A Prospective, Randomized Controlled Pilot Trial to Compare Vestibular Incision Subperiosteal Access and Sulcular Tunnel Access Root Coverage Procedures to Treat Gingival Recession.

The aim of this randomized prospective study was to compare clinical and patient-centered outcomes of Miller Class I and II gingival recession defects treated with acellular dermal matrix (ADM) grafts and either vestibular incision subperiosteal tunneling access (VISTA) or sulcular tunnel access (STA) techniques. A total of 29 gingival recession defects in nine patients were assessed to determine clinical outcomes, including probing depth (PD), gingival recession (GR), width of keratinized tissue (KT), width of attached tissue (AT), tissue thickness at the gingival margin (TT1), and tissue thickness 4 mm apical to the gingival margin (TT2). Visual analog scale (VAS) assessment of patient-perceived pain, bleeding, swelling, and changes in activity were assessed postoperatively at 7 and 30 days, and professional assessment of postoperative esthetics using the Pink Esthetic Score (PES) was performed at 6 months. All sites demonstrated significant improvements in midfacial GR. No statistically significant differences were noted between the VISTA and STA groups for clinical or patient-centered outcomes, except for preferable midfacial AT in the VISTA sites at 6 months. These findings indicate that both surgical techniques can be used with ADM grafts to achieve improvements in root coverage, alterations in periodontal phenotype, and improved esthetics with high levels of patient satisfaction.

A cost analysis of single-stage bilateral versus two-stage direct anterior total hip arthroplasty.

PURPOSE: The potential cost savings of single-stage bilateral total hip arthroplasty (THA) are unclear, and the risks associated with it are not well defined. We sought to compare the costs and perioperative complications of single-stage bilateral THA via the direct anterior approach (DAA) to a two-stage bilateral protocol. METHODS: We retrospectively reviewed patients who underwent a single- stage bilateral DAA THA and compared them to a two-stage THA group. We conducted a cost analysis from both the hospital perspective and the Ministry of Health (MOH) perspective. RESULTS: 24 patients were included in this study. The 2 groups were similar in age (58.9 vs 63.9 yrs), height (169.2 vs 170.9 cm), weight (80.2 vs 78.6 kg), BMI (27.9 vs 26.3 kg/m2), ASA score (2.2 vs 2.2), and CCI score (2.3 vs 2.9). The mean cost per patient from the hospital perspective for the single-stage group was $10,728.13 (SD = 621.46) compared to $12,670.63 (SD = 519.72) for the two-stage group (Mean Difference = $1,942.50, 95% CI = $1,457.49 to $2,427.51, p<0.001). Similarly, from the MOH perspective, the cost for the single-stage group was $12,552.34 (SD = 644.93) compared to $14,740.58 (SD = 598.07) for the two-stage group (Mean Difference = $2,188.24, 95% CI = $1,661.67 to $2,714.81, p<0.001). There were no significant differences in complication rate between groups. The largest percent of total cost savings from a hospital perspective was attributed to cost of operating room staff and OR set-up (55%). CONCLUSIONS: Our results suggest that single-stage bilateral DAA THA results in significant cost savings compared to two-stage DAA THA.

Maternal sensitivity and infant autonomic and endocrine stress responses.

BACKGROUND: Early environmental exposures may help shape the development of the autonomic nervous system (ANS) and hypothalamic-pituitary-adrenal (HPA) axis, influencing vulnerability for health problems across the lifespan. Little is known about the role of maternal sensitivity in influencing the development of the ANS in early life. AIMS: To examine associations among maternal sensitivity and infant behavioral distress and ANS and HPA axis reactivity to the Repeated Still-Face Paradigm (SFP-R), a dyadic stress task. STUDY DESIGN: Observational repeated measures study. SUBJECTS: Thirty-five urban, sociodemographically diverse mothers and their 6-month-old infants. OUTCOME MEASURES: Changes in infant affective distress, heart rate, respiratory sinus arrhythmia (RSA), and T-wave amplitude (TWA) across episodes of the SFP-R were assessed. A measure of cortisol output (area under the curve) in the hour following cessation of the SFP-R was also obtained. RESULTS: Greater maternal insensitivity was associated with greater infant sympathetic activation (TWA) during periods of stress and tended to be associated with greater cortisol output following the SFP-R. There was also evidence for greater affective distress and less parasympathetic activation (RSA) during the SFP-R among infants of predominantly insensitive mothers. CONCLUSIONS: Caregiving quality in early life may influence the responsiveness of the sympathetic and parasympathetic branches of the ANS as well as the HPA axis. Consideration of the ANS and HPA axis systems together provides a fuller representation of adaptive versus maladaptive stress responses. The findings highlight the importance of supporting high quality caregiving in the early years of life, which is likely to promote later health.

Examining aggression in male Vietnam veterans who receive VA services: the role of traumatic events and combat exposure.

We examined the relationship between trauma exposure and the perpetration of aggression by male Vietnam veterans (N = 1,328) using archival data from a multisite study conducted by the Cooperative Studies Program of the Department of Veteran Affairs (CSP-334) in the early 1990s. Both traumatic events in civilian life and combat exposure were examined as correlates of aggression. Results indicated that pre- and postmilitary traumatic events and combat exposure were all related to perpetration of aggression at the bivariate level; r = .07, r = .20, and r = .13, respectively. When these variables were examined simultaneously, only combat exposure (ß = .14, p < .001) and postmilitary traumatic events (ß = .20, p < .001) were associated with aggression. No interaction effects were found for civilian traumatic events and combat in relation to aggression. Results highlight the importance of attending to the psychological aftermath of exposure to traumatic events experienced during and following deployment before aggressive patterns develop.

Bringing home the patient centered medical home: lessons learned from an academic family medical center.

Putting patients at the center of health care is the basic premise of the Patient Centered Medical Home (PCMH). Our clinic, the Family Medical Center (FMC) is located at the University of Arkansas for Medical Sciences campus and has over 23,000 annual patient visits. In 2008, we decided to apply for the National Committee for Quality Assurance' (NCQA) PCMH recognition and had made several process changes at our clinic to meet the requirements. In 2010, FMC was the first clinic in Arkansas to be recognized by NCQA as a Level 3 PCMH. In this article, we share the actions taken and lessons learned in bringing home the PCMH to our practice.

Race/ethnicity as a predictor of change in working alliance during cognitive behavioral therapy for intimate partner violence perpetrators.

Despite evidence that the working alliance (WA) is an important factor in psychotherapy outcome and that race/ethnicity plays an important role in the processes of therapy, few studies have directly examined associations between WA and race/ethnicity. These relationships may be particularly salient for difficult-to-engage populations, such as men participating in treatment for intimate partner violence. The current study examined WA ratings in a sample of 107 male intimate partner violence perpetrators attending a 16-week cognitive-behavioral group program. Approximately 50% of these participants were Caucasian and 50% were members of a racial/ethnic minority group (African American, Asian American, Hispanic, and American Indian). Growth curve modeling was used to assess changes in both therapist and client WA ratings across four time points during therapy. Findings indicated that there was no mean level of change in therapist WA ratings over time. However, clients' WA ratings demonstrated a reliable, steady increase across sessions. A significant interaction between WA and race/ethnicity emerged such that Caucasian participants reported a significant increase in WA over time, whereas members of racial/ethnic minority group did not report a consistent pattern of change. The interaction between client race/ethnicity and WA was also a significant predictor of treatment outcome at 6-month follow-up.

Gene expression profiling in the fetal cardiac tissue after folate and low-dose trichloroethylene exposure.

BACKGROUND: Previous studies show gene expression alterations in rat embryo hearts and cell lines that correspond to the cardio-teratogenic effects of trichloroethylene (TCE) in animal models. One potential mechanism of TCE teratogenicity may be through altered regulation of calcium homeostatic genes with a corresponding inhibition of cardiac function. It has been suggested that TCE may interfere with the folic acid/methylation pathway in liver and kidney and alter gene regulation by epigenetic mechanisms. According to this hypothesis, folate supplementation in the maternal diet should counteract TCE effects on gene expression in the embryonic heart. APPROACH: To identify transcriptional targets altered in the embryonic heart after exposure to TCE, and possible protective effects of folate, we used DNA microarray technology to profile gene expression in embryonic mouse hearts with maternal TCE exposure and dietary changes in maternal folate. RESULTS: Exposure to low doses of TCE (10 ppb) caused extensive alterations in transcripts encoding proteins involved in transport, ion channel, transcription, differentiation, cytoskeleton, cell cycle, and apoptosis. Exogenous folate did not offset the effects of TCE exposure on normal gene expression, and both high and low levels of folate produced additional significant changes in gene expression. CONCLUSIONS: A mechanism by which TCE induces a folate deficiency does not explain altered gene expression patterns in the embryonic mouse heart. The data further suggest that use of folate supplementation, in the presence of this toxin, may be detrimental and not protective of the developing embryo.

Office-based management of diabetes: two-year trial of primary care quality improvement.

BACKGROUND AND OBJECTIVES: The goals of this study were to learn different approaches to improve the quality of care for the diabetic patients of the family practice setting FMC. METHODS: Participants of the study were 34 adult diabetic patients (Type 1 or 2) seen in the University of Arkansas of Medical Sciences' Family Medical Center by either family practice residents or faculty. Each CQI innovation was introduced in a stepwise fashion. The study team used a biopsychosocial, economic and environmental model of care to impact each dimension of ambulatory care. Not all cycles included all patients in the study, but patients and physicians received multiple interventions designed to improve hypertension control. RESULTS: The project intended to assess the feasibility of introducing a "package" of approaches to improve the outpatient management of diabetes rather than assess whether a specific innovation was efficacious. Improvement in blood pressure control, increased referral for eye exams, improved prescribing and/or use of aspirin and improved patient satisfaction with care were noted. CONCLUSION: The study demonstrated that the biopsychosocial and economic dimensions of the patients' diabetes must be addressed to achieve optimal care and that many approaches to improving outcomes can feasibly be introduced in a family practice setting.