Clinical traits of LRRK2-associated parkinson's disease in ireland: a link between familial and idiopathic PD

The role of genetics in parkinsonism has been confirmed over the last decade with the identification of genetic variation in seven genes, which are causative in familial forms of the disorder. A number of pathogenic mutations have been identified in the latest gene LRRK2, with a Gly2019Ser amino acid substitution identified in two siblings and one patient with idiopathic Parkinson's disease from Ireland. The clinical features resemble the idiopathic variant with a tremor predominant clinical picture shared by the siblings, slow progression of symptoms, and no observation of cognitive disturbance in all. The family and the sporadic individual were apparently not related and originated from different regions of Ireland, although haplotype analysis does suggest they share a common founder. The influence of the G2019S substitution on protein function and disease phenotype has yet to be fully resolved, but its elucidation will undoubtedly further our understanding of the mechanisms underlying Parkinson's disease.

Early pain experience, child and family factors, as precursors of somatization:a prospective study of extremely premature and fullterm children

In a prospective study of 36 children who were extremely low birthweight (ELBW: <1000 g) preterm infants and 36 matched full-term controls, differences were found in somatization at age 4 1/2 years. Only children who had been extremely premature, and thereby experienced prolonged hospitalization and repeated medical intervention in infancy, had clinically high somatization scores on the Personality Inventory for Children. The combination of family relations at age 4 1/2 years, neonatal intensive care experience, poor maternal sensitivity to child cues in mother-child interaction observed at age 3 years, and child avoidance of touch or holding at age 3, predicted somatization scores, prior to school entry. Due to the known higher incidence of actual medical problems among children with a history of extreme prematurity, the high somatization ELBW children were compared with the normal somatization ELBW children. There were no differences in prevalence of actual medical problems between the 2 ELBW groups, and the importance of maternal factors in relation to somatization was confirmed. Child temperament at age 3, but not personality at 4 1/2, was related to somatization. The etiology of recurrent physical complaints of no known medical cause appears to be a multi-dimensional problem. Non-optimal parenting may contribute to the development of inappropriate strategies for coping with common pains of childhood, or of chronic pain patterns, in some children who have experienced prolonged or repeated pain as neonates.

"From Indomania to Indophobia":Thomas De Quincey's Providential Orientalism

Thomas De Quincey’s terrifying oriental nightmares, reported to sensational acclaim in his Confessions of an English Opium-Eater (1821), have become a touchstone of romantic imperialism in recent studies of the literature of the period (Leask 1991; Barrell 1992 et al). De Quincey’s collocation of “all creatures, birds, beasts, reptiles, all trees and plants, usages and appearances, that are found in all tropical regions” in the hypnagogic hallucinations that characterized what he called “the pains of opium” seems to anticipate neatly Said’s theory of orientalism, whereby the orient was supplied by the west with “a mentality, a genealogy, an atmosphere,” the attitudinal basis as he argues for the continuing march of imperialism from the late eighteenth century. Yet, as Thomas Trautmann (1997) has pointed out, orientalist scholarship based in India and led by the influential Asiatic Society of Bengal in the late eighteenth century was extremely enthusiastic about Indian classical antiquity. The early orientalist scholarship posited ethnic, linguistic, cultural and religious links between Europe and India, while recognizing the greater antiquity of Indian civilization. This favourable attitude (which Trautmann calls “Indomania”) was overtaken in the nineteenth century by disavowal of that scholarship and repugnance (which he calls “Indophobia”), influenced by utilitarian and evangelical attitudes to colonialism. De Quincey’s lifespan covers this crucial period of change. My paper examines his evangelical upbringing and interest in biblical and orientalist scholarship to suggest his anxious investment in these modes of thinking. I will suggest that the bizarre orientalist fusions of his dreams can be better understood in the context of changing attitudes to the imperialism during the period. An examination of his work provides a far more dynamic understanding of the processes of orientalism than the binary model suggested by Said. The transformation implied from imperial scholarship to governance, I will suggest, is not irrelevant to a world which continues to pull apart on various grounds of race and ethnicity, and reflects on our own role in the academy today.

Genome-wide association analysis identifies 13 new risk loci for schizophrenia

Schizophrenia is an idiopathic mental disorder with a heritable component and a substantial public health impact. We conducted a multi-stage genome-wide association study (GWAS) for schizophrenia beginning with a Swedish national sample (5,001 cases and 6,243 controls) followed by meta-analysis with previous schizophrenia GWAS (8,832 cases and 12,067 controls) and finally by replication of SNPs in 168 genomic regions in independent samples (7,413 cases, 19,762 controls and 581 parent-offspring trios). We identified 22 loci associated at genome-wide significance; 13 of these are new, and 1 was previously implicated in bipolar disorder. Examination of candidate genes at these loci suggests the involvement of neuronal calcium signaling. We estimate that 8,300 independent, mostly common SNPs (95% credible interval of 6,300-10,200 SNPs) contribute to risk for schizophrenia and that these collectively account for at least 32% of the variance in liability. Common genetic variation has an important role in the etiology of schizophrenia, and larger studies will allow more detailed understanding of this disorder.

Two-year survival of ART restorations placed in elderly patients: A randomised controlled clinical trial

OBJECTIVES: Older dentate adults are a high caries risk group who could potentially benefit from the use of the atraumatic restorative treatment (ART). This study aimed to compare the survival of ART and a conventional restorative technique (CT) using rotary instruments and a resin-modified glass-ionomer for restoring carious lesions as part of a preventive and restorative programme for older adults after 2 years.

METHODS: In this randomised controlled clinical trial, 99 independently living adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations. The survival of restorations was assessed by an independent and blinded examiner 6 months, 1 year and 2 years after restoration placement.

RESULTS: Ninety-six (67.6%) and 121 (76.6%) restorations were assessed in the ART and CT groups, respectively, after 2 years. The cumulative restoration survival percentages after 2 years were 85.4% in the ART and 90.9% in the CT group. No statistically significant between group differences were detected (p=0.2050, logistic regression analysis).

CONCLUSIONS: In terms of restoration survival, ART was as effective as a conventional restorative approach to treat older adults after 2 years. This technique could be a useful tool to provide dental care for older adults particularly in the non-clinical setting. (Trial Registration number: ISRCTN 76299321).

CLINICAL SIGNIFICANCE: The results of this study show that ART presented survival rates similar to conventional restorations in older adults. ART appears to be a cost-effective way to provide dental care to elderly patients, particularly in out of surgery facilities, such as nursing homes.

Minimal intervention dentistry and older patients part 2: minimally invasive operative interventions

As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges. The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful armamentarium to the general dentist to provide ethical and conservative treatment to older patients.

Clinical Relevance: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to preserve the longevity of their natural dentition.

Subjective impact of minimally invasive dentistry in the oral health of older patients

OBJECTIVES: The aim of this study was to investigate if a minimally invasive oral health package with the use of atraumatic restorative treatment (ART) or a conventional restorative technique (CT) would result in any perceived benefit from the patients' perspective and if there would be any difference between the two treatment groups.

MATERIALS AND METHODS: In this randomised clinical trial, 99 independently living older adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations using minimally invasive/intervention dentistry (MID) principles. Patients completed an Oral Health Impact Profile (OHIP)-14 questionnaire before and 2 months after treatment. They were also asked to complete a global transition question about their oral health after treatment.

RESULTS: At baseline, the mean OHIP-14 scores recorded were 7.34 (ART) and 7.44 (CT). Two months after treatment intervention, 90 patients answered the OHIP-14 and the mean scores were 7.23 (not significant (n.s.)) and 10.38 (n.s.) for the ART and CT groups, respectively. Overall, 75.5 % of patients stated that their oral health was better compared to the beginning of treatment.

CONCLUSIONS: Although not shown by the OHIP-14, patients perceived an improvement in their overall oral status after treatment, as demonstrated by the global transition ratings in both groups.

CLINICAL RELEVANCE: Dental treatment using minimally invasive techniques might be a good alternative to treat older individuals, and it can improve their oral health both objectively and subjectively.

Minimal intervention dentistry and older patients Part 1: Risk assessment and caries prevention

Ten million people in the UK today are aged over 65. The latest projections estimate that there will be 5 1/2 million more people aged 65 and older in the next 20 years. This projected pattern of population ageing will have profound consequences for dentistry. Minimal intervention dentistry (MID) is a modern evidence-based approach to caries management in dentate patients that uses the 'medical model' whereby disease is controlled by the 'oral physician'. This approach offers considerable benefits over conventional dentistry for older patients. It encourages patients to be responsible for their oral health through the provision of both knowledge and motivation. MID encompasses risk assessment for dental disease, early detection and control of disease processes, and minimally invasive treatment. 

Clinical Relevance: Risk assessment tools can aid the general dental practitioner and the patient to develop a suitable caries prevention programme for that individual and reduce the need for future operative intervention.

Cost-effectiveness of ART restorations in elderly adults: a randomized clinical trial

BACKGROUND: As the world population ages, the requirement for cost-effective methods of treating chronic disease conditions increases. In terms of oral health, there is a rapidly increasing number of dentate elderly with a high burden of maintenance. Population surveys indicate that older individuals are keeping their teeth for longer and are a higher caries risk group. Atraumatic Restorative Treatment (ART) could be suitable for patients in nursing homes or house-bound elderly, but very little research has been done on its use in adults.

OBJECTIVES: To compare the cost-effectiveness of ART and a conventional technique (CT) for restoring carious lesions as part of a preventive and restorative programme for older adults.

METHODS: In this randomized clinical trial, 82 patients with carious lesions were randomly allocated to receive either ART or conventional restorations. Treatment costs were measured based on treatment time, materials and labour. For the ART group, the cost of care provided by a dentist was also compared to the cost of having a hygienist to provide treatment. Effectiveness was measured using percentage of restorations that survived after a year.

RESULTS: Eighty-two patients received 260 restorations, that is, 128 ART and 132 conventional restorations. 91.1% of the restorations were on one surface only. After a year, 252 restorations were assessed in 80 patients. The average cost for ART and conventional restorations was €16.86 and €28.71 respectively; the restoration survival percentages were 91.1% and 97.7%, respectively. This resulted in a cost-effectiveness ratio of 0.18 (ART) and 0.29 (CT). When the cost of a hygienist to provide ART was inserted in the analysis, the resulting ratio was 0.14.

CONCLUSIONS: Atraumatic restorative treatment was found to be a more cost-effective alternative to treat older adults after 1 year, compared to conventional restorations, especially in out of surgery facilities and using alternative workforce such as hygienists. Atraumatic restorative treatment can be a useful tool to provide dental care for frail and fearful individuals who might not access dental treatment routinely.

Caries and the older patient

Ageing of the population, together with prolonged retention of teeth, has brought new challenges to dentistry. Whereas in the past oral care for the elderly was restricted to provision of dentures, older patients are now presenting with dental caries and failed restorations. These problems may have an impact on their general health and quality of life. Poor oral hygiene, xerostomia and diet are among the risk factors for caries in older patients and need to be addressed in order to achieve control of the disease. Carious lesions can be treated conservatively in many cases or may need surgical management.

CLINICAL RELEVANCE: Caries is an oral health issue among older patients and can result in tooth loss. Oral health has a great impact on general health and quality of life of elderly people.

Gerodontology--how big is the challenge in Ireland?

Population trends suggest that the Irish population is ageing, and that this population will have substantial treatment needs. These patients will be better informed than previous generations, and will demand treatment aimed at preserving a natural dentition. This will impact upon delivery of oral healthcare and manpower planning needs to consider how to address the increased demand for dental care. Poor oral health is associated with systemic health problems, including cardiovascular disease, respiratory disease and diabetes mellitus. It also has a negative impact upon quality of life, and the World Health Organisation has encouraged public healthcare administrators and decision makers to design effective and affordable strategies for better oral health and quality of life of older adults, which, in turn, are integrated into general health management programmes. Treatment concepts such as minimally invasive dentistry and the shortened dental arch concept are discussed in the context of these demographic changes and recommendations.

Caries incidence following tooth replacement for partially dentate elders

Objective: To compare caries incidence following two different tooth replacement strategies for partially dentate older patients; namely functionally orientated treatment according to the principles of the Shortened Dental Arch (SDA) and conventional treatment using Removable Partial Dentures (RPDs). Method:A randomised controlled clinical trial (RCT) was conducted of partially dentate patients aged 65 years and older. Patients were randomly allocated to two different treatment groups: the RPD group and the SDA group. Each member of the RPD group was restored to complete arches with cobalt-chromium RPDs used to replace missing teeth. Patients in the SDA group were restored to a shortened arch of 10 occluding pairs of natural and replacement teeth using adhesive bridgework. All of the operative treatment was completed by a single operator. Caries incidence was measured over a 2-year period following treatment intervention and recorded using the International Caries and Detection System (ICDAS). Result:In total, 89 patients completed the RCT (45 SDAs and 44 RPDs). Patients in the RPD group recorded a significantly higher incidence of new carious lesions (p<0.001) and recurrent carious lesions (p<0.001) compared to the SDA group. A mixed model of covariance (ANCOVA) revealed that treatment group (p<0.001) and co-morbidity (p<0.001) were significant predictors of caries incidence. Conclusion:Two years after provision of prosthodontic treatment there was a significantly higher incidence of new and recurrent caries lesions in subjects provided with RPDs compared with SDA treatment. This will have a significant impact on the ongoing maintenance costs for these two treatment groups.

The Use of ART in Elderly Patients after 2 years

Caries experience is high in the elderly, and barriers to care for older adults include fear and cost. Access to care is especially problematic in the case of frail and homebound elderly. Objective: to compare the survival of restorations placed using Atraumatic Restorative Treatment (ART) and a conventional technique using rotary instruments and a resin-modified glass-ionomer (CT) to treat carious lesions in older patients. Methods: In this randomised clinical trial, 99 independently living adults (65-90 yrs) with carious lesions were recruited from a geriatric day hospital and a community centre and randomly allocated to receive either ART or conventional restorations. They received tailored oral hygiene instructions and scaling and polishing of teeth prior to restoration placement. The survival of restorations was assessed 6, 12 and 24 months after restoration placement by an independent examiner. Results: Ninety-nine patients participated in the trial, 46 males and 53 females, with a mean age of 73.2 (SD: 6.8). In total, 300 restorations were placed, 142 ART in 51 patients and 158 conventional restorations in 48 patients, with an average of 2.8 ART (SD: 1.83) and 3.2 conventional (SD: 2.62) restorations placed per patient. After 2 years, 88 ART and 117 conventional restorations were assessed. The restoration survival percentages were 93.1% and 94%, respectively. Conclusion: ART was found to be as effective as a conventional restorative approach to treat older adults after 2 years and could be a useful tool to provide dental care for older dentate adults.