Considering complementary and alternative medicine alternatives in cases of life-threatening illness: applying the best-interests test

In this article we explore decision-making about treatment when a child faces a life-threatening illness but conventional treatment presents substantial risk and uncertain benefit. When is it acceptable for parents to decide to use complementary and alternative medicine as an alternative, rather than a complement, to conventional care? We use the example of a young child suffering from progressive glycogen storage disease, for whom liver transplant offers the only prospect of a cure. Without a liver transplant, the disease usually results in death within a few years. However, experience using transplant to treat this illness has been limited, success is far from ensured, and the risks (including death and continued progression of the disease) are substantial. The child's parents, who are first-generation immigrants, consider the risks of the transplant unjustified because it still does not offer good prospects for a healthy future. They believe that traditional Chinese medicine could help remediate their daughter's disease. In the article we (1) review parents' obligation to make treatment decisions in the best interests of their child, (2) explain limits on parents' decision-making authority, (3) explore how "best interests" are determined, focusing on cases of serious illness for which conventional treatment is risky and benefit is possible but uncertain, (4) explain the standard of care that physicians must meet in advising about treatment, and (5) outline factors that clinicians and parents should take into account when making decisions.     

The levels of asymmetric dimethylarginine, homocysteine and carotid intima-media thickness in hypercholesterolemic children

The aim of this study was to examine the intima-media thickness (IMT) of carotid arteries and endothelial function parameters such as plasma asymmetric dimethylarginine (ADMA) and homocysteine levels in hypercholesterolemic children and to investigate the relations of these parameters with hypercholesterolemia. Fifty-seven hypercholesterolemic and 37 healthy children were included in the study. Hypercholesterolemia was defined as 155 mg/dl and above for low-density lipoprotein (LDL)-cholesterol. Plasma concentrations of ADMA and homocysteine were measured and the measurement of carotid IMT was determined. Both carotid IMT and plasma ADMA levels were significantly higher in hypercholesterolemic children than healthy children (p<0.01). No significant difference was determined in homocysteine concentration between hypercholesterolemic children and the control group (p>0.05). No significant correlation was observed between lipid profiles and the levels of ADMA and homocysteine. However, a significant positive correlation was found between carotid IMT and total and LDL-cholesterol levels and between the levels of ADMA and LDL-cholesterol. In conclusion, the progressive increase in ADMA levels and carotid IMT and the positive relationship between carotid IMT and serum cholesterol levels support that plasma ADMA levels and carotid IMT can be indicators of early atherosclerosis in hypercholesterolemic children.     

Frequency and risk factors of narrow angles in patients with pseudoexfoliation: a case–control study

International Ophthalmology - To determine the frequency and risk factors of narrow angles in pseudoexfoliation (PXF) patients. A prospective case–control study was conducted during the...     

Radiographic evaluation of periapical healing of permanent teeth with periapical lesions after extrusion of AH Plus sealer.

The aim of this study was to clinically and radiographically examine the effects of extrusion of AH Plus sealer on the healing of permanent teeth with apical periodontitis. A total of 87 root canals radiographically detected with apical periodontitis were included in the study. Posttreatment radiographs indicated sealer extrusion into 49 canals (Group 1) and no sealer extrusion into 38 canals (Group 2). Periapical treatment was judged as complete healing (CH), incomplete healing (IH) and no healing (NH) at the end of a 4-year follow-up period. Amounts of extraradicular sealer were recorded as "unchanged," "reduced," "almost absent," or "absent." The t test was used for the statistical analyses. In Group 1, CH was detected in 41 canals, IH in 4 canals, and NH in 4 canals. Differences between CH and both IH and NH were statistically significant (P < .001). In Group 2, CH was detected in 34 canals and NH in 4 canals. The difference between CH and NH was statistically significant (P < .001). A statistically significant difference (P < .05) between treatment groups was observed for CH at the 6-month follow-up appointment only; other than that instance, there were no statistical differences for CH or NH between the groups. In conclusion, extruded AH Plus does not prevent periapical healing, but can be a delaying factor for healing in children.     

Androgen Receptors in the Posterior Bed Nucleus of the Stria Terminalis Increase Neuropeptide Expression and the Stress-Induced Activation of the Paraventricular Nucleus of the Hypothalamus

The posterior bed nuclei of the stria terminalis (BST) are important neural substrate for relaying limbic influences to the paraventricular nucleus (PVN) of the hypothalamus to inhibit hypothalamic-pituitary-adrenal (HPA) axis responses to emotional stress. Androgen receptor-expressing cells within the posterior BST have been identified as projecting to the PVN region. To test a role for androgen receptors in the posterior BST to inhibit PVN motor neurons, we compared the effects of the non-aromatizable androgen dihydrotestosterone (DHT), the androgen receptor antagonist hydroxyflutamide (HF), or a combination of both drugs implanted unilaterally within the posterior BST. Rats bearing unilateral implants were analyzed for PVN Fos induction in response to acute-restraint stress and relative levels of corticotrophin-releasing hormone and arginine vasopressin (AVP) mRNA. Glutamic acid decarboxylase (GAD) 65 and GAD 67 mRNA were analyzed in the posterior BST to test a local involvement of GABA. There were no changes in GAD expression to support a GABA-related mechanism in the BST. For PVN neuropeptide expression and Fos responses, basic effects were lateralized to the sides of the PVN ipsilateral to the implants. However, opposite to our expectations of an inhibitory influence of androgen receptors in the posterior BST, PVN AVP mRNA and stress-induced Fos were augmented in response to DHT and attenuated in response to HF. These results suggest that a subset of androgen receptor-expressing cells within the posterior BST region may be responsible for increasing the biosynthetic capacity and stress-induced drive of PVN motor neurons.     

Survival of hydroxyapatite-coated implants: A meta-analytic review

PURPOSE: Some reports show a benefit of coating dental implants with hydroxyapatite (HA), and others assert that resorption of the HA coating compromises long-term implant survival. This study examined this controversy by systematically reviewing all the current literature that reports the outcomes of HA-coated implants in human clinical trials. MATERIALS AND METHODS: A systematic Medline computer search of the English literature yielded 45 human clinical trials that reported on the outcome of HA-coated implants. Eleven studies that met specific inclusion criteria were selected for detailed analysis. The studies were divided into 2 groups. One group of 5 studies reported implant survival using overall percentage, and another group of 6 studies reported implant survival using life-table analysis. RESULTS: The overall percentage survival rates ranged from 93.2% to 98.5%, with 4 to 8 years of follow-up. The cumulative survival rates for studies that used life-table analysis ranged from 79.2% to 98.5%, with 5 to 8 years of follow-up. The yearly interval survival rates reported for the studies using life-tables were variable but remained above 90% and did not show a progressive or precipitous decrease with increasing years of follow-up. CONCLUSIONS: The survival rates reported for HA-coated implants were similar to the survival rates reported for uncoated titanium implants. If resorption of the HA coating causes late failure of implants, the yearly interval survival rates should have decreased with increased years of follow-up. This decrease was not observed in the longitudinal human clinical trials that met the selection criteria for this study. Detailed analysis of these clinical trials did not show that HA-coating compromises the long-term survival of dental implants.     

HSP 60 expression in mucocutaneous lesions of Behçet''s disease

BACKGROUND: Heat shock protein (60 kd HSP) has been implicated in the etiology of Beh?et's disease, but its expression at sites of inflammation is unknown. OBJECTIVE: Our aim was to investigate local HSP 60 expression and to quantify T-cell receptor (TCR) gamma delta-positive cells, which are known to respond to HSP peptides. METHODS: Patients with active Beh?et's disease (n = 21) and controls (n = 18) were included. Flow cytometric analysis was performed on peripheral blood to investigate TCR gamma delta-positive cell counts. Biopsies were performed on active skin lesions, and immunohistochemical analysis was performed by a streptavidin-biotin method using the monoclonal ML-30 antibody; HSP staining intensity and distribution were evaluated in a blinded fashion. Immunohistochemical studies were performed to quantify TCR gamma delta-positive cells at lesional sites. RESULTS: Mucocutaneous lesions of patients with Beh?et's disease had statistically significantly increased expression of HSP 60/65. Peripheral blood TCR gamma delta-positive cell counts were similar in both groups. However, lesional skin of patients with Beh?et's disease had significantly increased gamma delta-positive T-cell counts. CONCLUSION: Up-regulation of HSP expression was found at lesional skin sites in Beh?et's disease. The increased number of TCR gamma delta-positive cells, which are known to respond to HSP peptides, may support the function of HSPs in the etiology of Beh?et's disease. However, these findings may also be an epiphenomenon that needs to be further investigated.     

Pattern of human leukocyte antigens in Turkish children with celiac disease

BACKGROUND: Regional variations in the human leukocyte antigen (HLA) distribution patterns of celiac disease (CD) have been reported. The aim of the present study was to assess the distribution of HLA class I and class II in Turkish children with CD and to compare the findings with a control group. METHODS: Human leukocyte antigen typing was performed in 33 children with CD and in 77 healthy individuals, who served as controls, by using standard National Institutes of Health lymphocytotoxicity techniques. RESULTS: A positive association was found between HLA A2 (42 vs 19% for sick subjects compared with healthy controls, respectively), B8 (39 vs. 9% for sick subjects compared with healthy controls, respectively), CW7 (45 vs. 25% for sick subjects compared with healthy controls, respectively), DR3 (70 vs. 17% for sick subjects compared with healthy controls, respectively), DR7 (30 vs. 13% for sick subjects compared with healthy controls, respectively) and DQ2 (52 vs. 34% for sick subjects compared with healthy controls, respectively). The combinations of DR3-DQ2 (30 vs. 12% for sick subjects compared with healthy controls, respectively), DR3-DR4 (21 vs. 1% for sick subjects compared with healthy controls, respectively) and DR7-DQ2 (21 vs. 6% for sick subjects compared with healthy controls, respectively) were also found to be significantly important in children with CD. The highest relative risk (RR) was for HLA B8 in class I (RR 6.50), for DR3 (RR 11.30) in class II and for combination of DR3-DR4 (RR 20.46). The highest etiologic fraction (EF) was for the DR3 antigen (EF 0.55). CONCLUSIONS: The present study emphasizes that HLA genotypes are an important background to CD development, but some additional susceptibility factors remain to be identified.     

Reconstruction of soft tissue defects of the hand using the shape-modified radial forearm flap.

We have reconstructed soft tissue defects in 121 hands with radial forearm flaps. So that the flap perfectly fitted the defect, and to minimise the size of the donor site, we divided the flap into two or three components in each case. We call this the shape-modified radial forearm flap. Of the 118 patients, 113 had complete survival of the flap. The follow-up time was 1 to 15 years. The donor sites were closed primarily in all patients, giving good aesthetic results. The shape-modified radial forearm flap seems to be reliable, and makes it possible to adjust the flap according to the defect. The donor area can be closed primarily in all cases.