Effect of hypnosis on masseter EMG recorded during the 'resting' and a slightly open jaw posture.

The aim of this experimental study was to determine whether minimal levels of electromyographic activity in the masseter muscle are altered when individuals are in a verified hypnotic state. Experiments were performed on 17 volunteer subjects (8 male, 9 female) all of whom gave informed consent. The subjects were dentate and had no symptoms of pain or masticatory dysfunction. Surface electromyograms (EMGs) were made from the masseter muscles and quantified by integration following full-wave rectification and averaging. The EMGs were obtained (i) with the mandible in 'resting' posture; (ii) with the mandible voluntarily lowered (but with the lips closed); (iii) during maximum voluntary clenching (MVC). The first two recordings were made before, during and after the subjects were in a hypnotic state. Susceptibility to hypnosis was assessed with Spiegel's eye-roll test, and the existence of the hypnotic state was verified by changes in ventilatory pattern. On average, EMG levels expressed as percentages of MVC were less: (i) when the jaw was deliberately lowered as opposed to being in the postural position: (ii) during hypnosis compared with during the pre- and post-hypnotic periods. However, analysis of variance followed by post hoc tests with multiple comparison corrections (Bonferroni) revealed that only the differences between the level during hypnosis and those before and after hypnosis were statistically significant (P < 0·05). As the level of masseter EMG when the mandible was in 'resting' posture was reduced by hypnosis, it appears that part of that EMG is of biological origin.

Effect of saliva and blood contamination on the bi-axial flexural strength and setting time of two calcium-silicate based cements: Portland cement and biodentine.

This study evaluated the effect of contamination with saliva and blood on the bi-axial flexural strength and setting time of pure gray Portland cement and Biodentine (Septodont, Allington, UK). A one-way ANOVA showed that contamination caused no significant difference between the cements in bi-axial flexural strength (P> 0.05). However there was a significant difference in setting time (P

Reduction of extracellular methemoglobin by erythrocytes.

Erythrocytes, suspended in a glucose-containing buffer, catalyzed the partial reduction of extracellular methemoglobin. Physiological concentrations of ascorbic acid or dehydroascorbic acid greatly enhanced the rate of reaction and the ultimate extent of reduction. The relationship between erythrocyte concentration and initial reaction rate was nonlinear, which suggested that the rate limiting factor was not an erythrocyte membrane enzyme. Also, significant dehydroascorbate-stimulated reduction occurred even when the erythrocytes and methemoglobin were separated by a dialysis membrane. The above observations indicate that the transfer of reducing equivalents across the erythrocyte membrane and reduction of extracellular methemoglobin can be accomplished by release and recycling of ascorbic acid.

Using sector endoluminal ultrasound to identify the normal pancreas when axial computed tomography is falsely positive.

RATIONALE AND OBJECTIVES: Little has been reported on the ability of endoluminal ultrasound (EUS) to identify a normal pancreas after an abnormal axial computed tomogram (CT). Many clinicians still use axial technology, as opposed to helical or spiral CT, which differ in scanning speed. Spiral CT and EUS are considered equal in their ability to diagnose pancreatic tumors. Although this is not the case with axial CT, the complementary role by EUS has not been defined. This study reports on the ability of EUS to identify the "true-negative" pancreas deemed abnormal by axial CT. METHODS: Sixty-five consecutive patients suspected of having a small pancreatic lesion were studied by comparing axial CT and EUS examinations, using each patient as his or her own control. Identification of a normal pancreas was reviewed using surgery, biopsy, and long-term clinical follow-up as the standard of truth. RESULTS: Thirty-three patients were documented as having small pancreatic lesions; the remaining 32 were normal. The sensitivity and specificity, respectively, were 91% and 41% for axial CT and 88% and 88% for EUS. The positive and negative predictive values, respectively, were 61% and 82% for CT and 88% and 88% for EUS. The statistical differences between axial CT and EUS were significant. CONCLUSION: An axial CT positive for a small pancreatic mass requires confirmation with additional imaging before invasive management. The specificity of EUS--twice that of CT--is strong evidence that EUS can fulfill this role. Review of the literature supports the conclusion that EUS should be required in the workup of small pancreatic lesions identified at axial CT.

Paecilomyces lilacinus cellulitis in an immunocompromised patient.

Paecilomyces lilacinus, a saprophytic soil fungus, is an uncommon human pathogen. An immunocompromised patient developed a deep cellulitis due to P lilacinus. The infection responded poorly to intravenous amphotericin B but eventually resolved after combination therapy with amphotericin B and flucytosine (5-fluorocytosine). Previous in vitro studies have suggested that miconazole is the most active antifungal agent against P lilacinus.

Foreign bodies of the gastrointestinal tract.

The majority of foreign bodies in the gastrointestinal tract require no medical or surgical intervention for removal. Prior to the era of modern gastrointestinal endoscopy, the management of ingested objects or nontherapeutic objects placed in the rectum required general anesthesia and was relegated to the general surgeon or otolaryngologist. With the advancement of therapeutic endoscopy, fewer affected individuals require surgical intervention. The physician involved with the initial evaluation of these patients must have a working knowledge of foreign bodies of the gastrointestinal tract to facilitate appropriate and timely management and referral.

Photopromotion of sister chromatid exchanges by psoralen derivatives.

Several derivatives of 8-methoxypsoralen and 4,5'8-trimethylpsoralen were compared with respect to their photopromotion of sister chromatid exchanges. Peripheral blood leukocytes from heparinized blood of human volunteers were cultivated for 24 h. Selected flasks received psoralens (6.5 X 10(-8) M) and/or were irradiated (UV-A, 365 nm, 0.9 J/cm2). Bromodeoxyuridine (20 micrograms/ml) was added and flasks were further incubated for 48 h when colchicine was added. Spreads of mitotic chromosomes were prepared, stained with Hoechst 33258 and Giemsa, and scored for the number of sister chromatid exchanges (SCEs) per 100 chromosomes. Results were: Control (16.5); 8-methoxypsoralen (23.9); 5'-methyl-8-methoxypsoralen (25.7); 4-methyl-8-methoxypsoralen (27.8); 4,5'-dimethyl-8-methoxypsoralen (31.9); 4'-methoxymethyl, 4,5'8-trimethylpsoralen (42.9); 4'aminomethyl, 4,5'8-trimethylpsoralen-hydrochloride (59.1); 4'hydroxymethyl,4,5'8-trimethylpsoralen (75). In general, the psoralens with strong affinity for DNA as determined by KD values promoted more SCEs than did those with lower affinity. Trimethylpsoralen and its derivatives promoted more SCEs than did 8-methoxypsoralen and its derivatives, which may be indicative of relative DNA cross-linking potential.

The induction by X-rays of chromosome aberrations in germ cells of male guinea-pigs, golden hamsters and rabbits. I. Dose response in post-meiotic stages.

The induction by X-rays of translocations in post-meiotic germ cells of the guinea-pig, golden hamster and rabbit was studied by cytological analysis of male offspring of the irradiated animals. As reported previously for the mouse, the pattern of sensitivity to dominant lethal induction, as indicated by litter-size, was similar to that for translocation induction in both the guinea-pig and golden hamster. In both speciesspermatids were more sensitive than spermatozoa, and in the golden hamster spermatocytes gave a lower yield than spermatids. The translocation frequency among post-meiotic germ cells treated with 600 rad was higher in the rabbit than the guinea-pig, and both were above that for the golden hamster. However, for spermatozoa, species differences with respect to the recovered translocation yield appeared to depend on dose. In the hamster, the translocation frequency after 600 rad, as measured in the female offspring, was similar to that obtained in the male offspring. A small amount of data on the induction of sex-chromosome aneuploidy by 200 rad in golden hamsters suggested that the hamster might be as sensitive as the mouse.

Twitch interpolation in the assessment of the maximum force-generating capacity of the jaw-closing muscles in man.

The method of twitch interpolation was employed to study the maximum potential bite forces of humans. Transcutaneous electrical stimuli were applied to parts of one or both masseter muscles in eight volunteers while they bit with a variable but controlled isometric force on a unidirectional force transducer held between the anterior teeth. In all participants the twitch force produced by a single 1-ms pulse, of 25 50 mA intensity, was inversely and linearly related to the voluntary bite force. For each participant the slope of the regression between twitch force and bite force depended on the stimulus intensity and not on whether the stimulus was applied to one or both masseters. Extrapolation of the regression lines to zero twitch force showed that they converged towards a bite-force value that, for any given participant varied only a small amount between different stimulus intensities. For most participants this bite force lay above the maximum that they produced voluntarily: voluntary maximum bites ranged from 153 to 593 N, while the extrapolations predicted a narrower and higher potential range of 282-629 N. It was concluded that, for the masseters at least, there is often spare force-generating capacity which individuals are either unable or not prepared to utilize. This method is non-invasive and may help to define better the maximum bite-force potential of humans.

Pilot study of a semi-flexible intra-oral appliance for the control of snoring.

OBJECTIVE: To determine the effectiveness and acceptability of an intra-oral appliance in the reduction of snoring, with construction and fitting as a 1-visit process. DESIGN AND SETTING: This was a prospective study. Patients were attending a hospital sleep breathing disorders clinic and appliances were made at a dental hospital. This work was carried out in the UK during 1996 and 1997. SUBJECTS AND METHODS: Patients were selected from those referred to a sleep breathing disorders clinic with socially disruptive snoring. MAIN OUTCOME MEASURES: Patients were assessed by means of limited sleep studies and by questionnaires before and after fitting of the appliances. The sleep studies consisted of monitoring respiratory variables (principally oronasal airflow and nocturnal oxygen saturation). A respiratory disturbance index was assigned. Questionnaires were completed by both patients and sleep partners, with many of the responses being marked on visual analogue scales. RESULTS: 16 male patients, mean age 49 years, were included in the trial. 14 were able to wear the appliance and their level of snoring, as assessed by their sleep partners, reduced from a mean of 8.8 out of 10 to 4.2 out of 10 (P = 0.0003, paired t-test). CONCLUSION: It is concluded that the semi-flexible intra-oral appliance is effective in the control of snoring.

The provision of hospital maxillo-facial prosthetic services in Scotland.

Maxillo-facial prosthetics can contribute much to the quality of life of patients with congenital problems or those treated surgically for a head and neck neoplasm. The availability of an adequate service varies internationally. The present study examines the current provision and requirements for such a service in Scotland. A questionnaire survey of 90 oral, plastic and ENT surgeons was carried out. Information was sought on numbers and types of cases seen, prosthetic treatment provided and involvement of Consultants in Restorative Dentistry in their management. The results show that most surgeons only treat a small number of such patients with a consequent dilution of experience, and with a possible need for supra-regional specialist centres. In addition there is a need for improvement of multi-disciplinary planning clinics for such cases.

Is it our turn to be CEO yet?

Physician executives continue to have ambitions for the health care CEO role, despite the difficult economic times. And though few have yet been chosen for the position, the expectation is that this will change markedly in the next five to seven years. Today, physician executives have legitimate, relevant professional experiences that directly qualify them for CEO roles in health initiatives. And no executive is more qualified to deal with medical care management issues than the physician executive. Key elements of preparedness are: Executive thinking, bundling projects, and learning to manage managers. The opportunities will be open to those who are ready to take them on.

Winning the interviewing game.

Those who don't "interview well" are not likely to receive the job offer, despite their qualifications. A job interview is actually a fierce competitive activity that offers only two grades: an A or F. By nature, physicians are competitive; they like to win. Infrequent interviewees are prone to making easily corrected mistakes, such as showing no enthusiasm or having poor eye contact. The key for interviewing success is preparation--doing research, developing a personal statement, and role-playing practice interviews. View the interview as a sales call whose bottom-line goal is to achieve an offer, or at least to let you leave with the option to return for future discussions.

High expectations mirror high stakes for physician executives.

Because the stakes in health care are high, physician executives are challenged to meet high expectations set by their CEOs and boards. These may be unrealistic--for example, demanding that physician executives possess expertise in finance or strategic planning. Job stresses for physician executives are specific to the role, but are not unlike those faced by other senior executives. It's a fact that professionals leave jobs for any number of reasons; sometimes, not through their own choice or fault. Thus, every time a physician executive leaves a job, it should not be characterized as "being fired," and not every job-leaving should be taken as a failure. Accept that you may make mistakes while doing the best job you can. Rely on your own value system and integrity to see you through.

The purpose of a job interview is a job offer.

Perhaps empathy has been overdone in recent years. Most of us would admit to some cynicism or disbelief when we hear the words, "I know how you feel." Having said that, however, I actually do know how you feel. If I can't identify exactly where you are coming from, I do know where you are likely to be going and how bumpy the ride is likely to be. I'm a physician and a physician executive. I am also an executive search consultant who is daily in the field interviewing physicians who may or may not be the right individuals for a client's situation. If I don't exactly feel your pain, at least I know its sources. I know how difficult it is to make the move from challenging clinical work to an administrative role in health care. While, as a group, physicians are multiskilled and multitalented, it's an unfortunate fact that some of the skills and talents that made you an excellent physician may be blocking you from succeeding in an executive capacity. My hope is that, through an occasional entry in this column, I can share my experiences and relate the remarkable wisdom of the impressive physician executives whom I meet every day. The first issue I'm opening up for discussion is employment interviewing: Why the interview is so important, what the interviewing process is, and how you can become more adept in this critical skill area.

The MBA mystique.

Is an MBA the solution for you? Do physician executives need to have a business degree to compete in today's competitive marketplace? What are clients looking for when they make hiring decisions? The answers may surprise you. This column is an attempt to dispel myths about physician executives and the MBA degree. Clients want to attract and hire physician executives who possess sometimes intangible skills--with or without the MBA credential. These intangible skills include the ability to educate other physicians to the new health care realities, a sales orientation emphasizing effective communication that focuses on patients and payers as customers, comfort with ambiguity, flexibility, and tact and sensitivity in negotiations.

Getting started as a physician executive.

In clinical practice, technical skills often outweigh interpersonal and leadership skills as success factors--you can be a great doctor and a so-so person. But the reverse seems to be true in the physician executive role; it is precisely the intangible leadership skills that contribute to and determine potential success. And they can be tough to master, especially when you focus on them for the first time, partway through an already-successful career. Practicing leadership is like practicing medicine. It's not just a matter of learning some new things--if it were only that, physicians are known to be excellent learners. Nor is it just a matter of determination or application--this is not a battle that sweat and effort alone can win. Most physicians will want to "try on" the executive role before making strategic moves in that direction. But be clear about what you want to get out of any project or activity before you jump in. If you're seeking a management degree, the best approach is to tie together developing your technical and interpersonal skills, as well as the formal credentials.

A great position before a great 'package'.

Should employment agreements (EAs) be the deciding factor in considering a new position? EAs are details--important details, but background just the same--to the key issue: Do you want the job? And because of the way many health care organizations create their EAs, there really is little room for negotiation. Perceptions persist that this is an entirely open area, a blank canvas upon which each physician executive, in each situation, must don his or her battle gear and fight fiercely for the best possible deal. And yet, this is an area in which you are unlikely to have control.

Be positive--it's a necessary strategy.

The hallmarks of successful health care organizations include: A positive physician culture; meaningful physician involvement in governance and top management; and stability and strong community roots. Success is most likely where physicians in the facilities are having professional fun, where freedom from negativity allows them to perform at their highest level of quality. When a positive physician culture takes hold, remarkable things can occur. In the best scenarios, physicians are deeply involved in strategic direction, as well as in practice. They are part of making the decisions, instead of merely grumbling about decisions made by others. The column provides suggestions for creating a positive physician culture.

Care management challenge is the toughest yet.

The newest health care trend involves changing the core business--health care delivery and the resources involved--through better care management. This impacts every practitioner all day, every day. This issue truly belongs to the physicians, and thus to physician executives. Care management is the latest frontier, the place where the delivery of quality care, in the most efficient way, at the best possible cost, all come together. And physician executives are being challenged to make it happen, to change the way medicine is practiced and health care is delivered across the country, to move from treating episodes of care to a true preventive mindset and population-based methodologies. This column outlines the skills in care management that systems-based physician executives will need to develop or enhance to remain competitive--effective communication skills and team-building capabilities are critical attributes for those who hope for success.