Postoperative Quality of Life after Open Transinguinal Preperitoneal Inguinal Hernia Repair Using Memory Ring or Three-dimensional Devices

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m2. MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different ( P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD ( P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation ( P = 0.02); 28.7 versus 14.8 per cent had movement limitations ( P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.

Longitudinal Multilevel Modeling of Facial Pain, Muscle Tension, and Stress

The role of masticatory muscle activation on pain in temporomandibular muscle and joint disorders (TMJD) is controversial. This single-group, prospective panel study examined the relationships among masticatory muscle tension, emotional distress, and TMJD pain in a sample of 7,023 observations obtained from 171 individuals using longitudinal multilevel modeling. Three main hypotheses were tested. The first posited that emotional distress and muscle tension directly influenced pain (hypothesis 1a: Distress → TMJD Pain; hypothesis 1b: Muscle Tension → TMJD Pain). The second posited that emotional distress directly influenced muscle tension (Distress → Muscle Tension), and the third posited that the effect of emotional distress on pain was mediated by muscle tension (Distress → Muscle Tension → TMJD pain). We also examined the fit of the data to possible alternative models. All the data used in this study were collected via an experience sampling methodology. The fit of the preferred models was better than that of the alternative models, with the preferred models explaining large proportions of the data, especially for level 2 variance (hypothesis 1a = 41% variance; hypothesis 1b = 69% variance; hypothesis 2 = 48% variance). In the mediation model, the addition of muscle tension to the model reduced the impact of emotional distress. The findings support a causal role for masticatory muscle tension in TMJD pain. Clinically, the results suggest that addressing tension and other oral parafunctions in those diagnosed with TMJDs should be an important part of the conservative, noninvasive care of individuals diagnosed with the myofascial pain or arthralgia of TMJD.

Impact of Implementing an Electronic Health Record on Surgical Resident Work Flow, Duty Hours, and Operative Experience

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means ( P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation ( P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation ( P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

Impact of implementing an electronic health record on surgical resident work flow, duty hours, and operative experience

Our objective was to assess the effect of implementing an electronic health record (EHR) on surgical resident work flow, duty hours, and operative experience at a large teaching hospital. In May 2012, an EHR was put into effect at our institution replacing paper documentation and orders. Resident time to complete patient documentation, average duty hours, and operative experience before EHR and afterward (at 1, 4, 6, 8, and 24 weeks) were surveyed. We obtained 100 per cent response rate from 15 surgical residents at all time intervals. The average time spent documenting before EHR was 9 ± 2 minutes per patient document and at Weeks 1, 4, 6, 8, and 24 after EHR implementation was 22 ± 10, 15 ± 7, 15 ± 7, 14 ± 8, and 12 ± 4 minutes, respectively. Repeated measures analysis of variance demonstrated a difference among the means (P < 0.0001). Discharge summary and operative note remained significantly longer to complete at Week 24 compared with paper documentation (P < 0.05). Average resident work hours and operative cases per week before EHR were 77 ± 5 hours and 12 ± 5 cases, respectively, which were similar at all time points after EHR implementation (P > 0.05). At 24 weeks after EHR, 74 per cent of residents felt their risk of performing a medical error using electronic documentation and order entry was higher compared with paper charting and orders. Transition to EHR led to a significant doubling in resident time spent performing documentation for each patient. It improved over 6 months after implementation but never reached the pre-EHR baseline for operative notes and discharge summaries. Average resident work hours and case logs remained similar during this transition.

Impact of the Establishment of a Specialty Hernia Referral Center

Background. Creating a surgical specialty referral center requires a strong interest, expertise, and a market demand in that particular field, as well as some form of promotion. In 2004, we established a tertiary hernia referral center. Our goal in this study was to examine its impact on institutional volume and economics. Materials and methods. The database of all hernia repairs (2004-2011) was reviewed comparing hernia repair type and volume and center financial performance. The ventral hernia repair (VHR) patient subset was further analyzed with particular attention paid to previous repairs, comorbidities, referral patterns, and the concomitant involvement of plastic surgery. Results. From 2004 to 2011, 4927 hernia repairs were performed: 39.3% inguinal, 35.5% ventral or incisional, 16.2% umbilical, 5.8% diaphragmatic, 1.6% femoral, and 1.5% other. Annual billing increased yearly from 7% to 85% and averaged 37% per year. Comparing 2004 with 2011, procedural volume increased 234%, and billing increased 713%. During that period, there was a 2.5-fold increase in open VHRs, and plastic surgeon involvement increased almost 8-fold, ( P = .004). In 2005, 51 VHR patients had a previous repair, 27.0% with mesh, versus 114 previous VHR in 2011, 58.3% with mesh ( P < .0001). For VHR, in-state referrals from 2004 to 2011 increased 340% while out-of-state referrals jumped 580%. In 2011, 21% of all patients had more than 4 comorbidities, significantly increased from 2004 ( P = .02). Conclusion. The establishment of a tertiary, regional referral center for hernia repair has led to a substantial increase in surgical volume, complexity, referral geography, and financial benefit to the institution.

Outcomes of pancreatic debridement in acute pancreatitis: analysis of the nationwide inpatient sample from 1998 to 2010

BACKGROUND

The objective of this study was to perform a national review of patients with acute pancreatitis (AP) who undergo pancreatic debridement (PD) to evaluate for risk factors of in-hospital mortality.

METHODS

The Nationwide Inpatient Sample was used to identify patients with AP who underwent PD between 1998 and 2010. Risk factors for in-hospital mortality were assessed with multivariate logistic regression.

RESULTS

From 1998 to 2010, there were 585,978 nonelective admissions with AP, of which 1,783 (.3%) underwent PD. From 1998 to 2010, the incidence of PD decreased from .44% to .25% (P < .01) and PD in-hospital mortality decreased from 29.0% to 15% (P < .05). Of patients undergoing PD, independent factors associated with increased odds of mortality were increased age (odds ratio [OR] 1.04, confidence interval [CI] 1.03 to 1.05; P < .01), sepsis with organ failure (OR 1.76, CI 1.24 to 2.51; P < .01), peptic ulcer disease (OR 1.83, CI 1.02 to 3.30; P < .05), liver disease (OR 2.27, CI 1.36 to 3.78; P < .01), and renal insufficiency (OR 1.78, CI 1.14 to 2.78; P < .05).

CONCLUSIONS

The incidence and operative mortality of PD have decreased significantly over the last decade in the United States with higher odds of dying in patients who are older, with chronic liver, renal, or ulcer disease, and higher rates of sepsis with organ failure.

The first nationwide evaluation of robotic general surgery: a regionalized, small but safe start

BACKGROUND

The purpose of this study was to evaluate the outcomes of the most commonly performed robotic-assisted general surgery (RAGS) procedures in a nationwide database and compare them with their laparoscopic counterparts.

METHODS

The Nationwide Inpatient Sample was queried from October 2008 to December 2010 for patients undergoing elective, abdominal RAGS procedures. The two most common, robotic-assisted fundoplication (RF) and gastroenterostomy without gastrectomy (RG), were individually compared with the laparoscopic counterparts (LF and LG, respectively).

RESULTS

During the study, 297,335 patients underwent abdominal general surgery procedures, in which 1,809 (0.6 %) utilized robotic-assistance. From 2009 to 2010, the incidence of RAGS nearly doubled from 573 to 1128 cases. The top five RAGS procedures by frequency were LG, LF, laparoscopic lysis of adhesions, other anterior resection of rectum, and laparoscopic sigmoidectomy. Eight of the top ten RAGS were colorectal or foregut operations. RG was performed in 282 patients (0.9 %) and LG in 29,677 patients (99.1 %). When comparing RG with LG there was no difference in age, gender, race, Charlson comorbidity index (CCI), postoperative complications, or mortality; however, length of stay (LOS) was longer in RG (2.5 ± 2.4 vs. 2.2 ± 1.5 days; p < 0.0001). Total cost for RG was substantially higher ($60,837 ± 28,887 vs. $42,743 ± 23,366; p < 0.0001), and more often performed at teaching hospitals (87.2 vs. 50.9 %; p < 0.0001) in urban areas (100 vs. 93.0 %; p < 0.0001). RF was performed in 272 patients (3.5 %) and LF in 7,484 patients (96.5 %). RF patients were more often male compared with LF (38.2 vs. 32.3 %; p < 0.05); however, there was no difference in age, race, CCI, LOS, or postoperative complications. RF was more expensive than LF ($37,638 ± 21,134 vs. $32,947 ± 24,052; p < 0.0001), and more often performed at teaching hospitals (72.4 vs. 54.9 %; p < 0.0001) in urban areas (98.5 vs. 88.7 %; p < 0.0001).

CONCLUSIONS

This nationwide study of RAGS exemplifies its low but increasing incidence across the country. RAGS is regionalized to urban teaching centers compared with conventional laparoscopic techniques. Despite similar postoperative outcomes, there is significantly increased cost associated with RAGS.

Postoperative quality of life after open transinguinal preperitoneal inguinal hernia repair using memory ring or three-dimensional devices

A transinguinal preperitoneal (TIPP) approach has become a common technique for inguinal hernia repair. Our goal was to compare the impact of the two mesh designs for this operation: a flat mesh with a memory ring device (MRD) or a three-dimensional device (3DD) containing both onlay and preperitoneal mesh components. The prospective International Hernia Mesh Registry (2007 to 2012) was queried for MRD and 3DD inguinal hernia repairs. Outcomes and patient quality of life (QOL), using the Carolinas Comfort Scale (CCS), were examined at 1, 6, 12, and 24 months. Standard statistical methods were used, and multivariate logistic regression was performed using a forward stepwise selection method. TIPP was performed in 956 patients. Their average age 57.4 ± 15.3 years, 94.0 per cent were male, and mean body mass index was 25.7 ± 3.2 kg/m(2). MRD was used in 131 and 3DD in 825. Follow-up was 97, 82, 87, and 80 per cent at 1, 6, 12, and 24 months, respectively. Complications were not significantly different (P > 0.05). Recurrence was 0.8 per cent for MRD and 2.1 per cent for 3DD (P = 0.45). Comparing patient outcomes of MRD with 3DD at 1 month, 18.9 versus 11.5 per cent had symptoms of mesh sensation (P = 0.02); 28.7 versus 14.8 per cent had movement limitations (P < 0.01). MRD use was a significant independent predictor of movement limitation (odds ratio, 2.3; confidence interval, 1.4 to 3.7). No significant differences in CCS scores were seen at 6, 12, and 24 months. TIPP repair is safe and has a low recurrence rate. Early postoperative QOL is significantly improved with a 3DD mesh compared with MRD.

Does ventral hernia defect length, width, or area predict postoperative quality of life? Answers from a prospective, international study

BACKGROUND

The goal of this study was to determine if ventral hernia defect length, width, or area predict postoperative pain and quality of life following ventral hernia repair (VHR).

METHODS

The International Hernia Mesh Registry, a prospective database from 40 institutions worldwide, was queried for patients undergoing VHR from October 2007 to June 2012. Laparoscopic and open VHR were evaluated separately. Width and length were stratified into large, ≥10 cm and small, <10 cm, along with area as large, ≥100 cm(2) and small, <100 cm(2).

RESULTS

In total, 865 International Hernia Mesh Registry patients underwent VHR. Large defect width, length, and area had no association with hernia recurrence or reoperation in both open and laparoscopic VHR. There was a significant increase in operating room time and length of stay for large compared with small width, length, and area for open and laparoscopic VHR patients (P < 0.05). Large area was associated with increased seroma and ileus in open and laparoscopic VHR (P < 0.05). There was greater pain and activity limitation at 1 mo for large versus small width and area whether repaired laparoscopically or open (P < 0.05). When comparing large to small length, there was no difference in pain for all follow-up time points when repaired laparoscopically, but there is significantly increased odds of pain and activity limitation at 1, 6, and 12 mo when repaired open (P < 0.05).

CONCLUSIONS

Patients undergoing laparoscopic or open VHR with large defect widths and total area have a greater chance of pain and activity limitation at 1-mo follow-up, but not long term. Large defect lengths are associated with increased early and chronic discomfort in open VHR only.

Preliminary results of surgical and quality of life outcomes of Physiomesh in an international, prospective study

Physiomesh is a novel, lightweight, large pore, polypropylene mesh designed to have flexibility that matches the compliance of the abdominal wall in an effort to improve patient quality of life (QOL). The International Hernia Mesh Registry was queried for ventral hernia repair (VHR) and inguinal hernia repair (IHR) with Physiomesh. Demographics, operative and postoperative details, and the Carolinas Comfort Scale (CCS) as a measure of QOL were recorded. Physiomesh was used in 100 patients, 29 IHR and 71 VHR. Their average age was 56.8 +/- 13.7, and BMI was 34.0 +/- 21.0 kg/m2. For IHR, preoperative pain (CCS > or = 2) was present in 41%, but decreased at 1, 6, and 12 months postoperatively to 25.9%, 0%, and 1.6%, while movement limitation decreased from 42.9% to 18.5%, 1.6%, and 3.1%. There were no complications or recurrences. The average VHR measured 66.4 cm2; 93% underwent a laparoscopic repair. Pain was present in 59.1% preoperatively but 21% at 12 months. Movement limitations reduced from 43.2% to 15.8% at 12 months. Mesh sensation was reported in only 10.5% at 1 year. There was 1 recurrence. Physiomesh is well tolerated by patients undergoing IHR and VHR. It is associated with a very favorable long-term QOL.

Surgical relief work in Haiti: a practical resident learning experience

INTRODUCTION

A once-a-year, week-long surgical missionary trip to Haiti has become incorporated into our residency experience on a voluntary basis since 2007. The purpose of this article is to describe our experience with this mission effort during the last 4 years.

METHODS

Since 2007, at least one PGY 3-5 surgical resident from our program has traveled to the Hôpital Sacré Coeur in Milot, Haiti for a voluntary, week-long surgical mission working with the local health care providers. Their personal and clinical experiences in Haiti, in the surgical clinics, and in the operating room, were recorded.

RESULTS

Since 2007, 6 surgical residents and members of the surgical staff have traveled to Haiti for this surgical mission. During that time, a total of 247 patients were observed in the clinic and 184 surgical cases were performed. The case distribution covered a wide range of defined categories, including head and neck, breast, hernia, abdominal, biliary, stomach, small and large bowel, colorectal, skin and soft tissue, and urology. The personal aspect of this experience could not be quantitated but was profound.

CONCLUSIONS

We feel that the surgical missionary trip to Haiti is an asset to our program. It provides humanitarian surgical care to patients in need, teaching and infrastructure support to the local health care providers, a clinical and operative experience to our residents, and an invaluable personal experience.

The Assessment of Transactional Analysis Ego States Via the Adjective Checklist

Transactional Analysis (TA) conceptualizes personality in terms of five functional ego states: Critical Parent (CP), Nurturing Parent (NP), Adult (A), Free Child (FC), and Adapted Child (AC). The present investigation was designed to develop a procedure for the assessment of the relative strength of ego states from the responses of persons who are not familiar with TA theory. Fifteen TA experts assigned ego-state ratings to the 300 items of the Adjective Check List (ACL) with high interjudge agreement being found. Using the judges' mean raft rigs, a system was developed for obtaining ego-state scores for any selected set of ACL adjectives. The use of the system was illustrated by its application to the ACL self-descriptions of 100 university students which were analyzed in terms of "egograms" in which the five functional ego states were expressed relative to one another. A test-retest study involving an additional 154 students demonstrated stable individual differences in ego-state scores. Mean egograms of female and male students did not differ from one another but showed appreciable differences from the expert judges' ratings of the "psychologically healthy person." The potential Usefulness of the procedure in clinical practice and in testing TA theory is discussed.

Effect of magnification lenses on student operator posture

A distinct body of literature supports the association between clinical postures of the dental practitioner and work-related musculoskeletal disorders (WRMD). Several aids or devices have been tested to improve clinical posture in the interest of decreasing WRMD. The use of magnification lenses while performing dental procedures may increase the quality of work and decrease the likelihood of musculoskeletal problems. To date, only anecdotal and personal opinions had existed regarding the benefits of using magnification lenses, and no empirical evidence had authenticated the contention that use of magnification lenses exerts a positive change in operator posture. The objective of this study was to assess the effect magnification lenses had on the posture of dental hygiene students. Using a randomized crossover design, researchers videotaped nineteen senior dental hygiene students performing an intra-oral procedure with and without the use of magnification lenses. The tapes were then evaluated by a panel of five dental hygiene educators calibrated in the use of Branson's Posture Assessment Instrument (PAI). Results of a paired t-test indicate that the posture of the students while wearing magnification lenses was more acceptable (p=.019) than when wearing traditional safety glasses. Results of this study indicate a quantifiable change in acceptability of posture for clinicians wearing magnification lenses and suggest that the use of such lenses in dental education may be warranted.

Development and application of a polymerase chain reaction assay for the detection and enumeration of bile acid 7alpha-dehydroxylating bacteria in human feces

BACKGROUND

Secondary bile acids are synthesized in the human colon from the bacterial 7alpha-dehydroxylation of primary bile acids. Increased levels of secondary bile acids have been correlated with an increased risk of colon cancer and cholesterol gallstone disease. Based on 16s rDNA sequence analysis, stock cultures of bacterial strains with bile acid 7alpha-dehydroxylation all belong to the genus Clostridium.

METHODS

We developed a polymerase chain reaction (PCR)-based assay that can specifically amplify the baiCD gene, specific to bile acid 7alpha-dehydroxylation pathway. The PCR primer pair was designed using known nucleotide sequences from two different baiCD genes described for Clostridium scindens VPI 12708 and Clostridium hiranonis TO931. Although the DNA sequences of these genes were <70% identical, several regions were conserved enough to design primers with little or no redundancy.

RESULTS

The PCR assay was effective in detecting the baiCD gene in several strains known to exhibit bile acid 7alpha-dehydroxylation activity. The PCR assay also detected the baiCD gene in DNA extracted from fecal dilution series and correlated with the levels of cholic acid 7alpha-dehydroxylating bacteria detected by activity assays. The PCR assay was sensitive enough to detect the baiCD gene in DNA samples extracted directly from as little as 0.5 mg feces.

CONCLUSIONS

This new method should be useful for the monitoring of levels of bile acid 7alpha-dehydroxylating bacteria in human fecal samples.

Effect of sonic and mechanical toothbrushes on subgingival microbial flora: a comparative in vivo scanning electron microscopy study of 8 subjects

OBJECTIVES

The purpose of this initial study was to evaluate the effects of both a sonic and a mechanical toothbrush versus the effects of no treatment on depth of subgingival penetration of epithelial and tooth-associated bacteria.

METHOD AND MATERIALS

Eight adult subjects exhibiting advanced chronic periodontitis with at least 3 single-rooted teeth that were in separate sextants with facial pockets > or = 4 mm and < or = 8 mm and that required extraction constituted the experimental sample. Teeth were either subjected to 15 seconds of brushing with a mechanical toothbrush or a sonic toothbrush or left untreated. The test tooth and the associated soft tissue wall of the periodontal pocket were removed as a single unit. Samples were processed and coded for blind examination by scanning electron microscopy. Distributional and morphologic characteristics of dominant bacteria with specific emphasis on spirochetes were evaluated for both epithelial- and tooth-associated plaque.

RESULTS

No differences were found in morphotypes or distributional and aggregational characteristics of epithelial-associated microbes in the 1- to 3-mm subgingival zone between the mechanical and sonic toothbrush-treated groups and the control group. Both toothbrush groups featured disruption of microbes that extended up to 1 mm subgingivally. Root surfaces on the sonic-treated samples appeared plaque-free at low magnification; however, at 4,700x, a thin layer of mixed morphotypes and intact spirochetes was found subgingivally and slightly subgingivally. In comparison, mechanical brush samples featured incompletely removed plaque, both subgingivally and subgingivally, with intact spirochetes present on subgingival root surfaces.

CONCLUSION

Results suggest similar effects for both sonic and mechanical toothbrushes on epithelial- and tooth-associated bacterial plaque in periodontal pockets and adjacent root surfaces that extend up to 1 mm subgingivally. Further, the presence of intact subgingival spirochetes suggests limited exposure to acoustical or mechanical energy from the toothbrushes evaluated.

Effectiveness of an oral and pharyngeal cancer awareness program for health professionals

BACKGROUND

Of approximately 31,000 patients diagnosed as having oral/pharyngeal cancers (OPCs) each year in the United States, about half will die of the disease within five years, for reasons associated with patient behaviors as well as delays in diagnosis by health care professionals.

METHODS

To address an apparent lack of OPC knowledge of health care professionals, a brief, non-discipline-specific, multi-component educational intervention was designed and presented to 352 health care professionals in community health centers and hospital training programs. OPC knowledge was assessed before and three months after the intervention.

RESULTS

A 44% post-intervention response rate was obtained. There were significant (p < or = 0.05) increases in knowledge regarding oral sites at risk for OPC, etiologic factors, and early signs and symptoms. There were significant interactions (p < or = 0.01) between increases in knowledge and various health provider groups. A significant increase in perceived competency in OPC knowledge (p < or = 0.001) was reported, and significantly fewer participants felt the need for additional training.

CONCLUSION

A brief, multi-component educational intervention can increase health care professionals' knowledge regarding OPC.

Perceptions of social support in doctoral programs among minority students

This study examined the perceptions of social support reported by 70 African-American, 44 Hispanic, 20 Native-American, and 69 Asian-American doctoral students (N = 203) concerning their experiences in graduate school. The Doctoral Student Survey was used to measure the levels and types of social support provided. One-way analysis of variance of mean scores indicated that a majority of doctoral students perceived the academic environment on campus and faculty advisers to be strong sources of social support, while perceiving the social environment on campus as unsupportive of their progress. The African-American and Native-American doctoral students perceived the social environment on campus to be less supportive than did the Hispanic and Asian-American doctoral students, and Native-American doctoral students perceived their departments to be less supportive than did the African-American, Hispanic, and Asian-American doctoral students.

Effect of an oral health training program on knowledge and behavior of state agency long-term-care surveyors

This study examines the effect of a training program on long-term-care (LTC) surveyors' knowledge of factors affecting oral health and their behavior in citing oral health deficiencies of LTC residents. Twenty surveyors were recruited for the experimental group, along with a non-equivalent comparison group of 31 surveyors. The experimental group participated in a three-hour interactive, case-based training program. The experimental group had a significant increase in total knowledge (p < 0.002) post-test scores with a moderate effect size, eta 2 = 0.115. The training program resulted in a statistically significant increase (p < 0.0001) in oral health citation behavior for the experimental group for six months following training. This study provides evidence that an interactive case-based training program can affect participants' knowledge regarding oral health of LTC residents and participants' oral health citation behavior. As the elderly population experiences an increased life expectancy with increased need for assistance with Activities of Daily Living (ADL), similar training programs will become an important factor in assessing the quality of care provided to LTC residents.

Dental hygiene fear: gender and age differences

Studies aimed at examining gender and age differences as they relate to dental anxiety have begun to appear in the literature. The purpose of this investigation was to explore fear and anxiety in a dental hygiene setting and evaluate gender and age differences among four sub-scales of dental hygiene fear. The Dental Hygiene Fear Survey (DHFS) was developed to address patient reaction to dental hygiene treatment. The University of Washington Dental Fears Model was the theoretical model used for it identifies four domains of dental fear: fear of specific stimuli, generalized anxiety, fear of catastrophe, and distrust. Males and females respond differently to dental hygiene treatment with women reporting significantly (p<.05) greater fear overall than males. Examination of the four dental hygiene fear sub-scales show that females report greater fear (p<.05) in relation to specific fear and generalized anxiety. There were no significant differences across age categories on total fear scores or within any of the sub-scales. Characterization of the dental hygiene fear patient along with knowledge of procedures that elicit anxiety can assist the practitioner in recognizing dental hygiene-related fear. With this foundation, the practitioner can then develop management strategies specific to this phenomenon.

Validity and reliability of the oral health-related quality of life instrument for dental hygiene

PURPOSE

The purpose of this study was to examine reliability, construct validity, and produce a concise instrument for assessing Oral Health-Related Quality of Life (OHRQL).

METHOD

The OHRQL model for dental hygiene served as the theoretical basis in the development of this instrument. The survey utilized five-point Likert scale items, designed to assess the domains of symptom status, functional status, and health perceptions. The instrument was administered to 321 functionally independent older adults from six Area Agency on Aging nutrition centers and three retirement communities in the Kansas City and St. Louis areas in Missouri. Scale reliability was demonstrated by calculating the coefficient alpha for each subscale. Item analysis was subsequently conducted to provide additional supportive evidence for reliability. Construct validity was assessed using a one-way multivariate analysis of variance MANOVA to examine the effect of known subgroups. Analysis of variances (ANOVA) for groups on each subscale was conducted as a follow-up test to the MANOVA.

RESULTS

Coefficient for the seven subscales ranged from 0.74 to 0.89. No significant difference was found among males and females. However, there were significant differences in patterns of subscale means (p < .05) for subgroups reporting 'good' versus 'poor' denture fit; 'presence' or 'absence' of recent toothache; 'presence' or 'absence' of loose teeth; 'presence' or 'absence' of gingival recession; 'presence' or 'absence' of dentures interfering with eating; and self-report of 'good' versus 'poor' general health.

CONCLUSION

These preliminary results provided initial supportive evidence of the OHRQL's reliability and validity. Future studies are needed to confirm this preliminary conclusion.

Clinical examination findings of temporomandibular disorder patients: a factor analytic study

To assess the latent factor structure of clinical examination findings obtained from temporomandibular disorder patients, exploratory factor analysis was used to examine the relationships of a large number of variables obtained from a clinical examination to a smaller number of latent variables, or factors. Two independent samples of patients--an initial sample that consisted of 330 patients who complained of facial pain and a validation sample of 161 additional patients--were examined to determine whether the factor structure was reliable. A principal axis factor analysis with varimax rotation was used for both sets of data. The factor structure for the two samples was consistent between the two sets of data. Results identified two muscle pain factors (an "intraoral muscle" factor and an "extraoral muscle" factor) two unilateral jaw pain factors, and two factors that concern joint noise (clicking and crepitus). The implications of these findings for the current nosologic systems for temporomandibular disorders are discussed.

Oral health-related quality of life: a model for dental hygiene

During the past decade, dental hygiene has been challenged to develop conceptual models to define the discipline. Such models can provide a common language and infrastructure for the discipline to define the process of care. Health-Related Quality of Life conceptual models have been adopted by many health professions to assist in planning health-related interventions and assessing outcomes to care. Based on the Natural History of Disease Schema, the Wilson & Cleary model, and Neuman's Systems Model, a new conceptual model for dental hygiene is proposed. The Oral Health-Related Quality of Life Model, composed of six primary domains: Health/Preclinical Disease, Biological/Clinical Disease, Symptom Status, Functional Status, Health Perceptions, and General Quality of Life. This model proposes a dynamic relationship among these domains and characteristics unique to individual clients or populations, and may have utility for interdisciplinary communication. As an integrated model, it may serve as a foundation for assessing, planning, implementing, and evaluating outcomes to dental hygiene care. This paper reviews possible application of the model for clinical practice, research, and education.

In vitro effect of the Sensonic toothbrush on Treponema denticola

The purpose of this in vitro study was to compare the effects of the Sensonic. Oral-B Braun mechanical and Oral-B manual toothbrushes upon the morphology and cellular integrity of Treponema denticola. This spirochete was chosen because of its frequent isolation from active lesions of inflammatory periodontal disease and its pathogenic potential. T. denticola, strain ATCC 33421, was grown in an anaerobic nitrogen rich atmosphere in enhanced 1186 mycoplasma broth. 160, 5-ml aliquots of cultured microbes were assigned to 1 of 3 brushing treatment groups and a control group. Samples were further divided into 4 groups of 10 samples each and assigned to one of 4 brushing exposure times: 15, 30, 45, and 60 seconds. After treatment, 0.2 ml of each sample was applied to a millipore filter and examined by SEM. Intact microbes were counted from 10 non-overlapping fields at 4500x. Remaining treated samples were pelleted and examined by TEM. A statistically significant reduction of intact microbes for the Sensonic treatment group at each exposure time was found when compared to Oral-B Braun, Oral-B manual, and non-treated controls. TEM examination of Sensonic treated samples revealed separation of the outer membrane at lower exposure times and only cellular debris after exposures of 45 and 60 s. These results suggest that exposure to the sonic frequency generated by the Sensonic toothbrush is capable of severely disrupting the structural integrity of T. denticola.

Effects of tartar-control dentifrice on tooth sensitivity: a pilot study

PURPOSE

The purpose of this three-week, double-blind pilot study was to assess the effects of a tartar-control dentifrice on tooth sensitivity.

METHOD

Fifty-six volunteer dental hygiene students completed a 14-item questionnaire regarding their oral health. Eighteen students were excluded from the study due to prior tooth sensitivity. Thirty-eight students were randomly assigned to either the experimental group using a tartar-control dentifrice (containing tetrapotassium pyrophosphate, PEG-6, disodium pyrophosphate, and tetrasodium pyrosulphate in a 5.0% soluble pyrophosphate formulation) or the control group using a regular dentifrice. Participants brushed for three weeks twice daily and then completed a post-treatment questionnaire, which included questions about tooth sensitivity. Differences between groups in reported sensitivity were measured by Fisher's Exact Test.

RESULTS

Fisher's Exact Test revealed a statistically significant difference in sensitivity experienced by the experimental group compared to the control group (p < 0.05), which reported no sensitivity. The phi coefficient, used to examine the strength of the relationship between tartar control paste and tooth sensitivity, was found significant at p < 0.02.

CONCLUSION

These findings suggest that patients may experience dentinal hypersensitivity when using the tartar-control toothpaste tested. Further long-term studies are required to test various brands of tartar-control dentifrice with a larger, more diverse sample for clinical measures of sensitivity.

Effectiveness of a prescale gel on subgingival calculus

A prescale gel product, designed to facilitate the removal of calculus, has recently been introduced and marketed to the dental profession. The purpose of this study was to evaluate the effectiveness of this gel on the removal of subgingival calculus. 10 patients, each with 5 periodontally diseased teeth scheduled for extraction, participated in this in vivo/in vitro study. 4 teeth per patient were randomly assigned using a 2-by-2 block design and treated in vivo with either active or placebo gel, with or without scaling, prior to extraction. To assess possible overexposure to the product, 10 selected teeth from the sample were treated with active gel for an extended exposure time. Standardized scaling was performed on a 4x4 mm treated root area in vitro on groups as assigned. Quantification of residual calculus was determined by one examiner blind to treatment group assignment using SEM photomicrograph montages and the Java image analysis computer system. Repeated measures ANOVA showed no statistically significant treatment effect for gel (p > 0.05) in the scaled and no-scaled groups. The 5th group exposed to the prescale gel for an extended time was evaluated descriptively for root surface morphological changes with no noticeable effect. Based on the results of this investigation, treatment of subgingival calculus with prescale gel offers no advantage for calculus removal over scaling alone. The findings suggest no significant clinical impact of product use.

Effects of subgingival irrigation with chlorhexidine on the periodontal status of patients with HA-coated integral dental implants

The purpose of this study was to examine the effect of chlorhexidine irrigation on the periodontal status of patients with HA-coated dental implants as measured by clinical, microbiological, and immunological measures. Thirty non-adjacent implants were randomly assigned to receive a one-time irrigation with either 0.12% chlorhexidine or sterile saline, or no irrigation. All parameters were measured at baseline, 2, 5, and 8 weeks. Results showed no significant differences between any treatment modalities at any time interval. A statistically significant decrease in probing depth (P < .05) occurred within the chlorhexidine and no-treatment groups at all time intervals compared to baseline.

The effect of personal protective equipment on high-and low-dental fear patients

PURPOSE

This investigation was designed to examine both high- and low-dental-fear patients' perceptions about and anxiety responses to personal protective equipment (PPE) as presented in a videotaped, simulated interaction between oral healthcare worker and patient.

METHODS

Sixty-two individuals representing a convenience sample presented at the University of Missouri-Kansas City (UMKC) Dental School and were screened for eligibility. The Dental Fears Survey was administered to participants to assess level of dental fear. Subjects were then matched according to fear level, gender, and age, and randomly assigned to an experimental or control group. Subjects viewed a videotaped vignette of a male dentist conducting a new patient interview. The control group viewed a tape in which the provider did not utilize PPE. The experimental group viewed the provider putting on PPE at completion of the interview. Subjects were instructed to complete a semantic differential scale at completion of the tape in order for the researchers to assess their attitude toward the scene. Paired adjectives in the semantic scale were scored from 1 to 7, with low scores reflecting negative evaluations and high scores reflecting positive evaluations. Heart rate and skin conductance were measured prior to and during the viewing of the videotapes by means of a photoplethysmograph and an electrodermograph, respectively.

RESULTS

A two-factor ANOVA found the main effect of fear to be significant (p < .05), with subjects exhibiting high levels of dental fear rating both videotapes (PPE & NO PPE) more negatively than subjects exhibiting low levels of dental fear. A repeated measure ANOVA was used for analysis of heart rate and skin conductance. The Dunn's Multiple Means Comparison Test showed that skin conductance increased significantly (p < .05) in both groups from baseline to presentation of the oral healthcare environment.

CONCLUSIONS

A videotaped presentation of the dental environment produced significantly more negative evaluations from patients with high fear than from patients with low fear. Both groups experienced a significant increase in skin conductance (perspiration) upon presentation of the oral healthcare environment. However, presence of PPE did not adversely affect patient perceptions of the oral healthcare provider.

A comparison of vascular-mediated tumor cell death by the necrotizing agents GR63178 and flavone acetic acid

A vascular component of tumor damage has been identified for the anticancer agent GR63178. The necrotizing activity of this drug and of flavone acetic acid has been compared with their ability to induce growth delay in six murine tumor models. At 24 hr, after a fixed dose of flavone acetic acid (200 mg/kg), all six tumor types appeared 80-100% necrotic histologically, although growth delays ranging from 3 to 79 days were measured. GR63178 (200 mg/kg) induced more variable degrees of necrosis (10 to 95%), but a uniformly small delay in growth (0 to 4 days). These data illustrate that the absence of a tumor-growth response should not be automatically equated with an absence of drug activity. Without assessing tumor response histologically, agents with unusual mechanisms of action may be missed, despite their potential for killing large numbers of tumor cells.

The prosthetic treatment of lower limb deficiency

The prosthesis required for a child with a transverse deficiency whilst a simple version of that appropriate for the adult follows the same principles. The child with a longitudinal deficiency may require an extension, or orthoprosthesis and this may be combined with surgical reconstruction. The principles, technique of measurement and fabrication methods using both traditional and modern composites are described.

The fractionated response of mouse stroma after X-rays and neutrons: influence of early vs late expression of damage

The sparing effect of dividing a radiation treatment into many small fractions is different for acutely responding tissues and those which have delayed expression of injury. We have used the Tumour Bed Effect assay (TBE) to investigate the influence of the time of damage expression on the response of the normally quiescent subcutaneous stroma. Implanted tumour cells provide an angiogenic stimulus which forces the vasculature to proliferate. The subcutaneous stroma of the mouse dorsum was irradiated with one to 32 equal fractions of X-rays, followed by a top-up dose of neutrons. CaNT cells were implanted into the treated site either within 3 days or not until 6 months after irradiation, to stimulate the expression of latent injury. The dose-response curves obtained for tumour growth in irradiated sites were much steeper at 1 to 3 days than at 6 months, suggesting some sort of repair of damage during this period. There was no suggestion that repair occurred preferentially after low doses per fraction and the alpha/beta ratio remained unchanged when the expression of stromal injury was delayed. The time of damage expression therefore seems unlikely to explain the difference in the alpha/beta ratios measured for early and late responding tissues. Rather, it seems to be determined by the proliferative status of the tissue at the time of irradiation.

Vascular collapse after flavone acetic acid: a possible mechanism of its anti-tumour action

Flavone acetic acid (FAA, LM 975) causes regression and growth retardation in several solid murine tumours. The mechanism of action is unknown, although various lines of evidence suggest an indirect cytotoxic effect. We have carried out preliminary studies on the effect of FAA on relative blood flow in six experimental murine tumours using 86RbCl extraction. We have also measured growth delay after treatment with the same dose of FAA (200 mg/kg). The data show that the drug induces a drop in tumour perfusion within 6 h of treatment in all of the tumours, and that this can be correlated with the growth delay measured. We conclude that vascular collapse may be an important component of the action of this drug, and that further investigation of this phenomenon is warranted.

The effect of oxygen on the delay in the initiation of DNA synthesis after irradiation

The effect of oxygen on cell cycle delay by low doses of radiation on synchronized Harding Passey melanoma cells has been studied. Cells were irradiated 5 h after subculturing into fresh medium, and the delay before the start of S was measured. DNA synthesis was measured by frequent pulse labeling of the cells with radioactive thymidine to obtain the S-phase profile. The amount by which the irradiated cells S-phase profile had to be moved in time so that both the ascending and descending portions of the first S phase overlayed that of the controls was used as a measure of the delay. The magnitude of the delay was exponentially related to radiation dose and the effect of irradiating in the absence of oxygen was a dose multiplying factor of 2.5. This was similar to the oxygen effect on survival for cells irradiated under the same conditions.

Immune localization of calmodulin in the ciliated cells of hamster tracheal epithelium

Melachronous beating of cilia of epithelial surfaces of most respiratory airways moves the overlying mucous layer in a caudal direction. The molecular mechanisms controlling ciliary beat remain largely unknown. Calcium, an element in its cationic form, is ubiquitous in biological functions and its concentration is critical for ciliary beating. Calmodulin, a calcium-binding protein which regulates the activity of many enzymes and cellular processes, may regulate ciliary beating by controlling enzymes responsible for mechanochemical movement between adjacent peripheral microtubule doublets composing the ciliary axoneme. As a first step in describing a calmodulin-related controlling mechanism for ciliary beating, calmodulin was localized in the ciliated cells lining the respiratory tracts of hamsters by electron microscopy, using an indirect immunoperoxidase technique with anticalmodulin antibodies as the molecular probe. Thin-sections revealed calmodulin located on microtubules and dynein arms of the ciliary shaft, basal body, apical cytoskeletal microtubules, and plasma membranes in specimens fixed with 1 mM Ca+2. Specimens fixed with less Ca+2 (1 microM), Mn+2, Mg+2, and EGTA showed a diffuse pattern of calmodulin with loci of greatest densities on basal body microtubule triplets. Demembranated specimens showed a less specific localization on axonemal microtubules but only on cells fixed with Ca+2. Calmodulin, by binding calcium, may function in ciliary beating in the respiratory tract of mammals either directly or indirectly through its effects on the energy-producing enzymes and by control of Ca+2 flux through plasma membranes.