Relating gastric scintigraphy and symptoms to motility capsule transit and pressure findings in suspected gastroparesis.

BACKGROUND: Wireless motility capsule (WMC) findings are incompletely defined in suspected gastroparesis. We aimed to characterize regional WMC transit and contractility in relation to scintigraphy, etiology, and symptoms in patients undergoing gastric emptying testing. METHODS: A total of 209 patients with gastroparesis symptoms at NIDDK Gastroparesis Consortium centers underwent gastric scintigraphy and WMCs on separate days to measure regional transit and contractility. Validated questionnaires quantified symptoms. KEY RESULTS: Solid scintigraphy and liquid scintigraphy were delayed in 68.8% and 34.8% of patients; WMC gastric emptying times (GET) were delayed in 40.3% and showed 52.8% agreement with scintigraphy; 15.5% and 33.5% had delayed small bowel (SBTT) and colon transit (CTT) times. Transit was delayed in ≥2 regions in 23.3%. Rapid transit was rarely observed. Diabetics had slower GET but more rapid SBTT versus idiopathics (P ≤ .02). GET delays related to greater scintigraphic retention, slower SBTT, and fewer gastric contractions (P ≤ .04). Overall gastroparesis symptoms and nausea/vomiting, early satiety/fullness, bloating/distention, and upper abdominal pain subscores showed no relation to WMC transit. Upper and lower abdominal pain scores (P ≤ .03) were greater with increased colon contractions. Constipation correlated with slower CTT and higher colon contractions (P = .03). Diarrhea scores were higher with delayed SBTT and CTT (P ≤ .04). CONCLUSIONS & INFERENCES: Wireless motility capsules define gastric emptying delays similar but not identical to scintigraphy that are more severe in diabetics and relate to reduced gastric contractility. Extragastric transit delays occur in >40% with suspected gastroparesis. Gastroparesis symptoms show little association with WMC profiles, although lower symptoms relate to small bowel or colon abnormalities.

Diabetic and idiopathic gastroparesis is associated with loss of CD206-positive macrophages in the gastric antrum.

BACKGROUND: Animal studies have increasingly highlighted the role of macrophages in the development of delayed gastric emptying. However, their role in the pathophysiology of human gastroparesis is unclear. Our aim was to determine changes in macrophages and other cell types in the gastric antrum muscularis propria of patients with diabetic and idiopathic gastroparesis. METHODS: Full thickness gastric antrum biopsies were obtained from patients enrolled in the Gastroparesis Clinical Research Consortium (11 diabetic, 6 idiopathic) and 5 controls. Immunolabeling and quantitative assessment was done for interstitial cells of Cajal (ICC) (Kit), enteric nerves protein gene product 9.5, neuronal nitric oxide synthase, vasoactive intestinal peptide, substance P, tyrosine hydroxylase), overall immune cells (CD45) and anti-inflammatory macrophages (CD206). Gastric emptying was assessed using nuclear medicine scintigraphy and symptom severity using the Gastroparesis Cardinal Symptom Index. RESULTS: Both diabetic and idiopathic gastroparesis patients showed loss of ICC as compared to controls (Mean [standard error of mean]/hpf: diabetic, 2.28 [0.16]; idiopathic, 2.53 [0.47]; controls, 6.05 [0.62]; P=.004). Overall immune cell population (CD45) was unchanged but there was a loss of anti-inflammatory macrophages (CD206) in circular muscle (diabetic, 3.87 [0.32]; idiopathic, 4.16 [0.52]; controls, 6.59 [1.09]; P=.04) and myenteric plexus (diabetic, 3.83 [0.27]; idiopathic, 3.59 [0.68]; controls, 7.46 [0.51]; P=.004). There was correlation between the number of ICC and CD206-positive cells (r=.55, P=.008). Enteric nerves (PGP9.5) were unchanged: diabetic, 33.64 (3.45); idiopathic, 41.26 (6.40); controls, 46.80 (6.04). CONCLUSION: Loss of antral CD206-positive anti-inflammatory macrophages is a key feature in human gastroparesis and it is associates with ICC loss.

Association of low numbers of CD206-positive cells with loss of ICC in the gastric body of patients with diabetic gastroparesis.

BACKGROUND: There is increasing evidence for specific cellular changes in the stomach of patients with diabetic (DG) and idiopathic (IG) gastroparesis. The most significant findings are loss of interstitial cells of Cajal (ICC), neuronal abnormalities, and an immune cellular infiltrate. Studies done in diabetic mice have shown a cytoprotective effect of CD206+ M2 macrophages. To quantify overall immune cellular infiltrate, identify macrophage populations, and quantify CD206+ and iNOS+ cells. To investigate associations between cellular phenotypes and ICC. METHODS: Full thickness gastric body biopsies were obtained from non-diabetic controls (C), diabetic controls (DC), DG, and IG patients. Sections were labeled for CD45, CD206, Kit, iNOS, and putative human macrophage markers (HAM56, CD68, and EMR1). Immunoreactive cells were quantified from the circular muscle layer. KEY RESULTS: Significantly fewer ICC were detected in DG and IG tissues, but there were no differences in the numbers of cells immunoreactive for other markers between patient groups. There was a significant correlation between the number of CD206+ cells and ICC in DG and DC patients, but not in C and IG and a significant correlation between iNOS+ cells and ICC in the DC group, but not the other groups. CD68 and HAM56 reliably labeled the same cell populations, but EMR1 labeled other cell types. CONCLUSIONS & INFERENCES: Depletion of ICC and correlation with changes in CD206+ cell numbers in DC and DG patients suggests that in humans, like mice, CD206+ macrophages may play a cytoprotective role in diabetes. These findings may lead to novel therapeutic options, targeting alternatively activated macrophages.

Clinical-histological associations in gastroparesis: results from the Gastroparesis Clinical Research Consortium.

BACKGROUND: Cellular changes associated with diabetic (DG) and idiopathic gastroparesis (IG) have recently been described from patients enrolled in the Gastroparesis Clinical Research Consortium. The association of these cellular changes with gastroparesis symptoms and gastric emptying is unknown. The aim of this study was to relate cellular changes to symptoms and gastric emptying in patients with gastroparesis. METHODS: Earlier, using full thickness gastric body biopsies from 20 DG, 20 IG, and 20 matched controls, we found decreased interstitial cells of Cajal (ICC) and enteric nerves and an increase in immune cells in both DG and IG. Here, demographic, symptoms [gastroparesis cardinal symptom index score (GCSI)], and gastric emptying were related to cellular alterations using Pearson's correlation coefficients. KEY RESULTS: Interstitial cells of Cajal counts inversely correlated with 4 h gastric retention in DG but not in IG (r = -0.6, P = 0.008, DG, r = 0.2, P = 0.4, IG). There was also a significant correlation between loss of ICC and enteric nerves in DG but not in IG (r = 0.5, P = 0.03 for DG, r = 0.3, P = 0.16, IG). Idiopathic gastroparesis with a myenteric immune infiltrate scored higher on the average GCSI (3.6 ± 0.7 vs 2.7 ± 0.9, P = 0.05) and nausea score (3.8 ± 0.9 vs 2.6 ± 1.0, P = 0.02) as compared to those without an infiltrate. CONCLUSIONS & INFERENCES: In DG, loss of ICC is associated with delayed gastric emptying. Interstitial cells of Cajal or enteric nerve loss did not correlate with symptom severity. Overall clinical severity and nausea in IG is associated with a myenteric immune infiltrate. Thus, full thickness gastric biopsies can help define specific cellular abnormalities in gastroparesis, some of which are associated with physiological and clinical characteristics of gastroparesis.

An investigation into the value and relevance of oral health promotion leaflets for young adolescents.

OBJECTIVES: To determine if oral health promotion leaflets of a novel design and content would be read by, acceptable to and influence 11-12-year-old children. METHOD: Three related leaflets were incorporated into a dental health education programme aimed at 11-12-year-old children. The leaflets were designed specifically, following consultation with focus groups. They had a romantic story line and emphasised the immediate gains from good dental health, relevant to this age group. A random sample of pupils completed a written questionnaire on the impact of the leaflets at the end of the one-year programme. These sample pupils underwent a clinical examination to measure plaque before and after the programme. RESULTS: 2,678 pupils with a mean age of 12.1 years participated in the programme. 895 were randomly selected to join the assessment study. Most pupils 81%, (725) reported they had read the leaflets; 61% (442) finding them enjoyable to read, 51% (370) attractive to look at and 71% (515) finding the story lines interesting. However, girls appreciated the leaflets more than the boys. There was some suggestion that the leaflets played a positive role in the overall success of the programme in that most pupils 83% (602) reported they thought more about caring for their teeth after reading the leaflets and 58% reported their brushing frequency had increased. CONCLUSION: The results indicate that for adolescents, leaflets which feature interpersonal relationships are well accepted and can stimulate better oral health behaviour.

A cluster randomized controlled trial of a dental health education program for 10-year-old children.

OBJECTIVE: Using a cluster randomized trial, this study tested the effectiveness of a dental health education program designed to improve the oral hygiene and dental knowledge of 10-year-old children. METHODS: Thirty-two primary schools in the northwest of England participated. After a baseline assessment of plaque and the completion of a dental knowledge questionnaire by the children, the schools were allocated randomly to active or control groups. Children in schools allocated to the active group received the dental health program, which consisted of four one-hour lessons. After four months the children were examined clinically and scored for plaque, and a second questionnaire was administered. The schools in the control group were then allocated randomly to receive the program or not over the following three months, the program being withdrawn from the schools who initially received it. A further assessment of plaque was made and a questionnaire administered seven months after the baseline of the study. RESULTS: The active groups had 20 percent and 17 percent lower mean plaque scores than the control group at four and seven months (P < .001). The children's knowledge of which type of toothbrush should be used and the role of disclosing tablets improved in the initial test group when compared with the control group and this was retained over the second part of the study. CONCLUSION: The children receiving the program had significantly lower mean plaque scores and greater knowledge about toothbrushes and disclosing tablets than the control children who had not received the program.

An oral health promotion programme for nursing caries.

AIM: To evaluate an oral health promotion programme involving health visitors and mothers of 8-month-old babies in order to address some of the risk factors associated with nursing caries. DESIGN: Two cross-sectional studies using postal questionnaires. SAMPLE: A random sample of 250 mothers who had not received the oral health promotion programme and 250 mothers who had received the programme. SETTING: The City of Salford. RESULTS: The oral health promotion programme significantly improved mothers recall of advice given by health visitors encouraging the use of a feeder cup, brushing their babies' teeth with fluoride toothpaste and restricting sugary foods and drinks. Significant improvements were also found in recall of advice regarding the use of sugar-free medicine and registering babies with a dentist. The programme encouraged a higher proportion of the mothers to bring their children to clinics for a hearing check. CONCLUSION: A simple oral health promotion programme facilitated by health visitors improved recall of advice and clinic visiting behaviour.

Evaluation of a teaching aid for dental students.

A new teaching aid to assist undergraduate dental students to learn charting methods was developed. The aim of this study was to evaluate the effectiveness of the aid. Baseline charting tests were completed by 58 inexperienced clinical students at the start of a weekly half-day attachment at 3 community dental service (CDS) teaching clinics. These students were randomly assigned, in their tutor groups, to act as either test or control groups. The test group was actively taught charting with the new aid over their first 5-week attachment and control students were taught in the traditional way. Final charting tests were completed at the end of the attachments by all students and their results compared with baseline test results. The test group improved their mean scores from 20 out of a possible 50 marks at baseline to 36 at final test, a mean increase of 15 marks and an improvement of 71%. The control group scored a mean of 18 marks at baseline and improved this to 25, an increase of 7 marks, an improvement of 39%. It is concluded that the new teaching aid is more effective in assisting the students to learn charting than the traditional method.

Expression of neuronal markers in oligodendrogliomas: an immunohistochemical study.

The oligodendroglioma has been considered to be a tumour showing oligodendrocyte differentiation, but studies of the expression of oligodendrocyte markers have not conclusively demonstrated this and the pattern of differentiation of this tumour remains uncertain. Recent studies have suggested that some oligodendrogliomas may show neuronal differentiation. The aim of this study was to determine whether there was evidence of neuronal differentiation in a series of oligodendrogliomas, and, if so, to determine whether this identified a biologically or clinically distinct group. Immunohistochemistry was carried out on paraffin sections using antibodies to synaptophysin, phosphorylated and non-phosphorylated neurofilament proteins. An archival series of 32 oligodendrogliomas had been previously characterized for histological features, histological grade, Ki-67 labelling index, apoptosis index and prognosis. Six per cent of tumours showed expression of synaptophysin. Thirty-one per cent of cases showed expression of neurofilament proteins with an antibody to non-phosphorylated epitopes, but no cases were positive with antibodies to phosphorylated neurofilament epitopes. Tumours showing expression of neuronal markers did not show a difference in the distribution of histological grade or GFAP expression from those which did not express these markers, and there was no difference in labelling indices or prognosis between the two groups. In conclusion, a subset of oligodendrogliomas showed expression of neuronal lineage markers; this is discussed in relation to histogenesis and differential diagnosis. The expression of such markers did not identify a biologically or clinically distinct subgroup.

Proliferation and cell death in oligodendrogliomas.

The rates of cell proliferation and of cell loss influence the growth rate of a tumour and reflect genetic changes. We studied proliferation and apoptosis in oligodendrogliomas and their relationship to progression of the tumours. Thirty-two cases of oligodendroglioma were retrieved spanning a 10-year period. The diagnosis and grade were reviewed and follow-up data obtained. Mitotic index (MI) and apoptotic index (AI) were determined from haematoxylin and eosin (H & E) stained sections. A labelling index (LI) of proliferating cells was obtained using the MIB1 antibody to the Ki-67 antigen. A further index of apoptosis was obtained using in situ end-labelling of DNA strand breaks (TUNEL index, TI). Fourteen cases were graded as II, 18 as III (1993 WHO). LI was significantly higher in grade III than in grade II tumours (P < 0.01) but the difference in apoptotic indices between grades was not significant. There was a significant (P = 0.036) positive correlation between the logarithms of TI and LI. Construction of survival curves demonstrated a significant difference in survival according to histological grade (P < 0.05). Stratification of cases by LI alone did not predict significantly different survival outcomes, and apoptotic indices did not demonstrate a relationship to survival. A positive relationship was demonstrated between proliferation and apoptosis in oligodendrogliomas. The levels of apoptosis observed indicate that this phenomenon may have an important influence on the overall rate of tumour growth.

Investigation of lay knowledge of the management of avulsed permanent incisors.

The prognosis of replanted avulsed permanent incisors depends largely on prompt and appropriate emergency management. The aim of this study was to investigate lay knowledge and attitudes in this respect. Postal questionnaires were sent to all physical education teachers, school nurses and secretaries, attendants in swimming baths and leisure centres and to 220 parents of teenage children in a defined area of North West England. The overall questionnaire response rate was 86.9%. Knowledge of methods of dealing with this problem was generally inadequate in both parents and the other groups. Although 53.6% of respondents claimed to have received first aid training only 3.1% could remember dental injuries being included. There was evidence that dental health education in this field can be effective, since the highest mean knowledge score was found in the 11.5% of respondents who recalled receiving advice from sources such as posters, magazines and newspapers. More than 80% of the respondents stated that they would not want to replant an avulsed incisor themselves, the main reason being lack of knowledge and training. It is suggested that there is a need for potentially effective dental health education in relation to this problem.

An investigation of dento-alveolar trauma and its treatment in an adolescent population. Part 1: The prevalence and incidence of injuries and the extent and adequacy of treatment received.

AIM: To measure the prevalence and incidence of dental trauma and to assess the extent and success of treatment provided. DESIGN: Cross-sectional and one-year incremental study. SUBJECTS AND METHODS: 2022 11-14-year-old pupils were examined in schools for clinical evidence of trauma of anterior teeth. 1891 were examined 15 months later. A history of the trauma and treatment provided were obtained together with some social data. Radiographs were taken of affected teeth. MAIN OUTCOME MEASURES: Degree of trauma, whether treatment was provided and its quality, ACORN classification. RESULTS: 34% had suffered trauma but only 12% needed treatment for 332 teeth. 47% of these teeth had received treatment, of which 59% was inadequate. After 15 months 4% had experienced new injuries. 42% of boys and 28% of girls (P < 0.01) had sustained injuries, as had 38% from ACORN group III and 30% from groups I and II. 67% of those with pain and 40% of those without attended for treatment (P < 0.01), while 69% who were unhappy with the appearance and 35% who were not (P < 0.01) attended. CONCLUSIONS: The primary care services currently available for the treatment of dental trauma are inadequate.

An investigation of dento-alveolar trauma and its treatment in an adolescent population. Part 2: Dentists' knowledge of management methods and their perceptions of barriers to providing care.

AIM: To assess dentists' knowledge of and perceived barriers to treatment of dental injuries. DESIGN: Cross-sectional postal questionnaire and personal interview. SUBJECTS AND METHODS: Questionnaires from 153 GDPs and 53 CDOs were received giving details of emergency options on 17 imaginary dental injuries and perceived barriers to treatment of trauma. Structured interviews with 21 of the GDPs and 19 CDOs seeking knowledge on diagnosis and long-term follow-up and treatment took place. Age and gender of dentist, type of practice and postgraduate courses attended were noted. MAIN OUTCOME MEASURES: Mean knowledge scores. RESULTS: Of a maximum of 14 correct responses on emergency treatment of injured teeth the mean was 7.5. Only 19% knew for how long avulsed teeth should be splinted. Of a maximum of 37 correct responses on long-term follow-up of treatment the mean was 15.4. Only 10% would correctly treat acute abscess on a traumatised tooth. 82% of dentists thought dental trauma should be treated in the primary care service, but 86% of GDPs thought fees for this type of treatment were too low. 72% of CDOs thought the treatment occupied too much clinic time and was not the responsibility of the CDS. CONCLUSIONS: Dentists in the primary care sector have insufficient knowledge to treat dental trauma.

A 30-month study investigating the effect of adding triclosan/copolymer to a fluoride dentifrice.

The aims of the study were (1) to compare the anticaries efficacy of a silica abrasive dentifrice containing 0.24% NaF and 0.3% triclosan/2.0% copolymer with a similar dentifrice without the triclosan/copolymer and (2) to study any disturbance of the oral mucosa associated with the test formulation. A double-blind, random, unsupervised, 30-month longitudinal clinical trial was conducted on 3,462 children who were initially 11-13 years of age. Two trained and calibrated dentists each examined approximately half the children. Examinations were undertaken at baseline, 15 months and 30 months. No significant differences were found between the DFS or DFT mean increments for the two dentifrice groups after 15 or 30 months. At 30 months the 90% confidence interval for the ratio of the mean increments satisfied the ADA criteria for equivalence. It is concluded that a 0.24% NaF/silica abrasive dentifrice containing 0.3% triclosan/2.0% copolymer is equivalent in its anticaries efficacy to a similar dentifrice without the addition of triclosan/copolymer. No side effects attributable to the test or control dentifrices were observed at any time during the study.

An investigation into the use of a voice operated data input system.

The aim of this study was to evaluate a voice operated data collection system intended for use in epidemiological surveys. Three groups of 45 adolescents, with similar caries experience, were examined by one examiner in schools. The caries data resulting from these examinations were collected in three ways; keyboard activated input to a portable computer, paper chart recording followed by manual input on return to base and examiner voice activated input direct to the computer. Maximum levels of accuracy were found with all three methods. The quickest method of collection in the field was by paper chart with a mean collection time per subject of 2.59 min, followed by 3.15 min for the manual keyboard method and 4.07 min for the voice activated method. When all the factors affecting time were taken into consideration it was found that overall the manual keyboard method was significantly faster than both the paper chart method and the voice activated method.

Dental care for elderly people by general dental practitioners.

In Salford, the care and facilities for elderly people provided by general dental practitioners in practices having three or more dentists were compared with those given in smaller practices. Accessibility and size of dental practice were significantly related, with larger practices being more accessible to elderly and disabled people than smaller ones. A domiciliary service was given by all dentists, regardless of size of the practice. Forty-three per cent of dentists in the larger but none in the smaller practices recalled full denture patients. Eighty-seven per cent of dentists in the larger practices, compared with 53% of those in small ones, gave correct answers to seven or more of 14 questions about the elderly. Attitudes towards the elderly were measured using a seven-point scale: the more favourable the attitude, the higher the score. The mean score for dentists in large practices was 5.13, which was significantly greater than the mean score of 4.16 for those in small practices (P less than 0.001).

The liver histology and frequency of clearance of the hepatitis B surface antigen (HBsAg) in chronic carriers.

Two hundred four volunteer blood donors with hepatitis B surface antigen found in their blood were followed for 3 to 44 months. The annual clearance rate of this antigen was 1.7%. Liver enzyme levels (aminotransferase) were elevated in 45 (22.1%) on at least one occasion, in 26 (12.7%) for one month or more, and in 13 for more than six months. Liver biopsies were performed on 17 chronic carriers with normal enzymes and nonspecific histologic abnormalities were found in 14 and mild diffuse hepatitis in three. Seventeen carriers with abnormal enzymes were biopsied, and specimens revealed chronic active hepatitis (CAH) in seven, including two with bridging necrosis and three with cirrhosis. CAH was found in 7 of 26 (26.9%) carriers with abnormal liver enzymes persisting for at least one month and 4 of 13 (30.8%) with abnormal liver enzymes for more than six months.