Rationale for novel intermittent dieting strategies to attenuate adaptive responses to energy restriction

Eating patterns involving intermittent energy restriction (IER) include 'intermittent fasting' where energy intake is severely restricted for several 'fasting' days per week, with 'refeeding' days (involving greater energy intake than during fasting days) at other times. Intermittent fasting does not improve weight loss compared to continuous energy restriction (CER), where energy intake is restricted every day. We hypothesize that weight loss from IER could be improved if refeeding phases involved restoration of energy balance (i.e. not ongoing energy restriction, as during intermittent fasting). There is some evidence in adults with overweight or obesity showing that maintenance of a lower weight may attenuate (completely or partially) some of the adaptive responses to energy restriction that oppose ongoing weight loss. Other studies show some adaptive responses persist unabated for years after weight loss. Only five randomized controlled trials in adults with overweight or obesity have compared CER with IER interventions that achieved energy balance (or absence of energy restriction) during refeeding phases. Two reported greater weight loss than CER, whereas three reported similar weight loss between interventions. While inconclusive, it is possible that achieving energy balance (i.e. avoiding energy restriction or energy excess) during refeeding phases may be important in realizing the potential of IER.

Intermittent energy restriction improves weight loss efficiency in obese men: the MATADOR study

Background/Objectives:

The MATADOR (Minimising Adaptive Thermogenesis And Deactivating Obesity Rebound) study examined whether intermittent energy restriction (ER) improved weight loss efficiency compared with continuous ER and, if so, whether intermittent ER attenuated compensatory responses associated with ER.

Subjects/Methods:

Fifty-one men with obesity were randomised to 16 weeks of either: (1) continuous (CON), or (2) intermittent (INT) ER completed as 8 × 2-week blocks of ER alternating with 7 × 2-week blocks of energy balance (30 weeks total). Forty-seven participants completed a 4-week baseline phase and commenced the intervention (CON: N=23, 39.4±6.8 years, 111.1±9.1 kg, 34.3±3.0 kgm⁻²; INT: N=24, 39.8±9.5 years, 110.2±13.8 kg, 34.1±4.0 kgm⁻²). During ER, energy intake was equivalent to 67% of weight maintenance requirements in both groups. Body weight, fat mass (FM), fat-free mass (FFM) and resting energy expenditure (REE) were measured throughout the study.

Results:

For the N=19 CON and N=17 INT who completed the intervention per protocol, weight loss was greater for INT (14.1±5.6 vs 9.1±2.9 kg; P<0.001). INT had greater FM loss (12.3±4.8 vs 8.0±4.2 kg; P<0.01), but FFM loss was similar (INT: 1.8±1.6 vs CON: 1.2±2.5 kg; P=0.4). Mean weight change during the 7 × 2-week INT energy balance blocks was minimal (0.0±0.3 kg). While reduction in absolute REE did not differ between groups (INT: -502±481 vs CON: −624±557 kJ d⁻¹; P=0.5), after adjusting for changes in body composition, it was significantly lower in INT (INT: −360±502 vs CON: −749±498 kJ d⁻¹; P<0.05).

Conclusions:

Greater weight and fat loss was achieved with intermittent ER. Interrupting ER with energy balance ‘rest periods’ may reduce compensatory metabolic responses and, in turn, improve weight loss efficiency.

Adiposity is related to decrements in cardiorespiratory fitness in obese and normal-weight children

BACKGROUND

Obese children are typically less physically active than their normal-weight peers and are often assumed to be 'unfit'.

OBJECTIVE

Investigate the relationships between adiposity, physical activity levels and cardiorespiratory fitness (CRF) in obese and normal-weight children. A secondary aim was to examine obese/normal-weight differences in CRF.

METHODS

Obese (N = 107) and normal-weight (N = 132) 10-13-year-olds participated. Fat-free mass (FFM), percent fat, physical activity and peak oxygen uptake (VO2peak ) were assessed. Analyses were adjusted for socioeconomic status (SES).

RESULTS

Higher percent fat was inversely associated with VO2peak normalized for mass (r = -0.780, P < 0.001) even after controlling for physical activity (r = -0.673, P < 0.001). While higher percent fat was also inversely associated with VO2peak normalized for FFM, this was only significant in males (r = -0.247, P = 0.004) and did not persist after controlling for physical activity (r = -0.059 P = 0.526). Compared with normal-weight children, obese children had higher absolute VO2peak , lower VO2peak corrected for mass (P ≤ 0.009) and lower VO2peak corrected for FFM (P = 0.041) that did not persist after controlling for SES (P = 0.086).

CONCLUSION

Obesity-related inefficiencies in CRF were evident. Higher adiposity was associated with poorer CRF relative to mass, irrespective of physical activity levels. However, low physical activity levels may be responsible for associations between adiposity and CRF relative to FFM seen in boys, indicating the importance of encouraging physical activity.

Human lung lysozyme: sources and properties

Lysozyme in human airway secretions is thought to defend the lung against airborne bacteria. Although lysozyme has been purified and characterized from human tears, milk, saliva, and other sources (1-5), human lung lysozyme has received little attention except for measurements of concentrations in sputum (6, 7), immunocytochemical and histochemical localization (8-12),and studies of secretion by alveolar macrophages (13). This study was designed to identify the sources of secreted lung lysozyme, to quantitate the secretory activities of the various sources,and to compare the properties of lysozyme from lung cells with those from other tissues.

Effect of a 4-week weight maintenance diet on circulating hormone levels: implications for clinical weight loss trials

The majority of weight loss studies fail to standardize conditions such as diet and exercise via a weight maintenance period prior to commencement of the trial. This study aimed to determine whether a weight stabilization period is necessary to establish stable baseline hormone concentrations. Fifty-one obese male participants with a body mass index of 30-40 kg m(-2) and aged 25-54 years underwent 4 weeks on an energy balance diet that was designed to achieve weight stability. Blood samples were collected in the fasting state at commencement and completion of the 4-week period, and circulating concentrations of 18 commonly measured hormones were determined. During the 4-week weight maintenance period, participants achieved weight stability within -1.5 ± 0.2 kg (-1.4 ± 0.2%) of their initial body weight. Significant reductions in serum insulin (by 18 ± 6.5%) and leptin (by 21 ± 6.0%) levels occurred, but no significant changes were observed for gut-derived appetite-regulating hormones (ghrelin and peptide YY), nor thyroid, adrenal, gonadal or somatotropic hormones. There were no significant correlations between the change in body weight and the change in circulating concentrations of insulin or leptin over the 4-week period, indicating that the observed changes were not due to weight loss, albeit significant negative correlations were observed between the changes in body weight and plasma ghrelin and peptide YY levels. This study demonstrates the need for baseline weight maintenance periods to stabilize serum levels of insulin and leptin in studies specifically investigating effects on these parameters in the obese. However, this does not apply to circulating levels of gut-derived appetite-regulating hormones (ghrelin and peptide YY), nor thyroid, adrenal, gonadal or somatotropic hormones.

A survey of training in pediatric flexible bronchoscopy

OBJECTIVE

There is currently no evidence-based method for defining competency in pediatric flexible bronchoscopy (FB). Based on expert opinion, guidelines using numbers of procedures have been published in defining competency for pediatric FB. The purpose of this study was to formally survey the opinion of USA pediatric pulmonology training directors about the assessment of competency and training experiences in pediatric FB in their programs.

METHODS

An Internet-based Survey Monkey™ of the Pediatric Pulmonary Training Directors Association (PEPTDA) was administered 10/12/10 through 11/1/10 with a supplemental survey 6/1/11-6/30/11.

RESULTS

This survey of US pediatric pulmonology training directors about competency and training in pediatric FB showed that a majority (86%) felt there was a minimum threshold of procedures for developing competency that could be defined, with a median of 50 and an average of 56.4 (SD = 33.0). The actual number of FBs performed by fellows during their 3-year fellowship averaged 89.4 (SD = 45.3) with a range of 10-200. The survey also revealed a variety of teaching techniques used for FB, including simulation technology. Finally many differences were reported in skill assessment, locations for performance of FB, and the range of underlying indications and patient populations. The apprenticeship model is the predominant method of learning FB in the surveyed programs.

CONCLUSIONS

A majority of US pediatric pulmonology training directors felt that a minimum number of procedures could be defined for developing competency in pediatric FB. There was variability in the numbers of procedures performed, training techniques and assessment, and application of FB. This survey represents an initial step in assessing training and defining competency in pediatric FB.

Error rates in bite mark analysis in an in vivo animal model

Recent judicial decisions have specified that one foundation of reliability of comparative forensic disciplines is description of both scientific approach used and calculation of error rates in determining the reliability of an expert opinion. Thirty volunteers were recruited for the analysis of dermal bite marks made using a previously established in vivo porcine-skin model. Ten participants were recruited from three separate groups: dentists with no experience in forensics, dentists with an interest in forensic odontology, and board-certified diplomates of the American Board of Forensic Odontology (ABFO). Examiner demographics and measures of experience in bite mark analysis were collected for each volunteer. Each participant received 18 completely documented, simulated in vivo porcine bite mark cases and three paired sets of human dental models. The paired maxillary and mandibular models were identified as suspect A, suspect B, and suspect C. Examiners were tasked to determine, using an analytic method of their own choosing, whether each bite mark of the 18 bite mark cases provided was attributable to any of the suspect dentitions provided. Their findings were recorded on a standardized recording form. The results of the study demonstrated that the group of inexperienced examiners often performed as well as the board-certified group, and both inexperienced and board-certified groups performed better than those with an interest in forensic odontology that had not yet received board certification. Incorrect suspect attributions (possible false inculpation) were most common among this intermediate group. Error rates were calculated for each of the three observer groups for each of the three suspect dentitions. This study demonstrates that error rates can be calculated using an animal model for human dermal bite marks, and although clinical experience is useful, other factors may be responsible for accuracy in bite mark analysis. Further, this study demonstrates that even under carefully controlled conditions, albeit in a forced-decision model, errors in interpretation occur even amongst the most experienced analysts.

Dental radiology considerations in DVI incidents: A review

Multiple fatality incidents frequently have a significant forensic dental identification component. The use of radiographs, that provide objective evidence of the dentition prior to and after death is a vital part of the reconciliation procedure. Although these events share some common elements, every multiple fatality incident response has its own idiosyncrasies that require both flexibility and advance planning. The focus, from a post mortem perspective, is the making of excellent, permanent, and archival-quality images. The post mortem plan should have a capability for conventional film-based and digital imaging. Additionally, images should be produced in a radiobiologically responsible manner using optimum body-substance precautions. Finally, images (both ante mortem and post mortem) must be held in a secure fashion at a distance, protected from further hazard.

Multidisciplinary management of Hunter syndrome

Hunter syndrome is a rare, X-linked disorder caused by a deficiency of the lysosomal enzyme iduronate-2-sulfatase. In the absence of sufficient enzyme activity, glycosaminoglycans accumulate in the lysosomes of many tissues and organs and contribute to the multisystem, progressive pathologies seen in Hunter syndrome. The nervous, cardiovascular, respiratory, and musculoskeletal systems can be involved in individuals with Hunter syndrome. Although the management of some clinical problems associated with the disease may seem routine, the management is typically complex and requires the physician to be aware of the special issues surrounding the patient with Hunter syndrome, and a multidisciplinary approach should be taken. Subspecialties such as otorhinolaryngology, neurosurgery, orthopedics, cardiology, anesthesiology, pulmonology, and neurodevelopment will all have a role in management, as will specialty areas such as physiotherapy, audiology, and others. The important management topics are discussed in this review, and the use of enzyme-replacement therapy with recombinant human iduronate-2-sulfatase as a specific treatment for Hunter syndrome is presented.

Advances in the diagnosis and management of chronic pulmonary aspiration in children

Chronic pulmonary aspiration (CPA) in children is an important cause of recurrent pneumonia, progressive lung injury, respiratory disability and death. It is sporadic, intermittent and variable, and often occurs in children with complicated underlying medical conditions and syndromes that produce symptoms indistinguishable from CPA. For most types of aspiration there is no gold-standard diagnostic test. The diagnosis of CPA is currently made clinically with some supporting diagnostic evaluations, but often not until significant lung injury has been sustained. Despite multiple diagnostic techniques, the diagnosis or exclusion of CPA in children is challenging. This is of particular concern given the outcome of unrecognised progressive lung injury and the invasiveness of definitive therapies. Although new techniques have been introduced since the 1990s and significant advances in the understanding of dysphagia and gastro-oesophageal reflux have been made, characterisation of the aspirating child remains elusive.

Clinical and histopathological examination of experimental bite marks in-vivo

Under rigorously controlled laboratory conditions, mechanically induced simulated human bite marks were made on pig skin to enable the clinical and histopatholgical study of experimental bite marks in-vivo. A series of bite marks were created on the abdomen and thorax of live anaesthetized juvenile pigs at specific times just prior to and after death. Following the release of the biting force clinical observations of antemortem wounds revealed slow diminishment of the bite indentations presumably due to dermal elastic recovery. Minutes after euthanasia of the animals, the indentations of the teeth from the postmortem bite marks faded rapidly. After the biting process the animals were placed on either the right or left side and this side was maintained until necropsy to examine for dependant and non-dependent side differences. All bite mark injuries located on the non-dependent side revealed specific pattern characteristics. However, on the dependent side whether the bite mark was antemortem or postmortem in areas of livor mortis, no clear pattern was visible. Histologically, the observations for each bite mark specimen were categorised by the presence or absence of extravasated red blood cells in the fatty or muscle layers. The histopathological findings correlate with the clinical observations of antemortem and postmortem bite marks located on the non-dependent side in regard to muscular erythema and extravasated red blood cells. It is clinically difficult to comment on temporal relationship of a bite mark in relation to time of death in areas affected by blood-pooling seen on the dependent side. In these situations, histopathological studies could be a reliable alternative to provide information regarding antemortem or postmortem injuries.

Forensic aspects of maxillofacial radiology

Radiology has been used extensively in conventional dental identification, anatomically based identification and identification using maxillofacial skeletal landmarks such as the frontal sinus. Examples of these are well documented in the literature. The purpose of this paper was to revisit the methods where radiographic methods may be used to determine identity using the teeth, the root structures and the frontal sinuses. Additionally suggestions are offered for management of radiography in mass disasters and cases where age determination is required. Computer assisted tomography can be used in the assessment of the degree of fit of a weapon to a wound in cases of blunt force skull injury and plane films can assist in depicting the pattern of post mortem skull fractures. Micro-computed tomography has been used in matching weapons to wounds in sharp-force injury cases. The radiologist's role in cases of civil litigation and fraud is discussed and case examples are given. There are gaps in the science where radiological methods are used. The author offers several suggestions for possible research projects to close some of these gaps.

Porcine skin as an in-vivo model for ageing of human bite marks

Porcine skin has been shown to have similar histological, physiological and immunological properties to human skin and has been suggested as a good analogue for medical and forensic research. This study was undertaken to examine the appearance of bite mark wounds inflicted at known time intervals before and after death. Under general anaesthesia, a series of bite marks were created on a pig's abdomen with a device designed to mechanically produce simulated human bite mark wounds. The pig skin model showed that bite mark characteristics are similar to those found on human skin. This study has provided information on the window of time showing clearly detailed bite marks occurring around the time of death. It also demonstrated that it is possible under certain conditions to determine that a bite mark was made before or after death in a porcine model. Under these experimental conditions, the results suggest that an in-vivo porcine skin model should be considered as a representative model for the study of human bite marks.

Clinical benefits of continuous leukocyte filtration during cardiopulmonary bypass in patients undergoing valvular repair or replacement

Valve operations in the form of repair or replacement make up a significant population of patients undergoing surgical procedures in the USA annually with the use of cardiopulmonary bypass. These patients experience a wide range of complications that are considered to be mediated by activation of complement and leukocytes. The extracorporeal perfusion circuit consists of multiple synthetic artificial surfaces. The biocompatibility of the blood contact surfaces is a variable that predisposes patients to an increased risk of complement mediation and activation. This can result in an inflammatory process, causing leukocytes to proliferate and sequester in the major organ systems. The purpose of this study was to determine whether filtration of activated leukocytes improved clinical outcomes following surgical intervention for valve repair or replacement. In this paper, we report a retrospective matched cohort study of 700 patients who underwent valve procedures from June 1999 to December 2002. The control group (CG) consisted of patients who had a conventional arterial line filter. In the study group (SG), patients had a conventional arterial line filter and a leukocyte arterial line filter (Pall Medical, NY). In the SG, blood diverted to the cardioplegia system was also leukocyte depleted to enhance myocardial preservation by adapting this device to the outflow port on the filter. Patient characteristics were similar for the SG and the CG, including 228 males and 122 females, mean age (62.4 versus 64.2 years), cardiopulmonary bypass time (127+/-64 versus 116+/-53 min), and aortic crossclamp time (84+/-23 versus 81+/-23 min). Our results demonstrate that the SG achieved statistically significant reduction in the time to extubation (p =0.03) and the number of patients with prolonged intubation in excess of 24 hours (p <0.04), in addition to improved postoperative oxygenation (p=0.01), and decreased length of hospital stay (p =0.03). We believe that leukocyte filters are clinically beneficial, as demonstrated by the results presented in this study.

A clinical comparison of glass ionomer, resin-modified glass ionomer and resin composite restorations in the treatment of cervical caries in xerostomic head and neck radiation patients

Controversy exists as to whether there is less secondary caries at the margins of glass ionomer restorations compared with other materials that do not release fluoride. This study examined the incidence of secondary caries for three types of restorative materials in Class V restorations in xerostomic patients. The study group consisted of 45 high caries-risk adult patients who had undergone head and neck irradiation for the treatment of cancer. All were substantially xerostomic and in need of at least three restorations in the same arch. Every patient received a restoration with each of the test materials, a conventional glass ionomer (GI), a resin modified glass ionomer (RMGI) and a resin composite (C). Patients were instructed in the daily use of a neutral pH sodium fluoride gel in custom trays. Recall appointments were made at 6, 12, 18 and 24 months, and the restorations were examined for material loss, marginal integrity and recurrent caries at the restoration margin. Fluoride compliance was determined at each recall period and recorded as the percentage of recommended use during that interval. Patients were categorized at the end of the study as fluoride non-users if their average compliance was 50% or less. Those with greater than 50% compliance were categorized as fluoride users. In the latter group, no recurrent caries was found for any of the restorations, whereas a material-dependent incidence of recurrent caries was found in the fluoride non-user group. None of the GI, one RMGI and eight C restorations failed due to recurrent caries. For the fluoride non-user patients, Fishers exact test (p=0.05) showed no statistical difference between GI and RMGI but statistical differences were found among those materials and resin composite at each recall period. Recurrent caries reductions for GI and RMGI relative to C were greater than 80% in xerostomic patients not using topical fluoride supplementation.

A prospective radiological analysis of fragment displacement in fractures of the mandibular condyle: evaluation of 96 consecutive cases

A prospective radiological study of 96 patients with mandibular condylar neck fractures was undertaken to assess frequency and nature of mandibular condylar displacement. Data collected included age, gender, aetiology, and anatomical site of fracture and direction of displacement. Men aged 20-29 years sustained the majority of condylar fractures. Assault was the major cause of condylar fracture, followed by motor vehicle accidents and sport accidents. No anterior or posterior displacement of the condyle was noted. Medial displacement of the superior fragment was most frequently observed.

Prospective analysis of endoscopic vein harvesting

BACKGROUND

Utilization of bridging vein harvesting (BVH) of saphenous vein grafts (SVG) for coronary artery bypass grafting (CABG) results in large wounds with great potential for pain and infection. Endoscopic vein harvesting (EVH) may significantly reduce the morbidity associated with SVG harvesting.

METHODS

A prospective database of 200 matched patients receiving EVH and BVH was compared. The patients all underwent CABG done over a period of 4 months (April to August 2000). Patients were excluded if they had prior vein harvesting.

RESULTS

The EVH and BVH group included 100 patients each with similar demographics. The patients in the EVH group had significantly fewer wound complications, mean days to ambulation, and total length of stay (P <0.05). There was no difference in harvest time or vein injuries.

CONCLUSION

Endoscopic vein harvesting results in significantly fewer wound complications, decrease in days to ambulation, and the total length of stay. EVH is superior to BVH in patients undergoing CABG.

Impact of guided exploration and enactive exploration on self-regulatory mechanisms and information acquisition through electronic search

Following instruction in basic skills for electronic search, participants who practiced in a guided exploration mode developed stronger self-efficacy and greater satisfaction than those who practiced in a self-guided exploratory mode. Intrinsic motivation was not affected by exploration mode. On 2 post-training tasks, guided exploration participants produced more effective search strategies. expended less effort, made fewer errors, rejected fewer lines of search, and achieved higher performance. Relative lack of support for self-regulatory factors as mediators of exploration mode impacts was attributed to the uninformative feedback from electronic search, which causes most people to remain at a novice level and to require external guidance for development of self-efficacy and skills. Self-guided learning will be more effective on structured tasks with more informative feedback and for individuals with greater expertise on dynamic tasks.

Does the lead apron and collar always reduce radiation dose?

The possibility that personal lead shielding devices can increase absorption of radiation has not been entertained. The purpose of the present investigation specifically was to determine whether pituitary dose might be increased when a leaded apron and thyroid collar are used. Thermoluminescent dosimeters (TLDs) were used to measure absorbed dose. They were calibrated at the kVp used in the clinical situation and a calibration curve relating light output to dose was generated. Lithium fluoride TLD discs were placed in the pituitary gland region of a Rando-Alderson female human phantom. The equivalent of 100 transpharyngeal exposures were delivered. The resultant light output from recovered dosimeters was converted to a uGy value using the calibration curve. The experiment was repeated using a 0.25 mm lead equivalent collar and apron fitted to the phantom in the customary manner. The entire process was repeated in order to have 30 dosimeters for the unshielded and 30 dosimeters for the shielded conditions. A further 30 dosimeters were sham irradiated and served as controls. A statistical comparison between unshielded and shielded conditions was performed. When the leaded apron and thyroid collar were used the absorbed dose to the pituitary gland was increased significantly (P < 0.05). Following this a second group, using a different dosimetry system and a male phantom repeated the experiment. In both cases, the shielded phantom received significantly higher dose to the pituitary region than the unshielded.

Extranodal non-Hodgkin's lymphoma of the maxillofacial region: analysis of 88 consecutive cases

Examination of the records of 88 consecutive patients with extranodal maxillofacial non-Hodgkin's lymphoma (ENHL) was undertaken. Each patient's complete record was reviewed. Males outnumbered females by 1.7:1. Age at diagnosis ranged from 22 to 94 years (median 60.0). Affected anatomic sites included: maxillary sinus (22), nasal cavity (8), maxilla (13), mandible (8), salivary glands (14), and other (23). The most common presenting symptom was a non-painful mass. Associated dental symptoms were present in 72 patients and included intraoral swelling, pain, and loose teeth. Treatment included chemotherapy and radiation with a follow-up of 1-25 years. Treatment trends indicate a shift towards multimodal therapy. Non-Hodgkin's lymphoma of the head and neck, if discovered early, has an excellent prognosis.

The emerging role of flexible bronchoscopy in pediatrics

Great advances had been made in rigid instrumentation, with the introduction of the glass rod telescope. With relatively few exceptions, however, bronchoscopy was still performed primarily for therapeutic indications, such as the removal of foreign bodies from the airway. It would remain for the introduction of the flexible bronchoscope to stimulate the widespread development of diagnostic bronchoscopy in pediatric practice.

Tooth root colour as a measure of chronological age

The purpose of this study was to assess a possible colour shift in the root surfaces of adult human teeth and if so, whether this colour change is related to chronological age. Teeth extracted from persons of known age and gender were obtained from Ontario dental practitioners and grouped into five-year age ranges. Three experiments were undertaken: (1) to identify a possible difference in yellow colouration between the four surfaces of tooth roots (mesial, distal, lingual, and buccal), (2) to investigate the difference in yellow colouration of tooth roots between non-molar teeth and molar teeth and (3) to assess the correlation between the age of teeth and root colour saturation for yellow, magenta, cyan and black. The teeth in all investigations were scanned by a flat-bed digital colour scanner with a Kodak colour scale control and viewed on a colour computer monitor. In the first two experiments the yellow colour saturation of the root surfaces was measured at six points on each root using Photoshop 5.0 software. A significant difference was observed in the percentage yellow colour saturation between the mesial and the other three anatomical surfaces (p < 0.01), and between the root surfaces of non-molar and molar teeth (p < 0.01) (ANOVA with Bonferroni post-test). The authors then randomly assigned tooth surfaces to select an equivalent number of posterior and anterior teeth in the study, assessing the relationship between age and root colouration. Four points of colour measurement on 40 teeth (sample size permitting, see Table 1) for each known age and gender were assessed for colour saturation (cyan, magenta, yellow and black). The correlation of chronological age to colour saturation was linear for all colours, with correlation coefficients ranging from r = 0.81 to r = 0.94. The high correlation values strongly support the conclusion that chronological age is related to increased root colouration.

The effects of antitumor irradiation on mandibular opening and mobility: a prospective study of 58 patients

OBJECTIVE

The purpose of this study was to analyze the effects of head and neck radiation therapy on jaw opening and mobility.

STUDY DESIGN

Maximum jaw opening and mandibular mobility were measured before and after radiation treatment in 58 patients presenting for angle down wedge, homolateral wedge pair, and parallel pair head and neck radiation treatment.

RESULTS

As dose to the temporomandibular joint and pterygoid muscles increased, maximal jaw opening decreased linearly. Mandibular dysfunction appeared to increase as radiation dose to the pterygoid muscles increased. Similar effects were not observed with temporomandibular joint irradiation. Irradiation of the pterygoid muscles appeared critical in the development of trismus. Angle down wedge treatment irradiated the temporomandibular joint and pterygoid muscles with clinical effects similar to those seen in homolateral wedge pair and parallel pair patients. Doses as low as 1493 cGy resulted in functional impairment.

CONCLUSIONS

Future investigations into radiotherapy delivery and appropriate postradiation trismus treatment may reduce head and neck radiation morbidity.

Digital dental radiographic identification in the pediatric, mixed and permanent dentitions

The purpose of this paper is to investigate the utility of digital dental radiographic superimposition in the various stages of development of the human dentition. Digital, computer assisted dental identification is a means of identification which allows the spatial relationships of the root and support structures of the teeth to be compared one to the other. The technique has not been tested in patients with developing dentitions. Dental radiographs from patients in the pediatric, mixed and permanent dentition stages of development, simulating "antemortem" and "postmortem" radiographs, were digitized using a flat field radiograph scanner. Anatomic features were used as points of comparison utilizing image editing software whereby anatomic sections were digitally cut from the antemortem image and compared to the same anatomic locations on the postmortem image to assess for points of concordance. The technique was applied to 25 cases within the primary dentition, 25 cases within the mixed dentition and 25 cases within the permanent dentition. Results showed that this was a viable technique within both the pediatric and permanent dentition although it was of little value within the mixed dentition.

Potential for fraudulent use of digital radiography

BACKGROUND

Digital radiographic images can be manipulated using personal computers. To test the potential for fraudulent use, the authors altered a series of dental radiographs, printed them to simulate duplicated films and submitted them for authorization of proposed treatment.

MATERIALS AND METHODS

The authors obtained periapical radiographs of teeth that contained small restorations or were unrestored from the files of three dental patients at a private dental practice. The authors used a flatbed scanner to digitize and import the radiographs into a computer. Then they added dental caries, large restorations, fractures and periapical pathosis to the radiographs. The authors proposed to the insurance companies that the teeth in question be restored using expensive treatment, such as root-canal therapy and full-coverage crowns.

RESULTS

In each case, the insurance companies authorized the proposed treatment based on the appearance of the teeth on the radiographs. The altered images illustrated an apparent need for dental treatment that was not required and that could have led to payment for treatment that was not actually performed.

CONCLUSIONS

This study illustrates the potential for the fraudulent use of manipulated digital radiographic images.

CLINICAL IMPLICATIONS

Dentistry should be aware of the implications of the potential for such abuse and should develop measures both to prevent it from occurring and to facilitate its detection.

A comparison of bitemark injuries between fatal wolf and domestic dog attacks

Bitemark patterns in adult human victims following a fatal wolf pack attack and a domestic dog pack attack are compared. Both victims exhibited a concentration of wounds to the extremities, left and right torso, but not to the groin or internal organs. The neck and face of the domestic dog attack victim were primary sites of attack while the feral wolf pack victim was spared damage to the neck, but had facial tissue destroyed postmortem. Most punctures were found on the ventral aspect of the domestic victim and dorsal aspect of the feral victim. It is speculated that most wounds were attributable to dominant animals of both packs and in both victims and this suggests a co-ordination of activity between. Differences in bitemark patterns may well have been caused in part by differences in genetics, training, breeding, socialization and impetus of attack between wolves and dogs. Distinct differences in bitemark patterns were found in these two human victims of a wolf and domestic dog attacks.

Implicit Theories versus the Social Construal of Ability in Self-Regulation and Performance on a Complex Task

The present experiment examined the relative impacts of implicit theories and the social construal of ability as either a fixed entity or an incremental skill on self-efficacy, affective reactions, self-set goals, and performance on a complex group-management task. It was also a novel task for participants. Participants who had an implicit theory that group-management ability is an incremental skill that can be acquired with experience developed stronger self-efficacy, maintained more positive affect, and set themselves more challenging goals across multiple trials. They also outperformed participants with a fixed-entity theory of group-management ability. Some of the motivational benefits of an incremental-skill conception were lost when the social construal of managerial ability emphasized a fixed-entity conception. However, the negative motivational effects of a fixed-entity theory of ability were not ameliorated by the social construal of managerial ability as an incremental skill. The effects of conceptions of ability were fully mediated by the self-regulatory responses of participants. The hypothesis that self-efficacy moderates the impact of ability conceptions on self-set goal challenges was not supported. Copyright 1999 Academic Press.

Operative therapy of coronary arterial aneurysm

In summary, a patient with multiple coronary aneurysms and operative therapy is described and 17 previously reported similar cases are reviewed. The proper type of operation for this condition is as yet unclear, but, nevertheless, the reported cases and our case with operative therapy have done well postoperatively despite a variety of procedures performed.

Optimum dental radiography in bone marrow transplant patients

OBJECTIVE

The purpose of this study was to establish an optimum radiographic examination regimen for patients undergoing bone marrow transplantation. Two radiographic examinations were compared: the panoramic radiograph and the full mouth series of radiographs.

STUDY DESIGN

A prospective analysis of 65 consecutive patients undergoing bone marrow transplantation was undertaken. All patients were examined through use of both panoramic and full mouth series intraoral radiographs, including bitewings. Significant findings were recorded and compared by means of paired t test analysis for parametric data, such as caries, periapical inflammation and subgingival calculus, and by means of McNemar's test for nonparametric data, such as the presence or absence of severe periodontal disease.

RESULTS

Acquired findings, such as caries, periodontal disease, and clinically significant faulty restorations, were detected more frequently from the full mouth series (P < .05). There was no significant difference in the detection of periapical pathosis. In 8 of 65 patients, clinically significant information, such as evidence of impacted wisdom teeth, neoplasms, and multiple myeloma, was better detected from the panoramic radiographs.

CONCLUSIONS

The results suggest a combination of both modalities as the optimum means of radiologic survey in this "high-risk" patient population.

Computer-based production of bite mark comparison overlays

Bite mark comparison protocols include measurement and analysis of the pattern, size, and shape of teeth against similar characteristics observed in an injury on skin or a mark on an object. The physical comparison of tooth position often depends upon transparent acetate overlays to detect similarities or differences between the teeth and the bite mark. Several methods are used to produce life-sized comparison overlays. The perimeter of the biting edges of the anterior teeth are usually recorded to produce facsimile images called hollow volume overlays. Some investigators hand-trace these outlines from dental study casts, or from bite exemplars produced in wax, styrofoam, or similar materials. Some use hand-traced outlines from xerographic images produced with office photocopiers that are calibrated to produce life-sized final images. Others use radiographic images and toneline photography of wax exemplars filled with radio-opaque materials, such as metal filings or barium sulfate. Dependence upon subjective input by the odontologist to trace these images manually is considered problematic. This is because the errors incorporated at any production stage are increased in the final product. The authors have developed a method to generate accurate hollow volume overlays using computer-based techniques. A PowerPC Macintosh computer, flatbed scanner, and Adobe Photoshop (a popular graphical interface application) are used to acquire, select, arrange and export detailed data from class and individual characteristics of a suspect's teeth to acetate film loaded in a high-resolution laser printer. This paper describes this technique to enable the odontologist to produce high-quality, accurate comparison overlays without subjective input.

Radiographic localization of mandibular anesthesia landmarks

The objective of this study was to assess whether bony landmarks used for the standard inferior alveolar nerve block can be used to accurately determine the position of the mandibular foramen and whether panoramic radiographs are appropriate for this purpose. A total of 11 landmarks from 79 panoramic radiographs and 70 corresponding cases of oblique (45-degree) cephalometric radiographs were examined. Ten measurements of the distance from each landmark to the mandibular foramen, as well as 6 ratios from these distances, were calculated from all radiographs. The results showed that the position of the mandibular foramen was highly individualistic and not consistently related to traditional clinical landmarks. Panoramic radiographs were as good as oblique cephalometric radiographs for the locating of the mandibular foramen. No age or gender correlations were found. It was concluded that the mandibular foramen can be localized in panoramic radiographs but that its relation to bony landmarks is highly variable.

Pain preceding recurrent head and neck cancer

Over a 7-year period, 12 patients experienced recurrence of primary head and neck cancers preceded by severe orofacial pain. Pain began within 6 months following treatment in 10 of 12 patients and was progressive in 11 of 12 patients. Six patients died from recurrence, five within 2 years following onset of pain. No clear indication of malignant disease was evident despite clinical examination, plain radiography, magnetic resonance imaging, and computed tomography. Pain was often mistaken for denture irritation. Frequently, no area of irritation was apparent.

A specimen positioning device for dental radiographic identification--image geometry considerations

Preventative dental treatment has reduced caries incidence and thereby rendered dental identification, in caries-free individuals, more difficult. An alternate method comparing spatial relationships of dental structures in digitized superimposed antemortem and postmortem radiographs has been previously developed. This paper examined the limitations of this technique and demonstrates a positioning device suitable for reproducing antemortem radiographic image geometry. The paper also examined three specific aspects of image geometry namely horizontal angulation, vertical angulation and focal film distance. Deviations in horizontal angulations between antemortem and postmortem radiographs by as little as 5 degrees makes identification difficult. Changes in vertical angulation or focal-film distance had no affect. This procedure, and the positioning device used to accurately replicate antemortem image geometry is an economical, easy to use adjunct to current methods of dental identification.

Ion composition of airway surface liquid of patients with cystic fibrosis as compared with normal and disease-control subjects

To test whether a major contribution of airways epithelial ion transport to lung defense reflects the regulation of airway surface liquid (ASL) ionic composition, we measured ASL composition using the filter paper technique. On nasal surfaces, the Cl- concentration (approximately 125 meq/liter) was similar to plasma, but the Na+ concentration (approximately 110 meq/liter) was below plasma, and K+ concentration (approximately 30 meq/liter) above plasma. The resting ASL osmolarity [2(Na+ + K+); 277 meq/liter] approximated isotonicity. There were no detectable differences between cystic fibrosis (CF) and normal subjects. In the lower airways, the Na+ concentrations were 80-85 meq/liter, K+ levels approximately 15 meq/liter, and Cl- concentrations 75-80 meq/liter. Measurements of Na+ activity with Na(+)-selective electrodes and osmolality with freezing point depression yielded values consistent with the monovalent cation measurements. Like the nasal surfaces, no differences in cations were detected between CF, normal, or chronic bronchitis subjects. The tracheobronchial ASL hypotonicity was hypothesized to reflect collection-induced gland secretion, a speculation consistent with observations in which induction of nasal gland secretion produced hypotonic secretions. We conclude that there are no significant differences in ASL ion concentrations between CF, normal, and chronic bronchitis subjects and, because ASL ion concentrations exceed values consistent with defensin activity, the failure of CF lung defense may reflect predominantly factors other than salt-dependent defensins.

Mediastinal lymphadenopathy caused by Mycobacterium avium-intracellulare complex in a child with normal immunity: successful treatment with anti-mycobacterial drugs and laser bronchoscopy

We report on the case of a 9-month-old Caucasian girl referred to our institution with a history of fever of unknown origin and wheezing, unresponsive to bronchodilator and anti-inflammatory therapy. Subsequent investigation led to a diagnosis of mediastinal lymphadenopathy caused by Mycobacterium avium-intracellulare (MAI). The infected lymph tissue infiltrated and obstructed the right bronchus and significantly compressed the left bronchus to the point of near closure. Given the high degree of morbidity and potential mortality from thoracic surgery in this patient, we treated her with a combination of anti-mycobacterial drugs (rifabutin, clarithromycin, ciprofloxacin, clofazimine, amikacin, ethambutol) and glucocorticoids to relieve airway compression. The endobronchial granulation tissue was resected by laser bronchoscopy. This combined approach led to eventual normalization of radiologic and endoscopic findings, and the anti-mycobacterial chemotherapy was discontinued 12 months after the first bronchoalveolar lavage culture was negative for MAI. The patient remains asymptomatic 1 year after completion of this course of therapy. We suggest that mediastinal lymphadenopathy with bronchial infiltration and extrinsic airway compression caused by MAI in otherwise healthy children can be successfully treated with aggressive chemotherapy, glucocorticoids, and laser bronchoscopy.

Influence of the addition of restorations on the diagnosis of caries from digitized bitewing radiographs

OBJECTIVES

The purpose of this study was to assess the influence of additional caries and restorations on the detection of caries on the same radiograph.

STUDY DESIGN

Six participants examined five series of four radiographs in which natural carious lesions were present. Each series consisted of the same image with progressively more restorative treatment digitally painted on. The films were randomly presented to the observers who examined the films for the presence and depth of carious lesions. The observers were not informed that the 20 films were disguised versions of the same original five radiographs.

RESULTS

The number of carious lesions reported by the six observers did not increase despite the apparent increased restorative intervention viewed on the radiographs.

CONCLUSIONS

The complexity of restorative care does not affect observers' ability to correctly detect approximal carious lesions.

Conservative management of osteoradionecrosis

A retrospective records analysis of 32 patients with mandibular osteoradionecrosis seen between August 1960 and September 1995 was undertaken to determine the effectiveness of nonsurgical/nonhyperbaric oxygen conservative management. Two patients died before final analysis. Of those alive, 65.5% of patients were spared resection, having lesions resolve (48.3%), improve (3.4%), or asymptomatically stabilize (13.8%). Sequestrum production allowing "gentle" removal predicted a more favorable clinical course when managed conservatively compared with nonsequestrating lesions (p < 0.05). Criteria to define clinical osteoradionecrosis are proposed.

A simple means of demonstrating skull fractures using radiographic altered image geometry

Multiple comminuted fractures distributed around a skull and resulting from repeated weapon impacts were poorly demonstrated on conventional lateral and upper frontal radiographs. This was due to superimposition of contralateral fractures, normal anatomy and tangential projection angles. Simple modification of a standard dental x-ray generator and manipulation of projection geometry allowed isolation of individual fractures with improved image quality. The above technique lends itself to cases in which soft tissue remains to obscure the detail of multiple fractures during clinical observation.