How well do services for young people with long term conditions deliver features proposed to improve transition?

BACKGROUND

For young people with long-term conditions, transition from child to adult-oriented health services is a critical period which, if not managed well, may lead to poor outcomes. There are features of transition services which guidance and research suggest improve outcomes. We studied nine such features, calling them 'proposed beneficial features': age-banded clinic; meet adult team before transfer; promotion of health self-efficacy; written transition plan; appropriate parent involvement; key worker; coordinated team; holistic life-skills training; transition manager for clinical team. We aimed to describe the extent to which service providers offer these nine features, and to compare this with young people's reported experience of them.

METHODS

A longitudinal, mixed methods study followed 374 young people as their care moved from child to adult health services. Participants had type 1 diabetes, cerebral palsy or autism spectrum disorder with additional mental health difficulties. Data are reported from the first two visits, one year apart.

RESULTS

Three hundred four (81.3%) of the young people took part in the second visit (128 with diabetes, 91 with autism, 85 with cerebral palsy). Overall, the nine proposed beneficial features of transition services were poorly provided. Fewer than half of services stated they provided an age-banded clinic, written transition plan, transition manager for clinical team, a protocol for promotion of health self-efficacy, or holistic life-skills training. To varying degrees, young people reported that they had not experienced the features which services said they provided. For instance, the agreement for written transition plan, holistic life-skills training and key worker, was 30, 43 and 49% respectively. Agreement was better for appropriate parent involvement, age-banded clinic, promotion of health self-efficacy and coordinated team at 77, 77, 80 and 69% respectively. Variation in the meaning of the features as experienced by young people and families was evident from qualitative interviews and observations.

CONCLUSIONS

UK services provide only some of the nine proposed beneficial features for supporting healthcare transition of young people with long term conditions. Observational studies or trials which examine the influence of features of transition services on outcomes should ensure that the experiences of young people and families are captured, and not rely on service specifications.

The effects of a CCR3 inhibitor, AXP1275, on allergen-induced airway responses in adults with mild-to-moderate atopic asthma

BACKGROUND

CCR3 is the cognate receptor for major human eosinophil chemoattractants from the eotaxin family of proteins that are elevated in asthma and correlate with disease severity.

OBJECTIVE

This proof-of-mechanism study examined the effect of AXP1275, an oral, small-molecule inhibitor of CCR3, on airway responses to inhaled allergen challenge.

METHODS

Twenty-one subjects with mild atopic asthma and documented early and late asthmatic responses to an inhaled aeroallergen completed a randomized double-blind cross-over study to compare early and late allergen-induced asthmatic responses, methacholine PC₂₀ , blood and sputum eosinophils and exhaled nitric oxide after 2 weeks of treatment with once-daily doses of AXP1275 (50 mg) or placebo.

RESULTS

There was a significant increase in methacholine PC₂₀ after 12 days of AXP1275 treatment compared to placebo (increase of 0.92 doubling doses versus 0.17 doubling doses, P = .01), but this protection was lost post-allergen challenge. There was no effect of AXP1275 on allergen-induced late asthmatic responses, or eosinophils in blood and sputum. The early asthmatic response and exhaled nitric oxide levels were slightly lower with AXP1275, but this did not reach statistical significance. The number of subjects who experienced treatment-emergent adverse events while receiving AXP1275 was comparable placebo.

CONCLUSIONS & CLINICAL RELEVANCE

AXP1275 50 mg administered daily was safe and well tolerated, and there was no difference in the type, severity or frequency of treatment-emergent adverse events in subjects while receiving AXP1275 compared to placebo. AXP1275 increased the methacholine PC₂₀ ; however, the low and variable exposure to APX1275 over a short treatment period may have contributed to poor efficacy on other outcomes.

Sputum inflammatory cells and allergen-induced airway responses in allergic asthmatic subjects

BACKGROUND

Allergen inhalation causes early and late bronchoconstrictor responses, airway hyperresponsiveness and airway inflammation in allergic asthmatics. The role of airway inflammatory cells in causing allergen-induced bronchoconstriction and airway hyperresponsiveness is controversial. The objective of this study was to examine the relationships between allergen-induced increases in airway inflammatory cells, early and late bronchoconstrictor responses and methacholine airway hyperresponsiveness.

METHODS

Allergen inhalation challenge was conducted in 50 allergic asthmatics. Changes in the forced expired volume in 1 s (FEV(1%) ) were followed for 7 h, induced sputum was obtained at 7 and 24 h, and the provocative concentration of methacholine causing a 20% fall in FEV(1) (MCh PC(20) ) was measured at 24 h.

RESULTS

There was a significant negative correlation between the baseline methacholine PC(20) and baseline sputum eosinophils (r = -0.512, P = 0.0001). Allergen-induced changes in methacholine PC(20) were also significantly negatively correlated to allergen-induced change in sputum eosinophils at 24 h (r = -0.434, P = 0.002), but not to changes in any other inflammatory cells. There were no significant correlations between sputum eosinophils or other inflammatory cells and the allergen-induced early or late asthmatic responses.

CONCLUSION

Allergen-induced increases in airway eosinophils in asthmatic dual responders may contribute to allergen-induced changes in methacholine PC(20) , but not the late asthmatic responses.

Allergen inhalation challenge in smoking compared with non-smoking asthmatic subjects

BACKGROUND

Smoking asthmatics experience more severe symptoms, require more rescue medication and have more asthma-related hospitalizations than non-smoking asthmatics. However, studies in mice suggest that mainstream cigarette smoke may reduce airway inflammation and may attenuate airway hyperresponsiveness. A comparison of allergen-induced airway inflammatory responses of smoking and non-smoking atopic asthmatics has not been examined previously.

OBJECTIVES

To determine whether allergen-induced airway responses and inflammatory profiles are attenuated in smoking when compared with non-smoking mild allergic asthmatic subjects.

METHODS

Allergen inhalation challenges were performed in 13 smoking and 19 non-smoking mild allergic asthmatic subjects. The forced expired volume in 1 s (FEV(1) ) was measured up to 7 h after allergen inhalation. Methacholine airway responsiveness was measured before and at 24 h after allergen and sputum was induced before and at 7 and 24 h after allergen.

RESULTS

Both the smoking and non-smoking groups developed similar allergen-induced falls in FEV(1) during the early and late asthmatic responses and similar increases in allergen-induced airway eosinophils. The mean maximum fall in FEV(1) during the late response was 16.3 ± 4.3% in non-smokers and 12.9 ± 7.2% in smokers. The smoking asthmatics, however, did not develop allergen-induced methacholine airway hyperresponsiveness, whereas the non-smoking controls developed a 1.18 doubling dose shift in methacholine PC(20) (P < 0.05).

CONCLUSIONS AND CLINICAL RELEVANCE

Mild allergic asthmatic subjects, who were current smokers with a mean 6-year pack history, develop allergen-induced eosinophilic airway inflammation and late responses, similar in magnitude to non-smoking asthmatics, but do not develop methacholine airway hyperresponsiveness associated with the allergen-induced airway eosinophilia.

Single-dose desloratadine and montelukast and allergen-induced late airway responses

Montelukast and desloratadine synergistically inhibit the allergen-induced early asthmatic response. Montelukast also suppresses the allergen-induced late asthmatic response, but there are no reports on the effect of desloratadine or the combination on the allergen-induced late asthmatic response. Atopic asthmatics (n = 10) completed a multicentric randomised double-blind crossover study comparing single-dose placebo, 5 mg desloratadine, 10 mg montelukast and the combination administered 2 h prior to allergen inhalation challenge. Methacholine challenges were performed 24 h before and after allergen challenge. Exhaled nitric oxide measurements and sputum inflammatory cell counts were also carried out. All active treatments significantly decreased the late asthmatic response area under the curve. Combination therapy provided the greatest inhibition compared to desloratadine and montelukast. Montelukast was nonsignificantly better than desloratadine but not as effective as the combination. There was a trend towards a decrease in airway responsiveness following montelukast and combination. Montelukast, but not desloratadine or the combination, decreased exhaled NO levels 24 h after allergen. The allergen-induced increase in sputum eosinophil numbers was significantly suppressed at 7 h with desloratadine and combination therapy, and at 24 h with montelukast and combination therapy. Single-dose co-administration of desloratadine and montelukast 2 h prior to allergen inhalation clinically abolished the late asthmatic response and eosinophil recruitment.

Circulating myeloid and plasmacytoid dendritic cells after allergen inhalation in asthmatic subjects

BACKGROUND

Dendritic cells are key contributors to initiation and maintenance of T-cell immunity to inhaled allergen. The purpose of this study was to enumerate the changes in peripheral blood myeloid (mDCs) and plasmacytoid dendritic cells (pDCs), the DCs expressing chemokine receptor 6 (CCR6) and chemokine receptor 7 (CCR7), following diluent and allergen inhalation in asthmatic subjects.

METHODS

Peripheral blood was obtained from 16 allergic asthmatic subjects before and at 0.5, 1, 2, 3, 4, 6, 24, and 48 h after inhaled diluent and allergen challenges. Dendritic cells were enumerated using flow cytometry.

RESULTS

Allergen inhalation significantly reduced mDCs at 6 h (21.3 +/- 2.0 vs 15.0 +/- 1.8/microl blood; P < 0.05) and 24 h (21.5 +/- 3.4 vs 16.4 +/- 2.4/microl blood; P < 0.05) after challenge. Circulating pDCs were significantly lower than baseline up to 24 h after both allergen and diluent challenges. There was a significant efflux of CCR6(+) mDCs from peripheral blood at 6 h and CCR6(+) pDCs at 4 h after allergen challenge, when compared with diluent. There was no difference in the number of circulating CCR7(+) mDCs or pDCs after diluent or allergen challenges.

CONCLUSIONS

Peripheral blood mDCs and CCR6(+) mDCs, but not pDCs, are reduced up to 24 h after allergen inhalation. Thus, allergen inhalation causes trafficking of immature CCR6(+) DCs from blood into the airway, while that of the trafficking of the mature CCR7(+) DCs from the airways into the regional lymph nodes probably occurs through the lymphatic system.

Effects of inhaled ciclesonide on circulating T-helper type 1/T-helper type 2 cells in atopic asthmatics after allergen challenge

BACKGROUND

The predominance of T-helper type 2 (Th2) lymphocytes is thought to underlie the pathogenesis of asthma. Allergen inhalation challenge in atopic asthmatic subjects is associated with decreased interferon-gamma (IFN-gamma) positive CD4+ and CD8+ lymphocytes in peripheral blood and induced sputum.

OBJECTIVE

This study examined the effects of an inhaled corticosteroid on these previously described allergen-induced changes in circulating Th1 and Th2 lymphocytes.

METHODS

Subjects were randomized to 7 days of placebo, 40 or 80 micro g ciclesonide in a crossover study. Airway responses and peripheral blood were measured before and after treatment, and 24 h after allergen challenge.

RESULTS

Ciclesonide 40 and 80 micro g significantly attenuated the late response and sputum eosinophils at 8 h post-allergen (P<0.05). Circulating IFN-gamma positive CD4+ lymphocytes decreased after allergen challenge with placebo (P<0.05), and this was inhibited by 40 micro g ciclesonide treatment (P<0.05). There was no effect of allergen inhalation or ciclesonide on IL-4-positive CD4+ lymphocytes or IFN-gamma and IL-4-positive CD8(high) lymphocytes. The allergen-induced change of IFN-gamma/IL-4 ratio on CD4+ cells correlated with the allergen-induced change of peripheral blood eosinophils.

CONCLUSIONS

The results of this study suggest that attenuation of allergen-induced airway responses by ciclesonide may be mediated through regulation of IFN-gamma-positive CD4+ cells.

The links between allergen skin test sensitivity, airway responsiveness and airway response to allergen

BACKGROUND

The allergen-induced early asthmatic response [provocation concentration (PC)20, the concentration causing a 20% forced expiratory volume in 1 s (FEV)1 fall] depends on the level of IgE sensitivity and the degree of nonallergic airway hyperresponsiveness (AHR) and can be predicted from histamine PC20 and allergen skin test endpoint.

OBJECTIVES

We examined the relationships between allergen PC20, methacholine PC20, and allergen skin test endpoint and assessed the accuracy of both the histamine PC20-based prediction of allergen PC20 (using methacholine) and a new methacholine PC20-based prediction equation.

METHODS

From 158 allergen challenges, the allergen PC20, the methacholine PC20, and the skin test endpoint were recorded and relationships between these three were sought. We compared the measured allergen PC20 to that predicted from the previous histamine PC20-based and the new methacholine-based formulae.

RESULTS

In single regressions, allergen PC20 correlated with both methacholine PC20 (r=0.25, P=0.0015) and skin test endpoint (r=0.52, P <0.00005). The relationship was improved by multiple regression of log-allergen PC20vs. log-methacholine PC20 and log-endpoint (r=0.61, P <0.00005). The histamine-based formula predicted allergen PC20 to within 2 doubling concentrations in 80% and within 3 in 92%. The new methacholine-based formula to within 2 and 3 concentrations in 81% and 94%, respectively; only nine of 158 subjects were outside the 3 concentrations.

CONCLUSIONS

We have confirmed the dependence of the allergen-induced early asthmatic response upon the level of allergic sensitivity and the degree of AHR, the latter as assessed by methacholine challenge. The allergen PC20 can be predicted to within 3 doubling concentrations in 94% of cases.

Identifying the position of an ear from a laser scan: the significance for planning rehabilitation

Laser scanning techniques are used to plan the construction of prosthetic ears as dimensional measurements between anthropometric points can be accurately measured on a screen image. The aim of this study was to determine if these techniques could be used to assess the position of ears on the face. Computer-generated images were created from laser scans of 20 subjects. Frames of reference were constructed by locating a series of anthropometric points on the face from which three orthogonal planes were constructed. A central reference point was identified at the intersection of the three orthogonal planes. Dimensional measurements were made between anthropometric points on the ear and the reference planes. The differences between anthropometric points and the reference planes on the left and right sides of the face were small. It was possible to describe the location of points three-dimensionally with respect to a central reference point. The development of frames of reference and a central reference point would appear to offer many advantages in the assessment and description of ear position for patients requiring reconstruction with prostheses.

Conformational changes in pediocin AcH upon vesicle binding and approximation of the membrane-bound structure in detergent micelles

Pediocin AcH is a 44-residue antimicrobial peptide with bactericidal potency against Gram-positive bacteria such as Listeria. It belongs to a family of bacteriocins that, when membrane-associated, is predicted to contain beta-sheet and alpha-helical regions. All bacteriocins in this family have a conserved N-terminal disulfide bond. An additional C-terminal disulfide bond in pediocin AcH is thought to confer enhanced potency and broader specificity range against sensitive bacteria. The C-terminal disulfide bond may also affect the conformation of the C-terminus. The secondary structures of pediocin AcH in aqueous solution and vesicles from susceptible cells, as well as the ability of trifluoroethanol (TFE) and detergent systems to induce secondary structures like those induced in vesicles, were studied by circular dichroism (CD) spectroscopy. Like related peptides, pediocin AcH was highly unordered in aqueous solution, 56%. However, it also contained 20% beta-strand and 15% beta-turn structures. Upon complete binding to vesicles, 32% alpha-helical structure formed, the unordered structure decreased to 32%, and the beta-strand and beta-turn structures remained largely unchanged. Thus, a betaalpha domain structure formed in vesicles. The helical structure likely forces the C-terminal tail to loop back on the helix so that the C24-C44 disulfide bond can form. Detergent micelles were superior to TFE in their ability to induce secondary structural fractions in pediocin AcH comparable to those observed in vesicles. This demonstrates the importance of a hydrocarbon-water interface to pediocin AcH structure induction and suggests that it is preferable to use detergent micelles as solvents in NMR studies of pediocin AcH structure.

Inhaled leukotriene E(4), but not leukotriene D(4), increased airway inflammatory cells in subjects with atopic asthma

Allergen-induced late airway responses are associated with increased numbers of airway eosinophils and basophils. The purpose of this study was to compare and contrast the effects of inhaled cysteinyl leukotrienes LTD(4) and LTE(4), which are released during allergen- induced airway responses, and allergen, on airway inflammatory cells. Fifteen subjects with atopic, mild asthma inhaled diluent, LTD(4), LTE(4), and allergen. Spirometry was performed for 7 h, and sputum inflammatory cells were measured before, 7 h, and 24 h after challenges. The maximum early percent fall in FEV(1) was 23.6 +/- 1.4%, 21.6 +/- 2.3%, 29.3 +/- 2.4%, and 4.0 +/- 1.1% after LTD(4), LTE(4), allergen, and diluent, respectively. Only inhaled LTE(4) and allergen significantly increased sputum eosinophils at 7 h and 24 h, and sputum basophils at 7 h. Six additional subjects underwent airway biopsies 4 h after inhalation. There were significantly more eosinophils in the lamina propria after inhalation of LTE(4) compared with LTD(4) and diluent (p < 0.05). These results suggest cysteinyl leukotrienes play a role in eosinophil migration into the airways in allergic asthma, and for the same degree of bronchoconstriction, inhaled LTE(4) causes more tissue and airway eosinophilia than LTD(4).

Dose-dependent effects of inhaled mometasone furoate on airway function and inflammation after allergen inhalation challenge

Comparisons of the potency of different inhaled corticosteroids, delivery devices, and treatment regimens in the management of asthma can only be made when outcome measurements display a dose-dependent effect. These outcomes have been difficult to identify. In this study, we compared in a randomized, double-blind, crossover design, the effects of 6 d treatment with placebo and three doses (50, 100, and 400 microg, twice daily) of mometasone furoate delivered by dry powder inhaler (MF-DPI) on responses after allergen inhalation challenge. Twelve mild asthmatic subjects with dual responses after allergen inhalation were studied. Outcome measurements included early and late asthmatic responses, the change in methacholine airway responsiveness 24 h after challenge, and sputum eosinophilia measured 7 and 24 h after challenge. All three doses of MF-DPI demonstrated similar attenuation of early responses and allergen-induced airway hyperresponsiveness relative to placebo (p < 0.05). The late maximal %fall in FEV(1) after placebo treatment was 23.5% and was significantly reduced in a dose-dependent manner to 12.3%, 11.0%, and 5.9% for the 50-, 100-, and 400-microg twice-daily treatments (p = 0.007). The allergen-induced increase in sputum eosinophilia (x10(4) cells/ml) 24 h after challenge during placebo treatment was 60.2 and was significantly reduced to 24.0, 15.3, and 6.2 for the 50-, 100-, and 400-microg twice-daily treatments. MF-DPI is effective at attenuating allergen-induced early and late responses, airway hyperresponsiveness, and sputum eosinophilia, and dose-response effects exist for the attenuation of the late response.

The reproducibility and sample size requirements of exercise-induced bronchoconstriction measurements

Dry air exercise challenges are frequently used to screen medications that have potential utility in the management of exercise-induced bronchoconstriction (EIB). The purpose of this study was to determine the reproducibility of three outcome measurements made using such challenges, and sample size requirements for drug evaluation studies based on these outcomes. Forty adult subjects with asthma, who tested positively on a screening exercise challenge, were subjected to two further identical challenges, separated by 1 to >35 days. Outcome measurements included the maximum per cent fall in forced expiratory volume in one second (FEV1), after exercise (% fallmax), and the area under the per cent fall in FEV1/time curve for 30 min (AUC30) and 60 min (AUC60) after exercise. The reproducibility of these outcomes, as assessed by intraclass correlation coefficients was 0.72, 0.53 and 0.35 for % fallmax, AUC30 and AUC60 measurements, respectively. The sample size requirements to demonstrate an attenuation of EIB equivalent to a 50% reduction in % fallmax was 9, 14 and 19 subjects for the % fallmax, AUC30 and AUC60 responses, respectively (90% power). It is concluded that the maximum percentage fall in forced expiratory volume in one second has greater reproducibility and results in greater power in clinical trials than area under the curve measurements. Sample size calculation curves are provided which may be used in study design and interpretation of published studies.

The contribution of imaging and digitised data to mandibular reconstruction and implant stabilised occlusal rehabilitation: a case report

Different methods are recommended for the surgical reconstruction of the resected mandible. The advantages for implant stabilised prostheses in restoring the occlusion are recognised but few papers provide adequate data to identify the successful outcome of treatment. The literature is reviewed and the advantages of imaging together with the use of digitised data is highlighted by a case requiring rehabilitation with enhanced planning methods.

The effects of inhaled budesonide on circulating eosinophil progenitors and their expression of cytokines after allergen challenge in subjects with atopic asthma

Allergen inhalation by dual responder subjects with atopic asthma is associated with an increase in circulating eosinophil/basophil colony-forming units (Eo/B CFU) and granulocyte-macrophage colony- stimulating factor (GM-CSF) immunolocalization in Eo/B colony cells grown in vitro. The current study examined the effect of the inhaled corticosteroid, budesonide, on the number of allergen- induced circulating eosinophils and Eo/B CFU, and immunolocalization of GM-CSF and interleukin-5 (IL-5) in Eo/B colony cells grown in vitro. Sixteen subjects with mild atopic asthma were treated for either 7 or 8 d with 200 microg inhaled budesonide or placebo twice a day. Peripheral blood was collected before and 24 h after allergen inhalation challenge and nonadherent mononuclear cells (NAMC) were grown in methylcellulose culture. Eo/B CFU were enumerated after 14 d in culture, and prepared on slides for immunocytochemistry. Budesonide attenuated the allergen-induced increase in circulating eosinophils (4.0 +/- 0.4 x 10(5)/ml versus 6.5 +/- 0.7 x 10(5)/ml, p = 0.0001), circulating Eo/B CFU (12.4 +/- 2.3/10(6) NAMC versus 18.8 +/- 4.6/10(6) NAMC, p = 0.05), and immunolocalization of GM-CSF in Eo/B colony cells (11.8 +/- 1.9% positive versus 18.0 +/- 2.2%, p = 0.01) but not immunolocalization of IL-5 (7.9 +/- 1.4% versus 4.5 +/- 0.6%, p > 0.05). Inhaled budesonide attenuated the number of allergen-induced circulating eosinophils and their progenitors grown in the presence of GM-CSF, which may partially be a result of regulating eosinophil progenitor expression of the autocrine growth factor GM-CSF.

Comparison of platelet activation in unstable and stable angina pectoris and correlation with coronary angiographic findings

We sought to investigate the relation between platelet activation and the angiographic evidence of ruptured plaque in patients presenting with unstable and stable angina pectoris. We prospectively enrolled 25 consecutive patients (5 women and 20 men, mean age 62 +/- 3 years), 17 with unstable angina and 8 with stable angina. Systemic venous blood samples were collected within 4 to 6 hours of admission for flow cytometry analysis. Activation-dependent epitope CD63 and glycoprotein IIb/IIIa on the platelet membrane were assayed. Fibrinogen levels were also measured. All patients with unstable angina underwent cardiac catheterization and had angiographic evidence of ruptured plaque. Of the patients with stable angina, 5 underwent coronary angiography with smooth noncomplex lesions and 3 had negative technetium-99m sestamibi stress tests. Patients with unstable angina were characterized by 39% higher levels of fibrinogen than patients with stable angina (423 +/- 304 vs 304 +/- 51 mg/dl, p = 0.004). The percentage of platelets positive for the activation-dependent epitope CD63 was 5 times higher in patients with unstable than stable angina (14.6 +/- 5.6% vs 2.75 +/- 1.6%, p = 0.0026). They also had a 15% higher expression of their glycoprotein IIb/IIIa (517 +/- 79 vs 449 +/- 50 mean fluorescence intensity, p = 0.038). Thus, this study establishes a direct relation between the morphology of ruptured plaque and platelet activation in patients with unstable angina. This may allow for further risk stratification. Patients with unstable complex lesions had a fivefold higher expression of the platelet activation epitope CD63 than patients with stable angina. Furthermore, they had 15% more glycoprotein IIb/IIIa aggregation sites expressed on their platelet membrane, thus indicating an intense thrombogenic potential.

Exercise-induced bronchoconstriction does not cause eosinophilic airway inflammation or airway hyperresponsiveness in subjects with asthma

The cysteinyl leukotrienes (LT) C(4), D(4), and E(4) may partially mediate eosinophilic airway inflammation in patients with asthma. High- intensity exercise by patients with asthma can result in exercise- induced bronchoconstriction, partly due to leukotriene production, but it is still debated whether this causes airway inflammation. Ten subjects completed a randomized, controlled study to examine the effects of exercise-induced bronchoconstriction on airway inflammatory cells. Subjects completed exercise challenge and methacholine challenge in random order separated by 1 wk. Spirometry was measured for 2 h after challenges, and airway responsiveness was measured the day before and 24 h after each challenge. Blood and sputum samples were obtained before, and 2, 4, 7, and 24 h after each challenge for measurement of inflammatory cells. Nine of the subjects inhaled allergen at least 3 wk before or 1 wk after the study. Sputum samples were collected before, 7 h, and 24 h after challenge. The maximum percentage fall in FEV(1) was 21.3 +/- 1.5% after exercise, 29.9 +/- 1.5% after methacholine, and 28.9+/-2.7% after allergen. Exercise had no effect on airway responsiveness or inflammatory cells measured in blood or sputum, unlike allergen inhalation, which resulted in significant airway hyperresponsiveness and increases in sputum eosinophils (p < 0.05). This study demonstrates that exercise-induced bronchoconstriction does not cause eosinophilic airway inflammation in subjects with asthma who develop airway inflammation with the same degree of allergen-induced bronchoconstriction. We conclude that exercise-induced bronchoconstriction does not cause airway inflammation or airway hyperresponsiveness.

Effects of once daily dosing with inhaled budesonide on airway hyperresponsiveness and airway inflammation following repeated low-dose allergen challenge in atopic asthmatics

BACKGROUND

Repeated low-dose allergen challenge increases airway hyperresponsiveness and sputum eosinophils in atopic asthmatics. Inhaled corticosteroids attenuate the airway responses to high-dose allergen challenge, but have not been evaluated against repeated low dose challenge.

OBJECTIVE

This study evaluates the effects of once daily treatments of two doses of inhaled budesonide on airway responses to repeated low-dose allergen challenge.

METHODS

Eight atopic asthmatics with a dual airway responses to inhaled allergen were recruited into a randomized, double-blind crossover, placebo-controlled study. In the mornings of four consecutive days (day 1-day 4), subjects inhaled budesonide 100 microg, 400 microg, or placebo, 30 min before inhaling a concentration of allergen causing a 5% early fall in FEV1. Airway hyperresponsiveness to methacholine and sputum eosinophils were measured at baseline, on the afternoon of day 2, day 4, and 24 h after the last challenge. There was a 1-week washout between each of the three treatment periods.

RESULTS

The repeated low-dose allergen challenge induced increases in the percentage sputum eosinophils from 2.0 +/- 0.7% at baseline to 16.6 +/- 7.1% on day 4 (P = 0.002), and this effect was reduced by once daily budesonide 100 microg to 5.6 +/- 1.8% (P = 0. 01) and by once daily budesonide 400 microg to 3.1 +/- 0.9% (P = 0. 004). Also, the allergen-induced methacholine airway hyperresponsiveness which occurred by day 4 (P = 0.03) of the repeated low dose challenge was inhibited by budesonide 400 microg (P = 0.017).

CONCLUSION

Both budesonide 100 microg and 400 microg inhaled once daily significantly reduces allergen-induced sputum eosinophilia after repeated low dose challenge; however, only the higher dose also attenuates the allergen-induced airway hyperresponsiveness.

Healing of spontaneous coronary dissection in the context of glycoprotein IIB/IIIA inhibitor therapy: a case report

Spontaneous coronary artery dissection is a rare cause of myocardial infarction. It is a condition with greater prevalence in young women, particularly in the peripartum or early postpartum period. It also has been described following intense physical exercise. The pathophysiologic characteristics remain unclear. Unlike atherosclerotic intimal dissection, the dissection plane lies within the media or between the media and adventitia. We describe a case of spontaneous coronary artery dissection in a 44-yr old menstruating woman with mitral valve prolapse, who experienced acute myocardial infarction after twisting and throwing a heavy piece of luggage. Coronary angiography showed coronary artery dissection in a left anterior descending coronary artery at the point of its emergence from its intramural course. An intimal plaque with 90-95% obstruction and reduced (TIMI I) flow was demonstrated. The patient was treated with continued glycoprotein IIb/IIIa inhibitor infusion. Angiographic resolution with return of prompt (TIMI III) flow was noted. Optimal management of spontaneous coronary artery dissection has not been established and may vary, depending upon the presence of intimal versus extramural compromise. Coronary artery bypass, stenting, and thrombolysis have been successful and also have failed, owing to extension of dissection. Our patient is the first reported patient to have received tirofiban therapy in the context of spontaneous coronary artery dissection. Medical therapy has been used most often, and angiographic resolution has been documented at 94 days, 7 mo, and 1 yr. We document the earliest case of spontaneous angiographic resolution-within 20 hr.

Protective effects of fluticasone on allergen-induced airway responses and sputum inflammatory markers

BACKGROUND

A direct comparison of the protective effects of single and regular doses of inhaled glucocorticoid on allergen-induced asthmatic responses and inflammation has not been made.

OBJECTIVE

To compare the effects of pretreatment with fluticasone 250 microg 30 min before allergen inhalation and two weeks of 250 microg twice daily (last dose 24 h before challenge) with single and regular (twice daily) placebo doses on early and late asthmatic responses, induced sputum cell counts and measures of eosinophil activation at 7 h and 24 h, and methacholine airway responsiveness at 24 h.

PATIENTS AND METHODS

Ten mild asthmatic patients were studied in a randomized, double-blind, placebo controlled crossover study.

RESULTS

Regular fluticasone increased the baseline mean provocative concentration of methacholine to cause a 20% fall (PC20) in forced expiratory volume in 1 s (FEV1) from 2.6 to 6.4 mg/mL (P<0.05) and lowered the eosinophil count from 3.1% to 0.4% (P<0.05) compared with regular placebo. Neither single nor regular fluticasone had any effect on the early asthmatic response. Single fluticasone attenuated the late asthmatic response, the mean +/- SEM maximum percentage fall in FEV1 (10.8+/-3.6 compared with single placebo 18. 8+/-3.5, P=0.03), the allergen-induced increase of airway responsiveness (P<0.05), and the eosinophilia (P<0.005) and activated eosinophils at 7 h (P<0.01) but not at 24 h. Regular fluticasone also attenuated the late asthmatic response (11.1+/-2.5) compared with regular placebo (19.6+/-4.5), but this was not statistically significant and did not protect against the induced increase in airway responsiveness or the sputum eosinophilia.

CONCLUSION

Two weeks of regular inhaled fluticasone discontinued 24 h before allergen challenge does not offer any additional protection against the early or late asthmatic responses, increased airway responsiveness or sputum eosinophilia compared with a single dose of 250 microg immediately before allergen challenge, despite increasing baseline PC20 and decreasing sputum eosinophilia prechallenge. The significance of the protective effect of a single dose of inhaled steroid before an allergen inhalation and the duration of the protective effect need further investigation.

The occlusal management of maxillary anterior single-unit implant-supported restorations

This paper, with the aid of clinical examples, highlights some of the common occlusal problems that can be associated with maxillary anterior single-unit implant-supported restorations. The authors stress the importance of thorough pre-operative planning to identify any likely occlusal problems. This allows patients to be fully informed of the impact of any necessary clinical compromise and of the need for and nature of modifications to the natural dentition.

Increased numbers of both airway basophils and mast cells in sputum after allergen inhalation challenge of atopic asthmatics

Mast cells and basophils are metachromatic cells that participate in allergic inflammation. Allergen challenge to the airways of atopic asthmatic individuals increases levels of metachromatic cells, which may reflect an increase in mast cells, basophils, or both. We conducted a study to characterize the kinetics of basophil and mast cell recruitment to the airways of atopic asthmatic subjects after allergen inhalation challenge, using monoclonal antibodies specific for each type of cell. Of 19 subjects, 14 developed both early- and late-phase asthmatic responses (dual responders [DRs]), whereas five developed only early asthmatic responses (early responders [ERs]) after allergen inhalation. There was a significant increase in the number of sputum eosinophils (p < 0.002) and basophils (p < 0.002) at 7 h and 24 h after challenge in both ERs and DRs. There was also a significant increase in the number of activated eosinophils (p = 0. 00002) and mast cells (p = 0.009) in sputum at 7 h and 24 h after challenge in DRs, but not in ERs (p > 0.4). DRs had a significantly higher number of allergen-induced sputum basophils than did ERs (p < 0.01), and sputum basophils correlated significantly with airway hyperresponsiveness (AHR) to methacholine at 24 h after challenge (r = 0.66, p = 0.002). DRs tended to have higher allergen-induced basophil levels than did ERs, which may contribute to the observed AHR.

A comparison of the early postoperative care required by patients treated with single and two stage surgical techniques for the provision of Brånemark implant supported mandibular overdentures

Patients who underwent a single stage surgical procedure to place two Brånemark implants to stabilise complete mandibular overdentures with bar attachments, required no more postoperative follow-up visits before definitive prosthesis construction than patients who had their implants placed at two separate surgical stages. However, the visits of the single stage group, occurred over a shorter time-scale and more attention was required to tighten or replace their healing abutments.

Laser scanning of the ear identifying the shape and position in subjects with normal facial symmetry

The objective of the present study was to discover if dimensional measurements of the ear could be determined with a laser scanning technique and whether or not the location of landmarks of the ear could be reliably measured with respect to those on the midline of the face. Computer-generated images were created from laser scans of 20 subjects. Dimensional measurements were made between landmarks on the ear and face. Differences between repeated dimensional measurements of the ear were very small, as were those measurements made between landmarks on the ear to the midline of the face. Differences between dimensions of the left and right ears were observed, but were of a small magnitude. The results suggest that the dimensions of the ear and its position with respect to landmarks in the midline of the face can be reliably measured on normal subjects and that laser scanning is a useful technique for planning and monitoring facial reconstruction of the ear.

Transcript quantitation in total yeast cellular RNA using kinetic PCR

Kinetically monitored, reverse transcriptase-initiated PCR (kinetic RT-PCR, kRT-PCR) is a novel application of kinetic PCR for high throughput transcript quantitation in total cellular RNA. The assay offers the simplicity and flexibility of an enzyme assay with distinct advantages over DNA microarray hybridization and SAGE technologies for certain applications. The reproducibility, sensitivity and accuracy of the kRT-PCR were assessed for yeast transcripts previously quantitated by a variety of methods including SAGE analysis. Changes in transcript levels between different genetic or physiological cell states were reproducibly quantitated with an accuracy of +/-20%. The assay was sufficiently sensitive to quantitate yeast transcripts over a range of more than five orders of magnitude, including low abundance transcripts encoding cell cycle and transcriptional regulators.

Kinetics of allergen-induced airway eosinophilic cytokine production and airway inflammation

Airway eosinophilia is the hallmark of asthma exacerbation. Coordination of cytokines such as interleukin (IL)-5, eotaxin and regulated on activation, normal T-cell expressed and secreted (RANTES) seem to be necessary for eosinophil extravasation including adhesion, chemotaxis, and activation. The purpose of this study was to characterize both the kinetics of allergen-induced inflammatory cell recruitment to the airways and cytokines selective for eosinophil chemotaxis, activation, or resolution. Eight atopic asthmatic individuals demonstrating a dual response to inhaled allergen completed a diluent-controlled crossover study. The subjects showed significant allergen-induced early and late airway asthmatic responses (p < 0.001), and an increase in the number of sputum eosinophils and metachromatic cells (p < 0.05). The number of eosinophils immunopositive for IL-5, eotaxin, and RANTES increased 7 h after allergen inhalation (p < 0.05), coincident with the peak number of activated eosinophils. Sputum cells immunopositive for IL-10 decreased significantly following allergen challenge (p = 0. 04), and correlated negatively with sputum eosinophils (r = -0.34, p = 0.02). This study shows that allergen-induced increases in sputum eosinophils are associated with the presence of cytokines specific for the activation and chemotaxis of eosinophils, and suggests that cooperation of eosinophilic cytokines may be important for the accumulation and regulation of activated eosinophils at the site of allergic inflammation.

Repeatability of allergen-induced airway inflammation

BACKGROUND

Allergen inhalation challenge is a useful clinical model to investigate the effects of asthma therapies on allergen-induced airway responses; however, the repeatability of allergen-induced airway inflammation is not known.

OBJECTIVE

The purpose of this study was to investigate the repeatability of allergen-induced increases in sputum eosinophils. This information will allow the prediction of the number of subjects required in studies evaluating asthma therapies.

METHODS

Seventeen subjects completed 2 allergen challenges using the same dose of allergen, at least 3 weeks apart. Allergen-induced airway responses were measured for 7 hours after challenge. Differential cell counts from induced sputum were determined the day before and 7 and 24 hours after challenge; methacholine PC20 was measured the day before and 24 hours after challenge.

RESULTS

The intraclass correlation coefficient for maximum percent late fall in FEV1 was 0.32 and for the area of the late response was 0.61. The sample size predicted to be necessary to observe 50% attenuation of the maximum percent late fall in FEV1 and the late area under the curve with a power of 0.95 was 9 subjects. The intraclass correlation coefficient for percent of allergen-induced sputum eosinophils was 0.60 at 7 hours and 0.53 at 24 hours after challenge. With a randomized cross-over study design, the sample size predicted to be necessary to observe 50% attenuation of allergen-induced percent of eosinophils with a power of 0.95 was 5 subjects.

CONCLUSION

Allergen inhalation challenge with measurements of sputum eosinophils is a noninvasive and reliable method for evaluating the anti-inflammatory effects of asthma therapies.

An inhaled corticosteroid, budesonide, reduces baseline but not allergen-induced increases in bone marrow inflammatory cell progenitors in asthmatic subjects

We have previously shown that allergen inhalation by asthmatics is associated with increases in bone marrow eosinophil/basophil colony-forming cells (Eo/B-CFU), and increases in CD34(+) hemopoietic progenitors expressing the alpha-subunit of the IL-5 receptor (IL-5Ralpha). This study investigated the effect of inhaled corticosteroid on baseline numbers and allergen-induced increases in these parameters. Nine subjects with mild, stable asthma inhaled budesonide (400 microgram/d) for 8 d in a placebo-controlled, double-blind, randomized crossover study. On Day 7, subjects inhaled allergen, with bone marrow sampling before and 24 h after challenge. Budesonide inhalation significantly attenuated the allergen-induced early and late asthmatic responses, degree of increase in sputum and blood eosinophils, as well as the baseline numbers of total bone marrow CD34(+) cells (p < 0.05), CD34(+)IL-3Ralpha+ cells (p < 0.01) and IL-5-responsive Eo/B-CFU (p < 0.05). Allergen inhalation significantly increased Eo/B-CFU grown in the presence of IL-3, GM-CSF, or IL-5 alone (p < 0.05) and in combination (p < 0.01), as well as the number of CD34(+)IL-5Ralpha+ cells (p < 0.01). However, these increases in Eo/B-CFU and CD34(+)IL-5Ralpha+ cells were not affected by budesonide treatment. These data demonstrate that short-term inhaled budesonide treatment has a systemic effect in inhibiting the turnover of a subpopulation of bone-marrow-derived progenitors, but that inhalation of allergen overcomes this inhibitory effect.

Effect of inhaled leukotriene D4 on airway eosinophilia and airway hyperresponsiveness in asthmatic subjects

Inhaled cysteinyl leukotrienes may cause recruitment of eosinophils into asthmatic airways. We compared the effects of inhaled leukotriene D4 (LTD4), methacholine, and allergen on airway eosinophils in 10 nonsmoking, atopic, mildly asthmatic subjects in a double-blind, diluent-controlled, randomized crossover study. Concentrations of LTD4, methacholine, and allergen resulting in a 30% decrease in FEV1, and diluent controls (ethanol and saline), were inhaled with at least 7 d between challenges. Spirometry was conducted for 4 h after inhalation challenge, and airway hyperresponsiveness (AHR) to methacholine was measured before and 24 h after challenge. Sputum was induced before and 4 h, 7 h, and 24 h after challenge. The maximum decrease in FEV1 was 31.4 +/- 1.8% with LTD4, 39.4 +/- 2.8% with methacholine, and 30.1 +/- 3.4% with allergen. AHR to methacholine, at the provocative concentration causing a 20% decrease in FEV1 (PC20), was enhanced 24 h after allergen challenge, but remained unchanged 24 h after LTD4 and methacholine (p > 0.05). The percentage of eosinophils in sputum was increased after inhalation of allergen at 7 h and 24 h (p = 0.003), but not after LTD4 or methacholine (p = 0.70). We demonstrated that neither inhalation of LTD4 nor of methacholine at concentrations causing submaximal bronchoconstriction increases the number of sputum eosinophils in the airways of mildly asthmatic subjects. However, LTD4 may still be an important cofactor for eosinophil recruitment in asthma.

Protective effects of inhaled PGE2 on allergen-induced airway responses and airway inflammation

Inhalation of prostaglandin E2 (PGE2) had been reported to prevent allergen-induced bronchoconstrictor responses; however, the effects of inhaled PGE2 on allergen-induced airway inflammation or hyperresponsiveness after allergen are unknown. This study examined the effects of inhaled PGE2 on allergen-induced airway responses and inflammation. Eight mild asthmatics with a dual airway response to inhaled allergen were recruited into a double-blind randomized crossover study comparing the effects of inhaled PGE2 (100 microgram) or placebo, on allergen-induced changes in FEV1 measured for 7 h, induced sputum inflammatory cells, obtained at baseline, 7 and 24 h, and methacholine airway responsiveness measured at 24 h after challenge. Inhaled PGE2 attenuated the allergen-induced early fall in FEV1 from 24.4 +/- 3.6% after placebo to 10.3 +/- 2.5% after PGE2 (p = 0.002), the late fall in FEV1 from 21.2 +/- 2.7% after placebo to 12.6 +/- 3.6% after PGE2 (p = 0.03), allergen-induced methacholine airway hyperresponsiveness (p = 0.03) and allergen-induced increases in percent sputum eosinophils from 36.3 +/- 8.8% after placebo to 21.0 +/- 7.3% after PGE2 (p = 0.01), percentage of EG2+ cells (p = 0.02), and percentage of metachromatic cells (p = 0.02). These results indicate that inhaled PGE2 attenuates allergen-induced airway responses, hyperresponsiveness, and inflammation, when given immediately before inhaled allergen.

Fabrication of a wax ear by rapid-process modeling using stereolithography

PURPOSE

The purpose of this article is to describe an automated technique that creates a mirror-image wax model of the contralateral ear using a rapid prototyping technique, which allows precise positioning and adaptation to the deficient side of the face.

MATERIALS AND METHODS

Magnetic resonance images (MRI) are taken of the face and then digitized and reformatted into a 3-dimensional image. The image of the normal ear is extracted, mirrored, and positioned onto the image of the deformed side of the face. The digitized data, when used in conjunction with stereolithography, produces a photopolymerized resin model ear. A model wax ear is created by pouring molten wax into a silicone mold of the resin model ear.

RESULTS

A model wax ear of identical dimensions, shape, and internal contouring as the contralateral normal ear is created. The technique allows the undersurface of the model wax ear to be precisely positioned against the surface contours of the deformed side of the face in 1 patient.

CONCLUSION

The use of stereolithography from MRI scan data is a suitable technique for producing a model wax ear that fits the deformed side of the face. The 3-dimensional computer image of the face may also be used to plan the position (level and protrusion) of the ear.

Pranlukast, a cysteinyl leukotriene receptor antagonist, attenuates allergen-induced early- and late-phase bronchoconstriction and airway hyperresponsiveness in asthmatic subjects

BACKGROUND

The cysteinyl leukotrienes (cysLTs) have been implicated in the pathogenesis of allergen-induced airway responses. The purpose of this study was to evaluate the effects of pretreatment with the cysLT receptor antagonist pranlukast on allergen-induced early asthmatic responses (EARs) and late asthmatic responses (LARs) and on allergen-induced airway hyperresponsiveness (AHR).

METHODS

Ten atopic, nonsmoking patients with mild asthma and previously demonstrated early- and late-phase allergen-induced asthmatic responses participated in a double-blind, placebo-controlled, cross-over study, comparing treatment with either 450 mg pranlukast given twice daily or placebo for 5.5 days. A methacholine challenge was performed before administration of medication, and the result was expressed as the PC20. An allergen inhalation challenge was performed on the morning of the fifth day of treatment 2 hours after administration of medication. Methacholine challenges were also performed 2 hours after medication on days 4 and 6 (24 hours before and 24 hours after allergen administration) to examine allergen-induced AHR.

RESULTS

Pranlukast attenuated allergen-induced early responses, late responses, and AHR. The mean (SEM) maximal percent fall in FEV1 from baseline during the early response was 30.0% (5.1%) during placebo treatment and 15.5% (3.5%) during pranlukast treatment (mean difference, 14.5%; 95% confidence interval [CI], 5.3 to 23.7; P = .007), with a mean protection afforded by pranlukast of 48.3%. The mean maximal percent fall in FEV1 during the late response was 34.7% (5.3%) during placebo treatment and 24.0% (4.4%) during pranlukast treatment (mean difference, 10.7%; 95% CI, 4.1 to 17.3; P = .006), with a mean protection afforded by pranlukast of 30.8%. The mean allergen-induced shift in PC20 was -1.76 (0.32) doubling doses during placebo treatment and -0.38 (0.31) doubling doses during pranlukast treatment (mean difference, -1.38 doubling doses; 95% CI, 0.44 to 2.32; P = .012), with a mean protection afforded by pranlukast of 78.4%.

CONCLUSION

These results demonstrate that pranlukast can attenuate allergen-induced early and late airways responses and AHR and adds further support for an important role for the cysLTs in mediating allergen-induced asthmatic responses.

Enhanced expression of GM-CSF in differentiating eosinophils of atopic and atopic asthmatic subjects

Higher numbers of eosinophil/basophil colony-forming units (Eo/B CFU) are observed in blood of atopic individuals, and can be enhanced in atopic asthmatics by allergen-inhalation challenge. It is known that mature basophils and eosinophils synthesize cytokines relevant to allergic inflammation. To investigate the potential role of growth factors in allergic disease we examined the expression of the hemopoietic cytokines, granulocyte-macrophage colony-stimulating factor (GM-CSF) and interleukin (IL)-5, in differentiating Eo/B colony cells from normal and atopic individuals, and from atopic asthmatics before and after allergen-inhalation challenge. Peripheral blood was collected from two normal and 12 atopic individuals, and also from 25 atopic asthmatics before and 24 h after allergen challenge. Nonadherent mononuclear cells were isolated and grown in semisolid growth medium. Eo/B colonies were selected and cytospins were prepared for immunocytochemical analysis of colony cells. Eo/B colonies, especially carbol chromotrope 2R+ cells, selected at Days 10, 14, and 18 from atopic donors contained messenger RNA for GM-CSF by combined in situ reverse transcription-polymerase chain reaction and cytochemistry, and demonstrated time-dependent expression of GM-CSF by immunocytochemistry (P = 0.007). Atopic individuals demonstrated a higher percentage of cells expressing GM-CSF than did normal subjects under all growth conditions when examined at Day 14 (P = 0. 04). Atopic asthmatics challenged with inhaled allergen who demonstrated a dual airway response, an increase in the number of blood eosinophils (P = 0.0001), and an increase in the number of Eo/B CFU (P = 0.02) also demonstrated a significant increase in the percentage of colony cells expressing immunostainable GM-CSF (P = 0. 0009), but only a variable effect on those expressing IL-5, 24 h after allergen. These results suggest that GM-CSF expression by differentiating Eo/Bs may provide an additional stimulus in vivo to enhance Eo/B progenitor differentiation in atopic and asthmatic individuals, especially after allergen challenge. The concept of microenvironmental differentiation, where blood progenitor cells may aid in their own differentiation, is supported by these ex vivo findings.

The utility of methacholine airway responsiveness measurements in evaluating anti-asthma drugs

BACKGROUND

Measurements of airway responsiveness are frequently used to evaluate anti-asthma drugs.

OBJECTIVE

This study investigated the utility of methacholine airway responsiveness measurements in evaluating anti-asthma medications, both in terms of a bronchoprotective effect and the ability to attenuate allergen-induced methacholine airway hyperresponsiveness.

METHODS

Methacholine airway responsiveness was measured as PC20 on two occasions (separated by 35+/-17 days, mean +/- SD) in 40 subjects with mild, stable asthma. Additional subjects had PC20 measurements made before and after administration of either inhaled salbutamol (200 microg) (n = 20) or allergen inhalation challenge (n = 31).

RESULTS

The reproducibility of the methacholine PC20 with this method was high (intraclass correlation coefficient = 0.94). The average shift in PC20 after salbutamol was 4.11 doubling concentrations (SD = 1.08). On the basis of these results, a sample size of 12 subjects would be required to demonstrate a 1 doubling concentration difference in the bronchoprotective effect of two drugs with a 90% power. The average shift in PC20 after allergen was 1.29 doubling concentrations. On the basis of these results and an estimated SD of 0.96, a sample size of 24 subjects would be required to demonstrate that a drug is effective in attenuating 50% of allergen-induced airway hyperresponsiveness with a 90% power.

CONCLUSION

These results confirm the high reproducibility of methacholine PC20 measurements in subjects with mild, stable asthma and demonstrate its utility in evaluating the effects of anti-asthma drugs.

Changes in bone marrow inflammatory cell progenitors after inhaled allergen in asthmatic subjects

Increases in inflammatory cell progenitors, particularly eosinophil/basophil colony-forming cells (Eo/B-CFU), occur in peripheral blood after allergen provocation. The role of bone marrow (BM) in these reactions is unclear. We examined the effect of allergen challenge on human bone marrow progenitor cell growth. Fifteen asthmatic subjects, eight dual responders (DR) and seven isolated early responders (IER), were challenged with inhaled allergen. BM aspirates were taken before and 24 h after challenge and progenitors were enumerated by a colony-forming assay. Eo/B-CFU numbers increased in both groups after allergen challenge (p < 0.0001). For DR, the increases were significant for BM incubated with optimal GMCSF and IL-5, but not with IL-3. For IER, the increases were significant for all three cytokines tested. At a suboptimal concentration of IL-5, there was a significant increase in the number of Eo/B-CFU after allergen in the DR, from 5.25 +/- 1.2 to 9.68 +/- 2.1 per 2.5 x 10(5) cells plated (p < 0.01), which was not demonstrated in the IER (p = 0.94). The responses at this concentration of IL-5 were different between groups (p < 0.05). These results demonstrate that inhaled allergen increases BM Eo/B-CFU, and that the bone marrow of dual responders is more responsive to IL-5 after allergen.

Effect of prefabricated bar design with implant-stabilized prostheses on ridge resorption: a clinical report

This investigation was concerned with the resorption of the posterior mandibular residual ridge in patients wearing mandibular overdentures supported by either parallel-sided bars (rigid joint) or oval straight bars (resilient joint) on two activated implants. Rotational tomographs were taken shortly after implant placement and up to 8 years later. Using proportional measurement, the area of residual ridge was measured in bilateral posterior areas. Patients rehabilitated with implant-stabilized mandibular overdentures demonstrated posterior mandibular residual ridge resorption at low rates, which were not significantly influenced by the design of the prefabricated bar.

The role of removable prostheses and implants in the restoration of the worn dentition

A variety of removable prostheses is available to restore the dentition which exhibits wear and extensive loss of teeth from the arch. Such treatment may be either interceptive or transitional in order to stabilise the occlusion or definitive as part of rehabilitation. Tooth surface loss may necessitate crowning with the provision of conventional removable partial dentures or decoronation and the use of overdentures. Extensive loading generated by parafunction is often considered to risk the failure of restorations stabilised by implants and so may contra-indicate treatment. Screening out unsuitable cases appears to result in few incidents of implant failure and new designs may further reduce the risk.

Effect of regular inhaled albuterol on allergen-induced late responses and sputum eosinophils in asthmatic subjects

Treatment with inhaled beta(2)-agonists immediately before allergen inhalation inhibits allergen-induced early, but not late asthmatic responses (LAR). By contrast, 2 wk treatment with inhaled albuterol increases airway responses to inhaled allergen. We examined the effects of regular albuterol treatment on allergen-induced increases in inflammatory cells in blood and induced sputum. Ten mild, stable allergic asthmatics inhaled albuterol (800 micrograms/day) or placebo for 7 d in a controlled, randomized, double-blind, crossover study. Allergen inhalation was performed 12 h after the final dose. Methacholine airway responsiveness and blood samples were analyzed before and 24 h after, and induced sputum was obtained before, 7 h and 24 h after allergen. Allergen significantly reduced methacholine PC20, increased blood eosinophil numbers, and numbers of sputum neutrophils, EG2 positive and metachromatic cells (p < 0.05), without significant differences between treatments. Albuterol treatment significantly increased the LAR compared to placebo treatment (p = 0.003) and significantly enhanced the number of sputum eosinophils (p = 0.009) and sputum ECP (p = 0.04) at 7 h but not 24 h post-allergen (p > 0.05). We conclude that regular use of inhaled albuterol significantly increases the LAR to inhaled allergen, in association with an increase in the number of sputum eosinophils and the release of ECP, suggesting albuterol increases the late response by increasing eosinophil influx into the airways.

Replacement of successful fixed implant prostheses using duplication techniques

Replication of desirable design features of an existing implant prosthesis is often appropriate in the construction of a replacement that produces the same spatial relationship to the supporting dental implants. An adaptation of a laboratory copy technique used in conventional complete denture prosthodontics is described. A silicone putty mold that enables the creation of the corresponding fit surface, polished surface, and arch form is used for making a transitional or a definitive complete or partial fixed implant prosthesis. Variations using a basic replication technique are appropriate in clinical practice for refabricating a prosthesis of a preferred design. The procedure is suitable for both acrylic resin-metal or metal ceramic restorations.