Sacroiliac joint arthropathy in adult spinal deformity patients with long constructs to the pelvis

OBJECTIVE

Sacroiliac joint (SIJ) arthropathy is an increasingly recognized problem in adult spinal deformity patients undergoing long construct surgery. S2-alar-iliac (S2AI) screw instrumentation is thought to reduce morbidity from pelvic fixation in these patients. The goal of this study is to assess the overall incidence of SIJ arthropathy in patients with long constructs to the pelvis as well as compare SIJ outcomes of partially threaded (PT) versus fully threaded (FT) S2AI screws.

METHODS

Data of eligible patients were collected from a prospectively maintained database with retrospective review of electronic records at an academic institution between 2016 and 2019.

RESULTS

65 consecutive patients who underwent S2AI screw instrumentation (40 in PT group, 25 in FT group) were enrolled. The rate of postoperative SIJ pain was higher in the PT (52.5 %) compared to FT (32 %) group. There was a significantly shorter time-to-pain development in the PT compared to FT group (11.8 versus 20.1 months, respectively). Of those who developed SIJ pain in the PT group, the pain worsened in 80.9 % versus only 25 % of those in the FT group despite conservative treatment. Cox regression found the PT group more likely to develop SIJ pain at any point during follow-up compared to the FT group (Hazard Ratio = 7.308). SIJ fusion was not detected on imaging of any patient during follow-up.

CONCLUSION

FT S2AI screws are associated with better SIJ outcomes compared to PT screws. However, our data suggest that S2AI screw instrumentation is not sufficient to achieve fusion or prevent development of SIJ pain. Concurrent SIJ fusion may be necessary in patients with long constructs to prevent SIJ arthropathy.

Management of Thoracic Disc Herniation Using the Mini-Open Retropleural Approach: Technique Illustration and Clinical Outcomes of 33 Patients From a Single Academic Center

BACKGROUND

Conventional surgical approaches used in the management of thoracic disc herniation (TDH) are associated with high morbidity. The development of minimally invasive and mini-open approaches has consistently improved patient outcomes.

OBJECTIVE

To report our experience and outcomes of patients with symptomatic TDHs who underwent discectomy and partial corpectomy using the mini-open retropleural (MORP) approach as well as provide a detailed and illustrated technical description of the approach.

METHODS

Retrospective chart review was performed on all patients with symptomatic TDHs who underwent a MORP approach at a tertiary academic center between 2011 and 2019. Patient demographic, clinical, and imaging data were examined (n = 33). The surgical technique is illustrated and described in detail.

RESULTS

Discectomy of the herniated thoracic discs was successfully achieved in all patients using the MORP approach. Calcified discs were present in 63.6% (n = 21) of patients. Immediate instrumentation and fusion were performed in 30.3% (n = 10) of patients, which were among the earlier cases in this series. Symptomatic pleural effusions and cerebrospinal fluid leakage occurred in 6.1% (n = 2) and 9.1% (n = 3), respectively. No patient required chest tube placement.

CONCLUSION

The MORP approach described in this manuscript is feasible and safe in achieving discectomy in patients with symptomatic TDHs. Compared to conventional open and other minimally invasive approaches, patients undergoing the MORP approach may have better outcomes with lower complication rates.

The Return Back to Typical Practice from the "Battle Plan" of the Coronavirus Disease 2019 (COVID-19) Pandemic: A Comparative Study

BACKGROUND

Every aspect of the medical field has been heavily affected by the coronavirus disease 2019 (COVID-19) pandemic, and neurosurgical services are no exception. Several departments have reported their experiences and protocols to provide insights for others impacted. The goals of this study are to report the load and variety of neurosurgical cases and clinic visits after discontinuing the COVID-19 Battle Plan at an academic tertiary care referral center to provide insights for other departments going through the same transition.

METHODS

The clinical data of all patients who underwent a neurosurgical intervention between May 4, 2020, and June 4, 2020 were obtained from a prospectively maintained database. Data of the control group were retrospectively collected from the medical records to compare the types of surgeries/interventions and clinic visits performed by the same neurosurgical service before the COVID-19 pandemic started.

RESULTS

One hundred sixty-one patients underwent neurosurgical interventions, and seven-hundred one patients were seen in clinic appointments, in the 4-week period following easing back from our COVID-19 "Battle Plan." Discontinuing the "Battle Plan" resulted in increases in case load to above-average practice after a week but a continued decrease in clinic appointments throughout the 4 weeks compared with average practice.

CONCLUSIONS

As policy-shaping crises like pandemics abate, easing back to "typical" practice can be completed effectively by appropriately allocating resources. This can be accomplished by anticipating increases in neurosurgical volume, specifically in the functional/epilepsy and brain tumor subspecialties, as well as continued decreases in neurosurgical clinic volume, specifically in elective spine.

Can mHealth Technology Help Mitigate the Effects of the COVID-19 Pandemic?

Goal: The aim of the study herein reported was to review mobile health (mHealth) technologies and explore their use to monitor and mitigate the effects of the COVID-19 pandemic. Methods: A Task Force was assembled by recruiting individuals with expertise in electronic Patient-Reported Outcomes (ePRO), wearable sensors, and digital contact tracing technologies. Its members collected and discussed available information and summarized it in a series of reports. Results: The Task Force identified technologies that could be deployed in response to the COVID-19 pandemic and would likely be suitable for future pandemics. Criteria for their evaluation were agreed upon and applied to these systems. Conclusions: mHealth technologies are viable options to monitor COVID-19 patients and be used to predict symptom escalation for earlier intervention. These technologies could also be utilized to monitor individuals who are presumed non-infected and enable prediction of exposure to SARS-CoV-2, thus facilitating the prioritization of diagnostic testing.

Impact of the COVID-19 Pandemic on Neurosurgical Practice at an Academic Tertiary Referral Center: A Comparative Study

BACKGROUND

Neurosurgical services have been affected by the 2019 novel coronavirus disease (COVID-19) pandemic, and several departments have reported their experiences and responses to the COVID-19 crisis in an attempt to provide insights from which other impacted departments can benefit. The goals of this study were to report the load and variety of emergent/urgent neurosurgical cases after implementing the "Battle Plan" at an academic tertiary referral center during the COVID-19 pandemic and to compare these variables with previous practice at the same institution.

METHODS

The clinical data of all patients who underwent a neurosurgical intervention between March 23, 2020, and April 20, 2020, were obtained from a prospectively maintained database. Data of the control group were retrospectively collected from the medical records to compare the types of surgeries/interventions performed by the same neurosurgical service before the COVID-19 pandemic started.

RESULTS

Over a 4-week period during the COVID-19 pandemic, 91 patients underwent emergent, urgent, and essential neurosurgical interventions. Patient screening at teleclinics identified 11 urgent surgical cases. The implementation of the Battle Plan led to a significant decrease in the caseload, and the variation of cases by subspecialty was evident when compared with a control group comprising 214 patients.

CONCLUSIONS

Delivery of optimal care and safe practice and education at an academic neurosurgical department can be well maintained with proper execution of crisis protocols. Teleclinics proved to be efficient in screening patients for urgent neurosurgical conditions, but in-person clinic visits may still be necessary for some cases in the immediate postoperative period.

Minimally Invasive Lateral Retropleural and Retroperitoneal Approaches in Patients with Thoracic and Lumbar Osteomyelitis: Description of the Techniques and a Series of 14 Patients

BACKGROUND

The growing interest in minimally invasive approaches to the thoracic and lumbar spine is mostly secondary to the high surgical morbidity and complication rates associated with conventional open approaches. The objective was to report the largest series of patients with thoracic and lumbar vertebral osteomyelitis who underwent multilevel corpectomies using the minimally invasive lateral (MIL) retropleural and retroperitoneal approaches.

METHODS

The surgical techniques of the MIL approaches are illustrated and described in detail. The MIL retropleural approach was performed in 9 patients, MIL retroperitoneal approach in 3 patients, and combined MIL retropleural/retroperitoneal approach in 2 patients with thoracic, lumbar and thoracolumbar vertebral osteomyelitis, respectively.

RESULTS

Multilevel corpectomies were successfully accomplished in all 14 patients using the MIL approaches (11 patients with 2-level corpectomy, 2 patients with 3-level corpectomy, and 1 patient with extension of a 3-level corpectomy to 6 levels). Correction of kyphotic deformity was achieved postoperatively in all 14 patients and remained stable with no proximal junctional kyphosis for a median of 10 months of follow-up on 10 patients; 4 patients were lost to follow-up after discharge from the hospital. Posterior instrumentation was performed in 12 patients to further support the spinal alignment.

CONCLUSIONS

The MIL retropleural and retroperitoneal approaches described in this manuscript are feasible and safe in achieving multilevel corpectomies, anterior column reconstruction, and spinal deformity correction in patients with thoracic, lumbar, and thoracolumbar vertebral osteomyelitis.

Baseline Cognitive Performance and Treatment Outcomes From Cognitive-Behavioral Therapies for Posttraumatic Stress Disorder: A Naturalistic Study

OBJECTIVE

Approximately 5%-20% of U.S. troops returning from Iraq and Afghanistan have posttraumatic stress disorder (PTSD), and another 11%-23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with an individual's ability to adhere to as well as benefit from such therapies. Comorbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. The authors hypothesized that poorer pretreatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD.

METHODS

This study was designed as a naturalistic examination of treatment as usual in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans, aged 18-50 years, with combat-related PTSD and a symptom duration of more than 1 year. Of these, 16 participants had mild TBI (mTBI). Predictor variables were well-normed objective tests of cognitive ability measured at baseline. Outcome variables were individual slopes of change of the PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over weeks of treatment, and of pretreatment-to-posttreatment change in PCL-5 and CAPS-5 (ΔPCL-5 and ΔCAPS-5, respectively).

RESULTS

Contrary to prediction, neither pretreatment cognitive performance nor the presence of comorbid mTBI predicted poorer response to CBTs for PTSD.

CONCLUSIONS

These results discourage any notion of excluding patients with PTSD and poorer cognitive ability from CBTs.

Pilot Study of Neurological Soft Signs and Depressive and Postconcussive Symptoms During Recovery From Mild Traumatic Brain Injury (mTBI)

Neurological soft signs (NSSs) tap into a variety of perceptual, motor, and cognitive functions. The authors administered a battery of NSSs serially to a group of 14 pilot patients recruited from an emergency room after they experienced a mild traumatic brain injury. Patients were seen within 96 hours after injury, and again 30 and 90 days later. Measures of balance, mood, and postconcussive symptoms and impairment were also obtained. NSSs and balance improved across visits. Across visits, NSSs and balance were not significantly associated with any postconcussive outcome measures, although depressive symptoms were. Initial neurological impairment appeared to predict subsequent residual postconcussive symptoms and impairment, but this result requires replication.

Stress, PTSD, and dementia

The physiological consequences of acute and chronic stress on a range of organ systems have been well documented after the pioneering work of Hans Selye more than 70 years ago. More recently, an association between exposure to stressful life events and the development of later-life cognitive dysfunction has been proposed. Several plausible neurohormonal pathways and genetic mechanisms exist to support such an association. However, many logistical and methodological barriers must be overcome before a defined causal linkage can be firmly established. Here the authors review recent studies of the long-term cognitive consequences of exposures to cumulative ordinary life stressors as well as extraordinary traumatic events leading to posttraumatic stress disorder. Suggestive effects have been demonstrated for the role of life stress in general, and posttraumatic stress disorder in particular, on a range of negative cognitive outcomes, including worse than normal changes with aging, Alzheimer's disease, and vascular dementia. However, given the magnitude of the issue, well-controlled studies are relatively few in number, and the effects they have revealed are modest in size. Moreover, the effects have typically only been demonstrated on a selective subset of measures and outcomes. Potentially confounding factors abound and complicate causal relationships despite efforts to contain them. More well-controlled, carefully executed longitudinal studies are needed to confirm the apparent association between stress and dementia, clarify causal relationships, develop reliable antemortem markers, and delineate distinct patterns of risk in subsets of individuals.

Report on World Workshops on Oral Medicine (WWOM) IV and V: research themes and citation impact: WWOM VI steering committee

The first World Workshop on Oral Medicine (WWOM) was held in 1988. The portfolio has continued to expand in scope and impact over the past 26 years. Five World Workshops were conducted between 1988 and 2010, focusing on creation of systematic reviews in biomedicine and health care of importance to the international oral medicine community. WWOM VI was conducted in April 2014 and further extended this modeling. This most recent Workshop also fostered creation of the inaugural joint meeting between the American Academy of Oral Medicine and the European Association of Oral Medicine, together with The British Society for Oral Medicine and the Oral Medicine Academy of Australasia. The goal of the WWOM portfolio is to strategically enhance international oral medicine research, education, and clinical practice. To this end, this report summarizes subject areas for WWOM IV (2004) and research recommendations for WWOM V (2010), as well as citation metrics relative to publications from these two conferences. The information is designed to provide research and clinical context for key issues in oral medicine as delineated by the WWOM portfolio over the past 10 years, as well as for projected outcomes of WWOM VI over the next 12 months.

Complications of lateral plating in the minimally invasive lateral transpsoas approach

Object

The aim of this study was to review the authors' experience with 101 cases over the past 3 years with minimally invasive lateral interbody fusion using a lateral plate. Their main goal was to specifically look for hardware-associated complications. Three cases of hardware failure and 3 cases of vertebral body (VB) fractures associated with lateral plate placement are reported. The authors also review the literature pertaining to lateral plates and related complications.

Methods

This study is a retrospective review of a database of patients who underwent minimally invasive lateral interbody fusion in the thoracolumbar spine during a 3-year period.

Results

Six complications were identified, resulting in an incidence of 5.9%. Three hardware failures, 2 coronal plane VB fractures, and 1 lateral VB fracture were identified. All complications occurred in multilevel cases. All cases presented with recurrent back pain except one, which was identified incidentally.

Conclusions

Minimally invasive lateral interbody fusion is a safe and direct technique that is practical, especially when trying to avoid other approaches for hardware insertion, and it also avoids the complications associated with other types of instrumentation such as pedicle screws. Careful consideration during patient selection and during the operation will aid in the avoidance of complications.

Local drug delivery for oral mucosal diseases: challenges and opportunities

There are few topical formulations used for oral medicine applications most of which have been developed for the management of dermatological conditions. As such, numerous obstacles are faced when utilizing these preparations in the oral cavity, namely enzymatic degradation, taste, limited surface area, poor tissue penetration and accidental swallowing. In this review, we discuss common mucosal diseases such as oral cancer, mucositis, vesiculo-erosive conditions, infections, neuropathic pain and salivary dysfunction, which could benefit from topical delivery systems designed specifically for the oral mucosa, which are capable of sustained release. Each condition requires distinct penetration and drug retention profiles in order to optimize treatment and minimize side effects. Local drug delivery may provide a more targeted and efficient drug-delivery option than systemic delivery for diseases of the oral mucosa. We identify those mucosal diseases currently being treated, the challenges that must be overcome and the potential of novel therapies. Novel biological therapies such as macromolecular biological drugs, peptides and gene therapy may be of value in the treatment of many chronic oral conditions and thus in oral medicine if their delivery can be optimized.

Persistent orofacial muscle pain

The pathophysiology of persistent orofacial myalgia has been the centre of much controversy. In this article we suggest a novel descriptive term; 'persistent orofacial muscle pain' (POMP) and review current evidence that supports the hypothesis that the induction of POMP involves the interplay between a peripheral nociceptive source in muscle, a faulty central nervous system component and decreased coping ability. In this context it is widely accepted that a complex interaction of variable intrinsic and extrinsic factors act to induce POMP and dysfunction.

Aspirin and recurrent intracerebral hemorrhage in cerebral amyloid angiopathy

OBJECTIVE

To identify and compare clinical and neuroimaging predictors of primary lobar intracerebral hemorrhage (ICH) recurrence, assessing their relative contributions to recurrent ICH.

METHODS

Subjects were consecutive survivors of primary ICH drawn from a single-center prospective cohort study. Baseline clinical, imaging, and laboratory data were collected. Survivors were followed prospectively for recurrent ICH and intercurrent aspirin and warfarin use, including duration of exposure. Cox proportional hazards models were used to identify predictors of recurrence stratified by ICH location, with aspirin and warfarin exposures as time-dependent variables adjusting for potential confounders.

RESULTS

A total of 104 primary lobar ICH survivors were enrolled. Recurrence of lobar ICH was associated with previous ICH before index event (hazard ratio [HR] 7.7, 95% confidence interval [CI] 1.4-15.7), number of lobar microbleeds (HR 2.93 with 2-4 microbleeds present, 95% CI 1.3-4.0; HR = 4.12 when >or=5 microbleeds present, 95% CI 1.6-9.3), and presence of CT-defined white matter hypodensity in the posterior region (HR 4.11, 95% CI 1.01-12.2). Although aspirin after ICH was not associated with lobar ICH recurrence in univariate analyses, in multivariate analyses adjusting for baseline clinical predictors, it independently increased the risk of ICH recurrence (HR 3.95, 95% CI 1.6-8.3, p = 0.021).

CONCLUSIONS

Recurrence of lobar ICH is associated with previous microbleeds or macrobleeds and posterior CT white matter hypodensity, which may be markers of severity for underlying cerebral amyloid angiopathy. Use of an antiplatelet agent following lobar ICH may also increase recurrence risk.

The safety and effectiveness of a dural sealant system for use with nonautologous duraplasty materials

Object

The DuraSeal dural sealant system, a polyethylene glycol hydrogel, has been shown to be safe and effective when used with commercial and autologous duraplasty materials. The authors report on the safety and effectiveness of this sealant when used in conjunction with nonautologous duraplasty materials.

Methods

In this retrospective, nonrandomized, multicenter study, the safety and efficacy of a dural sealant system was assessed in conjunction with primarily collagen-based nonautologous duraplasty materials in a sample of 66 patients undergoing elective cranial procedures at 3 institutions. This cohort was compared with 50 well-matched patients from the DuraSeal Pivotal Trial who were treated with this sealant system and autologous duraplasty material.

Results

The key end points of the study were the incidences of CSF leaks, surgical site infections, and meningitis 90 days after surgery. The incidence of postoperative CSF leakage was 7.6% in the study group (retrospective population) and 6.0% in the Pivotal Trial population. The incidence of meningitis was 0% and 4.0% in the retrospective and Pivotal Trial groups, respectively. There were no serious device-related adverse events or unanticipated adverse device effects noted for either population.

Conclusions

This study demonstrates that the DuraSeal sealant system is safe and effective when used for watertight dural closure in conjunction with nonautologous duraplasty materials.

Lumbar diskectomy in a human-habituated mountain gorilla (Gorilla beringei beringei)

The authors report a case of a human-habituated mountain gorilla, Alvila, resident at the San Diego Zoo, who was found to have a herniated intervertebral lumbar disc after being attacked by the gorilla troop's silverback male gorilla. Ultimately, the gorilla required surgical intervention for her disease and made a full recovery. To our knowledge, this is the only known case of spine surgery. A 36-year-old female human-habituated mountain gorilla (Gorilla beringei beringei), resident at the San Diego Zoo, was noticed by caregivers to walk with a substantial limp after being attacked by the gorilla troop's silverback male gorilla. Magnetic resonance (MR) imaging of her lumbar spine revealed a large herniated disk at the L1-2 level on the right. This finding appeared to correlate well with the gorilla's symptoms. The gorilla underwent a lumbar diskectomy under loupe. Post-operatively the gorilla did very well. The right leg weakness was immediately improved post-operatively. The gorilla continued to "crutch walk" initially, swinging on the upper extremities and not bearing weight on the lowers. However, by 2 weeks the limp was no longer noticeable to the zoo caregivers. The wound healed well and there was no evidence of wound infection or CSF leak. The gorilla was reunited with her troop and has reintegrated well socially. With 10 months of follow-up, the gorilla continues to do well. This is the only known case of spine surgery in a gorilla. For best surgical results, one needs to consider the similarities and differences between the gorilla and human vertebral anatomy. We believe that careful pre-operative planning contributed to the good early post-operative result. Ultimate assessment of the long-term outcome will require additional follow-up.

Biological responses of Lumbriculus variegatus exposed to fluoranthene-spiked sediment

Lumbriculus variegatus was used as a bioassay organism to examine the impact of the sediment-associated polycyclic aromatic hydrocarbon (PAH) fluoranthene on behavior, reproduction, and toxicokinetics. The number of worms increased between the beginning and end of the experiment at 59 microg x g(-1) fluoranthene, but at the next higher treatment (108 microg x g(-1)) the number of worms found was lower and not different from the control. Worms exposed to 95 microg x g(-1) also exhibited increased reproduction when fed a yeast-cerophyl-trout chow mixture. On a total biomass basis, only the 95 microg x g(-1) exposure with food exhibited a statistically significant increase over the nonfed control. Evaluation of reproduction at the two highest treatments was compromised by a brief aeration failure 2 days before the end of the experiment. The behavioral responses were followed as changes in biological burial rate (sediment reworking rate) of a 137Cs-labeled marker layer. The biological burial rate increased toward a plateau as the concentration increased from the control (3.9 microg x g(-1) dry weight total PAH) to 355 microg x g(-1) dry weight fluoranthene in sediment. The aeration failure had minimal impact on the determination of reworking rate because all the data for the rate determination were collected prior to the aeration failure. Uptake and elimination rates declined with increasing treatment concentration across the range of fluoranthene concentrations, 59-355 microg x g(-1) dry weight sediment. The disconnect between the increasing biological burial rates and the decreasing toxicokinetics rates with increasing exposure concentration demonstrates that the toxicokinetic processes are dominated by uptake and elimination to interstitial water. The bioaccumulation factor (concentration in the organisms on a wet weight basis divided by the concentration in sediment on a dry weight basis) ranged from 0.92 to 1.88 on day 10 and declined to a range of 0.52 to 0.99 on day 28 with the lowest value at the highest dose.

A retrospective study of the management of oral mucous membrane pemphigoid with dapsone

OBJECTIVE

The purpose of this retrospective study was to investigate the efficacy of dapsone therapy in the management of mucous membrane pemphigoid.

STUDY DESIGN

The charts of 29 patients who had been diagnosed with mucous membrane pemphigoid by means of routine histologic analysis and direct immunofluorescence were reviewed. The oral features were graded according to severity of disease from 1 to 3. Each patient was assigned to one of 4 groups according to his or her response to therapy.

RESULTS

Nine patients were treated successfully with topical corticosteroids alone. Eleven patients with moderate to severe disease who were treated initially with topical steroids showed minimal improvement; after dapsone was added, 7 of the 11 had total resolution of their lesions and 4 had greater than 75% improvement. Two patients had to discontinue dapsone because of side effects.

CONCLUSIONS

In this group of 20 patients with moderate to severe mucous membrane pemphigoid, the use of dapsone in combination with topical corticosteroids caused greater than 75% resolution of oral lesions in all patients studied.

Physiologically based pharmacokinetic modeling of inhaled trichloroethylene and its oxidative metabolites in B6C3F1 mice

A physiologically based pharmacokinetic (PBPK) model for inhaled trichloroethylene (TCE) was developed for B6C3F1 mice. Submodels described four P450-mediated metabolites of TCE, which included chloral hydrate (CH), free and glucuronide-bound trichloroethanol (TCOH-f and TCOH-b), trichloroacetic acid (TCA), and dichloroacetic acid (DCA). Inhalation time course studies were carried out for calibration of the model by exposing mice to TCE vapor concentrations of either 100 or 600 ppm for 4 h. At several time points, mice were euthanized and blood, liver, kidney, lung, and fat were collected and analyzed for TCE and its oxidative metabolites. Peak blood TCE concentrations were 0.86 and 7.32 microgram/mL, respectively, in mice exposed to 100 and 600 ppm TCE. The model overpredicted the mixed venous blood and tissue concentrations of TCE for mice of both exposure groups. Fractional absorption of inhaled TCE was proposed to explain the discrepancy between the model predictions and the TCE blood time course data. When fractional absorption (53%) of inhaled TCE was incorporated into the model, a comprehensive description of the uptake, distribution, and clearance of TCE in the blood was obtained. Fractional uptake of inhaled TCE was further verified by collecting TCE in exhaled breath following a 4-h constant concentration exposure to TCE and validation was provided by testing the model against TCE blood concentrations from an independent data set. The submodels adequately simulated the distribution and clearance kinetics of CH and TCOH-f in blood and the lungs, TCOH-b in the blood, and TCA and DCA, which were respectively detected for up to 43 and 14 h postexposure in blood and livers of mice exposed to 600 ppm TCE. This is the first extensive tissue time course study of the major metabolites of TCE following an inhalation exposure to TCE and the PBPK model predictions were in good general agreement with the observed kinetics of the oxidative metabolites formed in mice exposed to TCE concentrations of 100 and 600 ppm.

When believing is seeing: the effect of scripts on eyewitness memory

Two studies examined the conditions under which event schema or scripts produce gap-filling errors in eyewitness accounts of a robbery. In Study 1, scripts for the robbery of a convenience store were identified. Results revealed high agreement among the 120 participants concerning the sequence of actions for such a robbery. Based on the information obtained in Study 1, participants in Study 2 (N = 144) viewed one of two sequences of slides depicting a robbery of a convenience store by a lone robber. In one sequence, three central script actions were omitted and in the other, three peripheral script actions were omitted. In addition, rate of exposure was varied (2 vs. 8 sec) as was the length of the retention interval (5 min vs. 1 week). As predicted, there was a higher rate of false recognition for central as opposed to peripheral actions, and this tendency was exaggerated for the longer retention interval. The theoretical and practical implications of the findings are discussed.

Intraoral contact allergy: a literature review and case reports

Signs and symptoms of contact allergic reactions affecting the oral mucosa may mimic other common oral disorders, making diagnosis difficult. Patients frequently seek multiple consultations and do not receive the correct diagnosis or effective management. As intraoral contact allergy may be more prevalent than previously believed, a review of this topic is warranted. This article emphasizes signs and symptoms that suggest intraoral contact allergy, and the authors discuss the allergens that most frequently affect the oral mucosa.

Comprehensive health data systems spanning the public-private divide: the Massachusetts experience

As systems of health care delivery have evolved from claims-based fee-for-service to capitated or managed care, with its emphasis on cost-effectiveness, quality, and performance measurement, some states have begun to experiment with new ways to collect, organize, and share health information. In many cases, the drivers of these changes have been purchasers of health care, including large and small private employers and public agencies such as Medicaid. One of the results of these changes is the increased interest in the sharing of health information, between health plans and employers, and, in some instances, between private plans and public agencies such as public health. Massachusetts, which has one of the highest rates of managed care penetration in the United States, has brought together the various parties involved in the collection and utilization of health information, to craft agreements on standards and protocols that will allow the sharing of health data. While much of the activity involves business transactions between private sector health plans, the Department of Medical Assistance (Medicaid) has joined with its private sector purchasing partners in demanding cost-effective, high-quality care; it is these demands that have helped stimulate the need to reorganize previously proprietary health information systems. The activities of two public-private coalitions, the Massachusetts Healthcare Purchaser Group and the Massachusetts Health Data Consortium, have been critical in initiating and supporting the complex processes that have led to significant changes in state-based systems of health information.

Prevalence of hereditary hemochromatosis in a Massachusetts corporation: is Celtic origin a risk factor?

The prevalence of homozygous hereditary hemochromatosis (HHC) is estimated at 1:250 in Caucasian adults. Little is known about ethnic subpopulations that might be at increased risk for this disease. HLA data have suggested a Celtic origin for HHC. Screening for HHC was offered to all employees of the Massachusetts Polaroid Corporation. Participants with a transferrin saturation of >55% or >45% and an elevated serum ferritin concentration on two screenings were referred for liver biopsy. The diagnosis of HHC was based on histological criteria, quantitative hepatic iron determination, hepatic iron index, and the phlebotomy requirement for iron depletion. Participants completed a questionnaire regarding their ethnic background. Two thousand two hundred ninety-four employees were screened, and 5 cases of HHC were detected. All 5 cases involved Caucasian men, yielding a prevalence of 1:395 for the Caucasian population. Four of the 5 cases were of 100% British-Irish ancestry based on the country of origin of their grandparents. Additional analysis revealed that the majority of grandparents of all 4 individuals came from Ireland or Wales. The exact two-tailed trend test showed a significant association of HHC with Celtic background (P = .012). The estimated cost of screening per patient identified was $18,041. Polaroid Corporation has a high representation of employees of British-Irish ancestry. Our data suggest that they are at high risk for developing HHC. A significant association of HHC with Celtic ancestry was found in this subpopulation, supporting the concept of a Celtic origin for this disease.

Relationship of cytomegalovirus to salivary gland dysfunction in HIV-infected patients

In a previous retrospective study of HIV-infected patients we detected a relationship between xerostomia and the presence of cytomegalovirus in saliva. This prospective study compares 13 patients with HIV and a complaint of xerostomia and low salivary flow rates with a control group of 7 patients with HIV without xerostomia and normal salivary flow rates. Both groups were evaluated for the presence of cytomegalovirus in saliva, peripheral blood mononuclear cells, and labial minor salivary glands. Viral cultures, polymerase chain reaction, and histopathologic examination were used to detect cytomegalovirus. Xerostomia and low salivary flow rates were associated with the presence of CMV in saliva. The virus was detected in 10 of 13 xerostomia patients and 2 of 7 controls (p = 0.05, Fisher's exact test). Cytomegalovirus was detected in the saliva of patients who did not also have it in their blood suggesting a local source of virus replication such as the salivary glands. The minor salivary glands were not a major site of cytomegalovirus. Culture was more sensitive then polymerase chain reaction in detecting salivary cytomegalovirus as a result of the presence of inhibitors to the reaction in saliva. These results suggest a link between cytomegalovirus in saliva and salivary gland dysfunction in HIV-infected patients.

Toward standardization of health information

NCVHS has made recommendations to the DHHS to standardize 42 core health data elements, a number of which relate to medical conditions and services. The committee has asked the DHHS Data Council to actively promote, both within the department and externally, standardization of data elements and definitions where substantial consensus already exists. For those elements that have been recognized as significant core data elements, but for which there is not consensus on approach or definition, the NCVHS is recommending that the Data Council support the formation of a public-private working group to conduct further study and evaluation. This group, or a separate group, could also be the focus for evaluating additions to the list of core data elements and for setting up methods for testing and promulgating the final products. The coming 12-18 months will be exceedingly important for health data standardization efforts in the US as the DHHS responds to both the NCVHS recommendations and the legislation recently enacted by Congress.

(1S,2R)-D-erythro-2-(N-myristoylamino)-1-phenyl-1-propanol as an inhibitor of ceramidase

In this study, we have examined the cellular and biochemical activities of the ceramide analog (1S,2R)-D-erythro-2-(N-myristoylamino)-1-phenyl-1-propanol (D-erythro-MAPP). Addition of 5 microM D-e-MAPP to HL-60 human promyelocytic leukemia cells resulted in a concentration- and time-dependent growth suppression accompanied by an arrest in the G0/G1 phase of the cell cycle; thus mimicking the action of exogenous ceramides. Its enantiomer L-e-MAPP was without effect. Two lines of evidence suggested that D-e-MAPP may not function as a direct analog of ceramide. First, D-e-MAPP possesses a stereochemical configuration opposite to that of D-erythro-ceramide. Second, D-e-MAPP failed to activate ceramide-activated protein phosphatase in vitro. Therefore, we examined if D-e-MAPP functioned indirectly by modulating endogenous ceramide levels. The addition of D-e-MAPP to cells, but not L-e-MAPP, caused a time- and concentration-dependent elevation in endogenous ceramide levels reaching greater than 3-fold over baseline following 24 h of treatment. Both D-e-MAPP and L-e-MAPP underwent similar uptake by HL-60 cells. D-e-MAPP was poorly metabolized, and remained intact in cells, whereas L-e-MAPP underwent a time- and concentration-dependent metabolism; primarily through N-deacylation. In vitro, L-e-MAPP was metabolized by alkaline ceremidase to an extent similar to that seen with C16-ceramide. D-e-MAPP was not metabolized. Instead, D-e-MAPP inhibited alkaline ceramidase activity in vitro with an IC50 of 1-5 microM. D-e-MAPP did not modulate the activity of other ceramide metabolizing enzymes in vitro or in cells, and it was a poor inhibitor of acid ceramidase (IC50>500 microM). Finally, D-e-MAPP inhibited the metabolism of L-e-MAPP in cells. These studies demonstrate that D-e-MAPP functions as an inhibitor of alkaline ceramidase in vitro and in cells resulting in elevation in endogenous levels of ceramide with the consequent biologic effects of growth suppression and cell cycle arrest. These studies point to an important role for ceramidases in the regulation of endogenous levels of ceramide.

Herpesvirus infections

There are presently seven known herpes viruses that infect humans. Those viruses are important in the fields of oral medicine and dentistry because they cause oral lesions, infect saliva, and cause serious and potentially life-threatening infections in patients whose immune systems are compromised by cancer chemotherapy, immunosuppressive drugs, or HIV infection. This article reviews the basic virology and clinical manifestations of the herpes viruses while highlighting the clinical aspects of herpes-related diseases important to dentistry.

HIV-associated lesions

Oral lesions are common in HIV infection and may be the first sign of AIDS. This article reviews the oral fungal and viral infections commonly detected in HIV-infected patients, particularly candidiasis, deep fungal infections, herpes simplex virus infections, cytomegalovirus infections, and oral hairy leukoplakia. The neoplasms associated with AIDS such as oral Kaposi's sarcoma and lymphoma are related periodontal diseases. Each disorder is discussed by clinical appearance, diagnosis, and management. Recent advances in therapy are stressed.

Relationship of oral disease to the presence of cytomegalovirus DNA in the saliva of AIDS patients

Cytomegalovirus is an important pathogen in persons infected with human immunodeficiency virus. In this study a thorough oral examination was done and blood and urine cultures for cytomegalovirus were obtained from a group of 31 patients with acquired immunodeficiency syndrome with CD4 lymphocyte counts less than 150 cells/mm3. Whole saliva was also collected for detection of cytomegalovirus deoxyribonucleic acid (DNA) via the polymerase chain reaction. The presence of cytomegalovirus DNA in the saliva specimens was not related to the presence of cytomegalovirus in the urine, which suggests a local source of cytomegalovirus from salivary gland and kidney parenchyma. There was also a strong statistical relationship between salivary cytomegalovirus DNA and xerostomia (p = 0.0004), which suggests that cytomegalovirus may be a cause of salivary gland dysfunction in patients with acquired immunodeficiency syndrome with low CD4 counts.

Evidence for construct validity of the TMJ scale in a sample of chronic post-traumatic headache patients

The construct validity of the TMJ Scale was examined in a sample of chronic post-traumatic headache patients. Clinical indicators of temporomandibular (TM) dysfunction and measures of psychosocial distress were compared with relevant scales of the TMJ Scale. The clinical indicators were first subjected to principal components analysis. The resulting factor scores correlated significantly with selected physical domain scales of the TMJ Scale. The factor scores also significantly predicted the TMJ Global Scale in a regression analysis. Selected psychosocial domain scales of the TMJ Scale correlated strongly with measures of depression and anger and a clinical diagnosis of post-traumatic stress disorder. The results support the validity of the TMJ Scale and demonstrates its utility with post-traumatic headache patients.

Plasma cell gingivitis. Report of two cases

Plasma cell gingivitis is a disorder first described in the 1960s and was believed to be caused by an allergic reaction to flavored chewing gum and toothpaste. The lesion was believed to have been largely eliminated by removing the allergens from the products. We report two additional cases, not related to a known allergen. One patient was allergy tested thoroughly and given a strict elimination diet without resolution. Immunofluorescence study suggests a reactive rather than a neoplastic process.

Unrecognized attention-deficit hyperactivity disorder in adults presenting for outpatient psychotherapy

ABSTRACT Adult patients with significant childhood and current symptoms of attention-deficit hyperactivity disorder (ADHD), but whose ADHD had not been previously recognized, were evaluated by three clinical consultants working with diverse referral populations. These 60 adults shared common characteristics of physical and mental restlessness, impulsivity, disabling distractibility, low self-esteem, self-loathing, and a gnawing sense of underachievement. Specific learning or behavior problems were often present. These patients were chronically disaffected. The diagnosis of ADHD appeared to be missed because these individuals presented with atypical symptoms or had found ways to compensate for their deficits. Descriptive generalizations are offered concerning their coping strategies. These adults had sought previous psychiatric care for non-ADHD symptoms but had numerous unsuccessful treatment attempts. Most patients had been treated for mood or anxiety disorders. Traditional defense analysis had little beneficial effect and aggravated problems of self-esteem; modifications of the psychotherapeutic process are recommended. In open clinical trials without formal measures, the majority of such patients appeared to respond to low doses of antidepressants (i.e., desipramine 10-30 mg daily) and seemed to lose the therapeutic effect at higher antidepressant doses.

Combination of treatments for attention deficit hyperactivity disorder in adults

Three adults with DSM-III-R diagnoses of attention deficit hyperactivity disorder were treated with a combination of a psychostimulant and nadolol. Previous treatment with only a psychostimulant had not been effective or had not been tolerated. The combination treatment resulted in an increase in attention and focusing capacities, along with a decrease in anxiety, impulsiveness, and somatic discomfort. These improvements suggest an effective regimen for treatment-resistant adults with attention deficit hyperactivity disorder.

The association between congenital syphilis and cocaine/crack use in New York City: a case-control study

From 1987 to 1989, an epidemic of congenital syphilis was observed in New York City. A case-control study was done to assess the association between various maternal risk factors and congenital syphilis. Independent of the effect of other factors, the odds of being exposed to cocaine were 3.9 times greater among cases than controls (95% confidence interval, 2.8-5.3). This study suggests that the epidemic of congenital syphilis may be related to the increase in cocaine/crack use among delivering mothers.

Management of cheilitis granulomatosa

Peripheral facial nerve palsy, recurrent or persistent oral or facial swelling, and fissured tongue constitute a triad of symptoms known as Melkersson-Rosenthal syndrome. Granulomatous labial enlargement, known as cheilitis granulomatosa, is considered the single most important diagnostic feature of this syndrome. This lesion has been difficult to treat. This article describes a case of 8 months' duration of cheilitis granulomatosa of the lower lip, which was successfully managed with intralesional steroid injections.

Diabetes mellitus--a newly described risk factor for infection from Salmonella enteritidis

Infections due to Salmonella serotype enteritidis have increased markedly in the northeastern United States. Due to the potential severity of these infections, host risk factors for infection were determined in the largest nosocomial S. enteritidis outbreak to have occurred in the United States. In a case-control study, patients in a New York City hospital who developed infection after exposure to an S. enteritidis-contaminated meal were more likely to be medication-dependent diabetics than were those who did not develop infection (17/75 vs. 7/80, Mantel-Haenszel adjusted odds ratio = 3.1, 95% confidence interval = 1.1, 8.6). Proposed mechanisms for diabetes as a risk factor for infection include decreased gastric acidity in diabetic patients and an autonomic neuropathy of the small bowel that reduces intestinal motility and prolongs gastrointestinal transit time.