Dental fear and anxiety as a barrier to accessing oral health care among patients with special health care needs

Persons with special health care needs due to physical and cognitive impairment can be at increased risk for dental disease which can be attributed to, as well as exacerbate, existing medical conditions. This study assessed the nature of perceived barriers to obtaining oral health care among a special-needs population and the influence of these factors (in particular, fear and anxiety) on utilization of dental services. A total of 27.9% of the sample reported fear/anxiety about dental visits, with approximately half of those reporting to be very nervous or "terrified". There was an inverse relationship between the frequency of dental visits and the proportion of respondents reporting themselves as very nervous or terrified, and between the perception of oral health status and the level of dental fear/anxiety (P < 0.001). A large difference was reported between patient preference for pharmacologic modalities for anxiety control and those received at dental visits, with 40% of the youngest age group indicating that they would go to the dentist more frequently if sedation or general anesthesia were offered. The levels of self-reported fear/anxiety and the high proportion of respondents indicating an unmet need for adjunctive anesthesia services suggest that fear/anxiety acts as a barrier to dental care among this special-needs group which could be ameliorated with greater use of these services.

The use of transvaginal ultrasound and saline infusion sonohysterography for the evaluation of asymptomatic postmenopausal breast cancer patients on tamoxifen

Tamoxifen has been shown to decrease the recurrence rate of breast cancer. Evidence that tamoxifen use may be associated with an increased risk of endometrial cancer has caused investigators to recommend routine invasive sampling. We have assessed a minimally invasive alternative for endometrial surveillance of tamoxifen-treated patients utilizing transvaginal ultrasound and saline infusion sonohysterography. Asymptomatic women (n = 44) with breast cancer on postoperative tamoxifen treatment were referred to our gynecological ultrasound unit. Initially, the endometrial echo was measured with unenhanced transvaginal ultrasound. If a distinct echo measured < or = 5 mm, no further procedure was performed. For thickened or inadequately visualized echoes, sonohysterography was performed. If a thin echo was noted on sonohysterography, no further procedure was performed. If focal changes were detected, hysteroscopy/dilatation and curettage (D&C) was performed. For generalized symmetrically thickened echoes, a blind biopsy was done. If sonohysterography was unsuccessful, hysteroscopy/D&C was performed. Eleven (25%) patients had thin unenhanced echoes of < or = 5 mm. Twenty-five (57%) patients had thickened endometrial echoes. Three (7%) had naturally occurring endometrial fluid outlining a polyp. An endometrial echo could not be visualized in five (11%) patients. Sonohysterography was successfully performed in 21 out of 30 (70%) patients with either thickened or non-visualized unenhanced echoes. Of these, two patients had thin endometria with coexisting myomas; seven had thin endometria with typical tamoxifen-induced subendometrial changes: and seven had focal polypoid thickening confirmed by hysteroscopy/D&C. Histology revealed carcinoma associated with two, proliferation in one and four polyps. Five patients had thickened unenhanced echoes with symmetrically thickened single-layer measurements on sonohysterography. Histology revealed that three were proliferative, one was inactive and one was hyperplastic. In the nine patients with unsuccessful sonohysterography, hysteroscopy/D&C revealed inactive endometria in six, and three polyps. Our paradigm of evaluating the endometrial response to tamoxifen is concluded to overcome the shortcomings of either unenhanced transvaginal ultrasound or blind biopsy alone while it kept the number of invasive sampling procedures to 55% (24 out of 44).

Juvenile dermatomyositis and polymyositis: a follow-up study of long-term sequelae

BACKGROUND

Juvenile dermatomyositis/polymyositis (DMS/PM) are childhood inflammatory myopathies that normally affect children between 2 and 15 years of age. The disease is manifested as severe proximal muscle weakness and, in JDMS, as a characteristic cutaneous eruption. It is difficult to predict the course of the disease. This study is aimed at objectively assessing the long-term morbidity of dermatomyositis/polymyositis in children.

METHODS

Twelve cases of JDMS/PM identified through chart review were evaluated by physical and dermatologic examination, muscle testing, ultrasonography, and magnetic resonance imaging (MRI).

RESULTS

The patient population included 6 male and 6 female patients with a mean age of 18.8 years (standard deviation 12.4). The mean age at onset of JDMS/PM was 5.8 years (SD 2.8), and the mean time from onset of symptoms to beginning of the study was 10.1 years (SD 9.3). The mean duration of corticosteroid therapy was 53.1 months (SD 40.5), with patients reporting an average of 1.7 relapses (SD 1.5). Patients compared their own activity level with that of healthy control subjects, and on a scale of 1 to 5 with 5 being normal, their mean score was 3.9 (SD 0.9). Fifty-eight percent of the patients had at least one residual finding on physical examination, and 78% of those with JDMS had residual dermatologic sequelae. Despite these findings, the mean grade for the group was 4.6 (SD 0.6) for muscle strength, using a scale of 0 to 5 with 0 being no muscle resistance and 5 being normal. In 60% of patients examined by ultrasonography, increased echogenicity indicated possible residual fibrotic change in at least one muscle group. Although MRI showed no active disease process in four patients, scattered intramuscular calcification was found in one patient.

CONCLUSIONS

Multiple physical and dermatologic sequelae are commonly present in patients with JDMS/PM on long-term follow-up, but these do not preclude a productive life. Ultrasonography and MRI provide additional noninvasive means of analysis, but because of the current high cost, MRI is not routinely recommended.

Pathological changes in yearly protocol liver biopsy specimens from healthy pediatric liver recipients

Many centers perform biopsies on transplanted livers annually to assess allograft function because serum biochemical tests do not always correlate with histological findings. Although criteria exist for diagnosing acute cellular rejection, no similar criteria exist to describe the histopathological changes observed in the "normal" liver of an immunosuppressed but healthy child. The purpose of this study was to define the histopathological changes in the allografted livers of healthy children who have undergone transplantation and to evaluate them during long-term follow-up. One hundred fifty-eight yearly protocol liver biopsy specimens of 54 children who received transplants between January 1988 and March 1996 and at least 1 year of follow-up were reviewed, and the biopsy findings were correlated with those of serum tests of liver function performed concomitantly. Thirty-three biopsy specimens were excluded because serum transaminase levels were abnormal, the biopsy specimen was abnormal and diagnostic for a specific lesion, or follow-up showed progression of a specific disease process. In addition, time zero biopsy specimens from 21 of the 54 children were available for comparison. In the protocol biopsy specimens, portal and/or parenchymal mononuclear inflammatory infiltrates were frequent findings (48% and 25%, respectively). Other less common features were mild fibrosis (8%) and focal pericholangitis (6%). Findings in both protocol and time zero biopsy specimens included minimal to mild bile ductular proliferation (15% and 9.5%, respectively) and rare hepatocyte necrosis (1.6% and 5%). No yearly protocol biopsy specimens resulted in any patient benefit. Transplanted livers in immunosuppressed children who are clinically healthy and have normal transaminase levels commonly show histological changes consisting of scattered, mild to moderate, portal and/or parenchymal mononuclear infiltrates that are clinically insignificant. Yearly protocol biopsies in healthy pediatric recipients have been abandoned by the investigators after 3 years of follow-up.

Peer relationships of young children: affiliative choices and the shaping of aggressive behavior

Examined the occurrence of selective peer affiliation, and its impact on the development of aggressive behavior in four classrooms serving 72 preschool-age, high-risk boys and girls. Children classified as aggressive and nonaggressive were both highly selective in their peer affiliations, spending the majority of their time with a few same-sex classmates. Children generally established strong, stable, mutual affiliations with peers similar to themselves in aggression, but aggressive children had more difficulty establishing such affiliations. The interaction of peer dyads containing at least one aggressive child were characterized by more frequent, lengthy, and intense conflicts regardless of the affiliative relationship characterizing the dyad. The amount of time children spent interacting with aggressive peers predicted changes in observed and teacher-rated aggressiveness 3 months later.

Origins of antisocial behavior. Negative reinforcement and affect dysregulation of behavior as socialization mechanisms in family interaction

Theoretical models specifying the contribution of two social-familial mechanisms, negative reinforcement and affect dysregulation, to the development of child antisocial behavior were tested using a sample of 57 8- to 13-year-old boys referred for treatment of conduct problems. Negative reinforcement of boys' aggressive behavior and boys' affect dysregulation were found to covary with the boys' irritability toward parents and siblings and were reliable predictors of a composite measure of child antisocial behavior, defined by out-of-home placement, arrests, and school discipline incidents 2 years later. Reinforcement of aggression and affect dysregulation during family interaction may play complementary roles in the development of antisocial behavior by fostering the use of coercive means of dealing with social conflict. The findings are discussed in terms of research strategies for identifying social mechanisms contributing to child psychopathology and of implications for modification of current family interventions targeting child antisocial behavior.

A survey of graduates in practice from the University of New Mexico's conventional and community-oriented, problem-based tracks

PURPOSE

To survey graduates in practice from the first four classes of the University of New Mexico School of Medicine's (UNMSOM's) parallel curricular tracks, and compare data about the graduates' practice patterns, learning behaviors, and satisfaction with the profession of medicine.

METHOD

Between 1979 and 1993, the UNMSOM had two tracks for the first two years of medical school: a conventional track and the Primary Care Curriculum (PCC), a community-oriented, problem-based track. In 1990, a survey was conducted of the 140 graduates from the first four classes (1983-1986) who had completed their postgraduate training: 40 from the PCC and 100 from the conventional track. Statistical methods included two-way analyses of variance, logistic regression, and chi-square, adjusted by Bonferroni methods. Comparisons between tracks are reported after adjustments were made for specialty effects.

RESULTS

Thirty-three graduates (83%) from the PCC and 87 (87%) from the conventional tracks responded. The PCC graduates were much more likely to work in medically underserved areas, practice in publicly funded health care settings, and care for non-paying patients. The PCC graduates more often identified patient problems and curiosity as providing motivation for their learning. They more frequently studied clinical medicine and community health topics and spent time in community activities. The PCC graduates felt better prepared for practice by their undergraduate medical education. There was no difference between the graduates of the two tracks in the sizes of the populations in which they practiced, in the criteria they used for deciding on referrals to other physicians, in the ranges of community resource utilization, or in the degrees of satisfaction within their chosen professions. Large percentages of graduates from both tracks (67% conventional and 79% PCC) considered themselves to be practicing either primary care or a combination of primary care and non-primary care. In addition, 38% of all the graduates practiced in the state of New Mexico. More PCC graduates chose careers in family practice; however, no significant difference was found in a comparison between the proportions of PCC and conventional-track graduates who chose primary care careers.

CONCLUSION

Track differences favorable to the PCC were evident in relation to the two major goals established by the program: to attract graduates to careers in primary care in rural and underserved areas and to provide graduates with self-directed, lifelong learning skills. Some expected track effects were not found.

Immediate and long-term results of the splinting for acute closure trial

The ability of coronary splinting to salvage acute coronary occlusion was prospectively studied in 22 patients whose coronary occlusion was refractory to a 15-min balloon dilatation. Splinting was successful in 20 patients (91%). One patient required emergency bypass surgery, and one patient was treated medically for continued coronary occlusion. There was no late ischemic events. The peak CK was 1081 +/- 733 U/L and 1,451 +/- 1,646 U/L for the study and control patients (P = NS). The peak CK-MB was 110 +/- 102 mg/dl and 78 +/- 84 mg/dl, respectively (P = NS). There were no differences in electrocardiographic changes or Q-wave myocardial infarction between the groups. At 6-month follow-up, one patient required coronary artery bypass graft surgery. There were no late myocardial infarctions or deaths.

Improving organizational processes for gains during implementation

Reengineering work processes has not been a traditional part of health care automation. With the new emphasis on quality and cost cutting, users are more receptive to improving processes as they are automated in new or replacement systems. The authors describe a process flowcharting technique, which, as part of the implementation design phase, assists users in understanding and engineering the processes impacted during the implementation. Also described is a strategy for securing cooperation from physicians and other key players.

Special considerations for Orthodox Jewish patients in the emergency department

Orthodox Jews are a special cultural group; their entire lives revolve around the teaching of the Torah. Their religious beliefs are reflected in all aspects of their lives, in both health and illness. The emergency department at Maimonides Medical Center has strived to serve this community and has modified common patient care practices to meet the needs of this special population.

Outcome and long-term results following total hip replacement in elderly patients

The authors reviewed the preoperative and postoperative charts and radiographs of 100 patients who were at least 80 years old when they underwent total hip arthroplasty. Seventy-six of these patients were available for further reexamination and evaluation. The average patient age was 85.2 years old (range, 80-97 years). The average followup period was 59.4 months (range, 26-146 months). The female to male ratio was 4 to 1. Osteoarthritis was the most common diagnosis. Hospital stay ranged from 12 to 39 days. Preoperative Charnley pain and walking scores averaged 5.1 points of a possible 12 points, and postoperative scores averaged 10.6 points. Eighty-eight percent of patients remained community walkers, and 60% used a cane. Four percent of the patients had 1 dislocation. There were no instances of mechanical loosening and no deaths. Subjective satisfaction was high. The level of independent living was maintained in 96% of patients at long-term followup. A satisfactory and cost-effective health outcome can be anticipated after total hip arthroplasty in octogenarian and nonagenarian patients.

Monitoring of acute lung rejection and infection by bronchoalveolar lavage and plasma levels of hyaluronic acid in clinical lung transplantation

Local immunological injury caused by acute lung rejection leads to fibroblast proliferation. Hyaluronate is a product of activated fibroblasts and possibly an indicator of fibroblast proliferation. One hundred thirty-six bronchoalveolar lavage and plasma hyaluronate assays were performed in 57 lung transplant recipients. Pulmonary endothelial cell function was assessed by measuring bronchoalveolar lavage levels of purine nucleoside phosphorylase. Presence of acute cellular rejection was monitored by transbronchial biopsy histologic evaluation and was classified as minimal to mild (acute rejection I, II) and moderate to severe (acute rejection III, IV). Infection was confirmed by bronchoalveolar lavage culture and antibiotic sensitivity. Bronchoalveolar lavage hyaluronate levels in clinically stable recipients were 33.5 +/- 4.69 micrograms/L and were significantly higher than with clinically stable recipients (p = 0.0001), infection (p = 0.008), or mild rejection (p = 0.001). Levels were highest in recipients with diffuse alveolar damage (392.4 +/- 60.6 micrograms/L). Diffuse alveolar damage also resulted in significant elevations of plasma HA as compared with stable recipients (p = 0.001) and mild rejection. We conclude that clinically significant injury to the allograft from rejection or diffuse alveolar damage can be assessed by bronchoalveolar lavage hyaluronate assays and suggest that the source of hyaluronate in these instances are activated fibroblasts.

Analgesic efficacy of flurbiprofen in comparison with acetaminophen, acetaminophen plus codeine, and placebo after impacted third molar removal

PURPOSE

The analgesic efficacy of 50 and 100 mg flurbiprofen was compared with acetaminophen 650 mg, acetaminophen 650 mg plus codeine 60 mg, and placebo.

PATIENTS AND METHODS

Subjects undergoing the surgical removal of impacted third molars were randomly administered one of the five treatments after the onset of moderate to severe postoperative pain. Pain intensity, pain relief, and side effects were evaluated for 6 hours after drug administration.

RESULTS

Both doses of flurbiprofen resulted in significant analgesia in comparison with placebo, acetaminophen, and acetaminophen plus codeine as measured by pain intensity difference, pain relief, and global evaluation. The greatest incidence of side effects occurred in the group receiving acetaminophen plus codeine, and the fewest side effects were reported by subjects administered flurbiprofen.

CONCLUSION

The results of this study indicate that flurbiprofen is more effective and causes fewer effects than acetaminophen and codeine when used for post-operative dental pain, in ambulatory patients.

Predictors of infant birth weight in gestational diabetes

The objectives were to characterize and determine the predictors of birth weight among women with gestational diabetes mellitus (GDM), and to establish whether these predictors vary by prepregnancy body mass index (BMI). A cohort of 353 women with GDM was examined by using data from clinic charts and the McGill Obstetrical and Neonatal Database. Dietary treatment decreased the rate of weight gain (from 0.35 to 0.16 kg/wk, P < 0.0001) and fasting serum glucose (from 4.8 to 4.2 mmol/L, P < 0.001). Positive predictors of infant birth weight among the underweight and normal-weight women (BMI < or = 26) included prepregnancy BMI, height, parity, prediagnostic rate of weight gain, postprandial serum glucose, and gestational duration. Among the overweight and obese women (BMI > 26) the only variables that predicted increased birth weight were prediagnostic rate of weight gain, and fasting or postprandial serum glucose. Hence, prepregnancy body mass index exerts a strong effect on predictors of infant birth weight in GDM, indicating the need to consider prepregnancy weight in the treatment approach.

The toxic patient as a potential organ donor

The use of organs from poisoned victims for the purpose of transplantation has been poorly studied; criteria for organ donation is virtually non-existent in such cases. To further elucidate these indications, a retrospective review of all organ transplantation donated by poisoned victims in Northern and Central Illinois was undertaken. From January 1988 to December 1993, 17 poisoned victims were identified as having donated organs to 41 recipients. Eleven of the donors died as a direct result of drug toxicity, whereas six donors had drug-related deaths. The cases were reviewed for toxin involved, organ preoperative function and postoperative function (up to 1 year after transplant). Kidney transplants postoperative function was rated as good if creatinine was less than 1.9, fair if creatinine was 2 to 2.9, and poor if creatinine was 3. Donor age ranged from 2 years to 54 years. Toxins involved in donation included ethanol (n = 8), cocaine (n = 5), carbon monoxide (5), barbiturates (2) and lead (1), six patients had multiple drugs. Two of the nine recipients of livers died intraoperatively, both unrelated to organ function. Thirty-two kidneys were transplanted with 28 having good 10-day postoperative function, three having fair postoperative function, and one (cocaine donor) having poor postoperative function. One kidney transplanted from a cocaine donor had a thrombosed graft 5 days postoperatively. Deaths involving toxins in general does not seem to be a contraindication to donation of liver and kidney for transplantation.

External validity of the profile variability index for the K-ABC, Stanford-Binet, and WISC-R: another cul de-sac

Clinicians often attach interpretive significance to high variability among subtest scores in IQ profiles of adults and children. In this study we evaluated the external validity of a relatively new measure of IQ subtest variability, the profile variability index (PVI). Within a sample of referred children, we administered the Kaufman Assessment Battery for Children, the Fourth Edition Stanford-Binet, and the Wechsler Intelligence Scale for Children-Revised. We calculated PVIs for each child from each test and correlated these values with achievement scores and indexes of discrepancy between actual and predicted scholastic achievement. Against these external criteria, PVI information from all three cognitive-ability batteries had essentially nil validity. We discuss implications of these findings for future research in this area.

Performances on the NBME I, II, and III by medical students in the problem-based learning and conventional tracks at the University of New Mexico

BACKGROUND

Problem-based learning curricula are growing in popularity, and questions have been raised about the appropriateness of standardized examinations, such as the National Board of Medical Examiners (NBME) Parts I, II, and III examinations, for assessing students in these new curricula.

METHOD

Data on students' performances on the NBME I were analyzed for 508 graduates of the conventional track and 167 graduates of the problem-based Primary Care Curriculum (PCC) track at the University of New Mexico School of Medicine from the classes of 1983-1992; on NBME II, for 447 and 144 graduates, respectively (classes of 1983-1991); and on NBME III, for 313 and 100 graduates, respectively (classes of 1983-1989). The analyses also included data on the students' total Medical College Admission Test (MCAT) scores, undergraduate science grade-point averages (SGPAs), and admission subgroups within tracks. The statistical methods included analysis of covariance, Student's t-test, and the Fisher exact test.

RESULTS

The students who had requested the PCC track but had been randomized into the conventional track had the highest mean scores on all the study variables (for 34 students, 521 on the NBME I, and for 19 students, 551 on the NMBE III). The high-risk students who had requested but had not been accepted into the PCC track seemed to benefit from the highly structured conventional track with regard to their NMBE I performances (467 for 18 students). The PCC students--both those who had been randomized into the PCC and those who had been selected into the PCC--had significantly lower mean scores on the NBME I (455 for 85 students and 463 for 82 students compared with 505 for the 439 students who chose the conventional track), but significantly higher mean scores on the NBME III (521 for 38 students and 522 for 62 students compared with 483 for the seven high-risk students and 487 for the 276 students who chose the conventional track). For both tracks, strong relationships were found among the scores on the three NBME examinations. For the PCC students, significantly weaker relationships were found between mean SGPAs and mean scores on the NBME I, II, and III. For both tracks, MCAT scores, especially in the lowest and highest ranges, were most predictive of performances on the NBME I and II.

CONCLUSION

In the short run, the more teacher-centered and structured conventional curriculum better prepared the students for the NBME I, while in the long run, the more student-centered problem-based curriculum better prepared the students for the NBME III:

Who cares for Missouri's Medicaid nursing home residents? Characteristics of attending physicians

OBJECTIVE

To describe the characteristics of physicians attending Medicaid recipients in Missouri's certified nursing homes (NH).

DESIGN

Retrospective survey of multiple data sources.

SETTING

Missouri's certified nursing homes.

PARTICIPANTS

1,339 physicians attending 22,452 Medicaid recipients.

MEASUREMENTS

Physician characteristics were determined by reviewing a roster of medical directors of NHs compiled by the Missouri Department of Social Services' Division of Aging and physician directories compiled by the Missouri State Board of Registration for the Healing Arts, the AMA, the AOA, the ABFP, and the ABIM. Physician clinical activity was determined by examining NH inspection of care reports compiled by the Missouri Department of Social Services' Division of Aging.

RESULTS

Each physician attended a mean of 16.8 and a median of six Medicaid recipients in the nursing home. The skewed distribution is reflected by 426 (31.8%) of the physicians attending only one or two residents, and 28 (2.1%) of the physicians attending 100 or more residents. Twenty-seven percent of the state's licensed osteopaths (DOs, 362) attended nursing home patients, compared with 11% of allopathic physicians (MDs, 977). Significantly more DOs than MDs attended more than the median number of patients (57% vs 45%, P < 0.001). Half were attended by the 605 (45%) physicians without board certification. Of those who were board certified, family physicians were more likely to include Medicaid nursing home patients in their practices than internists (43% vs 18%, P < 0.001). Physicians licensed for 11 to 20 years and rural physicians had the heaviest patient loads.

CONCLUSIONS

Many doctors are caring for very few nursing home residents while a few doctors may be caring for too many patients. In addition, half the Medicaid recipients residing in Missouri's nursing homes in 1988 were attended by physicians without board certification, and almost one-third were attended by physicians who may be retiring between 2000 and 2010.