity is associated with features of psychiatric disorders and the irritable bowel syndrome.

BACKGROUND: Twenty per cent of patients with heartburn do not respond to proton pump inhibitors (PPIs). Many have normal oesophageal acid exposure. We hypothesized that such PPI non-responders have heightened oesophageal sensation, and that oesophageal hypersensitivity is associated with psychiatric features including somatization and anxiety. AIM: To compare oesophageal sensation in subjects with heartburn categorized by response to PPI, and to correlate oesophageal sensation with psychiatric features. METHODS: Twenty-one PPI responders, nine PPI non-responders and 20 healthy volunteers completed questionnaires of psychiatric disorders and gastrointestinal symptoms. Subjects underwent oesophageal sensory testing with acid perfusion and balloon distension. RESULTS: Healthy volunteers displayed higher thresholds for sensation and discomfort from balloon distension than heartburn subjects (sensation P = 0.04, discomfort P = 0.14). Psychiatric disorders were associated with increased intensity of sensation (P = 0.02) and discomfort from acid (P = 0.01). Somatization was associated with increased discomfort from balloon distension (P = 0.006). Features of irritable bowel syndrome were associated with increased sensation and discomfort. CONCLUSIONS: Heartburn subjects tend to have heightened oesophageal sensation, suggesting that oesophageal hypersensitivity may persist despite therapy with PPI. Oesophageal hypersensitivity is associated with features of psychiatric disease and with the irritable bowel syndrome, which might partly explain the aetiology of heartburn symptoms that are refractory to PPI.

Over or under: hydride attack at the metal versus the coordinated nitrosyl ligand in ferric nitrosyl porphyrins.

Hydride attack at a ferric heme-NO to give an Fe-HNO intermediate is a key step in the global N-cycle. We demonstrate differential reactivity when six- and five-coordinate ferric heme-NO models react with hydride. Although Fe-HNO formation is thermodynamically favored from this reaction, Fe-H formation is kinetically favored for the 5C case.

Clinical and endoscopic findings in patients early in the course of clostridium difficile-associated pseudomembranous colitis.

Endoscopic and clinical features are reported for 39 patients detected early in the course of pseudomembranous colitis. Disease was detected early by virtue of careful surveillance in patients in whom diarrhea developed. Early proctosigmoidoscopic findings in pseudomembranous colitis are illustrated. Clinical presentation includes development of fever, leukocytosis, abdominal pain, and even an ileus picture on radiography in addition to diarrhea.

Myocardial uptake of labeled oleic and linoleic acids.

Oleic acid labeled with 14C, (14C-OA) or 131I (131I-OA) and 131I-labeled linoleic acid (131I-LOA) were administered intravenously to rats and tissue distribution studies completed at various time intervals from 5 to 60 min. Tissue distribution of 131-I-labeled oleic acid or linoleic acid was also studied in dogs at 5- and 30-min time intervals after intravenous administration of the tracer dose. There were distinct differences in the patterns of tissue distribution between 14C-OA, 131I-OA, and 131I-LOA. Radioactivity concentration in the myocardium was the highest at all time intervals in the rats given 131I-OA only. In dogs, the myocardial uptake of 131I-OA was significantly higher than the radioactivity in the blood or other tissues at 30 min after injection. The disappearance rates of 131I-OA and 131I-LOA were almost identical but myocardial concentration of 131I-LOA at 30 min after the dose in the dog was half that of 131I-OA whereas 131I-LOA liver concentration was higher than that of 131I-OA. Since the concentrations of our formulated 131I-OA in the blood and in the myocardium are both highest at the earlier intervals, it should be difficult to detect myocardial ischemia or infarction with 131I-OA scanning.

Steroid and FSH action on LH receptors and LH-sensitive testicular responsiveness during sexual maturation of the rat.

This study examines the effect of FSH, testosterone and estradiol on testicular LH receptors and in vitro testicular responsiveness to LH in immature rats under various conditions. FSH treatment of 15-day-old immature rats significantly increased the number of LH receptors but did not alter testicular responsiveness. FSH treatment of hypophysectomized immature rats increased the number of LH receptors and markedly increased testicular responsiveness. Treatment of hypophysectomized rats with testosterone proprionate for 4 days, followed by a 5-day treatment with FSH, enhanced the effect of FSH on the number of LH receptors but did not increase the effect of FSH on testicular responsiveness. In contrast, treatment with estradiol for 4 days before FSH treatment had no effect on the FSH-induced increase in LH receptors but completely inhibited the FSH-induced increase in testicular responsiveness. These observations suggest that during male sexual maturation (1) regulation of LH receptors is distinct from regulation of testicular responsiveness to LH, (2) estradiol may be a factor in the regulation of testicular responsiveness to LH, and (3) testosterone may enhance the FSH-induced increase of LH receptors.

Reliability and validity of the digestive health status instrument in samples of community, primary care, and gastroenterology patients.

AIM: We evaluated a previously reported digestive health status instrument in community, primary care, and gastroenterology practice populations. Multiple types of reliability, validity and responsiveness were assessed to determine the performance of the questionnaire. METHODS: Study populations included community, primary care and gastroenterology subjects. Psychometric analyses included internal consistency and test-retest reliability, criterion and construct validity, and responsiveness. RESULTS: Acceptable internal consistency was seen on all scales in all three populations. Test-retest reliability was excellent in a speciality population with reflux disease. Criterion validity was demonstrated by strong correlation of reflux scale scores and results on 24-h pH monitoring. Scale scores varied predictably in those receiving gastrointestinal tract imaging and according to diagnosis, indicating construct validity. The reflux scale and pain index were sensitive to change with treatment for reflux disease. Multi-trait scaling analyses from the community sample revealed a structure equivalent to that reported from a primary care sample. CONCLUSIONS: The reliability and validity of the digestive health status instrument on multiple measures in multiple settings have been demonstrated. The instrument was responsive to change with treatment for reflux disease. The demonstrated robustness attests to the suitability for future studies and clinical application.

Effect of endothelin receptor antagonist on lung allograft apoptosis and NOSII expression.

BACKGROUND: It is postulated that apoptosis contributes to ischemia-reperfusion graft dysfunction after lung transplantation. The purpose of this study was to determine whether the improvement in lung function that we previously observed with the use of an endothelin-1 (ET-1) receptor antagonist after ischemia-reperfusion injury is associated with a reduction in inducible nitric oxide synthase (NOSII) expression and programmed cell death. METHODS: Left lung canine allotransplantation was performed. Harvested lung blocks were preserved with modified Eurocollins solution and stored at 4 degrees C for 18 to 20 hours. Lung allografts were tested for the expression of NOSII by immunohistochemistry, and extent of apoptosis by terminal dUTP nick end-labeling (TUNEL). Animals blindly received either an intravenous infusion of saline (control) or the ET-1 receptor antagonist (SB209670) (15 microg/kg/min). Infusion began 30 minutes pretransplantation and continued to 6 hours posttransplantation. RESULTS: Immunohistochemical analysis demonstrated significantly stronger NOSII immunostaining in the allografts of the saline control group (36.5%+/-3.6%) compared with native right lungs (6.9%+/-1.3%, p < 0.001) or the ET-receptor antagonist treatment group (9.6%+/-1.4%, p < 0.001). The TUNEL staining revealed a significantly stronger labeling in the allografts of the saline treatment control group (40.7%+/-6.2%) compared with native right lungs (5.0%+/-0.6%, p < 0.005) or the ET receptor antagonist treatment group (14.1%+/-2.8%, p < 0.01). CONCLUSIONS: We conclude that treatment of lung allografts with the ET-1 receptor antagonist SB209670 reduces the area of NOSII expression and the extent of apoptosis, factors known to contribute to the process of prolonged ischemia-reperfusion injury.

The use of monetary incentives in a community survey: impact on response rates, data quality, and cost.

OBJECTIVES: To assess the effect of incentive size on response rates, data quality, and cost in a digestive health status mail survey of a community sample of health plan enrollees. DATA SOURCES/SETTING: The study population was selected from a database of enrollees in various health plans obligated to receive care at Park Nicollet Clinic-HealthSystem Minnesota, a large, multispecialty group in Minneapolis, Minnesota, and the nearby suburbs. STUDY DESIGN: A total of 1,800 HealthSystem Minnesota enrollees were randomly assigned to receive a survey with an incentive of $5 or $2. The response rates for each incentive level were determined. Data quality, as indicated by item nonresponse and scale scores, was measured. Total cost and cost per completed survey were calculated. PRINCIPAL FINDINGS: The response rate among enrollees receiving $5 (74.3 percent) was significantly higher than among those receiving $2 (67.4 percent); differences were more pronounced in the first wave of data collection. Data quality did not differ between the two incentive groups. The total cost per completed survey was higher in the $5 condition than in the $2 condition. CONCLUSIONS: A $5 incentive resulted in a higher response rate among a community patient sample with one mailing than did a $2 incentive. However, the response rates in the $2 condition approached the level of the $5 incentive, and costs were significantly lower when the full follow-up protocol was completed. Response rates were marginally increased by follow-up phone calls. The incentive level did not influence data quality. The results suggest if a survey budget is limited and a timeline is not critical, a $2 incentive provides an affordable means of increasing participation.

Determination of beryllium in a stream sediment by high-performance chelation ion chromatography.

High-performance chelation ion chromatography (HPCIC), involving a chelating silica substrate bonded with aminomethylphosphonic acid, has been developed as a novel technique for the quantitative determination of beryllium in complex matrices. An isocratic separation method, using an eluent containing 1 M KNO3, 0.5 M HNO3 and 0.08 M ascorbic acid, allowed the Be2+ to elute away from the sample matrix peak in under 6 min in a sample containing in excess of 800 mg l(-1) matrix metals. A detection limit of 35 microg l(-1) Be(II) was found using a post-column reaction involving Chrome Azurol S (CAS), 1 M hexamine and 10 mM EDTA buffered at pH 6. The standard addition curve gave excellent linearity (R2>0.999). The procedure was applied to the determination of trace beryllium in a certified sediment sample. The results obtained compared well with the certified value for beryllium.

Correlation of manual dexterity and comprehension with oral hygiene and periodontal status in mentally handicapped adults.

Although there is relatively little information concerning the oral health of handicapped adults there is increasing evidence to suggest that their oral condition, particularly periodontal health, is poor. The present investigation involved assessment of 382 handicapped patients attending four different Adult Training Centres in Birmingham. The caries status, oral hygiene, and periodontal conditions were evaluated and the Community Periodontal Index of Treatment Need (CPITN) was calculated. In order to assess the manual dexterity and the comprehension of the trainees a standard test was devised. This consisted of timing each participant in carrying out simple instructions to pick up and position certain common objects. The results indicated high levels of plaque, calculus, and bleeding with a mean CPITN of 7.43. The mean time taken for the manual dexterity and comprehension test was 23.9 seconds with a range from 10 to 80 seconds, S.E.+/- 1.33. This compares with results from 34 "normal" adults of a mean time of 8.2 seconds +/- 1.8 with a range of 6 to 12 seconds. There was no significant correlation between the Manual Dexterity and Comprehension scores and the periodontal indices in the handicapped adults.

Principles of nutrition therapy for short-bowel syndrome.

Short-bowel syndrome is characterized by maldigestion, malabsorption, dehydration, electrolyte abnormalities, and both macronutrient and micronutrient deficiencies. Nutritional and hydration status are difficult to maintain without the provision of specialized nutrition support when more than 75% of the small intestine has been resected. Each patient's response to small-bowel resection is unique; therefore, the type of therapy must be tailored to each individual's bowel resection, complications that ensue, and specific nutrient needs. Clinical management should be guided by principles of nutrition assessment and treatment of nutrient deficiencies as well as routine monitoring of the patient's clinical course and response to therapy.

The effectiveness of differing dental health education programmes in improving the oral health of adults with mental handicaps attending Birmingham adult training centres.

There are few published data available relating to dental health in adults with handicaps, or to the effectiveness of dental health education in this group. The present study involved 382 people attending four different adult training centres in Birmingham, UK. Following baseline examinations all participants were given oral hygiene instruction and a scale and polish. Each of the centres was then randomly allocated to one of the four treatment regimens. No specific treatment was provided for the control group; daily supervised toothbrushing was carried out by the participants in the other three groups, with the addition of a three-monthly scale and polish and reinforcement of oral hygiene instruction in group 3 and one-monthly input in group 4. The participants were re-examined after three months and then at six-monthly intervals until 24 months after the baseline examination. The results showed that those people left to their own devices to carry out toothbrushing at home following instruction were not achieving an acceptable standard. Those who were reminded, encouraged and motivated by the adult training centre staff were obviously capable of better standards of oral care. The input of an experienced dental hygienist on a regular basis improved the periodontal condition considerably. Although there were significant differences between the groups throughout the study, particularly in the presence of calculus, the differences between the one-monthly and three-monthly hygienist input were not clinically very apparent after two years, and therefore a one-monthly input would be difficult to justify on a cost benefit basis.

The oral health in different groups of adults with mental handicaps attending Birmingham (UK) adult training centres.

The policies of normalisation and integration into the community of people with mental handicap have significant implications for dental care. Before dental services can be planned, the extent of the problem needs to be identified. A total of 382 people with mental handicap living in the community and attending day centres was examined; 52 of these people were edentulous. The mean age of the dentate adults was 30.9 years and the mean DMFT was 9.59. This was low in comparison with data available from national studies but when component parts of the DMF were evaluated it was apparent that far less restorative care had been received by the adults with mental handicap. There were also significant differences in the mean DMFT between mentally handicapped people who had additional handicaps; the mean DMFT for people with Down's syndrome was 10.95, whilst those mentally handicapped people who also had epilepsy had a mean DMFT of 11.19. The oral hygiene and periodontal condition was also poor and there were significant differences between the sub-groups. However, despite people with Down's syndrome having lower levels of plaque, they showed evidence of greater periodontal destruction. When resources are allocated, consideration should be given to raising the oral health of adults with mental handicap up to at least the same level as that of the rest of the population.

Audit in restorative dentistry.

Auditing activity requires patient data to be collected and analysed to allow comparisons to be made and conclusions drawn. Within the General Dental Services the Dental Practice Board regularly collects practitioner specific clinical data and distributes this to allow dentists to compare their own clinical activity with local and national means. In hospital dentistry, a software package has been developed to enable orthodontic audit to be performed in hospital practice. The package is now being piloted in several centres. A similar software package is required for auditing restorative dentistry activity in units where consultant services are provided. Hospital patient administration systems provide demographic data and appointment systems predominantly with little opportunity for patient specific clinical analysis. Carefully designed software will allow appropriate clinical data and analysis. To ensure compliance and accurate recording both by clinical and support staff it is essential that any software system should be easy to use.

Dental and oral lesions in two patients with focal dermal hypoplasia (Goltz syndrome).

This report is concerned with the manifestations associated with focal dermal hypoplasia (Goltz syndrome) in two patients. Goltz syndrome is a rare polydysplastic syndrome. Systemic findings were similar to those previously reported in the literature and are illustrated. More detailed descriptions of the dental abnormalities are presented. The possibility of root resorption being a previously unreported part of the syndrome is hypothesised.

The provision of dental implants in the National Health Service Hospital dental services--a national questionnaire.

OBJECTIVE: To assess the activity of consultants in restorative dentistry in the United Kingdom in the provision of osseointegrated dental implants within the National Health Service Hospital service and to evaluate their attitudes concerning the relevant medical and oral factors considered in patient selection for implant treatment. DESIGN/SETTING: Anonymous postal questionnaire in the United Kingdom. SUBJECTS: Consultants in restorative dentistry. RESULTS: Out of the sample of 145, 109 consultants (75%) completed the questionnaire in 1999. 54 of the 109 consultants (49.5%) are involved in the provision of osseointegrated implant treatment, treating an average of 29 cases/year (range 2-150). However, over one third of the respondents treated 10 or less cases/year. 89% worked with oral surgeons as an implant team. 68% used Branemark (Nobel Biocare) implants as their main system. The majority of consultants felt that smoking, psychoses and previous irradiation were the most important medical factors that contra-indicated implant retained restorations whilst untreated periodontitis, poor oral hygiene and uncontrolled caries were the most important oral contra-indications. Many centres were experiencing significant problems with the funding of implant treatment with one centre receiving no funding. The implications for patient care and specialist training are discussed. CONCLUSIONS: There is a marked variation in the number of patients treated with endosseous dental implants within the United Kingdom National Health Service hospitals. Many consultants treat 10 or fewer patients each year. In the main, there is agreement about the factors that contra-indicate implant treatment; these are in line with national guidelines.

Developing an index of restorative dental treatment need.

The process undertaken to establish an initial pilot index for restorative dental treatment is described. Following consultation with a wide range of clinicians and others, an outline framework for the index was developed and comprised three main components: 1. Patient identified need for treatment: the data from the patient perceived need questionnaire were inconclusive; 2. Complexity of treatment (assessed by clinicians): this was found to be a practical tool capable of being used by a range of dentists. A booklet has been produced which describes the process of using the scoring system; 3. Priority for treatment (assessed by clinicians): three levels of priority were identified; the highest priority was assigned to patients with inherited or developmental defects that justify complex care (eg clefts of the lip and palate). The initial development of the index has had some success in a difficult area. The treatment complexity component is the most developed and may allow both referrers and commissioners of specialist restorative dentistry to determine appropriate use of skilled clinicians' expertise.

A genetic algorithm-based approach to flexible flow-line scheduling with variable lot sizes.

Genetic algorithms (GAs) have been used widely for such combinatorial optimization problems as the traveling salesman problem (TSP), the quadratic assignment problem (QAP), and job shop scheduling. In all of these problems there is usually a well defined representation which GA's use to solve the problem. We present a novel approach for solving two related problems-lot sizing and sequencing-concurrently using GAs. The essence of our approach lies in the concept of using a unified representation for the information about both the lot sizes and the sequence and enabling GAs to evolve the chromosome by replacing primitive genes with good building blocks. In addition, a simulated annealing procedure is incorporated to further improve the performance. We evaluate the performance of applying the above approach to flexible flow line scheduling with variable lot sizes for an actual manufacturing facility, comparing it to such alternative approaches as pair wise exchange improvement, tabu search, and simulated annealing procedures. The results show the efficacy of this approach for flexible flow line scheduling.