Development and validation of the Child Oral Health Impact Profile - Preschool version.

OBJECTIVE: The Child Oral Health Impact Profile (COHIP) is a validated instrument created to measure the oral health-related quality of life of school-aged children. The purpose of this study was to develop and validate a preschool version of the COHIP (COHIP-PS) for children aged 2-5. BASIC RESEARCH DESIGN: The COHIP-PS was developed and validated using a multi-stage process consisting of item selection, face validity testing, item impact testing, reliability and validity testing, and factor analysis. PARTICIPANTS: A cross-sectional convenience sample of caregivers having children 2-5 years old from four groups completed item clarity and impact forms. Groups were recruited from pediatric health clinics or preschools/daycare centers, speech clinics, dental clinics, or cleft/craniofacial centers. Participants had a variety of oral health-related conditions, including caries, congenital orofacial anomalies, and speech/language deficiencies such as articulation and language disorders. MAIN OUTCOME MEASURE: COHIP-PS. RESULTS: The COHIP-PS was found to have acceptable internal validity (a = 0.71) and high test-retest reliability (0.87), though internal validity was below the accepted threshold for the community sample. While discriminant validity results indicated significant differences across study groups, the overall magnitude of differences was modest. Results from confirmatory factor analyses support the use of a four-factor model consisting of 11 items across oral health, functional well-being, social-emotional well-being, and self-image domains. CONCLUSIONS: Quality of life is an integral factor in understanding and assessing children's well-being. The COHIP-PS is a validated oral health-related quality of life measure for preschool children with cleft or other oral conditions.

Quality Appraisal of Child Oral Health-Related Quality of Life Measures: A Scoping Review.

BACKGROUND: Children's oral health-related quality of life (COHQoL) measures are well known and widely used. However, rigorous systematic reviews of these measures and analyses of their quality are in absence. OBJECTIVES: To systematically review and quantitatively assess the quality of COHQoL measures through a scoping review. DATA SOURCES: Systematic literature search of PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE (Excerpta Medica database), HaPI (Health and Psychosocial Instruments), and DOSS (Dentistry and Oral Sciences Source). STUDY ELIGIBILITY: The measure's focus was COHQoL; the child age ranged from 5 to 14 years; the publication was either a research article or a systematic review and related to caries; and it was written in English or had an English abstract. Two authors independently selected the studies. Disagreements were reconciled by group discussions with a third author. APPRAISAL: The International Society for Quality of Life Research minimum standards for patient-reported outcome measures were used for quality appraisal. SYNTHESIS: Descriptive analysis. RESULTS: We identified 18 measures. Their quality scores ranged from 9.5 to 15.0 on a scale of 16. The quality appeared to bear no relationship to the citation and use of these measures. However, elements of these measures might be more useful than others, depending on the age-specific use and primary quality concerns. LIMITATIONS: Some of the information on the minimum standards of the 18 measures cannot be found in the existing literature. Measures published without English abstract were not searched. CONCLUSIONS: The quality of these measures is suboptimal. Researchers and practitioners in this field should exercise caution when choosing and using these measures. Efforts at improving the quality of the COHQoL measures, such as refining existing ones or developing new measures, are warranted. KNOWLEDGE TRANSFER STATEMENT: Researchers, clinician scientists, and clinicians can use the results of this study when deciding which oral health-related quality of life measure they wish to use in children.

An Economic Evaluation of a Comprehensive School-Based Caries Prevention Program.

INTRODUCTION: Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars. OBJECTIVES: To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth. METHODS: To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY). RESULTS: We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77). CONCLUSIONS: This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars. KNOWLEDGE TRANSFER STATEMENT: The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.

School-Based Caries Prevention, Tooth Decay, and the Community Environment.

The school and community context can contribute to inequity in child oral health. Whether the school and community affect the effectiveness of school-based caries prevention is unknown. The association between the school and community environment and dental caries, as well as their moderating effects with school-based caries prevention, was assessed using multilevel mixed-effects regression. Data were derived from a 6-y prospective cohort study of children participating in a school-based caries prevention program. For the school and community, living in a dental-shortage area and the proportion of children receiving free or reduced lunch were significantly related to an increased risk of dental caries at baseline. Caries prevention was associated with a significant per-visit decrease in the risk of untreated caries, but the rate of total caries experience increased over time. Caries prevention was more effective in children who had prior dental care at baseline and in schools with a higher proportion of low socioeconomic status students. There was significant variation across schools in the baseline prevalence of dental caries and the effect of prevention over time, although effects were modest. The school and community environment have a direct impact on oral health and moderate the association between school-based caries prevention and dental caries. Knowledge Transfer Statement: School-based caries prevention can be an effective means to reduce oral health inequity by embedding dental care within schools. However, the socioeconomic makeup of schools and characteristics of the surrounding community can affect the impact of school-based care.

Inhibitors of prostaglandin synthesis or cathepsin B prevent muscle wasting due to sepsis in the rat.

Systemic infection with Streptococcus pneumoniae produced atrophy, decreased twitch and tetanic tension, and altered intracellular electrolyte composition in rat skeletal muscle. Cathepsin B activity was selectively elevated early in the course of illness. Luepeptin, a cathepsin B inhibitor, and indomethacin, a prostaglandin synthesis inhibitor, prevented muscle atrophy and impaired contractility. Indomethacin, but not leupeptin, prevented the intracellular electrolyte changes. Acetaminophen reduced fever but did not prevent muscle atrophy, impaired contractility, or altered intracellular electrolytes. Muscle wasting and impaired contractility associated with sepsis may involve selective prostaglandin stimulation of cathepsin B activity. Intracellular electrolyte changes may involve prostaglandin synthesis but do not require cathepsin B activation.

Viral studies in benign acute childhood myositis.

Thirty-five cases of benign acute childhood myositis followed infections with influenza A or B. Two children had recurrent myositis associated with infections of different influenza types. None of the children had acute-phase antibody titers to the infecting type of influenza. These results are consistent with the proposal that benign acute childhood myositis can occur only with the initial infection of a viral type.

Left hemisphere visual processes in a case of right hemisphere symptomatology. Implications for theories of cerebral lateralization.

A patient with a visuospatial disturbance characteristic of posterior right hemisphere disease was examined under different conditions of stimulus presentation. The visuospatial defect, which was shown by the failure to perceive abnormalities concerning the left side of objects and the misperception of spatial relations, was present under conditions of unrestricted visual exposure. However, when the stimulus material was briefly exposed in the right visual field, performance improved substantially. These data suggest that the visuospatial defect seen after right hemisphere disease is atributable to factors other than the incapacity of the left hemisphere to process visuospatial information. Our observations, together with other evidence, lead us to question those theories of cerebral lateralization based on the notion that visuospatial processing is special to the right hemisphere.

Vegetative state after closed-head injury. A Traumatic Coma Data Bank Report.

To elucidate the clinical course of the vegetative state after severe closed-head injury, the Traumatic Coma Data Bank was analyzed for outcome at the time of discharge from the hospital and after follow-up intervals ranging up to 3 years after injury. Of 650 patients with closed-head injury available for analysis, 93 (14%) were discharged in a vegetative state. In comparison with conscious survivors, patients in a vegetative state sustained more severe closed-head injury as reflected by the Glasgow Coma Scale scores and pupillary findings and more frequently had diffuse injury complicated by swelling or shift in midline structures. Of 84 patients in a vegetative state who provided follow-up data, 41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval. A logistic regression failed to identify predictors of recovery from the vegetative state.

Insulin acts in hypokalemic periodic paralysis by reducing inward rectifier K+ current.

OBJECTIVE: To define how insulin acts in hypokalemic periodic paralysis (HypoPP). BACKGROUND: HypoPP results from point mutations of the skeletal muscle L-type Ca2+ channel. Attacks of flaccid paralysis are associated with hypokalemia and triggered by insulin. A persistent inward current causes depolarization-induced paralysis. The relationships of the Ca2+ channel mutations to the persistent inward current and how insulin triggers paralytic attacks are not yet known. METHODS: Intercostal muscle fibers from HypoPP and normal subjects were studied in vitro at 37 degrees C using two electrodes to determine action potential thresholds and a three-electrode voltage clamp to study membrane currents. RESULTS: HypoPP fibers were depolarized in bathing solution with 4 mM K+. Reducing K+ from 4.0 mM to 2.5 or 1.0 mM depolarized HypoPP fibers but hyperpolarized normal fibers. Adding 12 mU/mL of insulin to bathing fluids increased the depolarization of HypoPP fibers and increased the hyperpolarization of normal fibers. Depolarized HypoPP had increased action potential thresholds. The fraction of excitable muscle fibers decreased with increasing fiber depolarization. Blocking Na+ channels or L-type Ca2+ channels did not prevent depolarization induced by hypokalemia or by insulin. Insulin reduced the conductance of the inward rectifier K+ channel for outward-flowing currents. CONCLUSIONS: Insulin potentiates depolarization of hypokalemic periodic paralysis (HypoPP) fibers by reducing inward rectifier K+ conductance. The Ca2+ mutations in HypoPP indirectly derange membrane excitability by altering the function of other membrane channels.

Dissociated weakness of sternocleidomastoid and trapezius muscles with lesions in the CNS.

We describe three patients with lesions in the CNS that produced dissociated weakness of trapezius (TM) and sternocleidomastoid muscles (SCM). One patient with a right cerebral hemisphere lesion had left TM weakness and right SCM weakness. A second, with a brainstem lesion, and a third, with a high cervical cord lesion, had TM weakness with preserved SCM strength. We discuss the findings according to the known neuroanatomy.

Aphemia resulting from a left frontal hematoma.

A 15-year-old right-handed woman had selective impairment of speech--aphemia--after drainage of a left frontal hematoma caused by an arteriovenous malformation. There was no buccofacial or pharyngeal muscle dysfunction. Computerized tomography demonstrated residual injury extending from the Broca area to the inferior left precentral gyrus. Aphemia may have resulted from disruption of the connection between Broca's area and the portion of the motor cortex that controls oral and pharyngeal muscles.

Evaluation of acute cerebral ischemia for anticoagulant therapy: computed tomography or lumbar puncture.

Of 217 patients with clinical diagnosis of acute stroke 23% had nonischemic lesions diagnosed by computed tomography (CT) or lumbar puncture (LP). CT demonstrated all 37 cases of intracerebral hemorrhagic lesions; 9 were detected by LP. CT failed to demonstrate 8 of 17 cases of subarachnoid hemorrhage, but only 1 of these lacked headache or stiff neck. In 7 of 342 patients who were treated with anticoagulants after LP, spinal hematoma followed LP ( 5 with paraparesis). CT evaluation reduced the incidence of fatal cerebral hemorrhage during anticoagulant therapy of acute stroke. However, even if patients were evaluated with both CT and LP, the incidence of fatal cerebral hemorrhage resulting from intravenous anticoagulant therapy was 2.4%.

Pneumatic sequential compression reduces the risk of deep vein thrombosis in stroke patients.

OBJECTIVE: To determine if pneumatic sequential compression devices (SCDs) combined with subcutaneous heparin and antiembolic hose reduce the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) in stroke patients. BACKGROUND: DVTs and PEs are serious complications among hospitalized stroke patients. Subcutaneous heparin and SCDs have both been used to prevent DVT. It is not known if SCDs combined with subcutaneous heparin can improve the protection afforded by heparin alone. METHODS: The study group was comprised of nonhemorrhagic stroke patients admitted to the neurology service from October 1988 through June 1996. From October 1988 through April 1991 (233 patients), and during February 1993 (16 patients), patients received 5,000 U subcutaneous heparin twice daily and antiembolic hose. From June 1991 through January 1993 and from March 1993 through June 1996 (432 patients) all nonambulatory stroke patients had SCDs applied to both legs in addition to subcutaneous heparin and antiembolic hose. RESULTS: Twenty-three of 249 patients (9.2%; 21 of 233 and two of 16 patients) treated with heparin alone developed DVT and six patients (2.4%) developed PE (six of 233 and zero of 16). Half the PE cases (three of six) were fatal and all PEs were in patients with DVT. Eighty-three of the 249 patients were nonambulatory. Twenty-two of the 23 DVTs and all the PEs developed in nonambulatory patients. Only one DVT (0.23%) and no PEs occurred among the 432 patients (148 nonambulatory) treated with SCDs as well as heparin. The addition of SCDs resulted in more than a 40-fold reduction in the risk of DVT. CONCLUSIONS: Nonambulatory stroke patients have an increased risk for DVT and PE. Adding SCDs to treatment with subcutaneous heparin and antiembolic hose reduced the risks of DVTs and PEs. SCDs should be considered for adjunctive DVT prophylaxis in nonambulatory stroke patients.

Familial 'sleep apnea plus' syndrome: report of a family.

We describe a familial disorder consisting of sleep apnea, anosmia, colorblindness, partial complex seizures, and cognitive dysfunction. The phenotypic expression of the syndrome suggests an autosomal dominant inheritance with incomplete penetrance.

Second occurrence of spinal epidural metastases.

We reviewed records of 79 men with spinal epidural metastases diagnosed from July 1984 to July 1989, imaged by myelography or MRI, and treated with radiation therapy. Thirteen men (16%) had second epidural metastases. The mean time between lesions that developed within two vertebral bodies of a prior lesion was 2.8 months, compared with 15.2 months for lesions that were three or more vertebral bodies from a prior lesion. Some secondary spinal metastases occurring soon after the initial metastasis may represent regrowth of tumor at the border of the radiation port, suggesting that larger radiation ports be constructed for patients with lengthy expected survival times.

A case of persistent cortical deafness: clinical, neurophysiologic, and neuropathologic observations.

A 61-year-old man became deaf after the second of two cerebral infarctions which successively involved the temporal and adjacent cortices. He remained completely deaf until death 27 months later. Click stimulation demonstrated normal short-latency potentials, middle-latency responses better developed to stimulation of the right than of the left ear, and absent long-latency potentials. Neuropathologic examination showed cystic infarctions involving both transverse temporal gyri and adjacent cortical areas with preservation of the brainstem auditory nuclei. Persistent deafness can result from bilateral lesions involving the auditory and adjoining cortices.

Effect of anticholinergic agents upon acquired nystagmus: a double-blind study of trihexyphenidyl and tridihexethyl chloride.

We conducted a randomized, double-blind, crossover trial of two anticholinergic agents--trihexyphenidyl and tridihexethyl chloride (a quaternary anticholinergic that does not cross the blood-brain barrier)--in patients with acquired nystagmus and measured visual acuity and nystagmus before and at the end of 1 month on each medication. Of the 10 patients admitted to the study, only five completed trials of both drugs due to intolerance of medication or intercurrent illness. Of six patients who completed the trial of trihexyphenidyl, only one showed improvement. Of six patients who completed a trial of tridihexethyl chloride, four showed improvement. We conclude that (1) trihexyphenidyl is not a reliable treatment for acquired nystagmus, although occasional patients may benefit; (2) anticholinergic agents may suppress nystagmus by peripheral rather than central mechanisms; and (3) the side effects of anticholinergic agents limit their effectiveness in the treatment of nystagmus.

Asymmetry of forearm rolling as a sign of unilateral cerebral dysfunction.

We compared the reliability of asymmetry of forearm rolling (rotation of one forearm around the other in front of the torso) as a sign of unilateral cerebral dysfunction with that of other standard clinical tests. We studied 62 patients with radiologically confirmed unilateral cerebral lesions and 20 control subjects with normal imaging. Asymmetric forearm rolling was the most sensitive indicator of unilateral hemispheric disease (85%). This simple test is a useful addition to the neurologic examination.

The gamma-subunit of the acetylcholine receptor is not expressed in the levator palpebrae superioris.

In extraocular muscle (EOM), expression of the gamma-subunit, which is associated with the fetal-type acetylcholine receptor (AChR), may offer a differential target for immune-mediated damage and could explain the preponderance of ocular manifestations caused by myasthenia gravis (MG). Using Poly(A)+ RNA hybridization, we investigated expression of the gamma-subunit in bovine levator palpebrae superioris (LP), a muscle also differentially involved by MG. There were no transcripts of the gamma-subunit of the AChR, but the epsilon-subunit, associated with the adult-type AChR, was present. The results indicate that the susceptibility of LP to MG is not mediated by gamma-subunit expression and suggest that multiterminal fibers in EOM may be the site of gamma-subunit expression.