Temporomandibular disorders in an adult population in northern Norway: A cross-sectional study.

OBJECTIVES: The aim of the study was to assess the prevalence of symptoms indicative of temporomandibular disorders (TMD) in an adult population in Troms County in Northern Norway, as well as the associations between TMD and socio-demographic factors, dental status, self-reported general, and oral health as well as oral health related quality of life (OHQoL). METHODS: Data were collected from a structured questionnaire and a clinical examination of a random sample of almost 2000 adults, 20-79-year-old, in Troms County in Northern Norway. RESULTS: Women had a higher prevalence of all self-reported and clinical signs of pain and dysfunction in the temporomandibular complex compared to men. For both genders, sounds from the temporomandibular joint (TMJ) upon clinical examination was the most common symptom, followed by pain to palpation of jaw muscles. Headache was the most common of the self-reported symptoms and sounds from the TMJ the second most common. Young women had a higher prevalence of self-reported headache and jaw- and face pain compared to middle-aged and elderly women. TMD-related symptoms of pain were significantly associated with poor self-reported general health and correlated with OHQoL as assessed by the oral health impact profile 14 questionnaire. CONCLUSION: Being women and having moderate to poor self-reported general health were associated with clinical signs and self-reported symptoms of pain in the jaw, face and head region. Self-reported symptoms of TMD correlated more strongly with OHQoL than clinical signs.

Are metal-induced hypersensitivities in harbor seals associated with liver function?

Environmental exposure to metals is believed to affect marine mammal health adversely including immunosuppression or acute as well as chronic inflammatory processes leading to hypersensitivities or autoimmune diseases. Metal-specific hypersensitivities were found in several pinnipeds of the North Sea. However, hypersensitivity is a complex phenomenon whose characteristics are still not completely understood; in particular, effects on health are not well established. In the present study, we compared basic hematological and biochemical parameters of seals with and without metal-specific hypersensitivities. We found altered hematological parameters and liver enzyme patterns in seals with a metal-induced hypersensitivity, including a reduction in macrophages, an increase in lymphocytes, and elevated levels of lactate dehydrogenase. These findings support the suggestion of a chronic influence of metal pollutants on the health of marine mammals of the North Sea.

First health and pollution study on harbor seals (Phoca vitulina) living in the German Elbe estuary.

The Elbe is one of the major rivers releasing pollutants into the coastal areas of the German North Sea. Its estuary represents the habitat of a small population of harbor seals (Phoca vitulina). Only little is known about the health status and contamination levels of these seals. Therefore, a first-ever seal catch was organized next to the islands of Neuwerk and Scharhörn in the region of the Hamburg Wadden Sea National Park. The investigations included a broad set of health parameters and the analysis of metals and organic pollutants in blood samples. Compared to animals of other Wadden Sea areas, the seals showed higher γ-globulin levels, suggesting higher concentrations of pathogens in this near-urban area, elevated concentrations for several metals in particular for V, Sn, Pb, and Sr, and comparable ranges for chlorinated organic contaminants, except for elevated levels of hexachlorobenzene, which indicates characteristic inputs from the Elbe.

Effects of methyl-, phenyl-, ethylmercury and mercurychlorid on immune cells of harbor seals (Phoca vitulina).

Mercury (Hg) is present in the marine environment as a natural metal often enhanced through human activities. Depending on its chemical form, Hg can cause a wide range of immunotoxic effects. In this study, the influence of methyl-, ethyl- and phenylmercury as well as mercurychloride on immune functions was evaluated. Two parameters of cellular immunity, proliferation and mRNA cytokine expression of interleukin-2, -4, and transforming growth factor beta, were investigated in harbor seal lymphocytes after in vitro exposure to Hg compounds. While all Hg compounds had a suppressive effect on proliferation, differences between juvenile and adult seals were found. Lymphocytes from juveniles showed a higher susceptibility to the toxic effect compared to lymphocytes from adults. Furthermore, the degree of inhibition of proliferation varied among the four Hg compounds. The organic compounds seem to be more immunotoxic than the inorganic compound. Finally, for the cytokine expression of methylmercury-incubated lymphocytes, time-dependent changes were observed, but no dose-dependency was found. Marine mammals of the North Sea are burdened with Hg, and lymphocytes of harbor seals may be functionally impaired by this metal. The present in vitro study provides baseline information for future studies on the immunotoxic effects of Hg on cellular immunity of harbor seals.

Blood metal levels and metal-influenced immune functions of harbour seals in captivity.

Immunological blood parameters and the effects of environmental pollutants on the immune system are important to assess the health status of seals. Animals living permanently in seal centres are useful for development and validation of diagnostic tools for free-ranging animals. In this study, parameters of cellular immunity as well as metal concentrations in blood and metal influence on cell proliferation of seven seals from a seal centre were investigated repeatedly using multi-element analysis and a lymphocyte proliferation assay. The metal concentrations, except for tin and chromium, were in general comparable to those of free-ranging animals of the North Sea. The unstimulated and mitogen-stimulated lymphocyte proliferation showed strong intra- and inter-individual variability, which reflected variability in activation of the immune status. Furthermore, both immunosuppressive and stimulative influences of metals on lymphocytes were found. Summarising, the methods used in this investigation provided useful information on these animals, and their application to free-ranging animals can be recommended.

Metal-induced impairment of the cellular immunity of newborn harbor seals (Phoca vitulina).

The cellular immunity of newborn harbor seals and the influence of pollutants are rarely investigated. This study evaluated the lymphocyte proliferation using a lymphocyte proliferation test (LTT) to understand the dynamics of immune response in seal pups of varying ages from the moment they arrived in a seal center after active beaching until their release into wildlife 3 months later after rehabilitation. Moreover, the effect of various metals (Ag, Al, Au, Be, Cd, Co, Cr, Cu, different Hg compounds, Mo, Ni, Pb, Pd, Pt, Sn, Ti) on lymphocyte proliferation in terms of immunosuppression and hypersensitivity was investigated. First, a strong lymphocyte proliferation in newborns as a reflection of relative immunocompetence was found. Second, different metal-induced influences on lymphocyte proliferation such as specific inhibition by Be, Cd, Hg, and Sn as well as stimulation induced by Mo and Ni were determined. For seals tested repeatedly, the suppressive effect was detected in newborns but not found in the same animals when they were older and had become immunologically competent. Summarizing, the lymphocyte proliferation used as a marker in this investigation provided useful immunological information on these developing animals, and its application for toxicological studies on pollutants can be recommended.

A novel lymphocyte transformation test (LTT-MELISA) for Lyme borreliosis.

Diagnosis of active Lyme borreliosis (LB) remains a challenge in clinically ambiguous, serologically indeterminant, and polymerase chain reaction-negative patients. Lymphocyte transformation tests (LTTs) have been applied to detect specific cellular immune reactivity, but their clinical application has been severely hampered by the poorly defined Borrelia antigens and nonstandardized LTT formats used. In this study, we describe the development and clinical relevance of a novel LTT using a validated format (MELISA) together with well-defined recombinant Borrelia-specific antigens. From an initial screening of 244 patients with suspected Borrelia infection or disease, 4 informative recombinant antigens were selected: OspC (Borrelia afzelii), p41-1 (Borrelia garinii), p41-2 (B. afzelii), and p100 (B. afzelii). Thereafter, 30 seronegative healthy controls were tested in LTT-MELISA(R) to determine specificity, 68 patients were tested in parallel to determine reproducibility, and 54 lymphocyte-reactive symptomatic patients were tested before and after antibiotic therapy to assess clinical relevance. Most (86.2%) of the 36.9% (90/244) LTT-MELISA positive patients were seropositive and showed symptoms of active LB. Specificity was 96.7% and reproducibility 92.6%. After therapy, most patients (90.7%) showed negative or markedly reduced lymphocyte reactivity correlating with clinical improvement. This novel LTT-MELISA assay appears to correlate with active LB and may have diagnostic relevance in confirming LB in clinically and serologically ambiguous cases.

Hypersensitivity to titanium: clinical and laboratory evidence.

OBJECTIVES: This study was carried out to investigate the potential of titanium to induce hypersensitivity in patients chronically exposed to titanium-based dental or endoprosthetic implants. METHODS: Fifty-six patients who had developed clinical symptoms after receiving titanium-based implants were tested in the optimized lymphocyte transformation test MELISA against 10 metals including titanium. Out of 56 patients, 54 were patch-tested with titanium as well as with other metals. The implants were removed in 54 patients (2 declined explantation), and 15 patients were retested in MELISA. RESULTS: Of the 56 patients tested in MELISA, 21 (37.5%) were positive, 16 (28.6%) ambiguous, and 19 (33.9%) negative to titanium. In the latter group, 11 (57.9%) showed lymphocyte reactivity to other metals, including nickel. All 54 patch-tested patients were negative to titanium. Following removal of the implants, all 54 patients showed remarkable clinical improvement. In the 15 retested patients, this clinical improvement correlated with normalization in MELISA reactivity. CONCLUSION: These data clearly demonstrate that titanium can induce clinically-relevant hypersensitivity in a subgroup of patients chronically exposed via dental or endoprosthetic implants.

LTT-MELISA is clinically relevant for detecting and monitoring metal sensitivity.

OBJECTIVES: Chronic low-level metal exposure may result in metal sensitization and undesirable side-effects. The main sources of metal exposure are from the environment or from corrosion of dental metal alloys. Affected patients are routinely diagnosed with the epicutaneous (patch) test. However, such testing may induce false-positive (irritative) reactions and may in itself sensitize or exacerbate symptoms. Alternatively, MELISA (Memory Lymphocyte ImmunoStimulation Assay), an optimized lymphocyte transformation test (LTT), can be used. In this study we analyzed the overall frequency and distribution of metal sensitization among symptomatic, metal-exposed patients. In addition, we determined the reproducibility of the assay and assessed its clinical relevance for detecting and monitoring hypersensitivity to metals. METHODS: To analyze the frequency and distribution of metal sensitization, blood from 700 consecutive patients was tested against a total of 26 metals in the validated LTT-MELISA. For reproducibility testing, 391 single metal tests from 63 patients were performed in parallel. Finally, to assess clinical relevance, 14 patients with known metal exposure showing local (dry mouth, Oral Lichen Planus, Burning Mouth Syndrome, eczema) and/or systemic (chronic infections, fatigue, autoimmune disorders, central nervous system disturbances, depression) effects were tested in LTT-MELISA. In 7 cases testing was repeated following removal of the allergy-causing metals or, in 2 additional cases, without therapeutic intervention. RESULTS: Of the 700 patients tested, 74.6% responded to >/= 1 metal in LTT-MELISA, with a subgroup of 17.9% responding to >/= 3 metals. Reactivity was most frequent to nickel (68.2%), followed by cadmium (23.7%), gold (17.8%), palladium (12.7%), inorganic mercury (11.4%), molybdenum (10.8%), beryllium (9.7%), titanium dioxide (4.2%), lead (3.7%), and platinum (3.4%). Reproducibility was 94.9%, with most discordant results in a low-positive range. Removal of the alloys or prostheses containing allergenic metals resulted in remarkable clinical improvement correlating with a significant reduction or complete normalization of specific lymphocyte reactivity. In contrast, both LTT-MELISA reactivity and clinical symptoms remained unchanged in follow-up samples from the 2 patients who did not remove the source of metal exposure. CONCLUSION: The optimized LTT-MELISA test is a clinically useful and reliable tool for identifying and monitoring metal sensitization in symptomatic metal-exposed individuals.

Immunological impact of metals in harbor seals (Phoca vitulina) of the North Sea.

Environmental pollutants may affect the immune system of marine mammals in many areas of the industrialized world. This study provides the first evidence for metal-induced hypersensitivity in harbor seals and demonstrates a relationship between this immunopathy and the level of metals in blood. The concentrations of 20 essential and nonessential elements were analyzed in the blood of 13 harbor seals from the North Sea. In addition, their T-lymphocyte response to metals in terms of hypersensitivity was investigated using a lymphocyte transformation test (LTT) according to the MELISA (memory lymphocyte immuno-stimulation assay) modification. The results showed metal hypersensitivities in 7 of 11 seals investigated in MELISA (data from two seals could not be assessed), reflecting a positive or possible positive reaction in 13 of 154 total single tests. Four animals responded to one metal and three animals to multiple metals. The sensitizing metals were molybdenum (Mo), titanium (Ti), nickel (Ni), chromium (Cr), aluminum (Al), lead (Pb), and tin (Sn). Furthermore, the seals with a Ni-, Al-,.and Cr-sensibilization showed the highest concentrations of these metals in blood. In 8 of the 13 positive cases, elevated blood metal concentrations correlated with the hypersensitivity reaction. Summarizing, we demonstrate in this first pilot study the potential immunological impact of metals in seals, a topic rarely investigated previously. Our results show the value of a combined biological and effect-monitoring tool to investigate pollution-induced immunopathies in live animals.

Fully automated, internally controlled quantification of hepatitis B Virus DNA by real-time PCR by use of the MagNA Pure LC and LightCycler instruments.

We report on the development of a fully automated real-time PCR assay for the quantitative detection of hepatitis B virus (HBV) DNA in plasma with EDTA (EDTA plasma). The MagNA Pure LC instrument was used for automated DNA purification and automated preparation of PCR mixtures. Real-time PCR was performed on the LightCycler instrument. An internal amplification control was devised as a PCR competitor and was introduced into the assay at the stage of DNA purification to permit monitoring for sample adequacy. The detection limit of the assay was found to be 200 HBV DNA copies/ml, with a linear dynamic range of 8 orders of magnitude. When samples from the European Union Quality Control Concerted Action HBV Proficiency Panel 1999 were examined, the results were found to be in acceptable agreement with the HBV DNA concentrations of the panel members. In a clinical laboratory evaluation of 123 EDTA plasma samples, a significant correlation was found with the results obtained by the Roche HBV Monitor test on the Cobas Amplicor analyzer within the dynamic range of that system. In conclusion, the newly developed assay has a markedly reduced hands-on time, permits monitoring for sample adequacy, and is suitable for the quantitative detection of HBV DNA in plasma in a routine clinical laboratory.

Validity of MELISA for metal sensitivity testing.

OBJECTIVE: This study was carried out to evaluate the reproducibility, sensitivity, specificity, and reliability of the MELISA Test for detecting metal sensitivity in patients with clinical symptoms of a type IV hypersensitivity to metal. DESIGN: Blood from 250 patients was tested in MELISA against up to 20 different metals in 2 to 3 concentrations. The frequency and distribution of metal reactivities, the sensitivity and specificity of nickel reactivity in patients with and without confirmed or suspected sensitivity to nickel, and the roles of lymphocyte concentration and concentration of inorganic mercury were analyzed. In addition, for reproducibility testing, 196 metal tests were performed in duplicate, and intra- and interassay variations of MELISA results were examined in patients patch-test positive for the relevant metal. RESULTS: Among the 250 patients, reactivity to 0, 1, 2, 3, 4, or > or = 5 metals was 26%, 36%, 15%, 12%, 6%, and 5%, respectively. Reactivity was most frequent to nickel (73%), followed by titanium (42%), cadmium (18%) gold (17%), palladium (13%), lead (11%), beryllium (9%), inorganic mercury (8%), tin (8%), and phenylmercury (6%). All patients (n=15) with confirmed or suspected nickel allergy were positive in MELISA, while patients with no suspicion of nickel allergy were either negative (n=6) or very low positive (n=4) in MELISA. MELISA reactivity is directly dependent on lymphocyte concentration: the higher the lymphocyte concentration per test, the stronger the reactivity. Concentrations of inorganic mercury > 0.5 microg/ml cause non antigen-specific (mitogenic) reactions in a majority of patients. The reproducibility rate was 94% using a cut-off of Stimulation Index > or = 3 or 99% using a cut-off of > or = 5. While the absolute intra- and interassay Stimulation Index values may vary, the qualitative results are highly reproducible. CONCLUSION: The MELISA Test is reproducible, sensitive, specific, and reliable for detecting metal sensitivity in metal-sensitive patients.

Quality control in nucleic acid testing--where do we stand?

Quality control has been playing an increasingly important role in the implementation of nucleic acid amplification techniques (NATs) for clinical diagnosis since the introduction of these methods in the early 1990s. Initial multicenter studies involving hepatitis B virus (HBV), hepatitis C virus (HCV), Mycobacterium tuberculosis, and human immunodeficiency virus type 1 (HIV-1) revealed serious problems in specificity (false-positive rates of ca. 40%) and sensitivity, large variations in quantitative results, and a plethora of units (largely not comparable between assays). The problem areas identified included the need for standardized reagents and common units, contamination control mechanisms, inhibition control mechanisms, genotype-independent detection and quantitation, facilitated nucleic acid isolation procedures, clinically relevant dynamic ranges, and internal run controls. Progress made in each of these areas will be discussed. In addition to the above-mentioned problem areas, the value of external quality control of existing and evolving NATs was recognized. To this end, the European Union Quality Control Concerted Action for Nucleic Acid Amplification in Diagnostic Virology was established in May 1998. During its three-and-a-half years of existence, a total of 14 proficiency panels containing 8-13 well-characterized, simulated clinical samples of various viral loads and genotypes were prepared for herpesviruses (herpes simplex virus, human cytomegalovirus), blood-borne viruses (HBV, HCV, HIV-1), enteroviruses, and Chlamydia trachomatis, distributed to up to 20 different countries, and tested by up to 97 different laboratories. The results show dramatic improvement in specificity (false-positive rates <3% for most panels), presumably due to a generally greater expertise of participating laboratories, more frequent use of enzymatic or mechanical contamination control mechanisms, and increased utilization of standardized reagents (commercial kits). However, considerable problems with sensitivity remain (false-negative rates up to 50%), reflecting the high detection limits of some commercial viral load kits still on the market as well as inadequate standardization of quantitation controls between assay systems. In conclusion, although considerable progress has been made, quality control of NATs in clinical diagnosis remains an ongoing challenge.

External quality assessment program for qualitative and quantitative detection of hepatitis C virus RNA in diagnostic virology.

To assess the performance of laboratories in detecting and quantifying hepatitis C virus (HCV) RNA levels in HCV-infected patients, we distributed two proficiency panels for qualitative and quantitative HCV RNA testing. The panels were designed by the European Union Quality Control Concerted Action, prepared by Boston Biomedica Inc., and distributed in May 1999 (panel 1) and February 2000 (panel 2). Each panel consisted of two negative samples and six positive samples, with HCV RNA target levels from 200 to 500,000 copies/ml. Panel 1 had four samples with at least 50,000 copies/ml, and panel 2 had two samples with at least 50,000 copies/ml. Fifty-seven laboratories submitted 45 qualitative and 35 quantitative data sets on panel 1, and 81 laboratories submitted 75 qualitative and 48 quantitative data sets on panel 2. In both panels, about two-thirds of the qualitative data sets and >90% of the quantitative data sets were obtained with commercial assays. With each panel, two data sets gave one false-positive result, corresponding to false-positivity rates of 1.3% and 0.8% for panel 1 and panel 2, respectively. Samples containing at least 50,000 copies/ml were found positive in 97% and 99% of the cases with panel 1 and panel 2, respectively. In contrast, the positive samples containing < or =5,000 copies/ml were reported positive in only 71% and 77% of the cases with panel 1 and panel 2, respectively. Adequate or better scores on qualitative results (all results correct or only the low-positive samples missed) were obtained in 84% (panel 1) and 80% (panel 2) of the data sets. In the analysis of quantitative results, 60% (panel 1) and 73% (panel 2) of the data sets obtained an adequate or better score (> or =80% of the positive results within the range of the geometric mean +/- 0.5 log(10)). Our results indicate that considerable improvements in molecular detection and quantitation of HCV have been achieved, particularly through the use of commercial assays. However, the lowest detection levels of many assays are still too high, and further standardization is still needed. Finally, this study underlines the importance of proficiency panels for monitoring the quality of diagnostic laboratories.