Special care dentistry: how prepared are we?

AIM: To assess and evaluate the confidence of the undergraduate dental team in Irish dental schools regarding their training in the field of special care dentistry (SCD). METHOD: A questionnaire was distributed amongst the undergraduate dental teams within Cork University Dental School and Hospital (CUDSH) and Dublin Dental University Hospital (DDUH). The data were analysed to assess for differences between the median responses of the various groups. RESULTS: A total of 139 students participated in the study; 82 from DDUH (59 dental science students, seven dental hygiene students and 16 dental nursing students) and 57 from CUDSH (43 dental science students and 14 dental hygiene students). Twenty-two per cent (n = 30) of respondents agreed that their training had been sufficient in providing treatment or assistance for patients requiring SCD. Seventy-five per cent agreed that more emphasis should be placed on clinical training in SCD (n = 76). Thirty-one per cent of students anticipated a high level of confidence in treating patients requiring SCD upon graduation (n = 43), with dental science students feeling the least prepared amongst the dental team. CONCLUSION: Confidence levels of the undergraduate dental team were low with regard to SCD. The existing hands-on clinical training in SCD was deemed insufficient by the respondents. Students believed more emphasis should be placed on SCD training in the undergraduate curriculum.

Prospective audit of postoperative instructions to patients undergoing root canal treatment in the DDUH and re-audit following introduction of a written patient information sheet.

STATEMENT OF THE PROBLEM: Concerns were expressed that postoperative written instructions following endodontic treatment are not available in the Dublin Dental University Hospital. MATERIALS AND METHODS: Data was collected in three phases: retrospective analysis of clinical notes for evidence of the delivery of postoperative instructions; a randomly distributed questionnaire to patients undergoing root canal treatment prior to the introduction of a written postoperative advice sheet; and, another survey following introduction of the advice sheet. RESULTS: Some 56% of patients' charts documented that postoperative advice was given. Analysis of phase two revealed that patients were not consistently informed of any key postoperative messages. In phase 3 analysis, the proposed benchmarks were met in four out of six categories. CONCLUSIONS: Postoperative advice after root canal treatment in the DDUH is both poorly recorded and inconsistently delivered. A combination of oral postoperative instructions and written postoperative advice provided the most effective delivery of patient information.

Complications of an uncovered metallic tracheal stent managed by veno-venous extracorporeal membrane oxygenation: a case report.

Airway stents are primarily inserted for the management of airway obstruction associated with an inoperable malignancy and are rarely indicated in benign disease. We outline the complications associated with tracheal stents and describe the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) to facilitate open tracheal surgery in an apnoeic patient who had an uncovered metallic tracheal stent left in place for an inappropriately long period. Computerised tomography imaging of the neck and thorax provided information for operative planning and described of the stent in addition to the extensive granulation tissue at the distal end of the stent. Veno-venous extracorporeal membrane oxygenation was used to facilitate open tracheal surgery, removal of the tracheal stent and formation of a surgical tracheostomy. Prolonged use of an uncovered metallic airway stent in younger patients with benign disease may lead to the stent being difficult to remove. There may be an accumulation of granulation tissue with the risk of airway obstruction.

Mass spectral similarity mapping applied to fentanyl analogs.

This manuscript outlines a straight-forward procedure for generating a map of similarity between spectra of a set. When applied to a reference set of spectra for Type I fentanyl analogs (molecules differing from fentanyl by a single modification), the map illuminates clustering that is applicable to automated structure assignment of unidentified molecules. An open-source software implementation that generates mass spectral similarity mappings of unknowns against a library of Type I fentanyl analog spectra is available at http://github.com/asm3-nist/FentanylClassifier.

Induction of suppressor T cells in systemic lupus erythematosus by thymosin and cultured thymic epithelium.

Patients with systemic lupus erythematosus lacked suppressor T cell function. Suppressor cell activity was induced in cells from many of these patients by incubation with thymosin or cultured thymic epithelium. These results suggest that thymic manipulation may be a useful therapeutic modality in this disease.

Stat4-dependent, T-bet-independent regulation of IL-10 in NK cells.

Interleukin-10 (IL-10) is intensely studied, yet little is known about the mechanisms that control IL-10 expression. We identified striking similarities between IL-10 and interferon-gamma (IFN-gamma) regulation in mouse natural killer (NK) cells. Like IFN-gamma, IL-10 expression is induced by IL-2 and IL-12 and IL-2+IL-12 stimulation is synergistic. Unlike IFN-gamma, neither IL-18 nor Ly-49D cross-linking induced IL-10 expression however. Additionally, the IL-12 homologs IL-23 and IL-27 also do not regulate NK cell-specific IL-10. We determined that a small population of NK cells accounts for IL-10 production. The induction of IL-10 by IL-2+IL-12 treatment in NK cells appears to be biphasic, with an initial burst of expression which diminishes by 12 h but spikes again at 18 h. We determined that much like IFN-gamma, Stat4 is largely required for IL-12-induced IL-10. Conversely, we observed normal induction of IL-10 in T-bet-deficient NK cells. We identified a Stat4-binding element in the fourth intron of the Il10 gene, which is completely conserved between mouse and human. This intronic Stat4 motif is within a conserved noncoding sequence, which is also a target for cytokine-induced histone acetylation. These findings highlight tissue- and receptor-specific IL-10 regulatory mechanisms, which may be part of an early feedback loop.

Aplidin induces JNK-dependent apoptosis in human breast cancer cells via alteration of glutathione homeostasis, Rac1 GTPase activation, and MKP-1 phosphatase downregulation.

Aplidin is an antitumor agent in phase II clinical trials that induces apoptosis through the sustained activation of Jun N-terminal kinase (JNK). We report that Aplidin alters glutathione homeostasis increasing the ratio of oxidized to reduced forms (GSSG/GSH). Aplidin generates reactive oxygen species and disrupts the mitochondrial membrane potential. Exogenous GSH inhibits these effects and also JNK activation and cell death. We found two mechanisms by which Aplidin activates JNK: rapid activation of Rac1 small GTPase and downregulation of MKP-1 phosphatase. Rac1 activation was diminished by GSH and enhanced by L-buthionine (SR)-sulfoximine, which inhibits GSH synthesis. Downregulation of Rac1 by transfection of small interfering RNA (siRNA) duplexes or the use of a specific Rac1 inhibitor decreased Aplidin-induced JNK activation and cytotoxicity. Our results show that Aplidin induces apoptosis by increasing the GSSG/GSH ratio, a necessary step for induction of oxidative stress and sustained JNK activation through Rac1 activation and MKP-1 downregulation.

Changing patterns and outcome of acute renal failure requiring hemodialysis.

To identify factors that may explain the persistently high mortality of acute renal failure (ARF), we compared the cause, clinical course, and outcome of 55 consecutive patients with ARF who underwent hemodialysis (HD) from 1962 to 1969 with 46 similar patients from 1979 to 1981 at the same medical center. We noted an overall increase in mortality from 54.5% to 71.7%. There was an increase in the number of elderly patients developing ARF, but age per se did not influence survival. There was a significant increase in mortality in younger patients resulting from the severity of their underlying illness. We saw an increase in the number of complicating factors occurring at the onset of ARF that correlated with the increase in mortality. In survivors ARF was more prolonged in our most recent experience. The development of prolonged, complicated ARF and the poor survival seen in younger patients led to the increase in mortality in our patients.

An epidemiological study of sheep pox infection in Karnataka State, India.

Analysis of retrospective quantitative sheep pox epidemiological data from the Government Animal Husbandry Department, Karnataka, India, covering 24 years revealed significant information on sheep pox. The state has a dense sheep population including some valuable breeds. Data revealed the endemicity of the disease: there were a considerable number of outbreaks and attacks, high mortality and case fatality rates and low immunisation coverage. None of the years studied were free from infection. Temporally, the disease was most prevalent between November and May. Spatially, the disease was recorded in 19 out of 27 districts; in some of these districts sheep pox was highly endemic, in some it was endemic at low levels and in the remaining districts outbreaks occurred sporadically. Environmental factors influenced disease occurrence. Vaccine production met only one tenth of the requirement, and its peak utilisation was in the dry season.

Thermodynamics of target peptide recognition by calmodulin and a calmodulin analogue: implications for the role of the central linker.

The thermodynamics of interaction of two model peptides melittin and mastoparan with bovine brain calmodulin (CAM) and a smaller CAM analogue, a calcium binding protein from Entamoeba histolytica (CaBP) in 10 mM MOPS buffer (pH 7.0) was examined using isothermal titration calorimetry (ITC). These data show that CAM binds to both the peptides and the enthalpy of binding is endothermic for melittin and exothermic for mastoparan at 25 degrees C. CaBP binds to the longer peptide melittin, but does not bind to mastoparan, the binding enthalpy being endothermic in nature. Concurrently, we also observe a larger increase in alpha-helicity upon the binding of melittin to CAM when compared to CaBP. The role of hydrophobic interactions in the binding process has also been examined using 8-anilino-1-naphthalene-sulphonic acid (ANS) binding monitored by ITC. These results have been employed to rationalize the energetic consequences of the binding reaction.

Nephrotic syndrome in Hodgkin's disease. Evidence for pathogenesis alternative to immune complex deposition.

The nephrotic syndrome has been reported to occur in patients with Hodgkin's disease even in the absence of amyloidosis, tumor infiltration of renal vein thrombosis. Three patients are presented with Hodgkin's disease and the nephrotic syndrome whose renal biopsy specimens studied with light, immunofluorescence and electron microscopy were compatible with "lipoid nephrosis" (minimal change disease). A review of the literature reveals 35 patients with Hodgkin's disease and the nephrotic syndrome. Renal tissue was available for examination in only 27 patients. The majority of patients apparently had glomerular alterations consistent with lipoid nephrosis. The nephrotic syndrome in most of these patients remitted with a variety of methods of therapy (including excision, irradiation, prednisone and cyclophosphamide) and tended to relapse with a recurrence of Hodgkin's disease. In three-fourths of the patients with Hodgkin's disease and the nephrotic syndrome, the Hodgkin's disease was of a mixed cellularity type. The etiology of lipoid nephrosis, although unclear, may be a consequence of altered lymphocyte function. Hodgkin's disease is a malignancy involving T lymphocytes, and the nephrotic syndrome occurring in the course of Hodgkin's disease may be a result of an adverse effect of glomeruli by products of tumor lymphocytes rather than of glomerular deposition of immune complexes.

Prospective trial of warfarin and dipyridamole in patients with membranoproliferative glomerulonephritis.

A prospective trial of warfarin and dipyridamole was performed in patients with membranoproliferative glomerulonephritis. Eighteen completed either a control or treatment year, and 13 completed both a control and treatment year. To obviate the bias of excluding control patients who had renal failure after one year, both an unpaired and a paired analysis were performed. The unpaired analysis compared 10 patients followed for an initial control year with eight patients receiving treatment first. Renal function remained stable over the year in the treated group, but worsened in the control group. Slopes of regression lines for reciprocal serum creatinine values were significantly different between groups (p less than 0.025). Urine protein excretion also decreased in the treated group. Four of 10 control patients had a two-fold increase in serum creatinine levels, but no treatment patient did. In the paired crossover analysis, significant differences in renal function were detected between control and treatment years in six patients whose renal function significantly changed over one of the years. In every instance, there was better preservation of renal function in the treatment year. Urinary protein also decreased significantly over the treatment year compared with the control year. Bleeding was the most frequent complication. These data suggest that warfarin and dipyridamole have a beneficial effect on renal function in membranoproliferative glomerulonephritis.

Variability of calcium binding to EF-hand motifs probed by electrospray ionization mass spectrometry.

The modulation of calcium binding by the EF-hand motifs present in a calmodulin (CAM) homologue, a calcium binding protein (CaBP) from Entamoeba histolytica by three external parameters-pH, ligand coordinator EGTA, and fragmentor voltage was investigated by mass spectrometry. Calcium binding follows expected patterns at highly acidic and alkaline pH with the preponderance of the apo and the completely saturated forms, respectively. Surprisingly, additional nonspecific binding is observed near neutral pH. Studies on EGTA chelation and effects of fragmentor voltage showed cooperativity in calcium removal in at least one of the domains. Similar studies on a smaller construct containing the two high affinity carboxy terminal sites revealed interesting differences and provided an estimate of the specificity and tolerance of the EF-hand motifs to calcium binding and removal.

"Spontaneous" atheroembolic disease as a cause of renal failure in the elderly.

An 86-year-old man with previous normal renal function was hospitalized because of renal insufficiency. He had a long history of atherosclerotic heart disease, mild hypertension and pulmonary embolism, requiring anticoagulant therapy. In view of the normal-sized kidneys and absence of casts in the urinary sediment, a diagnosis of atheroembolic renal disease was made. The patient's renal function deteriorated, but he refused hemodialysis. Death occurred within a few weeks. At autopsy, severe aortic atherosclerosis was observed and atheroembolic renal disease was confirmed as the cause of renal failure. Occasionally, renal failure can be the sole manifestation of spontaneous atheroembolic disease. This possibility should be considered if the physician is called upon to establish the diagnosis when renal insufficiency develops in atherosclerotic patients.

Conformation and structural transitions in the EF-hands of calmodulin.

Calcium plays a key role in cellular signal transduction. Calmodulin, a protein binding four calcium ions, is found in all eukaryotic cells and is believed to activate such processes. The calcium binding loop found in this protein, the canonical EF-hand, is also found in a large number of other proteins such as troponins, parvalbumins, calbindins etc. Earlier analysis of the amino acid sequences of these proteins with a view of understanding evolution of protein families and signaling mechanisms have provided extensive evidence for a characteristic double gene duplication event in this family of proteins. These analyses have been extended here to the three dimensional structures and the biophysical properties of the sequence segments of calmodulin EF-hands. The clear evolutionary history that shows up in sequences is not reflected as clearly in the conformation of individual EF-hands, which may be a consequence of the much higher conservation pressure on the structure. Some evidence for the proposed gene duplication is implicit in the apo-holo structural transitions of the EF-hands. The profile of amino acid properties that might be significant for calcium binding, however, clearly reflects the gene duplication. These profiles might also provide insightful information on the calcium affinity of the EF-hand motifs and the nature of amino acid residues that constitute them.

Renal disease in the elderly: clinicopathologic analysis of renal disease in 115 elderly patients.

We reviewed the clinical and renal biopsy information of 115 patients who presented with renal disease after the age of sixty years. The major clinical presentations were renal insufficiency in 57 patients, nephrotic syndrome in 35 patients, and hematuria with variable amounts of proteinuria in 23 patients. Crescentic glomerulonephritis, diagnosed in 19 patients, was the most common cause of renal insufficiency. Membranous glomerulonephritis and minimal change nephrotic syndrome were noted in 15 and 9 patients, respectively. While patients with crescentic glomerulonephritis had an unfavorable outcome, patients with minimal change nephrotic syndrome and diffuse proliferative glomerulonephritis had a benign course. We conclude that even in the elderly, the natural history of renal disease is similar to that of younger patients, and the clinical course appears to depend on the nature of the underlying renal disease.

End-stage renal disease (ESRD) in patients with eating disorders.

We report on the development of end-stage renal disease in four young women with long duration of eating disorders. No other reason for end-stage renal disease could be identified in these patients. Long standing hypokalemia was noted in all. Renal ultrasonography in three patients showed small kidneys with increased cortical echogenicity and multiple small bilateral cysts. A renal biopsy in one showed chronic tubulo-interstitial disease and non-specific glomerulosclerosis consistent with hypokalemic nephropathy. The development of end-stage renal disease is yet another medical complication to be considered in patients with long-standing eating disorder. Chronic hypokalemia may play a role in the pathogenesis of renal disease in this setting.

Relapse in anti glomerular basement membrane antibody mediated crescentic glomerulonephritis.

Patients with crescentic glomerulonephritis and anti glomerular basement membrane antibody typically experience a rapidly progressive course. Remission and relapse in renal disease are unusual. We report two patients with this syndrome who remitted following immunosuppressive therapy and relapsed 20 and 48 months later, respectively. The pathogenesis of relapse is discussed. It is different from the initial insult in that antiglomerular antibody may not be important.