Oral health care issues in HIV disease: developing a core curriculum for primary care physicians

BACKGROUND

Given the high occurrence of oral manifestations in patients infected with human immunodeficiency virus (HIV), the relative ease in recognizing these manifestations on physical examination, and their potential impact on the health care and quality of life in these patients, it is critical to provide adequate training for primary care physicians in this area.

METHODS

Based on a review of the published literature and the consensus of a national panel of primary care physicians and dentists with clinical and research expertise in this area, a core curriculum was developed for primary care physicians regarding oral health care issues in HIV disease.

RESULTS AND CONCLUSIONS

We describe the process of developing the core curriculum of knowledge, skills, and attitudes regarding oral health care issues in HIV disease. The final curriculum is in a format that allows for easy accessibility and is organized in a manner that is clinically relevant for primary care physicians.

Total hip replacement rates are higher among Caucasians than Asians in Hawaii

The etiology of hip osteoarthritis remains unknown but may involve genetic or lifestyle factors. Most cases of total hip replacement are performed because of osteoarthritis. To examine possible ethnic differences, hospital records in Hawaii from 1985 to 1989 were reviewed. Preoperative radiographs were reviewed for a subset of patients to ascertain the reason for total hip replacement. Osteoarthritis accounted for a greater percentage of total hip replacements among whites (59% for women and 66% for men) than among Japanese (36% of women and 30% of men). The incidence of total hip replacement for whites was three to 25 times greater than that of other ethnic groups (Japanese, Chinese, Filipino, and Hawaiians). For example, the risk of total hip replacement for white women 40 years to 84 years of age was 4.4%, compared with 1.1% for Japanese women and 1.7% for Chinese women of the same age group. Compared with published data, the incidence was similar for Chinese in Hawaii and San Francisco; however; whites in Hawaii had a total hip replacement incidence less than half that of whites in San Francisco. Lifestyle differences might account for the lower incidence of total hip replacement for whites in Hawaii, compared with those in San Francisco. The lower incidence among Asians suggests a possible genetic basis for osteoarthritis.

Identification and characterization of the human homologue of the short PDE4A cAMP-specific phosphodiesterase RD1 (PDE4A1) by analysis of the human HSPDE4A gene locus located at chromosome 19p13.2

The HSPDE4A gene spans 50 kb, consists of at least 17 exons and is orientated 5'-3', telomere to centromere. It is located at chromosome 19p13.2, being 350 kb proximal to the gene encoding TYK2 and 850 kb distal to the gene encoding the low-density lipoprotein receptor. Its structure is consistent with the production of active 'long' and 'short' isoenzymes as the result of alternative mRNA splicing at two splice junctions. Identified is the single alternatively spliced 5' exon encoding the unique N-terminal region of the long isoenzyme HSPDE4A4B (pde46). The upstream conserved regions, UCR1 and UCR2, which form characteristic domains of PDE4 long forms are each encoded by three exons. The PDE4A-subfamily-specific linker region LR1, which joins UCR1 and UCR2, is encoded by two exons, whereas LR2, which joins UCR2 to the catalytic unit, is encoded by a single exon. Identification of exons encoding an enzymically inactive product of this gene, HSPDE4A8A (2el), indicates that this is an authentic gene product. The 5' exon encoding the unique N-terminal region of the human homologue of the rodent isoform RNPDE4A1A (RD1) was located, and the splice junction used to produce this short PDE4A isoform shown to occur at a different position from that seen in both the rat PDE4B and PDE4D genes. Reverse transcriptase PCR analysis indicates that RD1 homologues are conserved across species, having a conserved membrane-targeting region and a hypervariable LR2 region. Human RD1 was expressed transiently in COS-7 cells and detected as an 83 kDa species primarily associated with the high-speed membrane fraction. Human RD1 exhibited a Km for cAMP of about 3 microM, an IC50 value for inhibition by the PDE4-selective inhibitor rolipram of about 0.3 microM and was considerably more thermostable than rat RD1. Human RD1 was generated as a mature 80 kDa species in an in vitro transcription-translation system and shown to be capable of binding to membranes. Knowledge of the gene structure and the associated sequence information should facilitate analysis of the involvement of PDE4A in hereditary disorders that may result from alterations in enzyme expression, activity, regulation and intracellular targeting and serve as a resource for determining authenticity of cloned PDE4A species.

Health education goes Hollywood: working with prime-time and daytime entertainment television for immunization promotion

This article presents an entertainment education strategy used to influence Hollywood prime-time and daytime television programs to add storylines on the importance of immunizations to their shows. Rather than giving information about immunizations to show producers, directors, actors, and writers, we furnished "log lines" and true stories about immunizations that could be used to inspire scripts that included immunization themes. By working through personal contacts within the entertainment television industry's closed system of networks, we were able to gain entree and some airtime for our campaign agenda. Embedded messages aired on eight popular shows in the 1996-1997 broadcast season, with five scheduled to air in the 1997-1998 season. These efforts were evaluated qualitatively, focusing on issues of personal networks, content of aired messages, and comparative costs for paid airtime. The strategy developed can be adapted for a range of entertainment education interventions.

An implantable centrifugal blood pump with a recirculating purge system (Cool-Seal system)

A compact centrifugal blood pump has been developed as an implantable left ventricular assist system. The impeller diameter is 40 mm, and pump dimensions are 55 x 64 mm. This first prototype, fabricated from titanium alloy, resulted in a pump weight of 400 g including a brushless DC motor. The weight of a second prototype pump was reduced to 280 g. The entire blood contacting surface is coated with diamond like carbon (DLC) to improve blood compatibility. Flow rates of over 7 L/min against 100 mm Hg pressure at 2,500 rpm with 9 W total power consumption have been measured. A newly designed mechanical seal with a recirculating purge system (Cool-Seal) is used for the shaft seal. In this seal system, the seal temperature is kept under 40 degrees C to prevent heat denaturation of blood proteins. Purge fluid also cools the pump motor coil and journal bearing. Purge fluid is continuously purified and sterilized by an ultrafiltration unit which is incorporated in the paracorporeal drive console. In vitro experiments with bovine blood demonstrated an acceptably low hemolysis rate (normalized index of hemolysis = 0.005 +/- 0.002 g/100 L). In vivo experiments are currently ongoing using calves. Via left thoracotomy, left ventricular (LV) apex descending aorta bypass was performed utilizing an expanded polytetrafluoroethylene (ePTFE) vascular graft with the pump placed in the left thoracic cavity. In 2 in vivo experiments, the pump flow rate was maintained at 5-9 L/min, and pump power consumption remained stable at 9-10 W. All plasma free Hb levels were measured at less than 15 mg/dl. The seal system has demonstrated good seal capability with negligible purge fluid consumption (<0.5 ml/day). In both calves, the pumps demonstrated trouble free continuous function over 6 month (200 days and 222 days).

Fluoxetine treatment of depressive disorders in methadone-maintained opioid addicts

This study tested the effectiveness of fluoxetine as a treatment for depression in a population of methadone-maintained opioid addicts. Methadone-maintained opioid addicts (44) with depression received fluoxetine or placebo in addition to their methadone, in a double-blind randomized trial, for 12 weeks. Depressive symptoms decreased significantly overall with no significant differences between the groups treated with fluoxetine versus placebo. In addition, drug use outcomes, including cocaine and heroin self-reported use and urine toxicology were measured. There was a significant decrease in heroin use in treatment, but no medication effect. Cocaine use, was unchanged from pre-treatment to endpoint. In separately analyzing data for the subsample of subjects with the most severe depression, there was a significant decrease in depression during treatment and a significant decrease in self-reported cocaine use, but no medication effect on either depressive symptoms or on cocaine use. This study suggests that fluoxetine is not an effective agent in treating depression or cocaine use in this population.

[A revolutionary Japanese method for treatment of lymphangioma]

Large cystic lymphangiomas of the neck (hygroma colli) have traditionally been treated surgically or by local injection of various sclerosing agents. Owing to the infiltrative growth of these cysts, radical surgery has often been difficult due to the risk of damage to nerves and adjacent organs; and the use of available sclerosing agents has often resulted in disfigurement due to extensive scarring, thus rendering secondary surgery even more difficult. However, OK-432, a new agent for local injection, has been tested with good results, especially in Japan. In five consecutive paediatric cases of lymphangioma, we found ultrasound-guided injection of the cysts with OK-432 to yield good response without complications. In three cases, the lymphangioma disappeared leaving the child's appearance quite normal, and there has been no recurrence. In one case, the lymphangioma disappeared but apparently recurred within half a year (during which time we had lost contact with the family). This was the only case of small cysts (cavernous lymphangioma), which are putatively more resistant to OK-432. The only child to be operated also had thoracic lymphangioma which was not injected, though the cervical part which was injected was reduced by 50 per cent pre-operatively, the final outcome being excellent with no visible cysts in any region. Thus, hitherto our results suggest the therapeutic effect of OK-432 to be good, and further clinical investigation is planned.

Flexor tendon repair using a stainless steel internal anchor. Biomechanical study on human cadaver tendons

We have developed a stainless steel internal tendon anchor that is used to strengthen a tendon repair. This study tested its use in vitro to produce a repair that can withstand the tensile strength demands of early active flexion. Fresh human cadaver flexor digitorum profundus tendons were harvested, divided, and then repaired using four different techniques: Kessler, Becker or Savage stitches, or the internal tendon anchor. The internal splint repairs demonstrated a 99-270% increase in mean maximal linear tensile strength and a 49-240% increase in mean ultimate tensile strength over the other repairs. It is hoped that this newly developed internal anchor will provide a repair that will be strong enough to allow immediate active range of motion.

Regions of sex-specific hypo- and hyper-recombination identified through integration of 180 genetic markers into the metric physical map of human chromosome 19

The order of and physical distance between 180 polymorphic markers, many from the Généthon and CHLC genetic maps, have been determined through inclusion of probe-positive cosmids in the metric physical map of human chromosome 19. The markers incorporated into the physical map include 38 genetic markers with heterozygosities of > 0.8 and approximately 120 markers with heterozygosities of > 0.60. The average distance between markers in this integrated map is approximately 320 kb. Clustering of markers is noted in several regions of the chromosome; only 11 intervals exist where the distance between markers is greater than 1 Mb, with the largest gap being 1.6 Mb. The ratio of sex-average genetic distance from the Généthon and CHLC genetic linkage maps to physical distance in the metric map is approximately 1.7 cM/Mb for the entire chromosome but ranges from 4 cM/Mb across the telomeric bands to 1 cM/Mb for the centromeric cytogenetic bands. The recombination distance in males is approximately twice that of females in the most telomeric bands but is only 10-25% of the activity observed in females in the more centromeric bands. Seven regions along the chromosome are noted where the recombination distance between markers in one sex is greater than 10 times the recombination distance in the other sex. The integration of genetic markers into the high-resolution physical map of human chromosome 19 provides a framework for isolation of disease genes and resources for studies of genome organization, such as regions of interesting recombinational activity.

Adoptive immunotherapy for leukemia: donor lymphocytes transduced with the herpes simplex thymidine kinase gene for remission induction. HGTRI 0103

This study will evaluate the safety and efficacy of allogenic donor lymphocyte infusions in patients who have relapsed hematologic malignancies after allogeneic bone marrow transplantation (BMT). Donor lymphocyte transfusions have resulted in the cure of some patients with relapsed leukemia or lymphoproliferative disorder after allogeneic BMT, but has been complicated by the development of graft versus host disease (GvHD). We hypothesize that a retroviral vector containing the Herpes simplex thymidine kinase (HStk) gene will allow for retention of the anti-leukemia response of transfused donor lymphocytes while allowing for the adverse effects of GVHD to be mitigated. Patients with relapsed hematologic malignancies after allogeneic BMT will be infused with ex vivo gene modified donor lymphocytes. The Herpes Simplex thymidine kinase (HStk) gene will be transduced into the cells ex vivo using LTKOSN. 1 vector supernate. Insertion of the HStk gene into lymphocytes confers a sensitivity to the anti-herpes drug ganciclovir (GCV). This selective destruction of donor lymphocytes in situ will be used to abrogate the effect of graft versus host disease, if it develops.

Effects of forearm pronation/supination on carpal tunnel pressure

The effects of forearm rotation and metacarpophalangeal (MP) flexion on carpal tunnel pressure were investigated in 17 healthy adults who had no evidence of carpal tunnel syndrome (CTS). Pressure was continuously recorded with a saline-filled catheter inserted into the carpal tunnel and connected to a pressure transducer while test subjects slowly rotated the forearm from full pronation to full supination. Forearm rotation was repeated with MP flexion of 0 degrees, 45 degrees, and 90 degrees. Both forearm rotation and MP flexion, and their interaction term, significantly affected carpal tunnel pressure and accounted for most of the variability in the data. Highest mean pressures (55 mmHg) were recorded in full supination and 90 degrees MP flexion and lowest pressures (12 mmHg) were recorded at 45 degrees pronation and 45 degrees MP flexion. These data may be useful in the design of tasks and hand tools in the management and prevention of CTS.

Long-term animal experiments with an intraventricular axial flow blood pump

A miniature intraventricular axial flow blood pump (IVAP) is undergoing in vivo evaluation in calves. The IVAP system consists of a miniature (phi 13.9 mm) axial flow pump that resides within the left ventricular (LV) chamber and a brushless DC motor. The pump is fabricated from titanium alloy, and the pump weight is 170 g. It produces a flow rate of over 5 L/min against 100 mmHg pressure at 9,000 rpm with an 8 W total power consumption. The maximum total efficiency exceeds 17%. A purged lip seal system is used in prototype no. 8, and a newly developed "Cool-Seal" (a low temperature mechanical seal) is used in prototype no. 9. In the Cool-Seal system, a large amount of purge flow is introduced behind the seal faces to augment convective heat transfer, keeping the seal face temperature at a low level for prevention of heat denaturation of blood proteins. The Cool-Seal system consumes < 10 cc purge fluid per day and has greatly extended seal life. The pumps were implanted in three calves (26, 30, and 168 days of support). The pump was inserted through a left thoracotomy at the fifth intercostal space. Two pursestring sutures were placed on the LV apex, and the apex was cored with a myocardial punch. The pump was inserted into the LV with the outlet cannula smoothly passing through the aortic valve without any difficulty. Only 5 min elapsed between the time of chest opening and initiation of pumping. Pump function remained stable throughout in all experiments. No cardiac arrhythmias were detected, even at treadmill exercise tests. The plasma free hemoglobin level remained in the acceptable range. Post mortem examination did not reveal any interference between the pump and the mitral apparatus. No major thromboembolism was detected in the vital organs in Cases 1 or 2, but a few small renal infarcts were detected in Case 3.

Diamond-Blackfan anaemia in a girl with a de novo balanced reciprocal X;19 translocation

A 7 year old girl is described with congenital hypoplastic anaemia (Diamond-Blackfan anaemia, DBA) and an apparently balanced reciprocal translocation, 46,XX,t(X;19)(p21;q13). The girl has associated features including short stature, unilateral kidney hypoplasia, and a branchial cyst. Fluorescent in situ hybridisation (FISH) studies with 19q specific cosmids showed that the chromosome 19 breakpoint is located between the RYR1 and the XRCC11 loci spanning a physical region of 5 Mb. There is no family history of DBA and the parents and two healthy sibs have normal karyotypes. This is the first report of a balanced translocation associated with DBA and we suggest that the distinct phenotype has resulted from a de novo disruption of a functional gene. DBA can be inherited as an autosomal trait and our observation may indicate a candidate gene for the disorder in the 19q13 region.

An implantable centrifugal blood pump for long term circulatory support

A compact centrifugal blood pump was developed as an implantable left ventricular assist system. The impeller diameter is 40 mm and the pump dimensions are 55 x 64 mm. This first prototype was fabricated from titanium alloy, resulting in a pump weight of 400 g including a brushless DC motor. Weight of the second prototype pump was reduced to 280 g. The entire blood contacting surface is coated with diamond like carbon to improve blood compatibility. Flow rates of over 7 L/min against 100 mmHg pressure at 2,500 rpm with 9 W total power consumption have been measured. A newly designed mechanical seal with a recirculating purge system ("Cool-Seal") is used as a shaft seal. In this seal system, seal temperature is kept under 40 degrees C to prevent heat denaturation of blood proteins. Purge fluid also cools the pump motor coil and journal bearing. The purge fluid is continuously purified and sterilized by an ultrafiltration filter incorporated into the paracorporeal drive console. In vitro experiments with bovine blood demonstrated an acceptably low hemolysis rate (normalized index of hemolysis = 0.005 +/- 0.002 g/100 L). In vivo experiments are currently ongoing using calves. Via left thoracotomy, left ventricular apex-descending aorta bypass was performed utilizing a PTFE (Polytetrafluoroethylene) vascular graft, with the pump placed in the left thoracic cavity. In two in vivo experiments, pump flow rate was maintained at 5-8 L/min, and pump power consumption remained stable at 9-10 W. All plasma free hemoglobin levels were measured at < 15 mg/dl. The seal system has demonstrated good seal capability with negligible purge fluid consumption (< 0.5 ml/ day). Both animals remain under observation after 162 and 91 days of continuous pump function.

Quick method for confirmation of quantitative trait loci

Numerous algorithms for the identification and genetic mapping of quantitative trait loci (QTL) have been developed. Methods for confirming QTL maps involve either examination of independent segregating populations or the construction of congenic lines differing only in the QTL of interest. Because these projects require a minimum of several years or thousands of marker assessments in laboratory mice, an alternative, faster congenic method has been proposed. In a preliminary study, we tested this method for confirming QTLs identified in crosses between the ILS and ISS selected lines of mice for differential sensitivity to the hypnotic effects of ethanol. Herein, we report the construction of "segregating congenic" strains in which each QTL is made homozygous in a single generation, whereas the remainder of the genetic background is allowed to segregate. Sensitivity to ethanol among the progeny of such mice is consistent with predictions. Phenotypic variation is high, as expected, due to the background segregation, and statistical significance was attained in only 2 of 7 comparisons. Such segregating congenic populations may be a valuable research tool for confirming QTL map positions and for subsequent assessment of individual pathways and mechanisms of action of individual QTLs.

Diamond-Blackfan anaemia: genetic homogeneity for a gene on chromosome 19q13 restricted to 1.8 Mb

Diamond-Blackfan anaemia (DBA; MIM#205900) is a rare disorder manifested as a pure red-cell aplasia in the neonatal period or in infancy. The clinical hallmark of DBA is a selective decrease in erythroid precursors and anaemia. Other lineages are usually normal and the peripheral white blood cell count is normal. In approximately one-third of cases, the disease is associated with a wide variety of congenital anomalies and malformations. Most cases are sporadic, but 10-20% of them follow a recessive or a dominant inheritance pattern. A female with DBA and a chromosomal translocation involving chromosome 19q was recently identified. We undertook a linkage analysis with chromosome 19 markers in multiplex DBA families of Swedish, French, Dutch, Arabic and Italian origin. Significant linkage to chromosome 19q13 was established for dominant and recessive inherited DBA with a peak lod score at D19S197 (Zmax = 7.08, theta = 0.00). Within this region, a submicroscopic de novo deletion of 3.3 Mb was identified in a patient with DBA. The deletion coincides with the translocation break-point and, together with key recombinations, restricts the DBA gene to a 1.8-Mb region. The results suggest that, despite its clinical heterogeneity, DBA is genetically homogeneous for a gene in 19q13.

A murine model of pulmonary damage induced by lipopolysaccharide via intranasal instillation

This study examines the intranasal instillation of lipopolysaccharide (LPS) into BALB/c mice causing acute pulmonary damage, due to neutrophil infiltration and sepsis. A dose response with LPS showed that an intranasal instillation of 167 microg/ml (10 microg/mouse) caused acute lung injury within 2-4 h and reached maximal damage at 24-48 h. We found the method of LPS administration for induction of acute pulmonary damage to be crucial. After 24 h post-LPS injection, a comparison showed a substantial increase in pulmonary damage with intranasal instillation of LPS. As for intravenous injection, it showed a baseline effect. This study indicates that LPS administered intranasally causes acute pulmonary damage, whereas with intravenous and intraperitoneal endotoxin administration a tissue-specific or similar degree of pulmonary injury may not develop.

Confirmation of quantitative trait loci for ethanol sensitivity in long-sleep and short-sleep mice

Initial insensitivity to alcohol is a strong predictor of human alcoholism, a widespread and heritable health problem. The Long Sleep and Short Sleep lines of mice were developed by genetic selection for high or low alcohol sensitivity. We have identified seven quantitative trait loci (QTLs) specifying differences in alcohol sensitivity using intercross progeny from these selected strains. These QTLs (Lorel-Lore7) together account for approximately 60% of the total genetic variance for this trait. This represents the first report of linkages for genes influencing alcohol action in any mammalian system using stringent, genome-wide mapping criteria.

Recurrent lower gastrointestinal hemorrhage: ileal neoplasm diagnosed by scintigraphy with Tc 99m red blood cells and angiography

A 71-year-old man with recurrent lower gastrointestinal bleeding had negative colonoscopic findings on three occasions. Preoperative diagnosis of a large stromal tumor in the right lower quadrant was based on scintigraphy with tagged red blood cells and mesenteric arteriographic features. The use of nuclear scintigraphy in the diagnosis and evaluation of stromal tumor of unknown malignant potential has not been previously described.