Renal nitrate clearance in chronic kidney disease

BACKGROUND

Nitric oxide (NO) is rapidly oxidised in humans to nitrite and nitrate, with nitrate being present in much greater abundance. These oxidation products can be recycled back into nitric oxide via a complex entero-salivary pathway, thus preserving NO activity. Approximately 65% of circulating nitrate is excreted in the urine in 48 h, with the excretory pathway of the remainder unknown. The effect of declining renal function on nitrate clearance is unknown METHODS: Forty five subjects, 21 M, 24F, median age 69 (range 27-75 years) with renal function assessed by CKD-EPI eGFR between 9 and 89 ml/min/1.73 m² completed the study. Following a 24 h low nitrate diet a microplate spectrophotometric method was employed to measure plasma nitrate concentration and 24 h urinary nitrate excretion were measured to determine renal nitrate clearance.

RESULTS

There was a strong positive correlation between urinary nitrate clearance and eGFR, (Spearman R = 0.7665, p < 0.0001) with a moderate negative correlation between plasma nitrate concentration and CKD-EPI eGFR, (Spearman's R = -0.37, p = 0.012). There was a trend between fractional excretion of nitrate and CKD-EPI eGFR (ml/min/1.73 m²) Spearman's R 0.27, p = 0.07 though this did not reach statistical significance. Plasma nitrate concentration and serum creatinine concentration were positively correlated, Spearman's R = 0.39, p = 0.008.

CONCLUSIONS

We have observed a strong positive association between renal nitrate clearance and renal function such that plasma nitrate rises as renal function falls. Fractional excretion of nitrate appears to decline as renal function falls. As such, urinary nitrate excretion is unlikely to be a reliable marker of endogenous NO synthesis in settings where renal function is altered.

Craniosynostosis and Resynostosis: Models, Imaging, and Dental Implications

Craniosynostosis occurs in approximately 1 in 2,000 children and results from the premature fusion of ≥1 cranial sutures. If left untreated, craniosynostosis can cause numerous complications as related to an increase in intracranial pressure or as a direct result from cranial deformities, or both. More than 100 known mutations may cause syndromic craniosynostosis, but the majority of cases are nonsyndromic, occurring as isolated defects. Most cases of craniosynostosis require complex cranial vault reconstruction that is associated with a high risk of morbidity. While the first operation typically has few complications, bone rapidly regrows in up to 40% of children who undergo it. This resynostosis typically requires additional surgical intervention, which can be associated with a high incidence of life-threatening complications. This article reviews work related to the dental and maxillofacial implications of craniosynostosis and discusses clinically relevant animal models related to craniosynostosis and resynostosis. In addition, information is provided on the imaging modalities used to study cranial defects in animals and humans.

Types of female partners reported by black men who have sex with men and women (MSMW) and associations with intercourse frequency, unprotected sex and HIV and STI prevalence

We used baseline data from a study of Black MSM/MSMW in 6 US cities to examine the association of female partnership types with disease prevalence and sexual behaviors among the 555 MSMW participants. MSMW reported more than three times as many total and unprotected sex acts with each primary as they did with each non-primary female partner. We compared MSMW whose recent female partners were: (1) all primary ("PF only", n = 156), (2) both primary and non-primary ("PF & NPF", n = 186), and (3) all non-primary ("NPF only", n = 213). HIV/STI prevalence did not differ significantly across groups but sexual behaviors did. The PF only group had the fewest male partners and was the most likely to have only primary male partners; the PF & NPF group was the most likely to have transgender partners. PF & NPF men reported the most sex acts (total and unprotected) with females; NPF only men reported the fewest. Implications for HIV risk and prevention are discussed.

'Information is information': a public perspective on incidental findings in clinical and research genome-based testing

The potential for genomic incidental findings is increasing with the use of genome-based testing. At the same time approaches to clinical decision making are shifting to shared decision-making models involving both the healthcare community and the public. The public's voice has been nearly absent in discussions on managing incidental findings. We conducted nine focus groups and nine interviews (n = 63) with a broad cross-section of lay public groups to elucidate public viewpoints on incidental findings that could occur as a result of genome-based testing in clinical and research situations. Data were analyzed using qualitative content analysis. Participants wanted incidental findings disclosed to them whether or not these were clinical or research findings. Participants used different terms to define and describe incidental findings; they wanted to know that incidental findings are possible and be given a choice to learn about them. Personal utility was an important reason for disclosure, and participants believed that managing information is a shared responsibility between professionals and themselves. Broad public input is needed in order to understand and incorporate the public's perspective on management of incidental findings as disclosure guidelines, and policies are developed in clinical and research settings.

Posttraumatic stress disorder diagnostic criteria and suicidal ideation in a South African Police sample

OBJECTIVE

Exposure to traumatic events may precipitate suicidal ideation. Once an individual is diagnosed with PTSD, a suicide risk assessment often follows. This study explores how PTSD symptom criteria correlate with suicidal ideation in a sample of police officers. While the psychometric measures of PTSD often mirror the DSM-IV-TR criteria, focusing on exposure, symptom, and duration criteria, suicidal ideation measures often focus on concepts quite different from that. In this report the focus was on investigating how PTSD symptom criteria correlate with the suicidal ideation.

METHOD

A group of South African police officers (N = 217) were assessed by means of the Posttraumatic Diagnostic Scale and a short version of the Adult Suicide Ideation Questionnaire. Linear and hierarchical regressions were used to determine which PTSD symptom criteria best predict suicidal ideation.

RESULTS

Hyperarousal was the primary predictor of suicidal ideation (R(2) [adjusted] = 0.249). Intrusive thoughts added only marginally to the model, contributing a further 2.5% to the declared variance. The contributions of the other two symptom types were negligible.

CONCLUSION

In this study hyperarousal correlated significantly with suicidal ideation. It is suggested that practitioners be alert to these symptoms as possible indicators of suicidal ideation. Implications for suicide risk assessment and prevention measures are discussed.

Gene editing of a human gene in yeast artificial chromosomes using modified single-stranded DNA and dual targeting

A single-nucleotide polymorphism (SNP) in a human gene can alter the behavior of the corresponding protein, and thereby affect an individual's response to drug therapy. Here, we describe a novel dual-targeting approach for introducing an SNP of choice into virtually any gene, through the use of modified single-stranded oligonucleotides (MSSOs). We use this strategy to create SNPs in a human gene contained in a yeast artificial chromosome (YAC). In the dual-targeting protocol, two different MSSOs are designed to edit two different bases in the same cell. A change in one of these genes is selective while the other is non-selective. We show that the population identified by selective pressure is enriched for cells that bear an edited base at the nonselective site. YACs with human genomic inserts containing particular SNPs or haplotypes can be used for pharmacogenomic applications, in cell lines and in transgenic animals.

Hypomineralised first permanent molars and the orthodontist

AIM

This paper discusses the orthodontic implications that need to be considered when a child presents with hypomineralised permanent molars. The various historical and present day orthodontic approaches are outlined and indications for the various sequences or extraction of first permanent molars presented.

Development of a treatment outcome standard as a result of a clinical audit of the outcome of fixed appliance therapy undertaken by hospital-based consultant orthodontists in the UK

Bristol's much-publicised cardiac surgery problems and subsequent enquiry(1) have drawn attention to the need for audit of treatment outcomes throughout all hospital specialties. Patient anxiety, government policy and the desire of the professions to re-establish public confidence, have further encouraged changes to the system. For medical and dental specialties, such challenges have already been taken up by the Royal Colleges with the establishment of clinical effectiveness committees. Hospitals have modified their procedures and, for consultants, yearly appraisal is already a reality. The Orthodontic Clinical Effectiveness Working Party of the Royal College of Surgeons of England (now the Clinical Effectiveness Committee of the British Orthodontic Society) set up this audit to measure the outcome of fixed appliance treatment and to establish a benchmark for the standard of treatment to be expected from a consultant orthodontist. This paper describes how the audit was carried out, presents the findings and goes on to discuss some of the wider issues involved in audit, clinical governance and appraisal. The Consultant Orthodontists Group of the British Orthodontic Society funded this audit and the results and data set of dental casts remain their property.

Genetic counseling outcomes validation by genetics nurses in the UK and US

PURPOSE

To validate genetic counseling outcomes with a sample of genetics nurses from the United Kingdom (UK), and to compare elements of genetic counseling outcomes with those from a sample of genetics nurses from the United States (US).

DESIGN

Descriptive-comparative survey.

METHODS

Concept analysis and literature review were used to designate outcomes, and genetics nurses were surveyed to validate the outcomes. A revision of Fehring's 1987 methodology for assessing content validity was used to estimate content validity and sensitivity of the genetic counseling outcomes. Data are reported on a convenience sample of 50 UK nurse members of the Association of Genetic Nurses and Counsellors. Findings were correlated with prior data from a convenience sample of 92 U.S. nurse members of the International Society of Nurses in Genetics, Inc., and data were compared between groups.

FINDINGS

A significant positive correlation was found between samples of U.K. and U.S. nurses regarding components of outcomes of the genetic counseling process and between groups regarding extent of contribution of nurses to the outcomes. Strength of nursing contributions to knowledge of disease and indicators of coping varied according to country.

CONCLUSIONS

Genetics nurses in the UK and US had similar definitions of outcomes of genetic counseling, but priorities of indicators differed between countries. Terminology used in measures to identify outcomes of the process of genetic counseling must be consistent with cultural norms.

What would be the properties of an ideal SERM?

Selective estrogen receptor modulators (SERMs) are drugs that bind to the estrogen receptor (ER); in some tissues they act like estrogen (agonists), while in other tissues they oppose the action of estrogen (antagonists). The SERM tamoxifen acts as an estrogen antagonist in the breast in that it prevents and treats breast cancer, but it acts as an estrogen agonist in the endometrium, where it can induce cancer. Estrogen, and to a lesser extent SERMs, are effective in preventing and treating osteoporosis. Contrary to the prevalent hypothesis that estrogen provides benefit to women with regard to secondary prevention of coronary heart disease (CHD), randomized clinical trials have demonstrated that estrogen is associated with an increased risk of CHD in this population of women. Conflicting results have been reported on the effect of estrogens on cognitive function. The latest and largest randomized clinical trials have demonstrated a beneficial role in short-term memory in nondemented women, in contrast to the absence of such benefit in improving symptoms in women with Alzheimer's disease. Although estrogens have been used successfully to treat some menopausal symptoms such as hot flashes, the SERMs tamoxifen and raloxifene actually induce or increase hot flashes. Data on the beneficial and adverse effects of estrogen and SERMs are reported along with an elaboration of the constellation of properties that would characterize an ideal SERM working through the ER.

Correlating two viral load assays with known detection limits

A timely objective common to many HIV studies involves assessing the correlation between two different measures of viral load obtained from each of a sample of patients. This correlation has scientific utility in a number of contexts, including those aimed at a comparison of competing assays for quantifying virus and those aimed at determining the level of association between viral loads in two different reservoirs using the same assay. A complication for the analyst seeking valid point and interval estimates of such a correlation is the fact that both variables may be subject to left censoring due to values below assay detection limits. We address this problem using a bivariate normal likelihood that accounts for left censoring of two variables that may have different detection limits. We provide simulation results to evaluate sampling properties of the resulting correlation estimator and compare it with ad hoc estimators in the presence of nondetects. In an effort to obtain improved confidence interval properties relative to the Wald approach, we evaluate and compare profile likelihood-based intervals. We apply the methods to HIV viral load data on women and infants from a trial in Bangkok, Thailand, and we discuss an extension of the original model to accommodate interval censoring arising due to the study design.

Mermithid nematode infections and drift in the mayfly Deleatidium spp. (Ephemeroptera)

Alterations in host phenotype induced by parasitic infection are often interpreted as either host or parasite adaptations, depending on which of the two appears to benefit. Mermithid nematodes typically castrate their insect hosts and, therefore, any change in host behavior has no further fitness consequences for the host; the adaptive value of the modified behavior must be assessed with respect to parasite fitness only. In a New Zealand stream, mermithid-infected nymphs of mayflies in the genus Deleatidium were disproportionately represented in drift samples compared with benthic samples, suggesting that infection by mermithids results in an increased tendency to drift. Drifting mayflies face a higher predation risk from trout, and the mermithid nematodes they harbor die if ingested by a fish. The change in mayfly behavior induced by mermithids thus appears to have negative fitness effects for the parasite, and one possible explanation for this phenomenon is that it is a nonadaptive, pathological side effect of infection.

Outcome analysis for correction of single suture craniosynostosis using resorbable fixation

A retrospective review was performed on 63 patients at Childrens Healthcare of Atlanta at Scottish Rite who underwent correction of single-suture craniosynostosis using a resorbable fixation system. Included in the series were 24 patients with metopic synostosis, 15 with sagittal synostosis, and 24 with unicoronal synostosis. The average age at operation was 22.7 months (range: 2.8 months-18 years), and mean follow-up time was 30.7 months (range: 7.1-10 years). Reoperation equal to or exceeding the magnitude of the original procedure occurred in 4.76% of the patients. This was comparable to the reoperation rate observed at our institution using traditional fixation systems. Minor complications related to the use of resorbable plates were also identified, and the final outcome for single-suture synostosis was favorable. Results suggest that resorbable plates and screws are as effective as titanium-based systems in the treatment of single-suture synostosis.

Interactive effects of soy protein and estradiol on coronary artery reactivity in atherosclerotic, ovariectomized monkeys

OBJECTIVE

Results of recent clinical trials indicate that mammalian estrogens may be less effective in reducing coronary heart disease risk than once thought. This study was designed to determine whether mammalian estrogen's coronary artery dilator benefits could be enhanced by adding soy with phytoestrogens.

DESIGN

Forty-five atherosclerotic, ovariectomized monkeys were fed one of four diets: (1) atherogenic diet with casein/lactalbumin as source of protein (Casein, n = 12); (2) casein diet with micronized estradiol equivalent to a woman's dose of 1 mg/day (Casein + E2, n = 12); (3) atherogenic diet with soy protein with phytoestrogens (129 mg woman/day equivalent) (Soy, n = 11); and (4) the soy diet plus estradiol (Soy + E2, n = 10).

METHODS

Quantitative angiography and intravascular Doppler were done after 6 months of experimental diet to measure changes in diameter and coronary flow reserve in the circumflex coronary artery in response to intracoronary acetylcholine and nitroglycerin.

RESULTS

Arteries from the E2 and Soy + E2 groups dilated in response to acetylcholine 5 +/- 3% and 12 +/- 5%, respectively (p < 0.05 vs. Casein). There was an interactive effect of soy and E2 on dilator response to acetylcholine (p < 0.05). Flow reserve was greatest in animals fed casein + E2 and soy + E2 (2.3 +/- 0.3 and 2.6 +/- 0.5, respectively; p < 0.05 vs. Casein). Soy protein alone had no effect on coronary artery reactivity (p > 0.05).

CONCLUSION

Soy protein itself does not affect coronary artery dilator responses but interacts with estradiol to promote dilator responses to acetylcholine.

Understanding evidence-based medicine: a primer

Evidenced-based medicine is the concept of formalizing the scientific approach to the practice of medicine for identification of "evidence" to support our clinical decisions. It requires an understanding of critical appraisal and the basic epidemiologic principles of study design, point estimates, relative risk, odds ratios, confidence intervals, bias, and confounding. By using this information, clinicians can categorize evidence, assess causality, and make evidence-based recommendations. Evidence-based medicine allows analysis of complicated material so that we can make the best possible clinical decisions for the populations we serve.

Current perspectives on oral contraceptive use

Oral contraceptives are one of the most highly effective forms of contraception and provide many short- and long-term noncontraceptive health benefits. They control menstrual cycle irregularities, such as breakthrough bleeding and amenorrhea, and are effective in treating dysfunctional uterine bleeding. In addition, for decades after oral contraceptive use is discontinued they are associated with substantial decreases in the risk of ovarian cancer (up to 80%) and of endometrial cancer (40%-50%), and nearly eliminate benign functional ovarian cysts. Long-term oral contraceptive use confers protection against benign breast disease and colorectal cancer, may help prevent rheumatoid arthritis, decreases ectopic pregnancy and hospitalizations for pelvic inflammatory disease, and helps preserve bone mineral density to reduce risk of fractures. Large bodies of evidence from extensive research have clarified the perceived association of oral contraceptive use with cardiovascular disease and with breast cancer. Findings indicate that there is no increased risk of myocardial infarction or stroke associated with oral contraceptive use in healthy, nonsmoking, normotensive women. Although there is a 3- to 4-fold increased risk of venous thromboembolism with current oral contraceptive use, the absolute risk is very small and is half that associated with pregnancy. Women of all reproductive ages, including perimenopausal women, can realize many health benefits through oral contraceptive use, including improved health status later in life.

From ecology to base pairs: nursing and genetic science

With the mapping of the human genome has come the opportunity for nursing research to explore topics of concern to the maintenance, restoration, and attainment of genetic-related health. Initially, nursing research on genetic topics originated primarily from physical anthropology and from a clinical, disease-focused perspective. Nursing research subsequently focused on psychosocial aspects of genetic conditions for individuals and their family members. As findings emerge from current human genome discovery, new programs of genetic nursing research are originating from a biobehavioral interface, ranging from the investigations of the influence of specific molecular changes on gene function to social/ethical issues of human health and disease. These initiatives reflect nursing's response to discoveries of gene mutations related to phenotypic expression in both clinical and community-based populations. Genetic research programs are needed that integrate or adapt theoretical and methodological advances in epidemiology, family systems, anthropology, and ethics with those from nursing. Research programs must address not only populations with a specific disease but also community-based genetic health care issues. As genetic health care practice evolves, so will opportunities for research by nurses who can apply genetic concepts and interventions to improve the health of the public. This article presents an analysis of the evolution of genetic nursing research and challengesfor the future.

Inhibition of apoptosis: a potential mechanism for syndromic craniosynostosis

The biologic pathogenesis of syndromic craniosynostosis remains unknown. The purpose of this investigation was to determine whether specific biologic differences exist between normal calvarial osteoblasts and osteoblasts derived from patients with syndromic craniosynostosis. This study (1) examined the apoptotic rate and cell cycle of osteoblasts derived from patients with syndromic craniosynostosis, and (2) investigated for the presence of soluble factors released from syndrome-derived osteoblasts. Osteoblast cell lines were established from calvarial specimens of patients with clinically diagnosed syndromic synostosis and from normal controls. A co-culture technique was used to investigate for the presence of elaborated soluble factors. Apoptotic rate and cell cycle analyses were performed by using flow cytometry after staining with annexin V-fluorescein isothiocyanate and propidiumiodide, respectively. The apoptotic rate was significantly reduced in syndrome-derived osteoblasts as compared with control osteoblasts. Control osteoblasts co-cultured with syndromic osteoblasts demonstrated a dramatic reduction in their apoptotic rate as compared with those co-cultured with control osteoblasts. These results indicate that osteoblasts derived from patients with syndromic craniosynostosis display a lower apoptotic rate, a normal DNA synthetic rate, and the capability to reduce the apoptotic rate in normal calvarial osteoblasts through the elaboration of soluble factors.

Assessment of hormonally active agents in the reproductive tract of female nonhuman primates

Using the ovariectomized macaque model of postmenopausal women's health, we investigated the effects of long-term treatments (5 weeks-3 years) with estradiol, conjugated equine estrogens (CEE), esterified estrogens, progestins such as medroxyprogesterone acetate (MPA) and nomegestrol acetate, CEE + MPA, tamoxifen, soybean phytoestrogens (SPEs), a variety of putative selective estrogen receptor modulators (SERMs), and androgens. Agents tested were selected on the basis of beneficial effects on arteries and/or bone. Doses were scaled on a caloric or serum-concentration basis to approximate human clinical doses. We evaluated endometrial and mammary gland histopathology and morphometry and used immunohistochemistry to evaluate cell proliferation and expression of estrogen receptor alpha and progesterone receptor (PR). Both estradiol and CEE induced endometrial hyperplasia. MPA antagonized epithelial proliferation induced by CEE in endometrium and induced pseudodecidual stromal hyperplasia in some animals. Tamoxifen induced endometrial polyps, cystic hyperplasia, stromal fibrosis, and PR expression but not Ki-67 expression. SPEs were not estrogenic at dietary doses and antagonized estrogen-induced proliferation in the endometrium and breast. Nandrolone induced mucometra and an adenomyosis-like change. The potential SERM 17 alpha dihydroequilenin did not have uterotrophic or mammotrophic effects. In general, experimental findings in macaques have been predictive of outcomes in human clinical trials of the same agents.

Development of a device for the delivery of agents to bone during distraction osteogenesis

Various agents have been theoretically and experimentally implicated as mediators of distraction osteogenesis (DO). The purpose of this study was to develop a vehicle for the potential delivery of these factors to the region of the distraction site in an attempt to manipulate this biologic process. Three adult mongrel dogs (12 months old) had oblique osteotomies performed bilaterally through the gonial regions. In group I, the external distracter was affixed to the right hemimandible of two dogs (n = 2 hemimandibles) with cannulated pins (external diameter = 1.5 mm; lumen diameter = 1.0 mm; length = 60 mm), whereas the distracter on the left was affixed with standard, noncannulated pins of the same dimensions. In group II, cannulated pins were used to affix the external distracter to both hemimandibles (n = 2 hemimandibles) of a dog. The devices were activated after a 5-day latency period and were lengthened at a rate of 1 mm/day for 20 days. During the distraction period, 0.1 ml/d of sterile india ink was injected into the cannulated pins, after which the sterile stylet was replaced. The activation protocol was followed by 28 days of fixation (consolidation period). The hemimandibles from group I underwent removal of soft tissues, acetone fixation, and gross examination/photography, whereas the hemimandibles from group II were prepared for histologic evaluation (whole mount, hematoxylin and eosin staining). All dogs survived to the end of the study and demonstrated successful DO without evidence of complications. Hemimandibles in group I displayed evidence of india ink on both the lingual and buccal cortex around the cannulated pin site, in the regenerate and on the neocortices of the distracted segment. Hemimandibles of group II showed histologic evidence of the india ink being deposited densely around the cannulated pin site and extending in a radial fashion around the pin site into the regenerate. This study demonstrates for the first time a vehicle device for the delivery of an inert dye to the regenerate site during distraction osteogenesis. This vehicle offers the potential of delivery of various factors implicated in distraction osteogenesis (i.e., mitogens) in an attempt to alter this process and also substances (i.e., chemotherapy, antibiotics, etc.) for use in the treatment of various osteopathies.

Evidence-based medicine and contraception

The concept of evidence-based medicine involves formalizing the scientific approach to the practice of medicine to identify the evidence supporting clinical decisions. To understand the concept, clinicians must have knowledge of critical appraisal and the basic epidemiologic principles of study design, relative risk, odds ratios, point estimates, confidence intervals, bias, and confounding. Using this information, clinicians can categorize evidence, assess causality, and make evidence-based recommendations. Evidence-based medicine allows clinicians to analyze complicated material so that the best possible clinical decisions can be made for the population served.

Redefinition: coping with normal results from predictive gene testing for neurodegenerative disorders

The purpose of this qualitative study was to describe the psychosocial impact and coping processes of normal (negative) results from predictive testing for an inherited neurodegenerative disease. Ten adults with normal results of predictive testing for the Huntington disease (HD) or the Pallido-Ponto-Nigral Degeneration (PPND) gene mutation participated in semi-structured interviews 1 month after receiving results, and seven of these participants were interviewed 6 months later. The major theme of Redefinition was derived using Knafl and Webster's analysis method (1988). People who received normal gene results experienced loss of former beliefs about themselves and developed new self definitions, relationships with family, and roles in society. This coping process evolved from a personal focus at 1 month to a broader future perspective at 6 months after testing. Identifying components of the redefinition process may be an important consideration in planning interventions to promote coping with normal gene results in persons within at-risk families.

Impact of genome research on children and their families

Human genome research has made it possible to identify the presence of gene mutations in persons with specific genetic, conditions, who may be carriers of genetic disorders, or who are at risk for future development of inherited diseases. Gene discovery has the potential to identify individual response to medications and new management and preventive interventions. Pediatric nurses must be informed about genetic discoveries and their implications for child and family health to act as advocates for children and their families in all child health care settings.

Psychosocial impact of predictive testing for Huntington disease on support persons

Although a support person is required by many centers during the predictive testing protocol for Huntington disease (HD), little is known about the psychosocial impact of predictive testing on persons serving in this role. Eighteen adults who were support persons during predictive HD testing in one HD testing center completed a semi-structured interview to describe their experiences. Participants also completed the Impact of Events Scale (IES) to assess perceptions of emotional distress regarding predictive testing and the State Anxiety Scale of the State Trait Anxiety Inventory (STAI) to assess anxiety regarding the interview. State anxiety scores were similar to normative values for working adults. Although support persons for individuals with a positive gene test scored higher on all measures of the IES than those who were support persons for persons with negative gene mutation results, these differences were not statistically significant. Support persons identified aspects of the protocol that did not fit their needs, perceived the testing process as extending into subsequent caregiving responsibilities when the test was positive, and were uninformed regarding specific caregiving issues for family members with the gene mutation. The impact of the testing experience appeared to be most intense for those support persons who were at-risk offspring of probands. Findings suggest that individual assessment of support person needs may allow more focused counseling of support persons during predictive genetic HD testing. Collaboration with health care providers may facilitate symptom management following testing.

Noncontraceptive benefits of oral contraceptive use: an evidence-based approach

Numerous noncontraceptive benefits of oral contraceptive (OC) use have been identified. These include a reduction in ovarian and endometrial cancers, functional ovarian cysts, pelvic inflammatory disease, benign breast disease, iron-deficiency, menstrual disorders, dysmenorrhea, bone loss, and acne. The best "evidence" is in the area of cancer prevention, maintenance of bone mineral density (BMD) and the treatment of acne vulgaris. Based on the body of evidence available today, several evidence-based clinical recommendations can be made regarding BMD. In young, reproductive-age women with a hypoestrogenic condition, there is a protective effect on BMD with OC use. In older reproductive-age women with declining ovarian function, there is also a protective effect on BMD with OC use. With long-term use of OCs (greater than 5 years) protection increases with increasing duration of use. There is a high degree of biologic plausibility for the beneficial effect of OC use on states associated with androgen excess, such as acne. Two randomized, placebo-controlled, multicenter clinical trials of a triphasic norgestimate-containing OC were published. Using evidence-based criteria, there is strong evidence that this OC effectively treats acne vulgaris. As further experimental and observational studies are completed, they should substantiate many of the other known benefits; thus, further evidence-based recommendations will be possible.

Consumption of soy protein reduces cholesterol absorption compared to casein protein alone or supplemented with an isoflavone extract or conjugated equine estrogen in ovariectomized cynomolgus monkeys

Dietary intake of soy protein is associated with reductions in plasma cholesterol. Isoflavones are thought to be active components of soy and responsible for the beneficial effects because of their structural similarities to estrogen. The purposes of this study were to determine if i) soy protein or a semipurified soy extract, rich in isoflavones, is responsible for improving the lipid profile and ii) altered intestinal cholesterol metabolism is one mechanism for hypocholesterolemic effects. Ovariectomized adult female cynomolgus monkeys (40) were assigned to groups fed diets containing i) casein-lactalbumin (CAS) ii) intact soy protein (SOY), iii) CAS plus an isoflavone-rich semipurified soy extract similar in isoflavone content as SOY (ISO) or iv) CAS plus conjugated equine estrogen (CEE) for 20 wk. Cholesterol absorption was determined using the fecal isotope ratio method. Bile acid excretion was measured using the 3alpha-hydroxysteroid dehydrogenase assay. The SOY group had significantly lower total- and VLDL + LDL-cholesterol compared to the other three groups and significantly higher HDL-cholesterol compared to the CAS and CEE groups. Cholesterol absorption was significantly lower in the SOY group compared to the other groups, but bile acid excretion was not significantly affected. The hypocholesterolemic effect of soy protein appears to be mediated in part by decreased cholesterol absorption. The semipurified soy extract, rich in isoflavones, added to casein protein did not have lipid-lowering effects. Other components of soy such as saponins, phytic acid or the amino acid composition may be involved in the hypocholesterolemic effects seen in this study.

Controlled multiplanar distraction of the mandible. Part III: Laboratory studies of sagittal (anteroposterior) and horizontal (mediolateral) movements

Distraction osteogenesis has proven to be an effective technique for the correction of mandibular deficiencies. However, problems have been encountered in achieving a final, idealized form of the mandible when using distraction devices capable of moving the bone segments in only one dimension (uniplanar). Specifically, occlusal irregularities and deficiencies in lower facial contour have been seen following uniplanar distraction. To address these problems, a distraction device capable of independent movements in three planes (multiplanar) was developed. Previously reported studies in a canine model have demonstrated that this device can successfully distract the mandible along both the sagittal axis (anteroposterior or z-axis) and the vertical axis (superoinferior or y-axis). This study examines the ability of the multiplanar device to distract along the sagittal and horizontal axes (mediolateral or x-axis). A total of 12 dogs were included in the study. All animals underwent unilateral or bilateral mandibular distraction using an external multiplanar device. After a latency period of 5 days, primary distraction along the anteroposterior axis at a rate of 1 mm/day for 10 days (10 mm total) was performed. During the following 10 days, along with an additional 11 mm to 20 mm of anteroposterior axis distraction, concomitant secondary distraction was performed along the horizontal (mediolateral) axis at a rate of 5 degrees/day (50 degrees total). Cephalometric radiographs were obtained preoperatively and at the conclusion of both anteroposterior and combined anteroposterior-mediolateral distraction. Computed tomography (CT) scans were obtained preoperatively and at the end of consolidation (28 days), after which all animals were sacrificed and the dry skulls examined. In all animals, distraction along the mediolateral or x-axis was found to change the anteroposterior projection of the mandible. Varus angulation of the device with respect to the midline of the mandible caused compression of the distracted segments and reduced the anteroposterior thrust of the mandible. In contrast, valgus positioning of the device, with respect to the midline of the mandible, created the opposite effect, increasing the distracted length in the anteroposterior direction. The bone (mandibular) segments being distracted assumed the orientation of the device only for valgus positioning of the device (producing a decrease in the bigonial distance). Conversely, there was no effect from the mediolateral angulation on the distracted segments during varus positioning of the device. A possible explanation for this finding may be a greater resistance to an increase in the bigonial distance (varus positioning of the device) posed by obstruction of lateral movement of the condyle. This stands in contrast to a decrease in the bigonial distance observed following valgus positioning of the device. These findings confirm the clinical impression that distraction along the anteroposterior or sagittal axis remains the critical or keystone therapeutic maneuver in distraction of the mandible. Mediolateral or horizontal axis distraction is best used only as a supplementary movement; in essence, it only affects the anteroposterior dimension with little impact on clinically relevant changes to the bigonial distance.

Intralesional laser therapy of extensive hemangiomas in 100 consecutive pediatric patients

The authors have treated 100 consecutive pediatric patients with capillary/cavernous hemangiomas (age range, 1.3 months to 16 years; mean age, 26.6 months; 30 male and 70 female patients) with intralesional laser therapy during a 3-year period. All patients have been followed for a minimum of 6 months after treatment (range, 6-36 months; mean, 18 months). Indications for intralesional laser treatment included interference with vision, blockage of the nose or mouth, ulceration, bleeding, and rapid, uncontrollable growth. The Nd:YAG laser was used in 70 patients, and the Potassium, Titanyl, Phosphate (KTP) laser was used in 30 patients. Fifty-five hemangiomas were in the head and neck region, excluding the orbit; 25 were in the trunk or extremities; 10 were periorbital; and 10 involved multiple sites. Seventy patients (70%) received one treatment, 20 patients (20%) received two treatments, 7 patients (7%) received three treatments, and 3 patients (3%) received four or more treatments. No appreciable differences were noted between treatment with the Nd:YAG and KTP lasers. Forty-six patients had more than a 90% reduction in the overall size of the hemangiomas whereas 54 patients had a 50% to 90% reduction in the size of the hemangioma. After maximal reduction in size of the cavernous component was achieved, the external capillary component, found in 68 patients, was treated with a tunable dye laser. Seventy-six patients underwent surgical resection after maximal lesion involution. Residual induration due to lesion fibrosis was treated with local steroid injections in 13 patients. There were four operative complications attributable to intralesional laser therapy. Two patients had residual midfacial weakness, and two patients had punctuated skin burns after intralesional treatment. The authors have found intralesional laser therapy to be a valuable tool in the treatment of large capillary/cavernous hemangiomas, often rendering an inoperable lesion safely resectable, or markedly decreasing the size and functional impact of the lesion.

Genetic testing and mental health: the model of Huntington disease

Genetic aspects of mental health disorders are being identified through human genome and family research. Gene discovery makes diagnostic and presymptomatic testing possible. The discovery of a gene mutation for Huntington Disease (HD) enables at-risk persons to request presymptomatic genetic testing. When HD genetic testing is offered through HD testing centers, a multi-visit protocol is followed in which education and counseling are provided for persons considering the option to have HD gene testing. A case study illustrates the clinical and ethical issues regarding privacy and disclosure as well as the personal and family consequences of gene mutation knowledge. Analysis of the impact of genetic knowledge on persons being tested for HD provides a model for the integration of emerging genetic information into mental health nursing practice for other mental health disorders.

State of the art in craniofacial surgery: nonsyndromic craniosynostosis

Craniosynostosis refers to the premature fusion of one of the six major sutures of the cranial vault. Functionally, craniosynostosis may be defined as the premature conversion of the dynamic region of growth and resorption between two adjacent bones of the cranium into a static region of bony union. Molecular analysis has blurred the traditional categories of nonsyndromic and syndromic synostosis to some extent, but, in general, the distinctions between the two groups still hold true. The complexity of the congenital anomalies may be limited with the former, whereas the latter usually requires reoperations and correction of the facial skeleton. This article briefly outlines the characteristic deformities produced from nonsyndromic craniosynostosis. Various approaches to surgical correction of the deformities are described. Finally, new biomaterials that are used in the correction of nonsyndromic craniosynostosis are reviewed.