A pilot study of intensive intervention using a novel trismus device.

PURPOSE: Trismus secondary to head and neck neoplasm treatment impacts upon quality of life, nutrition, oral hygiene, and dentition. Current treatment options for trismus apply unquantified force to the jaw, and in many cases, the device costs are prohibitive. This study aimed to prospectively evaluate the impact of a novel trismus device. METHOD: This single arm cohort study prospectively evaluated the impact of a novel trismus device on maximal incisal opening (MIO), trismus-related function and quality of life scores. Seventeen patients diagnosed with trismus were recruited to undergo a 10-week program using a novel device. The effect of the intervention was assessed by comparing pre- vs post-intervention validated measures. RESULT: A significant improvement in MIO was observed post the 10-week intervention period (12.6 mm). This was associated with an improvement in patient reported trismus symptomology including quality of life, swallowing, speech, and jaw pain. CONCLUSIONS: This pilot study demonstrates the feasibility of a novel device in the treatment of trismus. Further evaluation of this device is warranted to assess efficacy, safety, and cost-effectiveness in a larger cohort with appropriate controls.

Institutional-based and commercial virtual surgical planning in maxillomandibular reconstruction - Comparing the digital plan and postoperative scan.

BACKGROUND: Virtual surgical planning (VSP) is increasingly used in maxillomandibular osseous free flap reconstruction. Non-commercial ('in-house') VSP may offer the same level of accuracy and other benefits, without the inflated costs and time delays inherent in using commercial providers. Comparisons between commercial and in-house methods are lacking. This study aims to determine the accuracy of VSP, compare in-house and commercially planned cases, and explore predictors of the reconstruction error. METHODS: Seventy-six patients who had a virtually planned maxillomandibular reconstruction between January 2012 and July 2020 were retrospectively identified. The preoperative digital plan was compared to the postoperative CT scan in terms of length of bone segments, angle between adjacent segments and intercondylar, and intergonial angle distances (mandibular reconstructions only). RESULTS: Forty-four patients fulfilled the inclusion criteria. The mean intergonial and intercondylar distances error was 1.7 ± 1.01 mm, mean segment length error was 1.3 ± 1.40 mm, and mean angles error was 1.9 ± 2.32°. The difference in error of in-house VSP compared to commercial VSP was not statistically significant for intercondylar and intergonial distance (p = 0.76), segment length (p = 0.15), or angle between segments (p = 0.92). The increased error was associated with osteoradionecrosis as the indication for surgery, greater number of segments, and secondary reconstructions. CONCLUSION: VSP is an accurate method of maxillary and mandibular reconstruction. In-house VSP may be similar in accuracy to commercial VSP options. Higher levels of inaccuracy are likely to occur in more complex reconstructions, particularly secondary reconstructions, and in the setting of osteoradionecrosis.

Disaster declarations associated with bushfires, floods and storms in New South Wales, Australia between 2004 and 2014.

Australia regularly experiences disasters triggered by natural hazards and New South Wales (NSW) the most populous State is no exception. To date, no publically available spatial and temporal analyses of disaster declarations triggered by hazards (specifically, bushfires, floods and storms) in NSW have been undertaken and no studies have explored the relationship between disaster occurrence and socio-economic disadvantage. We source, collate and analyse data about bushfire, flood and storm disaster declarations between 2004 and 2014. Floods resulted in the most frequent type of disaster declaration. The greatest number of disaster declarations occurred in 2012-2013. Whilst no significant Spearman's correlation exists between bushfire, flood and storm disaster declarations and the strength of the El Niño/Southern Oscillation (ENSO) phase, we observe that bushfire disaster declarations were much more common during El Niño, and flood disaster declarations were five times more common during La Niña phases. We identify a spatial cluster or 'hot spot' of disaster declarations in the northeast of the State that is also spatially coincident with 43% of the most socio-economically disadvantaged Local Government Areas in NSW. The results have implications for disaster risk management in the State.

The exposure of Sydney (Australia) to earthquake-generated tsunamis, storms and sea level rise: a probabilistic multi-hazard approach.

Approximately 85% of Australia's population live along the coastal fringe, an area with high exposure to extreme inundations such as tsunamis. However, to date, no Probabilistic Tsunami Hazard Assessments (PTHA) that include inundation have been published for Australia. This limits the development of appropriate risk reduction measures by decision and policy makers. We describe our PTHA undertaken for the Sydney metropolitan area. Using the NOAA NCTR model MOST (Method for Splitting Tsunamis), we simulate 36 earthquake-generated tsunamis with annual probabilities of 1:100, 1:1,000 and 1:10,000, occurring under present and future predicted sea level conditions. For each tsunami scenario we generate a high-resolution inundation map of the maximum water level and flow velocity, and we calculate the exposure of buildings and critical infrastructure. Results indicate that exposure to earthquake-generated tsunamis is relatively low for present events, but increases significantly with higher sea level conditions. The probabilistic approach allowed us to undertake a comparison with an existing storm surge hazard assessment. Interestingly, the exposure to all the simulated tsunamis is significantly lower than that for the 1:100 storm surge scenarios, under the same initial sea level conditions. The results have significant implications for multi-risk and emergency management in Sydney.

Stabilising a planning guide in post-mandibulectomy prosthodontic rehabilitation.

Patients presenting with grafted reconstructions of the mandible often lack anatomical features that allow for the consistent placement of a diagnostic denture and planning guide. The mucosa covering the graft appears flat with no discernible ridge form. A method was therefore adapted to provide stability to a guide for the placement of implants. A diagnostic denture was constructed to the try-in stage and duplicated in clear acrylic, with radio-opaque markers placed into potential implant positions. Three mini-implants (Southern implants, Irene, SA) were then placed under local anaesthetic trans-mucosally into the bone graft at positions corresponding to teeth 46, 31 and 36. Access holes were created in the flanges of the diagnostic denture/planning guide to enable it to seat over the mini implant heads and to allow for final positioning. Auto-polymerising resin was then placed to cover each of these heads, thus stabilising the guide. The patient was then referred for a CT scan, to be taken with the planning guide in situ, and a surgical guide was made from the CT data, which also used the mini implants for orientation. At surgery, this ensured the optimal placement of the definitive implants, and the mini-implants could then be removed. This method thus provides enormous beneft to both the planning for, and the placement of, implants into grafted bone in mandibulectomy patients.

Prosthodontic management of patients with amelogenesis imperfecta.

INTRODUCTION: Amelogenesis Imperfecta (AI) is an heterogenous genetic disorder that disturbs the developing enamel structure. This rare ectodermal defect leads to a variety of clinical manifestations due to agenesis, hypoplasia, and/or hypomineralisation of the enamel. AIMS AND OBJECTIVES: To describe the prosthodontic management of dental anomalies commonly associated with AI. METHODS: By using the classification of Witkop and Rao (1971), the variation in clinical presentation of the different Types of AI are illustrated and discussed, in particular Type I AI and Type 4 AI. RESULTS AND CONCLUSIONS: Early diagnosis and prosthodontic management as part of a multidisciplinary, patient-centred approach are key factors to treatment success. Treatment options to address the oral complications are influenced by modifying factors including age, socioeconomic status, type and severity of the disorder, and intraoral status at the time of treatment planning. Ultimately, management includes pain and infection control, provision of aesthetics and restoration of function which may lead to patient satisfaction, psychological well-being and an improved quality of life.

The need for versatility in the prosthodontic treatment of maxillofacial defects.

The main objective of this study was to survey the different maxillofacial defects of patients who presented to the Wits Dental Hospital and to review the methods that have been used to rehabilitate these patients. Forty six patient records were retrieved from patients' files and from final year reports of prosthodontic postgraduate students. The data were used to determine the type of maxillofacial defects that these patients suffered from and the treatment that had been carried out. Duration and cost of treatment was also noted. The study showed that the majority of the patients' defects were caused by cancer resections, followed by trauma, clefts, burns, and infection. Most patients received conventional 'appropriatech' treatments such as the use of adhesive-retained prostheses, whilst a small number received more sophisticated 'high tech' treatments of implant rehabilitation. The need for versatility in the prosthodontic treatment of maxillofacial defects.

Effect of varying levels of fatty acids from palm oil on feed intake and milk production in Holstein cows.

To determine the optimum feeding level of fatty acids of palm oil (PALM; Energizer RP10; 86.6% palmitic acid) on milk production, lactating cows (n = 18) were randomly assigned to a treatment sequence in replicated 4 x 4 Latin squares. Animals were assigned to squares by parity (3 multiparous and 1 primiparous squares with primiparous in the incomplete square). The 4 diets were designed to provide 0, 500, 1,000, and 1,500 g of PALM per day. Cows were fed individually with feed intake measured daily. Each period lasted 16 d with milk production and composition determined the final 2 d. Milk production, milk composition and feed intake data were analyzed using the MIXED procedure of SAS. Milk yields were 30.9, 34.0, 34.2, and 34.2 kg/ d (SEM = 1.9) for the 0, 500, 1,000, and 1,500 g levels, respectively. Milk yield was increased by the addition of PALM; however, there were no differences among the levels of PALM. Milk fat percentage was also increased from 3.44% for 0 g to 3.95% (SEM = 0.17) across all levels of PALM but there were no differences among the PALM treatments. Dry matter intakes were 23.3, 26.4, 24.7, and 23.8 kg/d (SEM = 1.4) for the 0, 500, 1,000 and 1,500 g levels, respectively. The addition of PALM increased milk yield and milk fat percentage, and no adverse effects on dry matter intake were observed.

A penny for your thoughts: small bowel obstruction secondary to coin ingestion.

We report a case of small bowel obstruction secondary to coin ingestion. A 22-year-old woman presented to the Emergency Department (ED) with a 3-week history of abdominal pain. Upon initial history the patient denied any foreign body ingestion. Only after computed tomography (CT) scanning of the abdomen and pelvis did the patient admit to deliberate ingestion of a single United States penny coin. During surgical evaluation it was found that the coin had lodged near the ileocecal valve and an inflammatory mass had formed around the intraluminal coin, causing a 10 x 7 cm fibrous tumor to completely obstruct the small bowel. It is thought that oxidation of the coin, with subsequent exposure of its high zinc content, instigated the inflammatory cascade.

The zygomaticus implant protocol in the treatment of the severely resorbed maxilla.

The zygomaticus dental implant, designed by NobelBiocare, was developed primarily for the treatment of the severely resorbed maxilla. Brånemark has reported an overall success rate of 97.6% with the placement of over 200 zygomatic implants during the period 1989 to 2001. There are well-defined characteristics within the patient's resorbed skeletal frame which guide the surgical placement of the zygomatic implant, thus determining whether the surgeon should use an implant with a 45 degrees or 55 degrees angulated head. This allows implant-supported restoration of the resorbed maxilla with a fixed cross arch prosthesis in the maxilla without a bone graft to the posterior maxilla. The use of a modified head angulation of 55 degrees, with implant placement as close to the crest of the edentulous ridge as possible, allows restorative clinicians to achieve an ideal restorative position in the posterior maxilla. The use of a zygomatic implant with a 55 degrees head reduces the buccal cantilever by 20%.

The absorption, distribution and excretion of 1- and 2-.

Human breast milk is rich in 2-palmitoyl 1,3 unsaturated triacyglycerols and during the neonatal period, when milk is the sole source of nutrients, their role could be particularly important. Betapol is a novel triacylglycerol mix resembling human breast milk in its high palmitic acid content and positional distribution. The total fat absorption from Betapol has been shown to be higher than fat from conventional infant milk formulas and closer to human breast milk in infants. However, the relative fate of purified palmitic acid esterified to glycerol in the 1-, 3- and 2-positions in neonatal and young animals has not previously been established. Therefore, the fate of orally administered 1-[1-14C]palmitoyl, 2,3 dioleoyl glycerol ([14C]POO) and 1,3 dioleoyl,2-[1-14C]palmitoyl glycerol (O[14C]PO) was investigated in suckling and weanling rats using liquid scintillation counting of tissues and expired air and whole-body autoradiography. The results obtained indicate that orally administered [14C]POO and O[14C]PO are extensively absorbed from the gut, probably either as palmitic acid or as a palmitoyl glyceride in both suckling and weanling rats. Radioactivity initially concentrated in brown fat with apparent migration to the white fat of weanling rats by 96 h. Levels of 14C were low in blood, brain and other tissues. Excretion of 14C was mainly by expiration of CO(2) (approximately 72% in 96 h), indicating beta-oxidation as a major route of metabolism. Urine and faeces accounted for only approximately 6% of the excreted radioactivity. The design and size of the experiment did not allow tests of statistical significance between the absorption and excretion of OPO and POO to be conducted. However, the absorption, distribution, beta-oxidation and excretion appeared to be similar.

Fate of ethanol topically applied to skin.

Ethanol is a major component of many aerosol sprays and consumer products that are designed to contact the skin. It is theoretically possible that small amounts of ethanol from alcohol-based sprays can be absorbed across the skin or inhaled during spraying. In order to assess the potential systemic dose, three parameters were measured: the evaporation of [14C]ethanol from the skin surface, the in vitro penetration of [14C]ethanol through excised pig skin and the ethanol concentration in the blood of human volunteers following simulated use of an alcohol based deodorant spray. The rate of evaporation from Benchkote and whole pig skin was similar (t(1/2)=13.6 sec and 11.7 sec, respectively) while that from glass was longer (t(1/2)=24.8 sec). Ethanol penetration through pig skin in vitro was greater in occluded cells than in non-occluded cells (2.19 mg/cm(2) and 0.10 mg/cm(2) in 24 hours, respectively). At the maximum flux seen in this experiment under occlusion, the amount of ethanol penetrating from a 1 m(2) area of skin would give a blood alcohol level of about 4 mg% in a 70-kg man. In the human use study, none of the blood samples taken from 16 human volunteers exhibited a detectable level of alcohol. These studies provide evidence that a systemic dose of ethanol is likely to be very low after the use of formulations delivering ethanol to the skin.

Better health while you wait: a controlled trial of a computer-based intervention for screening and health promotion in the emergency department.

STUDY OBJECTIVE: We evaluate a computer-based intervention for screening and health promotion in the emergency department and determine its effect on patient recall of health advice. METHODS: This controlled clinical trial, with alternating assignment of patients to a computer intervention (prevention group) or usual care, was conducted in a university hospital ED. The study group consisted of 542 adult patients with nonurgent conditions. The study intervention was a self-administered computer survey generating individualized health information. Outcome measures were (1) patient willingness to take a computerized health risk assessment, (2) disclosure of behavioral risk factors, (3) requests for health information, and (4) remembered health advice. RESULTS: Eighty-nine percent (470/542) of eligible patients participated. Ninety percent were black. Eighty-five percent (210/248) of patients in the prevention group disclosed 1 or more major behavioral risk factors including current smoking (79/248; 32%), untreated hypertension (28/248; 13%), problem drinking (46/248; 19%), use of street drugs (33/248; 13%), major depression (87/248; 35%), unsafe sexual behavior (84/248; 33%), and several other injury-prone behaviors. Ninety-five percent of patients in the prevention group requested health information. On follow-up at 1 week, 62% (133/216) of the prevention group patients compared with 27% (48/180) of the control subjects remembered receiving advice on what they could do to improve their health (relative risk 2.3, 95% confidence interval 1.77 to 3.01). CONCLUSION: Using a self-administered computer-based health risk assessment, the majority of patients in our urban ED disclosed important health risks and requested information. They were more likely than a control group to remember receiving advice on what they could do to improve their health. Computer methodology may enable physicians to use patient waiting time for health promotion and to target at-risk patients for specific interventions.

Triage and initial evaluation of the oral facial emergency.

Essentially, emergency medicine encompasses the efficient application of limited resources to provide timely care to patients in health crisis. The appropriate triage, management, and disposition of patients with orofacial complaints requires systematic evaluation with attention to the ABCs. The first priority is to secure the airway. Once such a patient has been stabilized, a thorough examination, with documentation of the oropharyngeal and facial examination, should be conducted. Unfortunately, many conditions seen initially in the ED through patient self-referral ultimately require specialist care. Therefore, emergency physicians must temporarily provide pain relief and begin initial treatment of traumatic, infectious, or inflammatory conditions that await more definitive intervention. The emergency physician should consider it his or her role to exclude life threats, prevent complications, provide patient comfort, and ensure adequate and timely follow-up care.

The safety evaluation of phytosterol esters. Part 6. The comparative absorption and tissue distribution of phytosterols in the rat.

As part of an extensive safety evaluation programme, a series of studies has been conducted to determine the fate of phytosterols in the rat. Rats were dosed by oral gavage with 14C-labelled samples of cholesterol, beta-sitosterol or beta-sitostanol or (3)H-labelled samples of beta-sitostanol, campesterol, campestanol or stigmasterol dissolved in sunflower seed oil. Urine and faeces were collected for up to 96 hours after dosing. There was no quantification of biliary excreted material in these studies. Animals were sacrificed and either prepared for whole body autoradiography or tissues and carcass remains were assayed for 14C or (3)H. The overall absorption of phytosterols was low as judged by tissue and carcass levels of radioactivity. Elimination from the body was mainly in the faeces and was initially very rapid, but traces of material were still being excreted at 4 days after dosing. While total absorption of the phytosterols could not be fully quantified without biliary excretion data, it was clear that cholesterol was absorbed to the greatest extent (27% of the dose in females at 24 hours). Campesterol (13%) was absorbed more than beta-sitosterol and stigmasterol (both 4%) which were absorbed more than beta-sitostanol and campestanol (1-2%). The absorption of phytosterols was slightly greater in females than males. For each test material, the overall pattern of tissue distribution of radioactivity was similar, with the adrenal glands, ovaries and intestinal epithelia showing the highest levels and the longest retention of radioactivity.

Justification of pulse oximeter costs for paramedic prehospital providers.

OBJECTIVE: To assess the potential cost savings of decreasing prehospital oxygen utilization by using pulse oximetry to identify those patients who do not require supplemental oxygen. METHODS: A prospective, controlled trial was performed comparing rates of oxygen utilization by paramedics with and without access to pulse oximetry. Consecutive patient encounters over a ten-week period were randomized by day of presentation. Pulse oximeters were made available on alternate days. On those days, patients whose oxygen saturations were less than 95% were treated with supplemental oxygen. RESULTS: The use of pulse oximeters incurred a saving of 0.14 "D"-size oxygen cylinders per call. For the authors' service, this translates to a potential saving of $2,324 (C)/vehicle/year. CONCLUSION: For regions with patient demographics similar to the authors', the initial cost of providing paramedics with pulse oximeters may be offset by savings in oxygen consumption. A formula is provided to allow individual ambulance services to calculate the potential savings for their service.

Percutaneous penetration and dermal metabolism of triclosan (2,4, 4'-trichloro-2'-hydroxydiphenyl ether).

triclosan is widely used in many products that contact the skin of consumers. This study compares in vivo and in vitro skin absorption of triclosan and determines the potential of skin to metobolize it prior to entering the blood stream. After in vivo topical application of a 64.5mM alcoholic solution of [(3)H]triclosan to rat skin, 12% radioactivity was recovered in the faeces, 8% in the carcass 1% in the urine, 30% in the stratum corneum and 26% was rinsed from the skin surface at 24 hours after application. Free triclosan and the glucuronide and sulfate conjugates of triclosan were found in urine and faeces. triclosan penetrated rat skin more rapidly and extensively than human skin in vitro. 23% of the dose had penetrated completely through rat skin into the receptor fluid by 24 hours, whereas penetration through human skin was only 6.3% of the dose. Chromatographic analysis of the receptor solutions showed that triclosan was metabolized to the glucuronide, and to a lesser extent to the sulfate, during passage through the skin. triclosan glucuronide appeared rapidly in the receptor fluid whereas triclosan sulfate remained in the skin. Although the major site of metabolism was the liver, conjugation of triclosan in skin was also demonstrated in vitro and in vivo, particularly to the glucuronide conjugate which was more readily removed from the skin. The in vitro system provides a reasonable estimate of dermal absorption in vivo for the rat. Therefore by extrapolation of the comparative in vitro data for human and rat skin it is reasonable to deduce that dermal absorption in human of triclosan applied at the same dose is about one-third of that in the rat in vivo.

How to use the Internet to improve care delivery--without changing the way physicians work.

Martin's Point Health Care is a nonprofit organization with more than 30 primary care physicians and 280 health care professionals serving 43,000 patients in four sites in Maine and New Hampshire. Like many medical group practices, Martin's Point believed its patients needed more channels to communicate with their physicians. An increasing number of patients wanted more in-depth advice from their doctors, and many already used the Internet to obtain health care information. This article describes how Martin's Point developed an interactive Web communications program to build physician/patient relationships and improve practice efficiency.