Assessing lower incisor inclination change: a comparison of four cephalometric methods.

OBJECTIVE: Cephalometric inclination change of the lower incisors during orthodontics is used to assess treatment outcome. The lower border of the mandible is commonly used for measuring inclination change, despite it being subject to remodelling in growing patients. Superimposition of radiographs using Björk's 'stable structures' is intended to exclude these growth changes. We tested whether there is a significant difference for three commonly used methods to assess inclination change induced by orthodontic treatment (Me-Go, Go-Gn, the tangent to the lower border of the mandible) when comparing it to Björk's 'stable structures'. METHODS: Björk's superimposition does not allow measuring incisor inclination changes directly; hence, one pre- and mid-treatment cephalogram of 39 growing orthodontic patients were superimposed in this retrospective study. The radiographs were taken at least 1 year apart (120 weeks; SD = 34.4). Patients undergoing growth modification treatment were excluded. Standardized cephalograms were hand traced and changes in lower incisor inclination, using the three mandibular planes, were compared to the changes obtained by anatomical superimposition of Björk's 'stable structures'. RESULTS: Linear regression showed good intra-class correlation (ICC) between all methods. ICC was 0.96 for Me-Go, 0.94 for Go-Gn, and 0.92 for the lower border tangent. ICC for operator reliability was 0.99. LIMITATIONS: Measurement errors affect all investigations of both analogue and digital radiographs, but movement artefacts particularly apply to the latter. Cephalometry uses two-dimensional measurements of a three-dimensional subject, which can lead to further inaccuracies. These limitations have to be taken into account when interpreting the results of our investigation. CONCLUSION: Data obtained from Björk's superimposition did not vary significantly from the other more commonly used techniques (Me-Go, Go-Gn, and the tangent to the lower border of the mandible). Remodelling of the lower border of the mandible was insignificant for the time period investigated.

Effect of Model Variables on in vitro Erosion.

The aim of this study was to investigate the effects of tooth type (molar/premolar), tooth surface (buccal/lingual), smear layer or no smear layer, storage of specimens in deionised water, mode and speed of agitation, and rinsing method between cycles on mean step height loss and Knoop microhardness (KHN) change. Polished human enamel specimens embedded in acrylic resin were prepared from sound permanent molar and premolar tooth surfaces. A 0.3% (pH 3.2) solution of citric acid was used to erode the specimens, in a cycling procedure, consisting of 10 min immersion followed by rinsing in deionised water for 30 s with a spray bottle, for 5 cycles. The specimens were analysed with a non-contact white light profilometer and KHN. Molar teeth (148.99±24.49 KHN) and buccal surfaces (155.62±30.35 KHN) produced significantly less microhardness change compared to premolar (186.40±20.74 KHN) and lingual surfaces (179.76±23.21 KHN; p<0001). The effect of storage and rinsing showed little difference in mean step height loss (<1 µm) and microhardness change. With no smear layer a significantly lower mean step height loss and microhardness change (p<0.001) was observed. Agitation was performed with Orbital, Gyro and See-Saw rockers at 30, 40, 60, and 70 rpm. The mean step height loss was largest for See-Saw at 70 rpm (11.73±0.91 µm) and lowest for Orbital at 30 rpm (2.76±1.12 µm). A statistical difference was found between all types of agitation and speeds (p<0.001). In conclusion, this study has shown that the variables investigated here have a significant impact on the measurable outcome, highlighting the importance of accurate and detailed method sections.

Sniff nasal inspiratory pressure in patients with moderate-to-severe chronic obstructive pulmonary disease: learning effect and short-term between-session repeatability.

BACKGROUND: Sniff nasal inspiratory pressure (SNIP) is a non-invasive measure of inspiratory muscle function often used as an outcome measure in clinical studies. An initial period of familiarisation with the test is recommended to minimise the learning effect. The repeatability of SNIP in patients with chronic obstructive pulmonary disease (COPD) is currently unknown. OBJECTIVES: The aim of this study was to assess the between-session repeatability of SNIP over a 3-week period in moderate-to-severe COPD patients and compare it with that of maximal inspiratory (PI max) and expiratory pressure (PE max). METHODS: Twenty-one patients (13 males) with a mean forced expiratory volume in 1 s (FEV1) of 38% of predicted (SD: 15) and FEV1/forced vital capacity of 34.3% (SD: 10.4) performed SNIP and PI max and PE max manoeuvres on 3 different sessions (S1, S2 and S3) 3-7 days apart. SNIP was performed at functional residual capacity (FRC), and PI max was performed at FRC and at residual volume (RV) to explore volume-dependent differences in the learning effect between sessions and PE max from total lung capacity. RESULTS: The intra-class correlation coefficient (ICC) for SNIP was the highest of the three measures: S1-S3 ICC (95% CI) SNIP: 0.96 (0.88-0.94); PI max at FRC 0.82 (0.63-0.92); PI max at RV: 0.89 (0.78-0.95), and PE max: 0.96 (0.92-0.98), and had the lowest mean change between sessions [mean S2 - S1: 2.1(p = 0.4) and S3 - S2: -0.3 (p = 0.9)]. CONCLUSIONS: SNIP is repeatable over a period of 3 weeks in medically stable, moderate-to-severe COPD patients. In our study, 2 sessions were adequate to learn how to perform the test.

Framework for e-learning assessment in dental education: a global model for the future.

The framework presented in this article demonstrates strategies for a global approach to e-curricula in dental education by considering a collection of outcome assessment tools. By combining the outcomes for overall assessment, a global model for a pilot project that applies e-assessment tools to virtual learning environments (VLE), including haptics, is presented. Assessment strategies from two projects, HapTEL (Haptics in Technology Enhanced Learning) and UDENTE (Universal Dental E-learning), act as case-user studies that have helped develop the proposed global framework. They incorporate additional assessment tools and include evaluations from questionnaires and stakeholders' focus groups. These measure each of the factors affecting the classical teaching/learning theory framework as defined by Entwistle in a standardized manner. A mathematical combinatorial approach is proposed to join these results together as a global assessment. With the use of haptic-based simulation learning, exercises for tooth preparation assessing enamel and dentine were compared to plastic teeth in manikins. Equivalence for student performance for haptic versus traditional preparation methods was established, thus establishing the validity of the haptic solution for performing these exercises. Further data collected from HapTEL are still being analyzed, and pilots are being conducted to validate the proposed test measures. Initial results have been encouraging, but clearly the need persists to develop additional e-assessment methods for new learning domains.

The effects of dental anxiety and irregular attendance on referral for dental treatment under sedation within the National Health Service in London.

OBJECTIVE: To investigate whether the relationship between dental anxiety and referral for treatment under sedation is explained by attendance patterns and oral health. METHODS: Structural Equation Modeling was used on the covariance matrix of the covariates to test hypothesized inter-relationships. Subsequently, we modeled the probability of referral for treatment under sedation with a multiple logistic regression taking into account inter-relationships between the independent variables. RESULTS: A direct significant association of referral with dental anxiety and attendance patterns was detected, but not with oral health status. However, oral health and anxiety were highly correlated. Also signaled were correlations between age and education and between gender and bad past experience. CONCLUSION: Referral for treatment under sedation appears to be motivated by both fear and irregular patterns of attendance. Coupled with behavioral treatments to address dental fear and attendance, sedation can be an important part of comprehensive care where curative treatments are long or unpleasant for patients.

Risk score predicting decline in renal function postliver transplant: role in patient selection for combined liver kidney transplantation.

BACKGROUND: A combined liver and kidney transplantation (CLKT) is advocated for selected individuals with chronic kidney disease undergoing liver transplantation (LT). The aim was to develop a risk score to identify the patients whose estimated glomerular filtration rate (eGFR) would decline during the year post-LT to aid future patient selection for CLKT. METHODS: A training dataset of LT recipients was identified retrospectively from a prospectively compiled database (2000-2007). The eGFR was calculated at 1 year and those with an eGFR less than 30 mL/min were identified. Variables determined at the LT assessment were analyzed by logistic regression, discriminant function, and area under the receiver operating characteristic curve (AUC) analysis to develop the score. The score was validated in a prospective patient cohort. RESULTS: Three hundred sixty-eight LT recipients were followed up for 1 year (training dataset). The mean eGFR declined by 11.2+/-23.5 mL/min during that time (P<0.001). A pre-LT risk score to predict an eGFR less than 30 mL/min at 1-year post-LT was generated: -1.8+(1.5 if a history of hypertension)+(0.65 x proteinuria in g/24 hr)+(0.013 x serum creatinine in micromol/L)+(0.001 x duration of acute kidney injury or eGFR <60 mL/min in days). Reversible renal impairment should first be excluded. Progression was likely with a score more than 2.16. Sensitivity, specificity, and AUC were 99.2%, 100%, and 0.99, respectively. All, but one patient, in the validation cohort (n=149) were correctly classified. CONCLUSION: This information will complement previously published criteria for CLKT patient selection.

Thyroid cancer and renal transplantation: a meta-analysis.

Kidney transplantation and the associated immune suppression are associated with a significantly increased risk of developing cancer during long-term follow-up. Thyroid cancer has been recognised as a potential post-transplant risk but has not yet been subject of a focused review. We therefore performed a meta-analysis on data of 50,861 patients with a total follow-up of 198 595 patient-years and identified a 6.9-fold higher standardised incidence ratio (95% confidence interval 5.6-8.7, P<0.001) of thyroid cancer post renal transplantation as compared with a non-transplant group. All such cancers were of papillary type as far as histopathology was known. The mean time to discovery was 6.0 years post transplantation. This puts thyroid cancer into the group of high cancer risk following solid organ transplantation which already includes cervical cancer, non-melanoma skin cancer, oral and lip cancer and haematological malignancies. It is unclear what causes the increased cancer incidence. Inclusion of thyroid ultrasound in long-term post-transplant evaluation may help to ensure timely recognition of this condition.

Use of the out-of-hours emergency dental service at two south-east London hospitals.

BACKGROUND: Prior to the introduction of the 2006 NHS dental contract in England and Wales, general dental practitioners (GDPs) were responsible for the provision of out-of-hours (OOH) emergency dental services (EDS); however there was great national variation in service provision. Under the contractual arrangements introduced 1st April 2006, local commissioning agencies became formally responsible for the provision of out-of-hours emergency dental services. This study aimed to examine patients' use of an out-of-hours emergency dental service and to determine whether the introduction of the 2006 national NHS dental contract had resulted in a change in service use, with a view to informing future planning and commissioning of care. METHODS: A questionnaire was administered to people attending the out-of-hours emergency dental service at two inner city London hospitals over two time periods; four weeks before and six months after the introduction of the dental contract in April 2006. The questionnaire explored: reasons for attending; dental registration status and attendance; method of access; knowledge and use of NHS Direct; satisfaction with the service; future preferences for access and use of out-of-hours dental services. Data were compared to determine any impact of the new contract on how and why people accessed the emergency dental service. RESULTS: The response rate was 73% of attendees with 981 respondents for the first time period and 546 for the second. There were no significant differences between the two time periods in the gender, age, ethnic distribution or main language of service users accessing the service. Overall, the main dental problem was toothache (72%) and the main reason for choosing this service was due to the inability to access another emergency dental service (42%). Significantly fewer service users attended the out-of-hours emergency dental service during the second period because they could not get an appointment with their own dentist (p = 0.002 from 28% to 20%) and significantly more service users in the second period felt the emergency dental service was easier to get to than their own dentist (P = 0.003 from 8% to 14%). Service users found out about the service from multiple sources, of which family and friends were the most common source (30%). In the second period fewer service users were obtaining information about the service from dental receptionists (P = 0.002 from 14% to 9%) and increased use of NHS Direct for a dental problem was reported (P = 0.002 from 16% to 22%) along with more service users being referred to the service by NHS Direct (P = 0.02 from 19% to 24%). The most common preference for future emergency dental care was face-to-face with a dentist (79%). CONCLUSION: This study has provided an insight into how and why people use an out-of-hours emergency dental service and has helped to guide future commissioning of these services. Overall, the service was being used in much the same way both before and after the 2006 dental contract. Significantly more use was being made of NHS Direct after April 2006; however, informal information networks such as friends and family remain an important source of information about accessing emergency dental services.

An animal model of "syringe feel" during peripheral nerve block.

BACKGROUND: The perception of high resistance during injection of a local anesthetic during regional anesthesia may indicate intraneural injection. Anesthetists' ability to detect high resistance by "syringe feel" has been questioned in the past. The aim of our study was to investigate the anesthetist's ability to detect abnormal resistance to injection using an animal model. METHODS: We created a model using nerve, muscle, bone, and tendon tissue dissected from a sheep. Regional anesthesia needles of 21-gauge and 100 mm were placed into each of these tissues under direct vision, and 40 anesthetists were then asked to inject normal saline from a 20-mL syringe. They were unable to see the needle position. Once injected into all 4 tissues, they were asked to state which tissue they thought each was. RESULTS: Of the 40 anesthetists, 12 (30%) correctly identified the nerve. This was no better than chance (25%) and shows that the tested anesthetists were unable to correctly identify beyond chance what tissues they were injecting into. When those who did not practice regional anesthesia regularly (n = 7) were excluded, similar results were obtained. Ten (30%) of the 33 self-identified experienced regional anesthetists correctly identified the nerve. A score that measured the number of correctly identified tissues (score 1) was used to compare anesthetists on grade and level of experience. This showed that the more experienced anesthetists did better than the less experienced ones. CONCLUSION: Under the conditions of this study model, anesthetists were unable to correctly identify intraneural injection by syringe feel during simulated regional anesthesia.

The MRC superficial bladder cancer trial of intravesical mytomicin-c after complete surgical resection. Sequential statistical methods applied to survival data from a randomised clinical trial.

Reduction in the duration of a study and in the number of patients required can be obtained when we adopt a sequential design. In this paper we re-analyse a trial completed by the British Medical Research Council on the effects of chemotherapy to prevent the recurrence of surgically removed superficial bladder cancer as if it had been monitored sequentially. The aim is to illustrate the use and benefits of sequential designs (stopping rules) and to highlight how to handle some potential problems when the assumptions of the statistical model are not satisfied. These problems are not exclusive to the sequential design, but are also present when a conventional design is used.

Prevalence and prognostic significance of allelic imbalance by single-nucleotide polymorphism analysis in low-risk myelodysplastic syndromes.

Low-risk myelodysplastic syndrome (MDS) with normal cytogenetics accounts for approximately 50% of MDS patients. There are no pathognomonic markers in these cases and the diagnosis rests on cytomorphologic abnormalities in bone marrow and/or peripheral blood. Affymetrix high-resolution single-nucleotide polymorphism (SNP) genotyping microarrays allow detection of cytogenetically cryptic genomic aberrations. We have studied 119 low-risk MDS patients (refractory anemia [RA] = 22; refractory cytopenia with multilineage dysplasia [RCMD] = 51; refractory anemia with ringed sideroblasts [RARS] = 12; refractory cytopenia with multilineage dysplasia with ringed sideroblasts [RCMD-RS] = 12; 5q- syndrome = 16; refractory anemia with excess blasts [RAEB] = 6) using SNP microarrays to seek chromosomal markers undetected by conventional cytogenetics. Loss of heterozygosity (LOH) detected by 50K arrays was verified using 250K and 500K arrays. We demonstrate the presence of uniparental disomy (UPD) in 46%, deletions in 10%, and amplifications in 8% of cases. Copy number (CN) changes were acquired, whereas UPDs were also detected in constitutional DNA. UPD on 4q was identified in 25% of RARS, 12% of RCMD with normal cytogenetics, 17% of RAEB, and 6% of 5q- syndrome cases. Univariate analysis showed deletions (P = .04) and International Prognostic Scoring System (IPSS; P < .001) scores correlated with overall survival; however, on multivariate analysis only IPSS scores retained prognostic significance (P < .001). We show, for the first time, that SNP microarray analysis in low-risk MDS patients reveals hitherto unrecognized UPD and CN changes that may allow stratification of these patients for early therapeutic interventions.

The emerging dental workforce: why dentistry? A quantitative study of final year dental students' views on their professional career.

BACKGROUND: Dental graduates are joining a profession experiencing changes in systems of care, funding and skill mix. Research into the motivation and expectations of the emerging workforce is vital to inform professional and policy decisions. The objective of this research was to investigate final year dental students' perceived motivation for their choice of career in relation to sex, ethnicity and mode of entry. METHODS: Self-administered questionnaire survey of all final year dental students at King's College London. Data were entered into SPSS; statistical analysis included Chi Squared tests for linear association, multiple regression, factor analysis and logistic regression. RESULTS: A response of 90% (n = 126) was achieved. The majority were aged 23 years (59%), female (58%) and Asian (70%). One in 10 were mature students. Eighty per cent identified 11 or more 'important' or 'very important' influences, the most common of which were related to features of the job: 'regular working hours' (91%), 'degree leading to recognised job' (90%) and 'job security' (90%). There were significant differences in important influences by sex (males > females: 'able to run own business'; females > males: 'a desire to work with people'), ethnic group (Asians > white: 'wish to provide public service', 'influence of friends', 'desire to work in healthcare', having 'tried an alternative career/course' and 'work experience') and mode of entry (mature > early entry: 'a desire to work with people'). Multivariate analysis suggested 61% of the variation in influences is explained by five factors: the 'professional job' (31%), 'healthcare-people' (11%), 'academic-scientific' (8%), 'careers-advising' (6%), and 'family/friends' (6%). The single major influence on choice of career was a 'desire to work with people'; Indian students were twice as likely to report this as white or other ethnic groups. CONCLUSION: Final year dental students report a wide range of important influences on their choice of dentistry, with variation by sex, ethnicity and mode of entry in relation to individual influences. Features of the 'professional job', followed by 'healthcare and people' were the most important underlying factors influencing choice of career.

Fecal M2-pyruvate kinase (M2-PK): a novel marker of intestinal inflammation.

BACKGROUND: Surrogate markers of bowel inflammation are increasingly being recognized as important, not only as markers of disease activity in inflammatory bowel disease (IBD) but also to differentiate irritable bowel syndrome (IBS) from IBD. The dimeric M2-isoform of pyruvate kinase (M2-PK) has been reported to be elevated in fecal specimens from colorectal cancer (CA) patients, but its role in IBD is unknown. This study investigated the usefulness of fecal M2-PK in cohorts of patients with IBD, IBS, and CA. METHODS: Stool samples were obtained for calprotectin and M2-PK measurements in patients with previously diagnosed IBD or new patients being investigated for lower gastrointestinal (GI) symptoms in a UK university hospital. Other investigations were performed as directed by the investigating physician and patients with known IBD were assessed for disease activity by a physician global assessment, Harvey-Bradshaw index (HBI), or endoscopic grading. RESULTS: Fecal M2-PK and calprotectin measurements were obtained for 148 patients: 50 with ulcerative colitis (UC); 31 with Crohn's disease (CD), 43 with irritable bowel syndrome/functional bowel disorders (IBS); 7 with colorectal CA, and 17 with miscellaneous conditions (excluded from the analysis). Median M2-PK values (U/mL) were significantly elevated in UC: 20.0 (95% confidence interval [CI] 5.4-69.0, P < 0.0001), CD: 24.3 (95% CI 6.4-44.0, P < 0.0001), and CA: 7.0 (95% CI 4.3-88.0, P < 0.0006) compared to IBS: 0.1 (95% CI 0.0-3.2). There was a strong linear correlation of M2-PK with calprotectin levels. A predetermined cutoff level of 3.7 U/mL for a normal M2-PK test produced a sensitivity, specificity, and positive predictive value (PPV) of 73%, 74%, and 89%, respectively, for organic disease. Furthermore, M2-PK levels were significantly elevated in active, compared to inactive, disease for CD (30 versus 0.55 U/mL, P < 0.005) and UC (40 versus 1.2 U/mL, P = 0.006), respectively. CONCLUSIONS: Fecal M2-PK is elevated in IBD as well as in CA patients and is a sensitive and relatively specific marker for organic GI pathology, with a PPV of 89%. Furthermore, it appears to be a potentially valuable, noninvasive marker of disease activity in IBD.

Sleeping position, oxygen saturation and lung volume in convalescent, prematurely born infants.

OBJECTIVE: To determine whether the effects of sleeping position on lung volume and oxygenation are influenced by postmenstrual age (PMA) and oxygen dependency in convalescent prematurely born infants. DESIGN: Prospective study. SETTING: Tertiary neonatal unit. PATIENTS: 41 infants (21 oxygen dependent), median gestational age 28 weeks (range 24-31 weeks) and birth weight 1120 g (range 556-1780 g). INTERVENTION: Infants were studied both supine and prone at two-weekly intervals from 32 weeks' PMA until discharge. Each posture was maintained for 1 h. MAIN OUTCOME MEASURES: Pulse oximeter oxygen saturation (Spo(2)) was monitored continuously, and at the end of each hourly period functional residual capacity (FRC) was measured. RESULTS: Overall, lung volumes were higher in the prone position throughout the study period; there was no significant effect of PMA on lung volumes. Overall, Spo(2) was higher in the prone position (p = 0.02), and the effect was significant in the oxygen-dependent infants (p = 0.03) (mean difference in Spo(2) between prone and supine was 1.02%, 95% CI 0.11% to 1.92%), but not in the non-oxygen-dependent infants. There was no significant influence of PMA on Spo(2). CONCLUSION: In the present study, prone sleeping did not improve oxygenation in prematurely born infants, 32 weeks' PMA or older and with no ongoing respiratory problems. However, the infants were monitored in each position for an hour, thus it is recommended that oxygen saturation should continue to be monitored after 32 weeks' PMA to be certain that longer periods of supine sleeping are not associated with loss of lung volume and hypoxaemia.

Acquisition of competence in paediatric ileocolonoscopy with virtual endoscopy training.

This study prospectively compared the rates of skill acquisition in ileocolonoscopy in 2 consecutive groups of trainees in paediatric gastroenterology, with 1 cohort exposed to virtual endoscopy. All paediatric gastroenterology trainees rotating through our department during a 7-year period between 1997 and 2004 were formally assessed while performing ileocolonoscopies using a trainer case-by-case method. Fourteen consecutive trainees with no previous experience of ileocolonoscopy were assessed. Comparison of rates of skill acquisition and lesion recognition using multiple linear regressions revealed a significant acceleration of achievement of endoscopic goals (P < 0.0001) in the group with prior exposure to virtual endoscopy.

The effects of blood pressure reduction on cognitive function: a review of effects based on pooled data from clinical trials.

OBJECTIVE: To review systematically and synthesize quantitatively the evidence from completed randomized, controlled trials of blood pressure reduction on cognitive performance. METHODS: MEDLINE, EMBASE and Cochrane databases were searched to identify randomized, controlled trials that measured the effect of blood pressure reduction on cognitive performance. Additional studies were identified by searching bibliographies of retrieved articles and contacting experts in the field. Data were extracted on study quality, blood pressure, performance on cognitive function tests, antihypertensive treatment regimens and the duration of treatment. Studies were reviewed and abstracted independently by two trained researchers. RESULTS: Sixteen studies with 19 501 subjects were identified. Modest reductions in blood pressure (< 5/3 mmHg) in 13 860 subjects were associated with improvements in Mini Mental State Examination score [weighted mean difference (WMD) = 0.19; 95% confidence interval (CI) = 0.19-0.19] and performance on immediate (WMD = 0.62; 95% CI = 0.21-1.02) and delayed (WMD = 0.67; 95% CI = 0.23-1.11) logical memory tasks. However, studies in 2380 subjects that included tests of perceptual processing and learning capacity (trail making test-A, paired associated learning test) showed impaired performance (WMD = -1.12 s; 95% CI = -1.22 to -1.02 and WMD = -0.04; 95% CI = -0.04 to -0.04) on these tests. CONCLUSION: Blood pressure lowering may have a heterogeneous effect on different aspects of cognitive function. Future studies with specific cognitive end-points are needed for greater clarity to guide practice.

Antioxidants versus corticosteroids in the treatment of severe alcoholic hepatitis--a randomised clinical trial.

BACKGROUND/AIMS: Severe alcoholic hepatitis is associated with high morbidity and short-term mortality. Corticosteroids are the only widely used therapy but established contraindications to treatment or the risk of serious side-effects limit their use. The perceived need for alternative treatments together with the theoretical benefits of anti-oxidant therapy triggered the design of a randomised clinical trial comparing these treatment modalities. METHODS: One hundred and one patients were randomized into a clinical trial of corticosteroids or a novel antioxidant cocktail with a primary endpoint of 30-day mortality. RESULTS: At 30 days there were 16 deaths (30%) in the corticosteroid treated group compared with 22 deaths (46%) in the antioxidant treated group (P=0.05). The odds of dying by 30 days were 2.4 greater for patients on antioxidants (95% confidence interval 1.0-5.6). A diagnosis of sepsis was made more frequently in the AO group (P=0.05), although microbiologically proven episodes of infection occurred more often in the CS group (P<0.01). The survival advantage for corticosteroid treated patients was lost at 1 year of follow-up (P=0.43). CONCLUSIONS: This study has shown that corticosteroids in the form of prednisolone 30 mg daily are superior to a broad antioxidant cocktail in the treatment of severe alcoholic hepatitis.

Is the gag reflex useful in the management of swallowing problems in acute stroke?

The goal of this study was to compare the diagnostic value of an absent gag reflex in acute stroke patients with the bedside swallowing assessment (BSA) and assess its relationship to outcomes. Two hundred forty-two acute stroke patients had their gag reflex tested and a BSA performed. Numbers needing nasogastric or gastrostomy tube insertion were noted, also their discharge destination, discharge Barthel Index, and mortality. The mean age of the subjects was 76.5+/-10.2 years; 37.6% were male; 41.7% of the patients were dysphagic on BSA; 18.2% had an absent gag. Dysphagia was present in 88.6% of the patients with an absent gag and in 31.3% of those with an intact gag. The gag reflex was absent in 38.6% of dysphagic and 3.5% of nondysphagic patients. Comparing an absent gag against the criterion of the BSA, its specificity was 0.96, sensitivity 0.39, positive predictive value 0.89, and negative predictive value 0.69. Regression analyses found that an intact gag gave an Odds Ratio [CI] of 0.23 [0.06-0.91] for gastrostomy feeding but did not predict other outcomes. We conclude that the gag reflex is as specific as but less sensitive than the BSA in detecting dysphagia in acute stroke patients. An intact gag may be protective against longer-term swallowing problems and the need for enteral feeding.

Determinants of caregiving burden and quality of life in caregivers of stroke patients.

BACKGROUND AND PURPOSE: A large proportion of disabled stroke survivors live at home and are supported by informal caregivers. Identification of determinants of caregiver burden will help to target caregiver interventions. METHODS: Data on patient, caregiver, and health and social support characteristics were collected prospectively over 1 year in 232 stroke survivors in a randomized trial of caregiver training. The contribution of these variables to caregiver burden score (CBS) and quality of life (QOL) measures at 3 months and 1 year was analyzed using regression models. RESULTS: Stroke patients had a mean age of 74+/-11 years, and 120 (52%) were men. The mean age of caregivers was 65.7+/-12.5 years, 149 (64%) were females, and 116 (50%) had received caregiver training. The mean CBS was 48+/-13 and 38+/-11 (score range of bad to good 88 to 22) and QOL score was 75+/-16 and 75+/-15 (score range of bad to good 0 to 100) at 3 months and 1 year, respectively. CBS and QOL correlated with each other and with patient (age, dependency, and mood), caregiver (age, gender, mood, and training), and support (social services and family networks) variables. Of these, only patient and caregiver emotional status, caregiver age and gender, and participation in caregiver training were independent predictors of either outcome at 3 months. Patient dependency and family support were additional independent predictors at 1 year. Social services support predicted institutionalization but not caregiver outcomes. CONCLUSIONS: Advancing age and anxiety in patients and caregivers, high dependency, and poor family support identify caregivers at risk of adverse outcomes, which may be reduced by caregiver training.