Oral health-related quality of life after dental treatment in patients with intellectual disability.

BACKGROUND: The influence of dental treatment on oral health-related quality of life (OHRQOL) has rarely been evaluated in patients with intellectual disability (ID) through validated questionnaires. The aim of this study was to estimate the changes on OHRQOL in patients with ID after the implementation of an institutional dental treatment program under general anesthesia using the Franciscan Hospital for Children Oral Health-Related Quality of Life questionnaire (FHCOHRQOL-Q). MATERIAL AND METHODS: A prospective longitudinal study was conducted on 85 patients (mean age=24.85 years) classified according to DSM-V whose parents/caregivers completed the FHC-OHRQOL-Q. We analyzed the changes in the questionnaire's overall score and its dimensions from pre-treatment to 12-months of follow-up, considering effect sizes and minimal important differences estimated by the standard measurement error. The impact of clinical and therapeutic factors was evaluated using univariate and multiple linear regression analysis (p<0.05). RESULTS: Significant improvement of OHRQOL was found after dental treatment in oral symptoms (p0.001), daily life problems (p=0.018), parent's perceptions (p=0.013) and FHCOHRQOL-Q´s overall score (p=0.001). OHRQOL changes exhibited an intermediate magnitude (0.38-0.21) as estimated by effect sizes. Changes in oral symptoms showed positive correlation with DMFT index (r=0.375, p=0.002), decayed teeth (r=0.244, p=0.036), dental extractions (r=0.424, p<0.001) and number of treatments (r=0.255, p=0.019). The improvement was greater in patients with 4 decayed teeth (p=0.049) and undergoing 2 dental extractions (p=0.002). Multiple regression analysis demonstrated that dental extractions (p<0.001) and DMFT index (p=0.028) were significantly related to oral symptom improvement. CONCLUSIONS: Dental treatment under general anesthesia showed a positive effect on the overall FHC-OHRQOL-Q score and most of its dimensions. At 12-months of follow-up, the improvement of oral symptoms was significantly associated with DMFT index, decayed teeth, dental extractions and number of treatments. In our clinical setting, the implementation of a dental treatment program enhanced the OHRQOL of patients with ID.

Validation of the Spanish version of the Franciscan Hospital for Children Oral Health-Related Quality of Life questionnaire.

BACKGROUND: The Franciscan Hospital for Children Oral Health-Related Quality of Life questionnaire (FHC-OHRQOL-Q) is an instrument designed specifically for parents and caregivers of patients with special needs that has not yet been applied in Spain. The aim of this study was to adapt it to Spanish and evaluate its reliability and validity in patients with intellectual disability (ID) treated under general anesthesia. MATERIAL AND METHODS: The study was conducted in two different stages: a) cross-cultural adaptation of the original questionnaire, and b) cross-sectional study on 100 parents and caregivers who completed the piloted FHC-OHRQOL-Q. The patients were examined according to the WHO methodology. Dental treatments performed were recorded. Statistical tests were used to evaluate reliability (internal consistency) and validity (content, criterion, construct and discriminant) of the instrument. RESULTS: The mean age was 24 years (range=4-71 years). The most frequent causes of ID were psychomotor retardation (25%) and cerebral palsy (24%). The items most frequently answered by parents and caregivers were eating and nutrition problems (80%) and bad breath/taste (57%). Reliability (Cronbach's alpha coefficient) was considered excellent (alpha=0.80-0.95). The analysis of the factorial validity yielded similar results to the original questionnaire. The high response rate of items (>96%) allowed content validity. Criterion validity was confirmed by a significant correlation with questions on oral health and oral well-being. Discriminant validity was demonstrated by the significant association of ≥21.5 years of age with worse oral symptoms (p=0.034) and parental concerns (p=0.005), DMFT index ≥3 with daily life problems (p=0.02), ≥4 decayed teeth with daily life problems (p=0.001), and >2 dental extractions with oral symptoms (p=0.000), daily life problems (p=0.002) and parent's perceptions (p=0.043). CONCLUSIONS: The FHC-OHRQOL-Q in Spanish is a reliable and valid instrument to apply in clinical practice to evaluate the impact of OHRQOL in mostly adult patients with ID, accessible to Spanish-speaking parents and caregivers.

Preventive dental management of osteonecrosis of the jaws related to zoledronic acid treatment.

OBJECTIVE: To evaluate the effect of preventive dental management on reducing the incidence and delaying the onset of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in patients treated with intravenous zoledronic acid (ZA). MATERIALS AND METHODS: This single-center clinical study included 255 patients with cancer monitored over a 6-year period. Patients received dental treatment prior to (group A) or after (group B) the initiation of ZA therapy. Dental treatments performed, incidence proportion (IP), and incidence rate (IR) in both groups were analyzed using significance tests. BRONJ onset was estimated using the Kaplan-Meier estimator and log-rank test. Independent risk factors to develop BRONJ were evaluated using Cox regression analysis models. RESULTS: Thirty-seven patients suffered from BRONJ (IP = 14.5%), 7.3% in group A and 36.5% in group B (p = .000). The IR was 0.007 patients/month in group B and 0.004 in group A. BRONJ-free survival at 3 years was 97% in group A and 66% in group B. Survival curves were significant (p = .056) according to log-rank test. Multivariate Cox models showed that dental extractions (p = .000) were significant. CONCLUSIONS: BRONJ occurred significantly in patients who underwent dental extractions after the initiation of ZA and did not accomplish a preventive dental program.

Costo oportunidad de adolescentes en unidades de medicina familiar / Opportunity cost for adolescents at family medicine clinics

Objective: To determine the opportunity cost for adolescents requiring care at Family Medicine Clinics. Material and Methods: Study of cost performed on 624 patients, 10-19 years of age, Family Medicine Clinics, Pharmacy and Laboratory. A conglomerate sample technique was used (Medical Unit), and proportional sampling internally. Several sociodemographic variables were evaluated, including transfer, waiting time and care. Statistical evaluation included averages, percentages, and confidence intervals of 95 percent. Results: The cost-opportunity for Family Medicine and Pharmacy in the situations evaluated was $10.22 for the teenager, $71.43 for the first family member, and $14.28 for the second person accompanying the child. When they attend all three services, the cost is $12.26, $82.71 and $16.54 respectively. A weighted average cost of opportunity IFOR all three services is $93.18. Conclusions: The largest cost of opportunity for adolescents occurs when waiting for care in Family Medicine. It is suggested that strategies be implemented to decrese waiting times in the various services.

Objetivo. Determinar el costo oportunidad de los adolescentes que demandan atención en las Unidades de Medicina Familiar. Material y Métodos. Estudio de costo oportunidad realizado en 624 usuarios de 10 a 19 años de edad atendidos en tres Unidades de Medicina Familiar, en los servicios de Medicina Familiar, Farmacia y Laboratorio. Se empleó la técnica muestral por conglomerados (Unidad Médica) y al interior por cuota. Se estudiaron variables sociodemográficas y número de acompañantes; se estimó el costo oportunidad para el traslado, espera y atención. El análisis estadístico incluyó promedios, porcentajes e intervalos de confianza del 95 por ciento. Resultados: El costo oportunidad promedio para Medicina Familiar y Farmacia es de $10.22 para el adolescente, de S 71.43 para el acompañante 1 y de $14.28 para el acompañante 2; cuando acuden a los tres servicios es de $12.26, $82.71 y $16.54 respectivamente. El costo oportunidad promedio ponderado cuando acuden a los tres servicios es de $93.18. Conclusión: El mayor costo oportunidad para los adolescentes corresponde a la espera en el servicio de Medicina Familiar. Por lo que se sugiere implementar estrategias que disminuyan el tiempo de espera en los diferentes servicios.

Respiratory abdominal muscle recruitment and chest wall motion in myotonic muscular dystrophy.

Abdominal muscles are selectively active in normal subjects during stress and may increase the potential energy for inspiration by reducing the end-expiratory lung volume (EELV). We hypothesized that a similar process would occur in subjects with myotonic muscular dystrophy (MMD), but would be less effective, because of to their weakness and altered chest wall mechanics. Fine-wire electromyography (EMG) of the transversus abdominis (TA), internal oblique (IO), external oblique, and rectus abdominis was recorded in 10 MMD and 10 control subjects. EMG activity, respiratory inductive plethysmography, and gastric pressure were recorded during static pressure measurement and at increasing levels of inspiratory resistance breathing. EELV was reduced and chest wall motion was synchronous only in controls. Although the TA and IO were selectively recruited in both groups, EMG activity of the MMD group was twice that of controls at the same inspiratory pressure. In MMD subjects with mildly reduced forced vital capacity, significant differences can be seen in abdominal muscle recruitment, wall motion, work of breathing, and ventilatory parameters.

Ischemic peripheral neuropathy.

Ischemic neuropathy from sources other than diabetes is less common, but can be encountered in clinical practice. Diagnosis can be challenging, and many patients may be referred to the electrodiagnostic laboratory. Overlapping mononeuritis multiplex is a common presentation, but distal symmetric polyneuropathy and monomelic neuropathy patterns can be seen. Depending on the disease associated with ischemic neuropathy, a mononeuropathy or a sensory-motor, axonal-demyelinating peripheral neuropathy may be seen as well. The treatment of ischemic neuropathy varies depending on the associated disease. Prognosis can be poor in the case of amyloidosis and the primary vasculitides. The literature is limited to cross-sectional case series and rare longitudinal studies likely related to the incidence of the diseases. Further study is needed to fully define the extent of the neurologic consequences of peripheral ischemia and its significance clinically.

Pursed lips breathing improves ventilation in myotonic muscular dystrophy.

OBJECTIVE: To determine the effects of pursed lips breathing on ventilation, chest wall mechanics, and abdominal muscle recruitment in myotonic muscular dystrophy (MMD). DESIGN: Before-after trial. SETTING: University hospital pulmonary function laboratory. PARTICIPANTS: Eleven subjects with MMD and 13 normal controls. INTERVENTION: Pursed lips breathing. OUTCOME MEASURES: Electromyographic (EMG) activity of the transversus abdominis, external oblique, internal oblique, and rectus abdominis was recorded with simultaneous measures of gastric pressure, abdominal plethysmography, and oxygen saturation. Self-reported sensations of dyspnea, respiratory effort, and fatigue were recorded at the end of each trial. RESULTS: Pursed lips breathing and deep breathing led to increased tidal volume, increased minute ventilation, increased oxygen saturation, reduced respiratory rate, and reduced endexpiratory lung volume. Dyspnea, respiratory effort, and fatigue increased slightly with pursed lips breathing. EMG activity of the transversus abdominis and internal oblique muscles increased in MMD only and was associated with an increase in gastric pressure. CONCLUSIONS: Pursed lips breathing and deep breathing are effective and easily employed strategies that significantly improve tidal volume and oxygen saturation in subjects with MMD. Abdominal muscle recruitment does not explain the ventilatory improvements, but reduced end-expiratory lung volume may increase the elastic recoil of the chest wall. Further clinical studies are needed to ascertain if the ventilatory improvements with pursed lips breathing and deep breathing improve pulmonary outcomes in MMD.

Expanding the role of hospice care in amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive, ultimately fatal, motor neuron disease that poses a myriad of clinical and end-of-life problems. The needs of advanced ALS patients are well suited to the interdisciplinary, multi-modality setting of hospice, where comprehensive palliative strategies may ease suffering and allow the patient to die with dignity in the home. Unfortunately, hospice services are far underutilized in this setting. There is a great need to increase awareness of both patients and clinicians regarding the effectiveness of hospice in the care of advanced ALS patients.

A prospective controlled study of diagnostic imaging for acute shin splints.

OBJECTIVE: The purpose of this prospective, observational study was to examine the relationship of clinical examination, plain radiograph (XR), triple-phase bone scan (TPBS), and magnetic resonance imaging (MRI) in the investigation of patients presenting with acute shin splints. METHODS: 23 subjects with exercise induced lower leg pain and diffuse tibial tenderness of less than 3 months' duration were recruited. Subjects were excluded if there was clinical evidence of compartment syndrome, muscle hernia, or stress fracture. Each subject underwent XR, TPBS, and MRI within 2 wk of physical examination. Four asymptomatic controls underwent TPBS and MRI. Clinical findings, XR, TPBS, and MRI findings were independently recorded using a consistent template and subsequently analyzed. A single consensus lesion was chosen that provided the greatest overlap and highest grade to allow comparison of clinical and imaging findings. Sensitivity and specificity were calculated from data relating to clinical findings and diagnostic imaging. RESULTS: Eighteen subjects had bilateral symptoms and five unilateral with a mean duration of symptom of 5.4 wk (+/- 3.5). Of 41 symptomatic lower legs, there were TPBS abnormalities in 36 and MRI findings in 34. Analysis of clinical findings to TPBS and MRI demonstrated a sensitivity and specificity of 84%, 33% and 79%, 33%, respectively. Assuming TPBS as the "gold-standard," MRI findings demonstrated a sensitivity of 95% and specificity of 67%. There was poor agreement between the grading of TPBS and MRI (k = 0.3). In the 5/46 asymptomatic limbs, 3/5 demonstrated uptake on bone scan and 4/5 signal change with MRI. Imaging abnormalities were similarly seen in the four control patients. CONCLUSIONS: MRI may be used rather than TPBS and radiographs for evaluating acute tibial pain in athletes where avoidance of radiation exposure is desirable. Similar sensitivity and specificity may be expected from both investigations; however, in the light of abnormal TPBS and MRI findings in control and asymptomatic limbs, we recommend further studies be performed to define the extent of nonpathological TPBS and MRI changes.

Sensory axonopathy in mild to moderate peripheral arterial disease.

The effect of mild to moderate arterial occlusive disease on peripheral nervous system conduction was prospectively investigated in 18 subjects and 18 control subjects, aged 40 to 85 years. Experimental and control subjects underwent a thorough history and physical followed by vascular and electrophysiologic studies. The primary outcome measure was the sensory nerve action potential. Although 33% of the subjects with peripheral arterial disease had experienced paresthesias, the clinical evaluation of sensation was relatively unaffected. Sensory conduction studies revealed 30% absent sural responses and 56% absent superficial peroneal nerve responses in subjects with peripheral arterial disease compared with 3 and 14% absent responses in control subjects, respectively (P = 0.044; 0.025). There were no differences in distal latency or sensory amplitude, although the superficial peroneal amplitude did approach significance (P = 0.06). No significant differences were found in motor distal latency, amplitude, or conduction velocity. Age, leg length, temperature, disease severity, presence of paresthesias, cholesterol levels, and past alcohol or tobacco ingestion did not account for the difference in sensory responses. These results support the presence of a mild sensory axonopathy in subjects with peripheral arterial disease. Electromyographers should be cognizant of absent distal responses from peripheral arterial disease so as not to ascribe the findings to an alternative pathology and should not attribute abnormal motor conduction results to the presence of this degree of peripheral arterial disease.

Shin splints: MR appearance in a preliminary study.

PURPOSE: To investigate the magnetic resonance (MR) imaging appearance of activity-related lower leg pain (shin splints syndrome) and evaluate the relative involvement of bone and soft tissues. MATERIALS AND METHODS: Nineteen patients with activity-related lower leg pain and tenderness on palpation along the posteromedial tibia (shin splints) underwent clinical examination and MR imaging. Five also underwent plain radiography. MR findings were compared with patient demographics, clinical findings, and plain radiographs when available. RESULTS: Four MR patterns were identified: normal appearance (n = 7), periosteal fluid only (n = 5), abnormal marrow signal intensity (n = 5), and stress fracture (n = 2). Increased symptom duration correlated strongly with a normal MR image (P = .002). Plain radiographs appeared normal in all five patients for whom they were available. CONCLUSION: Patients with acute shin splints have a spectrum of MR findings, which suggests this clinical entity is part of a continuum of stress response in bone. The strong association between chronic symptoms and a normal-appearing MR image implies that this modality has less utility in these patients.

[Pharmacokinetic variations in anticonvulsants in Mexican epileptic women during different stages of the postpartum period]. / Variaciones farmacocinéticas de anticonvulsivantes en mujeres epilépticas mexicanas durante las diferentes etapas del postparto.

During pregnancy, there are several physiological changes that influence the kinetics of medication administrated during this time. These physiological changes are not reestablished immediately during delivery; so, its concentration in biologic fluids is different when is administered immediately after delivery, than several weeks after. The purpose in this work was to identify the changes of pharmacocinetics constants for fenitoin and carbamacepine, in epileptic patients. When the same dose is maintained, during different times of postpartum. In 20 Mexican epileptic women, the plasma and milk concentrations of fenitoina during 60 day postpartum and in 14 carbamacepine was determined. In all the patients pharmakocinetics of anticonvulsivant, in each study period (5, 15, 30, 45 y 60 days postpartum). Excretion index of maternal milk was determined. Maximal plasmatic concentration of fentoine had no variation; however, carbamacepine was higher during the late period. There were no differences in the areas under curve and life all the middle of elimination and in excretion index.

Variaciones farmacocinéticas de anticonvulsivantes en mujeres epilépticas mexicanas durante las diferentes etapas del postparto / Pharmakocinetic variation of anticonvulsants in Mexican epileptic women during different parts of puerperium

Durante el embarazo existen una serie de cambios fisiológicos que influyen en la cinética de los medicamentos administrativos durante esta etapa: Estos cambios fisiológicos no se restauran inmediatamente en el parto, de tal manera que su concentración en los fluidos biológicos es diferente cuando se administra inmediatamente después del parto que varias semanas posterior al mismo. El presente trabajo tiene como propósito identificar los cambios en las constantes farmacocinéticas de fenitoína y carbamacepina, en pacientes epilépticas cuando se mantiene una misma dosis durante diferentes etapas del postparto. En 20 mujeres mexicanas epilépticas se determinó la concentración en plasma y leche de fenitoína durante 60 días postparto y en 14 se determinó carbamacepina. A todas las pacientes se les realizó la farmacocinética de los anticonvulsivantes en cada periodo de estudio (5, 15, 30, 45 y 60 días posparto) y se determinó el índice de excreción en leche materna. Las concentraciones plasmáticas de fenitoína no presentaron variaciones, sin embargo la carbanacepina fue más alta en el periodo tardió, también se observaron diferencias en las áreas bajo la curva y vida media de eliminación y en los índices de excreción