A study of optic nerve head drusen in 38 pseudoxanthoma elasticum (PXE) patients (64 eyes). Location of optic nerve head drusen in PXE

PURPOSE

To investigate the prevalence and location of optic nerve head drusen and their potential association with other PXE-related ophthalmic abnormalities.

MATERIALS AND METHODS

Thirty-eight of the 155 patients (57 male and 98 female aged 49±17 years) included in this retrospective study had optic nerve head drusen. All of the patients underwent a comprehensive ophthalmic examination, including color images using red-free, blue and red filters, autofluorescence imaging and late-phase ICG frames. Comparative analysis of both groups (optic nerve head drusen or not) was conducted using R statistical software.

RESULTS

The prevalence of optic nerve head drusen in our cohort was 24.5%. In this study, no evidence of a significant link between optic nerve head drusen and other fundus abnormalities was detected. They were more commonly located in the nasal sector than in the temporal sector of the optic disc (P<0.001). They were more frequently situated superonasally than inferonasally (P<0.004), superotemporally (P<0.001) or inferotemporally (P<0.03). No central visual field defect was observed in OND+ patients who were unaffected by macular disorders.

DISCUSSION

We hypothesized this predominantly nasal primary location may result from greater sensitivity in the nasal optic nerve fibers which follow a much more angular path once they arrive in the scleral canal, accounting for accumulation of axoplasmic debris.

CONCLUSION

In PXE, optic nerve head drusen are mostly located in the superonasal quadrant, causing progressive optic nerve invasion but probably no central visual field defects.

Post-traumatic lower cervical spine instability: arthrodesis clinical and radiological outcomes at 5 years

BACKGROUND

Anterior cervical fusion is widely used to treat spinal injuries. Radiological evidence of disc abnormalities may develop on either side of the fused segment, raising concern about the potential for inducing adjacent-segment disease. Here, we report the long-term clinical, functional, and radiological outcomes after anterior cervical fusion.

HYPOTHESIS

Anterior cervical fusion influences the development of adjacent-segment disease.

MATERIALS AND METHODS

In a retrospective study, 15 patients aged 17 to 50 years were re-evaluated more than 5 years after anterior spinal fusion to treat post-traumatic cervical-spine instability. We used the Neck Disability Index (NDI) to assess function. Static and dynamic radiographs of the cervical spine were obtained.

RESULTS

NDI values indicated good clinical and functional outcomes, and fusion was achieved consistently. Adjacent-segment disease was a consistent finding at last follow-up but induced no neurological manifestations. Complete fusion of a level adjacent to the treated level was noted in 2 patients. Revision surgery for adjacent-segment disease was not required in any patient.

CONCLUSION

The causative factors of adjacent-segment disease are controversial. Disc degeneration is a normal manifestation of the ageing process. Nevertheless, disc disease is more prevalent at levels adjacent to interbody fusion than in the normal population, suggesting accelerated disc degeneration due to increased loading of the adjacent levels. Furthermore, lesions that are missed during the pre-operative work-up may play a role, as the available investigations do not always have high negative predictive values.

LEVEL OF EVIDENCE

Level IV, retrospective study.

An anatomically realistic and adaptable prostate phantom for laser thermotherapy treatment planning

PURPOSE

To construct a phantom for prostate cancer laser based thermotherapy treatment planning and simulation.

METHODS

A realistic and adaptable prostate phantom was designed. It exhibits the following properties: valid and complete description of the prostate anatomy, material with similar optical properties of prostate tissues and compatibility with clinical imaging protocols mainly multiparametric magnetic resonance (MR) and transrectal ultrasound imaging (TRUS).

RESULTS

Preliminary experiments with the phantom using an interstitial laser treatment protocol allowed obtaining results similar to those obtained on preclinical model.

CONCLUSIONS

These results proved that this phantom could allow a real simulation of laser therapy procedure: target definition and fibers' placement optimization using MR imaging, treatment delivery, and finally treatment monitoring using TRUS imaging.

Effectiveness of Maternal Counseling in Reducing Caries in Cree Children

This cluster-randomized pragmatic (effectiveness) trial tested maternal counseling based on Motivational Interviewing (MI) as an approach to control caries in indigenous children. Nine Cree communities in Quebec, Canada were randomly allocated to test or control. MI-style counseling was delivered in test communities to mothers during pregnancy and at well-baby visits. Data on outcomes were collected when children were 30 months old. Two hundred seventy-two mothers were recruited from the 5 test and 4 control communities. Baseline characteristics were comparable but not equivalent for both groups. At trial’s end, 241 children had follow-up. The primary analysis outcome was enamel caries with substance loss (d2); no statistically significant treatment effect was detected. Prevalence of treated and untreated caries at the d2 level was 76% in controls vs. 65% in test (p = 0.17). Exploratory analyses suggested a substantial preventive effect for untreated decay at or beyond the level of the dentin, d3 (prevalences: 60% controls vs. 35% test), and a particularly large treatment effect when mothers had 4 or more MI-style sessions. Overall, these results provide preliminary evidence that, for these young, indigenous children, an MI-style intervention has an impact on severity of caries (clinical trial registration ISRCTN41467632).

[Cricothyrotomy in emergency context: assessment of a cannot intubate cannot ventilate scenario]

OBJECTIVE

The aim of this study was to assess airway management by emergency physicians in case of a simulated situation where intubation and ventilation were both impossible.

STUDY DESIGN

Observational manikin study.

METHODS

A manikin (Airman®; Laerdal) allowing simulating difficult airway situations was used. The scenario assessed concerned a patient needing tracheal intubation for severe traumatic brain injury. The manikin was settled to make tracheal intubation under direct laryngoscopy impossible at the first attempt and to make facemask ventilation impossible after the second attempt. Manikin could initially be ventilated through the intubating laryngeal mask Airway (ILMA) but became impossible few seconds after its insertion. With impossible ventilation through the ILMA, arterial oxygen saturation decreased during 2 minutes before an hypoxic cardiac arrest occurred. Physicians could use classic laryngoscope with Macintosh blade, a Gum Elastic Bougie, an ILMA and a cricothyrotomy set. Adhesion to the national airway management algorithm was assessed. Time to cricothyroidotomy decision after ventilation through ILMA became impossible was measured.

RESULTS

Twenty-five emergency physicians were assessed. For 14 of them, national expert conference algorithm was perfectly followed. For ten physicians, cricothyroidotomy decision was taken after hypoxic cardiac arrest occurred.

CONCLUSION

Simulation with a manikin is useful to assess the adhesion rate to difficult intubation algorithms. Our study shows that the decision making process for cricothyrotomy is too often delayed as soon as ventilation became impossible and oxygenation compromized.

On the effect of tastant excluded fillers on sweetness and saltiness of a model food

In this study, the effect on taste due to the addition of air bubbles to a water-based gel was investigated. The gel phase contained either sucrose to give a sweet taste or sodium chloride to give a salty taste. For the sweet gels, taste intensities were evaluated for samples with different volume fractions of the air bubbles (up to 40%, v/v) and different concentrations of the sucrose. For the salty gels, samples were evaluated at 40% volume fraction of air bubbles. It was found that a reduction of the sodium chloride or sucrose by the same weight percentage as the volume fraction of the air bubbles in the samples gave equal taste perception as the nontastant-reduced samples. Moreover, saltiness and sweetness perception were clearly enhanced at 40% volume fractions of air bubbles if the sodium chloride or sucrose was not reduced. Thus, the overall tastes of the samples appeared to depend mainly on the concentration levels of the salt or the sucrose in the aqueous phase irrespective of the volume fraction of the air bubbles. However, the air bubbles were found to change the texture and appearance of the samples. It has been demonstrated that the inclusion of air bubbles offers scope for the reduction of sodium chloride or sucrose in food products.

Evaluation of a 7-year school-based community dental hygiene programme in Portugal by high school teachers

OBJECTIVES

To obtain high school teachers evaluation of a Community Dental Hygiene programme, developed as part of a clinical trial designed to assess the safety of low-level mercury exposure from amalgam restorations.

METHODS

A questionnaire to assess programme evaluation, personal opinion on programme relevance and satisfaction with activities was distributed among teachers. It had a total of 22 questions organized into three groups.

RESULTS

A total of 25 questionnaires were obtained from teachers who participated in the programme. Ninety-two per cent of the respondents had a positive opinion concerning the existence of the programme. Eighty-eight per cent of the teachers believed that the programme changed student's knowledge about dental hygiene. Ninety-two per cent of teachers supported the existence of the programme and 88% of them disagreed with a statement that participation in the programme was a waste of time. Teachers who did not collaborate actively with dental hygiene activities indicated belief that the programme affected school activities (P = 0.003). Teachers who actively participated in the programme believe that dental hygiene activities were important for students (P = 0.005).

CONCLUSIONS

Teacher evaluations of this kind of programme are critical for the development of school-based Dental Hygiene Education programmes. Teachers believe that Dental Hygiene Education is crucial for students' well-being.

Dépistage auditif néonatal systématique en région Champagne–Ardenne: à propos de 30500 naissances en deux années d'expérience

OBJECTIVES

To report a Universal Newborn Hearing Screening (UNHS) program developed in the Champagne-Ardennes region in 2004-2005.

METHODS

A team of ENT specialists and pediatricians set up a UNHS program designed to reduce the age of diagnosis and care of bilateral congenital deafness. The program was mainly based on automated acoustic otoacoustic emissions and a strict follow-up by the Regional Neonatal Screening Center.

RESULTS

In 2004 and 2005, 29,944 neonates from 30,518 births were screened (98.11%). Of the neonates screened, 409 (1.38%) failed the test and were referred. The average retest delay was 2 weeks. Eleven were lost to follow-up, 371 (94%) had a successful second test on one or both ears, 27 (7%) failed the test a second time and had a diagnosis of ABR. Twenty-four cases of bilateral deafness were identified early, 14 of which had no risk factors. One of the children lost to follow-up was actually deaf, which was diagnosed at 18 months of age. Since the beginning of the UNHS program, the average age of diagnosis was lowered to less than 3 months.

CONCLUSION

Our experience tends to demonstrate that UNHS is possible and the program allows an early diagnosis of bilateral congenital hearing loss.

Mise en place du masque Laryngé-Fastrach™ au sein d'un service médical d'urgence et de réanimation

OBJECTIVES

Assessment of the intubating Laryngeal Mask Airway(trade mark) in a prehospital emergency mobile unit (PEMU).

STUDY DESIGN

Observational study.

METHODS

All the emergency physicians and nurses of the PEMU were trained with the intubating laryngeal mask (ILMA) handling on manikin and a learning curve was carried out. One year after the initial formation, a reassessment of the operators was performed. Following the initial formation, all the vehicles of the PEMU were equipped with ILMA and during 15 months all cases of ILMA use were recorded. The success rate and the difficulties met were analysed.

RESULTS

Initial formation on manikin showed that at least 8 handling of the device were mandatory to achieve a 100% success rate. A significant reduction of tracheal tube insertion delay was observed up to the eight manipulations. One year after the initial formation, a significant loss of performance was observed. Over the clinical study period 20 ILMA were used with adequate ventilation through the mask in all cases and a possible intubation in 80% of the patients.

CONCLUSION

The ILMA is a potential useful device in the prehospital setting. Initial formation and maintenance of the skill acquired with this technique are essential.

Population pharmacokinetics of pyrimethamine and sulfadoxine in children with congenital toxoplasmosis

AIMS

To develop a population pharmacokinetic model for pyrimethamine (PYR) and sulfadoxine (SDX) in children with congenital toxoplasmosis.

METHODS

Children were treated with PYR (1.25 mg kg(-1)) and SDX (25 mg kg(-1)) (Fansidar) plus folinic acid (Lederfoline) 5 mg). Plasma concentrations, available from a therapeutic drug monitoring database, were determined by high-performance liquid chromatography. Population pharmacokinetic analysis was performed using a nonlinear mixed effects model.

RESULTS

Eighty-nine children, aged 1 week to 14 years and weighing 2.9-59 kg, were available for evaluation. Both PYR and SDX concentration-time profiles were best described by a one-compartment open model. Volume of plasma distribution (V) and clearance (CL) were significantly related to body weight (BW) using an allometric function. Typical CL and V estimates (95% confidence interval), for a child weighing 11 kg were 5.50 (5.28, 5.73) l day(-1) and 36 (33, 39) l for PYR and 0.26 (0.25, 0.27) l day(-1) and 2.1 (1.9, 2.3) l for SDX. For BW between 3.5 and 60 kg, plasma half-lives were predicted to vary from 4.0 to 5.2 days for PYR, and from 5.0 to 7.5 days for SDX.

CONCLUSION

This study indicated that body weight influences PYR and SDX pharmacokinetics in children. To optimize PYR/SDX combination treatment in congenital toxoplasmosis, short dosing intervals in very young low-wight children are probably appropriate.

Preconception seroconversion and maternal seronegativity at delivery do not rule out the risk of congenital toxoplasmosis

We describe two unusual cases of congenital toxoplasmosis, one occurring after preconception maternal infection with cervical adenopathies and the other occurring after maternal infection at the very end of pregnancy with maternal seronegativity at delivery. These documented cases of congenital toxoplasmosis demonstrate the value of extending the serologic monitoring period during pregnancy, according to the individual clinical context.

Effects of portal triad clamping on haemodynamic conditions during laparoscopic liver resection

To evaluate the haemodynamic effects of portal triad clamping (PTC) during laparoscopic liver resection, 10 patients without cardiac disease were studied by invasive monitoring including a pulmonary artery catheter and were compared with a control group of 10 patients undergoing liver resection by laparotomy. During laparoscopic surgery, intra-abdominal pressure was kept below 14 mm Hg and minute ventilation was adjusted to prevent hypercapnia. Measurements were made before PTC (T1), 5 min after PTC (T2) and 5 min after clamp release (T3). During clamping with pneumoperitoneum, mean arterial pressure (MAP) remained stable (+2%; not significant), systemic vascular resistance (SVR) increased by 37% (P<0.01, T2 vs T1) and cardiac index (CI) decreased by 19% (P<0.01, T2 vs T1). During laparotomy and clamping, MAP increased by 18% (P<0.01, T2 vs T1), SVR increased by 36% (P<0.01, T2 vs T1) and CI decreased by 9% (not significant). We were unable to demonstrate a difference in haemodynamic changes during clamping with pneumoperitoneum vs the open surgical technique, but in a small number of patients this lack of difference could have been a result of inadequate statistical power. The haemodynamic changes that we found were well tolerated in these patients, who had normal cardiac function.

[Posterior fossa hemorrhage in newborns following vaccum extractor delivery]

AIM

To emphasize the risk of posterior fossa hemorrhage in newborns following vacuum extraction.

PATIENTS AND METHODS

Over a period of 26 months (September 1996-December 1998), seven patients who underwent delivery with the vacuum extractor had symptoms of brain stem compression, related to posterior fossa hemorrhage. They were referred to the neonatal intensive care unit. Some parameters had been analyzed: gestational period, delivery circumstances, gestational age, parameters of newborn, indications of vacuum extraction and other paraclinical investigations (biological and radiological).

RESULTS

Ultrasound scan revealed intracranial hemorrhage in five cases of seven; mean time of diagnosis was 10 hours of age. All patients presented symptoms of brain stem compression. Mean period of follow-up was 22 months: six of seven patients had a normal neurodevelopment. One patient had a cerebellar ataxia, another one a palsy of the IIIrd cranial nerve.

CONCLUSION

Analyses of posterior fossa by ultrasound scan should be made for newborns delivered by vacuum extractor, especially if they had symptoms of brain stem compression.

Relationship between the standards of removable partial denture construction, clinical acceptability, and patient satisfaction

STATEMENT OF PROBLEM

Little is known about the importance of published fabrication standards in determining the outcome of treatment with mandibular distal extension removable partial dentures in patients of community practices.

PURPOSE

This study describes mandibular partial dentures worn by patients from King County, Wash., and examines the validity of standards of design and fabrication by relating the standards to measures of clinical acceptability and patient satisfaction.

MATERIAL AND METHODS

Eighty-two people treated in private dental practices who responded to a mail survey about satisfaction with a partial denture were examined. Eight standards of fabrication, overall clinical acceptability of the prosthesis, and tissue health were evaluated clinically. Patient satisfaction was assessed by questionnaire. Associations between variables were assessed by contingency tables and odds ratios.

RESULTS

Half the prostheses met 4 or fewer of the 8 standards, and these were responsible for nearly all the displacement of tissue by the framework. Forty-three percent of the dentures (35/82) were rated clinically acceptable. Of the remaining dentures, 38 could be made acceptable by modifications. The remaining 9 dentures needed replacement. Sixty-three percent of the patients examined were satisfied with the dentures. There was a relationship between tissue health and the fabrication standards related to rest form, base extension, stress distribution, and framework fit. This study found no relation between tissue health and other design or fabrication features. None of the standards were found to be related to patient satisfaction.

CONCLUSION

This study found partial support for the validity of design/fabrication standards for removable partial dentures. The most important standards are rest form, base extension, and stress distribution. The standards appear to be unrelated to patient satisfaction.

Laparoscopic splenectomy in patients with hematologic malignancies

BACKGROUND

Although laparoscopic splenectomy (LS) for benign hematologic disease is well accepted, its role in hematologic malignancies is not clearly defined. This study examined the efficacy and feasibility of LS for hematologic malignancies.

METHODS

Records were reviewed from patients who underwent LS at two university hospitals. Charts from 77 open splenectomies for malignancy (OM) during the same period were also reviewed.

RESULTS

Fifty-three patients underwent LS, 22 for hematologic malignancies (LM) and 31 for benign hematologic disorders (LB). Median splenic weight was greater in the LM group (930 g) than in the LB group (164 g, P = 0.001). LM was associated with longer operations and greater blood loss than was LB. LM had a 41% conversion rate. Morbidity, mortality, and transfusion rates were similar. Median hospital stay was shorter for LM (4 days) than for OM (6 days, P = 0.001).

CONCLUSIONS

LS is feasible in hematologic malignancies but is associated with increased operative time and blood loss and a high conversion rate. Morbidity and mortality, however, was similar. Shorter hospital stays for LM compared with OM may translate into earlier recovery and initiation of antineoplastic therapy.

Detection of specific immunoglobulin E during maternal, fetal, and congenital toxoplasmosis

Toxoplasma immunoglobulin E (IgE) antibodies in 664 serum samples were evaluated by using an immunocapture method with a suspension of tachyzoites prepared in the laboratory in order to evaluate its usefulness in the diagnosis of acute Toxoplasma gondii infection during pregnancy, congenital infection, and progressive toxoplasmosis. IgE antibodies were never detected in sera from seronegative women, from patients with chronic toxoplasma infection, or from infants without congenital toxoplasmosis. In contrast, they were detected in 86.6% of patients with toxoplasmic seroconversion, and compared with IgA and IgM, the short kinetics of IgE was useful to date the infection precisely. For the diagnosis of congenital toxoplasmosis, specific IgE detected was less frequently than IgM or IgA (25 versus 67.3%), but its detection during follow-up of children may be interesting, reflecting an immunological rebound. Finally, IgE was detected early and persisted longer in progressive toxoplasmosis with cervical adenopathies, so it was also a good marker of the evolution of toxoplasma infection.

Postoperative obstructive apnea

We studied electromyography (EMG) of the geniohyoid muscle (Gh) and diaphragm (Di) in 12 postoperative, premedicated (flunitrazepam 2 mg PO), asymptomatic patients who snored after recovering from general anesthesia, the induction of which was partly achieved by i.v. midazolam. After extubation of the trachea, integrated EMG activity of Gh (E-Gh(MTA)) and Di (E-Di(MTA)) were measured. For Gh, tonic and phasic activity were distinguished. Patients were studied during obstructive apnea, at the end of apnea, while breathing through an artificial Guedel airway, and during quiet breathing 5 min after flumazemil. All patients experienced episodes of postoperative upper airway obstruction and nine became apneic. Flumazenil restored consciousness and predominant tonic E-GhMTA associated with upper airway patency in all patients. Reduced tonic E-GhMTA characterized postoperative obstructive apnea. Resolution of apnea required a burst of both tonic and phasic E-GhMTA associated with intense E-Di(MTA). Breathing through the Guedal airway resulted in patent airway in 8 of 10 patients and was associated with low tonic and phasic E-GhMTA and reduced E-Di(MTA). In this study, we demonstrated that the tonic pharyngeal muscular support modulates airway patency in the postoperative period. Because it is reversed by flumazemil, benzodiazepines are certainly the main cause of airway obstruction in these patients.

IMPLICATIONS

Upper airway obstruction during recovery from general anesthesia induced by i.v. midazolam is associated with low tonic pharyngeal muscular support, which modulates upper airway patency in the postoperative period.

Pyrimethamine-sulfadoxine treatment of congenital toxoplasmosis: follow-up of 78 cases between 1980 and 1997. Reims Toxoplasmosis Group

The purpose of this study was to determine the clinical and immunological outcome of 78 children with congenital toxoplasmosis treated with the pyrimethamine-sulfadoxine combination between 1980 and 1997.

METHODS

Children were divided into 3 groups according to the initial duration of treatment (always including folinic acid, 5 mg/week by mouth), as follows: pyrimethamine (1.25 mg/kg every 15 d) + sulfadoxine (25 mg/kg every 15 d) for 12 months (Group 1, 47 children), or for 24 months, with or without prenatal therapy (respectively, Group 2, 19 children, and Group 3, 12 children).

RESULTS

Chorioretinitis occurred in 23% of these 78 children. Four children had unilateral blindness, 1 had mild epileptic fits and 1 had psychomotor retardation. The lowest rate of sequelae were in Groups 2 and 3. Immunological rebounds, generally without clinical repercussions, occurred frequently (90% of cases on average) during, or more often after therapy, regardless of the treatment duration. Treatment was always well tolerated.

CONCLUSIONS

Our current treatment strategy for congenital toxoplasmosis consists of a 24-month course of pyrimethamine-sulfadoxine (Fansidar) combined with folinic acid (Lederfoline). If the prenatal diagnosis is positive, we also prescribe this treatment to the mother until delivery. This combination offers satisfactory compliance, adequate serum concentrations, and good preventive efficacy.

Two missense point mutations in different alleles in the 3-hydroxy-3-methylglutaryl coenzyme A lyase gene produce 3-hydroxy-3-methylglutaric aciduria in a French patient

Two novel point mutations in the 3-hydroxy-3-methylglutaryl coenzyme A lyase gene were found in a French patient with double heterozygous 3-hydroxy-3-methylglutaric aciduria. Amplification by reverse transcriptase-polymerase chain reaction of the mRNA using five different pairs of oligonucleotides produced no differences in the fragments amplified with respect to the control. Single-strand conformation polymorphism analysis showed that only one amplified fragment was different in the patient vs. control. Sequencing of the amplified fragments showed two missense point mutations, A698G and T788C, each of them mixed with the wild-type sequence. These mutations produced the changes H233R and L263P, leading to changes in the enzyme activity, which was largely abolished. The father and one brother of the proband were heterozygous for the L263P mutation and the mother and one daughter were heterozygous for the H233R mutation, which confirms the double-heterozygous character of the patient. Another sibling was free of the mutations. An enzymatic restriction analysis has been proposed to screen the occurrence of these two mutations in future patients.

Prenatal diagnosis of congenital toxoplasmosis transmitted by an immunocompetent woman infected before conception. Reims Toxoplasmosis Group

We report a rare case of congenital toxoplasmosis transmitted by an immunocompetent woman infected before conception. Active toxoplasmosis was suspected due to persistent lymphadenitis with specific IgM, IgA, IgE antibodies. Prenatal diagnosis based on amniocentesis and fetal blood sampling at 24 weeks' amenorrhoea was positive on amniotic fluid, and fetal infection was confirmed after termination. In our opinion such cases need the same monitoring as when seroconversion occurs during the first trimester. A pregnancy-free interval of six to nine months is recommended after proven patent toxoplasmosis seroconversion.

[Delayed deliveries in multiple pregnancies: is this reasonable?]

Delivery of viable fetus with a long interval delay is an unusual occurrence. There is no clear attitude among obstetricians for such cases. We report a case of retention of the second and the third triplet after the delivery of the first one at 24 weeks of amenorrhea and 3 days. The duration of the retention was 6 days. Only the third infant survived. We attempt to outline the difficulties in managing such pregnancies.

Early childhood caries and risk factors in rural Puerto Rican children

A sample of 167 Puerto Rican children whose ages ranged from six months to forty-seven months (mean = 23 months) were studied. Children were examined for Early Childhood Caries with light and mirror and a structured interview was administered to parents and caretakers to identify risk factors. Results indicated that only 37.4 percent of the children were free of decalcification lesions or frank decay. While 53.9 percent of the children had lesions on maxillary incisors, 40.0 percent had molars affected by decalcification lesions and caries. Analysis of risk factors indicate that giving the baby a bottle when crying at night, number of adults and children in the family, use of fluoridated dentifrice, and age of the child were associated with the caries process in these children. Bottle and breast feeding, per se, were not risk factors. Disease patterns suggest other dietary risk factors, such as frequent snacking on food/drinks with sugar.

Approximate hierarchical modelling of discrete data in epidemiology

Hierarchical models are used in epidemiology to estimate and analyse multiple, related relative risks. Examples include meta-analyses of series of 2 x 2 tables and mapping of spatially correlated disease rates. Empirical transform and penalized quasilikelihood procedures, both of which may be implemented using standard programs for mixed model analysis, provide satisfactory approximate inferences for these problems when cell frequencies are large. Simulation studies show that, in certain situations involving small cell frequencies, penalized quasilikelihood provides satisfactory estimates of variance components and regression coefficients whereas the empirical transform approach does not.

Associations between initial, posttreatment, and postretention alignment of maxillary anterior teeth

Contradictory findings from studies on pretreatment malalignment as a risk factor for relapse of maxillary incisor alignment may be due to inappropriate sample selection and measurement technique. In an attempt to clarify the issue, 745 sets of study models made before (T1) and after (T2) orthodontic treatment and at long-term out of retention (T3) were screened. On the basis of the configuration of the maxillary anterior teeth on the T3 study models, three groups were established: one with significant spacing (group 1, n = 30); one with significant irregularity (group 2, n = 49); and one with perfect alignment (group 3, n = 28). The occlusal surfaces of the 321 maxillary study models at T1, T2, and T3 were photocopied and the tooth anatomic contact points digitized. An algorithm was used to fit the dental arch to the digitized points. Amount of incisor rotation and anatomic contact point displacement of the maxillary anterior teeth relative to the dental arch were computer generated. Interdental spaces in the maxillary anterior segment, as well as overjet and overbite, were measured manually. Nonstructural data were collected from the charts. Logistic regression analyses revealed that irregularity was associated with greater anatomic contact displacement and with greater incisor rotation both at T1 and T2 (P < 0.01). Similar analyses also revealed that spacing was associated with greater interdental spaces at T1 and T2 (P < 0.01). Correlation analyses revealed that the pattern of pretreatment rotational displacement has a strong tendency to repeat itself after retention (P < 0.001), as opposed to the pattern of contact point displacement and interdental spacing.

Prenatal diagnosis of congenital toxoplasmosis in 261 pregnancies

Two hundred and sixty-one pregnant women underwent prenatal screening by cordocentesis and/or amniocentesis between 1987 and 1994. The following tests were used: (i) detection of anti-Toxoplasma gondii IgM, IgA, and IgE antibodies by immunocapture and the comparative immunological profile method based on enzyme-linked immunofiltration assay of fetal blood and (ii) direct detection of the parasite in cell culture and by mouse inoculation with fetal blood (FB) and/or amniotic fluid (AF). Of the 31 cases of congenital toxoplasmosis, 24 (77 per cent) were detected prenatally. Overall, the FB and AF inoculation methods were the most effective (50 per cent sensitivity with FB inoculation to mice and/or cell culture and 74 per cent with AF). However, antibody detection in FB was the only positive test in three cases. Of 18 surviving children diagnosed prenatally, only one developed chorioretinitis (9 months of age). Seven newborns (23 per cent) with negative prenatal tests were diagnosed by postnatal laboratory monitoring, but none of these children developed clinical toxoplasmosis. There may have been more false negatives, as only 48 per cent of unaffected children were followed up for at least 12 months. All the tests had a specificity of 100 per cent. Fetal blood sampling has considerable value but also carries some risks and is currently being abandoned in favour of amniocentesis alone with gene amplification and mouse inoculation.

Pharmacokinetics of oral triazolam in children

The purpose of this study was to determine the pharmacokinetic behavior of triazolam in children. Nine healthy children, aged 6 to 9 years, received oral triazolam (0.025 mg/kg suspended in Kool-Aid, Kraft General Foods, Chicago, IL) before dental treatment. Plasma triazolam concentrations were measured by gas chromatography/mass spectrophotometry at approximately 5, 15, 30, 45, 60, 90, 120, 180, and 240 minutes. A one-compartment model with first-order absorption and varying parameters was used, and estimated concentration curves were obtained for each subject. The observed peak plasma concentration was 8.5 +/- 3.0 ng/mL (mean +/- SD). The observed time to peak plasma concentration was 74 +/- 25 minutes. Elimination half-life was 213 +/- 144 minutes. Substantial recovery from signs and symptoms of clinical sedation required 180 to 240 minutes. The long duration of effect and relatively slow elimination should be noted by clinicians concerned with patient safety.

Pain control in recovering alcoholics: effects of local anesthesia

OBJECTIVE

The medical literature suggests that alcoholics may present greater challenges to achieving clinical pain control than nonalcoholics. This study was undertaken to test the hypotheses that: (1) significant differences exist between alcoholics and nonalcoholics on detection and pain thresholds during electric tooth stimulation; (2) group differences exist in the depth and time course of pulpal anesthesia; and (3) responses to tooth stimulation are associated with severity of alcoholism and/or other psychological factors.

METHOD

Male alcoholics (n = 22) in aftercare treatment (mean length of sobriety = 113 days) and age-matched nonalcoholics (n = 22) received 1.0 ml of 3% mepivicaine at the apex of a maxillary lateral incisor and saline placebo at the apex of the contralateral incisor.

RESULTS

At baseline no group differences were found on sensory thresholds. During drug intervention significant drug and time effects for both detection threshold (p < .0001) and pain threshold (p < .0001) were found, but group differences and interactive effects were not significant. By exploratory regression analysis of alcoholic subjects, history of depression/unhappiness was significantly associated with shallower pulpal anesthesia, whereas high need for control/low actual control and frequency of treatment for detoxification were associated with deeper anesthesia.

CONCLUSIONS

Our findings suggest alcoholics in recovery are not at increased risk for inadequate pain control with local anesthesia.

[Screening for congenital toxoplasmosis: pregnancy outcome after prenatal diagnosis in 211 cases]

OBJECTIVE

To emphasize the importance of follow-up after birth of infants with an antenatal diagnosis of congenital toxoplasmosis.

METHODS

Retrospective study from July 1987 through January 31 1995 on 211 women (214 fetuses) who had undergone ovular biopsy for toxoplasmosis seroconversion during pregnancy.

RESULTS

Antenatal diagnosis was positive in 13 patients (6.2%). Four pregnancies were terminated during the second trimester. Delivery was triggered at 37 weeks gestation in one woman and in 8 others pregnancy was continued with Fansidar. All infants were born live with infraclinic disease. Two fetal deaths related to biopsy technique occurred (0.95%) and one pregnancy was terminated before the results had been obtained. Only 21.3% of the patients were delivered in our unit. A total of 197 infants were delivered with a negative antenatal diagnosis: 93 were healthy, 5 had congenital toxoplasmosis, 1 died at 3 months and 98 had no or incomplete follow-up.

CONCLUSION

Incomplete post-natal follow-up is in contradiction with the excellent performance of antenatal diagnosis of congenital toxoplasmosis. Greater care is needed, especially since now only an amniocentisis is required to detect the parasite genome with polymerase chain reaction.

Early neonatal diagnosis of congenital toxoplasmosis: value of comparative enzyme-linked immunofiltration assay immunological profiles and anti-Toxoplasma gondii immunoglobulin M (IgM) or IgA immunocapture and implications for postnatal therapeutic strategies

Diagnostic strategies for congenital toxoplasmosis have changed profoundly in recent years. Immunological diagnostic methods, long considered disappointing, can now be used at a very early stage. Over a 3-year period, 1,050 infants at risk of congenital toxoplasmosis (born to 1,048 mothers infected during pregnancy) were monitored for a minimum of 12 months and a maximum of 7 years. More than 6,000 serum specimens were analyzed by comparative mother-infant immunological profiles (CIPs) based on an enzyme-linked immunofiltration assay (ELIFA) and an immunocapture method for the detection of specific immunoglobulin M (IgM) and IgA. IgG antibodies were also titrated. One hundred three cases of congenital toxoplasmosis were demonstrated. The CIP-ELIFA method had a better diagnostic yield (sensitivity, 90%) than specific IgM and/or IgA detection by immunocapture assay (sensitivity, 77%). By using a combination of these tests, congenital infection was diagnosed in the first month and the first 3 months of life in 90 and 94% of infants with toxoplasmosis, respectively, with a specificity of 99.8% and a positive predictive value of 99% at 8 months of age. This dual diagnostic approach (ELIFA and IgM-IgA immunocapture) is highly efficient and has important implications for therapy. Indeed, early postnatal diagnosis based on objective evidence enables therapy with pyrimethamine-sulfadoxine to be started immediately for 24 months, while spiramycin (which used to be given preventively for 9 to 12 months to all infants at risk) can be stopped after the first 3 months of life.

A prospective study of the feeding and brushing practices of WIC mothers: six- and twelve-month data and ethnicity and familial variables

This study, part of a project that provided a baby cup to WIC children in Washington State, reports the feeding and brushing behaviors at six and twelve months and the influence of cultural and familial variables. Results show there are large differences in feeding and brushing practices among ethnic groups, i.e., Asian mothers reported the greatest reliance on the bottle at twelve months. Marital status was related to feeding practices, i.e., single women were more likely to put the baby to bed with a bottle at six and twelve months and were more likely to use a cup at twelve months. The presence of additional children at home was related to infrequent brushing and lower rates of cup use at twelve months. Awareness of ethnic and familial variables such as marital status and number of children may be useful in formulating specific recommendations when counseling mothers and other caretakers.

[Tuberculosis and pregnancy]

The authors report a case of pulmonary tuberculosis during pregnancy. They point out that the pregnancy does not change the natural course of the disease, congenital tuberculosis is rare but with a high rate of mortality, and the three most important antituberculosis (isoniazid, ethambutol and rifampicin) are safety during pregnancy.

Results of a promising open trial to prevent baby bottle tooth decay: a fluoride varnish study

One hundred thirty-three farm worker children with an average age of 17 months participated in a study of a fluoride varnish in WIC programs in the Yakima Valley of Central Washington. After parents were interviewed, the child was examined and a fluoride varnish applied to the maxillary incisors. At the six-month recall 62 children and their parents returned. Results indicated a significant decrease in decalcification from 35 percent to 21 percent and an increase in decay from 3 percent to 16 percent. The rate of decay was lower than the 30 percent found in this age-group in this population. Of 130 sound teeth at baseline, 13 percent were decayed or decalcified in six months; of 73 decalcified teeth at baseline, 51 percent were found to be sound in six months. Additional experimentation with fluoride varnish is warranted.

White spots caries in Mexican-American toddlers and parental preference for various strategies

One hundred and thirty Mexican-American children ages nine to thirty-four months (Mean = 17.1 months), and their parents/caretakers were studied at a farmworkers clinic in rural Washington. Parents/caretakers participated in a bilingual interview; then each child received a dental examination, and a cotton swab was used to collect plaque for a caries activity test (Cariostat). Results showed that 7 percent had at least one maxillary incisor decayed and 30.4 percent had at least one incisor with a white spot lesion. The Cariostat was related to dental age, but not to disease. Forty percent of the parents/caretakers whose children had disease were aware of the problem. Immediate substitution of cup for bottle and the elimination of extra nighttime feedings were the least likely interventions endorsed by the subjects. Other interventions, including periodic visits for fluoride applications were much more likely.

Pain management in school-aged children by private and public clinic practice dentists

A mail survey of 198 Seattle dentists who treat children assessed their beliefs about pain control in school-aged children and examined the relationship of those beliefs to pain management behaviors. The survey population of general dentists and pediatric dentists in clinics and private practice had a response rate of 89.6%. Two of three dentists always use local anesthetic when doing restorations or extractions and also provide more anesthetic at the child's request. One in three dentists never provides postoperative medication following tooth extractions. Ten percent regularly deny child pain and many do not believe child pain reports are valid. Dentists who work in private practice are more likely to provide local anesthetic than are dentists who work in clinics. Dentists who desire more control over a child are less likely to provide local anesthetic. Dentists who question children about comfort are more likely to provide additional anesthetic based on a child's report of discomfort and to provide postoperative medication if the dentist perceives a dental procedure to be painful.