Review and action plan for oral health improvement in Sheffield special schools.

A description of the process of a review of oral health improvement in special schools in Sheffield and the implementation of an action plan for these activities. Public health competencies encompassed: assessing the evidence on oral health and dental interventions, programmes and services; strategic leadership and collaborative working for health; oral health improvement.

Access to urgent dental care: a scoping review.

OBJECTIVE: To summarise the literature on urgent dental care and to identify research priorities on the organisation and delivery of urgent dental services. BASIC RESEARCH DESIGN: Scoping review using Andersen's behavioural model of health service utilisation for a framework analysis of the data. MAIN OUTCOME MEASURES: Gaps in the literature, defined as those factors and interactions identified by Andersen's model as having a contributory role in access to health services that were not evident in the source papers. RESULTS: Fifty-six papers met the inclusion criteria for the review. The factors most often considered were; demographic, socioeconomic, perceived and evaluated need, and health behaviours. Patient outcomes of evaluated health and quality of life following urgent dental care were the least studied variables, with the exception of patient satisfaction. No studies were identified on community values/norms of people accessing urgent dental care, on health economic evaluations or on studies of how urgent dental services mitigate use of other medical services. No studies were identified on urgent need for populations living in water fluoridated areas or on the relationship between service design and efficient or effective access as measured by patient outcomes. CONCLUSION: Future research on patient outcomes and the comparison of different service models for urgent dental care through measures of equity, effectiveness and efficiency of access are needed to inform future policy and organisation of these services.

Evaluation of the telephone and clinical NHS urgent dental service in Sheffield.

OBJECTIVE: Evaluate an NHS in- and out-of-hours urgent dental service (UDS) including both a telephone triage provider (TTP) and a sole clinical provider (CP) using a quality framework. BASIC RESEARCH DESIGN: Analysis of activity and patient experience data. MAIN OUTCOME MEASURES: Ratio of volume of services to activity provided; distance and time travelled; appropriateness of referrals and treatments; equity of utilisation; patient experience; cost per patient. RESULTS: Almost all calls (96.6%) to the TTP were answered within 60 seconds and of people referred to the CP 96.0% needed treatment. Proportionately more people from deprived areas used the TTP. Highest utilisation of the TTP was by people aged 20 to 44 years and lowest was by people over 54 years. Cost per patient utilising the TTP was £5.06. Of the available appointments provided by the CP, 90.9% were booked the TTP. Travel time to the CP was less than 30 minutes for 78.0% of patients. Of treatments provided, 77.9% were clinical interventions and 18.1% were prescription only. Proportionately more people from deprived areas attended the CP. Highest utilisation was by people aged 20 to 44 years and lowest by people over 54 years. Nearly half (47.0%) of those attending reported they did not have a dentist. There was a high level of patient satisfaction. Cost per course of treatment at the CP was £67.41. CONCLUSION: Overall the UDS provided a high quality service in line with Maxwell's dimensions of quality. Timely advice and treatment was provided with high levels of patient satisfaction with the CP. Comparison with other urgent dental service models would determine the relative efficiency of the UDS.

Patients are asking about e-cigarettes. What do we tell them?

E-cigarettes are electronic devices that deliver vaporised nicotine liquid into the lungs. Since the introduction of e-cigarettes in 2004, the market in the UK has rapidly expanded and increasingly people are asking health professionals about them. This article gives an overview of e-cigarettes, their use, their regulatory status and evidence for their safety, quality and efficacy. Advice about e-cigarettes for dental health professionals to give patients is provided, as well as the five questions, proposed by Action on Smoking and Health, to consider when deciding whether to permit or prohibit use of e-cigarettes on premises.

Multimodality preoperative imaging of pancreatic insulinomas.

Pancreatic insulinomas are rare tumours of the islet cells of the pancreas, which account for the majority of functional neuroendocrine tumours of the pancreas. There is often a typical history of recurrent hypoglycaemic collapse and dizzy spells. Insulinomas are usually solitary, and the vast majority are intra-pancreatic in location. They are characteristically small with approximately 66% being less than 2cm at presentation. Insulinomas continue to pose a diagnostic challenge to physicians, surgeons and radiologists alike. The role of imaging is to detect and provide precise anatomical localization and staging of tumours prior to surgery. Due to their small size at clinical presentation, they are notoriously difficult to localize radiologically, and specifically designed protocols are necessary to aid detection. In this review, we describe the current "state of the art" imaging protocols that may be used in the preoperative localization of insulinomas.

Radionuclide imaging of acute pulmonary embolism.

From the prospective and outcome-based studies that have been carried out in the past few years, the following conclusions regarding the diagnostic evaluation of patients with suspected PE can be made: 1. A normal V/Q scan interpretation excludes the diagnosis of clinically significant PE. 2. Patients with a very-low- or low-probability V/Q scan interpretation and a low clinical likelihood of PE do not require angiography or anticoagulation. 3. Patients with a very-low- or low-probability V/Q scan interpretation, an intermediate or high clinical likelihood of PE, and negative serial noninvasive venous studies of the lower extremities do not require anticoagulation or angiography. If serial noninvasive venous studies of the lower extremities are positive, patients should be treated. 4. Clinically stable patients with an intermediate-probability V/Q scan interpretation require noninvasive venous studies of the legs and, if negative, require CT angiography or pulmonary angiography for a definite diagnosis. 5. Clinically stable patients with a high-probability V/Q scan interpretation and a high clinical likelihood of PE require treatment and need no further diagnostic tests to confirm the diagnosis. 6. Clinically stable patients with a high-probability V/Q scan interpretation and a low or intermediate clinical likelihood of PE require noninvasive venous studies of the legs and, if negative, often require CT angiography or pulmonary CT for a definitive diagnosis.

Latent fingerprint detection using a scanning Kelvin microprobe.

Electrochemical interactions between latent human fingerprints and metal surfaces in ambient air are investigated using a scanning Kelvin microprobe. Inorganic salts present in sweat deposited at fingerprint ridges locally depassivate the metal surface producing a Volta potential decrease of greater than 200 mV. Volta potential patterns may persist for months and prints may be visualized by potential mapping, even when overcoated with a polymer layer. Because the Volta potential differences are produced by involatile salts they persist when the organic components of the fingerprint residue have been volatilized by heating to 600 degrees C.

Laparoscopic Heller myotomy improves esophageal emptying and the symptoms of achalasia.

HYPOTHESIS: Laparoscopic Heller esophageal myotomy improves esophageal clearance and symptoms of achalasia in the early and late postoperative periods. DESIGN: We followed up 98 consecutive patients attending a referral center between February 1, 1994, and July 1, 2000, who underwent laparoscopic myotomy. Operative time, complications, and length of stay were recorded. Postoperative outcomes were assessed using Van Trappen symptom scores (1 indicates no symptoms; 2, symptoms occurring less than once a week; 3, symptoms occurring more than once weekly; and 4, persistent symptoms) and scintigraphic esophageal transit studies. RESULTS: Of 98 patients, 91 underwent anterior fundoplication. There were no open conversions and 1 mucosal perforation, which was closed laparoscopically without complications. Mean operative times and postoperative days were 3.2 hours and 4.3 days, respectively, in the first 32 patients and 1.7 hours and 2.3 days, respectively, in the last 32 patients (P<.001). Postoperative complications included pneumothorax (4% of patients), atelectasis (5%), and delayed gastric emptying (1%). Seventy-five percent of patients gained weight after surgery. At longest follow-up, 91% of patients were satisfied with the outcome of the procedure. Mean Van Trappen scores for dysphagia improved from 4.0 in the preoperative period to 1.2 at early and late follow-up (P<.001). Fluid retention at 10 minutes in the upright position was 47% in the preoperative period and improved at early and late follow-up to 21% and 20%, respectively (P<.001). CONCLUSIONS: Laparoscopic Heller myotomy can safely reverse the symptoms of achalasia and improve esophageal transit. These benefits, realized during the early postoperative period, were maintained at longest follow-up.

Alveolar epithelial integrity in athletes with exercise-induced hypoxemia.

The effect of incremental exercise to exhaustion on the change in pulmonary clearance rate (k) of aerosolized (99m)Tc-labeled diethylenetriaminepentaacetic acid ((99m)Tc-DTPA) and the relationship between k and arterial PO(2) (Pa(O(2))) during heavy work were investigated. Ten male cyclists (age = 25 +/- 2 yr, height = 180.9 +/- 4.0 cm, mass = 80.1 +/- 9.5 kg, maximal O(2) uptake = 5. 25 +/- 0.35 l/min, mean +/- SD) completed a pulmonary clearance test shortly (39 +/- 8 min) after a maximal O(2) uptake test. Resting pulmonary clearance was completed >/=24 h before or after the exercise test. Arterial blood was sampled at rest and at 1-min intervals during exercise. Minimum Pa(O(2)) values and maximum alveolar-arterial PO(2) difference ranged from 73 to 92 Torr and from 30 to 55 Torr, respectively. No significant difference between resting k and postexercise k for the total lung (0.55 +/- 0.20 vs. 0. 57 +/- 0.17 %/min, P > 0.05) was observed. Pearson product-moment correlation indicated no significant linear relationship between change in k for the total lung and minimum Pa(O(2)) (r = -0.26, P > 0.05). These results indicate that, averaged over subjects, pulmonary clearance of (99m)Tc-DTPA after incremental maximal exercise to exhaustion in highly trained male cyclists is unchanged, although the sampling time may have eliminated a transient effect. Lack of a linear relationship between k and minimum Pa(O(2)) during exercise suggests that exercise-induced hypoxemia occurs despite maintenance of alveolar epithelial integrity.

Ventilation-perfusion-chest radiography match is less likely to represent pulmonary embolism if perfusion is decreased rather than absent.

PURPOSE: The authors' goal was to determine whether the prevalence of pulmonary embolism in patients with matching ventilation-perfusion (V-Q) defects and chest radiographic opacities differs depending on the degree of perfusion deficit (absent versus decreased). METHODS: The authors performed a retrospective analysis of the data obtained from the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study. In 233 patients, angiograms were of diagnostic quality for 275 lung zones that showed matching V-Q defects and chest radiographic opacities (triple matches). Of these, V-Q scans and chest radiographs from 217 patients with triple matches in 255 lung zones were retrieved and reviewed. Areas corresponding to chest radiographic opacities were scored as having either decreased perfusion or absent perfusion by consensus. Information regarding the presence or absence of pulmonary embolism in corresponding lung zones was obtained from the PIOPED database. RESULTS: The overall prevalence of pulmonary embolism in all lung zones with triple matches was 27% (69 of 255). Of the 255 areas of triple matches, the perfusion was decreased in 153 (60%) and absent in 102 (40%). The prevalence of pulmonary embolism in areas of triple matches with decreased perfusion and triple matches with absent perfusion was 13% (20 of 153) and 48% (49 of 102), respectively (P = 0.0001 by the chi-square test). When these were divided further by lung zones, triple matches with decreased perfusion and triple matches with absent perfusion in the upper-middle lung zone were associated with a prevalence of 0% (O of 44), and 25% (9 of 36), respectively. The prevalence of pulmonary embolism in areas of triple matches with decreased perfusion and triple matches with absent perfusion in the lower lung zone was 18% (20 of 109), and 61% (40 of 66), respectively. CONCLUSIONS: A V-Q/chest radiographic match is less likely to represent pulmonary embolism if perfusion is decreased rather than absent. The overall prevalence of pulmonary embolism associated with all triple matches in all lung zones varied from very low (0% in this series) to upper intermediate (61 %), depending on whether perfusion was decreased or absent and also on the location of the triple match.

Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy.

PURPOSE: To compare prospectively the accuracy of spiral computed tomography (CT) with that of ventilation-perfusion scintigraphy for diagnosing pulmonary embolism. MATERIALS AND METHODS: Within 48 hours of presentation, 142 patients suspected of having pulmonary embolism underwent spiral CT, scintigraphy, and (when indicated) pulmonary angiography. Pulmonary angiography was attempted if interpretations of spiral CT scans and of scintigrams were discordant or indeterminate and intermediate-probability, respectively. RESULTS: In the 139 patients who completed the study, interpretations of spiral CT scans and of scintigrams were concordant in 103 patients (29 with embolism, 74 without). In 20 patients, intermediate-probability scintigrams were interpreted (six with embolism at angiography, 14 without); diagnosis with spiral CT was correct in 16. Interpretations of spiral CT scans and those of scintigrams were discordant in 12 cases; diagnosis with spiral CT was correct in 11 cases and that with scintigraphy was correct in one. Spiral CT and scintigraphic scans of four patients with embolism did not show embolism. Sensitivities, specificities, and kappa values with spiral CT and scintigraphy were 87%, 95%, and 0.85 and 65%, 94%, and 0.61, respectively. CONCLUSION: In cases of pulmonary embolism, sensitivity of spiral CT is greater than that of scintigraphy. Interobserver agreement is better with spiral CT.

Laparoscopic esophageal myotomy and anterior partial fundoplication for the treatment of achalasia.

BACKGROUND: The purpose of this study was to determine the initial results of laparoscopic esophageal myotomy and anterior fundoplication in the treatment of 26 patients with achalasia. METHODS: Operative time, complications, and length of hospitalization were recorded for each patient. Postoperative outcomes were assessed by a standardized patient questionnaire, 24-hour esophageal pH studies, and esophageal transit studies. RESULTS: Twenty-six consecutive patients with class IV dysphagia underwent a laparoscopic esophageal myotomy and anterior partial fundoplication, with a single incidence of intraoperative esophageal perforation. The mean operative time was 3.5 hours. The median length of hospitalization was 5 days. Of the 21 patients for whom follow-up was available (median follow-up, 4 months), 19 (90%) were satisfied and 2 (10%) were somewhat satisfied with their surgery. After operation, 14 of the 21 patients (67%) reported no dysphagia (class I), whereas 6 (28%) had class II dysphagia (less than once per week) and only 1 (5%) had class III dysphagia (greater than once per week). Liquid-phase esophageal transit studies (n = 14) revealed a significant improvement in esophageal clearance in the supine position from 18% before operation to 44% after operation (p = 0.006). Distal esophageal acid exposure was normal in 6 of 7 patients. CONCLUSIONS: These early results suggest that laparoscopic esophageal myotomy and anterior partial fundoplication provides efficacious treatment of achalasia.

Osteoblastic metastases from breast carcinoma with false-negative bone scan.

The authors report a case of metastatic breast carcinoma that on investigation was shown to have a negative bone scan in spite of multiple densely sclerotic metastases on radiography and CT and a positive bone biopsy. The literature is reviewed with regard to the subject of negative bone scans in this situation.

Pulmonary nodules: differential diagnosis using 18F-fluorodeoxyglucose single-photon emission computed tomography.

OBJECTIVE: The objective of this study was to prospectively evaluate the feasibility and efficacy of single-photon emission computed tomography (SPECT) with 18F-fluorodeoxyglucose (FDG) for differentiating malignant from benign pulmonary nodules. SUBJECTS AND METHODS: Twenty-six patients with 28 radiologically indeterminate focal pulmonary lesions were examined. Fasting patients were injected with 5 MBq/kg of FDG (maximum dose, 370 MBq). Imaging was performed with dual-head SPECT cameras equipped with 511-keV collimators. RESULTS: Seventeen of 21 pathologically malignant nodules showed FDG uptake on SPECT imaging (sensitivity, 81%). None of the seven benign modules showed uptake (specificity, 100%). SPECT imaging with FDG was positive in all 16 malignant nodules that were larger than or equal to 2 cm in diameter. However, only one (20%) of five nodules smaller than 2 cm in diameter showed positive on SPECT imaging. CONCLUSION: Using current technology, we found FDG SPECT imaging useful for distinguishing benign from malignant pulmonary nodules that were larger than or equal to 2 cm in diameter. However, because of the relatively low sensitivity of SPECT, smaller malignant nodules were not adequately revealed.

Comparison of diagnostic performance with ventilation-perfusion lung imaging in different patient populations.

PURPOSE: To determine if patient age, chest radiographic abnormalities, or history of cardiopulmonary disease or venous thromboembolism affected diagnostic performance with ventilation-perfusion (V-P) imaging. MATERIALS AND METHODS: Receiver operating characteristic (ROC) analyses were performed on the final V-P imaging interpretation data obtained during the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study. Diagnostic performance with V-P imaging was not substantially different in patients with varying ages, an abnormal chest radiograph, or a history of venous thromboembolism or cardiopulmonary disease. CONCLUSION: Because diagnostic performance with V-P imaging in detection of pulmonary embolism was similar among the patient populations examined, an abnormal chest radiograph or history of venous thromboembolism or cardiopulmonary disease does not appear to adversely affect overall diagnostic performance in evaluation of acute pulmonary embolism.