Best practice guidelines for citizen science in mental health research: systematic review and evidence synthesis

Partnering with people most affected by mental health problems can transform mental health outcomes. Citizen science as a research approach enables partnering with the public at a substantial scale, but there is scarce guidance on its use in mental health research. To develop best practise guidelines for conducting and reporting research, we conducted a systematic review of studies reporting mental health citizen science research. Documents were identified from electronic databases (n = 10), grey literature, conference proceedings, hand searching of specific journals and citation tracking. Document content was organised in NVIVO using the ten European Citizen Science Association (ECSA) citizen science principles. Best practise guidelines were developed by (a) identifying approaches specific to mental health research or where citizen science and mental health practises differ, (b) identifying relevant published reporting guidelines and methodologies already used in mental health research, and (c) identifying specific elements to include in reporting studies. A total of 14,063 documents were screened. Nine studies were included, from Australia, Belgium, Canada, Denmark, Netherlands, Spain, the UK, and the United States. Citizen scientists with lived experience of mental health problems were involved in data collection, analysis, project design, leadership, and dissemination of results. Most studies reported against some ECSA principles but reporting against these principles was often unclear and unstated. Best practise guidelines were developed, which identified mental health-specific issues relevant to citizen science, and reporting recommendations. These included citizen science as a mechanism for empowering people affected by mental health problems, attending to safeguarding issues such as health-related advice being shared between contributors, the use of existing health research reporting guidelines, evaluating the benefits for contributors and impact on researchers, explicit reporting of participation at each research stage, naming the citizen science platform and data repository, and clear reporting of consent processes, data ownership, and data sharing arrangements. We conclude that citizen science is feasible in mental health and can be complementary to other participatory approaches. It can contribute to active involvement, engagement, and knowledge production with the public. The proposed guidelines will support the quality of citizen science reporting.

Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state

Background

The 100 mm visual analog scale (VAS) score is widely used to measure pain intensity after surgery. Despite this widespread use, it is unclear what constitutes the minimal clinically important difference (MCID); that is, what minimal change in score would indicate a meaningful change in a patient's pain status.

Methods

We enrolled a sequential, unselected cohort of patients recovering from surgery and used a VAS to quantify pain intensity. We compared changes in the VAS with a global rating-of-change questionnaire using an anchor-based method and three distribution-based methods (0.3 sd , standard error of the measurement, and 5% range). We then averaged the change estimates to determine the MCID for the pain VAS. The patient acceptable symptom state (PASS) was defined as the 25th centile of the VAS corresponding to a positive patient response to having made a good recovery from surgery.

Results

We enrolled 224 patients at the first postoperative visit, and 219 of these were available for a second interview. The VAS scores improved significantly between the first two interviews. Triangulation of distribution and anchor-based methods resulted in an MCID of 9.9 for the pain VAS, and a PASS of 33.

Conclusions

Analgesic interventions that provide a change of 10 for the 100 mm pain VAS signify a clinically important improvement or deterioration, and a VAS of 33 or less signifies acceptable pain control (i.e. a responder), after surgery.

The effect of bitewing radiography on estimates of dental caries experience among children differs according to their disease experience

BACKGROUND

Radiography is a regularly used and accepted adjunct to visual examination in the diagnosis of dental caries. It is assumed that not using radiographs can lead to underestimation of dental caries experience with most reports having involved studies of young adults or adolescents, and been focused on the permanent dentition. The aim of this study was to determine the relative contributions of bitewing radiography and clinical examination in the detection of dental caries in primary molars and to determine whether those contributions differ according to caries experience.

METHODS

A cross-sectional study was conducted, involving examinations undertaken in dental clinics. Bitewing radiographs taken at the time of the clinical examination were developed and read later, with the data from those used at the analysis stage to adjust the caries diagnosis for the mesial, occlusal and distal surfaces of the primary molar teeth. Children's clinically determined dmfs score was used to allocate them to one of three caries experience groups (0 dmfs, 1-8 dmfs, or 9+ dmfs).

RESULTS

Of the 501 three-to-eight-year-old children examined, nearly three-quarters were younger than six. Caries prevalence and mean dmfs after clinical examination alone and following radiographs were 63.1% and 4.6 (sd, 6.2), and 74.7% and 5.8 (sd, 6.5) respectively. Among children with a dmfs of 1-8, the number of lesions missed during the clinical examination was greater than the number of 106 (25.6%) in children with a dmfs of 9+. In the 185 children with no apparent caries at clinical examination, 124 lesions were detected radiographically, among 58 (46.8%) of those.

CONCLUSIONS

Taking bitewing radiographs in young children is not without challenges or risks, and it must be undertaken with these in mind. Diagnostic yields from bitewing radiographs are greater for children with greater caries experience. The findings of this study further support the need to consider using bitewing radiographs in young children to enhance the management of lesions not detected by a simple visual examination alone.

TRIAL REGISTRATION

ACTRN12614000844640 .

Regulation of the Urokinase Receptor by Its Plasminogen Activator

There is now ample evidence that the proteolytic action of urokinase (UK) is potentiated by a specific cell surface receptor. The present study was undertaken to assess the role of UK as a modulator of its receptor. GEO colonic cells, which secrete relatively low levels of UK (≃0.1 nM/72 h per 106 cells) and display approximately 104 receptors per cell, 10% of which are "tagged" with the endogenous plasminogen activator (PA), was selected for the study. A 90% reduction in the specific binding of radioactive DFP-UK was observed for cells cultivated in the presence of two-chain (TC) UK (M r 55,000). This only partly reflected occupation of the receptors with UK supplied in the culture medium, since the specific binding of the radioligand was still reduced by 60% after an acid pretreatment, which dissociates receptor-bound UK. The reduction in radioactive DFP-UK binding to cells treated with high molecular weight UK, either in the single or two-chain form, was both concentration and time dependent. Maximum reductions (70%) were achieved by treatment of the cells for 24 h with 1 nM of the plasminogen activator. In contrast, low molecular weight UK, which lacks part of the UK A chain, had no effect on ligand binding. Attenuation of radioactive DFP-UK binding to UK treated GEO cells was a consequence of a 60% reduction in the number of binding sites. Treatment of GEO cells with an antibody, which blocks the binding of endogenous UK to its receptor, augmented radioactive DFP-UK binding by two-fold. These data indicate that for one colonic cell line, at least, UK down-regulates its own binding site subsequent to it being bound to the receptor.

Expression of Urokinase and Its Receptor in Invasive and Non-Invasive Prostate Cancer Cell Lines

We previously reported that extracellular matrix invasion by the prostate cancer cell lines, PC-3 and DU-145 was contingent on endogenous urokinase being bound to a specific cell surface receptor. The present study was undertaken to characterize the expression of both urokinase and its receptor in the non-invasive LNCaP and the invasive PC-3 and DU-145 prostate cells. Northern blotting indicated that the invasive PC-3 cells, which secreted 10 times more urokinase (680 ng/ml per 106 cells per 48 h) than DU-145 cells (63 ng/ml per 106 cells per 48 h), had the most abundant transcript for the plasminogen activator. This, at least, partly reflected a 3 fold amplification of the urokinase gene in the PC-3 cells. In contrast, urokinase-specific transcript could not be detected in the non-invasive LNCaP cells previously characterized as being negative for urokinase protein. Southern blotting indicated that this was not a consequence of deletion of the urokinase gene. Crosslinking of radiolabelled aminoterminal fragment of urokinase to the cell surface indicated the presence of a 51 kDa receptor in extracts of the invasive PC-3 and DU-145 cells but not in extracts of the non-invasive LNCaP cells. The amount of binding protein correlated well with binding capacities calculated by Scatchard analysis. In contrast, the steady state level of urokinase receptor transcript was a poor predictor of receptor display. PC-3 cells, which were equipped with 25,000 receptors per cell had 2.5 fold more steady state transcript than DU-145 cells which displayed 93,000 binding sites per cell.

Temporal analysis of dissolution by-products and genotoxic potential of spherical zinc-silicate bioglass: "imageable beads" for transarterial embolization

Embolization of vascular tumors is an important tool in minimally invasive surgical intervention. Radiopaque, non-degradable, and non-deformable spherical zinc-silicate glass particles were produced in a range of 45-500 μm. Three size ranges (45-150, 150-300, and 300-500 μm) were used in the current study. The glass microspheres were eluted in polar (saline solution) and non-polar (dimethyl sulfoxide) medium, and ion release profiles were recorded using inductively coupled plasma atomic emission spectroscopy. Approximately 80% of Gaussian distribution was achieved by simple sieving. The ions released from the microspheres were dependent upon surface area to volume ratio as well as the nature of elution media. Greater ions were released from smaller particles (45-150 μm) having largest surface area in polar medium. For the genotoxicity bacterial mutation Ames assay, the concentrations of all the ions were well below their therapeutic concentration reported in the literature. No mutagenic effect was observed in the bacterial mutation Ames test. Hence, it can be concluded that the glass microspheres produced herein are non-mutagenic further supporting the materials potential as a suitable embolic agent.

A case report of Lemierre's Syndrome associated with dental sepsis

INTRODUCTION

Lemierre's syndrome is a potentially fatal condition characterised by spread of an oropharyngeal infection, resulting in thrombosis of the internal jugular vein. This leads to septicaemia and possible metastatic abscesses.

CASE PRESENTATION

We discuss the case of a previously healthy 17-year-old male who developed Lemierre's syndrome following dental sepsis. He presented with bilateral submandibular and submental swelling extending into the neck and chest. His management included a tracheostomy; incision and drainage of the abscesses; drainage of a pleural effusion and prolonged anticoagulant therapy.

CONCLUSION

The incidence of Lemierre's disease appears to be increasing and early diagnosis is essential. A high index of suspicion is needed in cases of oropharyngeal infection followed by fever, tender swelling of the neck and dysphagia - especially in young patients.

Novel adaptations to zinc-silicate glass polyalkenoate cements: the unexpected influences of germanium based glasses on handling characteristics and mechanical properties

Aluminum-free glass polyalkenoate cements (GPC) have been hindered for use as injectable bone cements by their inability to balance handling characteristics with mechanical integrity. Currently, zinc-based, aluminum-free GPCs demonstrate compression strengths in excess of 60MPa, but set in c. 1-2 min. Previous efforts to extend the setting reaction have remained clinically insufficient and are typically accompanied by a significant drop in strength. This work synthesized novel glasses based on a zinc silicate composition with the inclusion of GeO2, ZrO2, and Na2O, and evaluated the setting reaction and mechanical properties of the resultant GPCs. Germanium based GPCs were found to have working times between 5 and 10 min, setting times between 14 and 36 min, and compression strengths in excess of 30 MPa for the first 30 days. The results of this investigation have shown that the inclusion of GeO2, ZrO2, and Na2O into the glass network have produced, for the first time, an aluminum-free GPC that is clinically viable as injectable bone cements with regards to handling characteristics and mechanical properties.

Characterization of PLGA based composite nerve guidance conduits: effect of F127 content on modulus over time in simulated physiological conditions

PLGA/pluronic F127 based nerve guidance conduits (NGCs) for peripheral nerve regeneration offer excellent potential for clinical use. To date, little emphasis has been directed towards the effect of pluronic F127 on their subsequent mechanical properties as a function of degradation time or the physiological environment. This report was designed to redress the balance. This study synthesised 5 groups of 20wt% PLGA NGCs with varied additions of pluronic F127 (range 0-5wt%) to obtain Young's Moduli (E) in the range of 7-107MPa, depending on degradation conditions and pluronic F127 content.

In silico evaluation of stress distribution after vertebral body augmentation with conventional acrylics, composites and glass polyalkenoate cements

There exists clinical evidence of fractures in adjacent vertebrae subsequent to vertebral augmentation procedures, such as vertebroplasty (VP) and kyphoplasty (KP). A potential contributory factor to such fractures may be the excessive mismatch of mechanical properties between contemporary bone cements (i.e. polymethyl methacrylate (PMMA) and bisphenol-a-glycidyl dimethacrylate (BIS-GMA)) and bone. Aluminum-free glass polyalkenoate cements (GPCs) present an interesting alternative to conventional bone cements. GPCs adhere to the philosophy that implant materials should have mechanical characteristics similar to those of the bone, and also offer chemical adhesion and intrinsic bioactivity. However, their influence on the loading patterns of augmented vertebrae (as compared with conventional bone cements) is not available in the literature. The present work investigates how the moduli of PMMA, BIS-GMA and GPC implants affect the stress distribution within a single, augmented vertebra, in both healthy and osteoporotic states. Using a finite element model of the L4 vertebra derived from computed tomography data, with simulated augmentation, it was found that, as cement stiffness increased, stress was redistributed from the cortical and trabecular bone to the cement implant. The GPC implant exhibited the least effect on stress redistribution in both the healthy and osteoporotic models compared to its acrylic counterparts. The significance of this work is that, under simulated physiological loading conditions, aluminum-free GPCs exhibit stress distribution throughout the vertebral body similar to that of the healthy bone. In comparison to conventional augmentation materials, the use of aluminum-free GPCs in VP and KP may help to ameliorate the clinical complication of adjacent vertebral body compression fractures.

Composition-property relationships for an experimental composite nerve guidance conduit: evaluating cytotoxicity and initial tensile strength

The objective of this work was to examine the main (individual), combined (interaction) and second-order (quadratic) effects of: (i) poly(D,L-lactide-co-glycolide) (PLGA), (ii) F127, and (iii) a zinc-silicate based bioactive glass, on the cytotoxicity and ultimate tensile strength of an experimental nerve guidance conduit (NGC). The experimental plan was carried out according to a Box-Behnken design matrix. The effects of each compositional factor were quantified using response surface methodology (RSM) techniques. Linear and quadratic polynomial equations were developed to examine cytotoxicity (after incubation at 3, 7 and 28 days) and initial ultimate tensile strength (UTS(0)). Multiple regression analyses showed that the developed models yielded a good prediction for each response examined. It was observed that the beneficial effects of PLGA and bioactive glass on controlling cytotoxicity appeared greater than that of F127. Furthermore, the experimental conduits (with the exception of CNGC-I and CNGC-K) generally showed superior cytocompatibility when compared with the comparable literature for the clinically used nerve guidance conduit Neurolac(®). In this investigation, optimal compositions for cell viability were obtained for the following composition: PLGA = 18.89 wt%/F127 = 0.52 wt%/glass = 12.71 wt%. The optimization of composition with respect to ultimate tensile strength was also established (desired UTS(0) being based on the properties of the control device Neurolac(®) whose UTS is c.20 MPa). The desired UTS(0) of ≤ 20 MPa was found for the composition: PLGA = 18.63 wt%/F127 = 0.77 wt%/glass = 5.54 wt%. A UTS(0) ≤ 30 MPa was recorded for the composition: PLGA = 18.34 wt%/F127 = 0.62 wt%/glass = 9.83 wt%, such tensile strengths are comparable to, reported values for Neurolac(®). Examination of the composition-property relationships with respect to combining cell viability and UTS(0) indicated preferred compositions in the range 17.97-19.90 wt% PLGA, 0.16-1.13 wt% F127 and between 5.54 and ≤ 20 wt% glass. This research demonstrates the value of a design of experiments approach for the design of novel nerve guidance conduits, and shows that the materials examined may have potential for the repair of peripheral nerve discontinuities.

The effect of ionic dissolution products of Ca-Sr-Na-Zn-Si bioactive glass on in vitro cytocompatibility

Many commercial bone grafts cannot regenerate healthy bone in place of diseased bone. Bioactive glasses have received much attention in this regard due to the ability of their ionic dissolution products to promote cell proliferation, cell differentiation and activate gene expression. Through the incorporation of certain ions, bioactive glasses can become therapeutic for specific pathological situations. Calcium-strontium-sodium-zinc-silicate glass bone grafts have been shown to release therapeutic levels of zinc and strontium, however the in vitro compatibility of these materials is yet to be reported. In this study, the in vitro cytocompatibility of three different calcium-strontium-sodium-zinc-silicate glasses was examined as a function of their ion release profiles, using Novabone® bioglass as a commercial comparison. Experimental compositions were shown to release Si(4+) ranging from 1 to 81 ppm over 30 days; comparable or enhanced release in comparison to Novabone. The maximum Ca(2+) release detected for experimental compositions was 9.1 ppm, below that reported to stimulate osteoblasts. Sr(2+) release was within known therapeutic ranges, and Zn(2+) release ranged from 0.5 to 1.4 ppm, below reported cytotoxic levels. All examined glass compositions show equivalent or enhanced in vitro compatibility in comparison to Novabone. Cells exposed to BT112 ionic products showed enhanced cell viabilities indicating cell proliferation was induced. The ion release profiles suggest this effect was due to a synergistic interaction between certain combinations and concentrations of ions. Overall, results indicate that the calcium-strontium-sodium-zinc-silicate glass compositions show equivalent or even enhanced in vitro compatibility compared to Novabone®.

THE EFFECT OF MULTIPLE EMBOLI OF THE CAPILLARIES AND ARTERIOLES OF ONE LUNG

1. Injection of a suspension of potato starch cells into the left branch of the pulmonary artery, in quantity sufficient ordinarily to give rise to markedly accelerated respirations, resulted in no change in respiratory rate. 2. A method for injecting substances into the pulmonary artery or its branches without interfering with the blood flow to the lungs has been described. 3. Injection of similar material into one lung when the other is excluded from the circulation either by ligation or by temporary clamping does give rise to rapid and shallow breathing (from a rate of 10 to 15 per minute to one of 60 or over) identical in character to that brought about by introducing emboli into both lungs. 4. A method for clamping and releasing the pulmonary artery or its branches in a dog breathing normally with closed thorax has been devised. This is described in detail in another paper. 5. After rapid breathing has been initiated by the effect of emboli lodged in the arterioles and capillaries of the right lung, reestablishing the circulation in the other lung by releasing the clamp on its artery may or may not restore the respiratory rate to its original, normal level. 6. This discrepancy in results has not been correlated with any difference in oxygen saturation of the arterial blood, or in carbon dioxide tension or pH of its plasma. 7. It is, however, believed to be related to the gross and microscopic anatomy of the lung of which the artery has been temporarily clamped. Photomicrographs are published, showing in one dog (No. 3), in which the respiratory rate returned to normal, a normal histological picture of the left lung, and in another dog (No. 4), in which the rate remained rapid after release of the clamp, a picture characterized by congestion and dilatation of arterioles and capillaries. 8. The fact that accelerated respirations result from emboli in the pulmonary capillaries and arterioles only after a certain quantity of material has been introduced, and the fact that emboli in one lung do not occasion accelerated respirations unless the circulation through the other lung is occluded or abnormal, leads us to the conclusion that the phenomenon is not an irritative stimulus due to foreign bodies, but is in some manner related to (a) diminution of the pulmonary vascular bed, (b) resistance to the blood flow through the lungs or (c) congestion or dilatation of the arterioles and capillaries of the lungs.

Evaluation of a novel radiopacifiying agent on the physical properties of surgical spineplex

Polymethlylmethacrylate (PMMA) is the most frequently used cement for percutaneous vertebroplasty and kyphoplasty. To aid visualisation during surgery cements are doped with radiopacifying agents such as Barium sulphate (Ba(2)SO(4)) or Zirconium Dioxide (ZiO(2)). Mounting research suggests that these agents may impair the biocompatibility of the cements. However, incorporating an alternative radiopacifier agent with excellent biocompatibility would be a significant step forward. Bioactive radiopaque glasses incorporating elements such as strontium (Sr) and zinc (Zn), known to have beneficial and therapeutic effects on bone, are of great interest in this respect. In this study, the Ba(2)SO(4) of the commercially available Spineplex was incrementally replaced with a radiopaque therapeutic glass composition. The resulting effects on cement setting time, peak isotherm, ultimate compressive strength, Young's modulus (up to 30 days cement maturation) and radiopacity were evaluated. The substitution lead to an increase in cement setting time from 13.1 mins for Spineplex to 16.6-18.3 mins for the glass substituted cements. The peak exotherm during curing was reduced from 74 degrees C for Spineplex to a minimum of 51 degrees C for the fully substituted cement, indicating that reduced thermal necrosis in the in vivo setting is likely with these materials. Ultimate compressive strength and Young's modulus of each formulation showed no significant deterioration due to the substitution. Finally, the radiopacity of the substituted cements were reduced by up to a maximum of 18% in comparison to the control. However, the experimental formulations still maintained radiopacity equivalent to several millimetres of aluminium. As such the substituted cements had substantial equivalence to the Spineplex control. In order to assess the clinical relevance of these findings further investigation is warranted.

The effect of composition on ion release from Ca-Sr-Na-Zn-Si glass bone grafts

Controlled delivery of active ions from biomaterials has become critical in bone regeneration. Some silica-based materials, in particular bioactive glasses, have received much attention due to the ability of their dissolution products to promote cell proliferation, cell differentiation and activate gene expression. However, many of these materials offer little therapeutic potential for diseased tissue. Incorporating trace elements, such as zinc and strontium, known to have beneficial and therapeutic effects on bone may provide a more viable bone graft option for those suffering from metabolic bone diseases such as osteoporosis. Rational compositional design may also allow for controlled release of these active ions at desirable dose levels in order to enhance therapeutic efficacy. In this study, six differing compositions of calcium-strontium-sodium-zinc-silicate (Ca-Sr-Na-Zn-Si) glass bone grafts were immersed in pH 7.4 and pH 3 solutions to study the effect of glass composition on zinc and strontium release in a normal and extreme physiological environment. The zinc release levels over 30 days for all zinc-containing glasses in the pH 7.4 solution were 3.0-7.65 ppm. In the more acidic pH 3 environment, the zinc levels were higher (89-750 ppm) than those reported to be beneficial and may produce cytotoxic or negative effects on bone tissue. Strontium levels released from all examined glasses in both pH environments similarly fell within apparent beneficial ranges--7.5-3500 ppm. Glass compositions with identical SrO content but lower ZnO:Na(2)O ratios, showed higher levels of Sr(2+) release. Whereas, zinc release from zinc-containing glasses appeared related to ZnO compositional content. Sustainable strontium and zinc release was seen in the pH 7.4 environment up to day 7. These results indicate that the examined Ca-Sr-Na-Zn-Si glass compositions show good potential as therapeutic bone grafts, and that the graft composition can be tailored to allow therapeutic levels of ions to be released.

Comparison of failure mechanisms for cements used in skeletal luting applications

Glass Polyalkenoate Cements (GPCs) based on strontium calcium zinc silicate (Sr-Ca-Zn-SiO(2)) glasses and low molecular weight poly(acrylic acid) (PAA) have been shown to exhibit suitable compressive strength (65 MPa) and flexural strength (14 MPa) for orthopaedic luting applications. In this study, two such GPC formulations, alongside two commercial cements (Simplex P and Hydroset) were examined. Fracture toughness and tensile bond strength to sintered hydroxyapatite and a biomedical titanium alloy were examined. Fracture toughness of the commercial Poly(methyl methacrylate) cement, Simplex P, (3.02 MPa m(1/2)) was superior to that of the novel GPC (0.36 MPa m(1/2)) and the commercial calcium phosphate cement, Hydroset, for which no significant fracture toughness was obtained. However, tensile bond strengths of the novel GPCs (0.38 MPa), after a prolonged period (30 days), were observed to be superior to commercial controls (Simplex P: 0.07 MPa, Hydroset: 0.16 MPa).

Comparison of an experimental bone cement with a commercial control, Hydroset

Glass polyalkenoate cements based on strontium calcium zinc silicate glasses (Zn-GPCs) and high molecular weight polyacrylic acids (PAA) (MW; 52,000-210,000) have been shown to exhibit mechanical properties and in vitro bioactivity suitable for arthroplasty applications. Unfortunately, these formulations exhibit working times and setting times which are too short for invasive surgical applications such as bone void filling and fracture fixation. In this study, Zn-GPCs were formulated using a low molecular weight PAA (MW; 12,700) and a modifying agent, trisodium citrate dihydrate (TSC), with the aim of improving the rheological properties of Zn-GPCs. These novel formulations were then compared with commercial self-setting calcium phosphate cement, Hydroset, in terms of compressive strength, biaxial flexural strength and Young's modulus, as well as working time, setting time and injectability. The novel Zn-GPC formulations performed well, with prolonged mechanical strength (39 MPa, compression) greater than both vertebral bone (18.4 MPa) and the commercial control (14 MPa). However, working times (2 min) and rheological properties of Zn-GPCs, though improved, require further modifications prior to their use in minimally invasive surgical techniques.

Preliminary investigation of novel bone graft substitutes based on strontium-calcium-zinc-silicate glasses

Bone graft procedures typically require surgeons to harvest bone from a second site on a given patient (Autograft) before repairing a bone defect. However, this results in increased surgical time, excessive blood loss and a significant increase in pain. In this context a synthetic bone graft with excellent histocompatibility, built in antibacterial efficacy and the ability to regenerate healthy tissue in place of diseased tissue would be a significant step forward relative to current state of the art philosophies. We developed a range of calcium-strontium-zinc-silicate glass based bone grafts and characterised their structure and physical properties, then evaluated their in vitro cytotoxicity and in vivo biocompatibility using standardised models from the literature. A graft (designated BT109) of composition 0.28SrO/0.32ZnO/0.40 SiO(2) (mol fraction) was the best performing formulation in vitro shown to induce extremely mild cytopathic effects (cell viability up to 95%) in comparison with the commercially available bone graft Novabone (cell viability of up to 72%). Supplementary to this, the grafts were examined using the standard rat femur healing model on healthy Wister rats. All grafts were shown to be equally well tolerated in bone tissue and new bone was seen in close apposition to implanted particles with no evidence of an inflammatory response within bone. Complimentary to this BT109 was implanted into the femurs of ovariectomized rats to monitor the response of osteoporotic tissue to the bone grafts. The results from this experiment indicate that the novel grafts perform equally well in osteoporotic tissue as in healthy tissue, which is encouraging given that bone response to implants is usually diminished in ovariectomized rats. In conclusion these materials exhibit significant potential as synthetic bone grafts to warrant further investigation and optimisation.

Antibacterial coatings for medical devices based on glass polyalkenoate cement chemistry

A biofilm is an accumulation of micro-organisms and their extracellular products forming a structured community on a surface. Biofilm formation on medical devices has severe health consequences as bacteria growing in this lifestyle are tolerant to both host defense mechanisms and antibiotic therapies. However, silver and zinc ions inhibit the attachment and proliferation of immature biofilms. The objective of this study is to evaluate whether it is possible to produce silver and zinc-containing glass polyalkenoate cement (GPC) coatings for medical devices that have antibacterial activity and which may therefore inhibit biofilm formation on a material surface. Two silver and zinc-containing GPC coatings (A and B) were synthesised and coated onto Ti6Al4V discs. Their handling properties were characterised and atomic absorption spectrometery was employed to determine zinc and silver ion release with coating maturation up to 30 days. The antibacterial properties of the coatings were also evaluated against Staphylococcus aureus and a clinical isolate of Pseudomonas aeruginosa using an agar diffusion assay method. The majority of the zinc and silver ions were released within the first 24 h; both coatings exhibited antibacterial effect against the two bacterial strains, but the effect was more intense for B which contained more silver and less zinc than A. Both coatings produced clear zones of inhibition with each of the two organisms tested. In this assay, Ps. aeruginosa was more sensitive than S. aureus. The diameters of these zones were reduced after the coating had been immersed in water for varying periods due to the resultant effect on ion release.

Comparison of in vitro and in vivo Bioactivity of SrO—CaO—ZnO—SiO2 Glass Grafts

A range of calcium—strontium—zinc—silicate glass grafts are developed. Following characterization, their ability to form an apatite layer in simulated body fluid (SBF) is evaluated. Concurrently, their in vivo biocompatibility is determined. These glasses are incapable of forming an apatite layer in SBF. However, in vivo, each glass is well tolerated with new bone formation apparent in close apposition to implanted particles and no evidence of an inflammatory response. Such results are contrary to much of the literature and indicate that forecasting a materials ability to bond to bone based on SBF experiments may provide a false negative result.

Comparison of an experimental bone cement with surgical Simplex P, Spineplex and Cortoss

Conventional polymethylmethacrylate (PMMA) cements and more recently Bisphenol-a-glycidyl dimethacrylate (BIS-GMA) composite cements are employed in procedures such as vertebroplasty. Unfortunately, such materials have inherent drawbacks including, a high curing exotherm, the incorporation of toxic components in their formulations, and critically, exhibit a modulus mismatch between cement and bone. The literature suggests that aluminium free, zinc based glass polyalkenoate cements (Zn-GPC) may be suitable alternative materials for consideration in such applications as vertebroplasty. This paper, examines one formulation of Zn-GPC and compares its strengths, modulus, and biocompatibility with three commercially available bone cements, Spineplex, Simplex P and Cortoss. The setting times indicate that the current formulation of Zn-GPC sets in a time unsuitable for clinical deployment. However during setting, the peak exotherm was recorded to be 33 degrees C, the lowest of all cements examined, and well below the threshold level for tissue necrosis to occur. The data obtained from mechanical testing shows the Zn-GPC has strengths of 63 MPa in compression and 30 MPa in biaxial flexure. Importantly these strengths remain stable with maturation; similar long term stability was exhibited by both Spineplex and Simplex P. Conversely, the strengths of Cortoss were observed to rapidly diminish with time, a cause for clinical concern. In addition to strengths, the modulus of each material was determined. Only the Zn-GPC exhibited a modulus similar to vertebral trabecular bone, with all commercial materials exhibiting excessively high moduli. Such data indicates that the use of Zn-GPC may reduce adjacent fractures. The final investigation used the well established simulated body fluid (SBF) method to examine the ability of each material to bond with bone. The results indicate that the Zn-GPC is capable of producing a bone like apatite layer at its surface within 24 h which increased in coverage and density up to 7 days. Conversely, Spineplex, and Simplex P exhibit no apatite layer formation, while Cortoss exhibits only minimal formation of an apatite layer after 7 days incubation in SBF. This paper shows that Zn-GPC, with optimised setting times, are suitable candidate materials for further development as bone cements.

Zinc-based glass polyalkenoate cements with improved setting times and mechanical properties

The suitability of glass polyalkenoate cements (GPCs) for skeletal applications is limited by the presence, in the glass phase, of the aluminium ion (Al3+), a neurotoxin. The zinc ion (Zn2+), a bacteriocide, has been incorporated into aluminium-free GPCs based on zinc silicate glasses. However, these GPCs have considerably shorter working times and poorer mechanical properties than their Al3+-containing counterparts. Based on results for calcium phosphate cements, there is an indication that mixing a GPC with an organic compound, tricalcium citrate (TSC), may lead to cements with improved rheological and mechanical properties. We developed a range of Zn-based GPCs and determined their working times (Tw), setting times (Ts), compressive strength (CS) and biaxial flexural strengths (BFS). A GPC composed of 1g of a calcium-zinc silicate glass (BT100) mixed with a 50wt.% aqueous solution on polyacrylic acid (coded E9, Mw 80,800) at a powder liquid ratio of 2:1.5 exhibited the best combination of Tw, Ts, CS and BFS. We also found that the addition of TSC (over the range 5-15wt.%) to a GPC led to significant increases in both Tw (from 40+/-3 to 100+/-4s) and Ts (from 70+/-2 to 3000+/-4s) accompanied by changes in both CS and BFS that were affected by the duration of the aging time of the specimens in distilled water (for example, after aging for 7 days CS dropped from 62+/-2 to 17+/-1MPa, while after aging for 30 days, BFS increased 27+/-6 to 31+/-7MPa and then dropped to 17+/-1MPa). Future modification and characterization of the examined GPCs are needed before they may be considered as candidates for orthopaedic applications.

Calcium and zinc ion release from polyalkenoate cements formed from zinc oxide/apatite mixtures

Calcium and zinc ion release from hydroxyapatite-zinc oxide-poly(acrylic acid) (HAZnO-PAA) composite cements into deionised water was investigated as a function of HA content, PAA concentration, PAA molecular weight and maturation time. At any given maturation time, zinc ion release was constant until the HA content was at the maximum loading (60 wt%) resulting in the cement matrix breaking up, allowing exacerbated ion release. The calcium ion release increased with increased HA content in the composite until the maximum loading where the release drops off. Up to this point, the release of both ionic species was proportional to square root time for the initial 24 hour period, indicating that the release is diffusion controlled. In agreement with related data from conventional Glass Polyalkenoate Cements (GPCs), it is the concentration of the PAA, not the molecular weight, that influences ion release from these materials. However, unlike GPCs, the release of the active ions results in a pH rise in the deionised water, more conventionally seen with Bioglass and related bioactive glasses. It is this pH rise, caused by the ion exchange of Zn(2+) and Ca(2+) for H(+) from the water, leaving an excess of OH(-), that should result in a favourable bioactive response both in vitro and in-vivo.

The antibacterial effects of zinc ion migration from zinc-based glass polyalkenoate cements

Zinc-based glass polyalkenoate cements have been synthesised and their potential use in orthopaedic applications investigated. Zinc ions were released from the materials in a rapid burst over the first 24 h after synthesis, with the release rate falling below detectable levels after 7 days. Cement-implanted bone samples were prepared and the released zinc was shown, using energy dispersive X-ray analysis, to penetrate from the cement into the adjacent bone by up to 40 microm. Finally, the cements exhibited antibacterial activity against Streptococcus mutans and Actinomyces viscosus that reflected the pattern of zinc release, with the inhibition of growth greatest shortly after cement synthesis and little or no inhibition measureable after 30 days.

An investigation into the structure and reactivity of calcium-zinc-silicate ionomer glasses using MAS-NMR spectroscopy

The suitability of Glass Polyalkenoate Cements (GPCs) for orthopaedic applications is retarded by the presence in the glass phase of aluminium, a neurotoxin. Unfortunately, the aluminium ion plays an integral role in the setting process of GPCs and its absence is likely to hinder cement formation. However, the authors have previously shown that aluminium-free GPCs may be formulated based on calcium zinc silicate glasses and these novel materials exhibit significant potential as hard tissue biomaterials. However there is no data available on the structure of these glasses. (29)Si MAS-NMR, differential thermal analysis (DTA), X-ray diffraction (XRD), and network crosslink density (CLD) calculations were used to characterize the structure of five calcium zinc silicate glasses and relate glass structure to reactivity. The results indicate that glasses capable of forming Zn-GPCs are predominantly Q(2)/Q(3) in structure with corresponding network crosslink densities greater than 2. The correlation of CLD and MAS-NMR results indicate the primary role of zinc in these simple glass networks is as a network modifier and not an intermediate oxide; this fact will allow for more refined glass compositions, with less reactive structures, to be formulated in the future.