Correlations of dietary energy and protein intakes with renal function impairment in chronic kidney disease patients with or without diabetes

Dietary energy and protein intake can affect progression of chronic kidney disease (CKD). CKD complicated with diabetes is often associated with a decline in renal function. We investigated the relative importance of dietary energy intake (DEI) and dietary protein intake (DPI) to renal function indicators in nondiabetic and diabetic CKD patients. A total of 539 Stage 3-5 CKD patients [estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m² using the Modification of Diet in Renal Disease equation] with or without diabetes were recruited from outpatient clinics of Nephrology and Nutrition in a medical center in Taiwan. Appropriateness of DEI and DPI was used to subcategorize CKD patients into four groups:(1) kidney diet (KD) A (KD-A), the most appropriate diet, was characterized by low DPI and adequate DEI; (2) KD-B, low DPI and inadequate DEI; (3) KD-C, excess DPI and adequate DEI; and (4) KD-D, the least appropriate diet, excess DPI and inadequate DEI. Inadequate DEI was defined as a ratio of actual intake/recommended intake less than 90% and adequate DEI as over 90%. Low DPI was defined as less than 110% of recommended intake and excessive when over 110%. Outcome measured was eGFR. In both groups of CKD patients, DEI was significantly lower (p<0.001) and DPI higher (p=0.002) than recommended levels. However, only in the nondiabetic CKD patients were KD-C and KD-D significantly correlated with reduced eGFR compared with KD-A at increments of -5.63 mL/min/1.73 m² (p = 0.029) and -7.72 mL/min/1.73 m² (p=0.015). In conclusion, inadequate energy and excessive protein intakes appear to correlate with poorer renal function in nondiabetic CKD patients. Patients with advanced CKD are in need of counseling by dietitians to improve adherence to diets.

Plasma polyunsaturated fatty acids and periodontal recovery in Taiwanese with periodontitis: a significant relationship

BACKGROUND

Plasma levels of polyunsaturated fatty acids (PUFAs) are different before and after periodontal treatment. Asians and Westerners have significantly different baseline levels of plasma PUFAs. However, no Asian study has reported the effects of nonsurgical treatment on the correlation between periodontal condition and plasma levels of PUFAs. We analyzed whether recovery from periodontitis was correlated with the elevation of plasma fatty acids 3 months after the nonsurgical intervention and with no recommended supplements.

DESIGN

Thirty-five Taiwanese patients with periodontitis were recruited. Probing pocket depths (PPDs) and clinical attachment levels (CALs) were measured at baseline and 3 months after the nonsurgical treatment. Plasma levels of fatty acids were determined using gas chromatography. Differences and correlations between plasma fatty acid composition and periodontitis severity at baseline and 3 months after treatment were determined.

RESULTS

Twenty-six patients completed the study. At the baseline, PPDs were negatively correlated with plasma n-3 PUFAs (r=-0.52, p<0.01), but at 3 months post intervention, periodontitis severity had declined and the weight percentages of n-3 PUFAs, DPA, and DHA were significantly (p=0.019, 0.005, and 0.037, respectively) higher. The recovery percentages of CALs were positively and significantly correlated with plasma ΔPUFAs and the percentage of Δn-3 PUFAs in ΔPUFAs (r=0.42 and 0.45, respectively; p<0.05 for both).

CONCLUSIONS

We conclude that a higher weight percentage of n-3 PUFAs in total PUFAs was related to the recovery of CALs 3 months after the nonsurgical periodontal treatment. However, no such relationship was found for PPDs.

Impact of 24-month fluoride tablet program on children with disabilities in a non-fluoridated country

The aim of this study was to evaluate the caries preventive effects of a school-based fluoride tablet program in children with disabilities. Two hundred and seventeen children with disabilities were divided into two groups: the intervention group (IG) ingested 1.0mg fluoride tablet daily while the control group (CG) ingested a placebo. The initial oral examinations were conducted prior to fluoride intake and 24-month follow-up examinations were conducted to evaluate the effectiveness of fluoride tablet ingestion. The results from this study demonstrated significant reductions in the DMFT index (the sum of decayed, missing, and filled permanent teeth), 0.63, as well as the DMFS index (the sum of decayed, missing, and filled surfaces of the permanent dentition), 1.25, when compared with the CG. A statistically significant reduction in the DMFT index and DMFS index (30.42% and 36.84%, respectively) suggested an anti-cariogenic benefit to fluoride tablet administration. Greater caries reduction occurred on mesio-distal and bucco-lingual surfaces (53.27% and 52.57%, respectively). Fluoride tablets should be considered as a caries preventive strategy in school-based caries prevention programs for children with disabilities in fluoride deficient areas.

Polymorphisms in Kallikrein7 and 10 genes and oral cancer risks in Taiwan betel quid chewers and smokers

OBJECTIVES

We investigated the association between mRNA levels, polymorphisms of Kallikrein7 (KLK7) and Kallikrein10 (KLK10), and the development of oral squamous cell carcinoma (OSCC).

MATERIALS AND METHODS

We recruited 217 OSCC patients and 138 healthy controls. All were men, betel quid chewers, cigarette smokers, and Minnan ethnicity. Genotyping was performed using a TaqMan probe genotyping assay. Gene expression levels were determined using real-time polymerase chain reactions (PCRs) for 20 pairs of cancerous and non-cancerous tissues.

RESULTS

Kallikrein10 rs3745535G>T polymorphisms were significantly associated with OSCC development [adjusted OR (AOR) = 1.62, 95% CI = 1.02-2.59], but KLK7 polymorphisms were not. The KLK7 rs10581213(wt/ins + ins/ins) genotypes were significantly associated with early-stage cancer (AOR = 0.34, 95% CI = 0.14-0.78), but KLK10 polymorphisms were not. Relative expression analysis indicated that an increase in KLK7 and KLK10 mRNA levels was found in cancerous tissues (2(-ΔΔCT) = 25.23 ± 8.85 and 10.89 ± 4.97, respectively). A significantly higher level of KLK7 was expressed in early-stage cancer with the rs10581213(wt/ins + ins/ins) genotypes, but there was no significant difference in the mRNA levels of KLK7 and KLK10 between early- and advanced-stage cancers.

CONCLUSIONS

This is the first correlation of OSCC with KLK10 rs3745535G>T polymorphisms. Early-stage OSCC and high KLK7 mRNA levels were correlated with the rs10581213(wt/ins + ins/ins) genotypes. More studies with large sample sizes are needed to verify our findings.

Urinary fluoride concentration in children with disabilities following long-term fluoride tablet ingestion

Urine is the most commonly utilized biomarker for fluoride excretion in public health and epidemiological studies. Approximately 30-50% of fluoride is excreted from urine in children. Urinary fluoride excretion reflects the total fluoride intake from multiple sources. After administering fluoride tablets to children with disabilities, urinary fluctuation patterns should be investigated. The purpose of this study was to monitor the short and long term fluctuating patterns of urinary fluoride concentration after fluoride tablets were ingested by children with disabilities. Children with disabilities aged 6-12 years old were selected randomly and were divided into three groups: Group A, 1.0mg fluoride tablet, Group B, 0.5mg fluoride tablet, and Group C, control group. The urine samples were collected in the morning (MU) and 2h after fluoride tablets were ingested (AU). Urine was collected on the day prior to fluoride intake (baseline), the first, the third, the fifth and the eighth day of fluoride ingestion for a short term, and once every 6 months for a total of 18 months for long-term observation. The AU sample showed statistically significantly higher concentrations of urine fluoride than those of the MU samples, and no statistically significant difference was noticed in the MU samples among the three groups. Group A showed the highest urinary fluoride concentration (UFC) among the three groups. UFC increased as ingested fluoride tablet dosage increased, and it returned to the baseline level on the following day and persisted throughout the study period.

Placental docosahexaenoic and arachidonic acids correlate weakly with placental polychlorinated dibenzofurans (PCDF) and are uncorrelated with polychlorinated dibenzo-p-dioxins (PCDD) or polychlorinated biphenyls (PCB) at delivery: a pilot study

Long chain polyunsaturated fatty acids (LC-PUFA), ARA (arachidonic acid, 20:4n-6) and DHA (docosahexaenoic acid, 22:6n-3) have positive effects and environment pollutants, polychlorinated dibenzo-p-dioxins/dibenzofurans(PCDD/F) and polychlorinated biphenyls (PCB) have negative effects on neural development during early life. Placental dioxin/PCB serves as markers for cumulative exposure to fetus. Fatty acid composition of placenta depends on nutrient supply during pregnancy, serving as indicators for fetal ARA and DHA accretion. This study investigated correlation between placental PCDD/F and PCB toxic equivalent (TEQ) and LC-PUFA in 34 pregnant women from Taiwan. Placental PCDF TEQ were inversely correlated with placental ARA (p=0.020), C20:3n-6 (p=0.01), C22:4n-6 (p=0.04), C22:5n-6 (p<0.01) and with DHA (p=0.03), but ARA and DHA did not vary with PCDD, dioxin-like and indicator PCB. After adjustment for age and body mass index, a one-unit PCDF TEQ increase was associated with 1.021%w/w and 0.312%w/w decreases in ARA (β=-1.021, p=0.03) and DHA (β=-0.312, p=0.03). Since ARA and DHA were unrelated to three classes of toxins, and a weak negative association was found with PCDF, these data provide no basis for discouraging marine fish consumption during pregnancy for Taiwan women on the basis of these organics. Pregnant women should consume fish for its unique package of nutrients while avoiding few species with high organic pollutant or mercury contamination.

Expression of Cyr61 (CCN1) in human oral squamous cell carcinoma: An independent marker for poor prognosis

BACKGROUND

Cysteine-rich 61 (Cyr61 [CCN1]) has disparate functions in tumorigenesis that are dependent on the cell types. The aim of the study was to investigate its role in the growth of oral squamous cell carcinoma (SCC).

METHODS

The study used immunohistochemistry to examine Cyr61 expression in 93 oral SCC specimens and assessed the effect of Cyr61 overexpression on proliferation and migration of oral SCC cells in vitro and xenograft growth in severe combined immunodeficient (SCID) mice.

RESULTS

High expression of Cyr61 significantly correlated with large tumor size (p = .009) and advanced tumor stage (p = .036). Multivariate analysis revealed that high Cyr61 (relative risk [RR] 2.44, 95% confidence interval [CI] 1.209-4.95, p = .010) significantly correlated with mortality. Forced expression of Cyr61 stimulated the motility and growth of Ca9-22 cells in vitro and enhanced xenograft growth in SCID mice.

CONCLUSIONS

Cyr61 is a positive growth modulator of oral SCC and Cyr61 overexpression is an independent prognostic indicator for patients with oral SCC.

Gefitinib as first-line therapy for advanced or metastatic non-small cell lung cancer patients in southern Taiwan

Gefitinib, a selective epidermal growth factor receptor tyrosine kinase inhibitor, is effective in treating patients with non-small cell lung cancer (NSCLC) after unsuccessful chemotherapy. However, survival outcomes and predictors for its effectiveness in chemotherapy-naive NSCLC patients are still not clear. The goal of this study was to investigate the response and survival rates and identify the predictive factors for patients with advanced or metastatic disease receiving gefitinib as first-line therapy. We retrospectively analyzed the response and survival rates of patients with advanced or metastatic NSCLC who had received gefitinib as first-line therapy across six medical institutes in Southern Taiwan between May 2004 and April 2006. The relationship between the response and survival rates to the known predictive factors for gefitinib response and survival was also investigated. A total of 97 patients (65 females and 32 males) were enrolled in this study. Seventy-four patients (76%) had never smoked. Eighty-eight patients (91%) had adenocarcinoma or bronchioloalveolar cell carcinoma. The objective response rate was 56% and the disease control rate (partial response plus stable disease) was 76%. Only poor performance status (Eastern Cooperative Oncology Group score, 3-4) was statistically significantly associated with overall response in this study. The 1-year survival rate was 77%. We suggest that first-line gefitinib monotherapy is promising in some subgroups of Asian patients with NSCLC. Further randomized controlled studies are needed to validate the effectiveness of first-line gefitinib therapy.

Food intake and the occurrence of squamous cell carcinoma in different sections of the esophagus in Taiwanese men

OBJECTIVE

The main objective of this study was to further elucidate the effect of consuming various foods on the development of squamous cell carcinoma (SCC) in three different sections of the esophagus.

METHODS

A total of 343 patients with SCC of the esophagus and 755 cancer-free control subjects were recruited for this study from 1996 to 2005.

RESULTS

We found that intake of vegetables, raw onions/garlic, and fruits are significantly protective against esophageal SSC risk, whereas intake of hot foods can significantly increase its risk. There was a significant inverse relation between the frequency of tea consumption and esophageal SCC risk (P for trend = 0.005), with a 0.5-fold lower risk associated with the intake of unfermented tea (green tea, oolong tea, or jasmine tea). The effects of dietary factors on esophageal SCC were similar in all subsites, with the exception of consumption of coffee. Coffee consumption was more pronounced in having a protective effect in the middle third section compared with the lower third section of the esophagus (adjusted odds ratio 0.4, 95% confidence interval 0.2-0.9), although this protective effect was marginally significant (adjusted odds ratio 0.6, 95% confidence interval 0.4-1.0) against esophageal SCC in all subsites. Our data also suggest that discomfort when eating hot foods may exert a carcinogenic effect by direct contact with the esophageal mucosa and tend to have more harmful effects in the upper than in the lower esophagus. In contrast, vegetables, fruits, and tea with components that are thought to inhibit carcinogenesis by absorbed components affected all subsites similarly.

CONCLUSION

Our results add additional information that certain dietary components may affect carcinogenesis locally and systemically.

Stability of miniplates and miniscrews used for orthodontic anchorage: experience with 492 temporary anchorage devices

OBJECTIVES

The aim of this retrospective study was to evaluate systematically the potential factors that influence failure rates of temporary anchorage devices (TADs) used for orthodontic anchorage.

MATERIALS AND METHODS

Data on 492 TADs (miniplates, pre-drilling miniscrews, and self-drilling miniscrews) in 194 patients were collected. The factors related to TAD failure were evaluated using univariate analysis and multivariate forward stepwise logistic regression analysis.

RESULTS

There were no significant differences in failure rates among the TADs for the following variables: gender, type of malocclusion, facial divergency, implantation site (buccal, lingual, or crestal/midpalatal), location (anterior or posterior), method of force application (power chain or Ni-Ti coil spring), arch (upper or lower), type of soft tissue (attached gingiva or removable mucosa), and most of the cephalometric measurements that reflect dento-cranio-facial characteristics. An increased failure rate was noted for the self-drilling miniscrew type of TAD, TADs used for tooth uprighting, those inserted on bone with lower density, those associated with local inflammation of the surrounding soft tissue, those loaded within 3 weeks after insertion, and those placed in patients with greater mandibular retrusion. Failure rates of the self-drilling miniscrews installed by an oral surgeon and by an orthodontist did not differ significantly.

CONCLUSIONS

Inflammation of soft tissue surrounding a TAD and early loading within 3 weeks after insertion were the most significant factors predicting TAD failure. Both orthodontists and oral surgeons who install orthodontic TADs must undergo sufficient training to achieve clinical excellence.

Inadequate energy and excess protein intakes may be associated with worsening renal function in chronic kidney disease

OBJECTIVES

Dietary energy and protein play important roles in chronic kidney disease (CKD). This study investigates the relationship between energy/protein intake status and renal function in CKD.

DESIGN AND STUDY POPULATION

This cross-sectional study included 599 adult patients diagnosed with stage 3 to 5 CKD in nephrology and nutrition outpatient clinics in Taiwan.

MAIN OUTCOME MEASURE

Energy and protein intakes were assessed using 24-h dietary recall. We recorded recommended calorie/protein amounts and renal function indices, glomerular filtration rate (GFR), creatinine, and blood urea nitrogen (BUN). Patients were categorized into three intake calorie/protein groups by a ratio of actual intake vs. recommended intake. High intake was defined as a ratio of actual intake/recommended intake > or = 110%, moderate intake as > or = 90% to <110%, and low intake as <90%. Data were analyzed by paired t test, one-way analysis of variance, least significant differences, and multiple linear regression.

RESULTS

The energy and protein intakes in CKD patients were significantly higher and lower than recommended levels (P < .001). Low energy intake was significantly related to worsening GFR at increments of -4.41 mL/min/1.73 m(2), compared with moderate and high energy intake (P = .008); high protein intake was also associated with worsening GFR at increments of -3.50 mL/min/1.73m(2), compared with moderate and low protein intake (P < .001). Low energy intake and high protein intake were significantly positively correlated with elevations in creatinine and BUN.

CONCLUSION

Lower energy and higher protein intakes than recommended may be associated with deteriorating renal function.

Hepatitis B virus infection among pregnant women in Taiwan: comparison between women born in Taiwan and other southeast countries

BACKGROUND

Taiwan's national vaccination program has successfully decreased the prevalence of hepatitis B infection after twenty years of implementation and might be indirectly beneficial to the second generation. In this study, we compared the hepatitis B infection status of two groups: pregnant Taiwanese women and other Southeast Asian women, who because they had immigrated later in life to Taiwan by marriage to a Taiwanese man, had not been exposed to that vaccination program to evaluate the effect of hepatitis vaccination program on women of child-bearing age and further explored the potential impact of immigration on the hepatitis B public health policy in Taiwan.

METHODS

Data was collected from 10,327 women born in Taiwan and 1,418 women born in other Southeast Asian countries, both groups receiving prenatal examinations at Fooyin University Hospital between 1996 and 2005. The results of serum hepatitis B s-Antigen (HBsAg) and hepatitis B e-Antigen (HBeAg) tests and other demographic data were obtained by medical chart review.

RESULTS

The pregnant women from Taiwan had a higher HBsAg positive rate (15.5%) but lower HBeAg(+)/HBsAg(+) ratio (32.1%) than the women from other countries (8.9% and 52.4%). For those born before July, 1984, the period of no national vaccination program, Taiwanese women had a higher HBsAg positive rate than other Southeast Asian women (15.7% vs. 8.4%), but for women born after that day and before June 1986, the period of vaccination for high risk newborns, the HBsAg positive rates found to be slightly lower for Taiwanese women than for other Southeast Asian women (11.4% vs. 12.3%) and the difference was more significant (3.1% vs. 28.6%) after June 1986, the period of vaccination for all newborns. While the HBeAg(+)/HBsAg(+) ratios decreased with age in both groups, they were consistently higher in women from other Southeast Asian countries than in women born in Taiwan after age 20.

CONCLUSION

In Taiwan, the neonatal vaccination program that was implemented in 1984 has successfully reduced hepatitis B infection among pregnant women in present day, and is likely to indirectly prevent hepatitis B infection in the next generation. However, the increasing number of pregnant women from other Southeast Asian countries without a national neonatal vaccination program or with a program that was introduced later than the one in Taiwan will likely lessen the positive impact of this program and should be further assessed.

Effectiveness of comprehensive diabetes care program in Taiwanese with type 2 diabetes

OBJECTIVE

To assess continuing diabetic education in Taiwan, we evaluated the impact of comprehensive diabetes care program for Taiwanese people with type 2 diabetes.

METHODS

211 diabetic patients were enrolled and followed up for 1 year at Kaohsiung Medical University Hospital. Patients were provided comprehensive care and their medications were not changed. Clinical and biophysical variables were collected and assessed at 0, 3, 6, 9, 12 months.

RESULTS

Metabolic control had improved significantly by 1 year: fasting plasma glucose (164.6+/-60.4 vs. 137+/-37.5mg/dl, p<0.001); total serum cholesterol (198.7+/-38.8 vs. 187.2+/-43.1mg/dl, p<0.001); high-density lipoproteins cholesterol (43.2+/-10.2 vs. 46.2+/-11.7 mg/dl, p<0.001); low-density lipoproteins cholesterol (121.1+/-32.9 vs. 113.1+/-29.6 mg/dl, p<0.005). In the male group, HbA1c level fell from 8.16+/-1.99% to 7.61+/-1.31% and 7.72+/-1.40% after 9 months and 1 year, respectively, p<0.05. There were also significant improvements in female group after 6 months and 9 months (7.89+/-1.62% after 6 months; 7.94+/-1.66% after 9 months vs. 8.22+/-1.70% at baseline). The change of HbA1c level was significant in male patients, patients whose duration of disease was shorter and in those with higher baseline HbA1c levels after multi-variable and age-adjusted analysis.

CONCLUSION

The comprehensive diabetes care program effectively improved glycemic and cholesterol control. The patients who were more likely to achieve better glycemic control were male, had diabetes for shorter periods of time and had high baseline HbA1c levels. Therefore, diabetic education should be offered to patients as close to the time of diagnosis as possible.

A retrospective analysis of the failure rate of three different orthodontic skeletal anchorage systems

OBJECTIVES

The aim of this retrospective study was to assess systematically the case distribution among three types of mini-implants and to evaluate the clinical factors that influence the failure rates of mini-implants used as an orthodontic anchorage.

MATERIAL AND METHODS

Data for 359 mini-implants (miniplates, miniscrews, and microscrews) in 129 patients were collected. The factors related to mini-implant failure were evaluated using univariate analysis and multivariate stepwise logistic regression analysis.

RESULTS

Among these three different types of skeletal anchorage, there was a significant difference between the failure rates of these mini-implants, with the miniscrews and microscrews showing much higher failure rates. There were no significant differences in failure rates among the mini-implants for the following variables: gender, type of malocclusion, local or full-arch treatment, whether on the buccal or lingual side, length of the screw, loading pattern, or the duration of the healing phase. Greater risks for failure were found in younger patients, when an implant was placed for retraction/protraction, when it was placed on the mandibular arch, when it was placed anterior to the second premolars, or when using the miniscrew/microscrew systems. After adjusting for potential confounding effects, only three factors (type of mini-implant, placement on the mandibular arch, and age) were found to be statistically significant in predicting mini-implant failures (P<0.05) with an R2 value of 85.2%.

CONCLUSIONS

Mini-implants placed in younger patients or placed on the mandibular arch are at a greater risk of failing. The miniplate system has greater stability compared with miniscrews or microscrews. However, it requires flap surgery for insertion and removal, which usually causes swelling and discomfort. Therefore, selection of the proper type of skeletal anchorage should be based on the specific treatment needs of each individual patient.

Differential tissue dose responses of (n-3) and (n-6) PUFA in neonatal piglets fed docosahexaenoate and arachidonoate

Docosahexaenoic acid (DHA) and arachidonic acid (ARA) are commonly added to infant formula worldwide; however, dietary concentrations needed to obtain optimal tissue levels have not been established. Hence, we studied tissue responses in piglets fed various doses of DHA and ARA. Doses were 0, 1, 2, and 5 times those used in U.S. infant formulas and DHA/ARA in Diet 0, Diet 1, Diet 2, and Diet 5 were 0, 4.1/8.1, 8.1/16.2, and 20.3/40.6 mg/100 kJ formula, respectively. Supplementation of dietary DHA and ARA increased DHA in brain, retina, liver, adipose tissue, plasma, and erythrocyte by 1.1- to 25.8-fold of Diet 0 (P-trend < 0.01). Tissue ARA (1.1- to 6.0-fold of Diet 0) responded to dietary ARA in liver, adipose tissue, plasma, and erythrocytes (P-trend < 0.05); brain and retina ARA was, however, unresponsive to dietary DHA and ARA. Plasma and erythrocyte DHA were positively associated with DHA in neural (brain and retina) and visceral (liver and adipose) tissues (r(2) = 0.11-0.56; P < 0.001-P = 0.042). Plasma and erythrocyte ARA did not correlate with neural ARA. Only plasma ARA was associated with liver ARA (r(2) = 0.222; P = 0.02) and adipose ARA (r(2) = 0.867; P < 0.001) and erythrocyte ARA correlated with adipose ARA (r(2) = 0.470; P < 0.001). We conclude that dietary DHA supplementation affords an effective strategy for enhancing tissue DHA, ARA in visceral but not neural tissues is sensitive to dietary ARA, and erythrocyte and plasma DHA can be used as proxies for tissue DHA, although blood-borne ARA is not an indicator of neural ARA.

Admission Time and Outcomes of Patients in A Medical Intensive Care Unit

Studies have shown that weekend or night admissions to intensive care units (ICUs) are associated with increased mortality in critically ill patients. Our study aimed to evaluate the effects of admission time and day on patient outcomes in a medical ICU equipped with patient management guide-lines, and staffed by intensivists on call for 24 hours, who led the morning rounds on all days of the week but did not stay in-house overnight. The study enrolled 611 consecutive patients admitted to a 26-bed medical ICU in a university hospital during a 7-month period. We divided them into two groups, which we labeled as "office hours" (08:00-18:00 on weekdays) and "non-office hours" (18:00-08:00 on weekdays, and all times on weekends) according to their ICU admission times. The clinical outcomes were compared between the groups. The effects of admission on weekends, at night, and various days of the week on hospital mortality were also evaluated. Our results showed that there were no significant differences in ICU and hospital mortalities between patients admitted during office hours and those admitted during non-office hours (27.2% vs. 27.4%, p = 1.000; 38.9% vs. 37.6%, p = 0.798). The ICU length of stay, ICU-free time within 21 days, and length of stay in the hospital were also comparable in both groups. Among the 392 patients requiring mechanical ventilation, the ventilator outcomes were not significantly different between those in the office-hour group and the non-office-hour group. Multivariate logistic regression analyses showed that the adjusted odds of hospital mortality were not significantly higher for patients admitted to our ICU on weekends, at night, or on any days of the week. In conclusion, our results showed that non-office-hour admissions to our medical ICU were not associated with poorer ICU, hospital, and ventilator outcomes, compared with office-hour admissions. Neither were time of day and day of the week admissions to our ICU associated with significant differences in hospital mortality.

Factors associated with underdiagnosis from incisional biopsy of oral leukoplakic lesions

OBJECTIVES

Incisional biopsy is accepted by most clinicians as a dependable way of assessing the nature of oral leukoplakia (OL). The aim of the present study was to investigate its reliability and analyze risk factors associated with underdiagnosis from incisional biopsy.

STUDY DESIGN

A cross-sectional retrospective study was conducted in 242 patients with a clinical diagnosis of OL. The discrepancy between provisional diagnosis (from incisional biopsy) and definitive diagnosis (from resection specimen) was analyzed and correlated with clinical variables. Patients who had incisional biopsy taken from a single location and those who received multiple-site biopsies were analyzed separately.

RESULTS

In the 200 cases receiving single-site biopsy, the agreement rate between provisional and definitive diagnoses was only 56%, and underdiagnosis from incisional biopsy was noted in 29.5% of patients. Underdiagnosis rate in the 42 patients receiving multiple-site biopsies was significantly lower (11.9%; P < .05). The rate of unexpected carcinoma in resection specimen was also significantly lower in the multiple-biopsy patients than in the single-biopsy patients (2.4% vs. 12.0%; P < .05). For the single-biopsy group, multivariate analysis revealed that clinical appearance significantly influenced the risk of underdiagnosis and unexpected carcinoma (both P < .05). Compared with homogeneous lesions, nonhomogeneous OL were more prone to be underdiagnosed (adjusted odds ratio [AOR] 2.36, 95% confidence interval [CI] 1.16-4.82) and have carcinoma undetected by incisional specimen (AOR 15.94, 95% CI 2.09-121.72).

CONCLUSIONS

Incisional biopsy was found to have limitations in the assessment of OL, especially for nonhomogeneous lesions. Clinicians should be conscious of the possible underdiagnosis from incisional biopsy, and multiple biopsies should be taken whenever they think that it is necessary.

Factors associated with quitting areca (betel) quid chewing

OBJECTIVES

The purpose of this study was to provide useful data for a future abstinence project by identifying the factors related to quitting areca (betel) quid chewing.

METHODS

The study was cross-sectional. Data on demographic variables, psychological factors and substance-use behaviors were collected via questionnaires from 326 participants.

RESULTS

Multiple logistic regression analysis indicated that the areca/betel quid chewers who were less educated (OR = 0.58, 95% CI = 0.34-0.98) were least likely to try to give up. Among the chewers who tried to quit, those employed as full-time drivers (OR = 2.24, 95% CI = 1.14-4.39), who had drinking habits (OR = 2.41, 95% CI = 1.24-4.66), and who preferred to chew only betel quid wrapped with leaf (OR = 4.44, 95% CI = 1.99-9.90) were more likely to fail. Chewers who successfully quit had a higher internal health locus of control compared with those who failed to quit (one-point increments, OR = 0.94, 95% CI = 0.90-0.98).

CONCLUSIONS

The results suggest that health educators and researchers can better influence people's chewing behavior if the importance of chewers' education level, job type, substance use (i.e. drinking habits, type of betel quid), and level of health locus of control are all taken into consideration when devising interventions.

Pulpal inflammation and incidence of coronary heart disease

Pulpal inflammation is primarily caused by coronal caries, and leads to root canal therapy (RCT). Chronic inflammation has been associated with various cardiovascular diseases. This study evaluates the association between pulpal inflammation (using RCT as a surrogate) and incident coronary heart disease (CHD). We report results among males from the Health Professionals Follow-Up Study (HPFS), excluding participants with prior cardiovascular disease or diabetes. We obtained RCT data from the HPFS cohort (n = 34,683). Compared to men without RCT, those with >/=1 RCT had a multivariate RR of 1.21 (95% CI 1.05-1.40) for CHD. The association was limited to dentists (RR = 1.38; 95% CI 1.14-1.67). There was no association among nondentists (RR = 1.03). Dental caries was not associated with CHD. The results suggest a possible modest association between pulpal inflammation and CHD.

Carcinoma and dysplasia in oral leukoplakias in Taiwan: prevalence and risk factors

OBJECTIVES

The issue of existence of malignancy within oral leukoplakia has seldom been addressed in Taiwan. The aims of this study were to investigate the prevalence of carcinoma and dysplasia within oral leukoplakia at the time of clinical diagnosis and to identify the associated risk factors in Taiwan.

STUDY DESIGN

The prevalence rate of malignancy and dysplasia in 1046 oral leukoplakias at a university hospital was calculated. Univariate and multivariate analyses by the Mantel-Haenszel method and multiple logistic regression model were performed to examine risk factors associated with the presence of carcinoma and dysplasia within the lesions.

RESULTS

The prevalence rate of carcinoma was 12.9%. The relative risks for the presence of malignancy in leukoplakias on the tongue/floor of mouth and with nonhomogeneous appearance were 2.72- and 28.13-fold by multivariate logistic regression analysis, when compared with those on buccal mucosa and lesions having homogeneous surface (both P < .05). In contrast, patients who both smoked and chewed betel quid had a significantly lower risk for carcinoma than the abstainers (P < .05). A synergistic effect between the 2 major risk factors of clinical appearance and lesion site was evident. Nonhomogeneous leukoplakia on tongue/floor of mouth had a 43.10-fold higher risk compared to homogeneous lesions located on buccal mucosa or other sites (P < .05). However, homogeneous leukoplakia in buccal mucosa or other sites of the oral cavity still had the possibility of having carcinoma within the lesion. The prevalence of dysplasia was 45.6% among the noncancerous leukoplakias with risk factors similar to those for carcinoma.

CONCLUSIONS

Our results demonstrate that some leukoplakias contain a malignant component. Lesions with certain features are more prone to carcinoma, but no clinical attributes can bring certitude. Therefore, all oral leukoplakias should be submitted to microscopic analysis before any definite treatment or long-term follow-up.

The association between tooth loss and the self-reported intake of selected CVD-related nutrients and foods among US women

OBJECTIVES

Many studies have reported associations between oral health and cardiovascular diseases; poor nutritional status due to impaired dentition status has been suggested as a mediator. Our objective is to evaluate the associations between tooth loss and the self-reported consumption of fruits and vegetables and selected CVD-related nutrients.

METHODS

A total of 83,104 US women who completed a food frequency questionnaire (FFQ) in 1990 and 1994 and reported number of natural teeth in 1992, were included in a cross-sectional analysis relating dietary intake to number of natural teeth. A longitudinal analysis was also conducted to evaluate whether tooth loss in 1990-1992 was associated with change in diet between 1990 and 1994.

RESULTS

After adjusting for age, total calorie intake, smoking and physical activity, edentulous women appeared to have dietary intake associated with increased risk for CVD, including significantly higher intake of saturated fat, trans fat, cholesterol and vitamin B12, and lower intake of polyunsaturated fat, fiber, carotene, vitamin C, vitamin E, vitamin B6, folate, potassium, vegetables, fruits, and fruits excluding juices compared with women with 25-32 teeth. In the longitudinal analyses, women who lost more teeth were more likely to change their diet in ways that would potentially increase risk for development of CVD. They also tended to avoid hard foods, such as raw carrot, fresh apple or pear.

CONCLUSIONS

Women with fewer teeth have unhealthier diets such as decreased intake of fruits and vegetables, which could increase CVD risk. Diet may partially explain associations between oral health and cardiovascular disease.

Survivin expression predicts poorer prognosis in patients with areca quid chewing-related oral squamous cell carcinoma in Taiwan

Survivin, a recently characterized novel member of the inhibitor of apoptosis (IAP) family, is not detectable in most differentiated normal adult tissues but is expressed in a wide range of cancer tissues. Its expression in cancer has been correlated with poor prognosis, cancer progression and drug resistance. We immunohistochemically examined the expression of survivin in 62 cases of oral epithelial dysplasia (ED) and 96 cases of oral squamous cell carcinoma (SCC). Cytoplasmic survivin staining was detected in 60 of the 62 (97%) ED specimens and 94 of the 96 (98%) SCC specimens but not in adjacent normal oral mucosal tissues. The labeling index (LI) for survivin protein significantly increased from ED (32.3+/-16.3%) to SCC samples (49.4+/-28.5%) (p<0.001). In addition, the mean LI for ED cases with further malignant transformation into SCC (45.6+/-8.8%) was higher than those without malignant transformation (30.1+/-16.3%) (p=0.008). No significant correlation was found between the survivin expression and the patients' age, sex, oral habit, cancer location, or STNM status in SCC cases. Kaplan-Meier curves showed oral SCC patients with high survivin expression (LI>25%), advanced stage, larger tumor size, or positive lymph node metastasis had significantly shorter overall survival (p=0.014, 0.012, 0.005 and 0.011, respectively by log-rank test) than others. The associations remained significant after adjusting for age. These results indicate that survivin protein expression may be an important early event in oral carcinogenesis and predicts unfavorable prognosis for oral SCC. Furthermore, the unique expression of survivin in cancer cells but not in most normal adult tissues suggests that modulation of survivin protein expression may provide a novel strategy for the therapy of oral SCC.

Effects of the dietary phytoestrogen biochanin A on cell growth in the mammary carcinoma cell line MCF-7

Studies of the dietary phytoestrogen biochanin A on cell proliferation of the cultured estrogen responsive cells human breast carcinoma MCF-7 showed that biochanin A exhibits biphasic regulation on MCF-7 cells. At concentrations of less than 10 microg/mL, cells respond to biochanin A by increasing cell growth and de novo DNA synthesis. The addition of biochanin A at concentrations of greater than 30 microg/mL significantly inhibited cell growth and DNA synthesis in a dose-dependent fashion, resulting in an IC(50) value of 40 microg/mL. The reversibility of these inhibitory effects by biochanin A appears also to be concentration dependent. Cells previously treated with high concentrations (>60 microg/mL) of biochanin A did not regain normal growth after treatment ceased. Biochanin A was cytostatic at low concentrations (<40 microg/mL) and cytotoxic at higher concentrations. Upon exposure to 100 microg/mL of biochanin A, cell morphology was severely altered, cell volume decreased, and condensation of cell components was clearly noticeable. In addition, biochanin A damaged cell membranes by increasing membrane permeability. These results suggest possible molecular and cellular mechanisms of the action of dietary phytoestrogens on estrogen target cells.

The association between tooth loss and coronary heart disease in men and women

OBJECTIVES

This paper evaluates the relation of tooth loss to incidence of coronary heart disease in two large cohort studies.

METHODS

Participants included 41,407 men and 58,974 women free of any cardiovascular diseases at baseline. We recorded 1,654 incident coronary heart disease events (562 fatal events) among men during 12 years of follow-up and 544 events (158 fatal events) among women during 6 years of follow-up.

RESULTS

After controlling for important cardiovascular risk factors, compared to men with 25-32 teeth at baseline, men with 0-10 teeth had a significantly higher risk of coronary heart disease (relative risk [RR]= 1.36; 95 percent confidence interval [CI]=1.11, 1.67). The relative risk increased to 1.79 (95% CI=1.34, 2.40) when limited to fatal events. Women with 0-10 teeth were also at increased risk of coronary heart disease compared to women with 25-32 teeth (RR=1.64; 95% CI=1.31, 2.05). The association was similar for fatal events (RR= 1.65; 95% CI=1.11, 2.46). The association between number of teeth and incidence of coronary heart disease was similar between men with and without a history of periodontal disease, and there was no significant association between tooth loss during follow-up and coronary heart disease.

CONCLUSIONS

This study showed a significant association between number of teeth at baseline and risk of coronary heart disease and the mechanisms to explain this association should be further clarified.

Fruit and Vegetable Intake and Risk of Major Chronic Disease

BACKGROUND

Studies of fruit and vegetable consumption in relation to overall health are limited. We evaluated the relationship between fruit and vegetable intake and the incidence of cardiovascular disease and cancer and of deaths from other causes in two prospective cohorts.

METHODS

A total of 71 910 female participants in the Nurses' Health study and 37,725 male participants in the Health Professionals' Follow-up Study who were free of major chronic disease completed baseline semiquantitative food-frequency questionnaires in 1984 and 1986, respectively. Dietary information was updated in 1986, 1990, and 1994 for women and in 1990 and 1994 for men. Participants were followed up for incidence of cardiovascular disease, cancer, or death through May 1998 (women) and January 1998 (men). Multivariable-adjusted relative risks were calculated with Cox proportional hazards analysis.

RESULTS

We ascertained 9329 events (1964 cardiovascular, 6584 cancer, and 781 other deaths) in women and 4957 events (1670 cardiovascular diseases, 2500 cancers, and 787 other deaths) in men during follow-up. For men and women combined, participants in the highest quintile of total fruit and vegetable intake had a relative risk for major chronic disease of 0.95 (95% confidence interval [CI] = 0.89 to 1.01) times that of those in the lowest. Total fruit and vegetable intake was inversely associated with risk of cardiovascular disease but not with overall cancer incidence, with relative risk for an increment of five servings daily of 0.88 (95% CI = 0.81 to 0.95) for cardiovascular disease and 1.00 (95% CI = 0.95 to 1.05) for cancer. Of the food groups analyzed, green leafy vegetable intake showed the strongest inverse association with major chronic disease and cardiovascular disease. For an increment of one serving per day of green leafy vegetables, relative risks were 0.95 (95% CI = 0.92 to 0.99) for major chronic disease and 0.89 (95% CI = 0.83 to 0.96) for cardiovascular disease.

CONCLUSIONS

Increased fruit and vegetable consumption was associated with a modest although not statistically significant reduction in the development of major chronic disease. The benefits appeared to be primarily for cardiovascular disease and not for cancer.

Association between diet and esophageal cancer in Taiwan

BACKGROUND

Several studies have reported the importance of dietary factors in the development of esophageal cancer. The purpose of the present study was to evaluate the effects of several common dietary factors on the risk of squamous cell carcinoma of the esophagus in a Taiwanese population.

METHODS

The association between diet and esophageal cancer was examined in 284 male patients and 480 male controls, who were recruited during 6 year period.

RESULTS

Consumption of preserved and overheated foods was found to be associated with increased risk of esophageal cancer, whereas intake of fresh fruits, vegetables, and tea was inversely associated with this risk. Men who consumed fermented bean products, salted food and preserved/pickled vegetables more than once a week after age 40 years had a 3.4-fold risk (95% confidence interval (CI): 1.9-6.2), 2.3-fold risk (95%CI: 1.2-4.2), and 2.5-fold risk (95%CI: 1.3-4.5), respectively, compared to men eating these items less than once a week. It was further found that these preserved foods were more strongly associated with esophageal cancer among men who consumed fruit less than once per day than those who consumed fruits one or more times per day.

CONCLUSIONS

These results suggest that a high intake of preserved foods and overheated drinks might increase the risk of esophageal cancer, and intake of fruit, vegetables, and tea might be negatively associated with risk of esophageal cancer. The results also suggest that diet is an important factor in the development of esophageal cancer in Taiwan.

Indirect Traumatic Optic Neuropathy Complicated With Periorbital Facial Bone Fracture

This study evaluated the outcome for 45 consecutive, nonrandomized patients whose indirect type traumatic optic neuropathy and periorbital facial bone fracture were treated at the Chang Gung Memorial Hospital in Kaohsiung between June of 1996 and June of 2001. There were a total of 48 eye injuries in 45 patients (3 patients sustained bilateral eye injuries). Data related to megadose steroid treatment, timing of open reduction and internal fixation for periorbital facial fractures, and pretreatment and post-treatment of visual acuities were collected from the medical records. Measurements of visual improvement in terms of degree and percentage were calculated after the visual acuities were converted into the log of the minimum angle of resolution units. Visual acuities were significantly improved according to mechanism of injury, gender, or associated periorbital skin laceration wound. However, no light perception for eight patients at initial presentation and gradually deteriorating vision in four injured eyes of three patients were identified as poor prognostic factors. Therefore, repeated visual measurements are recommended to detect any gradually deteriorating vision, which although uncommon, has a poor prognosis. No significantly improved vision was found after treatment with megadose steroids. However, if improvement in vision did occur, treatment with megadose steroids resulted in a much greater visual improvement in terms of degree (p = 0.001) and percentage (p = 0.02). Thus treatment with megadose steroid is recommended. No significant differences were found in the visual improvement between those who received and those who did not receive periorbital open reduction and internal fixation operations, and between those who received early repair within 48 hours and those who received late repair after more than 48 hours. However, it seems medicolegally prudent to delay the procedure because some patients may experience gradually deteriorating vision, which has a poor prognosis, and because postoperative visual loss after facial fracture repair did happen.

The Association Between Fruit and Vegetable Consumption and Peripheral Arterial Disease

BACKGROUND

High fruit and vegetable consumption has been associated with a lower risk of cardiovascular diseases, but few studies have focused on peripheral arterial disease. In this study, we evaluated the association of consumption of fruits and vegetables with peripheral arterial disease.

METHODS

In a cohort of 44,059 men initially free of cardiovascular disease and diabetes, we documented 295 cases of peripheral arterial disease during a 12-year follow-up. Fruit and vegetable consumption was assessed by food frequency questionnaire.

RESULTS

In the age-adjusted model, men in the highest quintile had a relative risk of 0.55 (95% confidence interval = 0.38-0.80) for overall fruit and vegetable intake, 0.52 (0.36-0.77) for fruit intake, and 0.54 (0.36-0.81) for vegetable intake, compared with those in the lowest quintile of intake. However, the associations were greatly weakened after adjustment for smoking and other traditional cardiovascular disease risk factors. Comparing men in the highest quintile versus the lowest quintile, relative risks and 95% confidence intervals were 0.95 (0.62-1.44) for overall fruit and vegetable intake, 0.97 (0.64-1.48) for fruit intake, and 0.76 (0.50-1.17) for vegetable intake.

CONCLUSIONS

We did not find evidence that fruit and vegetable consumption protects against peripheral arterial disease, although a modest benefit cannot be excluded.

Tooth loss and dietary intake

BACKGROUND

Several studies have reported that impaired dentition status is associated with poor nutritional intake. However, most of these studies are cross-sectional and thus are unable to clarify the temporal sequence.

METHODS

We assessed the longitudinal relation between tooth loss and changes in consumption of fruits and vegetables and of nutrients important for general health among 31,813 eligible male health professionals.

RESULTS

Subjects who lost five or more teeth had a significantly smaller reduction in consumption of dietary cholesterol and vitamin B12, greater reduction in consumption of polyunsaturated fat and smaller increase in consumption of dietary fiber and whole fruit than did subjects who had lost no teeth. Men who had lost teeth also were more likely to stop eating apples, pears and raw carrots.

CONCLUSIONS

The results support the temporal association between tooth loss and detrimental changes in dietary intakes, which could contribute to increased risk of developing chronic diseases.

PRACTICE IMPLICATIONS

Dietary evaluation and recommendations can be incorporated into dental visits to provide a greater benefit to patients.

Synergistic effect of multiple indoor allergen sources on atopic symptoms in primary school children

Accumulating data show that the complex modern indoor environment contributes to increasing prevalence of atopic diseases. However, the dose-response relationship between allergic symptoms and complexity of indoor environmental allergen sources (IEAS) has not been clearly evaluated before. Therefore, we designed this study to investigate the overall effect of multiple IEAS on appearance of asthma (AS), allergic rhinitis (AR), and eczema (EC) symptoms in 1472 primary school children. Among various IEAS analyzed, only stuffed toys, cockroaches, and mold patches fit the model of 'more IEAS, higher odds ratio (OR) of association'. The association of IEAS and AR increased stepwise as more IEAS appeared in the environment (1.71, 2.47, to 2.86). In AS and EC, the association was significant only when all three IEAS were present (1.42, 1.98, to 4.11 in AS; 1.40, 1.76, to 2.95 in EC). These results showed that different IEAS had a synergistic effect on their association with atopic symptoms and also suggest that there is a dose-response relationship between kinds of IEAS and risk of appearance of atopic diseases.

Lifestyle and Psychosocial Factors Associated with Chronic Periodontitis in Taiwanese Adults

BACKGROUND

The development of chronic periodontitis (CP) is a multifactorial process and variation in severity cannot be explained by just a few risk factors. The aims of this study were: 1) to explore the lifestyle and psychosocial factors of CP patients and 2) to estimate the proportion of total CP cases attributable to one or more risk factors considered.

METHODS

A case-control study of 250 cases of CP patients and 250 controls were matched by age (within 3 years) and gender. Complete dental examinations were performed based on the clinical criteria for CP for both groups. Structured questionnaires were conducted to collect lifestyle and psychosocial factors. Multivariate logistic regression was applied to assess the association between risk factors and chronic periodontitis.

RESULTS

Conditional multivariable logistic regression analysis showed that toothbrushing frequency (odds ratio [OR]: 5.77, if rarely; OR: 3.50, if once a day), mental illness (OR: 5.32, if Chinese Health Questionnaire scores were > or = 6), and smoking (OR: 3.93, if pack years smoked was > 21) are significantly and independently associated with chronic periodontitis. In addition, all these variables reflected a dose-response effect (P trend = <0.001, 0.004, and 0.005, respectively).

CONCLUSIONS

For Taiwanese adults, 36.10% of CP cases were presumably attributable to toothbrushing frequency, mental illness, and smoking. These three factors should be the first priorities in establishing a preventive program to improve the periodontal health status.

Oral health and peripheral arterial disease

BACKGROUND

Many studies have reported the association between poor oral health and coronary heart disease or stroke, but few of them evaluated peripheral arterial disease (PAD). Hence, in this study we examined the associations between oral health and PAD.

METHODS AND RESULTS

In the prospective study of 45,136 eligible male health professionals free of cardiovascular diseases at baseline, we identified 342 cases of PAD during a 12-year follow-up period. We evaluated the association between different measures of oral diseases and the occurrence of PAD. Baseline number of teeth was not related to the risk of PAD, but cumulative incident tooth loss was significantly associated with elevated risk of subsequent occurrence of PAD. The relative risk for history of periodontal disease was 1.41 (95% CI, 1.12 to 1.77) and for any tooth loss during the follow-up period was 1.39 (95% CI, 1.07 to 1.82), controlling for traditional risk factors of cardiovascular disease. Among men with a history of periodontal diseases, the relative risk of tooth loss increased to 1.88 (95% CI, 1.27 to 2.77), whereas no association was found between tooth loss and PAD among those without periodontal diseases (RR, 0.92; 95% CI, 0.61 to 1.38). We further explored the potential induction period of tooth loss and found that tooth loss in the previous 2 to 6 years was most strongly associated with PAD.

CONCLUSIONS

We found that incident tooth loss was significantly associated with PAD, especially among men with periodontal diseases. The results support a potential oral infection-inflammation pathway.

Periodontal disease, tooth loss, and incidence of ischemic stroke

BACKGROUND AND PURPOSE

Periodontal and other infections have been suggested as potential risk factors for stroke. This study evaluates periodontal disease and tooth loss as risk factors for ischemic stroke.

METHODS

The study population consisted of 41 380 men who were free of cardiovascular disease and diabetes at baseline. Periodontal disease history was assessed by mailed validated questionnaires. During 12 years of follow-up, stroke incidence was assessed and subclassified by use of medical history, medical records, and imaging reports. Hazard ratios (HRs) were adjusted for age, amount smoked, obesity, alcohol, exercise, family history of cardiovascular disease, multivitamin use, vitamin E use, profession, baseline reported hypertension, and hypercholesterolemia. Sex and socioeconomic status were inherently controlled for by restriction. Confounding variables were updated in the analyses for each 2-year follow-up interval.

RESULTS

We documented 349 ischemic stroke cases during the follow-up period. Men who had < or =24 teeth at baseline were at a higher risk of stroke compared to men with > or =25 teeth (HR=1.57; 95% CI, 1.24 to 1.98). There was little evidence of an increased risk with recent tooth loss during follow-up. A modest association was seen between baseline periodontal disease history and ischemic stroke (HR=1.33; 95% CI, 1.03 to 1.70). Addition of dietary factors to the model changed the HR only slightly.

CONCLUSIONS

Our results suggest that periodontal disease and fewer teeth may be associated with increased risk of ischemic stroke.

Meta-analysis of the effect of scaling and root planing, surgical treatment and antibiotic therapies on periodontal probing depth and attachment loss

OBJECTIVE

This paper reports a meta-analysis of studies that have investigated the effect of scaling and root planing on periodontal probing depth and attachment loss.

MATERIAL AND METHODS

The criteria used for inclusion of studies were as follows: root planing and scaling alone was one of the primary treatment arms; patients or quadrants of each patient were randomly assigned to study groups; 80% of patients enrolled were included in first year follow-up examinations; periodontal probing depth and attachment loss were reported in mm; the sample size of each study and substudy was reported. Sample size was used to weight the relative contribution of each study since standard errors were not reported by many studies and sample size is highly correlated with standard error and therefore statistically able to explain a substantial portion of the standard error on studies that use similar measures.

RESULTS

The meta-analysis results show that periodontal probing depth and gain of attachment level do not improve significantly following root planing and scaling for patients with shallow initial periodontal probing depths. However, there was about a 1-mm reduction for medium initial periodontal probing depths and a 2-mm reduction for deep initial periodontal probing depths. Similarly, there was about a 0.50-mm gain in attachment for medium initial periodontal probing depth measurements and slightly more than a l-mm gain in attachment for deep initial periodontal probing depth measurements. Surgical therapy for patients with deep initial probing depths showed better results than scaling and root planing in reducing probing depths. When patients were followed up over 3 years or more, these differences were reduced to less than 0.4 mm. Antibiotic therapy showed similar results to scaling and root planing. However, a consistent improvement in periodontal probing depth and gain of attachment is demonstrated when local antibiotic therapy is combined with root planing and scaling.

Nutrition as a mediator in the relation between oral and systemic disease: associations between specific measures of adult oral health and nutrition outcomes

Recent associations between oral health and systemic disease have led to renewed interest in the mouth and its contribution to health outcomes. Many pathways for this relationship have been postulated, among them the potential mediating role of nutrition. The link between various nutrients and systemic disease has been established, but relatively little work has been done in relating oral conditions with nutrition. We searched MEDLINE, from 1966 to July, 2001, to identify articles relating specific oral measures to nutrition outcomes. We included original articles written in English with a sample size greater than 30 that used objective oral health measures. We reviewed a total of 56 articles. Only a small proportion of these studies were methodologically sound. Although many studies were small and cross-sectional, the literature suggests that tooth loss affects dietary quality and nutrient intake in a manner that may increase the risk for several systemic diseases. The impact of tooth loss on diet may be only partially compensated for by prostheses. To date, there is little information relating periodontal disease and oral pain and nutrition. A few studies suggest poorer nutrition among individuals with xerostomia and altered taste. Further, impaired dentition may contribute to weight change, depending on age and other population characteristics. There is a paucity of well-designed studies addressing oral health and nutrition. Before we can acquire a better understanding of how nutrition and oral health interrelate, however, more studies will be required to confirm these associations-preferably longitudinal studies with larger sample sizes and better control of important confounders.

Multiple unfolding intermediates of human placental alkaline phosphatase in equilibrium urea denaturation

Alkaline phosphatase is an enzyme with a typical alpha/beta hydrolase fold. The conformational stability of the human placental alkaline phosphatase was examined with the chemical denaturant urea. The red shifts of fluorescence spectra show a complex unfolding process involving multiple equilibrium intermediates indicating differential stability of the subdomains of the enzyme. None of these unfolding intermediates were observed in the presence of 83 mM NaCl, indicating the importance of ionic interactions in the stabilization of the unfolding intermediates. Guanidinium chloride, on the other hand, could stabilize one of the unfolding intermediates, which is not a salt effect. Some of the unfolding intermediates were also observed in circular dichroism spectroscopy, which clearly indicates steady loss of helical structure during unfolding, but very little change was observed for the beta strand content until the late stage of the unfolding process. The enzyme does not lose its phosphate-binding ability after substantial tertiary structure changes, suggesting that the substrate-binding region is more resistant to chemical denaturant than the other structural domains. Global analysis of the fluorescence spectral change demonstrated the following folding-unfolding process of the enzyme: N <--> I(1) <--> I(2) <--> I(3) <--> I(4) <--> I(5) <--> D. These discrete intermediates are stable at urea concentrations of 2.6, 4.1, 4.7, 5.5, 6.6, and 7.7 M, respectively. These intermediates are further characterized by acrylamide and/or potassium iodide quenching of the intrinsic fluorescence of the enzyme and by the hydrophobic probes, 1-anilinonaphthalene-8-sulfonic acid and 4,4'-dianilino-1,1'-binaphthyl-5,5'-disulfonic acid. The stepwise unfolding process was interpreted by the folding energy landscape in terms of the unique structure of the enzyme. The rigid central beta-strand domain is surrounded by the peripheral alpha-helical and coil structures, which are marginally stable toward a chemical denaturant.

Differentiation of the slow-binding mechanism for magnesium ion activation and zinc ion inhibition of human placental alkaline phosphatase

The binding mechanism of Mg(2+) at the M3 site of human placental alkaline phosphatase was found to be a slow-binding process with a low binding affinity (K(Mg(app.)) = 3.32 mM). Quenching of the intrinsic fluorescence of the Mg(2+)-free and Mg(2+)-containing enzymes by acrylamide showed almost identical dynamic quenching constant (K(sv) = 4.44 +/- 0.09 M(-1)), indicating that there is no gross conformational difference between the M3-free and the M3-Mg(2+) enzymes. However, Zn(2+) was found to have a high affinity with the M3 site (K(Zn(app.)) = 0.11 mM) and was observed as a time-dependent inhibitor of the enzyme. The dependence of the observed transition rate from higher activity to lower activity (k(obs)) at different zinc concentrations resulted in a hyperbolic curve suggesting that zinc ion induces a slow conformational change of the enzyme, which locks the enzyme in a conformation (M3'-Zn) having an extremely high affinity for the Zn(2+) (K*(Zn(app.)) = 0.33 microM). The conformation of the M3'-Zn enzyme, however, is unfavorable for the catalysis by the enzyme. Both Mg(2+) activation and Zn(2+) inhibition of the enzyme are reversible processes. Structural information indicates that the M3 site, which is octahedrally coordinated to Mg(2+), has been converted to a distorted tetrahedral coordination when zinc ion substitutes for magnesium ion at the M3 site. This conformation of the enzyme has a small dynamic quenching constant for acrylamide (K(sv) = 3.86 +/- 0.04 M(-1)), suggesting a conformational change. Both Mg(2+) and phosphate prevent the enzyme from reaching this inactive structure. GTP plays an important role in reactivating the Zn-inhibited enzyme activity. We propose that, under physiological conditions, magnesium ion may play an important modulatory role in the cell for protecting the enzyme by retaining a favorable geometry of the active site needed for catalysis.

Slow binding of metal ions to pigeon liver malic enzyme: a general case

Pigeon liver malic enzyme was inhibited by lutetium ion through a slow-binding process, which resulted in a concave down tracing of the enzyme activity assay. The fast initial rates were independent of lutetium ion concentration, while the slow steady-state rates decreased with increasing Lu(3+) concentration. The observed rate constant for the transition from initial rate to steady-state rate, k(obs), exhibited saturation kinetics as a function of Lu(3+) concentration, suggesting the involvement of an isomerization process between two enzyme forms (R-form and T-form). The binding affinity of Lu(3+) to the R-form is weaker (K(d,Lu) = 14 microM) than that of Mn(2+) (K(m,Mn) = 1.89 microM); however, Lu(3+) has much tighter binding affinity with the T-form ( = 0.83 microM). Lu(3+) was shown to be a competitive inhibitor with respect to Mn(2+), which suggests that Lu(3+) and Mn(2+) are competing for the same metal binding site of the enzyme. These observations are in accordance with the available crystal structure information, which shows a distorted active site region of the Lu(3+)-containing enzyme. Other divalent cations, i.e., Fe(2+), Cu(2+), or Zn(2+), also act as time-dependent slow inhibitors for malic enzyme. The dynamic quenching constants of the intrinsic fluorescence for the metal-free and Lu(3+)-containing enzymes are quite different, indicating the conformational differences between the two enzyme forms. The secondary structure of these two enzyme forms, on the other hand, was not changed. The above results indicated that replacement of the catalytically essential Mn(2+) by other metal ions leads to a slow conformational change of the enzyme and consequently alters the geometry of the active site. The transformed enzyme conformation, however, is unfavorable for catalysis. Both the chemical nature of the metal ion and its correct coordination in the active site are essential for catalysis.

Potent and competitive inhibition of malic enzymes by lanthanide ions

The catalytic activity of malic enzyme (ME), a member of a new class of oxidative decarboxylases, requires the presence of divalent cations (Mn(2+), Mg(2+), and others). The crystal structure at 2.9 A resolution of human mitochondrial NAD(+)-dependent malic enzyme in a ternary complex with NAD(+) and the lanthanide ion Lu(3+), which has similar radius as Mn(2+), reveals a new conformation of the enzyme. The active site in this ternary complex is in an open form, while the organization of the tetramer of the enzyme actually resembles that with a closed active site. The Lu(3+) ion is bound to the enzyme at the same site as Mn(2+). Kinetic studies showed that Lu(3+) is a potent inhibitor of both the human NAD(P)(+)-dependent ME and the NADP(+)-dependent ME from pigeon liver, and is competitive with respect to the divalent cation, consistent with the structural information.

Reverse micelles as life-mimicking systems

In this review, we attempt to demonstrate that reverse micelles are simple artificial systems that mimic many life systems from cell division to the creation of an enzyme catalytic mechanism. For a membranous enzyme like placental alkaline phosphatase, the kinetic properties observed in reverse micelles might represent those found under physiological conditions. The reverse micellar system, consisting of a positively charged surfactant, mimics a detoxification enzyme glutathione transferase. We propose a novel island-in-oil-lake reverse micellar model for the glutathione transferase that can account for almost all the catalytic properties of this enzyme. Reverse micelles may provide an excellent model system in investigating the reaction mechanism of other detoxification enzymes.

Successful initial treatment with weekly etoposide, epirubicin, cisplatin, 5-fluorouracil and leucovorin chemotherapy in advanced gastric cancer patients with disseminated intravascular coagulation

BACKGROUND

Acute disseminated intravascular coagulation (DIC) is a rare but severe complication of gastric adenocarcinoma. Conventional treatments, such as fresh frozen plasma, platelet replacement and heparin injections, are disappointing. The only way to correct this fatal condition is to control the underlying cancer promptly by effective chemotherapy. Here the successful initial control of acute DIC in gastric cancer patients with weekly EEPFL chemotherapy is reported.

METHODS

Advanced gastric cancer patients complicated with acute DIC were eligible. Patients were treated with weekly EEPFL therapy (etoposide 40, epirubicin 10, cisplatin 25, 5-fluorouracil 2200 and leucovorin 120 mg/m2 ). Response, survival and toxicity were evaluated.

RESULTS

From April 1997 to April 1999, six patients were included in this study. All patients received EEPFL chemotherapy. Clinical and laboratory evidence of acute DIC stabilized quickly after starting chemotherapy. Four patients showed a partial response, one stable disease and one progressive disease. The toxicity was mild and well tolerated. Median survival was 28 weeks (12, 14, 26, 30, 30 and 32 weeks). All patients suffered from a relapse of DIC after initial successful control and died within 30 days of clinical and laboratory evidence of acute DIC relapse.

CONCLUSION

EEPFL therapy is an effective chemotherapy regimen for patients with advanced gastric cancer associated with acute DIC. The prognosis is poor if the DIC relapses after the initial successful control.

Proximal arterioportal shunting associated with hepatocellular carcinoma: features revealed by dynamic helical CT

OBJECTIVE

This study investigated the findings revealed by dynamic helical CT of proximal arterioportal shunting associated with hepatocellular carcinoma. We also evaluated the diagnostic capability of this imaging technique to reveal the mass in patients with hepatocellular carcinoma.

CONCLUSION

On dynamic helical CT, proximal arterioportal shunting altered liver perfusion and tumor enhancement. Heterogeneous enhancement of liver parenchyma and decreased enhancement of hepatomas diminished diagnostic capability on the arterial dominant phase image. However, with the addition of imaging in the arterial portal phase, lesion conspicuity improved.

Klebsiella pneumoniae panophthalmitis: a possible complication of endoscopic variceal injection sclerotherapy

Complication of endoscopic variceal injection sclerotherapy for esophageal variceal hemorrhage is not unusual. However, sclerotherapy complicated panophthalmitis was never reported before. We report such an unusual complication and discuss its possible mechanism and treatment.

Radiotherapy in the treatment of duodenal bleeding due to hepatocellular carcinoma invasion

Haemorrhage from an hepatocellular carcinoma (HCC) directly invading the gastrointestinal (GI) tract is uncommon. A 58-year-old man was admitted with upper gastrointestinal (UGI) bleeding and panendoscopy on examination revealed a large duodenal ulcerative bleeding mass. The mass was eventually diagnosed as HCC by pathological examination. The bleeding failed to respond to conventional management of haemostasis, but resolved with an external beam of radiotherapy with a total dose of 6000 cGy over a 5 week period. This unusual presentation of UGI bleeding, due to HCC invading the duodenum and treated by radiotherapy, has not been previously reported.

Biphasic denaturation of human placental alkaline phosphatase in guanidinium chloride

Human placental alkaline phosphatase is a membrane-anchored dimeric protein. Unfolding of the enzyme by guanidinium chloride (GdmCl) caused a decrease of the fluorescence intensity and a large red-shifting of the protein fluorescence maximum wavelength from 332 to 346 nm. The fluorescence changes were completely reversible upon dilution. GdmCl induced a clear biphasic fluorescence spectrum change, suggesting that a three-state unfolding mechanism with an intermediate state was involved in the denaturation process. The half unfolding GdmCl concentrations, [GdmCl]0.5, corresponding to the two phases were 1.45 M and 2.50 M, respectively. NaCl did not cause the same effect as GdmCl, indicating that the GdmCl-induced biphasic denaturation is not a salt effect. The decrease in fluorescence intensity was monophasic, corresponding to the first phase of the denaturation process with [GdmCl]0.5 = 1.37 M and reached a minimum at 1.5 M GdmCl, where the enzyme remained completely active. The enzymatic activity lost started at 2.0 M GdmCl and was monophasic but coincided with the second-phase denaturation with [GdmCl]0.5 = 2.46 M. Inorganic phosphate provides substantial protection of the enzyme against GdmCl inactivation. Determining the molecular weight by sucrose-density gradient ultracentrifugation revealed that the enzyme gradually dissociates in both phases. Complete dissociation occurred at [GdmCl] > 3 M. The dissociated monomers reassociated to dimers after dilution of the GdmCl concentration. Refolding kinetics for the first-phase denaturation is first-order but not second-order. The biphasic phenomenon thereby was a mixed dissociation-denaturation process. A completely folded monomer never existed during the GdmCl denaturation. The biphasic denaturation curve thereby clearly demonstrates an enzymatically fully active intermediate state, which could represent an active-site structure intact and other structure domains partially melted intermediate state.

Solvent kinetic isotope effects of human placental alkaline phosphatase in reverse micelles

Human placental alkaline phosphatase was embedded in a reverse micellar system prepared by dissolving the surfactant sodium bis(2-ethylhexyl) sulphosuccinate (Aerosol-OT) in 2,2, 4-trimethylpentane. This microemulsion system provides a convenient instrumental tool to study the possible kinetic properties of the membranous enzyme in an immobilized form. The pL (pH/p2H) dependence of hydrolysis of 4-nitrophenyl phosphate has been examined over a pL range of 8.5-12.5 in both aqueous and reverse micellar systems. Profiles of log V versus pL were Ha-bell shaped in the acidic region but reached a plateau in the basic region in which two pKa values of 9.01-9.71 and 9.86-10.48, respectively, were observed in reverse micelles. However, only one pKa value of 9.78-10.27 in aqueous solution was detected. Profiles of log V/K versus pL were bell-shaped in the acidic region. However, they were wave-shaped in the basic region in which a residue of pKa 9.10-9.44 in aqueous solution and 8.07-8.78 in reverse micelles must be dehydronated for the reaction to reach an optimum. The V/K value shifted to a lower value upon dehydronation of a pKa value of 9.80-10.62 in aqueous solution and 11.23-12.17 in reverse micelles. Solvent kinetic isotope effects were measured at three pL values. At pL 9.5, the observed isotope effect was a product of equilibrium isotope effect and a kinetic isotope effect; at pL 10.4, the log V/K value was identical in water and deuterium. The deuterium kinetic isotope effect on V/K was 1.14 in an aqueous solution and 1.16 in reverse micelles. At pL 11.0 at which the log V values reached a plateau in either solvent system, the deuterium kinetic isotope effect on V was 2.08 in an aqueous solution and 0.62 in reverse micelles. Results from a proton inventory experiment suggested that a hydron transfer step is involved in the transition state of the catalytic reaction. The isotopic fractionation factor (pi) for deuterium for the transition state (piT) increased when the pH of the solution was raised. At pL 11.0, the piT was 1.07 in reverse micelles, which corresponds to the inverse-isotope effect of the reaction in this solvent system. Normal viscosity effects on kcat and kcat/Km were observed in aqueous solution, corresponding to a diffusional controlled physical step as the rate-limiting step. We propose that the rate-limiting step of the hydrolytic reaction changes from phosphate releasing in aqueous solution to a covalent phosphorylation or dephosphorylation step in reverse micelles.