Systematic Review of Patient-Reported Outcome Measures in Locally Recurrent Rectal Cancer

BACKGROUND

The availability of high-quality patient-reported outcome (PRO) data is crucial to guiding shared decision-making in the context of locally recurrent rectal cancer (LRRC), where potential treatment benefits must be balanced against the impact of both the disease and treatment on PROs, such as quality of life. This review aimed to identify the patient-reported outcome measures (PROMs) currently being reported in LRRC and to appraise the methodological quality of studies using these measures.

METHODS

PubMed, Embase and CINAHL databases were searched, including studies published up until 14th September 2022. Studies in adults with LRRC reporting PROMS as a primary or secondary outcome measure were included. Data were extracted concerning the methodological quality of the reporting of PROMs using criteria informed by the CONSORT-PRO checklist and the psychometric properties of the PROMs identified using the COSMIN Risk of Bias checklist.

RESULTS

Thirty-five studies including 1914 patients with LRRC were identified. None of the studies included in the review met all eleven criteria for the quality of reporting of PROMs. Seventeen PROMs and two clinician-reported outcome measures were identified, none of which have been validated for use in patients with LRRC.

CONCLUSIONS

None of the PROMs which are currently being used to report PROs in LRRC have been validated for use in this cohort of patients. Future studies in this disease area should focus on utilising PROMs that have undergone a robust development process including patients with LRRC, to produce data which is high quality, accurate and relevant.

The current status of robotic colorectal surgery training programmes

Robotic-assisted colorectal surgery (RACS) is steadily increasing in popularity with an annual growth in the number of colorectal procedures undertaken robotically. Further upscaling of RACS requires structured and standardised robotic training to safeguard high-quality clinical outcomes. The aims of this systematic review were to assess the structure and assessment metrics of currently established RACS training programmes. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines was performed. Searches were performed of the Ovid Medline, Embase and Web of Science databases between 2000 and 27th November 2021 to identify studies reporting on training curricula in RACS. Core components of training programmes and their relevant outcome assessment metrics were extracted. Thirteen studies were identified, with all training programmes designed for the da Vinci platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Common elements of multimodal programmes included theoretical knowledge (76.9%), case observation (53.8%), simulation (100%) and proctored training (76.9%). Robotic skills acquisition was assessed primarily during the simulation phase (n = 4, 30.1%) and proctoring phase (n = 10, 76.9%). Performance metrics, consisting of time or assessment scores for VR simulation were only mandated in four (30.1%) studies. Objective assessment following proctored training was variably reported and employed a range of assessment metrics, including direct feedback (n = 3, 23.1%) or video feedback (n = 8, 61.5%). Five (38.4%) training programmes used the Global Assessment Score (GAS) forms. There is a broad consensus on the core multimodal components across current RACS training programmes; however, validated objective assessment is limited and needs to be appropriately standardised to ensure reproducible progression criteria and competency-based metrics are produced to robustly assess progression and competence.

The impact of multidisciplinary team decision-making in locally advanced and recurrent rectal cancer

INTRODUCTION

Appropriate patient selection within the context of a multidisciplinary team (MDT) is key to good clinical outcomes. The current evidence base for factors that guide the decision-making process in locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) is limited to anatomical factors.

METHODS

A registry-based, prospective cohort study was undertaken of patients referred to our specialist MDT between 2015 and 2019. Data were collected on patients and disease characteristics including performance status, Charlson Comorbidity Index, the English Index of Multiple Deprivation quintiles and MDT treatment decision. Curative treatment was defined as neoadjuvant treatment and surgical resection that would achieve a R0 resection, and/or complete treatment of distant metastatic disease. Palliative treatment was defined as non-surgical treatment.

RESULTS

In total, 325 patients were identified; 72.7% of patients with LARC and 63.6% of patients with LRRC were offered treatment with curative intent (p = 0.08). Patients with poor performance status (PS > 2; p < 0.001), severe comorbidity (p < 0.001), socio-economic deprivation (p = 0.004), a positive predictive circumferential resection margin (p = 0.005) and metastatic disease (p < 0.001) were associated with palliative treatment. Overall survival in the curative cohort was 49 months (95% confidence interval [CI] 32.4-65.5) compared with 12 months (95% CI 9.1-14.9) in the palliative cohort (p < 0.001). The presence of metastatic disease was identified as a prognostic factor for patients undergoing curative treatment (p = 0.05). The only prognostic factor identified in patients treated palliatively was performance status (p < 0.001).

CONCLUSIONS

Our study identifies a number of preoperative, prognostic factors that affect MDT decision-making and overall survival.

Scrapie infection and endogenous retroviral expression in sheep lymphoid tissues

Transmissible spongiform encephalopathies, or prion diseases, are fatal neurodegenerative diseases affecting humans and animals. Although many host tissues express PrPC (essential for prion replication), relatively few cell types accumulate significant levels of infectivity, including neurons and other cell types in the nervous system, and follicular dendritic cells in secondary lymphoid organs. This suggests that tissue or cell-specific receptors or cofactors could play a role in controlling differential susceptibility to infection. Endogenous retroviruses (ERV), the remnants of ancient retroviral integration into the host germline, may represent one such cofactor. We examined the effect of scrapie infection on expression of three ovine ERV families (enJSRV/β1-OERV, γ1-OERV, γ2-OERV) in secondary lymphoid tissues of sheep at different time points following subcutaneous inoculation, using RT-qPCR. These OERVs were constitutively expressed in the prescapular lymph node and spleen of uninfected sheep. However, we were unable to find convincing evidence of specific differential expression of OERV in the same tissues following scrapie infection, in contrast to previous studies of ERV expression in brains of prion-infected mice and macaques. This study is the first to quantify the expression of potentially functional OERV transcripts in sheep lymphoid tissues, opening up interesting questions about the consequences for host immune function.

Creutzfeldt-Jakob disease and blood transfusion safety

Transmissible spongiform encephalopathies (TSEs) are untreatable, fatal neurologic diseases affecting mammals. Human disease forms include sporadic, familial and acquired Creutzfeldt-Jakob disease (CJD). While sporadic CJD (sCJD) has been recognized for near on 100 years, variant CJD (vCJD) was first reported in 1996 and is the result of food-borne transmission of the prion of bovine spongiform encephalopathy (BSE, 'mad cow disease'). Currently, 230 vCJD cases have been reported in 12 countries, the majority in the UK (178) and France (27). Animal studies demonstrated highly efficient transmission of natural scrapie and experimental BSE by blood transfusion and fuelled concern that sCJD was potentially transfusion transmissible. No such case has been recorded and case-control evaluations and lookback studies indicate that, if transfusion transmission occurs at all, it is very rare. In contrast, four cases of apparent transfusion transmission of vCJD infectivity have been identified in the UK. Risk minimization strategies in response to the threat of vCJD include leucodepletion, geographically based donor deferrals and deferral of transfusion recipients. A sensitive and specific, high-throughput screening test would provide a potential path to mitigation but despite substantial effort no such test has yet appeared. The initial outbreak of vCJD appears to be over, but concern remains about subsequent waves of disease among those already infected. There is considerable uncertainty about the size of the infected population, and there will be at least a perception of some continuing risk to blood safety. Accordingly, at least some precautionary measures will remain in place and continued surveillance is necessary.

Use of a preclinical test in the control of classical scrapie

Scrapie control in Great Britain (GB) was originally based on the National Scrapie Plan's Ram Genotyping scheme aimed at reducing the susceptibility of the national flock. The current official strategy to control scrapie in the national flock involves culling susceptible genotypes in individual, known affected flocks (compulsory scrapie flock scheme or CSFS). However, the recent development of preclinical test candidates means that a strategy based on disease detection may now be feasible. Here, a deterministic within-flock model was used to demonstrate that only large flocks with many home-bred ewes are likely to be a significant risk for flock-to-flock transmission of scrapie. For most other flocks, it was found that the CSFS could be replaced by a strategy using a currently available live test without excessive risk to other farmers, even if the proportion of susceptible genotypes in the flock is unusually large. Even for flocks that represent a high risk of harbouring a high prevalence of infection, there would be limited probability of onward transmission if scrapie is detected soon after disease introduction (typically less than 5 years). However, if detection of disease is delayed, the existing CSFS strategy may be the most appropriate control measure in these cases.

Patient satisfaction relating to implant treatment by undergraduate and postgraduate dental students--a pilot study

Recordings of patient satisfaction with provision of dental implant treatment are scarce. This study aimed to evaluate satisfaction amongst patients attending for provision of implant treatment by training undergraduate and postgraduate students at Dublin Dental School and Hospital (DDSH). A questionnaire was formulated and distributed to 100 individuals randomly selected from records of patients who had received implant treatment via student clinics in the previous 5 years. The response rate was 68%. Results showed a high overall level of satisfaction with treatment received.

Pathological phenotype of sheep scrapie after blood transfusion

Blood transfusion practices have resulted in iatrogenic cases of variant Creutzfeldt-Jakob disease (vCJD) and it is known that sheep blood is also infectious in the pre-clinical stages of natural scrapie and experimentally induced bovine spongiform encephalopathy (BSE). Further investigations have also shown that the pathological phenotype of sheep BSE and human vCJD is maintained after blood transfusion. The present study describes the pathological phenotype, in terms of accumulation of the disease-associated prion protein in brain and lymphoreticular tissues, in sheep receiving blood from donors infected with natural scrapie. The immunohistochemical examinations undertaken showed a degree of phenotypic variability within and between scrapie donors and recipients, which might be attributable to the presence of more than one scrapie strain amongst the donor sheep or to a host adaptation process, or to the interaction of both, rather than to the influence of the route of infection.

Pathogenetical significance of porencephalic lesions associated with intracerebral inoculation of sheep with the bovine spongiform encephalopathy (BSE) agent

Decreased rates of transmission of transmissible spongiform encephalopathies (TSEs) to sheep have been attributed to some polymorphisms of the prion protein (PrP) and to a 'species barrier' on interspecies experiments. In addition, the blood-brain barrier may be a further impediment to TSE neuroinvasion. The intracerebral (I/C) route is generally considered the most efficient for TSE transmission, as it may help to bypass those factors. Therefore, susceptibility of particular species to specific TSE agents is conducted by this route.

AIMS

This study characterizes the traumatic brain lesions associated with the I/C injection of the bovine spongiform encephalopathy agent in sheep, assesses the relevance of such lesions in the outcome of clinical disease and provides insight into the mechanisms of PrP(d) conversion and amplification following I/C challenge.

METHODS

A total of 27 hemibrains have been macroscopically and immunohistochemically examined to investigate the presence of lesions compatible with the needle track and the PrP(d) distribution, respectively.

RESULTS

No residual inoculum was found and the extension and severity of the traumatic brain lesions were unrelated to the clinical outcome. Sheep with PrP(d) accumulation in the brain also showed conspicuous focal aggregates in the porencephalic lesions and in the circumventricular organs. In contrast, sheep without PrP(d) deposits in the brain were also negative in the traumatic lesions.

CONCLUSION

Overall, these findings suggest that the efficiency of the I/C route is due to effective absorption and blood recirculation of infection, rather than to primary amplification at the site of injection.

Use of a new immunoassay to measure PrP Sc levels in scrapie-infected sheep brains reveals PrP genotype-specific differences

The diagnosis of prion diseases, such as scrapie and BSE, has traditionally relied upon the identification of the disease-associated form of the prion protein, PrP(Sc), based on its resistance to digestion by proteinase K (PK). A more recent development is the conformation-dependent immunoassay (CDI), which distinguishes between PrP Sc and normal PrP (PrP C) based on their differing solubility in guanidine hydrochloride rather than resistance or sensitivity to PK. We have developed a CDI-formatted sandwich immunoassay for the measurement of PrP Sc in sheep brain, which discriminates between clinically affected scrapie cases (natural or experimental) and uninfected controls of the same PrP genotype. Using this method, we have shown for the first time that, in sheep, the PrP genotype has a significant influence on the amount of PrP Sc deposited in the brains of animals experimentally infected with scrapie.

Expression of PrPC on cellular components of sheep blood

PrPC, a glycosylphosphatidylinositol-linked glycoprotein, plays a central role in the pathogenesis of transmissible spongiform encephalopathies (TSEs), undergoing a conformational alteration to the disease-associated isoform, commonly designated PrPSc. PrPC is expressed in many tissues other than the nervous system, although its precise function(s) remains unclear. It has previously been demonstrated that TSEs can be transmitted by blood transfusion in sheep. The aim of this work was to identify which components of blood carried the infection. As an initial step, the distribution of PrPC on cellular components of sheep blood was examined to identify potential targets for infection. Cell-surface expression of PrPC was found only on peripheral blood mononuclear cells (PBMCs); however, platelets also contained significant amounts of intracellular PrPC. The level of PrPC expressed on the cell surface of PBMCs was influenced by PrP genotype, with the highest levels found in scrapie-susceptible VRQ/VRQ sheep and the lowest levels in scrapie-resistant ARR/ARR sheep. In susceptible sheep, PrPC was expressed at varying levels on all major subsets of PBMCs, with the highest levels on the CD21+ subset of B cells, and PrP expression was upregulated dramatically on CD21+ B cells in some scrapie-infected sheep.

Epidemiological implications of the susceptibility to BSE of putatively resistant sheep

The experimental infection of sheep with bovine spongiform encephalopathy (BSE) by the oral route and the likelihood that sheep were fed BSE-infected meat and bone meal has led to extensive speculation as to whether or not sheep are naturally infected with BSE. In response, the UK government has initiated the National Scrapie Plan (NSP), an ambitious £120 million per year project to create a BSE- and scrapie-resistant national sheep flock, by selectively breeding for a genotype of sheep believed to be resistant to both diseases. This genotype has recently been shown to be susceptible to BSE by intracerebral (i.c.) inoculation. Should these sheep be sufficiently susceptible to BSE via natural transmission, the NSP might fail. Here we estimate the susceptibility of this genotype to horizontal (sheep-to-sheep) transmission of BSE by comparison with more extensive oral and i.c. exposure data for other sheep genotypes. We show that a previous estimate of the risk of BSE transmission to sheep via the feedborne route remains robust. However, using a mathematical model for the within-flock transmission of BSE, we show that, while the best estimate indicates that the NSP should be successful, current data cannot exclude the failure of the NSP.

Can prion diseases be transmitted between individuals via blood transfusion: evidence from sheep experiments

We have shown that it is possible to transmit bovine spongiform encephalitis (BSE) to a sheep by transfusion with whole blood taken from another sheep during the pre-clinical phase of an experimental BSE infection when the donor animal appears healthy. BSE and new variant Creutzfeld-Jakob disease (vCJD) in humans are caused by the same infectious agent and the sheep-BSE experimental model has similar pathogenesis, with involvement of the lymphoreticular system, to that of human vCJD. Although we have had only one case of positive transmission of BSE out of a total of 21 transfusions, our studies remain incomplete and further cases could occur. Our studies, however, reinforce the possibility that whole blood donated by pre-clinical vCJD-infected humans may represent a risk of spreading vCJD infection among the human population of the U.K.

Scrapie epidemic in a fully PrP-genotyped sheep flock

In scrapie-affected sheep flocks, host PrP genotype plays a vital role in determining which sheep will succumb to scrapie and the incubation period. Consequently, within-flock scrapie dynamics is best understood within the context of the genotype profile of the flock. Here we describe a 17 month epidemic of scrapie in a commercially farmed flock of 230 genotyped Texel sheep. At the start of the study, 70% of the sheep were of three genotypes only: ARR/ARQ, ARH/ARQ and ARQ/ARQ. Only 15% of sheep encoded the disease-associated VRQ allele and only a single sheep (0.4%) was of the most susceptible VRQ/VRQ genotype. For susceptible genotypes there was a marked deficit (P<0.025) of older animals (> or =3 years), implying that some cases of scrapie had occurred previously. In the ensuing 17 months, 18 sheep of known genotype were confirmed positive for the disease: seven VRQ/ARQ, six VRQ/ARH, two VRQ/ARR, three ARQ/ARQ. Median ages at death were 2.7, 2.8, 4.2 and 3.8 years respectively. Mortality rates were 55, 86, 13 and 3% respectively. Survival analysis revealed a highly significant effect of genotype on survivorship, but no difference between VRQ/ARQ and VRQ/ARH, or between VRQ/ARR and ARQ/ARQ. There was no difference in the survivorship of middle- and older-age cohorts of susceptible sheep. Scrapie risk group (as defined by PrP genotype) was not associated with submission as a scrapie suspect but later found to be negative, or with dying of unknown causes on the farm.

Vacuolar lesion profile in sheep scrapie: factors influencing its variation and relationship to disease-specific PrP accumulation

Detailed neuropathological examination for vacuolar lesions was performed on the brains of 42 sheep with clinical signs compatible with scrapie. The sheep were grouped according to their breed (Poll-Dorset, Cheviot, Welsh Mountain, Shetland and Suffolk), their PrP genotype at codons 136, 154 and 171 (VRQ/VRQ, VRQ/ARQ, VRQ/ARR and ARQ/ARQ) and the type of infection (experimental infection with SSBP/1, or natural disease). Twenty-two neuroanatomical sites from seven brain regions were examined for vacuolation in the neuropil and five sites at the level of the obex were examined for intraneuronal vacuolation. In 36 sheep, immunohistochemical examination for disease-specific PrP (PrP(d)) accumulation had also been performed in the same brain regions in an earlier study. The magnitude of total neuropil vacuolation was highest in the naturally affected ARQ/ARQ Suffolk sheep and lowest in the experimentally infected VRQ/VRQ Cheviot sheep and VRQ/ARR Poll-Dorset sheep. The severity of neuropil vacuolation at nine of the 22 neuroanatomical sites examined was used to generate a vacuolar lesion profile, which showed variations between the different sheep groups. These variations could be attributed to both PrP genotype and sheep breed and also possibly to scrapie agent; there was, however, considerable individual variation in lesion profile within sheep groups. All groups showed a similar ratio of neuropil vacuolation to neuronal vacuolation at the level of the obex. Although a positive correlation between neuropil vacuolation and PrP(d) deposition was generally observed, it was low except for the astrocyte-associated pattern of PrP(d) accumulation. The study suggests that vacuolar lesion profiles in sheep are affected by several factors and, by comparison with lesion profiles in mice, are of no more than limited value for discriminating between scrapie strains.

Effects of agent strain and host genotype on PrP accumulation in the brain of sheep naturally and experimentally affected with scrapie

Different cellular and neuroanatomical types of disease-specific prion protein (PrP(d)) accumulation in the brain were identified in sheep of different breeds and PrP genotypes exposed to experimental or natural scrapie infection. Immunohistochemical examination of the brains of 43 sheep with clinical signs compatible with scrapie revealed 12 different PrP(d)types, which were subjectively quantified in eight different brain regions. The PrP(d)types were grouped into four PrP(d)patterns, the relative magnitude of which provided the PrP(d)profile of each sheep examined. The analysis of the differences in magnitude and relative proportion of each of these PrP(d)types and patterns indicated (1) an effect of the scrapie strain on the PrP(d)profile, and (2) a possible effect of the host genotype on the magnitude of PrP(d)accumulation in the brain, apparently related to the incubation period. Furthermore, intraneuronal deposition of PrP(d)was the type most closely associated with the development of clinical disease. We conclude that different scrapie strains can be distinguished by PrP immunohistochemical examination of brains of affected animals.

The signature of scrapie: differences in the PrP genotype profile of scrapie-affected and scrapie-free UK sheep flocks

The amino-acid sequence of the PrP protein plays an important role in determining whether sheep are susceptible to scrapie. Although the genetics of scrapie susceptibility are now well understood, there have been few studies of the PrP gene at the population level, especially in commercially farmed sheep. Here we describe the PrP genetic profiles of the breeding stock of four UK sheep flocks, comprising nearly 650 animals in total. Two flocks had been scrapie affected for about eight years and two were scrapie free. Scrapie-resistant PrP genotypes predominated in all flocks but highly susceptible genotypes were present in each case. The distribution of PrP genotypes was similar in the scrapie-affected and scrapie-free flocks. The former, however, showed a slight but significant skew towards more susceptible genotypes despite their previous losses of susceptible sheep. Surprisingly, this skew was apparent in younger, but not older, sheep. We suggest that these patterns may occur if sheep flocks destined to become scrapie affected are predisposed by a genetic profile skewed towards susceptibility. The age structure of the scrapie-affected flocks suggests that the number of losses attributable directly or indirectly to scrapie considerably exceeds that recognized by the farmers, and also that significant losses may occur even in sheep of a moderately susceptible genotype. Similar patterns were not detected in the scrapie-free flocks, indicating that these losses are associated with scrapie infection as well as genotype.

Chronic treatment of old rats with donepezil or galantamine: effects on memory, hippocampal plasticity and nicotinic receptors

The function of the cholinergic system is known to change during normal aging and in pathological conditions such as Alzheimer's disease. The present study was designed to assess, within the same group of old animals, the behavioral, electrophysiological and neurochemical effects of chronic treatment with agents that increase the function of the cholinergic system through both muscarinic and nicotinic mechanisms. Doses were determined that produced 60% cholinesterase inhibition by donepezil and galantamine for the old rats. This was chosen to be analogous to therapeutic levels achieved for treatment of human Alzheimer's disease patients with these agents. Because of the well-known age-related changes in spatial memory and hippocampal synaptic plasticity, spatial working memory in the radial eight-arm maze and hippocampal long-term potentiation induction and decay, as well as nicotinic receptor density and affinity, were measured in old rats implanted with minipumps that delivered donepezil, galantamine or saline. There was no effect of drug treatment on baseline synaptic transmission or on the threshold or magnitude of long-term potentiation induction. Both drug treatment groups, however, showed significantly extended long-term potentiation decay times at the perforant path-granule cell synapse over the saline control animals, as measured during the week following induction. Both drugs also elevated the number of nicotinic receptors within the hippocampus and neocortex. This is the first demonstration of cholinergic modulation of synaptic plasticity over the time-course of days. Furthermore, the durability of long-term potentiation was significantly, positively correlated with nicotinic receptor binding in the hippocampus. Chronic treatment with donepezil or galantamine had no significant effect on a well-learned spatial working memory task on the radial maze. These data suggest that the therapeutic doses of cholinesterase inhibitors used to treat patients with Alzheimer's disease may have effects on neurophysiology and neurochemistry that are close to the threshold for producing detectable behavioral improvements.

Transmission of BSE by blood transfusion in sheep

We have shown that it is possible to transmit bovine spongiform encephalopathy (BSE) to a sheep by transfusion with whole blood taken from another sheep during the symptom-free phase of an experimental BSE infection. BSE and variant Creutzfeldt-Jakob disease (vCJD) In human beings are caused by the same infectious agent, and the sheep-BSE experimental model has a similar pathogenesis to that of human vCJD. Although UK blood transfusions are leucodepleted--a possible protective measure against any risk from blood transmission--this report suggests that blood donated by symptom-free vCJD-infected human beings may represent a risk of spread of vCJD infection among the human population of the UK.

The fit of cast and premachined implant abutments

STATEMENT OF PROBLEM

There is insufficient information regarding the adaptation of abutments to implants.

PURPOSE

This study assessed the adaptation of premachined, cast, and laboratory modified premachined abutments to implants at two sites: abutment/implant interface and screw to screw seat.

MATERIAL AND METHODS

Six combinations of abutments and implants were studied: CeraOne abutments joined to Nobel Biocare implants; STR (Implant Innovations Inc.) abutments joined to 31 implants; Cast UCLA (31) abutments subjected to porcelain firing cycles and joined to 31 implants; Cast UCLA abutments subjected to porcelain firing cycles and joined to Nobel Biocare implants; UCLA premachined abutments cast with gold palladium alloy and subjected to porcelain firing cycles (later joined to 31 implants); and UCLA premachined abutments joined to 31 implants. Each group contained five assemblies.

RESULTS

The adaptation of abutments to implants was closer and the amounts of contact larger for assemblies with premachined and laboratory modified premachined abutments than for those with cast abutments.

CONCLUSION

The finishing of custom-made abutments requires further refinement.

Cost-saving implant training aids

This article describes a simple step-by-step procedure that uses inexpensive materials to enable those who wish to learn procedures used in the construction of a screw-type implant overdenture to practice these procedures before they use expensive precious metal components. The use of this procedure will result in considerable savings in training costs and affords a greater opportunity to provide practical experience before making this type of an overdenture for patients. It could also provide for a rapid expansion in the number of trained personnel who could make this form of treatment available to a larger number of patients.

A comparison of the dimensional accuracy of the splinted and unsplinted impression techniques for the Bone-Lock implant system

STATEMENT OF PROBLEM

The precise transfer of intraoral relationships of implants to laboratory working models is central to the success of implant prostheses.

PURPOSE

In this study a stone master model incorporating five implants (Bone-Lock) was used to compare the dimensional accuracy of a splinted impression technique with an unsplinted impression technique.

METHODS

A three-factor analysis of variance was used to examine the effect of technique, relative position of the implant on the cast, and plane of measurement.

RESULTS

All three factors had a significant effect on dimensional accuracy.

CONCLUSIONS

The splinted technique exhibited more deviation from the master model than the unsplinted technique did. This was primarily associated with rotational discrepancies around the long axes of the implants for the splinted technique.

Comparison of the dimensional accuracy of one- and two-step techniques with the use of putty/wash addition silicone impression materials

This study compared the putty/wash one-step and two-step techniques for making addition silicone impressions. For each technique 15 impressions were made of a stainless steel base to which three tapered posts were attached. Stone models were made of all impressions. The results indicated that the interabutment distances increased slightly compared with the stainless steel model for both techniques, but the differences between techniques were not considered to be clinically important. The intraabutment measurements for the abutment without undercut increased, whereas abutments with undercuts decreased. These variations from the stainless steel model were also clinically insignificant.

Mandibular dysfunction and periodontitis. A comparative study of patients with periodontal disease and occlusal parafunctions

Fifty-one patients (mean age, 47.3 years) with moderate to severe periodontal disease and 40 patients (mean age, 48.9 years) with symptoms related to bruxism (occlusal parafunctions such as grinding and/or clenching of the teeth) were compared with regard to periodontal conditions and signs and symptoms of mandibular dysfunction. The bruxists reported more symptoms of pain and dysfunction of the masticatory system than the periodontal patients. The clinical dysfunction index was significantly higher among the bruxists, while there was a similarity between the groups in the variation of occlusal conditions, except for occlusal wear, which was more pronounced in the bruxist group. Attrition was in general positively correlated to alveolar bone height. This correlation was stronger (and statistically significant) for the canines than for other teeth. Attrition was negatively correlated to tooth mobility. It is concluded that patients with moderate to severe periodontal disease and patients with bruxism/occlusal parafunctions are distinctly different with regard to signs and symptoms of mandibular dysfunction. The results support the opinions that there is no or only weak correlation between periodontal disease and bruxism, and between bruxism and occlusal status.

Periodontal status and bruxism. A comparative study of patients with periodontal disease and occlusal parafunctions

This study investigated a possible association between bruxism and severity of periodontal disease. Subjects consisted of 51 patients (mean age 47.3 years) referred to the Department of Periodontology for treatment of moderate to severe periodontal disease (Perio-group) and 40 patients (mean age 48.9 years) referred to the Department of Stomatognathic Physiology for treatment of symptoms related to bruxism (Bruxism-group). Examination of the two groups included measurements of the alveolar bone height, probing attachment level, tooth mobility, and attrition of teeth. A questionnaire was also used to gain information on the patient's awareness of bruxism and tooth mobility. Awareness of clenching and/or grinding was reported by 57% of patients in the Bruxism-group and 24% of patients in the Perio-group. The perio-patients reported significantly higher frequency of tooth mobility than did the bruxism-patients. Alveolar bone loss, attachment loss, and tooth mobility were significantly more pronounced in the Perio-group than in the Bruxism-group. The Bruxism-group showed a higher frequency of tooth attrition than the Perio-group. Periodontal disease and bruxism seldom occurred in the same individual, and the results indicate that the two phenomena are in general not closely associated.

Healing after root reimplantation in the monkey

The aim of the present investigation was to evaluate the regenerative potential of the periodontal tissues following tooth reimplantation using a model which excluded the dentogingival epithelium from the process of healing. Maxillary and mandibular incisors, premolars and molars of 5 monkeys were used. Following root filling of all experimental teeth, the teeth were divided into 3 experimental groups. In 1 group, the teeth were extracted following the elevation of full thickness flaps. The crowns were separated from the roots at the level of the buccal cemento-enamel junction and the roots immediately reimplanted into their sockets. The flaps were replaced and sutured to accomplish complete coverage of the roots. In a 2nd group, the teeth were subjected to the same experimental procedure, but in addition, the buccal alveolar bone was removed to about half its original height prior to root reimplantation. The teeth of the 3rd group were subjected to identical experimental procedures as for group II with the addition that the buccal root surfaces were planed to the level of the surgically created bone crest. The animals were sacrificed after 6 months of healing. The jaws were removed and histological specimens prepared for microscopic examination. The results showed that a complete fibrous re-attachment formed onto roots on which the original periodontal ligament tissue was preserved. This occurred irrespective of whether the roots were reimplanted into sockets with normal (group I) or reduced (group II) bone height. When the original periodontal ligament tissue was removed by root planing before reimplantation (group III), healing resulted in a significant amount of new connective tissue attachment. However, coronal to the newly formed fibrous attachment, the root surface frequently showed signs of resorption and particularly so in those roots which remained covered by the soft tissue during the entire course of healing. In the majority of the roots which perforated the covering soft tissue during the early phase of healing, the dentogingival epithelium had migrated apically into contact with the coronally generated fibrous attachment. In these cases, root resorption was never discernible. New bone formation occurred to a variable extent in the roots of groups II-III. No relationship was found, however, between the amount of connective tissue reattachment or new attachment and newly formed alveolar bone, which in turn indicates that bone tissue regrowth and periodontal ligament regeneration are unrelated phenomena.

Healing following reimplantation of teeth subjected to root planing and citric acid treatment

The aim of the present study was to examine the effect of citric acid treatment on periodontal healing around teeth which were extracted, root planed and then reimplanted. Maxillary incisors and mandibular incisors, premolars and molars of 5 monkeys were used. The teeth were divided into 3 experimental groups. In 1 group, the teeth were extracted and immediately reimplanted into their own sockets. In a 2nd group, the teeth were extracted, root planed to a level corresponding to 50-75% of the root length and then reimplanted. In the 3rd group, periodontal breakdown extending to 50-75% of the root length was first induced by placing orthodontic elastic ligatures around the teeth. They were then extracted and root planed and transplanted into the sockets of the contralateral, periodontally healthy teeth which had just been extracted. Half the number of the teeth of groups 2 and 3 were treated with citric acid before reimplantation or transplantation. The animals were sacrificed after 6 months of healing. The jaws were removed and histological specimens prepared for microscopic examination. With the exception of a limited coronal regrowth of new cementum in the apical part of the planed portion of a few roots, connective tissue attachment failed to reform on most root surfaces deprived of their periodontal ligament tissue. Healing was most frequently characterized by root resorption and ankylosis. These were the most predominant features of healing both on root surfaces which had been deprived of the ligament tissue by mechanical means or during a course of experimentally-induced periodontal disease, and occurred in citric acid as well as non-citric acid treated roots. The findings imply that the result of healing following tooth reimplantation or transplantation is determined by the type of cells that repopulate the wound area adjacent to the denuded root surface.

Two year follow-up study of an outreach program in geriatric psychiatry

In Canada and the U.S. the percentage of elderly people is increasing and more funds are being spent on institutional programs. Yet many are not so impaired that they cannot be looked after by relatives. A number of community outreach programs are available. From an inpatient psychogeriatric unit in Hamilton Provincial Hospital an outreach program is described. A follow-up study was done during a 2 year period by contacting the referral sources. The 24% who had been admitted were compared with the 75.9% who remained in the community. While patients' relatives and referring sources were mostly pleased with the assessments, and those patients not admitted were less institutionalized, those admitted with affective disorder showed a higher recovery rate than those remaining in the community. The total number admitted to hospital showed a lower mortality rate than those not admitted, even though the latter three considered less mentally ill because of the criteria for admission to the hospital.

A histological study of the carrageenan-induced granuloma in the rat lung

Intralobular injection of 0.17 ml of 2% carrageenan, through a ventral slit in the trachea of rats, induced localised areas of inflammation with a high survival rate. This inflammation was characterised by immediate polymorphonuclear leucocyte (PMN) infiltration into the interstitial and alveolar spaces followed in 4 days by replacement of the PMNs by carrageenan-containing macrophages. Between days 10 to 70, the macrophages rapidly increased in size and accumulated numerous large vacuoles which stained for the presence of carrageenan. Several macrophages were so large that they each filled an entire alveolar space. From days 70 to 205, the macrophage appearance was unchanged except that the staining of their carrageenan-containing vacuoles was less metachromatic with toluidine blue. Fibrosis was first noted at day 205 and consisted of several small granulomas located near large airways and blood vessels. These granulomas had a central area filled with macrophages and a peripheral zone consisting of fibroblasts, new collagen, scattered macrophages and blood vessels. The morphology of the macrophages remained essentially unchanged from days 205 to 500 but by day 500, the macrophages were found only in numerous pockets within the inflamed lobe. They still stained positive for the presence of carrageenan at day 500. The extreme longevity of these macrophages and the lack of significant fibrosis may be due to the "un-naturalness", indigestibility, and low toxicity of the irritant, carrageenan. In addition, their size and numerous vacuoles may have inhibited their movement and subsequent removal from the lung. The paucity of significant fibrosis may be due to the lack or inhibition of a "fibroblast stimulating factor" released by the macrophages or possibly the collagen was degraded as soon as it was synthesised. This carrageenan-induced inflammation is a very suitable for the study of alveolar macrophages but appears to be inappropriate for the study of pulmonary fibrosis.