Addressing oral health disparities in settings without a research-intensive dental school: collaborative strategies

Research suggests that oral health is linked to systemic health, and those with poor oral health are potentially at greater risk for important diseases, including cardiovascular disease, stroke, diabetes mellitus, and adverse pregnancy outcomes. Asians and Pacific Islanders (APIs) in Hawaii have high rates of many such diseases. Studies in children in Hawaii have revealed disparities in dental health; for example, API children have significantly higher rates of cavities than other groups. Hence, conducting further study is vital in adults, particularly APIs, to assess oral health and its correlation to overall health outcomes. Given the lack of a dental school and the lack of fluoridated water in the state, the University of Hawaii's John A. Burns School of Medicine (ABSOM) has identified the need to assume a leadership role in creating effective community-based oral health research and treatment programs. With the support of the National Institute of Dental and Craniofacial Research, JABSOM fostered a collaborative relationship with the University of North Carolina at Chapel Hill School of Dentistry, a premiere research-intensive dental school, the Waimanalo Health Center, and the Hawaii State Department of Health. This partnership has worked together to implement a community-based approach to performing research designed to illuminate disparities and develop innovative strategies to promote oral health in Hawaii's diverse populations. We hope that this collaborative, culturally competent approach may serve as a model for use in other settings without a research-intensive dental school.

Emotional conversations in Parkinson's disease

OBJECTIVE

To learn how PD influences verbal description of emotional events.

BACKGROUND

Individuals with PD exhibit emotional processing deficits. Emotional experience likely involves several dimensions (e.g., valence, arousal, motor activation) subserved by a distributed modular network involving cortical, limbic, basal ganglia, diencephalic, and mesencephalic regions. Although the neurodegeneration in PD likely affects components in this network, little is known about how PD influences emotional processing. Because PD is associated with activation deficits, one could predict that the discourse of emotional experiences involving high activation would be reduced in patients with PD compared to control subjects. Alternatively, because patients with PD exhibit paradoxical sensitivity to externally evoked motor activation (kinesia paradoxica), it is possible that emotional stimuli may facilitate verbal emotional expression more so in patients with PD than in control subjects.

METHODS

The authors measured verbal descriptions of personal emotional experiences in subjects with PD and normal controls.

RESULTS

Compared with control subjects, individuals with PD showed a relative increase in the number of words spoken and in discourse duration when talking about emotional experiences that are usually associated with high levels of arousal and motor activation. Although the authors did not measure arousal or activation, prior research has shown that, when asked to recall an emotional experience, people will often re-experience the emotion previously experienced during that episode.

CONCLUSIONS

Recalling emotional episodes induces verbal kinesia paradoxica in patients with PD. Although recall of these emotional episodes may have been associated with increased arousal and activation, the mechanism underlying emotional verbal kinesia paradoxica is unclear.

Changes in vocal intensity in Parkinson's disease following pallidotomy surgery

The present study was designed to examine changes in vocal intensity following unilateral posteroventral pallidotomy (PVP) in a large sample of speakers with Parkinson's disease (PD) that exhibited a range of hypokinetic dysarthria. Twenty-five persons with PD were recorded using a variety of speech tasks, once prior to and once following PVP. The pre-PVP vocal SPL was subtracted from the post-PVP vocal SPL to derive a relative change in vocal SPL. Mildly dysarthric participants had significantly greater relative increases in vocal SPL following PVP than either moderately or severely dysarthric participants who had reduced vocal SPL following PVP. If future results follow those observed in the present data, mildly dysarthric Parkinson's patients may benefit most from unilateral PVP perhaps due to less overall destruction of the basal ganglia sensorimotor control circuits involved in oral facial functions, thus increasing the chances to observe improvements postsurgery.

Voice and speech characteristics of persons with Parkinson's disease pre- and post-pallidotomy surgery: preliminary findings

Pallidotomy surgery, lesioning the globus pallidus internal, has been performed to alleviate Parkinsonian symptoms and drug-induced dyskinesias. Improvements in limb motor function have been reported in recent years following pallidotomy surgery. The purpose of this preliminary study was to determine the effect of pallidotomy surgery on select voice and speech characteristics of 6 patients with Parkinson's disease. Acoustic measures were analyzed pre-pallidotomy surgery and again at 3 months following surgery. Preliminary findings indicated that all participants demonstrated positive changes in at least one acoustic measure; 2 of the participants consistently demonstrated positive changes in phonatory and articulatory measures, whereas 3 participants did not consistently demonstrate positive changes postsurgery. The results are discussed relative to the differential effects observed across participants.

The importance of cerebrospinal fluid lactate in the evaluation of congenital lactic acidosis

In 27 of 28 children with congenital lactic acidosis, cerebrospinal fluid lactate was higher than venous blood lactate. The mean +/- SEM difference between these variables was 2.4 +/- 0.3 mmol/L (P =.0001). Girls or patients with pyruvate dehydrogenase deficiency had higher cerebrospinal fluid lactate concentrations than boys or patients with respiratory chain defects or mitochondrial DNA mutations.

Cost effectiveness of pramipexole in Parkinson's disease in the US

OBJECTIVE

Pramipexole was recently approved in the US for treatment of the symptoms of idiopathic Parkinson's disease (PD). Although pramipexole has been found to be safe and efficacious when compared with placebo, little data are yet available on its cost effectiveness when compared with baseline treatment. The aim of this study was to estimate the costs and cost effectiveness (cost utility) of pramipexole compared with baseline treatment in patients with early and advanced PD.

DESIGN AND SETTING

We developed a cost-effectiveness (CE) model in the US setting that linked Unified Parkinson's Disease Rating Scale (UPDRS) Part II (activities of daily life) and III (motor) scores to disease progression, costs and patient utility. Data for the model were obtained from clinical trials, a literature review and a survey of 193 patients' health resource use and utility. We used cost and quality-adjusted life-year (QALY) estimates from the model to estimate the incremental cost effectiveness of pramipexole relative to baseline treatment patterns. We performed separate analyses for patients with early and advanced PD. We also performed extensive sensitivity analyses by adding other dopamine agonists to the no-pramipexole treatment regimen and varying disease progression parameters. The study was conducted from the societal perspective, although data presentation allows interpretation of cost effectiveness from either the societal or payer perspective.

MAIN OUTCOME MEASURES AND RESULTS

For patients with both early and advanced PD, treatment with pramipexole had higher costs but was more effective than baseline treatment. For patients with early onset of PD, the incremental total CE ratio for pramipexole was $US8837/QALY. For patients with advanced PD, the incremental CE ratio was $US12 294/QALY (1997 costs). These ratios were lower than the CE ratios of many widely used medical treatments.

CONCLUSIONS

Subject to the inherent limitations of modelling chronic disease progression and subsequent healthcare costs and patient utility, the results suggested that pramipexole was a cost effective treatment for patients with early and advanced PD in the US.

Stereotactic pallidotomy lengthens the transcranial magnetic cortical stimulation silent period in Parkinson's disease

We compared the duration of the EMG cortical stimulation silent period (CSSP) elicited in abductor pollicis brevis using transcranial magnetic stimulation (TMS) before and after stereotactic unilateral globus pallidus internus pallidotomy (PAL) in 12 patients with Parkinson's disease. We used TMS stimulus intensities of 200, 150, 120, and 100% of motor evoked potential (MEP) threshold before and after (86 +/- 25 days) PAL. PAL increased CSSP duration at stimulus intensities of 200% of MEP threshold in the hand contralateral to the stereotactic lesion. In a subset of five patients able to remain at rest during pre-PAL testing sessions, PAL decreased the resting MEP/M-wave area ratio in the hand contralateral to the lesion at a stimulus intensity of 120% of MEP threshold. PAL did not significantly modify the effects of TMS in the hand ipsilateral to the globus pallidus lesion. The results suggest that PAL improves the function of cortical motor inhibitory circuits in Parkinson's disease.

Pericranial muscle tenderness and exteroceptive suppression of temporalis muscle activity: a blind study of chronic tension-type headache

The aim of the present study was to examine the ability of pericranial muscle tenderness and the second exteroceptive suppression period to distinguish chronic tension-type headache sufferers, migraine sufferers, and controls in a young adult population utilizing a blind design. The second exteroceptive suppression periods were assessed using the methodology recommended by the European Headache Federation and were scored with an automated computer software program designed in our laboratory to provide reliable, standardized, and precise quantification of exteroceptive suppression periods and eliminate any influence of experimenter bias that may occur with manual scoring. Our sample consisted of 45 subjects diagnosed according to IHS criteria: 25 with chronic tension-type headache and 20 with migraine without aura. Twenty-three headache-free controls were recruited. Consistent with our previous findings, abnormalities in pericranial muscle tenderness, but not in the second exteroceptive suppression period distinguished chronic tension-type headache sufferers from controls. The chronic tension headache sufferers exhibited the highest pericranial muscle tenderness and the control group exhibited the lowest tenderness (P < .001). Pericranial muscle tenderness was quite successful in distinguishing recurrent headache sufferers from controls, but failed to distinguish chronic tension-type headache sufferers from migraineurs. Our findings raise the possibility that pericranial muscle tenderness is present early in the development of chronic tension-type headache and migraine without aura, and thus might contribute to the etiology of headache disorders. Our findings also indicate that a shortened second exteroceptive suppression period is not a reliable marker for chronic tension-type headache in young adults.

Human neutrophil Fc receptor-mediated adhesion under flow: a hollow fibre model of intravascular arrest

Human polymorphonuclear cells (PMN) were found to adhere to a novel model of blood vessel wall-associated IgG. The internal surfaces of cellulose acetate hollow fibres, of comparable internal diameter to small blood vessels, were coated with normal serum human IgG, heat-aggregated IgG (HAIgG), laminin or fibrinogen. Under conditions of flow mimicking those in a small vessel, PMN were found to adhere markedly only to immunoglobulin-coated fibres. Arrest on HAIgG was inhibited by excess soluble IgG but not by bovine serum albumin (BSA), demonstrating that the adhesion was IgG-specific and presumably mediated by Fc gamma R on the PMN surface. Pre-adsorption of serum components onto HAIgG-coated fibres enhanced PMN arrest, due most probably to fixation of complement components by immobilized HAIgG, resulting in additional potential to entrap PMN via complement receptors such as CR3. Treatment of PMN with the regulatory neuropeptide substance P also enhanced adhesion to HAIgG-coated fibres and caused increased surface expression of Fc gamma RI, Fc gamma RII and Fc gamma RIII. A mouse cell line derived from L cells, hR4C6, stably transfected with human Fc gamma RII, was found to adhere under flow to HAIgG-coated fibres, whilst untransfected parent L cells did not. This adhesion was similarly inhibited by excess soluble IgG, confirming the capability of Fc gamma R to mediate cell arrest. The study strongly suggests that Fc gamma R may play an important role in intravascular PMN arrest and we speculate that in inflammatory diseases PMN may adhere via Fc gamma R to immobilized immunoglobulin on the vascular endothelium, with subsequent degranulation and tissue damage.

A survey of selected issues involving pharmacy technician training in Canada

A non-random, snowball sampling technique was used to survey eleven Canadian pharmacy technician training programs and thirteen pharmacy regulatory and voluntary bodies on issues surrounding pharmacy technicians. A 100% response rate was achieved in the questionnaires which targeted issues such as nomenclature, certification, accreditation, and education of pharmacy technicians. Survey results indicate that while many provincial pharmacy regulatory boards have addressed issues such as the nomenclature and workplace role of pharmacy technicians, there is a lack of consensus and discussion in the areas of certification, accreditation, and responsibility for continuing education.

A nursing evaluation of unit dose and computerized medication administration records

A nursing evaluation of the unit dose system and a computerized medication administration record (MAR) was conducted to determine satisfaction with and perceptions of the effectiveness of these programs. A Nursing Evaluation Questionnaire was used to document nurses' attitudes towards the new programs. Of 228 questionnaires distributed on eleven nursing units, 152 were returned (response rate 66.7%). Full-time registered nurses represented 73.7% of the respondents, part-time 21% and casual 5.3%. Of the 152 respondents, 86.6% reported at least "some" time savings preparing and administering medications with the unit dose system, with 57% of this group reporting "significant" time savings. Unit dose was considered a safer distribution system by 82% of the respondents. Almost all of the respondents (99.3%) would choose to work with the unit dose system. Of the 152 respondents, 86% reported the computerized MAR decreased time spent charting medications administered, with half of this group reporting "significant" time savings. The computerized MAR was considered a safer charting method by 74% of the respondents. All of the respondents (100%) would choose to work with the computerized MAR. The evaluation indicated the unit dose system and computerized MAR were well accepted by nursing staff and were perceived to be working effectively.

Acute hemorrhagic leukoencephalitis. A successful recovery

A 50-year-old woman developed acute hemorrhagic leukoencephalitis approximately 7 days after the onset of a benign respiratory infection. Mycoplasmal pneumonia was suspected because of Coomb's positive hemolysis, cold agglutinins, and sensitivity to erythromycin base but was not proved. Acute hemorrhagic leukoencephalitis was demonstrated by brain biopsy 24 hours after admission. The patient recovered without lasting sequelae following reduction of increased intracranial pressure by mannitol, hyperventilation, and phenobarbital and prolonged immunosuppression by plasmapheresis, steroids, and cyclophosphamide.

Estimation of amounts of anti-La(SS-B) antibody directed against immunodominant epitopes of the La(SS-B) autoantigen

The contribution of circulating anti-La(SS-B) antibody to the hypergammaglobulinaemia seen in primary Sjögren's syndrome is unknown. In this study levels of anti-La(SS-B) antibody directed against three immunodominant epitopes of the anti-La(SS-B) autoantigen were measured by ELISA in 84 anti-La(SS-B)+ sera using purified recombinant protein and antibody affinity-purified against the three anti-La(SS-B) fusion proteins. There was marked variation in the amounts of IgG anti-La(SS-B) antibody detected, with levels ranging from 0.02 mg/ml to 11 mg/ml. The anti-La(SS-B) levels were greater than 1 mg/ml in 61% of patients; in 18% of sera the anti-La(SS-B) level constituted 10% or more of the total serum IgG. However, other patients were seen with marked hypergammaglobulinaemia and low anti-La(SS-B) concentrations. These results support an antigen-driven mechanism for the anti-La(SS-B) response and suggest that anti-La(SS-B) antibody production is regulated independently of other immunoglobulins.

Disease-specific electrophysiological findings in adult ceroid-lipofuscinosis (Kufs disease)

Two adults with mild dementia and a history of memory loss and disequilibrium were seen in the eye clinic following complaints of acuity loss in the 20/30-20/70 (Snellen) range. Results from the fundus examination of one patient were entirely normal; the other showed minimal vascular attenuation and optic atrophy. Electrophysiology was remarkable: (1) Photopic ERG b-waves were reduced, delayed, and showed pronounced oscillations. (2) EOG 'light-rise' potentials were absent or very small. (3) Binocular pattern-VER signals showed addition of the monocular signal. Scotopic ERG signals were normal. Brain biopsy and microscopy showed intercellular, autofluorescent ceroid deposits which provided a clear diagnosis of Kufs disease. Histology of model animal retinal cells show ceroid deposits in cell classes implicated by the human retinal signals. The cluster of electrophysiological results point toward early changes in the pigment epithelium and inner plexiform layer cells as a means of noninvasive diagnosis.

Recent developments in the treatment of Parkinson's disease

An acceptable level of motor improvement allows the patient to do the physical tasks necessary for independent functioning. Patients achieve this level of improvement, on an average, with less than six tablets daily of 25/100 carbidopa/L-dopa. Bromocriptine mesylate, one of the dopamine agonist drugs, may be used in patients without the concomitant use of other agents. However, my experience suggests it is more effective in conjunction with carbidopa and L-dopa.

Heart rate and blood pressure response to several methods of strength training

This study was undertaken to determine heart rate and blood pressure responses to various exercises used during strengthening programs. Heart rate, blood pressure, and pressure-rate product (systolic blood pressure X heart rate) were determined for five subjects performing five different strength-training exercises at 75 and 100 percent of maximum voluntary contraction (MVC). The exercises included isometric and isokinetic exercises and isotonic exercises with free weights. Systolic blood pressure, diastolic blood pressure, and pressure-rate product increased significantly with all exercises; heart rate increased with most of the exercises. In some, but not all, of the exercise sessions in which two measurements were made at different times, heart rate, blood pressure, and pressure-rate product were higher for the second measurement. Pressure-rate product was significantly higher for the exercises performed at 100 percent of MVC than for those performed at 75 percent of MVC. The isokinetic exercise performed at 100 percent of MVC produced the highest pressure-rate product.