Description of trunk neural crest migration and peripheral nervous system formation in the Egyptian cobra Naja haje haje

The neural crest is a stem cell population that forms in the neurectoderm of all vertebrates and gives rise to a diverse set of cells such as sensory neurons, Schwann cells and melanocytes. Neural crest development in snakes is still poorly understood. From the point of view of evolutionary and comparative anatomy is an interesting topic given the unique anatomy of snakes. The aim of the study was to characterize how trunk neural crest cells (TNCC) migrate in the developing elapid snake Naja haje haje and consequently, look at the beginnings of development of neural crest derived sensory ganglia (DRG) and spinal nerves. We found that trunk neural crest and DRG development in Naja haje haje is like what has been described in other vertebrates and the colubrid snake strengthening our knowledge on the conserved mechanisms of neural crest development across species. Here we use the marker HNK1 to follow the migratory behavior of TNCC in the elapid snake Naja haje haje through stages 1-6 (1-9 days postoviposition). We observed that the TNCC of both snake species migrate through the rostral portion of the somite, a pattern also conserved in birds and mammals. The development of cobra peripheral nervous system, using neuronal and glial markers, showed the presence of spectrin in Schwann cell precursors and of axonal plexus along the length of the cobra embryos. In conclusion, cobra embryos show strong conserved patterns in TNCC and PNS development among vertebrates.

Efficacy of mycophenolate treatment in adults with steroid-dependent/frequently relapsing idiopathic nephrotic syndrome

BACKGROUND

This study assessed the efficacy of therapy with mycophenolate (MF) and reduced doses of steroids in adults with steroid-dependent/frequently relapsing idiopathic nephrotic syndrome (SD/FR-INS).

METHODS

Twenty-nine nephrotic patients (including 16 males and 13 females; mean age: 40 years, range: 18-74) were treated. Starting doses of MF were 2000 mg/day for mofetil MF (1500 mg/day in one patient) or 1440 mg/day for sodium MF. The initial prednisone (PDN) dose was 10 mg/day in 14 patients, 5 mg/day in two patients and no steroids in one patient. In the remaining 12 patients, moderate initial doses of PDN were administered (mean: 23.7 mg/day, range: 15-40), tapering to 10 mg/day after 1 month.

RESULTS

Nephrotic syndrome remission was achieved in 27/29 cases (93.1%) (25 complete, 2 partial). Two patients showed resistance to the prescribed schedule. The first cycle of MF therapy was concluded in 20 patients after a mean (range) of 16.9 months (12-49). Maintenance of remission was observed in 11 of these 20 cases (55%) after a mean follow-up of 32.8 months (12-108). In nine patients with nephrotic syndrome relapse after tapering of MF (MF dependency), the same MF-PDN schedule was restarted, leading again to remission in all nine. The remaining seven MF-sensitive patients are still receiving their first therapeutic cycle. To date, the mean time under therapy in the 27 MF-sensitive patients is 38 months (4-216). Regarding complications, only minor digestive disorders and a slight decrease in blood haemoglobin levels were observed in a few patients.

CONCLUSIONS

MF plus reduced doses of PDN is an effective and well-tolerated therapy for adult SD/FR-INS. Though MF dependence is observed, its low toxicity could allow long periods of therapy if it is required to maintain nephrotic syndrome remission.

Use of mycophenolate in ANCA-associated renal vasculitis: 13 years of experience at a university hospital

INTRODUCTION

Standard therapy with corticosteroids (CS) and cyclophosphamide (CYC) followed by azathioprine has been shown to improve renal and patient survival in ANCA-associated renal vasculitis (rAAV). Mycophenolate mofetil (MF) has been progressively introduced for the treatment of rAAV in the last years because of its immunosuppressive efficacy combined with a lower toxicity profile. In this study, we retrospectively analyse the results of the introduction of MF for maintenance and induction therapy in rAAV in our institution from 2001 to 2013.

RESULTS

We reported 67 patients treated with MF as a maintenance treatment, divided by baseline serum creatinine (>500 µmol/L: Group 1 and <500 µmol/L: Group 2) and treatment schedule. Twenty-nine of the 67 patients were also treated with MF as induction treatment, mostly in Group 2. During the follow-up (2 years after the diagnosis) creatinine levels for serum glomerular filtration rate, ANCA titres, C-reactive protein and percentage of haematuria decreased in all groups. In Group 2, parameters and also relapse rates were similar at 24 months in patients treated with CYC or MF as an induction treatment (Subgroups 2a and 2b, respectively). Median dose of MF in maintenance treatment was 1000 mg daily and prednisone dose was tapered to 10 mg daily from Month 3. After 24 months, 82% of patients remained on MF therapy, 18% had discontinued the treatment, seven of them due to medical indication and two because of gastrointestinal intolerance. The percentage of patients that started renal replacement therapy was irregular in Group 1 depending on the subgroup (25-100%), and 10% in Group 2. Adverse effects, such as neutropenia, infections and neoplasia, were more prevalent in groups treated with CYC.

CONCLUSION

In conclusion, in our patients with rAAV, MF demonstrated to be an effective and well-tolerated option for maintenance treatment. As an induction treatment, MF seems to be similar to CYC for patients with moderate renal failure in the diagnosis.

Mycophenolate as maintenance therapy for lupus nephritis with impaired renal function

BACKGROUND

Mycophenolate (MF) is effective as a maintenance therapy after induction therapy in patients with lupus nephritis (LN). However, little is known about its role in patients with impaired renal function. The purpose of this study was to evaluate the efficacy and safety of MF as a maintenance therapy for LN and its association with renal function.

METHODS

Data were obtained for 56 Spanish patients who were receiving MF as a maintenance therapy for LN. Patients were classified into two groups according to renal function at the initiation of MF treatment: group 1 [estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m(2)] and group 2 (eGFR <60 ml/min/1.73 m(2)). The primary endpoints of the study were the rates of renal relapse and responses, and their relationship with baseline renal function. Secondary outcomes were the appearance of side effects during treatment.

RESULTS

At initiation of MF treatment, the only differences between the groups were for age, hemoglobin levels, anti-DNA antibody titer, proteinuria, and renal function. In group 1 (n = 38), the eGFR was 98 ± 34 ml/min/1.73 m(2) and in group 2 (n = 18) the eGFR was 43 ± 14 ml/min/1.73 m(2). Only 3 cases had an eGFR <30 ml/min/1.73 m(2). No significant differences were observed in the rate of relapse at 6 months (group 1: 20%; group 2: 23%) or at 12 months (group 1: 25%; group 2: 17%). Response rates were also similar in both groups. Side effects were unremarkable.

CONCLUSIONS

MF is effective and safe as a maintenance therapy for LN both in patients with normal renal function and in those with renal impairment.

Enhancing the efficacy of treatment for temporomandibular patients with muscular diagnosis through cognitive-behavioral intervention, including hypnosis: a randomized study

OBJECTIVE

This study evaluated the efficacy of a cognitive-behavioral therapy (CBT), including hypnosis, in patients with temporomandibular disorders (TMDs) with muscular diagnosis.

STUDY DESIGN

Seventy-two patients (65 women and 7 men with an average age of 39 years) were selected according to the Research Diagnostic Criteria for TMD, and assigned to the experimental group (n = 41), receiving the 6-session CBT program, and the control group (n = 31). All patients received conservative standard treatment for TMD. The assessment included pain variables and psychologic distress.

RESULTS

There were significant differences between the groups, the experimental group showing a higher improvement in the variables evaluated. Specifically, 90% of the patients under CBT reported a significant reduction in frequency of pain and 70% in emotional distress. The improvement was stable over time, with no significant differences between posttreatment and 9-month follow-up.

CONCLUSIONS

CBT, including hypnosis, significantly improved conservative standard treatment outcome in TMD patients.

Mycophenolate as induction therapy in lupus nephritis with renal function impairment

BACKGROUND

Mycophenolate (MF) is effective as induction therapy for lupus nephritis (LN) in patients with normal renal function; however, little is known about its role in patients with impaired renal failure. The purpose of this study was to evaluate the response to MF in LN and its association with baseline renal function.

METHODS

Data were obtained for 90 patients from 12 Spanish renal units who were receiving MF as induction therapy for LN. Patients were classified into 2 groups: group 1 (estimated glomerular filtration rate [eGFR] ≥60 ml/min/1.73 m(2)) and group 2 (eGFR <60 ml/min/ 1.73 m(2)). The primary outcome measure was the percentage of patients who achieved any response and its relationship with initial eGFR. The secondary outcome measures were the percentage of patients who achieved a complete response (CR) or partial response (PR) and the appearance of relapses during treatment and side effects.

RESULTS

At initiation of MF treatment, there were no differences in the main parameters between group 1 (n = 63; eGFR 87 ± 23 ml/min/ 1.73 m(2)) and group 2 (n = 27; eGFR 44 ± 12 ml/min/1.73 m(2)). Exposure to prednisone and MF was similar. The percentages of patients who achieved a response in groups 1 and 2 were, respectively, 69.2 and 43.8% at 6 months and 81.3 and 73.7% at 12 months. CR was more frequent in group 1, whereas PR was similar in both groups. Four patients relapsed and side effects were unremarkable.

CONCLUSIONS

MF is effective and safe as induction therapy for LN, and response is even achieved in patients with baseline renal impairment.

Low-dose sirolimus combined with angiotensin-converting enzyme inhibitor and statin stabilizes renal function and reduces glomerular proliferation in poor prognosis IgA nephropathy

BACKGROUND

There is a lack of new therapeutic strategies for IgA nephropathy. Low-dose sirolimus inhibits mesangial cell proliferation and renal fibrosis in animal models.

METHODS

We performed a pilot, randomized controlled trial to evaluate the efficacy and safety of low-dose sirolimus in patients with a high-risk IgA nephropathy. Twenty-three patients with a glomerular filtration rate (GFR) within 30-60 mL/min and/or proteinuria >1 g/day were randomly assigned to low-dose sirolimus plus enalapril and atorvastatin (SRL group, n = 14) or enalapril plus atorvastatin (CONTROL group, n = 9). Primary composite end point was variation of haematuria, proteinuria and blood pressure. Secondary end points were isotopic GFR, renal histology evaluated by Oxford classification and safety parameters evaluated at 6 and 12 months.

RESULTS

Primary end point improved significantly in the SRL group at 12 months. Regarding isotopic GFR, patients included in the CONTROL group lost 8 mL/min/1.73 m(2), whereas those in the SRL arm improved 5 mL/min/1.73 m(2) (P = 0.03). Proteinuria decreased similarly in both study groups. At 1 year, SRL treatment was associated with a significant reduction of mesangial and endocapillary proliferation, whereas glomerular sclerosis, tubular atrophy and interstitial fibrosis were similar. Sirolimus was well tolerated; all patients remained on therapy at 12 months.

CONCLUSION

The addition of low-dose sirolimus to enalapril and statin is safe, stabilizes renal function and reduces glomerular proliferative lesions in patients with poor prognosis IgA nephropathy.

Sjögren's syndrome of the oral cavity. Review and update

Sjögren's syndrome is one of the most frequent autoimmune diseases. It is a chronic and systemic disorder predominantly found in women, and is characterized by the appearance of a lymphocytic inflammatory infiltrate, with dryness of the oral cavity and eyes, secondary to involvement of the salivary and lacrimal glands. The underlying causal mechanism involves a number of factors and has not been clearly established, though an autoimmune response is known to be triggered, with the accumulation of immune complexes in the gland acini that interfere with gland function. In the oral cavity, xerostomia or hyposialia is the most disabling manifestation for patients, and is accompanied by rapidly progressing caries, candidiasis and an important worsening of buccodental health. The most important complication is a 44-fold increase in the risk of developing non-Hodgkin lymphoma, compared with the general population. The treatment of Sjögren's syndrome is limited to symptomatic management, and involves the use of solutions to replace salivary secretion and afford a measure of hydration, cholinergic agents such as pilocarpine to stimulate the unaffected gland tissue and, recently, the administration of substances that act against surface antigens of the B lymphocytes, such as anti-CD20 and anti-CD22 antibodies. The present study provides an update on this disease, placing special emphasis on its odontologic implications.

TRPC6 mutational analysis in a large cohort of patients with focal segmental glomerulosclerosis

BACKGROUND

Mutations in the TRPC6 gene have been reported in six families with adult-onset (17-57 years) autosomal dominant focal segmental glomerulosclerosis (FSGS). Electrophysiology studies confirmed augmented calcium influx only in three of these six TRPC6 mutations. To date, the role of TRPC6 in childhood and adulthood non-familial forms is unknown.

METHODS

TRPC6 mutation analysis was performed by direct sequencing in 130 Spanish patients from 115 unrelated families with FSGS. An in silico scoring matrix was developed to evaluate the pathogenicity of amino acid substitutions, by using the bio-physical and bio-chemical differences between wild-type and mutant amino acid, the evolutionary conservation of the amino acid residue in orthologues, homologues and defined domains, with the addition of contextual information.

RESULTS

Three new missense substitutions were identified in two clinically non-familial cases and in one familial case. The analysis by means of this scoring system allowed us to classify these variants as likely pathogenic mutations. One of them was detected in a female patient with unusual clinical features: mesangial proliferative FSGS in childhood (7 years) and partial response to immunosupressive therapy (CsA + MMF). Asymptomatic carriers of this likely mutation were found within her family.

CONCLUSIONS

We describe for the first time TRPC6 mutations in children and adults with non-familial FSGS. It seems that TRPC6 is a gene with a very variable penetrance that may contribute to glomerular diseases in a multi-hit setting.

Pediatric dental care in a tertiary public hospital. Four years of experience in the Service of Stomatology of Valencia University General Hospital (Valencia, Spain)

A study is made of the experience gained with the Child Oral Care Program (Plan de Atención Dental Infantil, PADI) in the Service of Stomatology of Valencia University General Hospital (Valencia, Spain) after four years in operation (July 2003 - July 2007).

STUDY DESIGN

The sample comprised 2626 children between 5-14 years of age, pertaining to department 9 of the Valencian public health system. A clinical history was compiled in each case, a radiological study was made, and a treatment plan was elaborated including fillings, extractions, and control visits.

RESULTS

Of the 2626 designated children, 2369 visited our Service - mostly referred from the Preventive Dental Care Units. A total of 5784 fillings were carried out (93.3% with silver amalgam, 5.6% with composites and the rest as provisional fillings). The permanent first molars were the teeth with the largest number of fillings (70.2% of the total). These were followed in order of frequency by the second molars (19.1%). As regards composite resin fillings, most involved the upper central incisors, followed by the upper lateral incisors. A total of 644 extractions were performed, corresponding to 110 permanent teeth and 534 temporary teeth. In the case of the permanent dentition, the first molars were the most commonly removed teeth. In the temporary dentition, the most frequently removed teeth were the second molars.

CONCLUSIONS

The response of the population to this program has been very good, and reinforces the preventive measures already in place, with the provision of restorative treatments to improve the oral and dental health of the pediatric population, and yielding good results in terms of the program quality indicators. The Service of Stomatology (Valencia University General Hospital) is able to address the demand and offers the public health network integrated and continuous patient care.

Prevalence of bacteraemia following third molar surgery

OBJECTIVE

To investigate the prevalence and aetiology of bacteraemia following third molar extractions (B-TME), analysing the factors affecting its development.

METHODS

The study group was formed of 100 patients undergoing third molar extractions under general anaesthesia. Peripheral venous blood samples were collected at baseline, 30 s after a mandibular third molar extraction and 15 min after completing the final extraction. Samples were inoculated into BACTEC aerobic and anaerobic blood culture bottles and were processed in the BacT/Alert. Subculture and further identification of the bacteria isolated was performed using conventional microbiological techniques.

RESULTS

The prevalence of bacteraemia following third molar surgery was 62% at 30 s after the first dental extraction and 67% at 15 min after finishing the final extraction. The bacteria most frequently identified in the positive blood cultures were Streptococcus viridans (87.9%).

CONCLUSION

In our series, the prevalence of B-TME at 30 s after a single third molar extraction was high, principally being of streptococcal aetiology, and was independent of the oral health status and the magnitude of the surgical procedure. Positive blood cultures persisted for at least 15 min after three to four dental extractions in a higher number of patients, questioning the supposedly transient nature of bacteraemia following dental extractions.

An update on the management of anticoagulated patients programmed for dental extractions and surgery

Oral anticoagulants (OACs) antagonizing vitamin K - fundamentally sodium warfarin and acenocoumarol - are widely used for preventing arterial thromboembolism in patients with atrial fibrillation and/or heart valve prostheses, and for the treatment and prevention of deep venous thrombosis and pulmonary embolism. The handling of these drugs requires correct monitorization and dose adjustment to obtain the desired therapeutic effect while minimizing the adverse effects associated both with excessive anticoagulation (which leads to bleeding) and with insufficient antithrombotic action (which can produce thrombosis). This is particularly important when patients must be subjected to surgical procedures such as tooth extractions. In this context, a number of management recommendations are available. The present study offers an update on the recommendations for the management of anticoagulated patients programmed for tooth extractions. In recent years, most studies do not recommend reducing or interrupting anticoagulation, or replacing it with heparin, prior to tooth extraction - provided therapeutic international normalized ration (INR) levels are maintained, with emphasis on the application of local measures such as antifibrinolytic agents, for the control of hemostasia.

Benign tumors of the oral mucosa: a study of 300 patients

OBJECTIVES

To analyze the frequency and type of the most common benign tumors of the oral mucosa found at the Hospital Stomatology Service, and to study the clinical characteristics and possible etiological factors.

MATERIAL AND METHODS

This is a retrospective study of 300 patients with histologically diagnosed benign tumors of the oral mucosa. Data was compiled for each case, documenting information relating to age, gender, medication, habits (smoking, oral hygiene), anamnesis (reason for consultation, symptomatology, evolution), and the characteristics of the lesion (site, color, size, surface, consistency, and base).

RESULTS

Of all the tumors studied, 53% were histologically diagnosed as fibroma. In the study of prevalence of benign tumors of the oral mucosa, no differences were found for age; however there were differences according to gender, finding a greater prevalence of fibromas, pyogenic granulomas, and giant cell granulomas in women, at a ratio of 2:1. The group of tumors studied showed a significantly asymptomatic behaviour, and self-limiting and slow growth. With respect to the possible etiologic agents, we found no statistically significant differences between them.

CONCLUSIONS

Following the study of 300 patients histologically diagnosed with benign tumor of the oral mucosa, we can state that with regard to prevalence, we found significant differences with respect to gender, being more frequent in women. The fibroma is the most frequent benign tumor of the oral cavity.

Epstein-Barr virus in oral proliferative verrucous leukoplakia and squamous cell carcinoma: A preliminary study

The aim of this study was to analyze proliferative verrucous leukoplakia (PVL) and oral squamous cell carcinoma (OSCC) for the possible presence of Epstein-Barr virus (EBV). We studied three groups: Sub-Group 1 was composed of 10 patients with PVL, (6 of whom had developed OSCC); Sub-Group 2 comprised 5 patients with OSCC but no preceding PVL; and Sub-Group 3 were 5 controls with clinically normal oral mucosa. Oral biopsies from all cases were examined for Epstein-Barr virus (EBV) by nested PCR. EBV was detected in 60% of Sub-Group 1 patients (PVL ) and in 40% of Sub-Group 2 (OSCC), but in 0% of Sub-Group 3 (controls).

[Renal involvement in benign monoclonal gammopathies: an underdiagnosed condition]

Renal involvement is observed frequently in association with malignant gammopathies, mainly those related to light chain deposition, although has also been described in non-malignant monoclonal gammopathy. This study reports the clinicopathological findings and outcome in 9 patients with nephropaty secondary to monoclonal immunoglobulin deposit in absence of malignancy. They were three men and six women and they were 59.2+/-12 years old. All patients presented proteinuria and different levels of renal insufficiency (mean creatinin = 315+/-187 micromol/L) at the moment of diagnostic. Two patients required dialysis at the time of renal biopsy. The pathology studies revealed a nodular sclerosing glomerulopathy in four cases, mesangiocapilary glomerulonephritis in three cases, only tubular lesions in one and mesangial lesions in the other one. The treatment applied was: Prednisone alone (two cases), with chemotherapy associated (melfalan in two, clorambucil in one and ciclophosphamide in another one). One patient received plasmapheresis and mycophenolate and another patient undergone a bone marrow authotransplant associated to mycophenolate and prednisone. One of the two patients who required dialysis at the moment of presentation was not treated. After a follow-up of more than 4 years (4.89 +/-DE: 3.69) renal function improved or remained stable in three patients and proteinuria was disappeared in more than 50% of patients. Four patients had a worsening of renal function and they required dialysis during the time of follow-up (in 2,4 years +/- DE: 4,3). In any case malignitation was observed. Chemotherapy stabilized or improved renal function in 3 of nine patients (33%) with non-malignant monoclonal gammopathy. Non-malignant monoclonal gammopathy could go unnoticed. Appearance of abnormalities in renal routine tests deserves more in-depth diagnostic procedures, including renal biopsy. Evolution to end stage renal disease could probably be avoided or reduced in severity with early detection and treatment of this entity.

Treatment of idiopathic membranous nephropathy with the combination of steroids, tacrolimus and mycophenolate mofetil: results of a pilot study

BACKGROUND

Membranous nephropathy is a common cause of nephrotic syndrome (NS) in adults. Its treatment is still under debate.

METHODS

We report our experience in a pilot study using initially low doses of steroids and tacrolimus (Tac). After 3 months of treatment, mycophenolate mofetil (MMF) was added if the proteinuria was higher than 1 g/day.

RESULTS

In accordance with this standard, 21 patients entered the study. A proteinuria level lower than 1 g/day was reached at month 3 of therapy with steroids and Tac in 11 patients. These patients continued this treatment for 12 months. MMF was added in nine cases after the third month and triple therapy was maintained for 12 more months. Two patients were withdrawn because of side effects. At the end of the treatment, remission of the NS was present in 15 out of all the patients (71.4%). Remission of the NS was complete in eight (53.3%) patients and partial in seven (46.7%) others. The remaining four patients did not respond. There were no significant changes in renal function. At a mean time of 23.1 months after treatment was discontinued, 11 (73.3%) patients had relapsed.

CONCLUSIONS

In this trial, treatment with tacrolimus showed a good efficacy but a high relapse rate when it was discontinued.

New immunosuppresor strategies in the treatment of murine lupus nephritis

Renal involvement in systemic lupus erythematosus is a common complication that significantly worsens morbidity and mortality. Although treatment with corticosteroids and cytotoxic drugs may be useful in many cases, morbidity associated with these drugs and the relapsing nature of the disease make it necessary to develop new treatment strategies. Five-month old female NZB/W F1 mice were divided into the following groups: CYP group (n = 10), cyclophosphamide (CYP) 50 mg/kg intraperitoneally every 10 days; RAPA 1 group (n = 10) oral daily sirolimus (SRL), 1 mg/kg; RAPA 12 group (n = 13), oral daily SRL, 12mg/kg; FTY group (n = 10), oral fingolimod (FTY720), 2 mg/kg three times per week. An additional group of 13 non-treated mice were used as a control (control group). Follow-up was performed over four months. Animal survival, body weight, anti-DNA antibodies and proteinuria were determined. Kidneys were processed for conventional histology and immunofluorescence for IgG and complement. Total histological score (HS) was the sum of mesangial expansion, endocapillary proliferation glomerular deposits, extracapillary proliferation, interstitial infiltrates, tubular atrophy and interstitial fibrosis. All treated groups had lower proteinuria at the end of the follow-up with respect to the control group (P < 0.0001). Serum anti-DNA antibodies were appropriately controlled in RAPA 1 and CYP groups, but not in FTY or RAPA 12 groups. SRL and CYP arrested, and perhaps reversed almost all histological lesions. FTY720 ameliorated histological lesions but did not control mesangial expansion or interstitial infiltrates. SRL produces great improvement in murine lupus nephritis, while FTY720 seems a promising alternative if used in appropriate doses.

Lack of association between proliferative verrucous leukoplakia and human papillomavirus infection

PURPOSE

To analyze proliferative verrucous leukoplakia (PVL) for the presence of human papillomavirus (HPV) in different stages of the disease.

MATERIALS AND METHODS

We studied 13 patients with PVL. In 10 patients (76.9%), a lesional biopsy was taken and frozen at -40 degrees C. Four patients were instructed to mouth rinse with sterile sera. The biopsy and rinse samples were analyzed for HPV by PCR.

RESULTS

We did not detect HPV infection in the PVL tissue or in the oral rinse of any of the 13 patients in any stage of the disease analyzed, neither in oral squamous cell carcinoma nor in the simple hyperkeratosis.

CONCLUSION

There was no association between PVL and HPV infection in our patients.

An examination of the psychometric structure of the Multidimensional Pain Inventory in temporomandibular disorder patients: a confirmatory factor analysis

Background

This paper seeks to analyse the psychometric and structural properties of the Multidimensional Pain Inventory (MPI) in a sample of temporomandibular disorder patients.

Methods

The internal consistency of the scales was obtained. Confirmatory Factor Analysis was carried out to test the MPI structure section by section in a sample of 114 temporomandibular disorder patients.

Results

Nearly all scales obtained good reliability indexes. The original structure could not be totally confirmed. However, with a few adjustments we obtained a satisfactory structural model of the MPI which was slightly different from the original: certain items and the Self control scale were eliminated; in two cases, two original scales were grouped in one factor, Solicitous and Distracting responses on the one hand, and Social activities and Away from home activities, on the other.

Conclusion

The MPI has been demonstrated to be a reliable tool for the assessment of pain in temporomandibular disorder patients. Some divergences to be taken into account have been clarified.

Psychological assessment of patients with temporomandibular disorders: confirmatory analysis of the dimensional structure of the Brief Symptoms Inventory 18

OBJECTIVE

This article analyzes the psychometric and structural properties of the Brief Symptoms Inventory 18 in a sample of patients with temporomandibular disorders (TMDs), given the convenience of a brief evaluation of distress in these patients.

METHODS

Confirmatory factor analysis was carried out in a sample of 114 patients with TMDs. Two models were tested: the theoretical model with the original structure proposed--which considers three dimensions--and the empirical model obtained through the exploratory factor analysis initially carried out by Leonard R. Derogatis--which consists of the four-factor structure.

RESULTS

Both models reached satisfactory indexes in confirmatory factor analysis. Empirical and theoretical reasons led us to prefer the original proposal of three dimensions: somatization, depression and anxiety, and general distress.

CONCLUSION

The Brief Symptoms Inventory 18 has been demonstrated to be a reliable and valid tool for the assessment of distress in patients with TMDs, with the advantage of its simplicity and ease of application.

Multidimensional approach to the differences between muscular and articular temporomandibular patients: coping, distress, and pain characteristics

OBJECTIVE

This study analyzes the differences in psychological variables and symptomatology between temporomandibular disorder diagnosis subgroups.

STUDY DESIGN

The sample included 114 temporomandibular disorder patients that were evaluated in coping, distress, and temporomandibular characteristics. Diagnostic muscular (n = 58) and articular (n = 56) subgroups were compared in these variables through a MANCOVA.

RESULTS

Muscular patients show a higher level of general distress, specifically in the anxiety and somatization subscales and a more active coping style, with a tendency of a minor use of humor and a higher number of parafunctional habits, specifically, biting nails, hangnails, and lips.

CONCLUSION

We discuss the differences found in order to design the targets of the psychological intervention of temporomandibular patients.

Multiple sclerosis as first manifestation in oral and facial area: presentation of four cases

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system, whose etiology is unknown, and which is characteristic by the appearance of a diverse neurological symptomatology consisting of outbreaks or gradual deterioration and lesions in any location of the brain s white matter which may provoke the after-effect of a definitive demyelination of the area. The disease affects young people, with its appearance being most frequent between 20 and 40 years of age, in temperate and cold climates, and with a man-woman rate of 0.46/0.67. The magnitude of this disease lies in the fact that it is the primary cause for permanent disablement among young adults. We are presenting 4 cases of MS whose initial symptom of the disease was the appearance of paraesthesia in the maxillofacial area, affecting one or more ramifications of the trigeminal nerve, and a progression time varying from 15 days to one year. All the patients were clinically diagnosed, with their diagnostics being confirmed both with magnetic resonance imaging as well as through the study of their cerebrospinal fluid (CSF) and the evoked potentials (EPs). Manifestations in the oral and facial area were the first manifestation of the disease in all cases.

Granulomatous facial reaction to injected cosmetic fillers--a presentation of five cases

The use of substances to augment soft tissues as aesthetic purpose is associated with, among other undesirable effects, the appearance of foreign body granulomas. The improvements made to these substances have reduced the incidence of adverse reactions, but not eliminated them. We present five cases of foreign body reactions to three different products, dimethylpolysiloxane (silicone), bovine collagen, and polylactic acid, which were injected into the subcutaneous cellular tissue of the patients (all five were women), between two and sixteen years before the appearance of the foreign body reaction. All five presented painless, diffuse facial tumefaction, of firm, elastic consistency. The magnetic resonance image (MRI) studies showed signs of intense inflammatory reaction in the affected areas. The histology revealed the presence of foreign body granulomas with giant multi-nucleated cells. The patients were treated with systemically administered corticoids, except in one case which did not require pharmacological treatment.

Avascular jaw osteonecrosis in association with cancer chemotherapy: series of 10 cases

BACKGROUND

We present a series of 10 patients with osteonecrosis of the jaws (ONJ) that appeared following cancer chemotherapy.

MATERIAL AND METHODS

Of the 10 cases with ONJ, six had bone metastases from breast cancers and the other four had multiple myeloma. We analysed the location of bone metastases, as well as the characteristics of the ONJ, and the drugs with which they had been treated for their bone metastases.

RESULTS

Of the 10 patients, all had ONJ in the mandible; 50% also had maxillary involvement. The average number of areas of painful exposed was 2.1 per patient (range 1-5). In seven patients a tooth extraction preceded the onset of ONJ. Two patients developed oroantral communications and another a cutaneous fistula to the neck with suppuration. In all the 10 patients the histopatholological diagnosis was of chronic osteomyelitis without evidence of metastatic disease to the jaws. All the patients had received treatment for their malignant bone disease with bisphosphonates. These were the only drugs that all patients had received.

CONCLUSION

ONJ appears to have a relationship with the use of bisphosphonates.

[Pharmacogenetics of angiotensin system in non diabetic nephropathy]

BACKGROUND

Genetic variability could contribute to the response to pharmacological treatment in patients with nephropathy. In albuminuric diabetic patients the renoprotective effect of angiotensin I-converting enzyme (ACE) inhibition should be lower among homozygotes for the deletion allele (DD) compared to II-homozygotes.

METHODS

A total of 71 non-diabetic chronic nephropathy patients were treated with losartan (n = 37) or amlodipine (n = 34). Blood pressure and proteinuria were determined before and after the treatment, and changes in the mean values were statistically compared. Patients were genotyped for the ACE-I/D, angiotensin I receptor type 1 (AGTR1)-1166 A/C, and angiotensinogen (AGT)-M235T polymorphims, and the reduction of blood pressure and proteinuria between the different genotypes were compared.

RESULTS

The reduction in systolic or diastolic blood pressure was not found to be different between the ACE-I/D or AGT-M/T genotypes in patients treated with losartan or amlodipine. In patients treated with losartan, we found a significantly higher reduction of diastolic blood pressure in AGTR1-AA patients compared to AC patients (p = 0,0024). We did not find differences in proteinuria-reduction between the different genotypes in patients treated with losartan or amlodipine.

CONCLUSIONS

Our data show that the effects of losartan and amlodipine on the absolute mean reduction of blood pressure and proteinuria in non-diabetic nephropathy patients are similar between the different ACE or AGT genotypes. Although based on a small number of patients, the AGTR1-AA genotype was associated with a significantly higher reduction in diastolic blood pressure among losartan-treated patients. Additional studies are necessary to refute or confirm this association.

Psychological variables and temporomandibular disorders: distress, coping, and personality

OBJECTIVE

This study analyzes the psychological variables of distress, personality, and coping that are related to the diagnosis based on the Research Diagnostic Criteria for temporomandibular disorder. Study design An age and sex-matched controlled study conducted with a convenience sample (n=89) in a tertiary care facility.

RESULTS

The MANCOVA between the muscular (n=47), articular (n=42), and control groups (n=100) showed that the muscular group differed from the control group, obtaining higher levels of distress, anxiety, and depression, and minor use of positive reinterpretation and humor as coping strategies; the articular group also showed higher distress, less positive reinterpretation, and a lower interest in the search of instrumental social support than the control group. The coping predictor of distress in both temporomandibular groups was behavioral disengagement; however, the personality predictors differed. Neuroticism and depression were present in the muscular group, whereas conscientiousness and self-discipline were in the articular group.

CONCLUSION

Temporomandibular disorder patients have different psychological features than control subjects. There are also some differences between the diagnostic groups that should be considered to address the treatment of these patients.

Proliferative verrucous leukoplakia: unusual locations of oral squamous cell carcinomas, and field cancerization as shown by the appearance of multiple OSCCs

Proliferative verrucous leukoplakia (PVL) is an uncommon entity with a high tendency to develop oral squamous cell carcinomas (OSCCs). The objective of this study was to analyse the presence of various OSCCs in the same patient with PVL. We studied 19 patients with PVL who had developed at least one OSCC. We analysed how many of these developed more than one OSCC over a period between 24 and a maximum of 130 months, indicating the location of their OSCC, clinical type and the time lapse between the appearance of each of the different OSCCs in the same patient. Of the 19 patients, 10 presented more than one of these cancers, one of whom even went on to develop five different cancers. The most frequent location of OSCC was the gingiva and the palate; the least common was the tongue/floor of mouth. Ninety percent were women and 20% were smokers. The average time elapsed between the detection of the first tumour and the appearance of the second was 19.20 months (SD 13.41). Our patients with PVL developed a high frequency of OSCCs, on many occasions manifesting several cancers at different oral locations, thus demonstrating the field cancerization of this entity. The OSCC in PVL patients were at sites quite uncommonly affected in patients who develop OSCC in the absence of PVL.

Odontogenic infections. Complications. Systemic manifestations

The term, odontogenic infection refers to an infection that originates in the tooth proper or in the tissues that closely surround it; said infection then progresses along the periodontia down to the apex, involving periapical bone and from this area, it then spreads through the bone and periosteum towards near-by or more distant structures. The relevance of this type of infection lies in that it can cause infections that compromise more distant structures (via direct spread and distant spread), for example, intracraneal, retropharyngeal and pulmonary pleural infections. Dissemination by means of the bloodstream can lead to rheumatic problems and deposits on the valves of the heart (endocarditis), etc. The conditions or factors that influence the spread of infection are dependent on the balance between patient-related conditions and microorganism-related conditions. The virulence of the affecting germs is dependent upon their quality and quantity and is one of the microbiological conditions that influences the infection. It is this virulence that promotes infectious invasion and the deleterious effects the microbe will have on the host. Patient-related conditions include certain systemic factors that determine host resistance, which may be impaired in situations such as immunodeficiency syndrome or in brittle diabetes, as well as local factors that will also exert their impact on the spread of the infection.

Antiproteinuric efficacy of losartan in comparison with amlodipine in non-diabetic proteinuric renal diseases: a double-blind, randomized clinical trial

BACKGROUND

Proteinuria is a significant independent determinant of the progression of chronic renal diseases. It induces an increased synthesis of angiotensin II, endothelin and profibrogenic growth factors, such as transforming growth factor-beta (TGF-beta), by mesangial and tubular cells. The antiproteinuric effect of angiotensin-converting enzyme inhibitors (ACEIs) in diabetic and non-diabetic nephropathies predicts long-term renoprotection afforded by these drugs. Angiotensin II receptor antagonists are renoprotective in patients with type 2 diabetes, but studies about their effect in non-diabetic proteinuric nephropathies are very scarce.

METHODS

We randomly assigned 97 patients with non-diabetic nephropathies and proteinuria >1.5 g/24 h to treatment with losartan (50 mg daily) or amlodipine (5 mg daily) for 20 weeks. Doses of the study medications were titrated to achieve a target blood pressure <140/90 mmHg in both groups. Primary outcome was the decrease in the level of 24 h proteinuria. Secondary outcomes were changes in the plasma and urinary levels of TGF-beta.

RESULTS

The baseline characteristics in both groups were similar. Proteinuria decreased by 32.4% (95% confidence interval -38.4 to -21.8%) after 4 weeks of treatment and by 50.4% (-58.9 to -40.2%) after 20 weeks in the losartan group, whereas no significant proteinuria changes were observed in the amlodipine group (P < 0.001). There was no significant correlation between the level of baseline proteinuria and the proteinuria decrease induced by losartan. Both losartan and amlodipine induced a similar and significant blood pressure reduction. Target blood pressure was achieved with the initial dose of study medication (50 mg daily) in 76% of losartan group patients and in 68% of the amlodipine group patients (5 mg daily). Urinary TGF-beta significantly decreased with losartan (-22.4% of the baseline values after 20 weeks of treatment), whereas it tended to increase with amlodipine (between-group difference P < 0.05). A significant correlation between proteinuria decrease and urinary TGF-beta reduction was found in the losartan group (r = 0.41, P < 0.005). Serum creatinine and serum potassium remained stable during the study in both groups.

CONCLUSIONS

Losartan induced a drastic decrease in proteinuria accompanied by a reduction in urinary excretion of TGF-beta in patients with non-diabetic proteinuric renal diseases.

[Anti-glomerular basement membrane antibody mediated disease: revision of 32 cases and follow-up at one year of the diagnosis]

Anti-basement membrane antibody mediated disease is an unfrequent entity but with a high mortality and morbidity. We present a revision of 32 patients diagnosed of anti-basement membrane antibody mediated disease between 1983 and 1997, and their evolution at one year of the diagnosis. The clinical pattern of presentation was as a Goodpasture's syndrome (glomerulonephritis and lung haemorrhage) in 15 patients and glomerulonephritis without lung involvement in 17. We reviewed retrospectively the features at the clinical presentation, the different treatments, and the delay of the starting of it since the beginning of the symptoms, in order to evaluate a prognosis dats of the disease. After the retrospective study we deduce that anti-basement membrane antibody mediated disease has a high mortality although the different regimes of treatment applied (25%), and the need of renal replacement therapy at one year of diagnosis is also high (70.8%). The renal survival at one year of the diagnosis is low and the response to therapy depends on the serum creatinine value at the diagnosis. The contribution of immunocompetent leucocytes to renal hypercellularity suggests that both humoral and cell-mediated immunity play a role in this disease.

Proliferative verrucous leukoplakia: high incidence of gingival squamous cell carcinoma

BACKGROUND

Proliferative verrucous leukoplakia (PVL) is a multifocal and progressive lesion of the oral mucosa, often associated with papillomavirus, seen mainly in older females, and characterized by a high recurrence rate and high rate of transformation into verrucous or oral squamous cell carcinoma (OSCC). The aim of this study was to analyse the clinical characteristics of a substantial group of patients with PVL, evaluating the characteristics of those who developed cancer, and comparing them with a group of patients with OSCC but no preceding PVL.

METHODS

A group of 30 patients with PVL was studied for the clinical aspects and characteristics, age, sex, location, recurrence, the appearance of new lesions, and the frequency of development of oral cancer. A disease control group was formed with 110 patients with OSCC chosen randomly from among those treated in the same Service in this period of time. The patients were grouped as PVL and no cancer (Group 1); PVL developing cancer (Group 2) and patients with OSCC without clinical lesions associated with PVL (Group 3).

RESULTS

The average age of the PVL patients (Groups 1 and 2 combined) was 70.97 +/- 12.73 years, of which 80% were women. Only 23.3% were cigarette smokers. The area most frequently affected with PVL was the lower gingiva. Recurrence after treatment was seen in 86.7%, and new lesions appeared in 83.3%. Many (63.3%) developed cancer (Group 2). Comparison of Groups 2 and 3 patients showed that those with PVL developing cancer were more likely to develop gingival carcinoma and also to be older, more often females, and less likely to smoke tobacco.

CONCLUSION

Cancer developing in patients with PVL manifested particularly on the gingiva.

Goodpasture syndrome during the course of a Schönlein-Henoch purpura

Two months after surgical resection of a bronchogenic carcinoma, a 69-year-old patient presented with Schönlein-Henoch purpura with kidney involvement followed by pulmonary hemorrhage. The presence of an IgA linear pattern on the kidney biopsy specimen and circulating anti-glomerular basement membrane (GBM) IgA antibodies led to the diagnosis of Goodpasture syndrome, which implies the possibility that the well-known pulmonary involvement during the course of Schönlein-Henoch purpura could be caused by Goodpasture syndrome in certain cases. In cases of glomerulonephropathy with lung involvement, clinicians should not limit their investigations to anti-GBM IgG.

[Rapid-detection GBM-ANCA ELISA. An emergency tool for the early diagnosis of type I and II rapidly progressive glomerulonephritis]

Rapidly progressive glomerulonephritides (RPGN) are forms of necrotizing glomerulonephritis associated with anti-glomerular basement membrane (anti-GBM) and anti-neutrophil cytoplasmic antibodies (ANCA) against the antigens proteinase-3 (anti-PR3) and myeloperoxidase (anti-MPO). RPGN have a course of rapid progression to renal failure. We compared the results from the semiquantitative ELISAs for anti-GMB antibodies, PR3-ANCA and MPO-ANCA and the indirect immunofluorescence technique (IIF) against a new rapid assay (30 minutes) for the same antibodies in patients with clinically suspected RPGN. The semiquantitative ELISAs for anti-GBM antibodies and PR3-ANCA and MPO-ANCA have a proven diagnostic significance in patients with RPGN I and III. There were no significant differences between the ANCA-GBM screening test and the results from the semiquantitative ELISAs (p > 0.05). We did not find significant differences between the results for PR3-ANCA and MPO-ANCA from the ANCA-GBM screening test with C-ANCA and P-ANCA IIF values (p > 0.05). We also corroborated that the ANCA-GBM screening test is a diagnostic tool for RPGN I and III as useful as the semiquantitative ELISAs and the IFF technique. The ANCA-GBM ELISA screening test is a tool as useful as the semiquantitative ELISA against anti-GBM antibodies for diagnosis of RPGN I. The comparison of the screening ELISA with the IIF technique and the semiquantitative ELISAs against PR3-ANCA and MPO-ANCA showed similar utility for diagnosis of RPGN III. The advantages of the new screening assay are that three antibodies are tested at the same time, yielding results in only 30 minutes.