Qualitative research methods in neurosurgery: an unexplored avenue

OBJECTIVE

Explore the value and potential of qualitative research to neurosurgery and provide insight and understanding to this underused methodology.

BACKGROUND

The definition of qualitative research is critically discussed and the heterogeneity within this field of inquiry explored. The value of qualitative research to the field of neurosurgery is articulated through its contribution to understanding complex clinical problems.

DISCUSSION

To resolve some of the misunderstanding of qualitative research, this paper discusses research design choices. We explore approaches that use qualitative techniques but are not, necessarily, situated within a qualitative paradigm in addition to how qualitative research philosophy aids researchers to conduct interpretive inquiry that can reveal more than simply what was said by participants. Common research designs associated with qualitative inquiry are introduced, and how complex analysis may contribute more in-depth insights is explained. Approaches to quality are discussed briefly to support improvements in qualitative methods and qualitative manuscripts. Finally, we consider the future of qualitative research in neurosurgery, and suggest how to move forward in the qualitative neurosurgical evidence base.

CONCLUSION

There is enormous potential for qualitative research to contribute to the advancement of person-centred care within neurosurgery. There are signs that more qualitative research is being conducted and that neurosurgical journals are increasingly open to this methodology. While studies that do not engage fully within the qualitative paradigm can make important contributions to the evidence base, due regard should be given to immersive inquiry within qualitative paradigms to allow complex, in-depth, investigations of the human experience.

Commelinid Monocotyledon Lignins Are Acylated by p-Coumarate

Commelinid monocotyledons are a monophyletic clade differentiated from other monocotyledons by the presence of cell wall-bound ferulate and p-coumarate. The Poaceae, or grass family, is a member of this group, and most of the p-coumarate in the cell walls of this family acylates lignin. Here, we isolated and examined lignified cell wall preparations from 10 species of commelinid monocotyledons from nine families other than Poaceae, including species from all four commelinid monocotyledon orders (Poales, Zingiberales, Commelinales, and Arecales). We showed that, as in the Poaceae, lignin-linked p-coumarate occurs exclusively on the hydroxyl group on the γ-carbon of lignin unit side chains, mostly on syringyl units. Although the mechanism of acylation has not been studied directly in these species, it is likely to be similar to that in the Poaceae and involve BAHD acyl-coenzyme A:monolignol transferases.

Dimensional Changes of Tracheids during Drying of Radiata Pine (Pinus radiata D. Don) Compression Woods: A Study Using Variable-Pressure Scanning Electron Microscopy (VP-SEM)

Variable-pressure scanning electron microscopy was used to investigate the dimensional changes in longitudinal, tangential and radial directions, on wetting and drying, of tracheids of opposite wood (OW) and three grades of compression woods (CWs), including severe CW (SCW) and two grades of mild compression wood (MCW) (MCW1 and MCW2) in corewood of radiata pine (Pinus radiata) saplings. The CW was formed on the underside and OW on the upper side of slightly tilted stems. In the longitudinal direction, the shrinkage of SCW tracheids was ~300% greater than that of OW tracheids, with the shrinkage of the MCW1 and MCW2 tracheids being intermediate. Longitudinal swelling was also investigated and hysteresis was demonstrated for the tracheids of all corewood types, with the extent of hysteresis increasing with CW severity. A statistical association was found between longitudinal shrinkage and the content of lignin and galactosyl residues in the cell-wall matrix. The galactosyl residues are present mostly as (1→4)-β-galactans, which are known to have a high capacity for binding water and swell on hydration. The small proportions of (1→3)-β-glucans in the CWs have similar properties. These polysaccharides may play a functional role in the longitudinal shrinking and swelling of CW tracheids. Tangential shrinkage of tracheids was greater than radial shrinkage but both were greatest for OW and least for SCW, with the MCW1 and MCW2 being intermediate.

Highly Decorated Lignins in Leaf Tissues of the Canary Island Date Palm Phoenix canariensis

The cell walls of leaf base tissues of the Canary Island date palm (Phoenix canariensis) contain lignins with the most complex compositions described to date. The lignin composition varies by tissue region and is derived from traditional monolignols (ML) along with an unprecedented range of ML conjugates: ML-acetate, ML-benzoate, ML-p-hydroxybenzoate, ML-vanillate, ML-p-coumarate, and ML-ferulate. The specific functions of such complex lignin compositions are unknown. However, the distribution of the ML conjugates varies depending on the tissue region, indicating that they may play specific roles in the cell walls of these tissues and/or in the plant's defense system.

Tricin-lignins: occurrence and quantitation of tricin in relation to phylogeny

Tricin [5,7-dihydroxy-2-(4-hydroxy-3,5-dimethoxyphenyl)-4H-chromen-4-one], a flavone, was recently established as an authentic monomer in grass lignification that likely functions as a nucleation site. It is linked onto lignin as an aryl alkyl ether by radical coupling with monolignols or their acylated analogs. However, the level of tricin that incorporates into lignin remains unclear. Herein, three lignin characterization methods: acidolysis; thioacidolysis; and derivatization followed by reductive cleavage; were applied to quantitatively assess the amount of lignin-integrated tricin. Their efficiencies at cleaving the tricin-(4'-O-β)-ether bonds and the degradation of tricin under the corresponding reaction conditions were evaluated. A hexadeuterated tricin analog was synthesized as an internal standard for accurate quantitation purposes. Thioacidolysis proved to be the most efficient method, liberating more than 91% of the tricin with little degradation. A survey of different seed-plant species for the occurrence and content of tricin showed that it is widely distributed in the lignin from species in the family Poaceae (order Poales). Tricin occurs at low levels in some commelinid monocotyledon families outside the Poaceae, such as the Arecaceae (the palms, order Arecales) and Bromeliaceae (Poales), and the non-commelinid monocotyledon family Orchidaceae (Orchidales). One eudicotyledon was found to have tricin (Medicago sativa, Fabaceae). The content of lignin-integrated tricin is much higher than the extractable tricin level in all cases. Lignins, including waste lignin streams from biomass processing, could therefore provide a large and alternative source of this valuable flavone, reducing the costs, and encouraging studies into its application beyond its current roles.

Monolignol ferulate conjugates are naturally incorporated into plant lignins

Angiosperms represent most of the terrestrial plants and are the primary research focus for the conversion of biomass to liquid fuels and coproducts. Lignin limits our access to fibers and represents a large fraction of the chemical energy stored in plant cell walls. Recently, the incorporation of monolignol ferulates into lignin polymers was accomplished via the engineering of an exotic transferase into commercially relevant poplar. We report that various angiosperm species might have convergently evolved to natively produce lignins that incorporate monolignol ferulate conjugates. We show that this activity may be accomplished by a BAHD feruloyl-coenzyme A monolignol transferase, OsFMT1 (AT5), in rice and its orthologs in other monocots.

Tracheid cell-wall structures and locations of (1 → 4)-β-D-galactans and (1 → 3)-β-D-glucans in compression woods of radiata pine (Pinus radiata D. Don)

BACKGROUND

Compression wood (CW) forms on the underside of tilted stems of coniferous gymnosperms and opposite wood (OW) on the upperside. The tracheid walls of these wood types differ structurally and chemically. Although much is known about the most severe form of CW, severe CW (SCW), mild CWs (MCWs), also occur, but less is known about them. In this study, tracheid wall structures and compositions of two grades of MCWs (1 and 2) and SCW were investigated and compared with OW in slightly tilted radiata pine (Pinus radiata) stems.

RESULTS

The four wood types were identified by the distribution of lignin in their tracheid walls. Only the tracheid walls of OW and MCW1 had a S3 layer and this was thin in MCW1. The tracheid walls of only SCW had a S2 layer with helical cavities in the inner region (S2i). Using immunomicroscopy, (1 → 4)-β-D-galactans and (1 → 3)-β-D-glucans were detected in the tracheid walls of all CWs, but in only trace amounts in OW. The (1 → 4)-β-D-galactans were located in the outer region of the S2 layer, whereas the (1 → 3)-β-D-glucans were in the inner S2i region. The areas and intensities of labelling increased with CW severity. The antibody for (1 → 4)-β-D-galactans was also used to identify the locations and relative amounts of these galactans in whole stem cross sections based on the formation of an insoluble dye. Areas containing the four wood types were clearly differentiated depending on colour intensity. The neutral monosaccharide compositions of the non-cellulosic polysaccharides of these wood types were determined on small, well defined discs, and showed the proportion of galactose was higher for CWs and increased with severity.

CONCLUSION

The presence of an S3 wall layer is a marker for very MCW and the presence of helical cavities in the S2 wall layer for SCW. The occurrence and proportions of (1 → 4)-β-D-galactans and (1 → 3)-β-D-glucans can be used as markers for CW and its severity. The proportions of galactose were consistent with the labelling results for (1 → 4)-β-D-galactans.

Lower cell wall pectin solubilisation and galactose loss during early fruit development in apple (Malus x domestica) cultivar 'Scifresh' are associated with slower softening rate

Substantial differences in softening behaviour can exist between fruit even within the same species. Apple cultivars 'Royal Gala' and 'Scifresh' soften at different rates despite having a similar genetic background and producing similar amounts of ethylene during ripening. An examination of cell wall metabolism from the fruitlet to the ripe stages showed that in both cultivars pectin solubilisation increased during cell expansion, declined at the mature stage and then increased again during ripening. This process was much less pronounced in the slower softening 'Scifresh' than in 'Royal Gala' at every developmental stage examined, consistent with less cell separation and softening in this cultivar. Both cultivars also exhibited a progressive loss of pectic galactan and arabinan side chains during development. The cell wall content of arabinose residues was similar in both cultivars, but the galactose residue content in 'Scifresh' remained higher than that of 'Royal Gala' at every developmental stage. The higher content of cell wall galactose residue in 'Scifresh' cell walls correlated with a lower β-galactosidase activity and more intense immunolabelling of RG-I galactan side chains in both microscopy sections and glycan microarrays. A high cell wall galactan content has been associated with reduced cell wall porosity, which may restrict access of cell wall-modifying enzymes and thus maintain better structural integrity later in development. The data suggest that the composition and structure of the cell wall at very early development stages may influence subsequent cell wall loosening, and may even predispose the wall's ensuing properties.

Cell wall structures leading to cultivar differences in softening rates develop early during apple (Malus x domestica) fruit growth

BACKGROUND

There is a paucity of information regarding development of fruit tissue microstructure and changes in the cell walls during fruit growth, and how these developmental processes differ between cultivars with contrasting softening behaviour. In this study we compare two apple cultivars that show different softening rates during fruit development and ripening. We investigate whether these different softening behaviours manifest themselves late during ethylene-induced softening in the ripening phase, or early during fruit expansion and maturation.

RESULTS

'Scifresh' (slow softening) and 'Royal Gala' (rapid softening) apples show differences in cortical microstructure and cell adhesion as early as the cell expansion phase. 'Scifresh' apples showed reduced loss of firmness and greater dry matter accumulation compared with 'Royal Gala' during early fruit development, suggesting differences in resource allocation that influence tissue structural properties. Tricellular junctions in 'Scifresh' were rich in highly-esterified pectin, contributing to stronger cell adhesion and an increased resistance to the development of large airspaces during cell expansion. Consequently, mature fruit of 'Scifresh' showed larger, more angular shaped cells than 'Royal Gala', with less airspaces and denser tissue. Stronger cell adhesion in ripe 'Scifresh' resulted in tissue fracture by cell rupture rather than by cell-to-cell-separation as seen in 'Royal Gala'. CDTA-soluble pectin differed in both cultivars during development, implicating its involvement in cell adhesion. Low pectin methylesterase activity during early stages of fruit development coupled with the lack of immuno-detectable PG was associated with increased cell adhesion in 'Scifresh'.

CONCLUSIONS

Our results indicate that cell wall structures leading to differences in softening rates of apple fruit develop early during fruit growth and well before the induction of the ripening process.

Comment on 'Modeling the conductance and DNA blockade of solid-state nanopores'

Recently, Kowalczyk et al (2011 Nanotechnology 22 315101) introduced a model for calculating the conductance of an hourglass-shaped nanopore, and the conductance change when DNA is introduced into such a pore. Here, we comment on their model in the context of other literature addressing the same general problem. Existing work includes widespread use of an alternative model, contradicts the authors' claim that the conductance change should be expected not to vary with pore size, and has frequently utilised access resistance.

Combining nutrition, food science and engineering in developing solutions to Inflammatory bowel diseases--omega-3 polyunsaturated fatty acids as an example

The Inflammatory bowel diseases, Crohn's disease and ulcerative colitis, are debilitating conditions, characterised by lifelong sensitivity to certain foods, and often a need for surgery and life-long medication. The anti-inflammatory effects of long chain omega-3 polyunsaturated acids justify their inclusion in enteral nutrition formulas that have been associated with disease remission. However, there have been variable data in clinical trials to test supplementary omega-3 polyunsaturated fatty acids in inducing or maintaining remission in these diseases. Although variability in trial design has been suggested as a major factor, we suggest that variability in processing and presentation of the products may be equally or more important. The nature of the source, and rapidity of getting the fish or other food source to processing or to market, will affect the percentage of the various fatty acids, possible presence of heavy metal contaminants and oxidation status of the various fatty acids. For dietary supplements or fortified foods, whether the product is encapsulated or not, whether storage is under nitrogen or not, and length of time between harvest, processing and marketing will again profoundly affect the properties of the final product. Clinical trials to test efficacy of these products in IBD to date have utilised the relevant skills of pharmacology and gastroenterology. We suggest that knowledge from food science, nutrition and engineering will be essential to establish the true role of this important group of compounds in these diseases.

Effect of apple cell walls and their extracts on the activity of dietary antioxidants

The effect of dietary fiber in the form of apple cell walls and pectin extracts on natural antioxidants was examined. Cell walls (CW), isolated from apples ( Malus domestica Borkh. cv. "Pacific Rose"), were incubated with ascorbic acid (AA) or quercetin in N-2-hydroxyethylpiperazine- N'-2-ethanesulfonic acid (HEPES) buffer (pH 6.5) at 37 degrees C for 2 h. The resulting supernatants were characterized by a ferric reducing antioxidant power (FRAP) assay and cyclic voltammetry (CV). The experiments were repeated with pectin isolated from the apple cell walls and commercial pectins and showed that polysaccharide preparations stabilized AA effectively but offered little protection against quercetin oxidation. The water-soluble components from cell walls appeared to be responsible for the observed effects of cell-wall polysaccharide preparations on antioxidant activity.

Variant Klinefelter syndrome 47,X,i(X)(q10),Y and normal 46,XY karyotype in monozygotic adult twins

Klinefelter syndrome (KS; 47, XXY) is characterized by increased body height, hypergonadotrophic hypogonadism, and infertility. We describe a patient with a variant KS (47,X,i(Xq),Y) who has a twin brother with a 46,XY karyotype. Molecular studies showed that the twins were monozygotic. The presence of an isochromosome Xq in one of two monozygotic twins allows precise investigation of its phenotypic effect. The patient was somewhat shorter (3.5 cm) and had a smaller volume of the testes (8 vs. 18 ml) as compared to his twin brother. Furthermore he had increased gonadotrophin levels and an extreme oligoasthenoteratozoospermia (OAT). These data support the view that genes on Xp cause increased body height and genes on Xq cause infertility in KS. To our knowledge this is the first report on a heterokaryotypic monozygotic twin with a variant KS.

Natural atypical Listeria innocua strains with Listeria monocytogenes pathogenicity island 1 genes

Identification of bona fide Listeria isolates into the six species of the genus normally requires only a few tests. Aberrant isolates do occur, but even then only one or two extra confirmatory tests are generally needed for identification to species level. We have discovered a hemolytic-positive, rhamnose and xylose fermentation-negative Listeria strain with surprising recalcitrance to identification to the species level due to contradictory results in standard confirmatory tests. The issue had to be resolved by using total DNA-DNA hybridization testing and then confirmed by further specific PCR-based tests including a Listeria microarray assay. The results show that this isolate is indeed a novel one. Its discovery provides the first fully documented instance of a hemolytic Listeria innocua strain. This species, by definition, is typically nonhemolytic. The L. innocua isolate contains all the members of the PrfA-regulated virulence gene cluster (Listeria pathogenicity island 1) of L. monocytogenes. It is avirulent in the mouse pathogenicity test. Avirulence is likely at least partly due to the absence of the L. monocytogenes-specific allele of iap, as well as the absence of inlA, inlB, inlC, and daaA. At least two of the virulence cluster genes, hly and plcA, which encode the L. monocytogenes hemolysin (listeriolysin O) and inositol-specific phospholipase C, respectively, are phenotypically expressed in this L. innocua strain. The detection by PCR assays of specific L. innocua genes (lin0198, lin0372, lin0419, lin0558, lin1068, lin1073, lin1074, lin2454, and lin2693) and noncoding intergenic regions (lin0454-lin0455 and nadA-lin2134) in the strain is consistent with its L. innocua DNA-DNA hybridization identity. Additional distinctly different hemolytic L. innocua strains were also studied.

Developing an index of restorative dental treatment need

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

Ferulic acid is esterified to glucuronoarabinoxylans in pineapple cell walls

The ester-linkage of ferulic acid (mainly E) to polysaccharides in primary cell walls of pineapple fruit (Ananas comosus) (Bromeliaceae) was investigated by treating a cell-wall preparation with 'Driselase' which contains a mixture of endo- and exo-glycanases, but no hydroxycinnamoyl esterase activity. The most abundant feruloyl oligosaccharide released was O-[5-O-(E-feruloyl)-alpha-L-arabinofuranosyl](1-->3)-O-beta-D-xylopyranosyl-(1-->4)-D-xylopyranose (FAXX). This indicated that the ferulic acid is ester-linked to glucuronoarabinoxylans in the same way as in the primary walls of grasses and cereals (Poaceae). Glucuronoarabinoxylans are the major non-cellulosic polysaccharides in the pineapple cell walls.

Effectiveness of the boston brace in treatment of large curves in adolescent idiopathic scoliosis

STUDY DESIGN

This is a retrospective study of 50 patients with adolescent idiopathic scoliosis with curves measuring 35 degrees to 45 degrees who were treated with a Boston brace.

OBJECTIVES

The purpose of this study was to determine whether the Boston brace could effectively halt long-term progression in skeletally immature adolescents with idiopathic scoliosis who had a curve between 35 degrees and 45 degrees.

SUMMARY OF BACKGROUND DATA

The Boston brace has been shown to be effective in preventing curve progression in adolescent idiopathic scoliosis, but its efficacy in large curves has not been fully studied.

METHODS

Fifty adolescents were treated with a Boston brace for idiopathic scoliosis curves of 35-45 degrees (mean, 38.55 degrees ). All were judged to be skeletally immature based on menarcheal status (mean, 2.6 months before menarche), Risser sign (mean, 0.90; range, 0-2), and chronologic age (mean, 13 +/- 1 years). Patients were recalled for long-term follow-up at a mean of 9.7 years (range, 6.23-13.22 years) after brace discontinuation. Three well-matched patient subsets were then identified based on compliance. Group 1 (n = 24) consisted of patients who were compliant with the brace program and wore the brace 18 or more hours per day, Group 2 (n = 14) contained patients who wore the brace 12-18 hours per day, and Group 3 (n = 12) contained patients who wore the brace 0-12 hours per day.

RESULTS

There was a significant difference in the amount of initial correction seen in the brace between the groups: 49%, 45%, and 33% curve correction in the brace for Groups 1, 2, and 3, respectively (P < 0.05). At long-term follow-up there was a statistically significant difference between Groups 1, 2, and 3 in the percentage of patients in whom the curve had progressed to more than 45 degrees (P < 0.001), who had more than 5 degrees of curve progression (P < 0. 05), or who had undergone posterior spinal fusion (P < 0.001).

CONCLUSIONS

These long-term data confirm that the Boston brace when used 18 or more hours per day is effective in preventing progression of large curves at a mean of 9.8 years after bracing is discontinued.

A literature review of the techniques to measure tooth wear and erosion

This paper reviews methods to measure tooth wear especially those more recently introduced as a result of improvements in technology. The review searched methods to measure tooth wear and dental erosion from large epidemiological investigations, in vitro and in vivo studies. There seems to be wide variation in techniques used to measure tooth wear and erosion. In vitro techniques may have little direct clinical relevance but can lead to new and more accurate clinical methods. In vivo studies have problems with reference points and accurate validation of the techniques. There is a need for a simple, reliable technique to quantify tooth wear due to erosion.

Oral pH and drinking habit during ingestion of a carbonated drink in a group of adolescents with dental erosion

OBJECTIVES

To investigate the relationship between dental erosion, oral pH and drinking habit in a group of adolescents.

METHODS

Oral pH was measured simultaneously at the surface of four teeth in 11 patients, aged 10-16 years, with erosion and in 10 controls subjects without erosion using antimony electrodes. Measurements were made before, during and after drinking 330 ml of a carbonated drink. The method and timing of drinking the beverage, reported dietary intake of acidic foods and flow rate and buffering capacity of saliva were recorded.

RESULTS

The erosion patients reported drinking more carbonated drinks (p<0.01) and drinking directly from a can more frequently than the controls (p<0.05). They also drank twice as quickly (p<0.05). The pH at the buccal surface of a molar remained lower for longer in the erosion patients than in the patients without erosion (p<0.01), whilst the labial surface of the upper central incisor had a longer exposure to low pH in the controls subjects (p<0.05).

CONCLUSION

The pattern of oral pH differed between subjects with and without erosion after drinking an acidic beverage. This may be related to observed differences in drinking habit, which could have influenced the pattern of erosion in these subjects.

Dielectric resonator-based side-access probe for muscle fiber EPR study

We present a novel dielectric resonator (DR)-based resonant structure that accommodates aqueous sample capillaries in orientations that are either parallel (i.e., side-access) or perpendicular to the direction of an external (Zeeman) magnetic field, B(0). The resonant structure consists of two commercially available X-band DRs that are separated by a Rexolite spacer and resonate in the fundamental TE(01delta) mode. The separator between the DRs is used to tune the resonator to the desired frequency and, by appropriately drilled sample holes, to provide access for longitudinal samples, notably capillaries containing oriented, spin-labeled muscle fibers. In contrast to the topologically similar cylindrical TE(011) cavity, the DR-based structure has distinct microwave properties that favor its use for parallel orientation of lossy aqueous samples. For perpendicular orientation of a dilute (6.25 microM) aqueous solution of IASL spin label, the S/N ratio was at least one order of magnitude better for the side-access DR-based structure than for a standard TE(102) cavity. EPR spectra acquired for maleimide spin-labeled myosin filaments also revealed ca. 10 times better S/N ratio than those obtained with a standard TE(102) cavity. For the side-access DR with sample capillaries oriented either parallel or perpendicular to the external magnetic field, the Q- and filling factors are in good agreement with the theoretical estimates derived from the distribution of magnetic (H(1)) and electric (E(1)) components.

The role of the esophagus in dental erosion

OBJECTIVE

The aim of this study was to measure lower esophageal sphincter pressure, sphincter length, and esophageal motility in patients with dental erosion and compare the results with measurements made in patients without gastroesophageal reflux or dental erosion.

STUDY DESIGN

Lower esophageal sphincter length and esophageal motility were measured in 39 patients (age range, 15-74 years) with dental erosion through use of static esophageal pressure monitoring; the data were compared with those from 10 control subjects (age range, 26-46 years) with nonparametric statistical tests.

RESULTS

Median lower esophageal sphincter pressure was 9 mmHg (range, 0-26 mmHg) in the patients with erosion and 9.5 mmHg (range, 0 -14 mmHg) in the controls; there was no statistically significant difference between the two subject groups. Similarly, there was no statistically significant difference in esophageal length between the subject groups. There was a statistically significant difference between the groups (P =.01) in the measurement of esophageal motility; the median value was 8% (range, 0% to 100%) in the patients with erosion and 0% (range, 0% to 18%) in the controls.

CONCLUSIONS

It appears that esophageal motility in patients with dental erosion is more likely to be associated with low amplitude changes than with sphincter pressure alone. Poor esophageal motility may therefore be a risk factor in regurgitation erosion.

The role of saliva in regurgitation erosion

It has been suggested that salivary characteristics are important in the progression of erosion. The aim of this investigation was to measure salivary parameters in 22 patients with erosion, 10 with normal (non-pathological) levels of reflux (Group I) and 12 with previously diagnosed pathological levels of gastro-oesophageal reflux (Group II). A further 10 subjects without evidence of erosion and no history of reflux disease acted as controls (Group III). No statistically significant differences in salivary flow rate, buffering power or the concentrations of calcium, phosphorus and fluoride were detected. The results suggest that variation in the characteristics of unstimulated and stimulated saliva collected during waking hours do not have a major role in erosion.

The road to specialization

This paper describes the history and current status of specialization within dental practice in the UK.

Results and morbidity in a consecutive series of patients undergoing spinal fusion for neuromuscular scoliosis

STUDY DESIGN

A retrospective clinical and radiographic review.

OBJECTIVES

To provide current data on the results and complications of patients who have undergone spinal fusion for neuromuscular scoliosis at a center with physicians experienced in these types of cases.

SUMMARY OF BACKGROUND DATA

The reported complication rate in the management of neuromuscular scoliosis ranges from 44% to 62% in the recent literature. This literature is that of 1991 or earlier reflecting operative techniques of the mid-1980s, and it has been used to argue against the efficacy of neuromuscular spinal fusions.

METHODS

A retrospective chart and radiographic review of 50 consecutive spinal fusions for neuromuscular scoliosis was performed at Connecticut Children's Medical Center between January 1990 and January 1994. The three most common diagnoses were spastic quadriplegic cerebral palsy (20 patients), myelomeningocele (13 patients), and muscle disease (8 patients). There were 38 posterior spinal fusions including two kyphectomies and 12 anteroposterior spinal fusions. The Luque-Galveston technique was used in 39 of 50 patients. The average age at surgery was 13 years and 6 months, with an average follow-up of 40 months (minimum, 24 months).

RESULTS

Before surgery, the mean major scoliosis measured 72 degrees, with mean best bend or traction view of 35 degrees. At most recent follow-up, the mean scoliosis magnitude was 25 degrees (mean correction, 65%). There were 17 minor complications in 14 patients and three major complications (deep wound infections) in three myelomeningocele patients. Rod breakage was noted in two patients, one of whom had an asymptomatic pseudarthrosis. There were no neurologic complications or deaths, and none of the complications affected the final results.

CONCLUSIONS

The data in the current study support the authors' belief that with current surgical techniques and perioperative management in an experienced center, the results for patients undergoing spinal fusion for neuromuscular scoliosis have been improved, and major complications have been minimized.

[Studies on the causative factors of cervical wedge-shaped defect of human teeth from three dimensions]

OBJECTIVE

To investigate causative factors of cervical wedge-shaped defect of human teeth and the significance of methods for measurement of the defect.

METHODS

Experimental cervical defects on 9 pairs of premolars were created by cross-brushing, erosion, or fatigue of occlusion force separately or combinedly and measured in depth and area of profile as well as in volume.

RESULTS

1. Profile depth of defects caused by three factors separately showed no statistical difference, but the profile depth caused by combining factors was much more than that caused by each individual factor; 2. The hardness of enamel and dentin in defect area was lower than that in normal area of tooth samples; 3. Measurement from one-dimension (depth) and two-dimension (area) showed only low relation in profile depth, however, measured three-dimensionally (volume) there existed moderate relationship.

CONCLUSION

For study of cervical defect, the profile depth is feasible provided that is a large sample group and without equipment for volume measuring; if the sample size is limited and there is sophiscated instrument for volume measuring, the 3-dimensional measurement is the most sensitive one.

Dose proportionality and pharmacokinetics of oral transmucosal fentanyl citrate

BACKGROUND

The pharmacokinetics of a single dose (15 microg/kg) of oral transmucosal fentanyl citrate (OTFC) have been characterized. A range of doses may eventually be used in clinical practice. The goal of this study was to determine if the pharmacokinetics of OTFC are dose proportional for doses ranging from 200 to 1,600 microg.

METHODS

Twelve healthy male volunteers were studied on four different occasions, receiving 200, 400, 800, and 1,600 microg OTFC in a double-blind, randomized protocol. Venous blood samples were collected at selected times during and after dosing for a 24-h period and assayed for fentanyl using a radioimmunoassay. Maximum concentration, time to maximum concentration, area under the curve, and elimination half-life were determined for each dose administered. In addition, respiratory rate, need for verbal prompting to breathe, and supplemental oxygen requirements were noted.

RESULTS

Mean fentanyl concentration time curves were similarly shaped with increasing doses. Both peak concentrations and area under the curve increased linearly with an increase in dose, whereas time to reach peak serum concentrations did not vary significantly between doses. Except for the 200-microg dose, the apparent elimination half-life remained relatively constant (358-386 min). The incidence of low respiratory rate, supplemental oxygen requirement, and number of breathing prompts significantly increased with increasing doses.

CONCLUSIONS

Oral transmucosal fentanyl citrate exhibits dose-proportional pharmacokinetics over the dose range of 200-1,600 microg.

Etiology and management of tooth wear: The association of drugs and medicaments

Teeth are sometimes worn excessively by erosion (chemical damage), abrasion (physical damage) or attrition (wear between opposing teeth). The most important role of self-prescribed or physician-prescribed drugs is the management of conditions which cause regurgitation erosion.

The prevalence, etiology and management of tooth wear in the United Kingdom

STATEMENT OF PROBLEM

Recent epidemiologic evidence suggests that tooth wear is now a significant problem in both children and adults. There is growing evidence that a major cause of severe wear in patients is regurgitation erosion due to a variety of factors including gastroesophageal reflux disease.

PURPOSE

The purpose of this article is to discuss the prevalence of tooth wear in the United Kingdom. Emphasis in management should be on accurate diagnosis, and in some patients, long-term monitoring before embarking on any irreversible, interventive treatment. Even when treatment is necessary, a period of monitoring is helpful to assess the rate of progress of the wear, the effectiveness of preventive measures, and therefore the extent of the treatment necessary.

Postreduction computed tomography in developmental dislocation of the hip: part I: analysis of measurement reliability

Twenty computed tomographic (CT) scans of infants in spica casts after closed or open reduction for developmental hip dislocation (DDH) were analyzed for intra- and interrater reliability. Ten measurements of infant hip anatomy were assessed by three raters by using standard statistical analysis. All six measurements of acetabular anteversion and lateral or posterior displacement of the femoral metaphysis from the acetabulum or from a modified Shenton's line drawn from the pubic rami demonstrated both intra- and interrater reliability. All four measurements of acetabular structure could not be reliably measured either within or between observers. We also introduced a new measurement based on the principle of Shenton's line to aid in the assessment of femoral-head location after reduction in patients with DDH; this was reliably determined both within and among observers.

Postreduction computed tomography in developmental dislocation of the hip: part II: predictive value for outcome

Computed tomographic (CT) scans were performed after closed reduction of 68 dislocated hips in 53 infants in spica casts with developmental hip dislocation (DDH). Ten measurements were made on the CT scans including acetabular indices and anteversion, hip-abduction angle, lateral and posterior displacement of the femur from the acetabulum, and femoral displacement from a modified Shenton's line drawn from the pubic rami. By using analysis of variance, the correlation of each variable with outcome after reduction was determined, including the development of avascular necrosis or the need for further surgery because of residual dysplasia. None of the variables was predictive of the outcome of persistent hip dysplasia. The subsequent development of avascular necrosis was statistically associated with hip-abduction angles >55 degrees as measured on postreduction CT scans, with 20% of the involved hips developing avascular necrosis on subsequent follow-up.

A New Mechanism for the Regulation of Stomatal Aperture Size in Intact Leaves (Accumulation of Mesophyll-Derived Sucrose in the Guard-Cell Wall of Vicia faba)

At various times after pulse-labeling broad bean (Vicia faba L.) leaflets with 14CO2, whole-leaf pieces and rinsed epidermal peels were harvested and subsequently processed for histochemical analysis. Cells dissected from whole leaf retained apoplastic contents, whereas those from rinsed peels contained only symplastic contents. Sucrose (Suc)-specific radioactivity peaked (111 GBq mol-1) in palisade cells at 20 min. In contrast, the 14C content and Sucspecific radioactivity were very low in guard cells for 20 min, implying little CO2 incorporation; both then peaked at 40 min. The guard-cell apoplast had a high maximum Suc-specific radioactivity (204 GBq mol-1) and a high Suc influx rate (0.05 pmol stoma-1 min-1). These and other comparisons implied the presence of (a) multiple Suc pools in mesophyll cells, (b) a localized mesophyll-apoplast region that exchanges with phloem and stomata, and (c) mesophyll-derived Suc in guard-cell walls sufficient to diminish stomatal opening by approximately 3 [mu]m. Factors expected to enhance Suc accumulation in guard-cell walls are (a) high transpiration rate, which closes stomata, and (b) high apoplastic Suc concentration, which is elevated when mesophyll Suc efflux exceeds translocation. Therefore, multiple physiological factors are integrated in the attenuation of stomatal aperture size by this previously unrecognized mechanism.

Measurement of tooth wear in patients with palatal erosion

AIM

To develop a reproducible method for the assessment of tooth wear in vivo using a laser profilometer.

DESIGN

A controlled study to measure tooth wear.

SUBJECTS AND METHODS

Wear was measured over a 6-month period in 13 patients with unexplained palatal dental erosion and compared with a group of 7 controls without any evidence of abnormal wear.

MAIN OUTCOME MEASURES

Metal disks were cemented to the tooth surface and impressions taken at 6-month intervals. Wear was estimated by scanning the impressions with a contacting laser profilometer and measuring a change in depth around the disk over a 6-month period using fixed reference points on the metal disks.

RESULTS

A statistically significant difference was observed between patients with palatal erosion and the controls. Patients with erosion had a median of 36.5 microns of wear over 6 months (range 17.6-108.2) and the controls had a median of 3.7 microns (range 0.5-15.8).

CONCLUSIONS

This paper presents a novel method for measuring erosion using fixed reference points cemented to the palatal surfaces of upper incisor teeth.

Oral regurgitation after reflux provoking meals: a possible cause of dental erosion?

Certain foods and drinks such as alcohol, heavily spiced or fatty meals are known to provoke gastro-oesophageal reflux (GOR). This may give rise to symptoms of heartburn, epigastric pain and occasionally oral regurgitation of the gastric contents. Oral regurgitation of gastric juice is important in dentistry because of its association with dental erosion. This study measured oesophageal and oral reflux in 12 healthy subjects after a curry meal taken with alcohol 2 h before sleep. Each subject repeated the test with a bland non-reflux provoking control meal. GOR was measured by recording distal and proximal oesophageal pH on a dual channel, portable pH monitor. Oral pH was measured with a pH sensitive radio-telemetry capsule (RTC) held on the palate in a vacuum formed splint. Signals from the RTC were received by an aerial worn around the head. The pH change produced by GOR was estimated as the percentage time that pH (PTpH) was less than 4 in the distal oesophagus. Similarly, the PTpH was estimated < 4 and < 5 in the proximal oesophagus and < 5.5 and < 6 in the mouth over a period of 16 h. All subjects tolerated the monitors overnight with little loss of data and data were collected from all studies. The curry meal provoked GOR in all subjects, but only in six subjects to pathological levels according to international guidelines. The results show that GOR measured as the PTpH < 4 was significantly higher in the distal oesophagus whilst subjects were supine after the curry meal than with the control meal (P = 0.0006) and in the proximal oesophagus in the upright position (P = 0.006). There was a significant difference in the oral PTpH < 5.5 between the two meals for the total study period (P = 0.005). The bland meal provoked pathological levels of reflux in only two subjects. In one of these subjects the bland meal provoked oral regurgitation with a PTpH < 5.5 of 13.5%. In the remaining subjects little oral regurgitation occurred.

A study of the association between gastro-oesophageal reflux and palatal dental erosion

Thirty-six patients aged 15-74 with palatal dental erosion where the aetiology was unclear were investigated for gastro-oesophageal reflux. Ten subjects without symptoms of reflux or palatal erosion acted as controls. Distal and proximal oesophageal reflux were measured over 24 hours by dual channel antimony electrodes. Oral pH was measured simultaneously over the same period by a radio-telemetry capsule held palatally in a vacuum formed splint. Data were logged onto two portable digitable recorders. Twenty-three patients (64%) with palatal erosion had pathological gastro-oesophageal reflux compared with standard criteria. More than 4% of the total percentage time that the pH is less than 4 in the distal oesophagus is internationally recognised by gastroenterologists as representing a pathological level of reflux. The median percentage time < pH 4 in the distal oesophagus for these patients was 5.7%, in the proximal oesophagus, pH 4 was 0.5% and pH < 5 was 3.1%. In the mouth, the results for the percentage time that the pH < 5.5 was 0.3% and < 6 was 4.4%. A relationship was observed between the pH < 4 in the distal oesophagus and the mouth pH < 5.5 (r = 0.47, P = 0.002) and pH < 6 (r = 0.34, p = 0.02). There was a relationship between oral acid exposure time pH < 6 and the tooth wear index (r = 0.37, P = 0.01). These results show that gastro-oesophageal reflux is strongly associated with palatal erosion and that some patients presenting with palatal dental erosion should be assessed for gastro-oesophageal reflux as a possible cause, even in the absence of clinical symptoms of reflux.

The relationship between gastro-oesophageal reflux disease and dental erosion

It is well known that acid regurgitated from the stomach into the mouth will erode teeth. Conditions such as anorexia and bulimia nervosa, chronic alcoholism and gastric disturbances cause palatal dental erosion. The common factor in these conditions is the role played by the stomach and oesophagus in the acid movement. Acid moving through the lower oesophageal sphincter into the oesophagus is described as gastro-oesophageal reflux (GOR). In some patients the acid movement becomes chronic, painful and requires treatment and is termed gastro-oesophageal reflux disease (GORD). It is felt by many gastroenterologists that GORD is a failure of the anti-reflux mechanism, which is predominantly controlled by the lower oesophageal sphincter (LOS). Regurgitation is the reflux of gastric juice through the upper oesophageal sphincter and into the oral cavity. Once the acid has reached the mouth the potential exists for damage to the teeth. This paper reviews the role of GOR, GORD and regurgitation in the aetiology of dental erosion.

The prevalence of toothwear in 1007 dental patients

The dental profession is becoming increasingly concerned about unacceptable levels of toothwear and there is an impression that the condition is becoming more prevalent. There is, as yet, little epidemiological evidence to illuminate the question and so this study is therefore intended to provide baseline data on the prevalence of toothwear in a sample of the dental attending population of South East England. A degree of toothwear is normal and progresses throughout life. Toothwear which is acceptable in an older age group would not be so with younger patients. It is therefore necessary to designate threshold values of acceptable levels of toothwear for different age groups to reach realistic conclusions about the prevalence of unacceptable levels of toothwear. Of the 1007 patients examined only nine had completely unworn dentitions. More than 93,500 tooth surfaces were examined and of these 5.1% had wear which exceeded the threshold values. Despite increasing the threshold values for the older age groups from those proposed in an earlier study by Smith & Knight (1984), these patients still had higher levels of unacceptable toothwear. There was a slight tendency for men to have more wear than women, but there was no clinically significant relationship between the number of missing posterior teeth and wear of the anterior teeth.

A personal, historical view of the management of tooth wear

The management of caries, periodontal disease and tooth wear has followed similar patterns over the last 30 years but at different rates. The reduced emphasis on surgery in the treatment of periodontal disease has now caught up with minimum interventive treatment of caries. Tooth wear is still, in my opinion, often over-treated and it is time that the management of tooth wear followed the same pattern.

Anorexia and bulimia nervosa (the eating disorders): conditions of interest to the dental practitioner

OBJECTIVES

This paper aims to give the dental practitioner an insight into the impact of the eating disorders on sufferers.

METHODS

A review of the psychiatric literature on the diagnosis, aetiology and treatment of these conditions is given.

CONCLUSIONS

The dental practitioner is in an ideal position to identify the warning signs of these conditions before they have attracted medical attention.

[Study on experimental cervical defect of human tooth by SEM]

Experimental cervical defects on 12 pairs of premolar caused by cross-brushing, erosion and occlusal force separately or together were observed under SEM Changes on the surface of cervical defects suggested that the defects were induced by the above three factors combined. It was interesting that various kinds of microcracks were noticed on sections of enamel and dentin at the cervical defect areas made by mimicking occlusal force combined with other factors. The results seemed to indicate that the occlusal force would play an important role on formation of the cervical wedge-shaped defect and that accumulation of the stress caused the hard tissue injured and microcracked.

Chronic alcoholism: an important condition in the dentist-patient relationship

OBJECTIVES

This paper aims to give the dental practitioner an insight into the impact of chronic alcoholism on sufferers.

METHODS

A review of the psychiatric and dental literature covering the aetiology, prevalence and complications is presented.

CONCLUSIONS

Chronic alcoholism has a number of serious medical and social problems which may affect the provision of dental treatment. It is important for the dental practitioner to be aware of the impact of this condition on patients as he or she may be in an ideal position to stop the alcoholic before a medical consultation has been sought.