Developing a national undergraduate medical education pain management and substance use disorder curriculum to address the opioid crisis: a program evaluation pilot study

BACKGROUND

Pain and addiction are one of the most common reasons for adults to seek health care, yet educational programs focused on pain are often underrepresented in medical school curricula. In January 2021, the Association of Faculties of Medicine of Canada (AFMC) launched an online national, bilingual, competency-based curriculum for undergraduate medical (UGME) students in pain management and substance use in response to the opioid crisis and to bridge the content gaps in programs across Canada. The purpose of this study is to evaluate the pilot of this national curriculum.

METHODS

UGME students, from across Canada, participated in the program evaluation by completing online pre- and post-program surveys that assessed the influence of the curriculum on participants' knowledge as well as the value, usability, and feasibility of this curriculum.

RESULTS

Participants' perceived confidence in their new knowledge and in utilizing resources required to maintain their knowledge significantly increased (75% and 51% respectively). Their perceived knowledge that addressed the 72 learning objectives within the curriculum significantly increased from pre- to post-program. Over 90% of participants reported that the curriculum was valuable, feasible, and usable. The most frequently discussed program strengths were the clear and comprehensive content, interactive and well-organized design, and relevance of curriculum content for future clinical practice. The overall weakness of the curriculum included the length, repetition of content, the lack of clarity and relevance of the assessment questions, end-user technology issues, and French translation discrepancies. Participant's recommendations for improving the curriculum included streamlining content, addressing technology issues, and enhancing the clarity and relevance of assessment questions embedded within each of the modules.

CONCLUSION

Participants agreed that an online pain management and substance use curriculum is a valuable, usable, and feasible learning opportunity. Given the severity of the opioid crisis in Canada, these online modules provide a curriculum that can be integrated into existing UGME programs or can provide self-directed learning.

Hedgehog signalling in Foxd1+ embryonic kidney stromal progenitors controls nephron formation via Cxcl12 and Wnt5a

Congenital anomalies of the kidney and urinary tract (CAKUT) are characterised by a spectrum of structural and histologic abnormalities and are the major cause of childhood kidney failure. During kidney morphogenesis, the formation of a critical number of nephrons is an embryonic process supported, in part, by signalling between nephrogenic precursors and Foxd1-positive stromal progenitor cells. Low nephron number and abnormal patterning of the stroma are signature pathological features among CAKUT phenotypes with decreased kidney function. Despite their critical contribution to CAKUT pathogenesis, the mechanisms that underlie a low nephron number and the functional contribution of a disorganised renal stroma to nephron number are both poorly defined. Here, we identify a primary pathogenic role for increased Hedgehog signalling in embryonic renal stroma in the genesis of congenital low nephron number. Pharmacologic activation of Hedgehog (Hh) signalling in human kidney organoid tissue decreased the number of nephrons and generated excess stroma. The mechanisms underlying these pathogenic effects were delineated in genetic mouse models in which Hh signalling was constitutively activated in a cell lineage-specific manner. Cre-mediated excision of Ptch1 in Foxd1+ stromal progenitor cells, but not in Six2+ nephrogenic precursor cells, generated kidney malformation, identifying the stroma as a driver of low nephron number. Single-cell RNA sequencing analysis identified Cxcl12 and Wnt5a as downstream targets of increased stromal Hh signalling, findings supported by analysis in human kidney organoids. In vivo deficiency of Cxcl12 or Wnt5a in mice with increased stromal Hh signalling improved nephron endowment. These results demonstrate that dysregulated Hh signalling in embryonic renal stromal cells inhibits nephron formation in a manner dependent on Cxcl12 and Wnt5a. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Single-arm trials supporting the approval of anticancer medicinal products in the European Union: contextualization of trial results and observed clinical benefit

BACKGROUND

Single-arm trials (SATs) can sometimes be used to support marketing authorization of anticancer medicinal products in the European Union. The level and durability of antitumor activity of the product as well as context are important aspects to determine the relevance of trial results. The aim of this study is to provide details on the contextualization of trial results and to evaluate the magnitude of benefit of medicinal products approved based on SATs.

MATERIALS AND METHODS

We focused on anticancer medicinal products for solid tumors approved on the basis of SAT results (2012-2021). Data were retrieved from European public assessment reports and/or published literature. The benefit of these medicinal products was evaluated via the European Society for Medical Oncology (ESMO)-Magnitude of Clinical Benefit Scale (MCBS).

RESULTS

Eighteen medicinal products were approved based on 21 SATs-few medicinal products were supported by >1 SAT. For the majority of clinical trials, a clinically relevant treatment effect was (pre)specified (71.4%) and most often an accompanying sample size calculation was provided. For 10 studies, each testing a different medicinal product, a justification for the threshold for a clinically relevant treatment effect could be identified. At least 12 out of 18 applications included information to facilitate the contextualization of trial results, including six supportive studies. Of the pivotal SATs analyzed (n = 21), three were assigned an ESMO-MCBS score of 4, which corresponds to 'substantial' benefit.

CONCLUSIONS

The clinical relevance of the treatment effects shown by medicinal products for solid tumors tested in SATs is dependent on the effect size and context. To better facilitate regulatory decision making, prespecifying and motivating a clinically relevant effect and aligning the sample size to that effect is important. External controls may facilitate in the contextualization process, but the associated limitations must be addressed.

Vasculogenesis in kidney organoids upon transplantation

Human induced pluripotent stem cell-derived kidney organoids have potential for disease modeling and to be developed into clinically transplantable auxiliary tissue. However, they lack a functional vasculature, and the sparse endogenous endothelial cells (ECs) are lost upon prolonged culture in vitro, limiting maturation and applicability. Here, we use intracoelomic transplantation in chicken embryos followed by single-cell RNA sequencing and advanced imaging platforms to induce and study vasculogenesis in kidney organoids. We show expansion of human organoid-derived ECs that reorganize into perfused capillaries and form a chimeric vascular network with host-derived blood vessels. Ligand-receptor analysis infers extensive potential interactions of human ECs with perivascular cells upon transplantation, enabling vessel wall stabilization. Perfused glomeruli display maturation and morphogenesis to capillary loop stage. Our findings demonstrate the beneficial effect of vascularization on not only epithelial cell types, but also the mesenchymal compartment, inducing the expansion of ´on target´ perivascular stromal cells, which in turn are required for further maturation and stabilization of the neo-vasculature. The here described vasculogenic capacity of kidney organoids will have to be deployed to achieve meaningful glomerular maturation and kidney morphogenesis in vitro.

The feasibility and effectiveness of a novel online mental health literacy course in supporting university student mental health: a pilot study

BACKGROUND

There is a need for effective universal approaches to promote and support university student mental health that are scalable and sustainable. In this pilot study we assess the feasibility and acceptability of a fully-digitalized, comprehensive mental health literacy course co-created with and tailored to the needs of undergraduate students. We also explore preliminary associations with mental health and positive behaviour change.

METHODS

An accredited online mental health literacy course was developed using state-of-the-art pedagogical principles and a reverse mentorship approach. The course was offered as an interdisciplinary undergraduate elective. Students completed an online survey before and after the 12-week course that collected demographic information and assessed mental health knowledge, emotional self-awareness, mental health, stigma, and health-related behaviors using validated measures. Dependent group t-tests were used to compare pre- and post-course levels of knowledge, mental health, sleep quality and substance use. Mental health outcomes of students who completed the course were compared to an age and sex-matched sample of students not enrolled in the course and who completed the same survey measures over the same academic year. Multivariable linear regression was used to examine the effect of course participation on outcomes at follow-up.

RESULTS

The course had good uptake and was positively reviewed by participants. Specifically, students found the course engaging, relevant, and applicable, and agreed they would recommend it to their peers. Among course participants there was improvement in mental health knowledge (p < 0.001) and emotional self-awareness (p = 0.02) at course completion. Compared to the matched comparison group, taking the course was associated with reduced alcohol (β = - 0.41, p = 0.01) and cannabis use (β = - 0.35, p = 0.03), and improved sleep quality (β = 1.56, p = 0.09) at the end of the term.

CONCLUSIONS

Findings suggest that delivering mental health literacy as an online accredited course may be an acceptable and effective way of promoting university student mental health through improved knowledge, emotional self-awareness, and healthy lifestyle choices. As the course is expanded to larger and more diverse student cohorts we will be able to further examine the short and long-term effectiveness of the course in supporting student mental health and the underlying mechanisms.

BIC extensions for order-constrained model selection

The Schwarz or Bayesian information criterion (BIC) is one of the most widely used tools for model comparison in social science research. The BIC however is not suitable for evaluating models with order constraints on the parameters of interest. This paper explores two extensions of the BIC for evaluating order constrained models, one where a truncated unit information prior is used under the order-constrained model, and the other where a truncated local unit information prior is used. The first prior is centered around the maximum likelihood estimate and the latter prior is centered around a null value. Several analyses show that the order-constrained BIC based on the local unit information prior works better as an Occam's razor for evaluating order-constrained models and results in lower error probabilities. The methodology based on the local unit information prior is implemented in the R package 'BFpack' which allows researchers to easily apply the method for order-constrained model selection. The usefulness of the methodology is illustrated using data from the European Values Study.

Reversal of Stroke-Like Episodes With L-Arginine and Meticulous Perioperative Management of Renal Transplantation in a Patient With Mitochondrial Encephalomyopathy, Lactic Acidosis and Stroke-Like Episodes (MELAS) Syndrome. Case Report

Mitochondrial encephalomyopathy, lactic acidosis and stroke like episodes (MELAS) syndrome is a maternally inherited mitochondrial disorder with recurrent non-arterial distribution stroke-like episodes (SLEs). A 17 yr old boy with MELAS (m.3243A>G tRNA^Leu(UUR)) presented with SLEs at ages 8 and 10 yrs. At 11 yrs, he suffered a third SLE involving left parietotemporal lobes with dense right hemiplegia and aphasia persistent for 1 week without improvement. On high dose IV L-Arginine (L-Arg) (0.5 g/kg/day divided TID) he had rapid recovery within 48 hours and was rapidly weaned. With emesis of oral L-Arg, his SLE recurred and he was again treated with high dose IV L-Arg with similar rapid recovery and discharged on a slow wean over 6 wks to 0.1 g/kg/day. On maintenance L-Arg he suffered only 2 SLEs at ages 13 and 16 yrs; both resolved rapidly with high dose IV L-Arg without recurrence during a slow wean to maintenance. His phenotype included seizures, ptosis, ophthalmoplegia, facial diplegia, sensorineural hearing loss, ataxia, myopathy, exercise intolerance, peripheral sensorimotor neuropathy, hypertrophic cardiomyopathy, hypertension, and failure to thrive. At 16 yrs he developed end-stage renal disease, due to MELAS, requiring hemodialysis and at 17 yrs he underwent cadaveric renal transplantation. His peri-operative protocol included strict maintenance of perfusion, oxygenation, normothermia, biochemical homeostasis and serum arginine concentrations during which time there were no neurologic decompensations. He was transitioned to oral L-citrulline maintenance therapy which maintained higher serum arginine concentrations with better tolerance. He had no SLEs or seizures in the ensuing 2 yrs.

Potassium and the kidney: a reciprocal relationship with clinical relevance

By controlling urinary potassium excretion, the kidneys play a key role in maintaining whole-body potassium homeostasis. Conversely, low urinary potassium excretion (as a proxy for insufficient dietary intake) is increasingly recognized as a risk factor for the progression of kidney disease. Thus, there is a reciprocal relationship between potassium and the kidney: the kidney regulates potassium balance but potassium also affects kidney function. This review explores this relationship by discussing new insights into kidney potassium handling derived from recently characterized tubulopathies and studies on sexual dimorphism. These insights reveal a central but non-exclusive role for the distal convoluted tubule in sensing potassium and subsequently modifying the activity of the sodium-chloride cotransporter. This is another example of reciprocity: activation of the sodium-chloride cotransporter not only reduces distal sodium delivery and therefore potassium secretion but also increases salt sensitivity. This mechanism helps explain the well-known relationship between dietary potassium and blood pressure. Remarkably, in children, blood pressure is related to dietary potassium but not sodium intake. To explore how potassium deficiency can cause kidney injury, we review the mechanisms of hypokalemic nephropathy and discuss if these mechanisms may explain the association between low dietary potassium intake and adverse kidney outcomes. We discuss if potassium should be repleted in patients with kidney disease and what role dietary potassium plays in the risk of hyperkalemia. Supported by data and physiology, we reach the conclusion that we should view potassium not only as a potentially dangerous cation but also as a companion in the battle against kidney disease.

Reporting after sexual violence: The influence of victim, assault and perpetrator characteristics

Sexual violence is a worldwide public health concern. Care for victims has improved with the development of sexual assault centres, which have served to professionalise and tailor care and to get different services to improve collaboration. Nonetheless, reporting rates remain low, causing perpetrators to walk free without prosecution. We aimed to investigate, firstly, the influence of victim, perpetrator and assault characteristics on the reporting rate, and, secondly, the reasons why victims did not report to the police. Data of a Dutch sexual assault centre was used in this cross-sectional study. All victims who attended the centre between January 2016 and January 2019 were included. Logistic regression analysis was used to assess the relation of certain characteristics with reporting. Forty per cent of the victims reported to the police. Age and injuries were significantly related to reporting. Victims of 26 years or over were less likely to report than victims under 18 years old. Victims with objectified injuries reported to the police more often. Contrary to previous research, no relation between the perpetrator being well-known to the victim and a lower reporting rate was found. Victims mainly refrained from reporting as they experienced conflicting emotions, followed by their feeling discouraged by the police. Other reasons were fear of the perpetrator and defamation, wanting to move on with their life and wanting to spare the perpetrator. Our findings will serve to further optimise care for victims of sexual violence and increase reporting rates.

Precision Health Resource of Control iPSC Lines for Versatile Multilineage Differentiation

Induced pluripotent stem cells (iPSC) derived from healthy individuals are important controls for disease-modeling studies. Here we apply precision health to create a high-quality resource of control iPSCs. Footprint-free lines were reprogrammed from four volunteers of the Personal Genome Project Canada (PGPC). Multilineage-directed differentiation efficiently produced functional cortical neurons, cardiomyocytes and hepatocytes. Pilot users demonstrated versatility by generating kidney organoids, T lymphocytes, and sensory neurons. A frameshift knockout was introduced into MYBPC3 and these cardiomyocytes exhibited the expected hypertrophic phenotype. Whole-genome sequencing-based annotation of PGPC lines revealed on average 20 coding variants. Importantly, nearly all annotated PGPC and HipSci lines harbored at least one pre-existing or acquired variant with cardiac, neurological, or other disease associations. Overall, PGPC lines were efficiently differentiated by multiple users into cells from six tissues for disease modeling, and variant-preferred healthy control lines were identified for specific disease settings.

High incidence of HCV in HIV-negative men who have sex with men using pre-exposure prophylaxis

BACKGROUND & AIMS

HCV has emerged as a sexually transmitted infection (STI) among HIV-positive men who have sex with men (MSM). We evaluated HCV incidence and its risk factors among HIV-negative MSM using HIV pre-exposure prophylaxis (PrEP).

METHODS

Participants of the Amsterdam PrEP project were tested for HCV antibodies or HCV-RNA every 6 months. Participants used daily or event-driven PrEP and could switch regimens during follow-up. We calculated incidence rates (IRs) for overall HCV infection and separately for primary and re-infection. A univariable Bayesian exponential survival model was used to identify risk factors associated with incident HCV infection. The HCV NS5B gene fragment (709 bp) was sequenced and compared to HCV isolates from HIV-positive MSM and other risk groups (n = 419) using phylogenetic analysis.

RESULTS

Among 350 participants contributing 653.6 person-years (PYs), we detected 15 HCV infections in 14 participants (IR = 2.30/100PY). There were 8 primary infections (IR = 1.27/100PY) and 7 re-infections (IR = 27.8/100PY). IR was 2.71/100PY in daily and 1.15/100PY in event-driven PrEP users. Factors associated with incident HCV infection were higher number of receptive condomless anal sex acts with casual partners (posterior hazard ratio [HR] 1.57 per ln increase; 95% credibility interval [CrI] 1.09-2.20), anal STI (posterior HR 2.93; 95% CrI 1.24-7.13), injecting drug use (posterior HR 4.69; 95% CrI 1.61-12.09) and sharing straws when snorting drugs (posterior HR 2.62; 95% CrI 1.09-6.02). We identified robust MSM-specific HCV clusters of subtypes 1a, 4d, 2b and 3a, which included MSM with and without HIV.

CONCLUSIONS

HIV-negative MSM using PrEP are at risk of incident HCV infection, while identified risk factors are similar to those in HIV-positive MSM. Regular HCV testing is needed, especially for those with a previous HCV infection and those reporting risk factors.

LAY SUMMARY

We report that hepatitis C virus infections are frequently acquired among HIV-negative men who have sex with men (MSM) using pre-exposure prophylaxis to prevent HIV infection. New infections occurred more frequently in those reporting receptive anal sex without using condoms, having an anal sexually transmitted infection, injecting drugs, and sharing straws when snorting drugs. The viruses found in HIV-negative men using pre-exposure prophylaxis are genetically similar to those in HIV-positive men, but not in other hepatitis C risk groups, suggesting that (sexual) transmission is occurring between HIV-positive MSM and HIV-negative MSM using pre-exposure prophylaxis.

CLINICAL TRIAL NUMBER

Dutch trial registration number NTR5411.

Cation exchange capacity of biochar: An urgent method modification

Biochar, produced through pyrolysis of organic matter, is negatively charged, thus contributing to electrostatic adsorption of cations. However, due to its porous structure and contents of alkaline ashes, the determination of the cation exchange capacity (CEC) is challenging. Literature values for the CEC of biochar are surprisingly variable and are often poorly reproducible, suggesting methodological problems. Here, we modify and critically assess different steps in the existing ammonium acetate (NH₄OAc) method (pH 7), where ammonium (NH₄⁺) is displaced by potassium chloride (KCl), following removal of excess NH₄OAc with isopropanol, in batch mode. We used pigeon pea biochar to develop the method and conducted a test on three additional biochars with different acid neutralizing capacity. A pretreatment step of biochar was introduced, using diluted hydrochloric acid, to decrease biochar pH to near neutral, so that 1 M NH₄OAc effectively buffers the biochar suspension pH at 7. This allows the CEC of all biochars to be determined at pH 7, which is crucial for biochar comparison. The dissolution of ashes may cause relatively large weight losses (e.g. for cacao shell biochar), which need to be accounted for when computing the CEC of raw biochar. The sum of NH₄OAC-extractable base cations provided a smaller and better estimate of the CEC than KCl-extractable NH₄⁺. We hypothesize that the overestimation of the CEC based on KCl-extractable NH₄⁺ is due to the ineffectiveness of the relatively large isopropanol molecules to remove excess NH₄OAc in biochars rich in micro-pores, due to size exclusion. The amount of base cations removed in the pretreatment was about three (rice husk biochar) to ten times (pigeon pea biochar) greater than the amount of exchangeable cations. The CEC values of biochar increased from 10.8 cmol/Kg carbon to 119.6 cmol/Kg carbon. These values are smaller than reported CEC values of soil organic carbon.

Hedgehog-GLI signaling in Foxd1-positive stromal cells promotes murine nephrogenesis via TGFβ signaling

Normal kidney function depends on the proper development of the nephron: the functional unit of the kidney. Reciprocal signaling interactions between the stroma and nephron progenitor compartment have been proposed to control nephron development. Here, we show that removal of hedgehog intracellular effector smoothened (Smo-deficient mutants) in the cortical stroma results in an abnormal renal capsule, and an expanded nephron progenitor domain with an accompanying decrease in nephron number via a block in epithelialization. We show that stromal-hedgehog-Smo signaling acts through a GLI3 repressor. Whole-kidney RNA sequencing and analysis of FACS-isolated stromal cells identified impaired TGFβ2 signaling in Smo-deficient mutants. We show that neutralization and knockdown of TGFβ2 in explants inhibited nephrogenesis. In addition, we demonstrate that concurrent deletion of Tgfbr2 in stromal and nephrogenic cells in vivo results in decreased nephron formation and an expanded nephrogenic precursor domain similar to that observed in Smo-deficient mutant mice. Together, our data suggest a mechanism whereby a stromal hedgehog-TGFβ2 signaling axis acts to control nephrogenesis.

A curious case of growth failure and hypercalcemia: Answers

BACKGROUND

Sarcoidosis is a multisystem granulomatous disease of unknown etiology that rarely presents in childhood. Here, we report a case of pediatric sarcoidosis, presenting with renal failure and hypercalcemia.

CASE DIAGNOSIS/TREATMENT

A previously well 14-year-old Caucasian boy was admitted to the Hospital for Sick Children, Canada, for hypertension and renal failure following work-up by his family physician for initial concerns of growth failure. On admission, his weight was 35 kg (<3rd percentile), his height was 148 cm (<<3rd percentile), and his blood pressure was 154/116 mmHg (>99th percentile for height). Laboratory findings showed elevated creatinine (218 umol/L), hypercalcemia (3.21 mmol/L), and normocytic anemia (hemoglobin 105 g/L). His further assessment showed a urinary concentrating defect with hypercalciuria (calcium/creatinine 1.76 mmol/mmol) and nephrocalcinosis on ultrasound. His eye examination showed uveitis with conjunctival biopsy remarkable for granulomas, which led to pursuit of a diagnosis of possible sarcoidosis. Angiotensin Angiotensin-converting enzyme was found to be high at 96 U/L, and he had a renal biopsy that was consistent with interstitial nephritis with granulomas. Treatment was started with prednisone leading to resolution of his hypercalcemia but persistence of his mild chronic kidney disease.

CONCLUSIONS

This case represents an atypical presentation of a rare pediatric disease and highlights the spectrum of renal manifestations and treatment options in sarcoidosis.

Platelet Loss across the Hemofilter during Continuous Hemofiltration

BACKGROUND

Thrombocytopenia is a common finding in patients in the intensive care unit receiving continuous renal replacement therapy (CRRT). It is unknown if the hemofilter itself contributes to the platelet loss.

OBJECTIVE

To measure the direct effect of the hemofilter on platelet counts during CRRT.

DESIGN

Prospective, observational study.

SETTING

Intensive care unit of a University hospital.

PATIENTS

Critically ill patients with acute renal failure receiving CRRT.

METHODS

Two samples of blood were drawn simultaneously, pre-filter and post-filter, and analyzed for platelet count. A correction factor was applied to the post-filter platelet count to adjust for the hemoconcentrating effect of net ultrafiltration.

RESULTS

Forty-eight sets of paired data from 22 patients were studied. There was a small but significant decrease in mean platelet count across the hemofilter. The mean platelet count drop was 2.32 x 10(9)/L (s.e. 1.06, p = 0.0487, 95% CI (0.01, 4.62)). Blood flow was strongly related to degree of platelet loss, with a decreased loss of 0.07 x 10(9)/L for every ml/min increase in blood flow (p = 0.015). There was no overall decrease in concurrently measured red cell counts across the hemofilter. However, there was a machine-specific affect on red cell loss (p < 0.0001). The total calculated daily platelet loss across the filter was 625 x 10(9) cells.

CONCLUSION

The hemofilter may contribute to the thrombocytopenia seen during CRRT, by means of either destruction or retention of platelets during passage. This affect appears attenuated by higher blood flows. This information is useful in the assessment of a low platelet count in patients receiving CRRT.

Impact of a multifaceted strategy to improve perioperative diabetes care

AIMS

To assess the impact of a multifaceted strategy to improve perioperative diabetes care throughout the hospital care pathway.

METHODS

We conducted a controlled before-and-after study in six hospitals. The purpose of the strategy was to target four predominant barriers that obstruct optimal care delivery. We provided feedback on baseline indicator performance, developed a multidisciplinary protocol and patient information, and provided professional education. After a 6-month intervention, we determined the performance changes against three outcome indicators and nine process indicators using data on 811 patients with diabetes who underwent major surgery. The progress of the interventions was monitored closely.

RESULTS

Two process indicators improved significantly in the intervention hospitals: the proportion of patients for whom glycaemic control had been evaluated preoperatively increased by 9% (P < 0.002) and the proportion of patients with blood glucose measurements within 1 h after surgery increased by 29% (P < 0.0001). Four other process indicators and all three outcome indicators improved more in the intervention hospitals than in the control hospitals, but the differences were not statistically significant. These included the proportion of patients with all glucose values at 6-10 mmol/l (+3%) and the proportion of patients with hyperglycaemia (-8%). The implementation of the multidisciplinary protocol was still ongoing after the 6-month intervention period.

CONCLUSIONS

The multifaceted improvement strategy had a limited impact on the quality of perioperative diabetes care. This study demonstrates the complexity of improving perioperative diabetes care throughout the multiprofessional hospital care pathway.

First findings of Trichinella spiralis and DNA of Echinococcus multilocularis in wild raccoon dogs in the Netherlands

The recent invasion of the raccoon dog in the Netherlands may be associated with the risk of introduction and spread of zoonotic pathogens. The aim of this study was to assess whether Echinococcus multilocularis and Trichinella spp. infections are present in Dutch raccoon dogs. Between 2013 and 2014, nine raccoon dogs, mainly road kills, were collected for necropsies. One raccoon dog tested repeatedly positive in the qPCR for E. multilocularis. The positive raccoon dog was collected in the province of Flevoland, which is not a known endemic region for E. multilocularis. Another raccoon dog tested positive for Trichinella spiralis by the digestion of the forelimb musculature and the tongue. Trichinella spiralis has not been reported in wildlife since 1998 and thus far was not found in wild carnivores in the Netherlands. It shows that despite the small raccoon dog population that is present in the Netherlands and the limited number of raccoon dogs that were tested, the raccoon dog may play a role in the epidemiology of E. multilocularis and Trichinella spp. in the Netherlands.

Caries-preventive Effect of Supervised Toothbrushing and Sealants

To investigate the effectiveness of 3 caries-preventive measures on high- and low-caries risk occlusal surfaces of first permanent molars over 3 y. This cluster-randomized controlled clinical trial covered 242 schoolchildren, 6 to 7 y old, from low socioeconomic areas. At baseline, caries risk was assessed at the tooth surface level, through a combination of ICDAS II (International Caries Detection and Assessment System) and fissure depth codes. High-caries risk occlusal surfaces were treated according to daily supervised toothbrushing (STB) at school and 2 sealants: composite resin (CR) and atraumatic restorative treatment-high-viscosity glass-ionomer cement (ART-GIC). Low-caries risk occlusal surfaces received STB or no intervention. Evaluations were performed after 0.5, 1, 2, and 3 y. A cavitated dentine carious lesion was considered a failure. Data were analyzed according to the proportional hazard rate regression model with frailty correction, Wald test, analysis of variance, and t test, according to the jackknife procedure for calculating standard errors. The cumulative survival rates of cavitated dentine carious lesion-free, high-caries risk occlusal surfaces were 95.6%, 91.4%, and 90.2% for STB, CR, and ART-GIC, respectively, over 3 y, which were not statistically significantly different. For low-caries risk occlusal surfaces, no statistically significant difference was observed between the cumulative survival rate of the STB group (94.8%) and the no-intervention group (92.1%) over 3 y. There was neither a difference among STB, CR, and ART-GIC on school premises in preventing cavitated dentine carious lesions in high-caries risk occlusal surfaces of first permanent molars nor a difference between STB and no intervention for low-caries risk occlusal surfaces of first permanent molars over 3 y.

Perioperative diabetes care: room for improving the person centredness

AIMS

Person centredness is an important principle for delivering high-quality diabetes care. In this study, we assess the level of person centredness of current perioperative diabetes care.

METHODS

We conducted a survey in six Dutch hospitals, among 690 participants with diabetes who underwent major abdominal, cardiac or large-joint orthopaedic surgery. The survey included questions regarding seven dimensions of person-centred perioperative diabetes care.

RESULTS

Complete data were obtained from 298 participants. The survey scores were low for many of the dimensions of person centredness. The dimensions 'information', 'patient involvement' and 'coordination and integration of care' had the lowest scores. Only half the participants had received information about perioperative diabetes treatment, and approximately one-third had received information about the effect of surgery on blood glucose values, target glucose values and glucose measurement times. Similarly, half the participants had an opportunity to ask questions preoperatively, and only one-third of the participants felt involved in the decision-making regarding diabetes treatment. Most participants knew neither the caregiver in charge of perioperative diabetes treatment nor whom to contact in case of diabetes-related problems during their hospital stay.

CONCLUSIONS

Current perioperative diabetes care is characterized by a lack of patient information and limited patient involvement. These results indicate that there is ample room for improving the person centredness of perioperative diabetes care.

Increase in number of helminth species from Dutch red foxes over a 35-year period

Background

The red fox (Vulpes vulpes) is host to a community of zoonotic and other helminth species. Tracking their community structure and dynamics over decades is one way to monitor the long term risk of parasitic infectious diseases relevant to public and veterinary health.

Methods

We identified 17 helminth species from 136 foxes by mucosal scraping, centrifugal sedimentation/flotation and the washing and sieving technique. We applied rarefaction analysis to our samples and compared the resulting curve to the helminth community reported in literature 35 years ago.

Results

Fox helminth species significantly increased in number in the last 35 years (p-value <0.025). Toxascaris leonina, Mesocestoides litteratus, Trichuris vulpis and Angiostrongylus vasorum are four new veterinary-relevant species. The zoonotic fox tapeworm (E. multilocularis) was found outside the previously described endemic regions in the Netherlands.

Conclusions

Helminth fauna in Dutch red foxes increased in biodiversity over the last three decades.

The efficacy of a specific stabilization splint

BACKGROUND

The use of a Tanner type stabilization splint, fabricated on a leaf gauge articulation for the treatment of patients with disc displacement without reduction, is lacking in the literature.

OBJECTIVES

The purpose of the study is to collect non-controlled, therapy-related observations; in other words, to demonstrate the efficacy of this appliance for the treatment of patients with disc displacement without reduction.

METHODS

The study enrolled 55 patients, 5 men, and 50 women, with the clinical diagnosis disc displacement without reduction, 42 with and 13 without limited mouth opening. All patients received a splint in the musculoskeletally stable centric relation (CR) position. Mouth opening, clinical performance, and the timeframe of splint treatment were assessed.

RESULTS

For 37 patients with a disc displacement without reduction with limited opening, the largest increase in mouth opening (9.5 +/- 5.6 mm) occurred in the first week (7.9 +/- 2.5 days). No occlusal adjustment of the splint was needed during the treatment sequence. For three patients, treatment took up to 3 months (8.1%), for 13 patients, between 3 and 6 months (35.1%), and for 17 patients, within a year (45.9%), making a total of 89.1% successfully treated patients. Out of 50 patients, 29 had a total resolution of signs and symptoms, whereas 21 patients still suffered from solitary temporomandibular disorder (TMD) signs.

CONCLUSION

A Tanner type stabilization splint, fabricated in the musculoskeletally stable CR position, appears to be an effective and efficient means for the treatment of patients with disc displacement without reduction. Its efficacy makes it eligible to be tested in a randomized controlled trial.

CLINICAL IMPLICATIONS

The efficacy of this specific splint, fabricated in the musculoskeletally stable CR position, makes it a promising tool to treat TMD patients with disc displacement without reduction.

The incidence of centric slides in healthy individuals and TMD patients

Controversy exists as to whether centric slide is an etiological factor for temporomandibular disorders. In this cross-sectional study the magnitude of centric slides, obtained with 2 different articulations and one with a millimetre ruler was compared. The study enrolled a group of 27 healthy individuals and 83 TMD patients, the latter divided in 3 groups of 26, 28 and 29 subjects with the RDC/TMD diagnoses of myofascial pain, osteoarthritis and disc displacement without reduction, respectively. Measurement reliability of a chinpoint guided articulation was compared with a musculoskeletally stable articulation, obtained using a leaf gauge. Next, centric slide was measured, if any, intraorally with a millimetre ruler and in both articulations measuring the difference between centric relation and the maximal intercuspal position. A mandibular full-arch Tanner type stabilisation splint was fabricated for each of the TMD patients. After splint treatment, new casts were obtained and mounted using both methods to locate centric relation. The magnitude of centric slide intraorally and in both articulations was reassessed. For the analysis of the variables a mixed-model procedure was applied (alpha = 0.05). At baseline and upon conclusion of splint treatment all groups exhibited centric slides with large standard deviations (ranging from 1.03 +/- 0.83 to 1.97 +/- 1.3 millimetre). In the mixed-model procedure a significant difference in magnitude existed between the millimetre ruler and both the chinpoint guidance as well as the leaf gauge articulation (P < 0.001). No correlation between centric slide and TMD could be demonstrated.

The sorption and desorption of phosphate-P, ammonium-N and nitrate-N in cacao shell and corn cob biochars

The sorption of PO4-P, NH4-N and NO3-N to cacao shell and corn cob biochars produced at 300-350°C was quantified. The biochars were used; (i) as received (unwashed), (ii) after rinsing with Millipore water and (iii) following leaching with Millipore water. In addition to sorption, desorption of PO4-P from the unwashed biochars was quantified. There was no sorption of PO4-P to either washed or rinsed biochars, but following leaching, both biochars adsorbed PO4-P and distribution coefficients (Kd L kg(-1)) were very similar for both materials (10(1.1±0.5) for cacao shell biochar and 10(1.0±0.2) for corn cob biochar). The BET surface area and micropore volume increased 80% and 60% for the cacao shell and corn cob biochars following leaching. After 60 d, 1483±45 mg kg(-1) and 172±1 mg kg(-1) PO4-P was released from the cacao shell and corn cob biochars. NH4-N was sorbed by both unwashed biochars, albeit weakly with Kd values around 10(2) L kg(-1). We speculate that NH4-N could bind via an electrostatic exchange with other cationic species on the surface of the biochar. There was no significant release or sorption of NO3-N from or to either of the biochars.

Reproducibility of 2 methods to locate centric relation in healthy individuals and TMD patients

No conclusive evidence exists for any maxillomandibular relationship as the preferable treatment position. Measurement reliability of 2 different methods to attempt to locate centric relation in control and TMD patients was assessed to determine if both methods lead to the same position. A group of 27 controls and 91 TMD patients were examined using the Research Diagnostic Criteria for TMD (RDC/TMD). Three patient groups were recruited: 27 patients with myofascial pain (MYO), 34 patients with disc displacement without reduction (ID), and 30 patients with osteoarthritis (OA). For each study participant centric relation was located with chinpoint guidance and a technique with a leaf gauge, for the controls once, for all TMD patients before and after stabilization splint treatment. The mixed model procedure revealed no significant differences between the methods, the patient groups and the time interval. However the patient groups at baseline and conclusion of treatment differed significantly from the controls. The percentage of patients (15.9%) having a coincident split-cast result for both methods was significantly smaller (P < 0.001) than the corresponding percentage (85.2%) of controls. After splint treatment, the percentage of coincident split-casts increased from 15.9% to 76.8%. Both methods are reproducible techniques to locate centric relation for control and TMD patients. However, the leaf gauge provides the clinician a different centric relation position in TMD patients than chinpoint guidance does.

Optimization of a charge-state analyzer for electron cyclotron resonance ion source beams

A detailed experimental and simulation study of the extraction of a 24 keV He(+) beam from an ECR ion source and the subsequent beam transport through an analyzing magnet is presented. We find that such a slow ion beam is very sensitive to space-charge forces, but also that the neutralization of the beam's space charge by secondary electrons is virtually complete for beam currents up to at least 0.5 mA. The beam emittance directly behind the extraction system is 65 π mm mrad and is determined by the fact that the ion beam is extracted in the strong magnetic fringe field of the ion source. The relatively large emittance of the beam and its non-paraxiality lead, in combination with a relatively small magnet gap, to significant beam losses and a five-fold increase of the effective beam emittance during its transport through the analyzing magnet. The calculated beam profile and phase-space distributions in the image plane of the analyzing magnet agree well with measurements. The kinematic and magnet aberrations have been studied using the calculated second-order transfer map of the analyzing magnet, with which we can reproduce the phase-space distributions of the ion beam behind the analyzing magnet. Using the transfer map and trajectory calculations we have worked out an aberration compensation scheme based on the addition of compensating hexapole components to the main dipole field by modifying the shape of the poles. The simulations predict that by compensating the kinematic and geometric aberrations in this way and enlarging the pole gap the overall beam transport efficiency can be increased from 16% to 45%.

Caries-preventive effect of sealants produced with altered glass-ionomer materials, after 2 years

OBJECTIVES

The aim of the present study was to investigate the caries-preventive effect of sealants produced with a high-viscosity glass-ionomer with an elevated powder-liquid ratio (ART), of having energy added to this glass-ionomer, and that of glass-carbomer, in comparison to that of resin composite sealants.

METHODS

The randomized controlled trial covered 407 children, with a mean age of 8 years. At a school compound three dentists placed sealants in pits and fissures of high caries-risk children. Evaluation by two independent evaluators was conducted after 0.5, 1 and 2 years. The Kaplan-Meier survival method, ANOVA and t-test were used in analyzing the data.

RESULTS

1352 first permanent molars were sealed. 6.6% of children and 6.8% of sealants dropped out within 2 years. 27 re-exposed pits and fissures, 20 in occlusal and 7 in smooth surfaces, in 25 children, developed a dentin carious lesion. The cumulative survival of dentin carious lesion-free pits and fissures in the glass-carbomer sealant group was statistically significantly lower (97.4%) than those in the high-viscosity glass-ionomer with energy supplied (99%) and the resin-composite (98.9%) sealant groups. There was no statistically significant difference in the cumulative survival of dentin carious lesion-free pits and fissures, between the high-viscosity glass-ionomer with (99%) and without (98.3%) energy supplied sealant groups, after 2 years.

SIGNIFICANCE

The survival of dentin carious lesion-free pits and fissures was high in all sealant types. More dentin carious lesions were observed in the glass-carbomer sealant group.

Prevalence and severity of clinical consequences of untreated dentine carious lesions in children from a deprived area of Brazil

Disadvantaged children suffer because tooth cavities are not being treated and their clinical consequences not being surveyed. The present study aimed to assess the prevalence and severity of clinical consequences of untreated dentine carious lesions in schoolchildren from a deprived area of Brazil and to investigate the determinants of the pufa index. A sample of 835 children aged 6-7 years, from six public schools, was examined by 3 calibrated examiners. Clinical consequences of untreated dentine carious lesions in primary teeth were diagnosed using the four codes of the pufa index: 'p' (pulpal involvement), 'u' (ulceration), 'f' (fistulae), 'a' (abscess). Effects of gender, age, school, history of extraction, and toothache on the prevalence of pufa codes were tested. The prevalence of pufa codes was 23.7%. The mean pufa score was 0.4 ± 0.9. Code 'p' was the most prevalent (19.5%), whereas code 'u' was least prevalent (0.1%). Children with a history of extracted primary teeth due to caries had a 2.7 times higher chance to have a pufa code than children with no previous extraction. Children with toothache had a 5.6 times higher chance to have a pufa code than children without toothache. The prevalence of clinical consequences of untreated dentine carious lesions was moderate and the severity was low. The pufa index is an epidemiological tool complementary to existing caries indices aimed to assess dental caries. However, there appears to be no need to include code 'u' nor to score codes 'f' and 'a' separately.

Discontinuation of long-term benzodiazepine use: 10-year follow-up

BACKGROUND

Several interventions aiming at discontinuation of long-term benzodiazepine use have been proven effective in the short term. However, data on the persistence of discontinuation are lacking.

OBJECTIVES

To assess 10-year follow-up status in patients who succeeded in stopping benzodiazepine use after a discontinuation letter from the patient's own GP. To identify determinants of successful discontinuation on the long term.

METHODS

Follow-up data of patients who participated in a large prospective, controlled stepped care intervention programme among long-term benzodiazepine users in primary care.

RESULTS

At 10-year follow-up, the percentage of benzodiazepine abstinence was 58.8%. Non-abstinent patients used lower doses of benzodiazepine. Being abstinent at 21 months after the intervention predicted abstinence at 10-year follow-up.

CONCLUSIONS

Ten years after a minimal intervention to decrease long-term benzodiazepine use, the majority of patients who were able to discontinue benzodiazepine use initially, does not use benzodiazepines at 10-year follow-up. Patients who did not succeed in maintaining abstinence from benzodiazepines appear to use lower or average dosages.

Caries experience of Egyptian adolescents: does the atraumatic restorative treatment approach offer a solution?

OBJECTIVES

To assess the prevalence and severity of dental caries amongst Egyptian adolescents and the prevalence of carious lesions treatable through the atraumatic restorative treatment (ART) approach.

SUBJECTS AND METHODS

Using a convenient sample procedure, two secondary schools with a dental clinic were selected (967 students, average age: 13.7 ± 0.8 years, range: 12-15). Dental caries was diagnosed using the ART caries criteria, and plaque and calculus were assessed using the Green and Vermillion criteria amongst students grades 1-3 in the dental clinic by 3 calibrated examiners. The effect of the independent variables gender, age, tooth surface, jaw side (left or right) and type of jaw (mandible/maxilla) on dependent caries experience variables and D(2) and D(3) variables were tested using ANOVA.

RESULTS

The prevalence of dental caries including enamel lesion (D(2)MFT) amongst the 967 students was 51.4% and that of dental caries excluding enamel lesions (D(3)MFT) was 38.1%. The mean D(2)MFT and D(3)MFT scores were 1.5 and 0.8, respectively. The percentage of teeth filled and extracted was low. Female students had statistically significantly higher mean D(3)MFT/S and D(2)MFT/S scores than males (p < 0.0001). The prevalence of cavitated carious lesions (D(3)) treatable through ART was 48% for score 2 and 28% for score 3.

CONCLUSIONS

Most of the cavitated lesions were found untreated despite the presence of a dental clinic and a dentist on the school premises. The majority of cavitated lesions without pulp involvement could be treated using the preventive and restorative components of the ART approach.

Randomized GH trial with two different dosages in combination with a GnRH analogue in short small for gestational age children: effects on metabolic profile and serum GH, IGF1, and IGFBP3 levels

BACKGROUND

GnRH analogue (GnRHa) combined with GH treatment has been proposed to increase adult height. Effect on metabolic profile and GH, IGF1, and IGFBP3 levels in short small for gestational age (SGA) children is unknown.

OBJECTIVE

To assess fat mass and lean body mass SDS, percentage trunk fat, blood pressure (BP), insulin sensitivity (Si), beta-cell function (disposition index, DI), lipid profile, and GH, IGF1, and IGFBP3 levels during 2 years of combined treatment.

SUBJECTS

Forty-one pubertal short SGA children with a mean (+/-S.D.) age of 12.1 (+/-1.0) years.

DESIGN

Children received 3.75 mg of leuprolide acetate depot subcutaneously every 4 weeks, and they were randomly assigned to receive 1 mg (group A) or 2 mg (group B) of GH/m(2) per day.

RESULTS

Percentage trunk fat increased in both groups, but to a lower extent in group B. Lean body mass SDS increased only in group B. Changes in BP, Si, DI, and lipids were similar in both groups. Si significantly decreased, but DI remained unchanged. Lipids remained normal. GH and IGF1 levels were significantly higher in group B.

CONCLUSION

Our study is the first to report that 2 years of combined treatment with a GnRHa and either 1 or 2 mg GH/m(2) per day does not adversely affect body composition and metabolic profile of short SGA children who come under medical attention at the onset of puberty. There was a dose-dependent effect on fat mass SDS(height), percentage trunk fat, lean body mass SDS(height), and GH and IGF1 levels in favor of treatment with GnRHa and the higher GH dose of 2 mg/m(2) per day.

Barriers to restorative care as perceived by dental practitioners in Tanzania

OBJECTIVE

To identify barriers to restorative care, as perceived by dental practitioners.

METHODS

Of the total of 147 dental practitioners employed in regional and district government hospitals and municipal health centres, 138 completed a pre-tested questionnaire: a response rate of 94%. Factor analysis was performed to extract barrier factors. Chi-square test was used to test the influences of independent variables on discrete dependent variables, and ANOVA was used to test the influences of independent variables on continuous dependent variables.

RESULTS

Knowledge of patients and beliefs of patients were perceived as the most important barriers. Others were financial, motivation of practitioners, dentistry looked down upon by administration and patients' fear of noise from drill. Practitioners who worked in high and medium economic zones perceived patients' fear of noise from drill as a barrier to restorative care more than their counterparts in low economic zones. Practitioners who worked in low economic zones perceived dentistry looked down upon by administration as a barrier to restorative care more than colleagues in high and medium economic zones.

CONCLUSIONS

Knowledge and beliefs of patients about restorative care were the two main factors that hindered restorative care, as perceived by dental practitioners in Tanzania. Organized information provision to the population and regular continuing education meetings for practitioners on restorative and preventive care, plus adoption of Atraumatic Restorative Treatment in daily clinical work are considered appropriate in addressing these barriers.

[Secular trends of caries prevalence among 6 and 12 year-old youths in the Netherlands]

In order to gain insight into the development of caries prevalence and caries experience among Dutch youth, a meta-analysis was carried out on epidemiological caries data collected in 5 and 6 and 11 and 12 year-olds between 1980 and 2009. From the present analysis it appears that after the mid-1980's a halt occurred in the decline of caries experience in the primary dentition among 5 and 6 year-olds. At the same time, the percentage of children with a caries-free primary dentition who were covered by public health insurance or participated in institutions for youth dental care decreased. Among 11 to 12 year-olds there is no indication that the prevalence of caries in the permanent dentition has changed. Considering the high percentage of 12 year-olds with a caries-free permanent dentition, an additional improvement in oral health for this age-group will be difficult to achieve. The average restorative index of the primary dentition in 5-6 year-old children covered by public health insurance and children in The Hague appears not to have changed dramatically in the last 15 years.

Efficacy of silver diamine fluoride for Arresting Caries Treatment

Arresting Caries Treatment (ACT) has been proposed to manage untreated dental caries in children. This prospective randomized clinical trial investigated the caries-arresting effectiveness of a single spot application of: (1) 38% silver diamine fluoride (SDF) with tannic acid as a reducing agent; (2) 38% SDF alone; (3) 12% SDF alone; and (4) no SDF application in primary teeth of 976 Nepalese schoolchildren. The a priori null hypothesis was that the different treatments have no effect in arresting active cavitated caries. Only the single application of 38% SDF with or without tannic acid was effective in arresting caries after 6 months (4.5 and 4.2 mean number of arrested surfaces; p < 0.001), after 1 year (4.1 and 3.4; p < 0.001), and after 2 years (2.2 and 2.1; p < 0.01). Tannic acid conferred no additional benefit. ACT with 38% SDF provides an alternative when restorative treatment for primary teeth is not an option.

Position of the impacted third molar in relation to the mandibular canal. Diagnostic accuracy of cone beam computed tomography compared with panoramic radiography

This study investigated the diagnostic accuracy of cone beam computed tomography (CBCT) compared to panoramic radiography in determining the anatomical position of the impacted third molar in relation with the mandibular canal. The study sample comprised 53 third molars from 40 patients with an increased risk of inferior alveolar nerve (IAN) injury. The panoramic and CBCT features (predictive variables) were correlated with IAN exposure and injury (outcome variables). Sensitivity and specificity of modalities in predicting IAN exposure were compared. The IAN was exposed in 23 cases during third molar removal and injury occurred in 5 patients. No significant difference in sensitivity and specificity was found between both modalities in predicting IAN exposure. To date, lingual position of the mandibular canal was significantly associated with IAN injury. CBCT was not more accurate at predicting IAN exposure during third molar removal, however, did elucidate the 3D relationship of the third molar root to the mandibular canal; the coronal sections allowed a bucco-lingual appreciation of the mandibular canal to identify cases in which a lingually placed IAN is at risk during surgery. This observation dictates the surgical approach how to remove the third molar, so the IAN will not be subjected to pressure.

Barriers to restorative care as perceived by dental patients attending government hospitals in Tanzania

OBJECTIVES

Perceptions of dental patients in Tanzania regarding barriers to restorative care were examined.

METHODS

A total of 1138 dental patients aged 15 years and above, attending 12 selected government dental clinics in January 2005, completed a pre-tested questionnaire. anova and logistic regression were used to identify the effects of independent variables upon the barrier factors.

RESULTS

Ten barriers to restorative care in Tanzania were identified. The five main barriers included: No advice received from dentist (mean = 3.82); Lack of knowledge on restorative care (mean = 3.58); Lack of habits for going for dental check-ups (mean = 3.31); Bother that one may get in seeking restorative care (mean = 3.28) and Past experience with dental treatment (mean = 3.25). Less respondents in the middle economic zone perceived issues related to beliefs and misinformation, lack of knowledge on restorative care and past experience with dental treatment to be barriers than respondents in low and high economic zones (P < 0.01). However, more of them perceived issues related to high fee for restoration, bother that one may get in seeking restorative care and few clinics rendering restorative care (P < 0.0001) to be barriers than respondents in the high economic zone did. Women, more than men, perceived few clinics rendering restorative care and no advice received from dentist as barriers to restorative care (P < 0.01). Respondents who had received a restoration and/or had relatives who had received a restoration perceived bother that one may get in seeking restorative care and no advice received from dentist more as barriers to restorative care than did those who lacked that experience and whose relatives had not received a restoration (P < 0.05).

CONCLUSIONS

No advice received from dentist and lack of knowledge on restorative care, were the two major barriers to restorative care, as perceived by dental patients in Tanzania. Implementation of the Atraumatic Restorative Treatment approach may overcome many of the barriers identified.

Nuclear receptors: mediators and modifiers of inflammation-induced cholestasis

Inflammation-induced cholestasis (IIC) is a frequently occurring phenomenon. A central role in its pathogenesis is played by nuclear receptors (NRs). These ligand-activated transcription factors not only regulate basal expression of hepatobiliary transport systems, but also mediate adaptive responses to inflammation and possess anti-inflammatory characteristics. The latter two functions may be exploited in the search for new treatments for IIC as well as for cholestasis in general. Current knowledge of the pathogenesis of IIC and the dual role NRs in this process are reviewed. Special interest is given to the use of NRs as potential targets for intervention.

Is there a need for a GP consultant at a university hospital?

BACKGROUND

Patients in hospital can develop complaints unrelated to the condition they are admitted for. The treating specialist will then call upon a co-specialist who is specialized in the clinical picture associated with the new complaint. For such a complaint, the GP is usually the first contact, when the patient is not in hospital. Normally specialists only encounter patients GPs have selected for referral. The risk of the specialist overestimating the predictive value of 'unselected' complaints and symptoms of a serious condition is high. This may lead to an overuse of diagnostic treatments. Such treatments weigh more heavily on the patient, cause inadequate use of hospital facilities and, as a consequence, generate higher costs. Because of these considerations, we wished to investigate if there is a need for the GP as a consultant for new complaints during hospital admittance.

METHOD

The files of a random sample of patients who had an interdisciplinary consultation during their stay in hospital were judged by an expertpanel whether the consultation fitted the expertise of a GP.

RESULTS

In 28 out of 84 files the consultation fitted the expertise of a GP; most cases concerned a specific condition that is not part of the specialist's expertise, most frequently dermatological problems. In a minority of cases the specialist is confronted with a clinical problem with symptoms of which the cause is not clear, for example fever.

CONCLUSION

Generally, the consultations concern serious, often very complex conditions, i.e. cases that should be assessed by a specialist. Nevertheless, the expert panel's judgment of the interdisciplinary consultations shows that in more than half of the dermatological cases and in a limited number of consultations by a specialist of internal medicine and geriatrics the problems fit the GP's expertise. Given the morbidity in academic hospitals we suppose that the results of a similar study in a peripheral hospital might even show more perspective for a GP consultant. These results offer sufficient arguments to start a pilotstudy into the role of a GP consultant in hospital.

A needle guidance device compared to free hand technique in an ultrasound-guided interventional task using a phantom

In this in vitro study, a needle guidance device and a 'free hand' technique for ultrasound guided needle insertion were compared in a simulated ultrasound-guided interventional task using a porcine phantom. Residents inexperienced in using ultrasonography were asked to insert a needle, using an in-plane techniques, and to make contact with metal rods at a depth of 2 and 4 cm in the phantom. The transducer made angles of 90 degrees, 60 degrees and 45 degrees with the surface of the phantom. The times to perform the procedures were significantly shorter and the needle visualisation was significantly better when using the needle guidance device. The residents ranked their satisfaction with the needle-guidance device significantly better than the 'free-hand' technique. This device may be beneficial when performing ultrasound guided peripheral nerve blocks, especially by inexperienced operators.

[Prevalence of and health care consumption for asthma and COPD in relation to ethnicity]

OBJECTIVE

To determine whether there are differences in prevalence of and health care consumption for asthma and COPD between Dutch people of Turkish, Moroccan and Surinamese origin and indigenous Dutch people.

DESIGN

Retrospective.

METHOD

Based on data from the 'Second Dutch national study into morbidity and interventions in general practice', we compared the prevalence of asthma and COPD in the different ethnic groups. In addition, we compared the use of various airway medications and the number of general practice contacts between these ethnic groups.

RESULTS

We analysed data of 240,067 indigenous Dutch, 2,942 Turkish, 2,416 Moroccan and 3,320 Surinamese subjects. Asthma is more prevalent among Surinamese and seems less prevalent among Moroccans. COPD seems less prevalent among immigrants than among the indigenous Dutch population. Immigrants tend to have less prescriptions of prophylactic maintenance airway medication and they also tend to have less airway-related general practice contacts than indigenous Dutch patients.

CONCLUSION

Differences exist in the prevalence of and health care consumption for asthma and COPD between the different ethnic groups in the Netherlands. There seems to be underdiagnosis of COPD in immigrants. Moreover, immigrant asthma and COPD patients are probably undertreated.

[A tooth located in a mandibular fracture line. Treatment by oral- and maxillofacial surgeons in The Netherlands]

Mandibular fractures are among the most common facial bone injuries. Approximately 50% of the fractures occur in teeth bearing areas. Consequently, the likelihood that a tooth will be in the fracture line is substantial. A review of the literature reveals that there is not a clear guideline for preserving or removing a tooth in a mandibular fracture line. By means of a questionnaire, information was collected about how dental surgeons in The Netherlands deal with this problem. The research sample consisted of 194 active oral and maxillofacial surgeons in The Netherlands in 2005. One hundred and two surgeons responded (52.6%). The response rate was sufficient to allow for reliable deductions and statistical analysis. The results of the questionnaire showed that the respondents were in agreement. Generally, the respondents strove to preserve a tooth in the mandibular fracture line. The respondent's treatment of a mandibular fracture was in agreement with the state of the art as presented in the current literature. The respondent's choice of treatment did not depend on age, gender, university clinic at which the respondent was trained to be a dental surgeon, year of registration as a specialist, place of work and position. According to the respondents, the dentist's role in the aftercare of a mandibular fracture is treatment of the teeth injuries, follow-up of the posttraumatic oral self care, and regularly testing the vitality of the teeth in and around the mandibular fracture line.

Ion source development at KVI

Ion source development at KVI is focused on increasing the beam intensity from the electron cyclotron resonance ion source injector and optimizing the beam transport and injection into the superconducting AGOR cyclotron. We describe several modifications that have resulted in a significant performance increase of the ion source. We also present the first results of ion transport simulations that have been performed to better understand beam losses in the extraction region and in the low-energy beam transport system. Finally, a new emittance meter based on a combination of the pepperpot and scanning techniques will be described, which will be used to benchmark the simulation studies of ion extraction and transport in detail.