EXHANCE-3: a cohort study of the exhalation delivery system with fluticasone for chronic sinusitis with or without nasal polyps.

BACKGROUND: Inhaled nasal corticosteroid sprays (INS) are often inadequate to treat chronic rhinosinusitis (CRS). The exhalation delivery system with fluticasone (EDS-FLU; XHANCE®) may improve outcomes in CRS by increasing medication delivery to target superior/posterior anatomic sites. This study assessed safety and efficacy of EDS-FLU in a large population with moderate-to-severe CRS with or without nasal polyps (CRSwNP, CRSsNP). METHODS: Prospective, multicenter, 12-week, single-arm study of EDS-FLU 372 Â#181;g twice daily (BID) at 38 U.S. sites. Safety was assessed by adverse-event evaluations, nasal endoscopy, and ocular examinations. Efficacy was serially assessed by outcomes including nasal endoscopy (Lund-Kennedy Score, polyp grade), patient- and physician-reported outcomes (22-item Sinonasal Outcome Test [SNOT-22]), study-defined surgical indicator assessment, and Patient Global Impression of Change (PGIC). RESULTS: 705 comparatively refractory subjects were enrolled, 603 CRSsNP and 102 CRSwNP [moderate-to-severely symptomatic; baseline SNOT-22 ~43, high rates of prior INS use (92.3%) and/or prior surgery (27.5%)]. More than 90% reported improvement on treatment by PGIC. SNOT-22 scores improved substantially and similarly in patients with NP (-23.7) and without NP (-24.4). Among patients with baseline Lund-Kennedy edema scores >0, 33.3% (CRSwNP) and 54.8% (CRSsNP) had complete resolution of edema. In CRSwNP patients, 48% had polyp elimination in ?1 nostril, 63% had ?1-point improvement in polyp grade, mean bilateral polyp grade decreased from 2.9 to 1.6, and study-defined surgical eligibility decreased. EDS-FLU was generally well tolerated, with a safety profile similar to conventional INS sprays when used to treat CRS CONCLUSION: EDS-FLU 372 #181;g BID in the treatment of CRS with or without polyps was safe, well-tolerated, and produced substantial improvement across a broad range of both objective and subjective measures.

Severe food allergies by skin contact.

BACKGROUND: Ingestion is the principal route for food allergens, yet some highly sensitive patients may develop severe symptoms upon skin contact. CASE REPORT: We describe five cases of severe food allergic reactions through skin contact, including inhalation in one. METHODS: The cases were referred to a university allergy clinic, and evaluation comprised detailed medical history, physical examination, skin testing, serum total and specific IgE, and selected challenges. RESULTS: These cases were found to have a strong family history of allergy, early age of onset, very high total serum IgE level, and strong reactivity to foods by skin prick testing or RAST. Interestingly, reactions occurred while all five children were being breast-fed (exclusively in four and mixed in one). CONCLUSIONS: Severe food allergic reactions can occur from exposure to minute quantities of allergen by skin contact or inhalation. Food allergy by a noningestant route should be considered in patients with the above characteristics.

Dental management of the patient with Alzheimer's disease.

This paper summarizes factors to be considered in the dental management of the patient who presents with Alzheimer's disease. The information contained in this article will expand the understanding of the etiology, suspected pathophysiology and the clinical features of patients with Alzheimer's who may present for oral rehabilitation. The objective is to better prepare the dental professional in order that he/she may provide effective treatment planning for these patients.

Diversity in presenting manifestations of systemic lupus erythematosus in children.

OBJECTIVE: To describe the diversity in presenting manifestations of systemic lupus erythematosus (SLE) in children. STUDY DESIGN: Initial clinical and laboratory manifestations of 39 children, who fulfilled >/=4 American College of Rheumatology criteria for SLE, were retrospectively analyzed. RESULTS: Median age at onset was 12 years. The male to female ratio was 1:18.5, and racial/ethnic backgrounds were white 41%, black 33%, and Hispanic 26%. Initial manifestations included musculoskeletal 74%, cutaneous 72%, constitutional 67%, neurologic 28%, renal 28%, lymphadenopathy 15%, and Raynaud's phenomenon 10%. Laboratory abnormalities at presentation to our clinic included elevated erythrocyte sedimentation rate 87%, anemia 72%, lymphopenia 59%, leukopenia 31%, proteinuria or cellular casts 44%, low C(3) or C(4) level 77%, antinuclear antibodies 97%, and anti-double-stranded DNA 95%. One third (33%) presented with features not initially suggestive of SLE. Six patients presented with unusual manifestations including parotitis, quadriplegia, chorea, severe abdominal pain, persistent cough, and dizziness. However, 85% of patients with atypical manifestations had abnormal complete blood count or urinalysis results at presentation. CONCLUSION: Presenting manifestations of SLE in children are diverse. A detailed history, thorough review of systems, complete physical examination, complete blood count, urinalysis, and a high index of suspicion help to make the correct diagnosis of SLE in patients with atypical presentations.

Natural remedies recommended for the management of oral health.

This paper discusses various practices recommended by homeopaths, herbalists, spiritual and natural healers for the management and maintenance of oral health. It is intended as a partial guide to educate the dental professional on self-administered, over-the-counter remedies that are easily available to the general population. Since few if any clinical studies exist assessing the efficacy or side effects of these ingested products, little is known about the beneficial or potentially harmful course these remedies may take on the human body.

Intravenous immunoglobulin therapy: magic or black magic.

Intravenous immunoglobulin (IVIG) therapy has been used not only as replacement treatment for immunodeficiency, but also as treatment of autoimmune diseases, specifically Kawasaki disease, systemic juvenile arthritis and juvenile dermatomyositis. In Kawasaki disease, IVIG reduces the incidence of coronary artery abnormalities, as well as rapidly improving clinical and laboratory variables such as fever and rash, platelet count, white blood cell count and serum albumin. Furthermore, a single high dose of 2 g/kg is as effective as 400 mg/kg x 4 days. In systemic juvenile arthritis, followup of at least one year demonstrated that monthly treatment with IVIG resulted in improvement of systemic disease in 10/11 patients, allowed for cessation of prednisone treatment in 7/8 patients and significant improvement of arthritis in 8 patients. In juvenile dermatomyositis, we report 2 uncontrolled trials of IVIG treatment that resulted in significant clinical improvement and steroid-sparing. In contrast, IVIG treatment of systemic lupus erythematosus (SLE) resulted in improvement in 3 patients, but exacerbation or new onset of renal disease in 3 patients. Overall, our report demonstrates that IVIG has been effective both in a controlled trial in Kawasaki disease and in uncontrolled trials in systemic juvenile arthritis and juvenile dermatomyositis. We suggest that IVIG should be used cautiously in SLE.

The incidence of mucogingival defects: report of case.

The term true mucogingival defects has been used to denote a complete absence of attached gingiva. This study attempted to establish how often true mucogingival defects occur in a random population sample. Of the 1,302 teeth studied, 13 teeth (1%) had a mucogingival defect, indicating that the true mucogingival defect is not a common occurrence.

Fetal alcohol syndrome: report of case.

A report of a patient with fetal alcohol syndrome has been presented with a review of the syndrome and the literature. Although the patient was treated in the operating room, many patients with less severe medical involvement or less extensive dental needs can be treated as outpatients. Each case must be considered individually with the prime concern being the patient's safety. Such patients may have numerous emotional or physical problems that the dentist must recognize. These patients are at high risk for several types of heart defects, many of which will require consultation for bacterial endocarditis precautions. The major and minor anomalies associated with fetal alcohol syndrome have been outlined.

HLA-DR and MT associations with the clinical and serologic manifestations of pauciarticular onset juvenile rheumatoid arthritis.

Significant HLA-DR and MT associations were observed with certain clinical and serologic manifestations of pauciarticular onset juvenile rheumatoid arthritis (PO-JRA). An increase in the MTI frequency was found in 56 children with PO-JRA in comparison to 95 normal controls. This association was limited to children with a younger age of onset (less than 6 years) and a persistent pauciarticular course. An increase in HLA-DRW8 and a decrease in DR4 were associated with a younger age of onset and antinuclear antibody (ANA) seropositivity. In addition, an increased frequency of DR5 was seen in ANA positive children. All of these HLA-DR and MT associations were independent of coassociating Ia specificities.

A survey of complications in segmental orthognathic surgical procedures.

This article is a summary of responses of oral-maxillofacial surgeons to a questionnaire related to their experiences in dentoalveolar segmental osteotomy surgery. It is presented as an evaluation of complications and as an overview of medications, splinting techniques, and suggestions on measures to avoid future complications.

Two Ia.17-specific monoclonal antibodies detect the same epitope but do not share idiotype.

The clonal diversity of anti-Ia antibodies was studied by using heterologous anti-idiotypic reagents generated against two Ia.17-specific monoclonal antibodies (Mab). The Mab 10-2.16 and 10-3.6 are specific for the Ia.17 public specificity expressed on I-A molecules of the k, s, f, u, r, and j haplotypes. Competitive inhibition experiments demonstrated that 10-2.16 and 10-3.6 inhibited the binding of each other to Ia.17-positive cell targets, indicating that they detected the same or overlapping epitope(s). Identical inhibition patterns of 125I-10-2.16 binding by 10-3.6 by using Ia.17-positive target cells of four different strains indicated that inhibition was not due to steric hindrance from binding to spatially related epitopes. Rabbit anti-10-2.16 serum detected both site-specific and framework-specific 10-2.16 idiotypic determinants not shared by 10-3.6. Conversely, rabbit anti-10-3.6 serum detected 10-3.6 idiotypic determinants not shared by 10-2.16. C3H/J (I-Ak) anti-10-2.16 serum detected only 10-2.16 framework-specific idiotypes, suggesting that 10-2.16 site-specific determinants represent cellular determinants for syngeneic Ia antigens. Furthermore, anti-Ia.17 immune serum from three of 10 mice with the Igh-Cb allotype expressed the 10-2.16 framework-specific idiotype. We have demonstrated that two anti-Ia.17 Mab, 10-2.16 and 10-3.6, lack a shared idiotype, even though they detect a similar epitope. This observation and the variable expression of 10-2.16 idiotypic determinants in immune sera indicate that the B cell response to the Ia.17 epitope detected by 10-2.16 and 10-3.6 is diverse.

Treatment of oro-antral-nasal fistula after anterior maxillary osteotomy.

A case of a patient with an open bite deformity was presented that, because of improper preoperative treatment planning, resulted in an oro-antral-nasal communication. The subsequent re-evaluation of the patient and the corrective surgical procedure are discussed, with a retrospective evaluation of the total treatment sequence.