Effect of Operator Experience on Ability to Place Sequential, 2-mm-thick Increments of Composite.

OBJECTIVE: To measure and compare the effect of operator experience in their ability to place composite in increments that are 2 mm thick. METHODS AND MATERIALS: Fifteen volunteers from each class of freshmen, sophomores, juniors, and senior dental students and 15 clinical faculty (total number of volunteers = 75) were asked to restore a Class I preparation that was 5 mm in diameter and 8 mm deep from the cusp tips using three increments of composite that were each to be 2 mm thick. Once completed, the models were sectioned, and the thickness of each increment was measured. A repeated-measures analysis of variance (pre-set α=0.05) was used to compare the mean increment thickness with respect to operator experience level and increment sequence number. In addition, the proportion of operators placing clinically acceptable increments (between 1.75 and 2.25 mm thick), as well as the proportions from each group who placed increments that either were thinner or thicker than this range, was determined using nonparametric analyses. RESULTS: Overall, there was an increasing trend for groups with a higher experience level to provide mean incremental thickness values close to 2 mm. However, the likelihood of placing an increment that was thicker or thinner than the manufacturer-recommended thickness was not significantly different. Regardless of the increment value, only about one-third of the increments placed fell within the desired range of 1.75 to 2.25 mm. CONCLUSIONS: Operator experience had no overwhelming significant influence on the ability to place increments of composite that were between 1.75 and 2.25 mm thick. An operator has only about one chance out of three to place a composite increment within this clinically acceptable range when using no external measurement system.

Amniotic fluid index curves in the obese gravida.

OBJECTIVE: To determine whether amniotic fluid volume as measured by amniotic fluid index (AFI) is influenced by maternal pre-gestational obesity as measured by body mass index (BMI). METHODS: This was a retrospective cohort study of pregnant women between 20 and 43 weeks gestation receiving ultrasounds with AFI measurements at Augusta University Medical Center between 2003 and 2017. A subset of 500 charts that met inclusion and exclusion criteria were reviewed to obtain maternal clinical data. The study cohort was subdivided by maternal BMI at initial obstetric visit into three groups: normal weight (18.5 kg/m2-24.9 kg/m2), overweight (25.0 kg/m2-29.9 kg/m2), and obese (≥ 30 kg/m2). Chi-square analysis was used to compare BMI groups in terms of categorical clinical characteristics and outcome variables, and analysis of variance (ANOVA) was used for continuous variables. Mixed effects regression models (MRMs) were used to evaluate AFI throughout gestation separately in each group, and MRM-based analysis of covariance was used to compare AFI throughout gestation among groups. AFI curves were constructed for the 5th, 50th, and 95th percentiles for all study subjects combined and separately for normal weight, overweight, and obese subjects. RESULTS: Fitted curves relating AFI percentiles to estimated gestational age (EGA) showed statistically significant differences among BMI groups. There was also a significant difference in AFI over gestation across the obesity groups. CONCLUSION: Fitted curves for AFI throughout pregnancy showed statistically significant differences among BMI groups.

Diagnosis of Pit-and-fissure Caries Using Three-dimensional Scanned Images.

Diagnosis of the extent of pit-and-fissure caries has been subjective and thus difficult to teach and categorize for treatment planning. This in vitro study compares occlusal caries diagnosis of extracted posterior teeth (n=49) using three-dimensional (3D) scanned images vs visual examination, according to the International Caries Detection and Assessment System (ICDAS). The surfaces chosen for study represent all ICDAS classifications. Five experienced restorative faculty members examined scanned images for 60 seconds from a standardized series of views of each surface and scored them independently. One month later, the same teeth were examined visually by the same five raters with magnification and LED headlamps, with compressed air available. Intrarater and interrater agreement and validity were assessed using intraclass correlation coefficients (ICCs). The ICCs, ranging from 0.90 to 0.93, indicated excellent agreement between and within raters and between the raters and the gold standard ICDAS determination. This suggests that both photographs and 3D scans of pits and fissures are equally effective in diagnosing caries.

Application of radiopaque micro-particle fillers for 3-D imaging of periodontal pocket analogues using cone beam CT.

BACKGROUND: Periodontitis is an infectious/inflammatory disease most often diagnosed by deepening of the gingival sulcus, which leads to periodontal pockets (PPs) conventional manual periodontal probing does not provide detailed information on the three-dimensional (3-D) nature of PPs. OBJECTIVES: To determine whether accurate 3-D analyses of the depths and volumes of calibrated PP analogues (PPAs) can be obtained by conventional cone beam computed tomography (CBCT) coupled with novel radiopaque micro-particle fillers (described in the companion paper) injected into the PPAs. METHODS: Two PPA models were employed: (1) a human skull model with artificial gingiva applied to teeth with alveolar bone loss and calibrated PPAs, and (2) a pig jaw model with alveolar bone loss and surgically-induced PPAs The PPAs were filled with controlled amounts of radiopaque micro-particle filler using volumetric pipetting Inter-method and intra-method agreement tests were then used to compare the PPA depths and volumes obtained from CBCT images with values obtained by masked examiners using calibrated manual methods. RESULTS: Significant inter-method agreement (0.938-0.991) and intra-method agreement (0.94-0.99) were obtained when comparing analog manual data to digital CBCT measurements enabled by the radiopaque filler. SIGNIFICANCE: CBCT imaging with radiopaque micro-particle fillers is a plausible means of visualizing and digitally assessing the depths, volumes, and 3-D shapes of PPs This approach could transform the diagnosis and treatment planning of periodontal disease, with particular initial utility in complex cases Efforts to confirm the clinical practicality of these fillers are currently in progress.

Biomimetic analogs for collagen biomineralization.

Inability of chemical phosphorylation of sodium trimetaphosphate to induce intrafibrillar mineralization of type I collagen may be due to the failure to incorporate a biomimetic analog to stabilize amorphous calcium phosphates (ACP) as nanoprecursors. This study investigated adsorption/desorption characteristics of hydrolyzed and pH-adjusted sodium trimetaphosphate (HPA-Na(3)P(3)O(9)) to collagen. Based on those results, a 5-minute treatment time with 2.8 wt% HPA-Na(3)P(3)O(9) was used in a single-layer reconstituted collagen model to confirm that both the ACP-stabilization analog and matrix phosphoprotein analog must be present for intrafibrillar mineralization. The results of that model were further validated by complete remineralization of phosphoric-acid-etched dentin treated with the matrix phosphoprotein analog and lined with a remineralizing lining composite, and with the ACP-stabilization analog supplied in simulated body fluid. An understanding of the basic processes involved in intrafibrillar mineralization of reconstituted collagen fibrils facilitates the design of novel tissue engineering materials for hard tissue repair and regeneration.

Root canal debridement using manual dynamic agitation or the EndoVac for final irrigation in a closed system and an open system.

AIM: This study examined canal debridement efficacy by testing the null hypothesis that there is no difference between a 'Closed' and an 'Open' system design in smear layer and debris removal using either manual dynamic agitation or the EndoVac for irrigant delivery. METHODOLOGY: Forty teeth were divided into four groups and submitted to a standardized instrumentation protocol. Final irrigation was performed with either manual dynamic agitation or the EndoVac on groups of teeth with or without a sealed apical foramen. Smear and debris scores were evaluated using SEM and analysed using Cochran-Mantel-Haenszel statistic. RESULTS: The ability of manual dynamic agitation to remove smear layer and debris in a closed canal system was significantly less effective than in an open canal system and significantly less effective than the EndoVac (P<0.001). CONCLUSION: The null hypothesis was rejected; the presence of a sealed apical foramen adversely affected debridement efficacy when using manual dynamic agitation but not the EndoVac. Apical negative pressure irrigation is an effective method to overcome the fluid dynamics challenges inherent in closed canal systems.

The effect of ultrasonic removal of various root-end filling materials.

AIM: To compare residual root-end filling material in apical root-end cavities following their removal with ultrasonic retrotips. METHODOLOGY: Thirty single-rooted teeth were filled with Thermafil and AH Plus sealer. Root-ends were resected at 90 degrees, 3 mm from the apex. Root-end cavities were prepared with diamond burs and ultrasonic retrotips and filled with one of three filling materials: group I: Retro-TC (calcium silicate-based cement), group II: IRM (Dentsply, Germany), group III: Vitrebond (3M ESPE, USA). After 30 days of storage, ultrasonic retrotips were used to remove materials from the root-end cavities. The ultrasonic application time was fixed at 60 s. Polyether impressions and replicas of the root-ends were made. Root apices and replicas were examined by one operator under a scanning electron microscope. Remnants of residual materials were evaluated using a four-level scoring system; fractures, smear layer and exposed dentinal tubules were also examined. RESULTS: Forty per cent of the specimens filled with Retro-TC revealed complete removal of the material with exposure of dentinal tubules, whilst 60% contained residual cement. Twenty per cent of specimens filled with IRM were completely devoid of material, whereas 80% had retained material. Ten per cent of specimens filled with Vitrebond retained a moderate amount of material whilst 90% had substantial retention of the material. Statistically significant differences were found (P < 0.05) amongst the three groups of materials. CONCLUSIONS: Retro-TC was successfully removed in 40% of cases using ultrasonics retrotips for 60 s, whereas IRM and Vitrebond specimens had evidence of retained material in 80% and 90% of all specimens respectively.

Activity participation and affect among nursing home residents: support for a behavioural model of depression.

One focus of interventions being developed for depression in nursing homes is increasing pleasant events. The conceptual foundation of such interventions requires establishing links among activity levels, depressive symptoms and positive affect. We observed activity and affect among 28 nursing home residents, five-days-a-week for four weeks, and concurrently collected self-reported affect and depression data. Inclusion of intra-individual analyses using random effects models demonstrated considerable individual variability in the relationship between positive affect and activity, although the results broadly supported the association. Participants differed with regard to what types of events were pleasurable and with regard to the relationships among pleasure, interest and activity. Depression levels were related to some of these individual differences. Activity was related primarily to interest rather than pleasure and higher interest was related to fewer depressive symptoms. Our findings emphasize the importance of individually tailoring pleasant events interventions and suggest that prescriptive group activities are unlikely to prove effective as means for improving positive affect.

Breast conservation therapy for invasive lobular carcinoma: the impact of lobular carcinoma in situ in the surgical specimen on local recurrence and axillary node status.

Forty patients undergoing breast-conserving therapy for invasive lobular carcinoma were studied for the volume of lobular carcinoma in situ (LCIS) in the surgical specimen and its relationship to the surgical margins. The pathology of all cases was reviewed for margin status as well as the volume of LCIS in the surgical specimen. Mean follow-up time was 67 months. There were no local recurrences despite the fact that 38 per cent of patients had close or involved margins. There was one cancer-related death. Increasing tumor size and moderate or extensive involvement of the surgical specimen with LCIS were found to be independent predictors of axillary node metastases. The volume of LCIS in the surgical did not appear to have an impact on local recurrence. This paper adds to the growing body of literature suggesting that in patients undergoing breast-conserving therapy, LCIS in the surgical margin does not impact the risk of local recurrence and therefore may not require reexcision for close or involved surgical margins.

Effects of a minimal intervention to increase physical activity in women: daily activity records.

BACKGROUND: Effective interventions to increase physical activity levels are critical in a nation where inactivity is a national public health problem. OBJECTIVE: This pilot study examined whether a minimal intervention (daily records of physical activity) increased activity levels in a community sample of working women. METHODS: In a longitudinal, pretest-posttest design, 49 working women were randomly assigned at the work site level to the control (n = 25) or intervention group (n = 24). At pretest and posttest, subjects completed self-report questionnaires that measured psychological, social-environmental, physical activity, and demographic variables. Subjects in the intervention group kept daily records of their physical activities during the 12-week study, while those in the control group kept no records. In order to compare activity in the two groups, all subjects wore pedometers daily that recorded number of steps. RESULTS: There was a significant difference between groups in the pedometer values (mean number of daily steps) at the end of the study period (mean difference +/- SE 2147 +/- 636, p = .022) (2000 steps = approximately 1 mile). Multiple regression analysis showed that only the intervention (p = .003) was a significant predictor of the pedometer values. Hierarchical data analysis was used to account for the intra-class correlation of 0.48 within work site. CONCLUSION: Results from this sample of 49 women indicated that mean activity was greater in the intervention group compared to the control group. Recording daily activity is a cost-effective and acceptable intervention that may increase activity levels in women. However, more research is recommended to study the dual role of activity records as a data collection method as well as a potential intervention to increase physical activity.

Dental metal allergy in patients with oral, cutaneous, and genital lichenoid reactions.

BACKGROUND: The subject of lichen planus (LP) and dental metal allergy long has been debated. An overwhelming majority of the existing literature focuses on mercury and gold salts in relation to oral lichen planus. OBJECTIVE: Our objective was to expand current knowledge regarding LP and lichenoid lesions (LL) and dental metal allergy by investigating more metals and investigating cutaneous and genital disease in addition to oral disease. METHODS: Fifty-one patients with known LP or LL were patch tested to a series of dental metals. Patients chose to replace their dental metals or make no revision. A telephone survey was conducted after 1 year to determine disease state. RESULTS: Thirty-eight of 51 patients (74.5%) had at least 1 positive reaction. Twenty-five of 51 patients (49.0%) showed sensitivity to at least 1 mercurial allergen. Prevalence data for patients patch tested by the North American Contact Dermatitis Group (NACDG) from 1996 to 1998 was available for chromate, cobalt, gold, nickel, and thimerosal. The prevalence of positive reactions was higher in our group than in the NACDG group for all 5 of these allergens, and statistical significance was achieved for chromate (P = .028), gold (P = .041), and thimerosal (P = .005). Of patients who had a positive patch test reaction to 1 or more metals, 100% (9 of 9) reported improvement after metal replacement, whereas 62.5% (15 of 24) reported improvement without metal replacement. CONCLUSION: Sensitization to dental metals is more common among LP and LL patients than in routinely tested patients, and might be an etiologic or triggering factor in the disease.

Can recovering alcoholics help hospitalized patients with alcohol problems?

OBJECTIVE: The researchers evaluated the relative effectiveness of 2 interventions for patients with alcohol problems. STUDY DESIGN: A nonrandomized intervention study was used to compare usual care (control) with a 5- to 15-minute physician-delivered message (brief intervention) and with the physician message plus a 30- to 60-minute visit by a recovering alcoholic (peer intervention). Telephone follow-up was obtained up to 12 months after hospital discharge that focused on patient behaviors during the first 6 months following discharge. POPULATION: The study included 314 patients with alcohol-related injuries admitted to an urban teaching hospital. OUTCOMES MEASURED: Researchers measured complete abstinence from alcohol during the entire 6 months following hospital discharge, abstinence from alcohol during the sixth month following hospital discharge, and initiation of alcohol treatment or self-help within 6 months of hospital discharge. RESULTS: Valid responses were obtained from 140 patients (45%). Observed success rates were: 34%, 44%, and 59% (P=.012) for abstinence from alcohol since discharge in the usual care group, the brief intervention group, and the peer intervention group, respectively; 36%, 51%, and 64% (P=.006) for abstinence at the sixth month following hospital discharge; and 9%, 15%, and 49% (P &it.001) for initiation of treatment/self-help. During the telephone follow-up interview, several patients in the peer intervention group expressed gratitude for the help they received with their drinking problems while in the hospital. A few patients dramatically changed their lives. They went from being unemployed and homeless to full-time employment and having a permanent residence. They credited the peer intervention as being the most important factor that motivated them to seek help for their alcohol use disorder. One of these individuals serves as a volunteer, visiting hospitalized patients with drinking problems. CONCLUSIONS: Among trauma victims with injuries severe enough to require hospital admission, brief advice from a physician followed by a visit with a recovering alcoholic appears to be an effective intervention. Although further study is needed to confirm these findings, in the meantime physicians can request that members of Alcoholics Anonymous (AA) visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are part of their twelfth-step work (an essential part of the AA program) and are simple, practical, involve no costs, and pose little patient risk. They can be arranged from the patient's bedside telephone. Some patients will show a dramatic response to these peer visits.

Effect of music on anxiety of women awaiting breast biopsy.

The authors investigated the effect of music on the state anxiety of a sample of 20 patients awaiting breast biopsy at a suburban medical facility. The patients were assigned alternately to either the control or experimental group. The individuals in the experimental group were given a 20-minute music-based intervention in a preoperative holding area, whereas the patients in the control group received the customary preoperative care. Clinicians measured blood pressure, heart rate, and respiration in both groups of patients, and the participants completed the State portion of the self-administered State-Trait Anxiety Inventory (STAI). After the patients completed the 20 minutes of music or of preoperative care without music, clinicians again measured the participants' vital signs and the patients completed the STAI. The authors' findings indicated that the posttest state anxiety and respiratory rates of the patients in the experimental group were significantly lower than those of the patients in the control group.

Depression among nursing home elders: testing an intervention strategy.

This study focused on the assessment of depression among nursing home elders, and on determining the efficacy of an intervention strategy for depression using a geropsychiatric nurse in conjunction with trained older adult volunteers in the role of mental health paraprofessionals. Nursing home residents (n = 139) were assessed for depression using the Geriatric Depression Scale (GDS); 94 (68%) were found to have depressive symptomatology. Among those receiving the intervention, depressive symptomatology was significantly reduced, but no significant decline was evident in the control group. The ability of the minimum data set (MDS) to detect depression as compared to the GDS was evaluated. Relationships between depression and health status, life satisfaction, and social support were also examined.

Minimum time interval adjustment for 4-3-1 immunization rates among two-year-old children.

BACKGROUND: The purpose is to determine the administrative validity of the 4-3-1 immunization rates for DPT-OPV-MMR vaccines for 2-year-old children in a community health status assessment project by accounting for premature administration of specific vaccine doses according to ACIP recommended minimal timing intervals. METHODS: A retrospective survey of immunization certificates was made on a random sample of 1,059 kindergarten enrollees in the county, including public, private, and parochial schools. The immunization rates by the crude 4-3-1 counting method were compared with the same method adjusted for minimal time interval vaccine dosing. RESULTS: By the crude 4-3-1 counting method, 55.5% of the students had complete immunizations by their second birthdate, and 11.8% did not meet the minimum interval recommendations on at least one of 4-3-1 vaccine series. The adjustment for minimum time interval reduced the percent in compliance with the 4-3-1 counting method by age 2 in the community to 50.7%. CONCLUSION: The premature timing of vaccine doses is a threat to the validity of the 4-3-1 counting method. The crude 4-3-1 method over-estimates the completed immunization rates for 2-year-olds in this community-based study by about 4.8%.

Which medical school applicants will become generalists or rural-based physicians?

The hypotheses that data, available at the time when a medical school admission decision is made, can be used to predict generalist specialty choice and rural practice location were tested. Applicant data, available to admissions committee members at the University of Louisville in 1986 and 1987 about the classes of 1990 and 1991 respectively, were correlated with specialty choice and practice location in a retrospective cohort study. Data collected from 1994 to 1996 about the 1990 and 1991 graduates were used to develop a mathematical model to predict specialty choice and practice location using stepwise logistic regression. These models were more accurate in predicting which applicants would not select a generalist career (negative predictive value = 80.7%) than those who would (positive predictive value = 42.7%) and in predicting those who would not practice in a rural location (negative predictive value = 91.9%) than those who would (positive predictive value = 37.8%). We conclude that applicant data, available at the time admission decisions are made, are of limited value for identifying those who will eventually become generalist physicians or practice in a rural area. However, the data are useful for identifying those who will not.

An update on biostatistics requirements in U.S. medical schools.

PURPOSE: To update the results of previous surveys of medical schools in the United States concerning their courses in introductory biostatistics and to acquire additional information about these courses. METHOD: In 1993, the authors sent a questionnaire to each of the 125 U.S. medical schools listed in the 1992-93 AAMC Directory of American Education. The questionnaire sought information about biostatistics courses and the subjects covered therein. RESULTS: One hundred of the 125 medical schools (80%) responded to the survey. Of those, 74 required a course in biostatistics as part of their undergraduate medical curriculum. The courses had large enrollments (median, 134) and a median of only 20 hours of instructional time. Most courses included a large amount of material, with 25 possible topics covered by at least 75% of the schools with required courses. CONCLUSION: While efforts have been made to incorporate innovative instructional techniques into these courses, most still follow the traditional lecture format and make minimal use of computers. Nevertheless, medical students appeared to have a favorable attitude toward these courses at over half of the schools surveyed.

Do parotid duct abnormalities occur in patients with chronic alcoholic pancreatitis?

OBJECTIVE: Several studies have suggested that ethanol affects the pancreas and parotid gland. We performed a prospective study to determine whether ductal lesions of ethanol-induced chronic pancreatitis occur in the parotid. METHODS: Parotid sialograms were performed in 11 alcoholic patients who had endoscopic retrograde pancreatograms. Sialograms and pancreatograms were examined in all subjects for ductal abnormalities. RESULTS: Seven of nine patients (77.8%) with ductal lesions of the pancreas had coexistent ductal abnormalities of the parotid gland (Kendall's tau = 0.578, p = 0.035). CONCLUSIONS: Chronic ethanol intake induces ductal alterations in the parotid gland similar to those seen in the pancreas. These results suggest a common histopathological effect of alcohol in the ductal system of the parotid gland and pancreas and raise the possibility that the parotid sialogram could be useful as an adjunct in the diagnosis of ethanol-induced chronic pancreatitis.

A retrospective review of 61 patients with antiphospholipid syndrome. Analysis of factors influencing recurrent thrombosis.

BACKGROUND: Antiphospholipid syndrome (APS) is a disorder of recurrent venous or arterial thrombosis, pregnancy losses, and thrombocytopenia. Recurrent thrombosis has particularly adverse effects on patients prognosis. The factors that influence recurrence and management techniques that prevent these events remain controversial. To add further insight regarding predisposing factors and the prevention of thrombotic recurrence, 61 well-characterized patients with APS were followed up for a median time of 77 months. METHODS: A retrospective cohort study was conducted in which the following factors were examined to determine their influence on thrombotic recurrence: primary vs secondary syndrome; the presence of hypertension, hyperlipidemia, diabetes, or smoking; patient age, sex, and race; pregnancy and oral contraceptives use; and treatment with warfarin sodium, warfarin plus aspirin, aspirin alone, prednisone, or no treatment. RESULTS: There was no difference between patients with primary and secondary APS with respect to recurrent arterial (55% vs 38%, respectively) or recurrent venous (47% vs 50%, respectively) thrombotic events. In all patients with APS, white race (P = .02) was associated with recurrent arterial events. Venous thrombosis occurred during pregnancy or in the postpartum period in 16 (30%) of 53 women and in 8 women taking oral contraceptives. Recurrent arterial and venous thromboses were significantly decreased with prophylactic warfarin use when compared with prednisone use or no treatment. Recurrences were infrequent in patients with prothrombin ratios of 1.5 to 2.0. CONCLUSIONS: Treatment with warfarin was most effective in preventing recurrent arterial and venous thrombosis. Pregnancy and the use of oral contraceptives or prednisone may also influence recurrence.

Prevalence of positive Osler's manoeuver in 3387 persons screened for the Systolic Hypertension in the Elderly Program (SHEP)

The purpose of this study was to examine the prevalence of a positive Osler's manoeuver (OM) among persons screened for the Systolic Hypertension in the Elderly Program (SHEP). Information obtained from all individuals included age, gender, and race; history of antihypertensive, anticoagulant, insulin, or cardiac pacemaker use; and history of heart attack, coronary bypass surgery, or stroke. Among the persons aged 60 and over that were screened for eligibility at the Louisville SHEP Center, OM was performed on 3387 subjects. Of these, 7.2% (243 of 3387) were determined to be Osler maneuver positive (O+). O+ was more prevalent among males than among females (P = 0.025). A higher prevalence of O+ was associated with both higher age (P < 0.001) and higher blood pressure (P < 0.001). There were significantly more Osler positives among those who responded positively to 'Have you had a stroke?' (P = 0.007) and 'Are you taking anticoagulants' (P = 0.044) than among those who responded negatively to these questions. O+ was also less prevalent among those that were normotensive at the time of the screening (P = 0.046). The results of this study, when taken with those of previous studies of OM, support the cautious use of OM as a screening tool for pseudohypertension in the elderly population and as an adjunct in determining the cardiovascular risk profile of individual patients. However, further study of OM is required before it can be recommended for routine use in the assessment of hypertension among the elderly.