Long-term nutritional and neurodevelopmental outcome of liver transplantation in infants aged less than 12 months.

BACKGROUND: Liver transplantation is established treatment for children with end-stage liver disease and has a 5-year survival rate of 80% to 85%, even in infants under 12 months. Long-term outcome in nutritional rehabilitation and normal development is unknown. This study aimed to prospectively evaluate growth and psychoneurologic performance of children who undergo liver transplantation in infancy. METHODS: Twenty-five infants (18 girls, 7 boys) who underwent liver transplantation at less than 12 months of age (median age, 9 months) were evaluated for 4 years. Growth measurements were expressed as standard deviation scores (SDSs; mean +/- SEM), and psychoneurologic performance was assessed with the unrevised Griffiths Mental Ability Scales (normal range, 80-120). RESULTS: Four children died during the study (4-year survival, 84%). The children were malnourished before transplantation (SDSs: weight, -1.9 +/- 0.2; midarm muscle area, -0.93 +/- 0.3; midarm fat area, -1.52 +/- 0.3; and height, -0.95 +/- 0.3). Nutritional rehabilitation for all parameters occurred within 12 to 24 months after transplantation, which was most significant for weight (-1.1 +/- 0.2, P = 0.001), midarm muscle area (0.74 +/- 0.3, P = 0.001), and midarm fat area (-0.44 +/- 0.3, P = 0.01). There was some improvement in height (-0.72 +/- 0.3, P = 0.14), which was not significant, although infants who were severely stunted before transplantation (mean height standard deviation score [SDS] -2.46) showed significant catch-up at 1 year after transplantation (mean height SDS -1.2, P = 0.003). Psychoneurologic scores were within normal limits before transplantation and were maintained for the 4-year follow-up period, although individual scores varied during this period. Improved nutritional status was associated with increased muscle bulk and subsequent improvement in motor scores from 90.6 at initial assessment to 97.3 at 4 years (P = 0.28). There was a temporary reduction in social skills and eye-hand coordination in the first year, which may have been an effect of the hospital environment or cyclosporine immunosuppression. Language abilities also regressed during the first year, possibly related to the effect of nasogastric tube feeding in delaying normal speech development. CONCLUSIONS: Liver transplantation in infancy has not only a successful outcome but is also associated with long-term catch-up growth and nutrition and maintenance of normal development.

Measurement of changes in dimensions of resorbing alveolar bone: description of a method.

This study evaluated a cast-measuring device used to investigate effects of augmenting fresh extraction sockets with dense hydroxyapatite granules. Following reproducible location of the casts, alterations in ridge tracings were related to radiographically determined ridge height alterations. A randomised controlled study compared two groups of immediate complete denture wearers. One group received conventional immediate dentures, the other received immediate complete dentures after dense hydroxyapatite implantation into canine sockets. Ridge height alterations with time were recorded from radiographs. Alterations in ridge form were recorded from several models transferred reproducibly to a mounting jig attached to a profiling apparatus. Further, the osteo-retentive ability of the hydroxyapatite in the sockets was seen to be close to significance (after six months width differences, in the canine region: P = 0.059, LHS, and P = 0.065, RHS).

Mechanical behaviour and structure of light-cured special tray materials.

OBJECTIVES: This study relates some structural characteristics of representative special tray visible light cured (VLC) resin composites to their creep-recovery, hardness and flexural strength properties. VLC prosthodontic materials have not yet achieved the same acceptance as the VLC resin composites, perhaps because less is known of their structural and performance characteristics. METHODS: The VLC resin composites used were Triad, Convertray and Palatray. The inorganic composition was analysed quantitatively by heating known amounts of resin composite to 800 degrees C, and weighing the ash. Elemental composition was determined using X-ray microanalysis. Mechanical properties, including hardness, flexural behaviour and creep recovery, were obtained by standard methods. RESULTS: The inorganic filler content for Palatray was higher than that of Convertray or Triad, and the flexural modulus and flexural strength of Palatray were superior to that of Triad or Convertray. The mean maximum creep strain for the Palatray specimens was only 2.45% after 5 h loading under 37 MPa and there was a permanent set of 1.5% after 7 h recovery. CONCLUSIONS: Palatray exhibited superior overall properties and this evidently related primarily to the high volume fraction of filler.

Analysis of optical transmission by 400-500 nm visible light into aesthetic dental biomaterials.

The penetration of visible light into dental biomaterials is an essential factor in photoinitiation of setting reactions and in the optical aspects of dental aesthetics. Light of visible blue wavelengths, 400-500 nm, has been applied at normal angles to 0.2-5.0 mm sections of human dentine and representative ceramic, polymerceramic composites and hybrid glass-polyalkenoate materials. The integrated optical transmission has been determined for each material section. The data have been converted to absorbance values and analysed to check for mathematical conformity to the Beer-Lambert Law. It is found that conformity (typically, P < 0.01) to the linear Beer-Lambert Law is only attained by making a substantial correction for the intensity of light reflected from the surface of aesthetic biomaterials. This is otherwise expressed by distinguishing between true and apparent absorbance. From linear regression of apparent absorbance with section thickness, the intercept depends upon the logarithm of the surface-reflection ratio. This factor ranges from 30% to 90% in the materials investigated. It follows that there is a high degree of inefficiency in the transmission of visible light into and through aesthetic biomaterials for the purposes of photoactivation using existing technology. Means by which this limitation and inefficiency may be reduced are discussed. While the reflectivity of aesthetic biomaterials has been perceived by dental practitioners, the magnitude of this effect and its implications in connection with light-cured materials have not been analysed and emphasized hitherto.

Successful liver transplantation in babies under 1 year.

OBJECTIVE: To review the outcome of liver transplantation in babies aged less than 1 year. DESIGN: Prospective evaluation of survival, clinical complications, and nutritional and developmental status before and one year after liver transplantation. SETTING: The Children's Hospital and Queen Elizabeth Hospital, Birmingham. SUBJECTS: All 25 babies who received liver transplantation from January 1989 to December 1992 were included. Median age was 9 months and median weight was 7.0 kg. Seven babies were assessed but were not given transplants because they died while on the waiting list (two) or had severe extrahepatic disease (five). RESULTS: 24 babies had severe decompensated liver disease and 20 were severely malnourished despite nutritional support. Six babies received a whole liver graft and 19 received a reduction hepatectomy. Postoperative complications included primary nonfunction of the transplanted liver (one baby), hepatic artery thrombosis (two), biliary obstruction (seven), acute and chronic rejection (six), and sepsis (18). Three babies required a second transplant; all survived. Three babies, two of whom presented with fulminant hepatic failure, died. The overall actuarial survival rate (4 months to 4 years) is 88%. Review at 12 months showed a dramatic improvement in growth (p < 0.001) and normal psychosocial development with good quality of life. CONCLUSION: The improvement in survival rates and quality of life in this group of very sick babies is related not only to the development of reduction hepatectomy but also to advances in medical and nursing expertise. Early referral for liver transplantation is justified even if babies are critically ill.

Gastrooesophageal reflux in children with cerebral palsy.

Feeding difficulties, vomiting and recurrent chest infections associated with poor growth and nutrition are common in children with cerebral palsy (CP). However, the role of gastrooesophageal reflux as a possible cause has been little studied. We therefore investigated 23 children with cerebral palsy (median age 2.3 years, range 0.6-11.8) whose symptoms were consistent with gastrooesophageal reflux (severe feeding difficulties 70%, failure to thrive 52%, anaemia 31% and recurrent chest infections 31%). Using 24-hour ambulatory oesophageal pH monitoring, we determined the relationship between gastrooesophageal reflux and: (a) developmental age (Griffith's scales); (b) feeding behaviour skills score; (c) nutritional status and (d) clinical assessment of cerebral palsy (type and severity). Abnormal gastrooesophageal reflux (i.e. reflux index > 5%) was detected in 16 (70%) patients (median reflux index 11.4%; range 5.4-59%). Reflux was unrelated to chronological or developmental age, but there was a significant, unexplained association with male gender (P < 0.01). No correlation was found with feeding behaviour skills score, malnutrition (which was commonly severe) and type and severity of cerebral palsy. We conclude that gastrooesophageal reflux is common and should be sought in symptomatic, neurologically handicapped children as effective treatment is likely to improve quality of life.

Determination of polymerization shrinkage kinetics in visible-light-cured materials: methods development.

An instrument for the reproducible measurement of polymerization shrinkage kinetics is described, constructed around a disc-shaped specimen sandwiched between two glass plates. Test specimens of light-sensitive dental restorative materials were irradiated through the lower, rigid plate. The upper, non-rigid plate was readily deflected by an increase of the adhesive stress from the polymerizing and shrinking sample. Deflection was measured by an LVDT transducer and computer-recorded. Dimensional changes were confined to the specimen disc-thickness dimension, such that the fractional linear shrinkage approximated the volumetric shrinkage. Shrinkage data are reported for representative materials: unfilled and resin composites, base-lining materials, and an impression material. Equilibrium shrinkage magnitudes ranged from 0.65%, for the impression material, to 7.9% for the unfilled resin. The kinetic behavior was approximately characterized by an overall time constant, ranging from 12.5 to 280 s, associated with an exponential growth curve, although the initial shrinkage was near-linear in time, for many materials, due to non-steady-state concentrations of polymer free-radicals. The test-specimen geometry facilitates rapid and essentially uniform cure and hence the determination of minimum possible time-constants at each ambient temperature and incident light-intensity. Study of hybrid glass-ionomer materials, without spurious dehydration effects, was also achieved.