Organizational Readiness to Implement System Changes in an Alaskan Tribal Dental Care Organization.

INTRODUCTION: Tribal health care systems are striving to implement internal changes to improve dental care access and delivery and reduce health inequities for American Indian and Alaska Native children. Within similar systems, organizational readiness to implement change has been associated with adoption of system-level changes and affected by organizational factors, including culture, resources, and structure. OBJECTIVES: The objectives of this study were to assess organizational readiness to implement changes related to delivery of evidence-based dental care within a tribal health care organization and determine workforce- and perceived work environment-related factors associated with readiness. METHODS: A 92-item questionnaire was completed online by 78 employees, including dental providers, dental assistants, and support staff (88% response rate). The questionnaire queried readiness for implementation (Organizational Readiness for Implementing Change), organizational context and resources, workforce issues, organizational functioning, and demographics. RESULTS: Average scores for the change commitment and change efficacy domains (readiness for implementation) were 3.93 (SD = .75) and 3.85 (SD = .80), respectively, where the maximum best score was 5. Perceived quality of management, a facet of organizational functioning, was the only significant predictor of readiness to implement change (B = .727, SE = .181, P < .0002) when all other variables were accounted for. CONCLUSION: Results suggest that when staff members (including dentists, dental therapists, hygienists, assistants, and support staff) from a tribal health care organization perceive management to be high quality, they are more supportive of organizational changes that promote evidence-based practices. Readiness-for-change scores indicate an organization capable of institutional adoption of new policies and procedures. In this case, use of more effective management strategies may be one of the changes most critical for enhancing institutional behaviors to improve population health and reduce health inequities. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by clinicians and other leaders implementing changes within dental care organizations. To promote organizational readiness for change and, ultimately, more expedient and efficient adoption of system-level changes by stakeholders, consideration should be given to organizational functioning generally and quality of management practices specifically.

The economic impact of antimicrobial stewardship programmes in hospitals: a systematic literature review.

BACKGROUND: Antimicrobial stewardship programmes (ASPs) include strategies that enable sustainable management of rational anti-infective treatment in the clinical setting. The successful introduction of ASPs requires close interdisciplinary collaboration among various health professionals, including the hospital management. So far, ASPs have been evaluated mainly from a clinical-pharmacological and infectious disease perspective. AIM: To identify and evaluate parameters with decisive significance for the economic impact of ASPs. METHODS: A systematic literature search for peer-reviewed health-economic studies associated with antimicrobial stewardship programmes was performed. Primary outcomes included savings in drug costs and lower revenue losses for hospitals. FINDINGS AND CONCLUSIONS: A total of 16 studies met all inclusion criteria. Most of the evidence from published clinical trials demonstrated savings through reduced direct cost of antibiotics. However, there are also studies that prove revenue effects of ASPs through decreases in length of stay and readmission rates.

Evaluation of a parent-designed programme to support tooth brushing of infants and young children.

OBJECTIVES: This study developed and tested an intervention to help parents establish a routine of brushing their young children's teeth twice a day. METHODS: Community-based participatory research methods were used to engage parents in the design of the intervention to maximize its relevance and acceptability to others. Input was obtained by interviews and focus groups. The resulting intervention was four 90-min small-group sessions that provided educational information, direct instruction, practice and peer-to-peer problem-solving. A pre- to post-non-randomized design was used to evaluate the intervention's effect to increase or maintain parents' twice daily brushing. RESULTS: Intervention participants were 67 primary caregivers of children under six years of age. Of the 67 initial participants, 50 completed a post-intervention questionnaire administered 4 to 8 weeks following the intervention. The proportion of parents who reported brushing their young children's teeth twice a day increased significantly from 59 per cent prior to the intervention to 89 per cent post-intervention (McNemar's X(2)  = 10.71, P = 0.002). There were concomitant and statistically significant increases over the study period in parents' confidence for brushing twice a day, attitudes about the importance of brushing and their self-efficacy for tooth brushing. Parents' knowledge of children's oral health, assessed by a 15-item scale developed for this study ('Things to Know About Baby Teeth'), also increased significantly. CONCLUSIONS: Twice daily tooth brushing is a low-cost, effective strategy to reduce the risk of childhood caries. As demonstrated here, community-based efforts can help parents achieve this important health behaviour.

Parent-reported distress in children under 3 years old during preventive medical and dental care.

PURPOSE: This study examined factors related to young children's distress during preventive oral health visits. Additionally, associations between parent-reported child behaviour during the dental visit and during previous medical visits were tested. METHODS: One hundred twenty-two children under 3 years of age enrolled in a government insurance programme for low-income children were seen for examination, prophylaxis, and fluoride application at a university-based dental clinic. Child distress was rated by parents on a numerical rating scale. RESULTS: The average age of children enrolled was 23.5 ± 7.3 months. The majority (55.7 %) were judged to have little or no distress pre-examination. Mild or no distress during the examination was reported for 42.6 % of the children and severe distress was reported for 39.4 %. Intensity of distress during the examination was not associated with the child's age, gender, dental health, or previous experience with dental care. Distress was also unrelated to the caregiver's education level or own dental health. Intensity of distress was associated with the child's pre-dental examination distress and distress during prior medical examinations and injections. CONCLUSIONS: Dental professionals can better anticipate child distress by assessing children before a dental examination and enquiring about previous medical experiences. Strategies to prepare parents and alleviate distress may help children cope with the preventive dental visit.

Implementation partnerships in a community-based intergenerational oral health study.

BACKGROUND: University-community partnerships are a common strategy used in implementing community-based health promotion trials, yet few published studies report these interactions in detail. "Baby Smiles" was a five-year intervention study in Oregon, USA. The study involved 400 low-income women during and after pregnancy across four rural counties. In this report, we describe and assess four university-community health partnerships formed to support the intervention. METHODS: A community health partnership advisory group for the study was established in each of the four participating counties. Group membership ranged from 9 to 23 individuals. A survey was administered to the groups five times in a 2.5 year period. The survey asked members' opinions of the intervention's goals, scientific basis and relevance to their organisation. Questions also asked about members' knowledge of oral health, beliefs about access to dental care for low-income pregnant women and children in their county and how their organisation functioned. RESULTS: There was strong overall support by each partnership group despite differences in the groups' structure, foci and turnover in membership during intervention period. Responses to specific survey items indicating misinformation or negative opinions about oral health care were used to address weaknesses in study implementation throughout the conduct of the study. CONCLUSION: Systematic monitoring of community support for a multi-year oral health intervention is feasible and can identify potential barriers to address while the study is underway.

A first look: determinants of dental care for children in foster care.

PURPOSE: This hypothesis-generating study sought to identify potential determinants of dental care use and oral health among children living in foster care. METHOD: Using a grounded theory approach, fourteen key informant interviews were conducted among health and social services professionals experienced with children in foster care and families in western Washington State. RESULTS: The identified potential determinants of oral health and dental use among children living in foster care included: (1) linguistic and cultural barriers; (2) lack of dentists willing to accept children's Medicaid dental insurance; (3) lack of resources available to case workers (i.e., large caseload burden) (4) lack of federal funding for specialized dental care; (5) lack of systematic health record-keeping; (6) child transience, leading to the lack of a dental home; (8) foster parents' competing needs; (7) child behavior problems; and (9) lack of dental "buy in" from adolescents. CONCLUSION: Additional studies are needed to determine whether children living in foster care achieve oral health, and the extent of their unmet dental need.

Effect of CPP-ACP paste on dental caries in primary teeth: a randomized trial.

This clinical trial tested the effect of daily application of 10% w/v calcium phosphopeptide-amorphous calcium phosphate (CPP-ACP) paste for 1 yr when added to regular toothbrushing with fluoridated toothpaste to prevent dental caries in pre-school children. High-caries-risk children aged 2½ to 3½ yrs in a suburban area of central Thailand were assigned to receive either CPP-ACP (n = 150) or a placebo control (n = 146) in addition to fluoridated toothpaste. The International Caries Detection and Assessment System (ICDAS) was recorded at baseline, 6 mos, and 1 yr. At 1 yr, a significant increase in mean numbers of enamel and dentin caries lesions, as well as dmfs, was found in both groups (p < 0.001). No significant difference was observed between groups on these 3 outcome measures (p = 0.23, 0.84, and 0.91, respectively). The odds of enamel caries lesion transitions to a state of regression or stability, compared with progression from baseline, was also not different between groups [OR = 1.00, 95% CI (0.86, 1.17)]. This trial found that daily application of 10% w/v CPP-ACP paste on school days for 1 yr, when added to regular toothbrushing with a fluoride toothpaste, had no significant added effect in preventing caries in the primary dentition of these pre-school children (ClinicalTrials.gov number CT01 604109).

PTPN2 but not PTPN22 is associated with Crohn's disease in a New Zealand population.

Recent genome-wide association studies have provided evidence for the involvement of the genes PTPN2 and PTPN22 in the pathogenesis of Crohn's disease (CD). We investigated whether genetic variants in these genes were associated with CD in a New Zealand population. Single-nucleotide polymorphisms (SNPs) rs2542151 (PTPN2) and rs2476601 (PTPN22) were genotyped in 315 CD cases and 481 controls. In this sample, we were able to confirm an association between CD and PTPN2 (genotypic P = 0.019 and allelic P = 0.011), and phenotypic analysis showed an association of this SNP with late age at first diagnosis, inflammatory and penetrating CD behaviour, requirement of bowel resection and being a smoker at diagnosis. There was no evidence for an association with PTPN22.

Single nucleotide polymorphisms in human Paneth cell defensin A5 may confer susceptibility to inflammatory bowel disease in a New Zealand Caucasian population.

BACKGROUND: Human Paneth cell alpha-defensins, especially DEFA5, are involved in maintaining homeostasis of the human microbial microflora. Since breakdown of normal mucosal antibacterial defence occurs in inflammatory bowel disease (IBD), variants in the DEFA5 gene could be associated with IBD risk. SUBJECTS: A cohort of 25 patients with indeterminate colitis (IC), 405 with ulcerative colitis (UC), and 385 with Crohn's disease (CD), were compared with 201 control individuals from the Canterbury region in New Zealand. METHODS: A 15 kb haplotype block surrounding DEFA5 contained 35 HapMap markers which were polymorphic in Caucasians. Four markers (A-D) were selected to tag 27 of the 35 markers at r(2)>0.68, and were genotyped in DNA samples. RESULTS: Minor allele frequencies for all single nucleotide polymorphisms (SNPs) were somewhat elevated in patients. Subgroup analysis showed SNP A had odds ratio 1.44 in UC patients with pancolitis (95% C.I. 1.07-1.94), SNP B odds ratio 2.37 in CD patients with onset prior to 17 years age (95% C.I. 1.12-5.03), SNP C odds ratio 1.68 in UC patients with left colonic localisation (95% C.I. 1.12-2.52), and SNP D had odds ratio 1.56 in CD patients with one or more relatives with IBD (95% C.I. 1.03-2.35). Two two-marker haplotypes and one three-marker haplotype were associated with UC (p-values 0.025-0.05). CONCLUSIONS: The SNPs genotyped in our study were surrogates for common variants, and observed associations between these and IBD status are likely due to linkage disequilibrium with a functional common DEFA5 variant. Identifying such functional variants will be prioritized in subsequent work.

Gender-stratified analysis of DLG5 R30Q in 4707 patients with Crohn disease and 4973 controls from 12 Caucasian cohorts.

BACKGROUND: DLG5 p.R30Q has been reported to be associated with Crohn disease (CD), but this association has not been replicated in most studies. A recent analysis of gender-stratified data from two case-control studies and two population cohorts found an association of DLG5 30Q with increased risk of CD in men but not in women and found differences between 30Q population frequencies for males and females. Male-female differences in population allele frequencies and male-specific risk could explain the difficulty in replicating the association with CD. METHODS: DLG5 R30Q genotype data were collected for patients with CD and controls from 11 studies that did not include gender-stratified allele counts in their published reports and tested for male-female frequency differences in controls and for case-control frequency differences in men and in women. RESULTS: The data showed no male-female allele frequency differences in controls. An exact conditional test gave marginal evidence that 30Q is associated with decreased risk of CD in women (p = 0.049, OR = 0.87, 95% CI 0.77 to 1.00). There was also a trend towards reduced 30Q frequencies in male patients with CD compared with male controls, but this was not significant at the 0.05 level (p = 0.058, OR = 0.87, 95% CI 0.74 to 1.01). When data from this study were combined with previously published, gender-stratified data, the 30Q allele was found to be associated with decreased risk of CD in women (p = 0.010, OR = 0.86, 95% CI 0.76 to 0.97), but not in men. CONCLUSION: DLG5 30Q is associated with a small reduction in risk of CD in women.

Quality of life and health-risk behaviors among adolescents.

PURPOSE: To assess the association between health-risk behaviors and self-perceived quality of life among adolescents METHODS: A sample of 2801 students (957 seventh and eighth graders and 1844 ninth through twelfth graders) completed the Teen Assessment Survey (TAP) and the surveillance module of the Youth Quality of Life Instrument (YQOL-S). TAP responses were used to determine health-risks related to tobacco use, alcohol use, illicit drug use, and high risk sexual behavior. Separate multivariate analyses of variance showed mean differences in contextual and perceptual items of the YQOL-S for each health-risk behavior. Differences among engagers (adolescents who often engage), experimenters (occasionally engage), and abstainers (never engage) in the health-risk behavior were evaluated by gender and junior/senior high school groups. RESULTS: In general, adolescent abstainers reported higher quality of life (QoL) than engagers and experimenters on YQOL-S items. Adolescents who engaged in multiple risk behaviors scored even lower than those who engaged in only one health-risk behavior. Experimenters tended to rate their QoL more similar to that of abstainers than to that of engagers. CONCLUSIONS: The framework of QoL proved useful in the evaluation of adolescents' engagement in health-risk behaviors. Additionally, assessing the areas of QoL that differ between the groups may provide information for planning interventions aimed at risk reduction among engagers and experimenters.

PrePare: a program of enhanced prenatal services within health-maintenance organization settings.

This paper presents the conceptual framework and implementation strategies of a relationship-focused behavioral intervention for pregnant women and their families. The program, PrePare ('Prenatal Parenting'), was designed as a prenatal precursor to the pediatric health care model, Healthy Steps. PrePare includes preventive intervention elements that address parents' universal concerns about pregnancy and parenthood, as well as specific activities to support optimum pregnancy health and reduce high-risk behaviors. As described here, the program is embedded within a large not-for-profit health-maintenance organization (HMO). Delivery of the prenatal component is carried out by Healthy Steps interventionists through three home visits and telephone follow-up during mothers' second and third trimesters of pregnancy. An evaluation of program outcomes is underway. The design compares three groups of families, those who receive PrePare followed by Healthy Steps, Healthy Steps alone and a usual HMO-practice comparison. It is hypothesized that initiating expanded services during the prenatal period will lead to increases in reported patient satisfaction, provider satisfaction and organizational efficiency within the health care delivery system.

Airbag-induced fracture in a patient with osteoporosis.

Since the introduction of automotive airbag technology, patterns of airbag-induced injuries have emerged. Various types of upper-extremity trauma including fractures have been described. Previous reports have focused on the location of the forearm before deployment as the major determinant of fracture. We describe a case of forearm fracture resulting from an airbag deployment in a lupus patient with documented osteoporosis. Bone strength has recently been determined in laboratory testing to be an important factor determining airbag-induced fracture risk. An airbag-induced forearm fracture in an otherwise healthy individual may be an indicator of reduced bone strength.

Hepatitis C and inclusion body myositis.

Hepatitis C is known to be associated with a myriad of autoimmune diseases. Inclusion body myositis is an inflammatory myopathy of unknown etiology. We report the first case of chronic hepatitis C with inclusion body myositis.

Proteoglycans from osteoarthritic human articular cartilage influence type II collagen in vitro fibrillogenesis.

Collagen fibrils were formed in the presence of dermatan sulfate (DSPG) and high density (HDPG) proteoglycans isolated from human adult knee femoral articular cartilage. Eroded cartilage had a higher percentage of DSPGs in the extracted proteoglycans than normal cartilage (p = .018). The dermatan sulfate proteoglycans (DS-PGI and DS-PGII) were detected in normal and osteoarthritic cartilage. DSPGs compared to HDPG inhibited in vitro collagen fibrillogenesis producing a longer lag phase (p less than .05) and a slower rate of fibril formation (p less than .05). DSPGs from eroded osteoarthritic cartilage alone or in combination with HDPG produced a longer lag phase than DSPGs from normal cartilage alone or in combination with HDPG (p less than .05). The inhibition of fibrillogenesis by DSPGs suggests that collagen fibril formation in vivo may be abnormal due to the influence of molecular changes in proteoglycan as well as an increased proportion of DSPGs occurring in osteoarthritic cartilage. Abnormal fibril formation may produce a weakened cartilage matrix, thus contributing to an accelerated process of cartilage degeneration in osteoarthritis.

Angiotensin converting enzyme inhibitors: 1-glutarylindoline-2-carboxylic acids derivatives.

The preparation of a series of 1-glutarylindoline-2(S)-carboxylic acid derivatives, 6a-v and 21a-c, is described. The above compounds were tested for inhibition of angiotensin converting enzyme. The structure-activity relationship of the series is also discussed. Compound 6u, the most potent member of the series, had an in vitro IC50 of 4.8 X 10(-9) M. Compound 6v, an ethyl ester of 6u, lowered blood pressure 70 mm in spontaneous hypertensive rats at an oral dose of 30 mg/kg.