Exploring the attitudes of general dental practitioners to providing dietary advice alongside oral rehabilitation for older adults

OBJECTIVE

We aimed to capture General Dental Practitioners' (GDPs) views on delivering dietary advice to older adults in combination with treatment to replace missing teeth and identify solutions to help inform the development and implementation of future dietary interventions within primary dental care.

BACKGROUND

As natural teeth are lost, older adults may need to choose softer, more manageable foods which might be of lower nutrient density. Previous research has indicated that prosthodontic rehabilitation can improve masticatory function but not the intake of nutrients, highlighting a potential need for a combined approach of oral rehabilitation and dietary counselling.

MATERIALS AND METHODS

Semi-structured telephone interviews were conducted with a purposive sampling strategy of 12 GDPs. Interviews were digitally recorded and transcribed verbatim. An iterative coding process using theme-analytic methods was used.

RESULTS

Twelve interviews were conducted with GDPs in the United Kingdom. The themes that emerged from the interviews included: the awareness of the importance of dietary advice among GDPs; the concerns GDPs had on patients' adherence to dietary advice; uncertainty over roles and responsibilities in the provision of dietary advice; and the limited time and remuneration for dietary advice in dental practice. A minor theme identified was the motivation of GDPs to implement dietary advice alongside oral rehabilitation. All reported that they were already providing dietary advice to their patients but that this was limited to caries prevention.

CONCLUSION

The GDPs interviewed expressed positive attitudes towards providing dietary advice alongside oral rehabilitation for older adults. However, a lack of confidence, awareness, time and remuneration are barriers to its provision in primary dental care. To facilitate the implementation of dietary advice alongside oral rehabilitation, clear guidance on and training in delivering dietary advice and multidisciplinary cooperation are required.

General dentists' attitudes and perceived barriers in providing domiciliary dental care to older adults in long-term care facilities or their homes in Northern Ireland: A descriptive qualitative study

OBJECTIVE

Many older patients, housebound or living in long-term care facilities (LTCFs) have limited access to dental care. This descriptive qualitative study aimed to understand general dental practitioners (GDPs) attitudes and perceived barriers to undertaking Domiciliary Dental Care (DDC) for those patients in Northern Ireland (NI).

METHODS

Semi-structured telephone interviews were conducted with a purposive sample of 12 GDPs in Northern Ireland. Interviews were digitally recorded and transcribed verbatim. An iterative coding process using theme-analytic methods was used.

RESULTS

The data were characterised into four major themes-risk of professional litigation, remuneration for those undertaking DDC, complexity of treatment, and the overall framework of the dental care system in NI. Two minor themes identified were practice culture and reasons for undertaking DDC. The GDPs in the study identified a number of barriers to undertaking DDC including a legal requirement to transport oxygen, lack of organisation and limited oral hygiene care provision in LTCFs, and confusion around their responsibilities for provision of DDC. Those GDPs who were providing DDC indicated that they did so out of kindness and a sense of loyalty to their long-standing patients.

CONCLUSION

The GDPs in this study identified a number of significant barriers to provision of DDC at organisational, structural and clinical levels. The GDPs indicated that they required clarification of their responsibilities around DDC with clear guidelines necessary given the increase in demand for this service.

First live birth after uterus transplantation in the United States

Uterus transplantation has proven to be a successful treatment for women with absolute uterine infertility, caused either by the absence of a uterus or the presence of a nonfunctioning uterus. We report the first birth of a healthy child following uterus transplantation in the United States, from a recipient of a uterus allograft procured from an altruistic living donor. Two major modifications from the previously reported live births characterized this uterus transplant. First, the transplanted uterus relied upon and sustained the pregnancy while having only the utero-ovarian vein as venous outflow. The implication is a significantly simplified living donor surgery that paves the way for minimally invasive laparoscopic or robot-assisted techniques for the donor hysterectomy. Second, the time from transplantation to embryo transfer was significantly shortened from prior protocols, allowing for an overall shorter exposure to immunosuppression by the recipient and lowering the risk for potential adverse effects from these medications.

Live nondirected uterus donors: Psychological characteristics and motivation for donation

Emerging research suggests that uterus transplantation is a viable option for women without a uterus who want to become pregnant and carry a child to term. Currently, no knowledge exists regarding nondirected uterus donors. This study (NCT 02656550) explored the baseline psychological characteristics of nondirected uterus donors at a single study site. Of the 62 potential donors who underwent initial screening, 6 nondirected donors were chosen and participated in uterus donation. Participants received a comprehensive evaluation, which included clinical history and psychological assessments. The mean age of the donors was 42 years; most (83%) were white/not Hispanic, and all had a college degree. Current depression was reported by 2 participants, past depression was reported in 2 participants, and past anxiety was reported in 3 participants. Based on several different psychological measures, donors had a higher general well-being than the normative sample, and none of the participants' scores indicated psychological distress. All 6 women indicated that giving another woman an opportunity to carry her own child was a motivation for pursuing uterus donation. Further research on potential psychological motives and gains for the donor as well as long-term effects on donors is crucial for ethical practice.

Deceased donor uterus retrieval: A novel technique and workflow

Uterus transplantation has proven successful when performed with a living donor. Subsequently, interest in the novel field of reproductive transplantation is growing. The procedure is still considered experimental, with fewer than 25 cases performed worldwide, and the techniques of both uterus procurement and transplantation are still developing. We detail a new approach to deceased donor uterus procurement. In contrast to reported techniques and our own initial experience, in which the deceased donor uterus was procured post cross-clamp and after other organs were procured, our approach now is to perform the uterus procurement prior to the procurement of other organs in a multiorgan donor and hence prior to cross-clamp. We describe our practical experience in developing and implementing the logistical workflow for deceased donor uterus procurement in a deceased multiorgan donor setting.

Living Donor Uterus Transplantation: A Single Center's Observations and Lessons Learned From Early Setbacks to Technical Success

Uterus transplantation is a vascularized composite allograft transplantation. It allows women who do not have a uterus to become pregnant and deliver a baby. In this paper, we analyze the first five cases of living donor uterus transplantation performed in the United States. The first three recipients lost their uterus grafts at days 14, 12, and 6, respectively, after transplant. Vascular complications, related to both inflow and outflow problems, were identified as the primary reason for the graft losses. Two recipients, at 6 and 3 mo, respectively, after transplant, have functioning grafts with regular menstrual cycles. Ultimate success will be claimed only after a live birth. This paper is an in-depth analysis of evaluation, surgical technique, and follow-up of these five living donor uterus transplants. The lessons learned were instrumental in allowing us to evolve from failure to technical and functional success. We aim to share our conclusions and build on knowledge in the evolving field of uterus transplantation.

Periodontal Manifestations of Chronic Atypical Neutrophilic Dermatosis With Lipodystrophy and Elevated Temperature (CANDLE) Syndrome in an 11-Year-Old Patient

INTRODUCTION

Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) is an autoinflammatory syndrome caused by an autosomal recessive gene mutation. This very rare syndrome has been reported in only 14 patients worldwide. A number of clinical signs have been reported, including joint contractures, muscle atrophy, microcytic anemia, and panniculitis-induced childhood lipodystrophy. Additional symptoms include recurrent fevers, purpuric skin lesions, periorbital erythema, and failure to thrive. To the best of the authors' knowledge, this is the first reported case of periodontal manifestations associated with CANDLE syndrome.

CASE PRESENTATION

An 11-year-old boy was referred to Cork University Dental School and Hospital, Cork, Ireland, with evidence of severe periodontal breakdown. The patient's medical condition was managed in Great Ormond Street Children's Hospital, London, United Kingdom. The patient's dental management included initial treatment to remove teeth of hopeless prognosis, followed by prosthodontic rehabilitation using removable partial dentures. This was followed by additional non-surgical periodontal treatment and maintenance. In the long term, the potential definitive restorative options, including dental implants, will be evaluated in discussion with the patient's medical team.

CONCLUSIONS

Periodontitis as a manifestation of systemic disease is one of seven categories of periodontitis as defined by the American Academy of Periodontology 1999 classification system. A number of systemic diseases have been associated with advanced periodontal breakdown, including diabetes mellitus, leukemia, and Papillon-Lefèvre syndrome. In the case described, treatment necessitated a multidisciplinary approach with input from medical and dental specialties for a young patient with severe periodontal breakdown associated with CANDLE syndrome.

The current status of medical marijuana in the United States

Medical marijuana is currently a controversial issue in medicine. There are strong pro and con opinions but relatively little scientific data on which to base medical decisions. The unfortunate scheduling of marijuana in class I has limited research and only serves to fuel the controversy. This article will review the history of laws to regulate drugs in the United States in the 20th century to provide context for the current status of medical marijuana. It will include the rationale for opposing medical marijuana laws and the problem of the Schedule I inclusion of marijuana as well as other drugs. It will examine the problems associated with smoking raw marijuana and review other routes of administration. Finally, it examines the inadvisability of medicine's promotion of smoked marijuana.

Trends in material choice for direct restorations by final year students from University College Cork 2004-2009

Traditionally, undergraduate students in University College Cork (UCC) have been taught to use amalgam as the first choice material for direct restoration of posterior cavities. Since 2005 the use of composite resins has replaced amalgam as the first choice material. An audit was conducted of all direct restorations placed by final year students from UCC from 2004 until 2009. Results showed that over a six year period, final year UCC dental undergraduate students placed proportionately more direct composite resin restorations and significantly fewer amalgam restorations. The need for and undergraduate exposure to, provision of amalgam restorations may have to be revisited.

Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression

Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.

Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression

Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.

Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression

Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.

Induction of immune hyporesponsiveness after portal vein immunization with ovalbumin

BACKGROUND

Previous work has demonstrated prolonged allograft survival after donor-specific portal vein immunization before the transplantation. The purpose of this study was to examine the potential mechanism of portal vein-induced hyporesponsiveness after portal vein immunization with the soluble protein ovalbumin.

METHODS

Balb/c mice were immunized with a portal vein injection of ovalbumin. After the immunization, in vivo delayed-type hypersensitivity response and in vitro proliferative response of ovalbumin-specific T cells were assessed to determine host immune response. Type 1 (IL-2, IL-12, IFN-gamma) and type 2 (IL-4, TGF-beta) regulatory cytokines were assessed by semiquantitative reverse transcriptase polymerase chain reaction. Sera anti-ovalbumin IgG, IgG1, and IgG2a were measured by enzyme-linked immunosorbent assay, and the antigen-presenting ability of liver nonparenchymal cells (NPCs) was assessed by T-cell proliferation to ovalbumin in vitro.

RESULTS

There was significant inhibition of ovalbumin-specific delayed-type hypersensitivity and T-cell proliferation in portal vein-immunized mice compared with intraperitoneal-immunized or control mice. Reverse transcriptase polymerase chain reaction analysis results showed that lymphocytes from portal vein-immunized mice exhibited decreased type 1 and increased type 2 cytokine messenger RNA expression compared with intraperitoneal-immunized or control animals. The type 2 cytokine response of lymphocytes from ovalbumin portal vein-immunized mice correlated with increased sera ovalbumin-IgG1 and decreased IgG2a. The results of an antigen-presenting assay revealed that liver NPCs were deficient antigen-presenting cells compared with adherent cells from heart or spleen.

CONCLUSIONS

Processing of ovalbumin by hepatic NPCs results in hyporesponsiveness to ovalbumin by an impaired type 1 cytokine response and a preferential shift toward a type 2 cytokine response, possibly because of defective antigen presentation by hepatic NPCs. Intrahepatic processing of antigen may play an important role in the development of strategies to reduce host immunoreactivity against transplanted allografts.

Prolongation of heterotopic heart allograft survival by portal venous injection of alloantigen: the role of hepatic nonparenchymal cells

The induction of immune hyporesponsiveness in transplantation is a complex interaction between the immune system and the alloantigen. The route by which an antigen is introduced to the immune system plays an important role in the immune response. Antigen delivered via the portal circulation has the ability to induce T-cell hyporesponsiveness. In this study we examined the mechanism responsible for the induction of hyporesponsiveness by assessing immune response following portal vein (pv) injection of donor alloantigen. C57B1/6 mice were immunized via pv with splenic mononuclear cells (SMNC) from BALB/c mice. The recipient immune response was assessed in vivo by murine heterotopic heart transplant survival. SMNC and hepatic nonparenchymal cells (NPC) were isolated from pv immunized animals and used as regulatory cells in a one-way mixed lymphocyte culture (MLC) as a measure of in vitro recipient responder SMNC proliferation. Survival of murine heterotopic heart transplants was prolonged following pv injection of alloantigen (p < .04 compared to nonimmunized or systemically immunized mice). Stimulation of responder SMNCs isolated from pv immunized mice resulted in an antigen-specific hyporesponsiveness (p < .05 compared with nonimmunized or systemically immunized mice). Cocultures of responder SMNCs from nonimmunized (naive) mice with hepatic NPC from previously pv immunized mice resulted in attenuation of T-cell proliferation in MLR following stimulation with donor alloantigen (p < .05 compared to coculture with NPC from nonimmunized mice or SMNC from pv immunized mice). These data would suggest that the hepatic NPC plays an important role in the regulation of the immune response. With further identification of cell subtypes responsible for induction of hyporesponsiveness, future therapies may be directed at these specific targets, thereby minimizing the harmful side effects of current immunosuppressive therapies.

Assessment of immunologic status of liver transplant recipients by peripheral blood mononuclear cells in response to stimulation by donor alloantigen

OBJECTIVE

To determine whether there is a role for assessing peripheral blood mononuclear cell (PBMC) cytokine patterns as a means of measuring the immunologic and clinical status of liver transplant recipients.

SUMMARY BACKGROUND DATA

The role of assessing cytokine patterns in the prediction of clinical graft rejection or acceptance remains unclear. The purpose of this study was to examine the cytokine profiles of PBMC stimulated in vitro with donor alloantigen and to correlate prospectively the data with clinical assessment of graft status in orthotopic liver transplant (OLT) recipients.

METHODS

PBMCs from OLT recipients were examined for proliferation and cytokine mRNA expression after stimulation by donor alloantigen, third-party alloantigen, or phytohemagglutinin (PHA). mRNA extracted from PBMC was amplified by reverse transcriptase-polymerase chain reaction with oligospecific primer pairs for interleukin (IL)-2, IL-4, IL-6, IL-10, interferon (IFN) gamma, tumor necrosis factor (TNF) alpha and transforming growth factor (TGF) beta. Results were prospectively correlated with each patient's allograft status.

RESULTS

Increased IL-4 and TGF-beta and decreased IL-2, IFNgamma, and TNF-alpha mRNA expression by PBMCs in response to donor alloantigen stimulation predicted immunologic graft stability over a minimum 60-day interval compared with mRNA expression of PBMCs from patients with established rejection or those who experienced a rejection episode within a 30-day period (p < 0.05). Stimulation of recipient PBMCs with third-party alloantigens or PHA yielded similar but less specific results. PBMC proliferation to varying antigenic stimulation did not correlate with clinical graft status, nor did cytokine production by unstimulated PBMC.

CONCLUSIONS

Prospective assessment of cytokine expression by PBMC from OLT recipients in response to stimulation by donor alloantigen is helpful for predicting the clinical status of the allograft and may be useful in the development of more precise immunologic monitoring protocols.

A rapid restriction fragment length polymorphism polymerase chain reaction-based diagnostic method for identification of T-cell lymphoproliferative disorders

BACKGROUND

Identification of a clonal proliferation of lymphocytes is central to the diagnosis of lymphoma compared with a reactive lymphoproliferation. We propose a novel diagnostic technique based on restriction fragment length polymorphism (RFLP) of amplified polymerase chain reaction (PCR) products of the T-cell receptor -gamma (TCR-gamma) gene rearrangement to rapidly identify monoclonality in T-cell lymphomas and improve diagnosis of malignancy.

MATERIALS AND METHODS

DNA from peripheral blood mononuclear cells (PBMCs) of 10 healthy volunteers and 7 T-cell lymphoma patients were isolated and the TCR-gamma was amplified with consensus primers for the different variable (V) and joining (J) segments. Restriction digests were done using BstN1 and the fragments separated via gel electrophoresis. Verification was by Southern analysis.

RESULTS

Restriction digests of the 10 healthy controls show a characteristic nine-band digest pattern whereas the restriction digests of the 7 T-cell lymphomas each show altered banding patterns completely distinct from the normal nine-band pattern (Fisher exact test = 0.00005). Sensitivity assays demonstrate the test can detect clonal populations representing 2% of total. This method also enables identification of particular clonal populations. The entire procedure can be performed in one day, does not require radioactivity, and requires only small quantities of specimens.

CONCLUSIONS

This RFLP-PCR-based diagnostic method for T-cell lymphomas is specific, sensitive, efficient, and reproducible, and enables the identification of clonally expanded populations of T lymphocytes. It offers the ability to identify particular clonal populations, as with Southern analysis, combined with the benefits of a PCR method.

A role for sunlight in skin cancer: UV-induced p53 mutations in squamous cell carcinoma

Sunlight is a carcinogen to which everyone is exposed. Its UV component is the major epidemiologic risk factor for squamous cell carcinoma of the skin. Of the multiple steps in tumor progression, those that are sunlight-related would be revealed if they contained mutations specific to UV. In a series of New England and Swedish patients, we find that 14/24 (58%) of invasive squamous cell carcinomas of the skin contain mutations in the p53 tumor suppressor gene, each altering the amino acid sequence. Involvement of UV light in these p53 mutations is indicated by the presence in three of the tumors of a CC----TT double-base change, which is only known to be induced by UV. UV is also implicated by a UV-like occurrence of mutations exclusively at dipyrimidine sites, including a high frequency of C----T substitutions. p53 mutations in internal malignancies do not show these UV-specific mutations. The dipyrimidine specificity also implicates dipyrimidine photoproducts containing cytosine as oncogenic photoproducts. We believe these results identify a carcinogen-related step in a gene involved in the subsequent human cancer.

Ego functions and psychopathology in narcotics and polydrug users

The literature reporting on aspects of ego functioning and psychopathology among narcotics and polydrug dependent individuals is reviewed. Data are presented which indicate impairment in ego functioning and evidence of considerable psychopathology in three groups of drug-dependent individuals entering an inpatient detoxification/treatment unit. The data support the view that drug misuse of any sort does not result in a homogeneous group. The Psychiatric Status Schedule of Spitzer and Endicott was the instrument used in gathering the data. Recommendations for discriminate thinking in diagnostic evaluation and treatment planning for any drug-dependent individuals are made.

Psychopathology in Drug Dependent Individuals: A Clinical Review

There has long been an effort to develop a single unifying theory to explain the phenomenon of drug dependence. Some of these efforts have focused on psychoanalytic theory, various aspects of ego functioning, socio-economic factors, and physiological effects of drugs. Most investigators, however, have focused on character pathology in addicts and have considered addiction as representing one form of character disorder. There has been a lack of emphasis on various psychiatric conditions which could predispose and accompany drug dependence. This author considers drug dependence as a multi-etiological phenomenon. This paper explores various psychiatric problems identified in drug dependent individuals and how they interact with the drug dependence. The use of psychotropic agents in the treatment of drug dependent persons is also explored.