Loss of ARF/INK4A Promotes Liver Progenitor Cell Transformation Toward Tumorigenicity Supporting Their Role in Hepatocarcinogenesis

Liver progenitor cells (LPCs) contribute to liver regeneration during chronic damage and are implicated as cells of origin for liver cancers including hepatocellular carcinoma (HCC). The CDKN2A locus, which encodes the tumor suppressors alternate reading frame protein (ARF) and INK4A, was identified as one of the most frequently altered genes in HCC. This study demonstrates that inactivation of CDKN2A enhances tumorigenic transformation of LPCs. The level of ARF and INK4A expression was determined in a panel of transformed and nontransformed wild-type LPC lines. Moreover, the transforming potential of LPCs with inactivated CDKN2A was shown to be enhanced in LPCs derived from Arf^-/- and CDKN2A^fl/fl mice and in wild-type LPCs following CRISPR-Cas9 suppression of CDKN2A. ARF and INK4A abundance is consistently reduced or ablated following LPC transformation. Arf^-/- and CDKN2A^-/- LPCs displayed hallmarks of transformation such as anchorage-independent and more rapid growth than control LPC lines with unaltered CDKN2A. Transformation was not immediate, suggesting that the loss of CDKN2A alone is insufficient. Further analysis revealed decreased p21 expression as well as reduced epithelial markers and increased mesenchymal markers, indicative of epithelial-to-mesenchymal transition, following inactivation of the CDKN2A gene were required for tumorigenic transformation. Loss of ARF and INK4A enhances the propensity of LPCs to undergo a tumorigenic transformation. As LPCs represent a cancer stem cell candidate, identifying CDKN2A as a driver of LPC transformation highlights ARF and INK4A as viable prognostic markers and therapeutic targets for HCC.

Splice variant insertions in the C-terminus impairs YAP's transactivation domain

The yes-associated protein (YAP) is a key effector of the mammalian Hippo signaling pathway. YAP has eight known alternately spliced isoforms and these are widely expressed across multiple tissues. Variable effects have been ascribed to different YAP isoforms by inducing their expression in cells, but whether these differences are due to variability in the transcriptional potency of individual YAP isoforms has not been addressed. Indeed a systematic comparison of the transcriptional potencies of YAP isoforms has not been done. To address this, using overexpression and transcriptional reporter analyses we investigated the transcriptional activities of several human YAP isoforms and determined the effects of the splice variant insertions within the transactivation domain on its transcriptional potency. Utilising full-length coding sequence constructs we determined that the number of WW domains and disruption of the leucine zipper motif within YAP’s transactivation domain both contribute to transcriptional activity. Notably, disruption of YAP’s leucine zipper had a greater effect on transcriptional activity than the absence of the second WW domain. Using GAL4-YAP transcriptional activation domain fusion proteins we found that disruption of the leucine zipper significantly decreased YAP’s transcriptional activity in several cell lines. Our data indicates that expression of different YAP isoforms with varying transcriptional potencies may enable fine control of Hippo pathway signaling. Furthermore the specific isoform being utilised should be taken into consideration when interpreting published data or when designing experiments to ascribe YAP’s function.

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Transcriptional activities of yes-associated protein (YAP) isoforms were compared.

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YAP’s WW domains and leucine zipper motif both contribute to transcriptional activity.

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Absence of YAP’s second WW domain weakens transcriptional potency.

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Disruption of YAP’s leucine zipper weakens the transactivation domain (TAD).

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Potency of the TAD from YAP α, β, γ, δ isoforms is cell-context dependent.

A modified choline-deficient, ethionine-supplemented diet reduces morbidity and retains a liver progenitor cell response in mice

The choline-deficient, ethionine-supplemented (CDE) dietary model induces chronic liver damage, and stimulates liver progenitor cell (LPC)-mediated repair. Long-term CDE administration leads to hepatocellular carcinoma in rodents and lineage-tracing studies show that LPCs differentiate into functional hepatocytes in this model. The CDE diet was first modified for mice by our laboratory by separately administering choline-deficient chow and ethionine in the drinking water (CD+E diet). Although this CD+E diet is widely used, concerns with variability in weight loss, morbidity, mortality and LPC response have been raised by researchers who have adopted this model. We propose that these inconsistencies are due to differential consumption of chow and ethionine in the drinking water, and that incorporating ethionine in the choline-deficient chow, and altering the strength, will achieve better outcomes. Therefore, C57Bl/6 mice, 5 and 6 weeks of age, were fed an all-inclusive CDE diet of various strengths (67% to 100%) for 3 weeks. The LPC response was quantitated and cell lines were derived. We found that animal survival, LPC response and liver damage are correlated with CDE diet strength. The 67% and 75% CDE diet administered to mice older than 5 weeks and greater than 18 g provides a consistent and acceptable level of animal welfare and induces a substantial LPC response, permitting their isolation and establishment of cell lines. This study shows that an all-inclusive CDE diet for mice reproducibly induces an LPC response conducive to in vivo studies and isolation, whilst minimizing morbidity and mortality.

Summary: This modified choline-deficient, ethionine-supplemented model induces liver injury in mice and reproducibly minimizes morbidity and mortality, whilst maintaining a liver-progenitor-cell response sufficient for cell-line establishment.

TAZ Protein Accumulation Is Negatively Regulated by YAP Abundance in Mammalian Cells

The mammalian Hippo signaling pathway regulates cell growth and survival and is frequently dysregulated in cancer. YAP and TAZ are transcriptional coactivators that function as effectors of this signaling pathway. Aberrant YAP and TAZ activity is reported in several human cancers, and normally the expression and nuclear localization of these proteins is tightly regulated. We sought to establish whether a direct relationship exists between YAP and TAZ. Using knockdown and overexpression experiments we show YAP inversely regulates the abundance of TAZ protein by proteasomal degradation. Interestingly this phenomenon was uni-directional since TAZ expression did not affect YAP abundance. Structure/function analyses suggest that YAP-induced TAZ degradation is a consequence of YAP-targeted gene transcription involving TEAD factors. Subsequent investigation of known regulators of TAZ degradation using specific inhibitors revealed a role for heat shock protein 90 and glycogen synthase kinase 3 but not casein kinase 1 nor LATS in YAP-mediated TAZ loss. Importantly, this phenomenon is conserved from mouse to human; however, interestingly, different YAP isoforms varied in their ability to degrade TAZ. Since shRNA-mediated TAZ depletion in HeLa and D645 cells caused apoptotic cell death, we propose that isoform-specific YAP-mediated TAZ degradation may contribute to the contradicting roles reported for YAP overexpression. This study identifies a novel mechanism of TAZ regulation by YAP, which has significant implications for our understanding of Hippo pathway regulation, YAP-isoform specific signaling, and the role of these proteins in cell proliferation, apoptosis, and tumorigenesis.

Sub-cellular localisation studies may spuriously detect the Yes-associated protein, YAP, in nucleoli leading to potentially invalid conclusions of its function

The Yes-associated protein (YAP) is a potent transcriptional co-activator that functions as a nuclear effector of the Hippo signaling pathway. YAP is oncogenic and its activity is linked to its cellular abundance and nuclear localisation. Activation of the Hippo pathway restricts YAP nuclear entry via its phosphorylation by Lats kinases and consequent cytoplasmic retention bound to 14-3-3 proteins. We examined YAP expression in liver progenitor cells (LPCs) and surprisingly found that transformed LPCs did not show an increase in YAP abundance compared to the non-transformed LPCs from which they were derived. We then sought to ascertain whether nuclear YAP was more abundant in transformed LPCs. We used an antibody that we confirmed was specific for YAP by immunoblotting to determine YAP’s sub-cellular localisation by immunofluorescence. This antibody showed diffuse staining for YAP within the cytosol and nuclei, but, noticeably, it showed intense staining of the nucleoli of LPCs. This staining was non-specific, as shRNA treatment of cells abolished YAP expression to undetectable levels by Western blot yet the nucleolar staining remained. Similar spurious YAP nucleolar staining was also seen in mouse embryonic fibroblasts and mouse liver tissue, indicating that this antibody is unsuitable for immunological applications to determine YAP sub-cellular localisation in mouse cells or tissues. Interestingly nucleolar staining was not evident in D645 cells suggesting the antibody may be suitable for use in human cells. Given the large body of published work on YAP in recent years, many of which utilise this antibody, this study raises concerns regarding its use for determining sub-cellular localisation. From a broader perspective, it serves as a timely reminder of the need to perform appropriate controls to ensure the validity of published data.

Study of tuberculosis and AIDS stigma as barriers to tuberculosis treatment adherence using validated stigma scales

BACKGROUND

Adherence to tuberculosis (TB) treatment is important for TB control. The effect of stigma on adherence has not been well quantified.

OBJECTIVE

To identify the effects of TB and acquired immune-deficiency syndrome (AIDS) stigma on missed doses during TB treatment.

DESIGN

Validated TB and AIDS stigma scales assessing perceived and experienced/felt stigma were administered in a prospective cohort of 459 TB patients at TB treatment initiation and after 2 months. Repeated measures and multivariable models estimated the effects of stigma on the rate of missed doses.

RESULTS

Fifty-six per cent of patients missed no doses, and associations between stigma and missed doses were minimal. Heterogeneity of effects was observed, how- ever, with higher experienced and felt TB stigma increasing missed doses among women (adjusted RR 1.22, 95%CI 1.10-1.34) and human immunodeficiency virus (HIV) co-infected patients (aRR 1.39, 95%CI 1.13-1.72). Experienced and felt AIDS stigma also increased missed doses among HIV co-infected patients (aRR 1.43, 95%CI 1.31-1.56).

CONCLUSION

Stigma has a minimal effect in this population with good adherence. Among women and HIV co-infected patients, however, experienced and felt stigma, and not perceived stigma, increased the rate of missed doses. Further research is needed to determine if stigma or coping interventions among these subgroups would improve adherence.

Tuberculosis and AIDS stigma among patients who delay seeking care for tuberculosis symptoms

BACKGROUND

Delay in presentation to a health facility is an important concern for tuberculosis (TB) control. The effect of stigma on delay in seeking care for TB symptoms is not well studied, especially in the context of the human immunodeficiency virus (HIV) co-epidemic.

OBJECTIVE

To estimate the association of TB and acquired immune-deficiency syndrome (AIDS) stigma on delay in seeking care for TB symptoms.

METHODS

For 480 newly diagnosed patients with TB, time from first TB symptom to the first visit to a qualified provider was calculated. Stigma scales were administered to each patient to obtain a stigma score.

RESULTS

Among men, those with higher TB stigma had a small increase in delay times, while women had a small decrease in delay. Among patients presenting with hemoptysis, higher TB stigma was associated with a small increase in delay, while among patients presenting with fever or extra-pulmonary symptoms only, higher TB and AIDS stigma resulted in shorter delay times.

CONCLUSION

In a population with a relatively short median delay (26 days), the impact of TB and AIDS stigma translates into a minimal change in delay time. This suggests that stigma does not have a clinically relevant effect on TB patient delay in southern Thailand.

What is community? An evidence-based definition for participatory public health

Increased emphasis on community collaboration indicates the need for consensus regarding the definition of community within public health. This study examined whether members of diverse US communities described community in similar ways. To identify strategies to support community collaboration in HIV vaccine trials, qualitative interviews were conducted with 25 African Americans in Durham, NC; 26 gay men in San Francisco, Calif; 25 injection drug users in Philadelphia, Pa; and 42 HIV vaccine researchers across the United States. Verbatim responses to the question "What does the word community mean to you?" were analyzed. Cluster analysis was used to identify similarities in the way community was described. A common definition of community emerged as a group of people with diverse characteristics who are linked by social ties, share common perspectives, and engage in joint action in geographical locations or settings. The participants differed in the emphasis they placed on particular elements of the definition. Community was defined similarly but experienced differently by people with diverse backgrounds. These results parallel similar social science findings and confirm the viability of a common definition for participatory public health.

The role of community advisory boards: involving communities in the informed consent process

Ethical research involving human subjects mandates that individual informed consent be obtained from research participants or from surrogates when participants are not able to consent for themselves. The existing requirements for informed consent assume that all study participants have personal autonomy; fully comprehend the purpose, risks, and benefits of the research; and volunteer for projects that disclose all relevant information. Yet contemporary examples of lapses in the individual informed consent process have been reported. The authors propose the use of community advisory boards, which can facilitate research by providing advice about the informed consent process and the design and implementation of research protocols. These activities could help reduce the number of individual informed consent lapses, benefiting study participants and the scientific integrity of the research in question.

Developing a behavior rating scale for comparing teachers' ratings of children with and without craniofacial anomalies

OBJECTIVE

Published psychometric tools are often insensitive to the experience of children with craniofacial anomalies (CFAs). The purposes of this study were to develop a valid and reliable assessment of behavior among children with and without CFAs and to compare teacher ratings of these two groups of children.

METHODS

Teachers were asked prospectively to assess social competence and peer acceptance among 99 consecutively evaluated school-aged patients with CFAs and 99 "controls" (classmates without CFA matched by race, gender, intellectual status, general socioeconomic status, and grade). Sixth grade was the median grade of the subjects.

OUTCOME MEASURE

Child Behavior Rating Scale (CBRS).

RESULTS

Using oblique promax rotation, four factors emerged from the CBRS with the CFA patient group and controls. The factors explained 67% of the total variance and 69% of the variance of the two groups, respectively. The four factors were: (1) self-maintenance, (2) social adjustment, (3) independence, and (4) teasing. Cronbach alpha results averaged 0.77 for the CFA group and 0.83 for the controls; test-retest reliability estimates were .93. Results demonstrate the consistency of the factors and high level of interrelationship among the items across subject groups. Expected differences (p <.05) were found among subject groups on the total score and factor 4.

CONCLUSIONS

The CBRS demonstrates psychometric worthiness. The findings indicated that patients with CFA had lower total scores on the CBRS, and they were rated as experiencing more teasing than their matched peers.

"Only skin deep": health, resilience, and craniofacial care

The literature on psychological and social responses to cleft palate and craniofacial conditions focuses on the challenges and limitations posed by biological factors, cognitive status, and social stigma. In spite of the various challenges experienced by persons with these conditions, many individuals have rich and satisfying lives. This paper develops a theoretical perspective to elucidate factors that account for health, life success, and resiliency in persons with craniofacial conditions. Three steps are proposed to change how craniofacial conditions are envisioned by clinicians and researchers: (1) creating optimism and positivity around the time of birth and diagnosis, (2) asking children and parents new and different questions, and (3) launching a new craniofacial social science model for research built around understanding resilience and health.

Willingness to volunteer in future preventive HIV vaccine trials: issues and perspectives from three U.S. communities

This study examined perceived risks, benefits, and desired information related to willingness to volunteer in preventive HIV vaccine trials.

SAMPLE

Purposive sampling was used to select 90 participants among injecting drug users (Philadelphia, PA, U.S.A.); gay men (San Francisco, CA, U.S.A.); and black Americans (Durham, NC, U.S.A.).

METHODS

A qualitative interview guide elicited perceived benefits, risks, and desired information relating to trial participation. Themes were developed from the transcribed texts and from freelists.

RESULTS

Stated willingness to volunteer in a preventive HIV vaccine trial was similar across the three communities. Eight perceived benefits were reported, including self-benefits, altruism, and stopping the spread of AIDS. Seven perceived risks were reported, including negative side effects and vaccine safety issues, contracting HIV from the vaccine, and social stigmatization. Participants voiced the desire for eight types of information about issues relating to trust and confidentiality in the research process, health complications and later assistance, and vaccine trial methodology.

CONCLUSIONS

In this study, many benefits as well as risks of preventive HIV vaccine trial participation were cited. Scientists conducting preventive HIV vaccine trials need to address community perceptions of risks and provide information about the research if trial enrollment is to be diverse and successful.

Factors affecting African-American participation in AIDS research

BACKGROUND

Although African Americans are disproportionately affected by the AIDS epidemic, they are underrepresented in AIDS research, particularly in AIDS clinical trials. This study examines a multidimensional construct of distrust and other factors that may affect willingness to participate in AIDS research.

METHODS

A total of 301 African Americans (aged >/=18 years) in Durham, North Carolina participated in a cross-sectional survey. In-person interviews, 20 to 25 minutes in length, were conducted with participants. Structural equation modeling was used to develop models exploring distrust and other factors affecting willingness to participate in AIDS research among African Americans.

RESULTS

Distrust was the strongest inverse predictor of willingness to participate in AIDS clinical trials. Distrust was not significantly associated with willingness to participate in AIDS surveys and educational interventions. Altruism, facilitators/barriers, religiosity, and economic group membership were also significantly associated with willingness to participate in AIDS clinical trials. Only altruism was significantly associated with willingness to participate in AIDS surveys and educational interventions.

CONCLUSIONS

Distrust about research institutions is a significant barrier to recruiting African Americans in AIDS clinical trials. Issues of distrust need to be acknowledged by researchers to develop better recruitment and retention strategies when conducting AIDS clinical trials in African-American communities.

Factors associated with periodontitis in an HIV-infected southeast USA study

OBJECTIVES

To determine the relationship of immunosuppression with measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL) in an HIV-infected population from North Carolina (NC), a state in the southeastern United States (USA).

DESIGN

Cross-sectional study of HIV-infected adults (n = 326) treated at the University of North Carolina Hospitals. Clinical medical record review and sociodemographic interview data were collected. Median age of study participants was 37 years (range 19-67). Males comprised 78% and Blacks 60%. Analyses were limited to those who were dentate (n = 316).

MAIN OUTCOME MEASURES

Main outcomes were cases vs non-cases of notable PPD, REC, and CAL. Immunosuppression measured by CD4+ cell count microL was the exposure of interest.

RESULTS

Defined cases of PPD (n = 148) were 2.6 (95% CI = 1.3, 5.3) times less likely to occur at CD4+ cells < 200 than non-cases, whereas, cases of REC (n = 94) were 2.8 (95% CI = 1.2, 6.6) times more likely to occur at that level of severe immunosuppression, controlling for confounders.

CONCLUSION

Sub-groups of persons with HIV experience a high burden of periodontitis where notable severity and extent of PPD, CAL, and REC were clearly evident at different stages of immunosuppression.

Maternal cigarette smoking during pregnancy and risk of oral clefts in newborns

The results of previous epidemiologic research on the possible association between maternal smoking during pregnancy and risk of oral clefts in offspring have been inconsistent. This may be due in part to methodological limitations, including imprecise measurement of tobacco use, failure to consider etiologic heterogeneity among types of oral clefts, and confounding. This analysis, based on a large case-control study, further evaluated the effect of first trimester maternal smoking on oral facial cleft risk by examining the dose-response relationship according to specific cleft type and according to whether or not additional malformations were present. A number of factors, including dietary and supplemental folate intake and family history of clefts, were evaluated as potential confounders and effect modifiers. Data on 3,774 mothers interviewed between 1976 and 1992 by the Slone Epidemiology Unit Birth Defects Study were used. Study subjects were actively ascertained from sites in areas around Boston, Massachusetts and Philadelphia, Pennsylvania; the state of Iowa; and southeastern Ontario, Canada. Cases were infants with isolated defects--cleft lip alone (n = 334), cleft lip and palate (n = 494), or cleft palate alone (n = 244)--and infants with clefts plus (+) additional malformations: cleft lip+ (n = 58), cleft lip and palate+ (n = 140), or cleft palate+ (n = 209). Controls were infants with defects other than clefts, excluding defects possibly associated with maternal cigarette use. There were no associations with maternal smoking for any oral cleft group, except for a positive dose response among infants with cleft lip and palate+ (for light smokers, odds ratio (OR) = 1.09 (95% confidence interval (CI): 0.6, 1.9); for moderate smokers, OR = 1.84 (95% CI: 1.2, 2.9); and for heavy smokers, OR = 1.85 (95% CI: 1.0, 3.5), relative to nonsmokers). This finding may be related to the additional malformations rather than to the cleft itself.

Prevalence of HIV-associated periodontitis and chronic periodontitis in a southeastern US study group

OBJECTIVES

This study estimates factors associated with the prevalence of HIV-associated periodontal diseases (HIV-P) and the severity and extent of periodontitis in HIV-infected adults from North Carolina (NC).

METHODS

Data are derived from a cross-sectional study of HIV-infected adults (total n = 326, dentate n = 316) treated at the University of North Carolina Hospitals. Outcomes were a diagnosis of HIV-P and measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL). Immunosuppression was measured by peripheral blood CD4+ cells/mm3.

RESULTS

In addition to persons with HIV (non-AIDS), this study included 10 percent of the AIDS cases in North Carolina. Median age was 37 years (range = 19-67); 78 percent were male and 60 percent were black. Sixty-two percent of persons had a probing pocket depth > or = 5 mm; 46% had recession > or = 3 mm, and 66 percent had attachment level > or = 5 mm in one or more sites. Cases of HIV-P (n = 15) were rare. Persons taking HIV-antiretroviral medication were one-fifth (OR = 0.20; 95% CI = 0.07, 0.63) as likely to have HIV-P as those not taking those medications, controlling for CD4+ cell counts.

CONCLUSIONS

HIV-infected persons in this study group from North Carolina exhibited severe and extensive measures of adult periodontitis. A small proportion experienced a severe form of HIV-P, which was attenuated by antiretroviral therapy.

The organization and delivery of craniofacial health services: the state of the art

The dominant organizational structure providing care for cleft palate and other craniofacial conditions is the health care team. Various types of health care team organization are profiled, including intradisciplinary, multidisciplinary, and interdisciplinary teams. Effective team-based care delivery has the ability to address the fragmentation and dehumanization that can result when a variety of specialists and disciplines are required to provide assessment and technical care. A team's leadership and its hierarchy of professional authority can be expected to affect its ability to function effectively. Health reform and managed care are considered for their impact on the team and on the doctor-patient relationship. Trends in team regionalization, quality assurance, outcomes research, and consumer advocacy are reviewed. The cleft palate and craniofacial team is profiled as an organizational model that is being affected by the forces of health system change.

Cleft palate and craniofacial teams in the United States and Canada: a national survey of team organization and standards of care. The American Cleft Palate-Craniofacial Association (ACPA) Team Standards Committee

OBJECTIVE

This study is the first comprehensive national survey of the organization, function, and composition of cleft palate and craniofacial teams in the U.S. and Canada. Complete descriptions of cleft and craniofacial teams are not currently provided in the literature, and this study will provide an overview for health services research and policy use. Conducted by a national organization, this study examines teams in detail using a pretested and standardized methodology.

DESIGN

All known (n = 296) North American cleft palate and craniofacial teams were contacted for team listing purposes using a self-assessment method developed by an interdisciplinary committee of national stature. Team clinical leaders classified their teams into several possible categories and provided data on team care. The response rate was 83.4% (n = 247).

RESULTS

The distribution of listed teams was: 105 (42.5%) cleft palate teams, 102 (41.3%) craniofacial teams (including craniofacial teams that are both cleft palate and craniofacial teams), 12 (4.9%) geographically listed teams, and 28 (11.3%) other teams (including interim cleft palate teams, low-density cleft palate teams, and evaluation and treatment review cleft palate teams). Eighty-five percent of all teams systematically collected and stored clinical data on their team's patient population in the past year. Furthermore, 50% of all teams had a quality assurance program in place to measure treatment outcomes. Other findings presented include the annual number of face-to-face team meetings; new and follow-up patient censuses; and surgical rates for initial repair of cleft lip/palate, orthognathic/osteotomy procedures, and intracranial/craniofacial procedures.

CONCLUSIONS

Two of five North American teams classify themselves as having the capacity to provide both cleft palate and craniofacial care. An additional two of five teams limit their primary role to cleft palate care. Issues are raised regarding the distribution of teams, the regionalization of craniofacial services, health policy, and resource allocation.

Oral manifestations of HIV in a southeast USA population

OBJECTIVES

Examine variations in oral manifestations of HIV by gender, race, risk behaviors, substance use and immune status in a previously unstudied population in the southeast region of the USA.

DESIGN

Cross-sectional analytic study.

SETTING

Academic medical center, North Carolina, USA.

SUBJECTS

First 238 HIV-infected adults (76% male; 59% Black) enrolled in an ongoing longitudinal study.

METHODS

Oral examination, medical chart review, sociodemographic and behavioral interview. Descriptive, bivariate, and multivariable analyses.

OUTCOMES

Presence of oral manifestations of HIV.

RESULTS

50% had recent CD4 counts < 200 cells microliters-1, 48% had one or more oral lesion. Specific lesion prevalence: hairy leukoplakia (OHL) 26.5%; candidiasis (OC) 20%; HIV-associated periodontal diseases (HIV-PD) 8.8%; aphthae 4.2%; papillomas 2.5%; herpes simplex 2.1%; HIV salivary gland disease 2.1%; Kaposi's sarcoma (KS) 1.7%; other 1.3%. In bivariate analyses, OHL was associated with being male, White, having a CD4 < 200, and men who have sex with men (MSM); OC was associated with CD4 < 200 and current smoking; HIV-PD was associated with consumption of more than seven alcohol-containing drinks per week; KS was associated with being male and MSM. Significant variables in multivariable analysis for presence of any oral lesion were White, CD4 < 200, and more than seven drinks/week; for OHL were male and CD4 < 200; and for OC were White, CD4 < 200, current smoking, and not MSM.

CONCLUSIONS

MSM were at increased risk for KS and OHL, not OC, while smokers were at increased risk of OC. OC, OHL, and any oral lesion were associated with immune suppression. OHL was more likely in males independent of CD4 count.

Conference summary: assessing oral health outcomes--measuring health status and quality of life

OBJECTIVE

This paper summarises proceedings of a conference that aimed to evaluate existing measures of oral health related quality of life and to recommend new directions for their use in oral health outcomes research.

METHOD

A two day conference was held in Chapel Hill, North Carolina, USA, in June 1996. Background papers, poster-discussion sessions, small group discussions and reactor papers were used to analyse 11 oral health related quality of life instruments and to evaluate their potential for use in health outcomes research.

RESULTS

Speakers emphasised the need to include quality of life in multidimensional assessments of oral health outcomes. Existing instruments capture numerous quality of life dimensions using a variety of question- and response-formats. The instruments have been used primarily in cross-sectional, observational studies rather than longitudinal, intervention studies that evaluate health outcomes. There is little experience from their use in long-term follow-up studies and with some special population sub-groups. Recommendations for further research are presented in papers that follow this summary paper.

CONCLUSIONS

There has been substantial development and use of quality of life measures in oral health surveys, and there is an immediate need for further research that modifies and uses those instruments in oral health outcomes research.

Children as income-producing assets: the case of teen illegitimacy and government transfers

This paper develops a classical model of the teen fertility decision in the presence of public income transfers. The theoretical model predicts that welfare payments will encourage fertility, holding constant other economic opportunities, and that better economic opportunities will discourage fertility. Considering the possible simultaneity of illegitimacy rates and benefit levels, due to the collective choice process, the authors confirm the theoretical model's predictions with state-level data from 1980 through 1990. The authors find that including fixed effects in the regression to control for unobserved differences between states does not sufficiently control for endogeneity. After controlling for endogeneity, real welfare benefits are strongly and robustly related to teen illegitimacy. The point estimates of the elasticity with respect to changes in the illegitimacy rate are around +1.3 for White teens and +2.1 for Black teens. Real wages for women with a high school education or less are negatively related to teen illegitimacy for White teens, with an elasticity of around -0.4. Finally, male wages appear to have little effect on the illegitimacy rate for White teens but appear negatively correlated with the illegitimacy rate for Black teens in some model specifications.

Assessing dental anxiety, dental care use and oral status in older adults

This study examined associations between dental anxiety and dental care use and oral health status in dentate older adults. Analysis of data from the Piedmont 65+ Dental Study revealed that aspects of dental care use and oral health status were independently associated with high dental anxiety. These results suggest that measures to control dental anxiety may help to improve dental care use and oral health status in older adults.

Culture, dental professionals and oral health values in multicultural societies: measuring cultural factors in geriatric oral health research and education

Culture has significant impacts upon professional practice and patient health behaviours, especially in multicultural societies. This paper introduces the concept of culture and examines how it may be of importance to dental health professionals. Using the Dental Impact Profile and other dental social science measures, dental researchers and students can be engaged in studying cultural values and characteristics as a way of dealing with cultural differences.

Variations in the social impact of oral conditions among older adults in South Australia, Ontario, and North Carolina

Previous studies among older adults have demonstrated that oral disease frequently leads to dysfunction, discomfort, and disability. This study aimed to assess variations in the social impact of oral conditions among six strata of people aged 65 years and older: residents of metropolitan Adelaide and rural Mt Gambier, South Australia; residents of metropolitan Toronto-North York and non-metropolitan Simcoe-Sudbury counties, Ontario, Canada; and blacks and whites in the Piedmont region of North Carolina (NC), United States. Subjects were participants in three oral epidemiological studies of random samples of the elderly populations in the six strata. Some 1,642 participants completed a 49-item Oral Health Impact Profile (OHIP) questionnaire which asked about impacts caused by problems with the teeth, mouth, or dentures during the previous 12 months. The percentage of dentate people reporting impacts fairly often or very often was greatest among NC blacks for 41 of the OHIP items. Two summary variables of social impact were used as dependent variables in bivariate and multivariate least-squares regression analyses. Among dentate people, mean levels of social impact were greatest for NC blacks and lowest for NC whites, while people from South Australia and Ontario had intermediate levels of social impact (P < 0.01). Missing teeth, retained root fragments, root-surface decay, periodontal pockets, and problem-motivated dental visits were associated with higher levels of social impact (P < 0.05), although there persisted a two-fold difference in social impact across the six strata after adjustment for those factors Among edentulous people, there was no statistically significant variation in social impact among strata. The findings suggest that there are social and cultural factors influencing oral health and its social impact, and that those factors differ most between dentate blacks and whites in NC.

Resource allocation, health policy, and rationing craniofacial care

The United States allocates health care without an overt system of rationing. This article analyzes the forces that guide resource allocation to craniofacial care. Various possible allocation systems are reviewed for how decision makers might evaluate proposed programs for legislative funding. Using a case-based exercise, readers are asked to weigh the potential costs and benefits of six health and social programs. These programs are also systematically examined for factors that are likely to affect resource allocation decisions. Eleven factors that affect decision-making are utilized in the analysis, ranging from the cost per client to emotional or human interest content of the proposed programs. Decisions about preventive programs are compared with those involving therapeutic programs. The allocation of resources to craniofacial programs, including those for children with rare major craniofacial conditions, is considered in the context of social justice and broad contemporary ethical and health care delivery issues.

Differences between racial groups in the impact of oral disorders among older adults in North Carolina

OBJECTIVES

This study investigated variations in impact of oral disorders between older black adults and older white adults living in North Carolina.

METHODS

Using the Oral Health Impact Profile (OHIP) questionnaire, 440 participants aged 70 and older provided data on their perceptions of the impact of oral disease on aspects of their lives during the previous 12 months.

RESULTS

For 22 of the 49 items queried in the OHIP questionnaire, older blacks reported more frequent impact than older whites (P < .05). For none of the OHIP items did whites report more frequent impact. The impacts reported were diverse and included items reflecting pain, physical disability, psychological disability, and social disability. When the number of items occurring fairly often or very often were summed for dentate participants, blacks reported more items than did whites (3.7 vs 1.1, P < .0001). This difference decreased to 2.7 vs 2.0 (P < .346) after controlling statistically for greater mean periodontal pocket depth, more unreplaced missing teeth, and more episodic dental visits among blacks.

CONCLUSIONS

Older dentate blacks reported more impact from oral problems than older dentate whites. The differences in reported impact likely are linked to differences in oral status and dental visit history between these two racial groups in North Carolina.

Physicians and the communication of "bad news": parent experiences of being informed of their child's cleft lip and/or palate

OBJECTIVE

Physicians often are called on to deliver "bad news" in the form of a diagnosis with unhappy implications. Few guidelines exist for practitioners who wish to meet patient and family expectations for clear and caring communication. To develop recommendations for physicians, this study was undertaken to document how biologic parents of children born with a specific, non-life-threatening birth defect perceive the encounter with a physician during which they were informed of their children's diagnosis. The study also examines parental preferences for how this communication might best be managed and compares those with parent reports of their actual experiences.

METHODOLOGY

Biologic parents of children born with cleft lip and/or palate (n = 100) were studied with a self-administered questionnaire about the diagnostic encounter in which they rated theoretically derived dimensions of physician communication. Their experiences, as well as their preferences for communication in a hypothetical case, were compared through the use of ratings and open-ended qualitative narratives.

RESULTS

Parents learned the diagnosis at birth (90%) from a physician (96%). Many report positive experiences, but there are significant differences between what parents experienced and what they desire in the informative interview. Parents wanted more opportunity to talk and to show their feelings and wanted the physician to try harder to make them feel better. As compared with their experiences, parents indicated a desire to have more information and more of a discussion about the possibility of mental retardation. They wanted the physician to show more caring and confidence, and wanted more referral to other parents, than they had experienced. Dimensions of physician behavior were more positively perceived by parents who were informed by a physician whom they felt they knew well.

CONCLUSIONS

It is possible for physicians to effectively deliver bad news, such as the diagnosis of a birth defect, to parents. This study suggests specific communicative and educational approaches that are likely to improve parental satisfaction with such physician communications.

Effects of visible and invisible orofacial defects on self-perception and adjustment across developmental eras and gender

Self-ratings of satisfaction with appearance and accomplishment of psychosocial tasks were examined by age and gender among school aged children with visible defects (cleft lip and/or palate, n = 272), or invisible defects (cleft palate only, n = 159), and dental patients (n = 128) without clefts. Using weighted least squares ANOVA and logistic regressions, the results revealed that subjects with visible defects expressed greater dissatisfaction with their appearance than those subjects with invisible defects (p < .001). Subjects with invisible defects consistently expressed lower problem solving ability than subjects with visible defects (p < .001) and dental patients with no defects (p < .05). Both groups with clefts expressed less social independence (p < .001); and subjects with clefts reported having more friends than other children (p < .01). Implications for clinicians and further research are discussed.

Sociodemographic correlates of health beliefs among black and white community dwelling elderly individuals

This study examined the hypothesis that sociodemographic characteristics such as age, education, race, and gender would be predictive of Multidimensional Health Locus of Control Subscale scores in a population-based sample of 342 community dwelling elderly individuals. Bivariate analysis revealed associations between black race, lower socioeconomic status, and lower education on the Chance and Powerful Others Subscales. While the multivariate analysis revealed no predictors for the Internal Subscale, a higher socioeconomic status, white race, and a higher level of education continued to predict low scores on the Chance Subscale when controlling for all other variables. Scores on the Powerful Others Subscale appeared to be a function of socioeconomic status and gender. Of note, the higher the education level for both men and women, the lower the scores on the Chance and Powerful Others Subscales. This sex by education interaction term reached statistical significance for the Chance Subscale. The results demonstrate the measurable influence of sociodemographic variables on the health beliefs of community dwelling elderly individuals.

Health policy and craniofacial care: issues in resource allocation

The distribution of health care services, including craniofacial services in the United States, is examined. The U.S. has a unique health care financing and organizational system in which persons are most commonly covered by health insurance as a benefit of their employment. Current estimates are that nearly 40 million Americans have no health insurance (Himmelstein et al., 1992). Approximately half of the uninsured persons are in low-wage employment that does not provide health insurance benefits nor allow them to qualify for Medicaid (Pepper Commission, 1990). Personal health care costs now exceed 11% of the U.S. gross domestic product, a significantly higher percentage than that found in other industrialized nations (Consumer Reports, 1990b). Within the current system, is health care distributed in a fair or moral manner? What are the effects of the allocation scheme? Possible changes in health care financing and delivery are examined and basic ethical and social issues associated with a changing U.S. health care delivery system are explored.

Children with cleft lip/palate and mental retardation: a subpopulation of cleft-craniofacial team patients

This study compares a subpopulation of persons with cleft lip/palate who have mental retardation (n = 56) to those with normal learning (n = 420), at a large university-based cleft-craniofacial center. Many of the patients identified as having mental retardation in this sample have the diagnosis of isolated cleft palate (46.8%). Nearly half (46.3%) of the patients with mental retardation were found to have multiple anomalies, syndromes or associated medical findings. Common findings included cardiopulmonary defects, seizures, and deviations in head size. In this clinic population, mental retardation was found more commonly among African-American patients with clefts, than among Caucasian patients with clefts. Higher rates of facial disfiguration and impaired speech were found in patients with clefts and mental retardation. This research demonstrates that among a population of persons with cleft lip and/or cleft palate, there is a subpopulation of children who also have mental retardation. Craniofacial-cleft teams will need to develop strategies to address the special needs of this group of patients.

Pulsed dye laser therapy for port-wine stains in children: psychosocial and ethical issues

The port-wine stain is a disfiguring vascular birthmark that commonly occurs on the face. Amelioration of this condition in children was difficult or impossible until the introduction of the flashlamp-pumped pulsed dye laser in the late 1980s. This article provides an interdisciplinary social and ethical examination of pulsed dye laser therapy for port-wine stain in childhood. Specific issues raised relate to the management of pain during therapy, rationale for care, expectations of treatment, the high costs of care, equity, marketing pressures, and therapeutic activism. Laser therapy in the dermatologic care of children is an exciting innovation that has transformed clinical practice and raised important social, ethical, and health policy issues.

Understanding the value of teeth to older adults: influences on the quality of life

Understanding the value of teeth to older adults is important in marketing dental services and motivating patients to care for their teeth. The authors surveyed more than 1,000 older adults in North Carolina to determine how teeth affect the quality of their lives.

Ethical and health policy issues in the treatment of children with major craniofacial deformities

The advent of craniofacial surgery and neonatal intensive care has made it possible for children with serious craniofacial deformities to live and possibly to experience effective habilitation. These therapeutic innovations also raise important social and ethical issues that are rarely examined. This paper reviews the dilemmas that relate to the gatekeeper role for physicians, the impact of prenatal diagnosis, and the allocation of scarce fiscal and health resources to craniofacial care. The high degree of cost, the intense investment of medical resources, and the uncertain outcomes in the care of children with major craniofacial deformities, must be considered in the distribution of resources within a health system. The rationing of health resources is discussed as a future determinant of how care for major craniofacial deformities may be delivered in the United States.

Communicating medical bad news: parents' experiences and preferences

Parents (N = 189) of children enrolled in 15 developmental day care centers completed questionnaires that examined the experience of being told bad news and elicited preferences for physician behavior in a hypothetical situation (communicating the diagnosis of Down syndrome). Parents, in comparison with their experiences, preferred (p < 0.001) more communication of information and feelings by their physician. Their strongest preferences were for physicians to show caring (97%), to allow parents to talk (95%), and to allow parents to show their own feelings (93%). They wanted physicians to share information (90%) and to be highly confident (89%). Most parents (87%) desired parent-to-parent referral, but only a few (19%) were referred. We conclude that there is a difference between what parents experience and what they desire in physicians who communicate bad news. Physicians control the interaction and are highly confident, but parents especially value physicians who show caring and allow parents to talk and share their feelings.

Habilitation of patients with clefts: parent and child ratings of satisfaction with appearance and speech

This study examined ratings regarding satisfaction with facial appearance and speech performance from 495 parent-child pairs. Data were obtained from school-aged children (5-18 years old) and their parents using standardized independent interviews. Results revealed that 54 percent of the children with cleft lip (CL) or cleft lip and palate (CLP) were very pleased with their appearance, and 62 percent of the cleft palate or CLP subjects were very pleased with speech. Low, but statistically significant correlations exist between the female subjects and their parents in satisfaction with appearance. Although older cleft lip and/or palate patients reported increased satisfaction with speech, no age differences in patient satisfaction with appearance were observed in subjects with CL/CLP. Parents of females expressed more concern about their daughters' appearance than parents of males, while parents of males were more concerned about speech. Implications for craniofacial habilitation teams and research suggestions are discussed.

Cognitive and attitudinal impacts of a university AIDS course: interdisciplinary education as a public health intervention

This paper describes an interdisciplinary, variable credit-bearing university course on acquired immunodeficiency syndrome (AIDS) that enrolled 429 students. Pre- and post-course questionnaires were used to assess knowledge and attitudes relative to AIDS and these were compared to National Health Interview Survey findings. Considerable cognitive and attitudinal changes occurred over the course period. University courses, taught annually, were found to be an efficient mechanism for educating large numbers of future community leaders and professionals about AIDS.

Directions and issues in psychosocial research and methods as applied to cleft lip and palate and craniofacial anomalies

Psychosocial research into cleft lip and/or palate and craniofacial conditions has historically employed a "medical model" of research that sought to clarify whether patients experienced psychopathology as a consequence of the birth defect. In recent years, this paradigm has been replaced by a "social science model" of research that posits that most individuals with clefts do not manifest psychological pathology. The "social science model" examines adjustment and adaptation in the patients and their families. Research questions may consider the social, cultural, and psychological ramifications of being different in terms of speech, appearance, or identity. The authors suggest that an expanded set of research questions be considered, and that researchers from sociology, anthropology, ethics, economics, health services research, as well as psychology, become engaged. This paper proposes a range of possible research topics and indicates likely trends in research design and methodology.

Culture, health care, and birth defects in the United States: an introduction

Culture impacts both professional practice and patient health behaviors. This paper introduces the concept of culture and examines how it may be of importance to health professionals engaged in craniofacial care. The taking of a cultural history is presented as a way of assessing cultural differences. This paper is the first in a series of interrelated papers that define cultural perspectives toward health and craniofacial care in United States subpopulations.

Prenatal detection and fetal surgery of clefts and craniofacial abnormalities in humans: social and ethical issues

Sophisticated prenatal diagnostic imaging has facilitated the progression of fetal surgery from the experimental possibility to a clinical therapy for several life-threatening congenital conditions. Guidelines for such fetal surgery include the expectation that the child will be reasonably healthy as a result and that the in utero approach will improve the outcome or is safer than postnatal intervention. Prenatal ultrasound detection of craniofacial anomalies is now common. Reports of experimental cleft repairs in animal fetuses suggest advantages including diminished scarring, improved health and nursing. While fetal craniofacial surgery has not been attempted in humans, speculations exist about the psychological and social benefits of being born with a repaired defect. Fetal surgery is an emerging technology that may alter experimentation, cleft treatment, and the allocation of scarce resources. This paper examines the social and ethical implications of prenatal diagnosis and fetal surgery, focusing on fetal/maternal rights, and clinical decision making.

The accuracy of oral self-perceptions in a dentate older population

A random sample of 1,016 subjects aged 65 and older were interviewed and examined in their own homes. The sample was stratified by race and place of residence. As part of the interview, the 821 dentate subjects were asked to rate their mouth appearance, chewing ability, and mouth health. Most subjects responded positively to these questions. The self-perception of mouth health was most related to the presence of anterior teeth. Perception of chewing ability was most related to the number of anterior teeth present, total number of teeth present, and the need for extractions. Subjects also were asked about their perceived dental needs. A small proportion of subjects thought they needed restorations, periodontal treatment, or teeth replacement. Subjects generally were not able to define the extent of their treatment needs, but their self-perceptions of mouth appearance, chewing ability, and mouth health had some relationship to their oral health.

Self-concept of early primary school age children with visible or invisible defects

This study compares self-concept scores on the Primary Self-Concept Inventory (PSCI) of 58 7-year-old children. The experimental groups included the three following subgroups: those with visible defects (cleft lip), mixed visible and invisible defects (cleft lip and palate), and invisible defects (cleft palate). The control consisted of first grade students with no physical defects. Significant differences between the subjects with clefts and controls were found. Children with cleft lip and palate (visible and invisible defects) demonstrated the lowest self-concept scores. These test results suggest that early primary school age children experience significant stigma. Therefore, early evaluation of psychosocial stress factors for children with clefts is suggested. School personnel can contribute to addressing self-concept concerns of children with defects. Suggestions for further research are presented.

Psychosocial responses to oral and maxillofacial surgery for head and neck cancer

This study involved extensive interviews with 28 patients who had disfiguring oral and maxillofacial surgery for head and neck cancer. The patients, ages 42 to 76 years, had all been informed of their diagnosis and were in 2- to 5-year postoperative follow-up. Findings pertain to how patients deal with the interpersonal and social ramifications of diagnosis and surgical treatment. Fatalism, delays in help-seeking, responses to diagnosis, postsurgical anxiety, and adjustment were reported. Reassurance prior to surgery was sometimes found to limit understanding of postoperative impairment. Oral and maxillofacial surgeons were seen in heroic or imposing roles that impacted on their capacity to be supportive to patients coping with life change and "handicap." The patient treatment decisions were found to be determined by attitudes about death, which motivated patients and surgeons to make difficult or extreme choices. Suffering, social changes, and postoperative uncertainty were patient concerns. Patient strategies for adjusting to disfiguration are examined, and specific recommendations for the oral and maxillofacial surgeon are made.

Perceptions of appearance and speech by adolescent patients with cleft lip and palate and by their parents

This study surveyed 102 patients with cleft lip, cleft palate, or cleft lip and cleft palate (ages 13 to 19) and their parents to assess satisfaction with appearance, speech ability, and intelligibility. The data were based upon standardized interviews conducted at a cleft palate treatment center, using simple questions with high face validity. Surgical experience was high among this sample, as reflected by the finding that the majority of patients (55.7%) had had three or more operations on the face or mouth. Patient ratings of facial appearance showed that most patients were very pleased (59.3%) or moderately pleased (13.2%); others were somewhat (18.7%) or very (8.8%) disappointed. Many parents indicated that their children expressed occasional (22.0%) or frequent (27.5%) concerns about appearance. Nearly all patients (91.9%) felt that their operations had accomplished what they expected, though some of the cleft lip patients (35.7%) and their parents (43.9%) were less than very pleased with the appearance of the lip. When asked how pleased they were with the way they presently talked, most patients (69.1%) were very pleased, though some disappointment was expressed. Although often pleased with their current speech status, many patients rated themselves as only moderately understandable (19.1%) or as not understandable (8.5%). No significant gender effects were found in satisfaction, appearance, or speech ratings. There were no significant differences found between parent and child ratings. The findings indicate that at a center delivering team-based cleft palate care, both adolescent patients and their parents have considerable concerns about appearance and speech results.