The impact of socially-accountable, community-engaged medical education on graduates in the Central Philippines: Implications for the global rural medical workforce.

INTRODUCTION: Developing and retaining a high quality medical workforce, especially within low-resource countries has been a world-wide challenge exacerbated by a lack of medical schools, the maldistribution of doctors towards urban practice, health system inequities, and training doctors in tertiary centers rather than in rural communities. AIM: To describe the impact of socially-accountable health professional education on graduates; specifically: their motivation towards community-based service, preparation for addressing local priority health issues, career choices, and practice location. METHODS: Cross-sectional survey of graduates from two medical schools in the Philippines: the University of Manila-School of Health Sciences (SHS-Palo) and a medical school with a more conventional curriculum. RESULTS: SHS-Palo graduates had significantly (p < 0.05) more positive attitudes to community service. SHS-Palo graduates were also more likely to work in rural and remote areas (p < 0.001) either at district or provincial hospitals (p = 0.032) or in rural government health services (p < 0.001) as Municipal or Public Health Officers (p < 0.001). Graduates also stayed longer in both their first medical position (p = 0.028) and their current position (p < 0.001). CONCLUSIONS: SHS-Palo medical graduates fulfilled a key aim of their socially-accountable institution to develop a health professional workforce willing and able, and have a commitment to work in underserved rural communties.

Mortality attributable to rheumatic heart disease in the Kimberley: a data linkage approach.

BACKGROUND: Acute rheumatic fever (ARF) and its sequelae, rheumatic heart disease (RHD) are now uncommon in the general Australian population. However, these preventable and treatable diseases continue to affect Aboriginal Australians disproportionately, especially in remote communities. In the Kimberley region of Western Australia (WA), the prevalence of RHD is approximately 1% among Aboriginal residents. Yet an accurate and comprehensive picture of RHD-related mortality is lacking. AIM: This study aims to determine the mortality burden attributable to ARF and RHD in the Kimberley using linked hospitalisation and death registry data. METHODS: A retrospective cohort study was undertaken comprising all Kimberley residents with a WA hospital admission for ARF or RHD between 1970 and 2010, linked with the WA Death Register. We manually classified RHD-attributable deaths ('definite' or 'probable') to determine mortality burden. Hospitalisation prior to death, including valvular surgery was also ascertained. RESULTS: There were 35 RHD-attributable deaths in the Kimberley between 1990 and 2010, with 94% occurring in Aboriginal people. Their median age of death was 40 years. The age-standardised RHD annual death rate was 15.6 per 100 000 with a total of 1100 premature years of life lost before age of 75 within this group. Conventional International Classification of Diseases-generated mortality data underestimated mortality burden. CONCLUSION: RHD remains a significant cause of premature mortality for Aboriginal people in the Kimberley, with mortality rates unmatched in the general Australian population since the first half of the 20th century. Efforts to reduce progression of this disease through RHD Register and Control Programs are crucial alongside action to address underlying socioeconomic and environmental inequities.

A comparison of McGrath and Macintosh laryngoscopes in novice users: a manikin study.

Direct laryngoscopy using the Macintosh laryngoscope is a difficult skill to acquire. Videolaryngoscopy is a widely accepted airway management technique that may be easier for novices to learn. We compared the McGrath videolaryngoscope and Macintosh laryngoscope by studying the performance of 25 medical students with no previous experience of performing tracheal intubation using an easy intubation scenario in a manikin. The order of device use was randomised for each student. After brief instruction each participant performed eight tracheal intubations with one device and then eight tracheal intubations with the other laryngoscope. Novices achieved a higher overall rate of successful tracheal intubation, avoided oesophageal intubation and produced less dental trauma when using the McGrath. The view at laryngoscopy was significantly better with the McGrath. Intubation times were similar for both laryngoscopes and became shorter with practice. There was no difference in participants' rating of overall ease of use for each laryngoscope.

Brain gamma-aminobutyric acid deficiency in dialysis encephalopathy.

We measured levels of gamma-aminobutyric acid (GABA) in the CSF and in the autopsied brain of patients with dialysis encephalopathy. GABA concentrations were low in the CSF of three of five living patients. Mean GABA content was reduced by 30 to 50% in five brain regions (frontal, occipital, and cerebellar cortex, caudate nucleus, and medial dorsal thalamus) in five fatal cases. GABA content was normal in brain regions where GABA is characteristically reduced in Huntington's disease. Choline acetyltransferase activity was diminished (by 25 to 35%) in cerebral cortex of the dialysis encephalopathy patients.

Denture sore mouth.

Denture sore mouth is most often caused by improperly fitting dentures. Ulcers, stomatitis, hyperplasia, bone resorption, and chronic candidiasis may develop under improperly fitting dentures. If extensive bone resorption occurs, dental implants may be necessary. Malignant changes can develop.

Qualitative analysis of peripheral peri-implant bone and influence of alendronate sodium on early bone regeneration.

BACKGROUND: Alendronate sodium increases alveolar bone density with systemic use. It inhibits osteoclast activity and is thought to result in a net increase in osteoblastic activity. However, little is known about local in vivo use. The purpose of this study was to evaluate the effect of local delivery of alendronate on bone regeneration within peri-implant defects. Peri-implant bone was examined histomorphometrically to evaluate the amount of supporting bone peripheral to the bone-implant interface. METHODS: Six adult hound dogs were evenly divided into 2 groups, with one group receiving alendronate-coated dental implants and the other group serving as controls. Dental implants were placed immediately after extraction of right and left second, third, and fourth mandibular premolars. Forty-eight dental implants were placed (2 types in each dog: 24 hydroxyapatite [HA]-coated and 24 titanium machine-polished [TMP]), for a total of 4 variables. A bioabsorbable collagen membrane was secured over the implants and defects, and the flaps closed primarily. The dogs were sacrificed on day 28. Specimens were sectioned, mounted, and stained with Stevenel's blue and van Gieson's picric fuchsin. The amount of bone adjacent and 1 mm peripheral to the implant surface was recorded with a computerized microscopic digitizer. RESULTS: Locally applied alendronate resulted in significantly increased amounts of bone (P<0.0002, ANOVA) in the peripheral area with both HA and TMP implants. However, the most influential factor in the amount of peripheral bone was the type of implant surface (P<0.0001). CONCLUSIONS: Local application of alendronate is useful in increasing the amount of peripheral peri-implant bone. Also, the amount of supporting bone was not related to the bone-to-implant contact but to the surface characteristics of the implant. The findings of the present study indicate that the evaluation of dental implant-supporting bone should include peripheral bone as well as bone-to-implant interface.

Albers-Schönberg disease complicated with periodontal disease. Report of a case with 36-year history.

A patient had the benign form of Albers-Schönberg disease complicated by periodontitis. Review of the patient's 36-year history revealed that the long-term prognosis can be good. Determining factors in the prognosis are the severity of bony involvement and proper periodontal and dental maintenance.

Lyophilized bone allografts in periodontal intraosseous defects.

Nine patients with 10 pairs of intraosseous periodontal defects were treated. Most of the patients had identical bilateral lesions (referred to as "mirror-image" defects). In each pair, one of the defects was randomly selected and treated as a flap and currettage control whereas the other defect was grafted with freeze-dried cortical powdered allografts of bone. Evaluation was based on radiographs, photographs, and measurements taken during both the initial surgery and at reentry approximately 1 year after transplantation. Control procedures (flap and curettage) demonstrated the same amount of osseous regeneration as that seen with the graft procedure. The amount of osseous regeneration demonstrated with the grafting procedures agreed with previously published studies. Evaluation revealed that (1) an autologous control such as incorporated in the "mirrow-image" design of this study is probably the most valid experimental model available for evaluating the clinical effectiveness of any human periodontal grafting procedures; (2) the effectiveness of freeze-dried cortical powdered bone allografts in human periodontal osseous defects is questionable and needs additional study; and (3) nongrafting procedures may be more effective in generating new attachments or reattachments in human periodontal osseous defects than previously believed.

Use of alendronate in peri-implant defect regeneration.

BACKGROUND: Previous studies have demonstrated an increase in bone mass and density with use of systemic alendronate sodium. This agent acts as an inhibitor of osteoclast activity, and is thought to result in more net osteoblastic activity. The objective of this study was to determine the effects of locally applied alendronate sodium on guided bone regeneration around dental implants. METHODS: Six adult mongrel dogs were divided into 2 groups: one group received alendronate-coated dental implants, and the other group served as control. Two types of dental implants were used in each dog: hydroxyapatite (HA)-coated and titanium machine-polished (TMP), for a total of 4 groups. Dental implants were placed immediately after extraction of the right and left second, third, and fourth mandibular premolars; a resorbable collagen membrane was secured over the implants and defects; and the flaps were closed primarily. Fluorescent labels were administered intravenously on days 0, 6, 12, and 22 to measure bone formation rate. Dogs were sacrificed on day 28. The specimens were sectioned and mounted, and bone formation rate was recorded with a computerized microscopic digitizer. Specimens were stained with Stevenel's blue and van Gieson's picric fuchsin. Bone-to-implant contact was recorded with a computerized microscopic digitizer. RESULTS: The results indicated a significant effect of locally applied alendronate (P < 0.0001) with both types of implants (HA and TMP), as well as the HA coating (P< 0.02) on increased bone formation rate. Additionally, alendronate had a significant effect on bone-to-implant contact, with an increase in the TMP model (P < 0.0001) and a decrease in the HA model (P < 0.0001 ). HA coating also had a significant effect on increasing bone-to-implant contact (P < 0.04). CONCLUSIONS: The results indicate that alendronate increases early bone formation rate around dental implants. Additionally, the local application as described resulted in greater bone-to-implant contact with TMP implants.

Lymphocytotosicity for gingival epithelial cells in periodontal disease.

An immune pathogenesis has been implicated in periodontal disease. Lymphocytotoxicity assays utilizing a suspension of peripheral blood lymphocytes incubated with allogeneic trypsinized gingival epithelium were performed. The results demonstrate a significant in vitro lymphocytotoxicity for gingival epithelial target cells when the aggressor lymphocytes are from patients with destructive periodontal disease (high PDI). No significant lymphocytotoxicity was demonstrated with lymphocytes for periodontal disease-free (low PDI) patients. We conclude that there is a significant reduction in gingival epithelial cell survival after an 18-hour incubation with aggressor lymphocytes obtained frompatients who have destructive periodontal disease, and suggest there is a pathologic relationship between the patient's lymphocytes and the disease process.

Biosynthesis of prostaglandins in gingiva of patients with chronic periodontitis.

This study was undertaken to determine the ability of inflamed and normal gingival tissues to synthesize prostaglandins (PGs) from the precursor arachidonic acid. Thirteen samples of inflamed human gingival tissue and six samples of normal human gingival tissue were studied. The inflammation was characterized histologically. After incubation of the tissue with [14C]arachidonate, PG metabolites were separated by thin-layer chromatography and identified by comparison with co-chromatographed standards. Inflamed gingival tissue synthesized significantly larger amounts, compared to normal tissue, of 6-keto-PGF1 alpha (P less than 0.05), thromboxane B2 (P less than 0.01), PGD2 (P less than 0.05), and PGA2 (P less than 0.001). Some unidentified metabolites, possibly lipoxygenase products were detected in significantly (P less than 0.001) larger amounts in inflamed than in normal tissue.

Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery.

Both the modified Widman flap and the intrasulcular incision technique produced significant and similar reductions in pocket depth and increases in attachment. Loss of attachment occurred where the initial pocket depth was less than 3 mm. Both techniques resulted in significant and similar increases in gingival recession. Neither technique affected tooth mobility or plaque scores to a clinically important degree. Historically, the necessity for removal of the sulcular epithelium in the course of periodontal therapy is a widely accepted tenet. This study fails to clinically validate this concept.

Treatment of peri-implant defects with combination growth factor cement.

BACKGROUND: The use of growth factor agents in the regeneration of oral tissues is an area of current investigation. Combinations of growth factors have been used synergistically to improve tissue regeneration. The aim of this study was to determine the effects of a combination growth factor cement (GFC) on guided bone regeneration around dental implants. METHODS: A combination of bone morphogenetic protein-2 (BMP-2), transforming growth factor-beta (TGF-beta), platelet-derived growth factor (PDGF), and basic fibroblast growth factor (bFGF) was used in a bioabsorbable, non-hydroxyapatite, calcium phosphate cement. Five adult hound dogs were used to compare the effects of GFC, plain cement, and control (no cement). The right and left second, third, and fourth mandibular premolar teeth were extracted; the implant osteotomies were prepared; and a uniform circumferential gap was prepared 1.5 mm beyond the width of the implant in the coronal half of the osteotomy for cement placement. Titanium machine-polished dental implants were placed in the prepared sites, and coronal defects were treated according to previously randomized, assigned modality. A bioabsorbable collagen membrane was secured over the control site, and the flaps were closed primarily. The dogs were maintained on a soft diet to avoid soft tissue trauma. The dogs were sacrificed at 3 months. The specimens were sectioned, mounted, and stained with Stevenel's blue and van Gieson's picric fuchsin. The bone-to-implant contact and bone 1 mm peripheral to the implant surface were recorded with a computerized microscopic digitizer. RESULTS: The findings of this study indicate a significant effect of GFC on increased bone-to-implant contact and amount of bone per surface area compared with the other treatment modalities (P <0.0009). Plain cement demonstrated slight but nonsignificant increases compared with the control (P>0.05). CONCLUSIONS: GFC increases bone-to-implant contact and bone surface area within peri-implant defects. Further studies may be beneficial to determine the feasibility of its use for other regenerative applications.

A randomized study of cyclosporine with and without prednisone in renal allograft recipients. Canadian Transplant Group.

Sixty-nine patients receiving Cs after cadaveric or LRD renal transplants were randomly allocated to receive prednisone or no prednisone beginning on the day of transplant. There were 36 in the prednisone group and 33 in the group assigned to no prednisone. Of these latter, only seven (21%) never received prednisone and an additional four had one short course for rejection episodes (11%). Of the remaining 22 who were placed on continuous steroids, only 12 met rejection criteria and either some or all of the remainder probably had Cs nephrotoxicity. The patient and graft survival were better but not statistically so in the no-prednisone group (97% v 89%) and (88% v 78%), and the number of infections was only half that of the prednisone-treated group (22% v 42%). A policy of withholding steroids except for rejection episodes does not prejudice graft or patient survival in Cs-treated patients.

Toward an understanding of adult intellectual development: investigating within-individual convergence of interest and knowledge profiles.

To further our understanding of the role interests play in the development of adult intellect, this study examines the relationship between intraindividual differences in interest and knowledge profiles. On the basis of a sample of 330,154 individuals, results show a moderate, positive average intraindividual correlation between interest and knowledge that increases as individuals age and is stronger for men than for women. Consistent with recent theories regarding the development of adult intelligence, expertise, and talent, these results demonstrate that noncognitive intraindividual differences can add to one's understanding of the acquisition of knowledge and skills. The current findings regarding the intraindividual convergence of interests and knowledge substantiate K. Murphy's (1998) call for renewed research on interests and point to the usefulness of an intraindividual perspective in applied psychology.

Dental considerations and treatment of the oncology patient receiving radiation therapy.

As many as 400,000 out of 1 million patients newly diagnosed with cancer may develop oral complications. The trend toward people's maintaining their teeth longer coupled with the rising age of the population suggest that dentists frequently may be treating patients with cancer, and should be informed about aspects of their oncologic care that will affect their oral health. This article highlights some of the important clinical considerations and offers guidelines for treating patients receiving radiation therapy.

A case report. Treating localized refractory idiopathic gingivitis with Superoxol.

The authors describe a case of localized refractory idiopathic gingivitis in a 29-year-old patient that was successfully treated with hydrogen peroxide (Superoxol, Sultan Chemists, Inc.). The gingivitis was refractory to previous oral hygiene measures and was persistent in the face of meticulous oral hygiene. This case illustrates a successful treatment measure for an uncommon clinical challenge.

Familial LCAT deficiency. Report of two patients from a Canadian family of Italian and Swedish descent.

A 16-year-old male (S.F.) and his 21-year-old sister (D.H.) from a large family of Italian and Swedish descent had virtually identical lipoprotein pattern and complete absence of LCAT activity. Both had typical corneal opacities and mild anemia with target cells. S.F., but not D.H., presented with proteinuria, which has increased over three years of follow-up. His kidney biopsy revealed lipid deposits in the glomerular basement membrane. Ten relatives in 4 generations had normal LCAT activity and/or lipoprotein pattern. The patients and their relatives had haptoglobin type 2. Factors that might influence the different clinical presentation in our patients (previous renal disease, diet, abnormal lipoproteins), prognosis, and treatment (diet, enzyme replacement, cholestyramine) are discussed.