Periodontology in the undergraduate curriculum in UK dental schools.

INTRODUCTION: In 1980 the British Society of Periodontology published a series of educational goals which have guided periodontal curricula at UK dental schools. Further, a survey of UK dental schools evaluated aspects of teaching and learning in periodontology. The aims of this project were to identify teaching practices and assessments in periodontology and best practice which may be developed in the future. MATERIALS AND METHODS: A questionnaire was sent to dental schools who had participated in the previous survey. The questionnaire sought information on aspects of teaching and learning in periodontology: teaching manpower, curriculum structure, assessment, research opportunities for students and whether implantology is delivered in the undergraduate curriculum. RESULTS: There is consistency between the education providers with respect to teaching and learning in periodontology. Most are developing integrated learning between dental undergraduates and members of the dental team although there are opportunities for further development. Students are expected to have knowledge of complex treatments but are not expected to be competent at undertaking periodontal surgery nor placing and restoring implants. CONCLUSION: The findings confirm that there is considerable consistency between the education providers with respect to aspects of teaching and learning in periodontology.

EULAR recommendations for the management of large vessel vasculitis.

OBJECTIVES: To develop European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis. METHODS: An expert group (10 rheumatologists, 3 nephrologists, 2 immunolgists, 2 internists representing 8 European countries and the USA, a clinical epidemiologist and a representative from a drug regulatory agency) identified 10 topics for a systematic literature search through a modified Delphi technique. In accordance with standardised EULAR operating procedures, recommendations were derived for the management of large vessel vasculitis. In the absence of evidence, recommendations were formulated on the basis of a consensus opinion. RESULTS: Seven recommendations were made relating to the assessment, investigation and treatment of patients with large vessel vasculitis. The strength of recommendations was restricted by the low level of evidence and EULAR standardised operating procedures. CONCLUSIONS: On the basis of evidence and expert consensus, management recommendations for large vessel vasculitis have been formulated and are commended for use in everyday clinical practice.

EULAR recommendations for the management of primary small and medium vessel vasculitis.

OBJECTIVES: To develop European League Against Rheumatism (EULAR) recommendations for the management of small and medium vessel vasculitis. METHODS: An expert group (consisting of 10 rheumatologists, 3 nephrologists, 2 immunologists, 2 internists representing 8 European countries and the USA, a clinical epidemiologist and a representative from a drug regulatory agency) identified 10 topics for a systematic literature search using a modified Delphi technique. In accordance with standardised EULAR operating procedures, recommendations were derived for the management of small and medium vessel vasculitis. In the absence of evidence, recommendations were formulated on the basis of a consensus opinion. RESULTS: In all, 15 recommendations were made for the management of small and medium vessel vasculitis. The strength of recommendations was restricted by low quality of evidence and by EULAR standardised operating procedures. CONCLUSIONS: On the basis of evidence and expert consensus, recommendations have been made for the evaluation, investigation, treatment and monitoring of patients with small and medium vessel vasculitis for use in everyday clinical practice.

Outcomes from studies of antineutrophil cytoplasm antibody associated vasculitis: a systematic review by the European League Against Rheumatism systemic vasculitis task force.

OBJECTIVES: We undertook a systematic literature review as a background to the European League Against Rheumatism (EULAR) recommendations for conducting clinical trials in anti-neutrophil cytoplasm antibody associated vasculitis (AAV), and to assess the quality of evidence for outcome measures in AAV. METHODS: Using a systematic Medline search, we categorised the identified studies according to diagnoses. Factors affecting remission, relapse, renal function and overall survival were identified. RESULTS: A total of 44 papers were reviewed from 502 identified by our search criteria. There was considerable inconsistency in definitions of end points. Remission rates varied from 30% to 93% in Wegener granulomatosis (WG), 75% to 89% in microscopic polyangiitis (MPA) and 81% to 91% in Churg-Strauss syndrome (CSS). The 5-year survival for WG, MPA and CSS was 74-91%, 45-76% and 60-97%. Relapse (variably defined) was common in the first 2 years but the frequency varied: 18% to 60% in WG, 8% in MPA, and 35% in CSS. The rate of renal survival in WG varied from 23% at 15 months to 23% at 120 months. METHOD: used to assess morbidity varied between studies. Ignoring the variations in definitions of the stage of disease, factors influencing remission, relapse, renal and overall survival included immunosuppressive therapy used, type of organ involvement, presence of ANCA, older age and male gender. CONCLUSIONS: Factors influencing remission, relapse, renal and overall survival include the type of immunosuppressive therapy used, pattern of organ involvement, presence of ANCA, older age and male gender. Methodological variations between studies highlight the need for a consensus on terminology and definitions for future conduct of clinical studies in AAV.

Lower extremity injury: complex problems, complex answers.

Patients with traumatic injury to the lower extremities are admitted to the hospital with multiple interrelated problems requiring an interdisciplinary team approach to meet their needs. This article will explore the assessment and formulation of nursing diagnoses, implementation of care, and patient outcomes achieved. It will describe the nurse's role as the link between the patient and the physician and other members of the health care team. The cooperative actions of the different health care teams that work to achieve the desired outcomes are explained. A case study will be presented to illustrate these points.

Different collagenase gene products have different roles in degradation of type I collagen.

Vertebrate collagenases, matrix metalloproteinases (MMPs), cleave type I collagen at a single helical locus. We show here that rodent interstitial collagenases (MMP-13), but not human fibroblast collagenase (MMP-1), cleave type I collagen at an additional aminotelopeptide locus. Collagenase cDNAs and chimeric constructs in pET-3d, juxtaposing MMP-13 sequences amino-terminal to the active site in the catalytic domain and MMP-1 sequences carboxyl-terminal and vice versa, were expressed in Escherichia coli. Assays utilized collagen from wild type (+/+) mice or mice that carry a targeted mutation (r/r) that encodes substitutions in alpha1(I) chains that prevent collagenase cleavage at the helical locus. MMP-13 and chimeric molecules that contained the MMP-13 sequences amino-terminal to the active site cleaved (+/+) collagen at the helical locus and cleaved cross-linked (r/r) collagen in the aminotelopeptide (beta components converted to alpha chains). Human MMP-1 and chimeric MMP-1/MMP-13 with MMP-1 sequences amino-terminal to the active site cleaved collagen at the helical locus but not in the aminotelopeptide. All activities were inhibited by TIMP-1, 1,10-phenanthroline, and EDTA. Sequences in the distal two-thirds of the catalytic domain determine the aminotelopeptide-degrading capacity of MMP-13.

Effects of host switching on gypsy moth (Lymantria dispar (L.)) under field conditions.

Effects of various single and two species diets on the performance of gypsy moth (Lymantria dispar (L.)) were studied when this insect was reared from hatch to population on intact host trees in the field. The tree species used for this study were red oak (Quercus rubra L.), white oak (Q. alba L.), bigtooth aspen (Populus grandidentata Michaux), and trembling aspen (P. tremuloides Michaux). These are commonly available host trees in the Lake States region. The study spanned two years and was performed at two different field sites in central Michigan. Conclusions drawn from this study include: (1) Large differences in gypsy moth growth and survival can occur even among diet sequences composed of favorable host species. (2) Larvae that spent their first two weeks feeding on red oak performed better during this time period than larvae on all other host species in terms of mean weight, mean relative growth rate (RGR), and mean level of larval development, while larvae on a first host of bigtooth aspen were ranked lowest in terms of mean weight, RGR, and level of larval development. (3) Combination diets do not seem to be inherently better or worse than diets composed of only a single species; rather, insect performance was affected by the types of host species eaten and the time during larval development that these host species were consumed instead of whether larvae ate single species diets or mixed species diets. (4) In diets composed of two host species, measures of gypsy moth performance are affected to different extents in the latter part of the season by the two different hosts; larval weights and development rates show continued effects of the first host fed upon while RGRs, mortality, and pupal weights are affected strongly by the second host type eaten. (5) Of the diets investigated in this study, early feeding on red oak followed by later feeding on an aspen, particularly trembling aspen, is most beneficial to insects in terms of attaining high levels of performance throughout their lives.

Nutritional indices in the gypsy moth (Lymantria dispar (L.)) under field conditions and host switching situations.

A large proportion of gypsy moths (Lymantria dispar (L.)) are likely to experience multiple species diets in the field due to natural wandering and host switching which occurs with these insects. Nutritional indices in fourth and fifth instar gypsy moth larvae were studied in the field for insects that were switched to a second host species when they were fourth instars. The tree species used as hosts were northern pin oak (Quercus ellipsoidalis E. J. Hill), white oak (Q. alba L.), big-tooth aspen (Populus grandidentata Michx.), and trembling aspen (P. tremuloides Michx.). Conclusions of this study include: 1) Insects which fed before the host switch on northern pin oak performed better after the host switch than did insects with other types of early dietary experience. While the northern pin oak-started insects had very low relative food consumption rates on their second host species immediately after the switch, one instar later they had the highest ranked consumption rates. During both instars they had the second highest efficiencies of converting ingested and digested food to body mass. High food consumption rates and relatively high efficiency of food conversion helped these insects to obtain the highest ranked mean relative growth rates in the fifth instar compared to the relative growth rates obtained by insects from any of the other first host species. 2) Among the four host species examined, a second host of trembling aspen was most advantageous for the insects. Feeding on this species after the switch led to higher larval weights and higher relative growth rates for insects than did any of the other second host species. The insects on trembling aspen attained excellent growth despite only mediocre to low food conversion efficiencies. The low efficiencies were offset by high relative food consumption rates. 3) Low food consumption rates often tend to be paired with high efficiency of conversion and vice versa. 4) There is no discernable tendency for the first plant species eaten to cause long-term inductions which affect the ability of gypsy moths to utilize subsequent host plants. Insects did not tend to consume more, grow faster, or be more efficient if their second host plant was either the same as their rearing plant or congeneric to it. Methods are delineated which allow values of nutritional indices to be obtained for insects on intact host plants under field conditions. These methods are useful for the purpose of answering questions about the relative effects that different diet treatments have on insect response.

Inflammation and cartilage metabolism in rheumatoid arthritis. Studies of the blood markers hyaluronic acid, orosomucoid, and keratan sulfate.

Single analyses of peripheral blood of rheumatoid arthritis (RA) patients showed a significant reduction in the mean value for keratan sulfate (KS) compared with that in control subjects, but the mean value for orosomucoid (OM) was elevated compared with that in control subjects. Some RA patients displayed highly elevated levels of hyaluronic acid (HA), while others exhibited normal levels. There was a significant inverse correlation between OM and KS content in RA patients, as well as a direct correlation between HA and OM. In longitudinal studies of RA patients, parallel changes in OM and HA and inverse changes between KS and OM or HA were commonly observed. Clinical analyses revealed that there was an inverse correlation between KS and morning stiffness, and direct correlations between the number of tender joints and HA, and between HA or the erythrocyte sedimentation rate and the number of joints with effusions. The reason(s) for the inverse correlation between KS and OM as an index of systemic inflammation remains to be established. Circulating HA represents an index of joint inflammation, for which a marker has not been previously available.

Immunodetection and characterization of the degradation of cartilage proteoglycans in vitro and in vivo.

The large aggregating cartilage proteoglycans can be detected immunologically using antibodies directed against the hyaluronic acid-binding region, core protein, keratan sulfate, chondroitin sulfate, and hyaluronic acid. With radioimmunoassays we have detected proteoglycans released from adult human articular cartilage in vitro and in vivo. In vitro cleavage appears to occur mainly adjacent to the hyaluronic acid binding region with the release of the rest of the molecule. Two distinct populations have been observed, the larger of which is chondroitin sulfate-rich and the smaller keratan sulfate-rich. Although they are a little smaller and probably aggregate less with hyaluronic acid, these populations correspond in size and composition to two similar populations detected in situ in healthy adult human articular cartilage. In vivo studies of synovial fluid have revealed that the proteoglycan fragments are smaller and the most commonly detected fragment is the hyaluronic acid binding region. This suggests that in vivo further degradation occurs, probably due to degradation mediated by the inflamed synovium and polymorphonuclear leucocytes present in the synovial fluid of inflamed joints.

The immunologic detection and characterization of cartilage proteoglycan degradation products in synovial fluids of patients with arthritis.

Antibodies were used in radioimmunoassays with gel chromatography to detect the hyaluronic acid-binding region, core protein, and keratan sulfate of human cartilage proteoglycan in the synovial fluids of patients with rheumatoid arthritis, juvenile rheumatoid arthritis, and osteoarthritis. All fluids contained proteoglycan that was mainly included on Sepharose CL-4B; this result indicates cleavage of proteoglycan (which is normally excluded). The hyaluronic acid-binding region was the smallest and most commonly detected fragment. It was relatively free of keratan sulfate and core protein, and it could sometimes bind to hyaluronic acid. Other larger fragments containing core protein and/or keratan sulfate were detected in every fluid.

Origin of excess urinary nitrate in the rat.

The ability of intestinal microorganisms to N-oxidize nitrogenous compounds to nitrite or nitrate was evaluated both in vivo and in vitro. Nitrate balance studies with germ-free and conventional rats indicated that the host and not the microbial flora is responsible for excess urinary nitrate. In vitro studies showed that most intestinal microorganisms are not able to N-oxidize nitrogenous compounds to nitrite. Although the metabolic pathway for endogenous nitrate formation remains unknown, the capacity of the rats to N-oxidize acetohydroxamate and hydroxylamine to nitrate indicates that such compounds could be intermediates in nitrate synthesis.

Evaluation of nitrate synthesis by intestinal microorganisms in vivo.

The nitrate balance of germfree and conventional rats was assessed to determine whether the intestinal flora produces nitrate in vivo. The results indicate that there can be excess nitrate in the urine of germfree as well as conventional rats. This nitrate is apparently of host origin, and the presence of intestinal flora decreases the output of nitrate in urine.

Distribution and metabolism of ingested NO3- and NO2- in germfree and conventional-flora rats.

Germfree and conventional-flora Sprague-Dawley rats were fed sodium nitrate or sodium nitrite in their drinking water (1,000 microgram/ml), and various organs, tissues, and sections of the intestinal tract were assayed for nitrate (NO3-) and nitrite (NO2-) by a spectrophotometric method. When fed NO3-, germfree rats had chemically detectable levels of NO3- (only) in the stomach, small intestine, cecum, and colon. Conventional-flora rats fed NO3- had both NO3- and NO2- in the stomach, but only NO3- in the small intestine and colon. When fed NO2-, germfree rats had both NO3- and NO2- in the entire gastrointestinal tract. Conventional-flora rats fed NO2- had both ions in the stomach and small intestine, but only NO3- in the large intestine. Conventional-flora rats fed NO3- or NO2- had lower amounts of these ions in the gastrointestinal tract than comparably fed germfree rats. Control (non-NO3- or NO2--fed) germfree and conventional-flora rats had trace amounts of NO3- (only) in their stomachs and bladders. These results, in conjunction with various in vitro studies with intestinal contents, suggest that NO3- or NO2- reduction is a function of the normal bacterial flora, whereas NO2- oxidation is attributable to the mammalian host. In addition, the distribution of these ions after their ingestion appears more widespread in the body than previously thought.

Distribution of nitrogen-13 from labeled nitrate and nitrite in germfree and conventional-flora rats.

The in vivo distribution of physiological concentrations of NO3- and NO2- labeled with 13N was studied in germfree and conventional-flora Sprague-Dawley rats after gastric intubation (gavage), intravenous (cardiac or tail vein), or intraluminal (intestinal) injection. Some in vitro studies were performed to determine the influence of the bacterial flora on ion distribution. After gavage with 13NO3-, essentially all of the label passed into the upper small intestine, where most was absorbed; however, up to 24% of the 13N could reach the ileum within 1 h. Gavage with 13NO2- resulted in some gastric absorption of the label, but most seemed to exit the stomach via passage into the duodenum. The exit of 13NO2- from the stomach was slower, and less 13N appeared to be absorbed from the small intestine than with 13NO3-. Movement of label through the gastrointestinal tract could be enhanced by inducing diarrhea. Absorbed 13N was either excreted in the urine, reentered the gastrointestinal tract at various points, or was temporarily stored in the eviscerated carcass. The bacterial flora, either by incorporation or chemical alteration, appeared to have some influence on the distribution of 13N from 13NO3- or 13NO2-.

Distribution of nitrogen-13 from labeled nitrate (13No3-) in humans and rats.

The body distribution of gavaged or intravenously administered nitrate labeled with nitrogen-13 was studied in humans and rats with the following results: (i) the labeled compound is not quickly absorbed from the stomach; (ii) the concentration of the label increases inside the lower intestinal tract (cercum and large intestine) when ingested or intravenously injected; and (iii) humans and rats have the capacity to store a portion of the label in their bodies. These observation indicate that depletion of body stores, the passage of nitrate down the gut, or the secretion of nitrate into the intestinal lumen may be a better explanation of the urinary, ileal, and fecal concentrations of nitrate and nitrite recently measured in humans that a bacterial nitrification reaction in the intestines, as suggested by Tannenbbaum et al.