Provocation testing in polymorphic light eruption using fluorescent ultraviolet (UV) A and UVB lamps.

BACKGROUND: Provocation testing is frequently performed during investigation of patients with suspected polymorphic light eruption (PLE). Techniques are not standardized between centres. OBJECTIVES: We sought to evaluate the efficacy of different fluorescent ultraviolet (UV) radiation lamps for provocation testing in PLE. METHODS: We analysed results in 68 patients referred consecutively for phototesting in whom a diagnosis of PLE seemed likely based on clinical history. Patients' case notes were reviewed and responses recorded to provocation testing on forearm skin over three consecutive days using broadband UVA, narrowband and broadband UVB lamps. RESULTS: A positive papular response to broadband UVA exposure was seen in 38 patients [56%, estimated 95% population confidence interval (CI) 43-67.9]. Thirty-four patients (50%) had a positive papular response to narrowband UVB exposure (95% CI 37.6-62.4). The probability of a positive provocation test following irradiation with both lamps was 80.9% (95% CI 69.5-89.4). From April 1999, 34 patients also had provocation testing with broadband UVB. Although six patients (18%) had a positive papular response, they all showed a positive response to one or both of the other lamp types. CONCLUSIONS: Provocation testing with fluorescent UVA and UVB lamps is a cheap and readily available method that can be used as a diagnostic aid to investigate patients with suspected PLE. Using both broadband UVA and narrowband UVB lamps for testing increases the likelihood of confirming the diagnosis than if either lamp is used alone.

Snoring, daytime sleepiness and stroke: a case-control study of first-ever stroke.

Previous reports have shown an association between snoring and stroke but it is not clear whether this reflects confounding factors nor whether the association is attributable to obstructive sleep apnoea (OSA). We performed a case-control study of 181 patients admitted to hospital with first-ever stroke and community control subjects matched individually for age, sex and general practitioner. Subjects were interviewed with a structured questionnaire to identify snoring, daytime sleepiness and stroke risk factors. The association between snoring alone and stroke was not statistically significant: odds ratio (95% CI) 1.44 (0.88, 2.41). Daytime sleepiness was, however, significantly associated with stroke: odds ratio 3.07 (1.65, 6.08). Multiple logistic regression showed that hypertension, current smoking, taking alcohol regularly (negatively) and a higher Epworth sleepiness score were independently associated with stroke. The results suggest that the previously reported association between 'simple' snoring and stroke might have been due to poor controlling for confounding variables. Our study suggests an association with greater sleepiness prestroke, the cause of which is unclear, although OSA is a possible candidate.

Response of psoriasis to sunbed treatment: comparison of conventional ultraviolet A lamps with new higher ultraviolet B-emitting lamps.

BACKGROUND: Sunbeds fitted with conventional ultraviolet (UV) A lamps that have about 0.7% UVB emission are widely used by patients with psoriasis even though they are minimally effective. A new fluorescent sunbed lamp has been developed that emits a higher proportion of UVB (4.6%) than conventional lamps and also requires shorter exposure times to achieve equivalent erythema. OBJECTIVES: To perform a randomized, within-patient comparison of conventional sunbed lamps (Cleo Performance) with the new lamps (Cleo Natural) in the treatment of psoriasis. METHODS: A sunbed and canopy unit were modified to allow exposure to Cleo Performance lamps on one side of the body (front and back) and Cleo Natural lamps to the other side of the body. Two studies were done. In study 1, equal erythemal doses were given from the two lamp types. In study 2, equal exposure times were given. We treated 34 patients with psoriasis, giving 12 exposures over a period of 4 weeks. Assessment was made using a modified Psoriasis Area and Severity Index (PASI) score, individual plaque assessment and patient questionnaire. RESULTS: Fourteen patients completed each study. In study 1, there was no significant difference in median improvement in half-body PASI score for the two lamp types. In study 2, there was a significant difference in PASI score improvement between the two lamps (median Cleo Performance change minus median Cleo Natural change was - 2.20; 95% confidence interval - 3.75 to - 0.65; P = 0.006). CONCLUSIONS: That no difference in response was found when equal erythemal doses were given suggests that the spectral emission of the Cleo Natural lamp is of no greater advantage for clearance of psoriasis than conventional lamps. However, the Cleo Natural lamps are more erythemally powerful, and exposure times similar to those used in conventional sunbeds result in a significant improvement of psoriasis. The risk of non-melanoma skin cancer from different patterns of exposure to Cleo Natural lamps can be estimated using established numerical models.

An interesting byproduct of screening: assessing the effect of HRT on arterial calcification in the female breast.

Arterial calcification in the female breast (BAC) is a common but unreported finding on breast screening mammograms. Accumulating evidence suggests that BAC may have importance as a marker for generalised vascular disease. In this study, we have assessed the influence of HRT usage on the prevalence of BAC in 4400 women undergoing mammography for breast cancer screening. Significantly increased levels of breast arterial calcification were observed in women who had never used HRT compared with a group of women presently using HRT.

Quantification of relative afferent pupillary defects induced by posterior sub-Tenon's, peribulbar, and retrobulbar anaesthetics.

AIMS: The effect of local anaesthetics on optic nerve function can be investigated by quantifying the relative afferent pupillary defect (RAPD). METHODS: The study compared the depth of induced RAPD following posterior sub-Tenon's, retrobulbar, and peribulbar local anaesthetics using crossed polarising filters before cataract surgery (time 1 = 5 minutes), immediately after surgery (time 2 = 42 minutes (av)), and once again on the ward (time 3 = 107 minutes (av)). RESULTS: All patients developed a RAPD. There was no significant difference in the depth of RAPD between the groups at any one time period. The peribulbar group had a significantly steeper decay in RAPD from time 1 to time 2 (p = 0.014). This effect was reduced when the shorter operation time for this group was entered as a cofactor (p = 0.063). By time 3 the RAPDs for all groups had decayed similarly so that no differences could be detected. CONCLUSION: All three anaesthetic methods caused a similar level of disruption to optic nerve conduction immediately following administration and at the time of day case discharge.

The development of a General Nasal Patient Inventory.

Most available clinical outcome measures for rhinology patients relate to specific nasal disease or general quality of life. Fairley's validated 12-item questionnaire measures general nasal symptoms, but is a 'physician-derived' clinical tool and may not reflect all the problems that rhinology patients experience. Our aims were to develop a patient-orientated questionnaire, representing the concerns of a large number of rhinology patients, called the General Nasal Patient Inventory (GNPI) and compare this with the Fairley nasal questionnaire (FNQ). The GNPI was developed from the open-ended problem lists of 211 rhinology patients, from the 45 most frequent complaints. Both questionnaires were then administered to 153 general rhinology patients and the results compared. The highest-ranking items for each questionnaire were different, but the total scores were highly correlated (r = 0.79, P < 0.0001). Factor analysis showed six factors to account for 75% of FNQ variance and 18 factors for 78% of GNPI variance. The 45-item GNPI, the first patient-derived, comprehensive nasal questionnaire could be a time-saving tool in rhinology clinics and more sensitive to change after intervention than other available measures.

Drink and drugs: from medical students to doctors.

Drinking and illicit drug use were assessed longitudinally in a cohort of medical students who were surveyed in the second and fifth year of their undergraduate studies and after 1 year as PRHOs. Mean alcohol consumption had increased significantly (P<0.015) over the three time points; 15.2-16.0-18.8 units/week. Experimentation with illicit drugs had increased from 50 to 63 to 65%. Although education on alcohol and illicit drugs should be part of core curriculum in medical schools, support and intervention in the workplace is also needed for individuals with alcohol and/or drug problems.

Evidence for redundancy in cysteine biosynthesis in Rhizobium leguminosarum RL3841: analysis of a cysE gene encoding serine acetyltransferase.

A cysE gene encoding a serine acetyltransferase (SAT) potentially involved in the biosynthesis of cysteine was identified approximately 4 kb upstream of the previously described aapJQMP gene cluster that encodes an amino acid permease in Rhizobium leguminosarum strain 3841. The gene exhibits >40% identity to the family of SATs containing N-terminal extensions that have been described for other bacteria and plants. The ORF has three possible translation initiation sites which potentially encode polypeptides of 311, 277 and/or 259 amino acid residues, respectively. All three ORFs complemented the cysE mutation in an Escherichia coli cysteine auxotroph, strain JM39. Insertion of Tn5-lacZ into cysE in the genome of R. leguminosarum (strain RU632) lowered SAT activity in crude extracts by >95%. However, RU632 was not a cysteine auxotroph, which suggests that R. leguminosarum possesses some redundancy in cysteine biosynthesis. Additional copies of cysE could not be detected in the genome when the R. leguminosarum cysE gene was used as a hybridization probe. Therefore it is possible that R. leguminosarum possesses an alternative pathway for cysteine biosynthesis which avoids O-acetylserine. Strain RU632 was unaffected in its ability to nodulate Pisum sativum, and the nodules were effective for N(2) fixation (measured by C(2)H(2) reduction). Transcriptional activity of cysE was determined by measuring the beta-galactosidase arising from cysE::Tn5-lacZ fusions. Maximal levels of expression were observed during early exponential growth and were not influenced by the level of sulphur (supplied as sulphate). However, transcription was repressed by approximately twofold in ammonium-grown, as opposed to glutamate-grown, cultures. Repression by ammonium was not seen in a strain defective for ntrC.

Solute-binding protein-dependent ABC transporters are responsible for solute efflux in addition to solute uptake.

The ATP-binding cassette (ABC) transporter superfamily is one of the most widespread of all gene families and currently has in excess of 1100 members in organisms ranging from the Archaea to manQ1. The movement of the diverse solutes of ABC transporters has been accepted as being strictly unidirectional, with recent models indicating that they are irreversible. However, contrary to this paradigm, we show that three solute-binding protein-dependent (SBP) ABC transporters of amino acids, i.e. the general amino acid permease (Aap) and the branched-chain amino acid permease (Bra) of Rhizobium leguminosarum and the histidine permease (His) of Salmonella typhimurium, are bidirectional, being responsible for efflux in addition to the uptake of solutes. The net solute movement measured for an ABC transporter depends on the rates of uptake and efflux, which are independent; a plateau is reached when both are saturated. SBP ABC transporters promote active uptake because, although the Vmax values for uptake and efflux are not significantly different, there is a 103-104 higher affinity for uptake of solute compared with efflux. Therefore, the SBP ABC transporters are able to support a substantial concentration gradient and provide a net uptake of solutes into bacterial cells.

A patient-based assessment of implant-stabilized and conventional complete dentures.

STATEMENT OF PROBLEM: Outcomes of oral implant therapy have been described primarily in terms of implant survival rates and the durability of implant superstructures. Reports of patient-based outcomes of implant therapy have been sparse, and none of these studies have used oral-specific health status measures. PURPOSE: This study assessed the impact of implant-stabilized prostheses on the health status of complete denture wearers using patient-based, oral-specific health status measures. It also assessed the influence of preoperative expectations on outcome. MATERIAL AND METHODS: Three experimental groups requesting replacement of their conventional complete dentures completed an Oral Health Impact Profile (OHIP) and a validated denture satisfaction scale before treatment. One group received an implant-stabilized prosthesis (IG), and 2 groups received new conventional complete dentures (CDG1 and CDG2). After treatment, all subjects completed the health status measures again; preoperative data were compared with postoperative data. RESULTS: Before treatment, satisfaction with complete dentures was low in all 3 groups. Subjects requesting implants (IG and CDG1) had high expectations for implant-stabilized prostheses. Improvement in denture satisfaction and OHIP scores was reported by all 3 groups after treatment. Subjects who received their preferred treatment (IG and CDG2 subjects) reported a much greater improvement than CDG1 subjects. Preoperative expectation levels did not appear to influence satisfaction with the outcomes of implant therapy in IG subjects. CONCLUSION: Subjects who received implants (IG) that replaced conventional complete dentures reported significant improvement after treatment, as did subjects who requested conventional replacement dentures (CDG2). The OHIP appears useful in identifying patients likely to benefit from implant-stabilized prostheses.

The causes of fever in children attending hospital in the north of England.

OBJECTIVES: Fever is a common symptom in children presenting to casualty. Identifying the seriously ill is difficult. Previous studies, mainly from North America, suggest that symptoms, signs and simple investigations may help to do this. The aim of the present study was to assess the causes of fever and identify clinical and laboratory features suggesting serious disease in U.K. children presenting to hospital with temperatures >or=38 degrees C. METHODS: All children with a temperature of >or=38 degrees C seen in two hospitals between August and October 1999. RESULTS: One hundred and forty one children between 8 days and 16 years of age were studied, 64% male, 55% aged under 2 years. Eighty three percent had temperatures between 38 and 39 degrees C. Ninety six percent were casualty or GP referrals and 4% were tertiary referrals. Twenty nine percent (41/141) had serious disease but microbiologically or radiologically proven in only 22% (31/141); pneumonia (nine), meningitis (seven), sepsis (five), urinary tract infection (five), brain abscess (two), toxic shock syndrome (one), appendicitis (one), ischiorectal abscess (one). Forty two percent (5/12) of microbiologically proven meningitis and sepsis and 36% (8/22) of all meningitis and sepsis were meningococcal. Seventy one percent had non-serious diseases. In cases of serious disease the temperature was >39 degrees C in 15% (sensitivity: 14%, specificity: 82%, PPV: 25%). Poor feeding and restlessness predicted serious disease with a sensitivity of 78% and 76%, respectively. Full blood count (FBC) was taken in 50% of patients on admission; in 44% of serious and 24% of non-serious diseases WBC was between 5000 and 15,000/mm(3) and WBC >or=15,000/mm(3) was seen in 39% of serious diseases (sensitivity:10%, specificity: 95%, PPV: 44%). CONCLUSIONS: One out of three of children referred with fever had a serious disease. Degree of temperature and WBC count were poor predictors of serious disease. Interestingly, poor feeding and restlessness were more sensitive predictors, suggesting high fever and WBC count can not replace clinical assessment of the child with a temperature.

A controlled study of ultraviolet A sunbed treatment of psoriasis.

BACKGROUND: Ultraviolet (UV) A sunbeds are widely used by patients with psoriasis in an attempt to treat their skin disease. However, there is little evidence that UVA therapy improves psoriasis, and the long-term risks of sunbed exposure are not known. OBJECTIVES: To perform a randomized, placebo-controlled study of UVA sunbed therapy for psoriasis. METHODS: A sunbed and canopy unit was modified to allow UVA exposure on one side of the body (front and back), and 'placebo' visible light exposure on the other side of the body. We treated 38 patients with psoriasis, giving 12 exposures over a period of 4 weeks. Assessment was made using a modified Psoriasis Area and Severity Index (PASI) score, individual plaque assessment and patient questionnaire. RESULTS: In 17 patients (47%) the PASI score showed a greater reduction on the UVA side compared with placebo, in 11 patients (31%) no difference was recorded between the two sides, and in eight (22%) the improvement was greater on the placebo-treated side. Overall, the median pretreatment half-body modified PASI score was 4.4 units, reducing to 3.9 units on the UVA-treated side and 4.2 units on the placebo-treated side (P = 0. 044 for difference in response). Breakdown of the plaque score into the individual components of erythema, scale and thickness revealed significant improvement only with the score for erythema. Although the degree of improvement was small, 64% of patients felt that the response was sufficiently good that they would use a sunbed again to treat their psoriasis. CONCLUSIONS: Our results show that a short course of sunbed treatment does improve psoriasis in some patients, but that the degree of improvement is small.

Effect of motor tasks on the cortical topography of the human masseter muscle.

Non-invasive magnetic stimulation of the brain was earlier used to reveal the corticomotor representation of the human masseter muscle but it is unclear how motor tasks affect this map. An experimental approach incorporating transcranial magnetic stimulation of verified locations on the scalp, surface electromyography, and controlled muscle facilitation was used to disclose the corticomotor output map of the masseter during three isometric tooth-contact tasks, viz., tooth clenching in the intercuspal position, biting on the left molar teeth, and biting on the incisors. Map area was significantly different for all tasks, and map height and volume were also different for biting on the incisor teeth (p<0.05). There was evidence of task-related modulation of corticobulbar activity that appeared to be mainly of corticomotoneuronal origin, although the role of differential, task-associated peripheral afferent input from orofacial receptors could not be discounted.

The efficacy of Emla and 5% lignocaine gel for anaesthesia of human gingival mucosa.

OBJECTIVE: To compare the analgesic effect of a mixture of 2.5% lignocaine and 2.5% prilocaine (Emla) with that of lignocaine gel alone for minor operations on the gingiva. DESIGN: Randomized double-blind trial. SETTING: Teaching hospital, UK. SUBJECTS: 10 healthy dental students (7 men and 3 women, 20-21 years old). INTERVENTIONS: Construction of a reservoir within a splint on each side of the mouth and insertion of splints. The volunteers acted as their own controls, and the sides used for each anaesthetic were chosen at random. MAIN OUTCOME MEASURES: Measurement of pressure-pain threshold by a standard technique. RESULTS: The median (range) duration of anaesthesia after Emla (22.5, 12-30) was significantly longer than after lignocaine alone (12.5, 0-25) (P=0.01), and the area under the curve for the pressure-pain threshold for Emla (2053, 199-4564) was significantly greater than for lignocaine alone (986, 169-2942) (P=0.01). CONCLUSION: Emla is a more effective topical anaesthetic agent than lignocaine alone. Although its duration of action is relatively short it is adequate for minor operations on the gingiva.

Pressure-pain threshold in the human tongue.

AIMS: A new pressure algometer was used to quantify the pressure-pain threshold (PPT) in the human tongue. METHODS: A custom-made device controlled by software and a personal computer was used to measure the PPT in the anterior part of the tongues of 14 young, healthy subjects. The PPT was measured at 3 different rates of pressure application on 3 occasions, 1 week apart. Data were evaluated with analysis of covariance and intraclass correlations. RESULTS: The prototype device had linear output characteristics within the operational range. The mean PPT ranged from 18 to 44 g. The PPT appeared to increase approximately linearly with increasing rate of pressure application (P < 0.001). There were no significant differences in the PPT on different experimental occasions. In individual subjects, the PPT was reliable and uniform. There were significant inter-subject differences in the PPT (P < 0.001). CONCLUSION: The PPT can be measured consistently in the anterior part of the tongue, provided the pressure rate is controlled. The new-pressure algometer appears to have potential clinical utility for quantifying sensation in the human tongue.

A comparison of the validity of generic- and disease-specific measures in the assessment of oral health-related quality of life.

UNLABELLED: In recent years, a number of instruments have been developed to measure the outcomes of oral disease. The Oral Health Impact Profile (OHIP) is the most sophisticated and comprehensive measure developed to date. At present, reports of the use of this measure are confined to descriptive population studies. OBJECTIVES: The aim of this study was to compare the validity of the OHIP with a generic health-related quality of life measure, the SF36. METHODS: Study subjects were in three groups, namely, edentulous patients seeking dental implants ("implant subjects", n = 32), edentulous patients seeking conventional dentures ("edentulous control", n = 35) and dentate patients ("dentate control", n = 21). All subjects completed an OHIP and SF36 prior to receiving any treatment. The edentulous subjects also completed a subjective assessment of satisfaction with their existing conventional dentures. OHIP data were computed using the simple count and weighted scores methods. RESULTS: The median number of negative impacts reported for each group was: 17 (implant subjects), six (conventional control) and one (dentate control). OHIP sub-scale scores were significantly higher (P < 0.001) for implant subjects than control subjects. There were no significant differences between the SF36 sub-scale scores. There was a significant correlation (P < or = 0.01) between aspects of satisfaction with conventional dentures worn by the edentulous subjects and OHIP sub-scale scores. Correlations between denture satisfaction variables and SF36 scores were not significant. CONCLUSIONS: It was concluded that the OHIP shows good discriminant and construct validity properties. As it is oral specific, it will be of greater use in measuring outcomes of oral disorders than generic measures such as SF36. This finding will be relevant when considering the use of health-related quality of life measures to target resources and measure the outcome of clinical intervention.

Patient expectations of oral implant-retained prostheses in a UK dental hospital.

STATEMENT OF PROBLEM: The loss of the natural dentition leads to severe functional impairment in many edentulous adults. A prosthesis retained and supported by osseointegrated dental implants may provide a satisfactory solution for people who have lost all their natural teeth. However, little information is available as to what patients requesting implants expect of implant-retained prostheses. AIM: The aim of this study was to assess the expectations of a group of edentulous patients requesting implant therapy. METHOD: The study included two groups: (1) a group of edentulous adults who requested implant therapy ('implant group'); and (2) an edentulous control group, of similar age and gender distribution as the implant group, receiving conventional complete dentures. Following a clinical and radiographic examination of the patients, data were collected using validated questionnaires. Both groups made a subjective assessment of current dentures. The implant group also completed a questionnaire which assessed expectations of implant-retained prostheses. RESULTS: Baseline satisfaction with current dentures was low in both groups, with the implant group being significantly less satisfied with comfort and stability of their mandibular dentures. Perceived ability of the implant group to chew hard foods was less than the control group. The implant group's expectations of an implant-retained prosthesis were significantly greater than for a conventional denture. CONCLUSION: Careful assessment of patient expectation of implant therapy is essential to determine appropriate treatment need, and to highlight unrealistic expectations.

Improved reproducibility of magnetic stimulation-evoked motor potentials in the human masseter by a new method for locating stimulation sites on the scalp.

In magnetic-stimulation studies where motor-evoked potentials (MEP) are measured on different occasions, accurate relocation of the stimulation site on the scalp is essential. Here a novel method of locating neural stimulation sites was tested and the reproducibility of MEPs in the human masseter assessed. The heads of the participants were immobilized in a plastic mask that incorporated a grid overlying the left cerebral hemisphere. A figure-of-eight coil was oriented with a micromanipulator. Electrodes were placed over the right masseter using a standardized method. Two discrete sites on the grid were stimulated alternately at threshold + 10% whilst participants clenched their teeth. Recordings were repeated after the mask and electrodes had been removed and replaced. Within individual participants, the latency and amplitude of the MEP were reproducible between trials and when the mask and electrodes were replaced. The new method appears to be accurate and practical when recording longitudinal MEP data in the masseter.