The effect of bitewing radiography on estimates of dental caries experience among children differs according to their disease experience.

BACKGROUND: Radiography is a regularly used and accepted adjunct to visual examination in the diagnosis of dental caries. It is assumed that not using radiographs can lead to underestimation of dental caries experience with most reports having involved studies of young adults or adolescents, and been focused on the permanent dentition. The aim of this study was to determine the relative contributions of bitewing radiography and clinical examination in the detection of dental caries in primary molars and to determine whether those contributions differ according to caries experience. METHODS: A cross-sectional study was conducted, involving examinations undertaken in dental clinics. Bitewing radiographs taken at the time of the clinical examination were developed and read later, with the data from those used at the analysis stage to adjust the caries diagnosis for the mesial, occlusal and distal surfaces of the primary molar teeth. Children's clinically determined dmfs score was used to allocate them to one of three caries experience groups (0 dmfs, 1-8 dmfs, or 9+ dmfs). RESULTS: Of the 501 three-to-eight-year-old children examined, nearly three-quarters were younger than six. Caries prevalence and mean dmfs after clinical examination alone and following radiographs were 63.1% and 4.6 (sd, 6.2), and 74.7% and 5.8 (sd, 6.5) respectively. Among children with a dmfs of 1-8, the number of lesions missed during the clinical examination was greater than the number of 106 (25.6%) in children with a dmfs of 9+. In the 185 children with no apparent caries at clinical examination, 124 lesions were detected radiographically, among 58 (46.8%) of those. CONCLUSIONS: Taking bitewing radiographs in young children is not without challenges or risks, and it must be undertaken with these in mind. Diagnostic yields from bitewing radiographs are greater for children with greater caries experience. The findings of this study further support the need to consider using bitewing radiographs in young children to enhance the management of lesions not detected by a simple visual examination alone. TRIAL REGISTRATION: ACTRN12614000844640 .

A novel treatment of patients with chronic hepatitis C.

OBJECTIVES: Interferon alpha-2b therapy for Chronic Hepatitis C patients has been unsatisfactory. Recombinant Granulocyte Macrophage Colony-Stimulating Factor has been shown to have anti-viral effects in vivo and in vitro via cytokines release. Recently its effects on chronic hepatitis B and possibly chronic hepatitis C were reported. We, decided to conduct a pilot study to evaluate the anti-viral effects of recombinant human GM-CSF mono-therapy in patients with chronic hepatitis C and to assess its side effects. METHODS: A total of 10 patients (male/female: 5/5) (age: 34-60, mean: 45) seen in our center between 2/95 to 2/96 were randomly selected to receive recombinant human Granulocyte Macrophage Colony-Stimulating-Factor at 125 ug/m2 subcutaneously daily for two weeks followed by three times weekly for another 8 weeks. Biochemical (ALT) and viral (HCV-RNA) responses were measured prior to treatment and at weeks four and eight. Side effects were recorded. RESULTS: Six out of the ten patients treated had significant viral reduction but none became negative. Eight out the ten patients treated showed biochemical improvement and three out of the eight had normalized liver enzymes. Age, sex, stage of the disease did not influence the response but there seems to be a tendency for patients with higher pre-treatment viral level to respond virally. Side effects are minimal and well-tolerated. CONCLUSION: Recombinant human Granulocyte Macrophage Colony-Stimulating-Factor in the dose used has anti-viral effects in the majority of the chronic hepatitis C patients studied. Side effects are minimal and well tolerated. Further study with higher doses and longer duration is needed to prove its clinical efficacy in treating patients with chronic hepatitis C.

A pilot randomized, controlled trial of the effect of iron depletion on long-term response to alpha-interferon in patients with chronic hepatitis C.

BACKGROUND/AIMS: Some studies have suggested that hepatic iron may influence the response to interferon therapy in chronic hepatitis C patients. We conducted this randomized, controlled trial to evaluate the effect of iron depletion on: (1) aminotransferase activity and hepatitis C RNA levels; and (2) response to interferon therapy in 38 patients with elevated alanine aminotransferase levels and who were HCV RNA positive. METHODS: Seventeen patients underwent a 500-ml phlebotomy every 2 weeks until iron deficiency was achieved. Patients were then started on a 6-month course of alpha-interferon 2b (3 mu tiw). Controls were 21 patients who were monitored for a 6- to 8-week period without phlebotomy prior to interferon therapy. Response to interferon was defined as loss of serum HCV RNA by reverse transcriptase-polymerase chain reaction. Serum HCV RNA was quantitated by bDNA technique. RESULTS: Alanine aminotransferase levels decreased in 15/17 patients after phlebotomy. Mean alanine aminotransferase fell from 156.8 to 89.7 U/l (p=0.008). Changes in iron indices and alanine aminotransferase after phlebotomy were not accompanied by changes in HCV RNA levels. In control patients, neither alanine aminotransferase nor HCV RNA levels changed during the observation period. At the end of 24 weeks of interferon therapy, 7/17 phlebotomized patients had a response, compared to 6/21 control patients (p=ns). After 6 months of follow-up, 5/17 phlebotomized patients remained HCV RNA negative, in contrast to only 1/21 controls (p=0.07). CONCLUSIONS: Iron depletion led to a reduction in aminotransferase levels; this was not accompanied by changes in levels of hepatitis C RNA. There may be an improvement in the sustained response to interferon therapy, but this requires confirmation.

Effect of iron depletion on long-term response to interferon-alpha in patients with chronic hepatitis C who previously did not respond to interferon therapy.

About half of patients with chronic hepatitis C treated with interferon will not have a biochemical or virological response. Several studies suggested that increased hepatic iron content may negatively influence the response to interferon. We conducted this prospective trial to evaluate the effect of iron depletion on the response to a repeat course of interferon in 20 chronic hepatitis C patients who previously had not responded to interferon. The patients underwent 500-ml phlebotomies every 2 weeks until iron deficiency was achieved. Patients were then started on a 6-month course of interferon alfa-2b (3 million units, t.i.w.). These patients required a mean of 6.0 (range, 1-14) phlebotomies to become iron deficient. ALT levels decreased in 18 of 20 patients and became normal in 4 patients. Mean ALT levels decreased from 154.2 to 87.9 U/L (p = 0.0006). At the end of 24 wk of interferon therapy, ALT levels were normal in 11 patients, 3 of whom had undetectable HCV RNA in the serum. One additional patient with abnormal ALT had undetectable HCV RNA. After 6 months of follow-up, one of the HCV RNA negative patients relapsed with reappearance of HCV RNA and elevation of ALT. In summary, 15% of chronic hepatitis C patients who previously failed interferon now had a sustained response to interferon therapy that was preceded by iron depletion.

The origin of lower extremity deep vein thrombi in acute venous thrombosis.

BACKGROUND: It has been taught that most deep venous thromboses (DVT) begin in the deep veins of the calf and propagate proximally. The duplex ultrasound scan, with its noninvasive characteristics and accuracy, has brought this premise into question. The purpose of this study was to determine the pattern and distribution of acute DVT as well as the different types of thrombi. METHODS: We performed a retrospective review of all duplex scans ordered for a diagnosis of acute lower extremite DVT at a 200-bed hospital over a 5-year period. RESULTS: There were 3,585 examinations performed on 2,654 patients. There were 461 patients (17.4%) with a venous thrombosis. Four types of venous thrombosis were identified: an isolated thrombosis in one venous segment (34%), a thrombosis extending over two or more contiguous segments (52%), multiple thromboses in noncontiguous segments (8%), and bilateral thrombi in different locations (6%). CONCLUSION: Calf vein thrombi represented 24% of all DVT. Thrombi in the major veins of the thigh and popliteal space without calf involvement were present in 49% of all DVT. The data in this paper indicate that most significant deep venous thromboses do not begin in the calf but instead arise in the proximal thigh or groin.

Coagulation disorders in cancer.

Coagulation disorders are common in cancer patients. This article reviews the coagulation laboratory findings in these patients and the thromboembolic and hemorrhagic manifestations of malignancy. Among the many topics addressed are Trousseau's syndrome, disseminated intravascular coagulation, and acquired von Willebrand disease. Pathogenesis of the coagulation disorders and recommendations for treatment of various syndromes are discussed.

Selective use of the duplex scan in diagnosis of deep venous thrombosis.

BACKGROUND: The introduction of managed care, with its emphasis on cost containment, makes it of paramount importance that all tests ordered be specific, selective, and appropriate. METHOD: The data concerning patients who underwent a duplex scan to determine the presence of deep venous thrombosis (DVT) over a 68-month period, were reviewed in order to determine if the test was ordered appropriately. The symptoms that prompted the test, type of physician ordering the test, and demographic data for both the patients who tested positive and negative were tabulated. RESULTS: A total of 2,841 duplex scans were ordered over a 68-month period for presumptive diagnosis of DVT of an extremity. A total of 524 (18%) scans were positive for thrombosis; however, 27% (144) of these were superficial or a small isolated thrombus in the calf or forearm. Thus, only 380 studies, or 13% of the total scans ordered, were positive for a major DVT requiring treatment. The only symptoms consistently found in the positive group were pain, edema, dyspnea, and a history of DVT. Of the types of physicians ordering the test, emergency department physicians were least specific, with only 12% of the scans ordered being positive for DVT; surgeons were more selective and had a 19% positive rate, while internal medicine physicians had a 20% positive rate. CONCLUSION: The duplex scan allows the physician the ability to easily diagnose venous thrombosis, but its indications need to be more carefully guided by history, physical examination, risk factors, and logic to enhance its use and effectiveness. This study analyzes the risk factors and symptoms involved in order to assist the clinician in determining when the duplex scan is indicated.

Pentosan-induced thrombocytopenia: support for an immune complex mechanism.

Pentosan polysulphate is a low molecular weight heparinoid that is used as an anticoagulant. Because the drug also has antineoplastic properties, it has been used experimentally at the National Institutes of Health to treat metastatic malignancies. We present the case of a patient who developed thrombocytopenia resembling Type II heparin-induced thrombocytopenia (HIT) during the course of pentosan therapy. The patient's plasma demonstrated platelet reactivity both by aggregometry and 14C-serotonin release in the presence of pentosan. Heparin and other polyanions could substitute for pentosan in aggregation studies. The aggregating activity co-purified with the patient's IgG and was inhibited by pre-incubation with monoclonal antibody (MoAb) to the platelet Fc receptor. To elucidate the relationship between the platelet, the polyanion and the antibody, we measured the binding of 3H-heparin to platelets in the presence of the patient's IgG and found that it was increased 6-fold over binding in the presence of control IgG. Heparin binding was not reduced by MoAb against the Fc receptor. Taken together, these data support a model in which polyanion-antibody complexes attach to the platelet surface by the polyanion and secondarily stimulate the platelet via their Fc termini.