Dental disease in type 3 Von Willebrand disease: a neglected problem

  Type 3 Von Willebrand disease (VWD) is a rare, severe, autosomal recessive bleeding disorder. In our institution, we follow 17 children with type 3 VWD. We have observed a high prevalence of dental disease in these patients prompting us to undertake a retrospective review of our cohort of patients with type 3 VWD to catalogue the extent of their dental disease. Sixteen of these patients have been assessed by our dentistry department. Five children have undergone minor dental procedures (e.g. restorations, stainless steel crowns) and seven major procedures (e.g. dental extractions, pulpotomies and root canal treatments). These patients have collectively used 85,400 (ristocetin cofactor) IU of Humate-P on dental procedures alone. In addition to the considerable costs of factor are the cost of operating room time, dentists' costs, and the cost of other topical haemostatic agents (e.g. Tisseel) used during their dental procedures. As such there is considerable morbidity and cost from dental disease in these patients that is much higher than what is seen in patients with haemophilia or in the normal paediatric population. We speculate that the combination of these patients having a significant mucosal bleeding disorder together with various socioeconomic factors contribute to the significant degree of dental disease seen in this group of patients. We would suggest that better preventive dental care needs to be provided to these patients to avoid the considerable morbidity and very high burden of dental disease in type 3 VWD.

Parenting knowledge and its role in the prediction of dysfunctional parenting and disruptive child behaviour

BACKGROUND

There is a paucity of research on the relationship between parental knowledge, parenting and parenting self-efficacy, and some inconsistencies have been reported in the literature.

METHOD

Parent knowledge of effective parenting strategies was assessed among 68 parents from a non-clinic sample, who also completed questionnaires relating to parenting confidence, quality of parenting and child behaviour.

RESULTS

Parents with greater knowledge tended to be less dysfunctional, and reported significantly higher education and income levels. Parenting confidence explained a significant proportion of the variance in reported frequency of disruptive child behaviour while knowledge did not independently contribute to the prediction. However, the relationship between parenting confidence and dysfunctional parenting was moderated by the level of knowledge. There was a stronger negative relationship between confidence and dysfunctional parenting when knowledge level was low than when it was high. Post hoc analyses indicated that the relationship between parenting knowledge and disruptive child behaviour was moderated by the level of parenting dysfunction. Parenting knowledge and reported frequency of disruptive behaviour were positively related when the level of dysfunction was low, but were unrelated when it was high.

CONCLUSIONS

Parents with low levels of knowledge and confidence in their parenting may be at greater risk of dysfunctional parenting and might benefit from interventions designed to enhance both knowledge and confidence. Results are interpreted in relation to inconsistencies with previous research and implications for future methodologies.

[Really drunk?]

We report about a 42-year-old patient who was admitted to the emergency department because of suspected alcohol abuse. He declared himself to be drunk. He stated in his case history that he had suffered from right sided neck and facial pain for several days. The clinical examination revealed a left sided hemiparesis. Together with the demonstrated right hemispherical brain ischemia by computed tomography, a presumptive diagnosis of a dissection of the right internal carotid artery was made. This diagnosis was finally confirmed by ultrasound and magnetic resonance imaging. A therapy with full dose heparin was begun and oral anticoagulation was subsequently initiated. After two weeks of follow-up, the neurological deficiencies were partially regredient.

Magnetic resonance imaging in suspected rectal cancer: determining tumor localization, stage, and sphincter-saving resectability at 3-Tesla-sustained high resolution

PURPOSE

To assess image quality and overall accuracy of 3-Tesla (3T)-sustained high-resolution magnetic resonance (MR) imaging for diagnostic preoperative workup in suspected rectal carcinoma.

MATERIAL AND METHODS

Twenty-three patients with suspected rectal cancer underwent unenhanced and contrast-enhanced fat-suppressed pelvic high-resolution MR imaging using a four-channel phased-array pelvic coil at 3T. Image quality, tumor stage, distance from the anorectal margin, and sphincter-saving resectability were prospectively assessed by two blinded readers. The results were correlated with clinical, surgical, and histopathologic findings.

RESULTS

In all 23 patients, MR images were of diagnostic quality, and malignancy was correctly identified in 21 patients. The accuracy for determining sphincter-saving resectability was 100% (19/19). T stage and N stage were correctly diagnosed in 95% and 91%, respectively. MRI allowed correct identification of tumor extension and its relation to surgically relevant pelvic structures including the anorectal margin and mesorectal fascia. Transverse T2-weighted fast spin-echo images compared superiorly to all other sequences for the diagnosis of mesorectal infiltration and lymph node involvement. Moreover, transverse fat-suppressed contrast-enhanced T1-weighted images were valuable for identifying tumor infiltration, while sagittal sections were useful for the detection of longitudinal tumor extension.

CONCLUSION

MR imaging with phased-array receiver coils at 3T facilitated both visualization of different pathologic conditions of the rectum and accurate determination of tumor stage in rectal carcinomas. Thus, this noninvasive diagnostic approach appeared highly suitable for the assessment of patients with suspected rectal carcinoma.

Oral out-patient chemotherapy medication errors in children with acute lymphoblastic leukemia

9028

Background: Oral out-patient chemotherapy medications (OOCMs) compromise the majority of therapy for children with acute lymphoblastic leukemia (ALL). OOCM are administered at the patient’s home, usually by parents with limited medical training. The frequency of errors in OOCM dose or schedule is unknown in children with ALL. Methods: We conducted a prospective case series. After providing informed consent, parents were interviewed during an ambulatory clinic visit to determine the dose and frequency of OOCMs administered since the last ambulatory clinic visit or hospitalization. Parents also completed a questionnaire regarding their understanding of the child’s OOCMs. Patient medical records were reviewed to determine the appropriate OOCM doses and schedules and then compared to the parent report. Pharmacy records were reviewed to determine how OOCMs were prescribed. OOCM errors included omission of any OOCM, use of an incorrect OOCM, > 10% deviation from the intended OOCM dose, or incorrect OOCM schedule. Results: 69 children (median age 6.4 years, range 1.3–17.9 years) participated, with a total of 171 OOCMs assessed. Fifteen (8.7%) OOCMs were given incorrectly, including 10 OOCMs administered incorrectly by parents, and five prescribed incorrectly. Eight errors involved under- or over-dosing within 10–20% of the intended OOCM dose. There were no errors in pharmacy dispensing. Errors were more common with glucocorticoids (9/60 OOCMs evaluated) than anti-metabolites (6/111 OOCMs evaluated). Conclusions: OOCM errors are unusual in children with ALL. Both administration and prescription errors were observed. Efforts to improve optimal use of OOCMs should include prevention of errors, potentially by identifying patients at higher risk for OOCM errors.

No significant financial relationships to disclose.

Magnetic resonance imaging including magnetic resonance cholangiopancreatography for tumor localization and therapy planning in malignant hilar obstructions

PURPOSE

To assess image quality and overall accuracy of magnetic resonance imaging (MRI), including two magnetic cholangiopancreatography (MRCP) techniques, for the diagnostics and preoperative work-up of malignant hilar obstructions.

MATERIAL AND METHODS

Thirty-one patients with malignant hilar obstructions (hilar cholangiocarcinoma, n=30; hepatocellular carcinoma, n=1) received MRCP by two techniques (single-shot thick-slab and multisection thin-slice MRCP) and unenhanced and contrast material-enhanced MRI. MR assessment included the evaluation of image quality and visualization of bile ducts (5-point scale), and the classification of tumor status. MR results were subsequently correlated with the results from surgery and pathology.

RESULTS

The maximum intensity projections of multisection thin-slice MRCP had significantly more artifacts compared to MRCP in the single-shot thick-slab technique, and overall image quality of single-shot thick-slab MRCP was rated significantly superior compared to multisection thin-slice MRCP (4.4 +/- 0.7 and 4.1 +/- 0.9, respectively). Moreover, ductal visualization of different parts of the biliary system was rated superior with single-shot thick-slab MRCP. In contrast, the original data from multisection thin slice MRCP facilitated visualization of periductal lesions and adjacent structures. Overall MR accuracy for the assessment of tumor status, periductal infiltration, and lymph node metastases was 90%, 87%, and 66%, respectively.

CONCLUSION

For evaluation of malignant hilar obstructions, MRCP by the single-shot thick-slab technique had superior image quality and fewer artifacts; in contrast, besides sole biliary visualization, multisection MRCP depicted complementary adjacent parenchymal and periductal structures. We therefore recommend MRI, with a combination of both MRCP techniques, for the diagnostic work-up and therapy planning of malignant hilar obstructions.

Auswirkung der Feldstärke bei der standardisierten Kernspintomographie des Gehirns am Beispiel der Darstellung von Hirnnerven und Gefäßen in den basalen Zisternen: Vergleich zwischen 1,5 und 3,0 Tesla

PURPOSE

Comparison of MR images acquired as routine examinations at a field strength of 3.0 T and 1.5 T to determine whether and to which degree the image quality improves at the higher field strength of 3.0 T.

MATERIALS AND METHODS

Routine MR images of 200 patients were examined retrospectively, with 100 images obtained at 1.5 T and 100 obtained at 3.0 T. The examinations were performed with a quadrature head coil and focused on the basal cisterns because of the abundance of small distinct structures in this region. We selected the T2-weighted 2D-FSE sequence in transverse direction for comparison. At both field strengths, the same section thickness of 5 mm and a matrix of 512 x 388 (FOV: 220 mm) were used. The quality of the images was evaluated with regard to depicting the cranial nerves N. III, V - X, the AICA and PICA. For comparison, image quality was rated with a score from 1 (well defined) to 5 (not depicted).

RESULTS

A score of 1 was obtained in 46 % of the anatomic structures examined at 3.0 T and in only 9.2 % at 1.5 T. A score of 2 was given in 27.6 % of the anatomic structures at 3.0 T vs. 23.5 % at 1.5 T, a score of 3 in 17.2 % vs. 28.1 %, a score of 4 in 8.6 % vs. 28.7 %, and a score of 5 in 0.4 % vs. 10.3 %, respectively. The Mann-Whitney U test showed significance at p < 0.001 for the comparison of images at 1.5 and 3.0 Tesla.

CONCLUSION

Routine magnetic resonance imaging using the same quadrature coil technique and similar acquisition times at 3.0 T and 1.5 T shows an improvement for T2-weighted images at the higher field strength.

Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study

Although there has been considerable interest in racial differences in family caregiving for persons with dementia, most research to date has either ignored racial diversity or based conclusions on small numbers of caregivers drawn primarily from single site studies. The current study utilized participants from four sites of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) multi-site study to compare well-being, appraisal, and religious coping by race. African-American (n = 295) and Caucasian (n = 425) dementia caregivers from four cities (Birmingham, Memphis, Boston, and Philadelphia) were compared in their demographics, care recipient characteristics, mental and physical health, and psychosocial coping resources including appraisal and religious coping. African-American caregivers reported lower anxiety, better well-being, less use of psychotropic medications, more benign appraisals of stress and perceived benefits of caregiving, and greater religious coping and participation, than Caucasian caregivers. Self-rated health did not differ by race, but African-American caregivers reported more unhealthy behaviors than Caucasian caregivers. Some results were specific to site, possibly due to differences in recruitment strategies, inclusion/exclusion criteria, and regional differences. Adjustment for covariates, including caregiver relationship to the care recipient, gender, age, socioeconomic status, and care recipient behavioral problems, altered few of these differences. Results are discussed in terms of their relevance to psychosocial intervention programs for ethnically diverse caregivers.

Investigation of health perspectives of those with physical disabilities: the role of spirituality as a determinant of health

PURPOSE

To identify key determinants of health and the process of health attainment for people with musculoskeletal disabilities.

METHOD

Focus groups of people with musculoskeletal disorders, including 30 members and their five trained facilitators, provided data. Discussed were 'What is health for you?' and 'What has helped, or would help you achieve this health?' Delphi-structured analysis identified health themes and a health process model was developed with the facilitators comprising the expert panel.

RESULTS

Health was perceived as centred on relationships that required a spiritual awareness for a strong and resilient identity. The Self Attributes Model developed portrays the processes perceived to be required for health.

CONCLUSIONS

Although physical, social and psychological interventions are essential aspects of health intervention, by themselves they are not sufficient. Also required for health is a strong resilient self resulting from interaction and connection with other people and the natural world. Moreover, development of such an identity requires a spiritual world-view comprising an acknowledgement of the essence of self and focus upon the nature of the connection of this essence with all other aspects of life. Further research is required to advance understanding of the process by which this occurs for people with chronic disorders.

Antinociceptive properties of neurosteroids: a comparison of alphadolone and alphaxalone in potentiation of opioid antinociception

In this study, we investigated the antinociceptive and sedative effects of the opioids fentanyl, morphine, and oxycodone given alone and in combination with two neurosteroids: alphadolone and alphaxalone. An open-field activity monitor and rotarod apparatus were used to define the sedative effects caused by opioid and neurosteroid compounds given alone intraperitoneally to male Wistar rats. Dose-response curves for antinociception were constructed using only nonsedative doses of these drugs. At nonsedating doses, fentanyl, morphine, and oxycodone all caused dose-dependent tail flick latency (TFL) antinociceptive effects. Because neither neurosteroid altered TFL, electrical current was used as the test to determine doses of neurosteroid that caused antinociceptive effects at nonsedative doses. Alphadolone 10 mg/kg intraperitoneally caused significant antinociceptive effects in the electrical test but alphaxalone did not. All three opioid dose-response curves for TFL antinociception were shifted to the left by coadministration of alphadolone even though alphadolone alone had no effect on TFL. Alphaxalone given alone had no antinociceptive effects at nonsedative doses and it had no effect on opioid antinociception. Neither neurosteroid caused sedative effects when combined with opioids. We conclude that coadministration of alphadolone, but not alphaxalone, with morphine, fentanyl, or oxycodone potentiates antinociception and that this effect is not caused by an increase in sedation.

Evaluating home environments of persons with dementia: interrater reliability and validity of the Home Environmental Assessment Protocol (HEAP)

PURPOSE

This article reports on an interrater reliability and preliminary validity study of an investigator-developed tool, the Home Environmental Assessment Protocol (HEAP) for use in homes of persons with dementia.

METHOD

The HEAP consists of 192 items that are summed into separate indices representing the number of hazards, adaptations, and level of clutter and comfort in eight areas of the home. Interrater reliability was examined among four raters, two environmental experts and two non-experts, who observed 22 dementia households.

RESULTS

The Kappa statistic was used to evaluate agreement level for each measured item and found that agreement ranged from slight to almost perfect. Intraclass correlations (ICCs), were used to evaluate agreement level for indices. The hazard index in each room ranged from fair (0.36) to moderate (0.66) for all raters. For the adaptation, clutter and comfort indices in each room, ICCs ranged from 0.51 to 0.90 for all raters. Agreement level between expert and non-expert raters differed minimally for all indices. Adaptations to dining rooms (r= -0.080, p = 0.001), kitchens (r = -0.52, p = 0.02) and bedrooms (r = -0.76, p = 0.001) were associated with patient deficits such that more adaptations were made in homes of dependent persons. Low Mini-Mental Status Examination scores were associated with fewer hazards, more adaptations, and less clutter.

CONCLUSION

Findings show that both experts and non-expert raters use the HEAP consistently. Also, measured attributes are related to cognitive and functional status in the expected direction.

A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia

PURPOSE OF STUDY

The authors determined short-term effects of a home environmental intervention on self-efficacy and upset in caregivers and daily function of dementia patients. They also determined if treatment effect varied by caregiver gender, race, and relationship to patient.

DESIGN AND METHODS

Families (N = 171) of dementia patients were randomized to intervention or usual care control group. The intervention involved 5 90-min home visits by occupational therapists who provided education and physical and social environmental modifications.

RESULTS

Compared with controls, intervention caregivers reported fewer declines in patients' instrumental activities of daily living (p = .030) and less decline in self-care and fewer behavior problems in patients at 3 months post-test. Also, intervention spouses reported reduced upset (p = .049), women reported enhanced self-efficacy in managing behaviors (p = .038), and women (p = .049) and minorities (p = .037) reported enhanced self-efficacy in managing functional dependency.

IMPLICATIONS

The environmental program appears to have a modest effect on dementia patients' IADL dependence. Also, among certain subgroups of caregivers the program improves self-efficacy and reduces upset in specific areas of caregiving.