A multi-site 99mTc-HMPAO SPECT study of cerebral blood flow in a community sample of patients with major depression.

Prior regional Cerebral Blood Flow (rCBF) studies in Major Depressive Disorder (MDD) have been limited by small, highly selective, non-representative samples that have yielded variable and poorly replicated findings. The aim of this study was to compare rCBF measures in a large, more representative community sample of adults with MDD and healthy control participants. This is a cross-sectional, retrospective multi-site cohort study in which clinical data from 338 patients 18-65 years of age with a primary diagnosis of MDD were retrieved from a central database for 8 privately owned, private-pay outpatient psychiatric centers across the United States. Two 99mTc-HMPAO SPECT brain scans, one at rest and one during performance of a continuous performance task, were acquired as a routine component of their initial clinical evaluation. In total, 103 healthy controls, 18-65 years old and recruited from the community were also assessed and scanned. Depressed patients had significantly higher rCBF in frontal, anterior cingulate, and association cortices, and in basal ganglia, thalamus, and cerebellum, after accounting for significantly higher overall CBF. Depression severity associated positively with rCBF in the basal ganglia, hippocampus, cerebellum, and posterior white matter. Elevated rCBF was especially prominent in women and older patients. Elevated rCBF likely represents pathogenic hypermetabolism in MDD, with its magnitude in direct proportion to depression severity. It is brain-wide, with disproportionate increases in cortical and subcortical attentional networks. Hypermetabolism may be a reasonable target for novel therapeutics in MDD.

Diagnosis, Treatment Planning, and Full-mouth Rehabilitation in a Case of Amelogenesis Imperfecta.

Amelogenesis imperfecta is a genetic condition affecting the teeth resulting in aberrations of the structure and clinical appearance of enamel. The treatment of amelogenesis imperfecta involves a multidisciplinary treatment approach requiring a comprehensive examination, diagnosis, and effective treatment planning strategy along with satisfaction of patient-related factors. The clinical case described here involves judicious involvement of different disciplines to formulate a treatment plan best suitable to confirm with the patient's needs and expectations, at the same time maintaining the integrity and harmony of associated hard and soft tissues.

Impact of all oral anti-hepatitis C virus therapy: A meta-analysis.

AIM: To investigate the efficacy, safety, and cost of treatment of direct acting antivirals (DAAs) with and without peg interferon alfa2a (P), and/or ribavirin (R) in treating hepatitis C virus (HCV) genotype 1 patients. METHODS: MEDLINE was searched for randomized controlled trials (RCT) using DAAs for HCV treatment. Phase 1 trials and studies with investigational drugs on genotype 2 or 3, and on human immunodeficiency virus patients were excluded. Data were pooled for sustained virologic response (SVR), serious adverse effects, and drug discontinuation rate on various treatment arms in trials: P + R; 1(st) generation DAA (telaprevir or boceprevir) + P + R; 2(nd) generation DAA (sofosbuvir or simeprevir) + P + R; 2(nd) generation DAA + R; two 2(nd) generation DAA + R; and two 2(nd) gen DAA. Data were analyzed separately for each arm for treatment naive and non-responders (NR) to previous treatment. The cost of treatment with each regimen for achieving one SVR was also compared. RESULTS: Twenty three RCTs (n = 9354, 62% male, 11% cirrhosis) were analyzed. All oral (P free) regimens with combination of 2 DAA achieved SVR above 95%. The cost of treatment to achieve an SVR with DAA based regimens was lower for NR compared to P+R regimen. However, the cost per SVR remained higher for treatment naive patients. CONCLUSION: Second generation and emerging DAAs are promising agents in HCV treatment, with a very high level of safety and efficacy. An important drawback is their high cost. However, the present meta-analysis shows that the cost per SVR for non responders (but not for naive patients) was lower compared to P + R. This finding together with the superior safety profile and better compliance makes these drugs highly attractive. It is possible that further reduction in treatment duration may make them even more cost effective.

Clinical Awareness of Do's and Don'ts of Cardiopulmonary Resuscitation (CPR) Among University Medical Students-A Questionnaire Study.

BACKGROUND: Medical students today are tomorrow's future doctors. One of the key skills that students should develop during their graduation training is to be prepared for emergency life saving measures like cardiopulmonary resuscitation (CPR) anytime, anywhere. The students play integral role in learning, mastering and inculcating the most pragmatic clinical skill of CPR. OBJECTIVES: a) To evaluate the CPR awareness among undergraduate medical students. b) To screen the knowledge regarding accurate, effective CPR procedural techniques and various barriers of CPR failure in clinical practice from student perspective. c) To ascertain interest in CPR training programs and also inculcating CPR as an active part of clinical practice in future. MATERIALS AND METHODS: The questionnaire comprised of three parts, first one dealing with general questions to know the importance of CPR in clinical practice, second one comprised of the main goal and accuracy of CPR intervention and the last segment consisted of questions targeting the indications, methods and effectiveness of CPR. STATISTICAL ANALYSIS: Descriptive statistics and multiple response analyses were done by using SPSS 17. RESULTS: The students had good knowledge about the importance of CPR in clinical practice and stand average in knowing its indications and effectiveness. Whereas, only 1.2% of them were completely aware about the universal compression ventilation ratio, and 20.4% were aware of the current order of CPR being compression, airway and breathing. CONCLUSION: Though, CPR awareness is good among the students but skills of CPR have to be mastered by proper certified training programs at regular intervals and knowledge has to be updated with the changing trends in CPR.

Tooth Supported Overdenture Retained with Custom Attachments: A Case Report.

Overdenture is a favored treatment modality for elderly patients with few remaining teeth. Roots maintained under the denture base preserve the alveolar ridge, provide sensory feedback and improve the stability of the dentures. Furthermore, the use of copings and precision attachments on the remaining teeth enhances the retention of the denture. This clinical report describes a novel method of fabricating a tooth supported overdenture retained with custom made ball attachments using orthodontic separators as a female component. Customized ball attachments with orthodontic separators are a simple and cost effective alternative treatment to the use of prefabricated attachments for enhancing the retention of tooth supported overdentures.

Anxiety during respirator use: comparison of two respirator types.

Anxiety may interfere with proper respirator use. This study directly compares the effect of two types of respirators--elastomeric half-face mask with dual-cartridges (HFM) and N95 filtering facepiece--on anxiety levels. Twelve volunteers with normal or mildly impaired respiratory conditions performed a series of simulated work tasks using the HFM and N95 on different days. The State-Trait Anxiety Inventory (STAI) measured state anxiety (SA) before and during respirator use. STAI also measured trait anxiety (TA), a stable personal characteristic. The effect of the respirator was measured as the difference between SA pre-use and during use. Work with HFM was associated with an increase in SA (2.92 units, p < .01), whereas work with the N95 had no observed effect. Anxiety should be considered in the selection of the best respirator for a user. Impact on anxiety should be considered for respirator design and certification purposes, particularly if the device is to be widely used in workplace and community settings.

Respirator impact on work task performance.

OBJECTIVE: Respirators are used to maintain work performance and protect against inhaled toxins. The study compared the effects of two commonly used respirator classes--dual cartridge half face mask (HFM) and filtering face piece (N95)--upon work productivity. METHODS: 107 volunteers performed eight simulated work tasks when using the HFM and N95 respirators. Tasks included several body positions, exertion levels, and concentration requirements. Objective measures of accuracy and speed were developed for each task. Scores for each task were based on the subject's rank among all subjects. RESULTS: All subjects were capable of performing the tasks. There were no statistically significant differences between respirator types in either task performance metric. CONCLUSIONS: Productivity impact can be measured effectively and should be considered as part of respirator design testing and when selecting the optimal respirator for a worker.

Subjective response to respirator type: effect of disease status and gender.

OBJECTIVE: To assess the effect of respirator type and user characteristics (eg, health status) on the subjective response to respirator use. METHODS: The subjective responses for multiple domains were evaluated in 104 volunteers performing work tasks in a simulated work environment. Each used a dual cartridge half face mask and a filtering facepiece (N95) respirator. The study population was recruited to include four groups (normal respiratory status, mild asthma, chronic obstructive pulmonary disease, or chronic rhinitis). Mixed model regression analyses determined the effects of respirator type, disease, gender, and age. RESULTS: Half face mask produced more adverse subjective response than the N95 for most scales. There were significant interactions such that disease status modified the effect of respirator type. In general, women reported greater adverse ratings than did men. CONCLUSIONS: The effect of respirator type depends on disease status. Respirator design evaluation panels should include persons with mild respiratory disease.

Respirator physiologic impact in persons with mild respiratory disease.

OBJECTIVE: To assess whether mild respiratory disease affects physiologic adaptation to respirator use. METHODS: The study compared the respiratory effects of dual cartridge half face mask and filtering facepeice (N95) respirators while performing simulated-work tasks. Subjects with mild chronic obstructive pulmonary disease (n = 14), asthma (n = 42), chronic rhinitis (n = 17), and normal respiratory status (n = 24) were studied. Mixed model regression analyses determined the effects of respirator type, disease status, and the respirator-disease interactions. RESULTS: Respirator type significantly affected several physiologic measures. Respirator type effects differed among disease categories as shown by statistically significant interaction terms. Respiratory timing parameters were more affected than ventilatory volumes. In general, persons with asthma showed greater respirator-disease interactions than chronic obstructive pulmonary disease, rhinitis, or healthy subjects. CONCLUSIONS: The effects of respirator type differ according to the category of respiratory disease.

Progression from beryllium exposure to chronic beryllium disease: an analytic model.

BACKGROUND: Understanding the progression from beryllium exposure (BeE) to chronic beryllium disease (CBD) is essential for optimizing screening and early intervention to prevent CBD. METHODS: We developed an analytic markov model of progression to cbd that assigns annual probabilities for progression through three states: from BeE to beryllium sensitization and then to CBD. We used calculations of the number in each state over time to assess which of several alternative progression models are most consistent with the limited available empirical data on prevalence and incidence. We estimated cost-effectiveness of screening considering both incremental (cost/case) and cumulative program costs. RESULTS: No combination of parameters for a simple model in which risk of progression remains constant over time can meet the empirical constraints of relatively frequent early cases and continuing development of new cases with long latencies. Modeling shows that the risk of progression is initially high and then declines over time. Also, it is likely that there are at least two populations that differ significantly in risk. The cost-effectiveness of repetitive screening declines over time, although new cases will still be found with long latencies. However, screening will be particularly cost-effective when applied to persons with long latencies who have not been previously screened. CONCLUSIONS: To optimize use of resources, the intensity of screening should decrease over time. Estimation of lifetime cumulative CBD risk should consider the declining risk of progression over time.

How frequently should workplace spirometry screening be performed?: optimization via analytic models.

BACKGROUND: Our objective was to determine how to select the optimal frequency of workplace spirometry screening using diacetyl-exposed workers as an example. METHODS: A Markov model was constructed to assess the likelihood of progressing from healthy status to early or advanced disease, starting from four different exposure levels, and performing longitudinal or cross-sectional interpretation of spirometry results over time. Projected outcomes at 10 years were evaluated to inform the optimal frequency of workplace spirometry testing. RESULTS: The optimal screening interval depends on the population risk and is highly sensitive to the real-life impact (utility) associated with false-positive results (eg, related to the availability of alternative work). Screening interval is particularly important for high-risk individuals with rapid transition from early to advanced disease, where the 10-year prevalence of advanced disease would be reduced from 5.3 to 2.5% using a 6-month interval rather than a 12-month interval. Longitudinal test interpretation, based on observing trends within each person over time, is marginally preferable to traditional cross-sectional spirometry interpretation. CONCLUSIONS: There is no single best screening interval. For high-risk populations, annual testing may be too infrequent.

Multidomain subjective response to respirator use during simulated work.

OBJECTIVE: : Evaluate subjective tolerance to respirator use outside of traditional industrial settings by users including persons with mild respiratory impairment. METHODS: : The response to respirator use (half face mask dual cartridge and N95) was measured during eight types of work activities as well as in an exercise laboratory setting. The 43 research subjects included persons with mild respiratory impairments. Multiple domains of subjective response were evaluated. RESULTS: : Mixed model regression analyses assessing the effect of respirator type and task type showed: 1) most tolerated respirator use well; 2) half face mask respirators typically had greater adverse impact than N95 types; 3) multiple subjective outcomes, rather than only comfort/breathing impact, should be measured; and 4) rated subjective impact during work activities is less than in exercise laboratory settings. CONCLUSIONS: : The results suggest that respirator use may be feasible on a widespread basis if necessary in the face of epidemic or terror concerns.

Respirator physiological effects under simulated work conditions.

This study compared the physiological impacts of two respirator types in simulated work conditions. Fifty-six subjects included normal volunteers and persons with mild respiratory impairments (chronic rhinitis, mild COPD, and mild asthma). Respiratory parameters and electrocardiogram were measured using respiratory inductive plethysmography while performing eight work tasks involving low to moderate exertion using two respirators: (1) a dual cartridge half face mask (HFM) respirator, and (2) the N95. Mixed model regression analyses evaluating the effect of task and respirator type showed that task affected tidal volume, minute ventilation, breathing frequency and heart rate; all were greater in heavier tasks. Although respirator type did not affect respiratory volume parameters and flow rates, the HFM led to increase in the inspiratory time, reduction of the expiratory time, and increase in the duty cycle in comparison with the N95. The magnitude of differences was relatively small. The results suggest that most individuals, including persons with mild respiratory impairments, will physiologically tolerate either type of respirator at low to moderate exertion tasks. However, because effective protection depends on proper use, differences in subjective effect may have greater impact than physiological differences. Using respirators may be feasible on a widespread basis if necessary for maintaining essential services in the face of widespread concern about an infectious or terrorist threat.

Prediction of mortality and morbidity by simplified acute physiology score II in obstetric intensive care unit admissions.

BACKGROUND: Critical care in obstetrics has received much attention in recent times. Despite progress in medical field and improvement in health facilities provided, maternal mortality is still very high in most of the developing countries. AIM: To study and analyze records of patients requiring intensive care in obstetrics and to assess utility of simplified acute physiology score (SAPS II) for predicting maternal mortality. SETTING: A multidisciplinary intensive care unit (ICU) at a tertiary care center. DESIGN: Retrospective review. MATERIALS AND METHODS: Fifty-seven consecutive obstetric patients' records requiring ICU admissions were studied for clinical picture, diagnosis, complications, morbidity and mortality over a period of 21/2 years - from 1st May 2002 to 31st Oct. 2004. SAPS II score was calculated according to the different variables for predicting mortality. STATISTICAL ANALYSIS: SAPS II scores were regressed on mortality status using logistic regression analysis. The predictability was assessed by goodness-of-fit test and receiver operated characteristic curve. RESULTS: Maternal mortality in obstetric ICU admissions was 1.15/1,000 deliveries, amounting to 40.35% of obstetric ICU admissions. The mean SAP II score was significantly higher (40.04 +/- 12.97 vs. 22.6 +/- 7.31) in those patients who died compared to survivors (P < 0.001%). CONCLUSIONS: The SAPS II accurately predicted mortality in obstetric patients admitted to ICU. Computation of the score as a routine in ICU may help in identifying those at high risk of mortality and then to reduce this risk.