Patient comfort discussing sensitive behavioral health topics.

BACKGROUND: : Following implementation of routine screening for depression in primary care, screening for other behavioral health issues is expanding. However, prior to implementing additional screening it is important to consider patient comfort answering sensitive questions related to behavioral health topics to determine screening acceptability and effectiveness. METHODS: : A self-report survey was completed by U.S. adults over the age of 18 (n = 378) using Amazon Mechanical Turk. The survey assessed comfort discussing demographics, physical health, behavioral health, oral health, and living conditions with medical providers. Comfort levels of behavioral health topics were compared to comfort discussing depression symptoms and reasons for discomfort discussing topics were also surveyed. RESULTS: : There were significant differences in comfort level discussing various behavioral health issues (F(8) = 51.70, P < .001). Participants reported being more comfortable discussing cigarette smoking and less comfortable discussing trauma, intimate partner violence (IPV) and gun ownership compared to depression. Privacy and perceived irrelevance were the most common reasons for discomfort. CONCLUSIONS: : Accurate indices of patient behavioral health are essential for patient care. However, patients may be uncomfortable discussing some topics such as trauma, IPV, and gun ownership that patients view as private and/or unrelated to their treatment. Patient comfort may increase through provider trainings that focus on communication skills training, clear administrative procedures that allow for privacy and adequate time for discussions, and community education that underscores how these issues impact physical health.

Vaso-occlusive Pain Crisis Mimicking Mandibular Abscess in an Adolescent with Sickle Cell Disease.

In people with sickle cell disease (SCD), oral abscesses are concerning clinical conditions and carry a high risk of postoperative sickle cell complications. We present an unusual case of a 14-year-old girl with SCD whose initial presentation of facial swelling, headaches, jaw pain, and paresthesia mimicked an odontogenic abscess. She was diagnosed with vaso-occlusive crisis in the mandibular bone and successfully managed noninvasively. This is among the youngest cases of paresthesia in the lower lip in SCD, which provided a clue that postponing invasive aspiration or biopsy was possible under empiric antibiotics and close observation.

Prevalence of Radiographically Identifiable Dental Anomalies in Children and Association with Health Status.

Purpose: The purpose of this study was to describe the prevalence of radiographically identifiable developmental dental anomalies (DDA) in a university-based pediatric dental clinic and to assess for associations between DDA and health status. Methods: Retrospective data, obtained from the electronic dental records of a three-year pediatric patient cohort, were evaluated by two trained and calibrated examiners. Strict inclusion/ exclusion criteria were applied. A validated image quality grading system was used for radiograph assessment, and the physical status classification of the American Academy of Anesthesiology was utilized. A chi-square test and bivariate logistic regression were used for statistical analysis. The inter- and intraexaminer reliability was assessed using Cohen's Kappa. Results: A total of 1,478 subjects (69 percent medically healthy) were enrolled. DDA were identified in 25 percent of the subjects, with hyperdontia, hypodontia, and microdontia being more common. A statistically significant association was found between the presence of DDA and health status (P<0.001) and between DDA and asthma (P=0.035). Patients with systemic disturbances showed 2.12 times greater odds of having DDA (P<0.001, 95 percent confidence interval equals 1.7-2.7). Conclusions: The prevalence of developmental dental anomalies was high, with one in four patients affected. DDA in number were the most common. Patients with systemic disturbances had greater odds of having DDA.

Barrier for Particle Dispersion Control During Mastoidectomy.

Introduction The China Health Authority alerted the World Health Organization (WHO) of several cases of pneumonia, and the WHO has declared the novel coronavirus (COVID-19) a global pandemic. Mastoidectomy is a high-risk aerosol generating procedure with the potential to expose the surgeon to infectious particles. Objective Aim to develop a low-cost prototype for a barrier device that can be used during mastoidectomy. Methods Describe the steps involved during otological emergency, requiring immediate surgical procedure, in untested patients. The Otorhinolaryngology Surgical Team of Walter Cantídio Hospital developed the barrier for particle dispersion presented here. Results During surgery, the prototype did not compromise visualization of the surgical field and instrumentation. Microscope repositioning was not compromised or limited by tent Instrumentation and instrument pouch under the Microscope-Tent (MT) performed surgery. After surgery, the plastic sheet was removed simply, without requiring strength. Bone dust and irrigation droplets were collected on the tent. Conclusion Our team developed and practiced, in an otologic emergency, a low-cost and reproducible barrier device that can be used in mastoidectomy in COVID-19 patients. Further tests on efficacy may be necessary.

Barrier for Particle Dispersion Control During Mastoidectomy

Abstract Introduction The China Health Authority alerted the World Health Organization (WHO) of several cases of pneumonia, and the WHO has declared the novel coronavirus (COVID-19) a global pandemic. Mastoidectomy is a high-risk aerosol generating procedure with the potential to expose the surgeon to infectious particles. Objective Aim to develop a low-cost prototype for a barrier device that can be used during mastoidectomy. Methods Describe the steps involved during otological emergency, requiring immediate surgical procedure, in untested patients. The Otorhinolaryngology Surgical Team of Walter Cantídio Hospital developed the barrier for particle dispersion presented here. Results During surgery, the prototype did not compromise visualization of the surgical field and instrumentation. Microscope repositioning was not compromised or limited by tent Instrumentation and instrument pouch under the Microscope-Tent (MT) performed surgery. After surgery, the plastic sheet was removed simply, without requiring strength. Bone dust and irrigation droplets were collected on the tent. Conclusion Our team developed and practiced, in an otologic emergency, a low-cost and reproducible barrier device that can be used in mastoidectomy in COVID-19 patients. Further tests on efficacy may be necessary.

Barrier device prototype for open tracheotomy during COVID-19 pandemic.

OBJECTIVE: To present a low-cost prototype for a barrier enclosure device which can be used during open surgeries such as tracheotomy. METHODS: We provide detailed description of a novel device called COVID-Box, developed by The Surgical Airway Team for COVID-19 Pandemic, a temporary task force formed by Walter Cantídio University Hospital. Safety guidelines for performing tracheotomies in COVID-19 patients are also stated. RESULTS: Our prototype device provides greater hand mobility than previous barrier devices reported, making it more suitable for airway surgical procedures, such as tracheotomy. The curved shaped format and the customizable access ports provides ergonomics, without compromising safety. CONCLUSION: The COVID-Box appears to be an efficient, reproduceable, low-cost barrier enclosure device that can be used for open tracheotomies in ICU patients during the COVID-19 pandemic.

Sternectomy for Treating Advanced Non-Melanoma Skin Cancer.

INTRODUCTION: Skin cancer is a rare indication of sternectomy. Our goal is to report the clinical course of seven patients who underwent sternectomy for skin cancer. METHODS: The survey data were collected from medical records of patients treated between 2008 and 2018 at Ceará Cancer Institute. RESULTS: All patients had prolonged sunlight exposure and average disease time of two years and age of 60 years. Most patients recovered favorably after treatment with prolonged survival. CONCLUSION: Sternectomy remains an option with curative purposes for locally advanced skin cancer.

Prevalência da mutação BRAF V600E, NRAS Q61L e KIT V559A e padrão da expressão imunoistoquímica das proteínas BRAF V600E, PTEN e p53 em melanomas cutâneos primários tratados no Hospital Haroldo Juaçaba-associação com parâmetros clínicos, histopatológicos e com fototipo da pele / Prevalence of the BRAF V600E, NRAS Q61L and KIT V559A mutations and immunohistochemical expression pattern of BRAF V600E, PTEN and p53 proteins in primary cutaneous melanomas treated at Haroldo Juaçaba Hospital ­ association with clinical, histopathological and skin phototype parameters

Introdução: Melanoma cutâneo tem etiologia multifatorial. BRAF, NRAS, KIT, PTEN e TP53 são importantes genes envolvidos na patogênese do melanoma. Objetivo: Caracterizar o perfil clinicopatológico e molecular do melanoma cutâneeo primário no Estado do Ceará, Brasil. Metodologia: Dados demográficos, clínico-patológicos foram coletados. Fototipo da pele foi determinado conforme Fitzpatrick (1988) e elastose solar foi classificada de acordo com LANDI et al. (2006). Realizado rastreamento das mutações BRAF V600E, NRAS Q61L e KIT V559A por RT-PCR e imunoistoquímica para avaliação de BRAF V600E (mutada), PTEN e p53. Resultados: Nos 156 melanomas incluídos, sexo feminino, fototipo II e sítio tronco predominaram. Breslow foi maior que 4mm em 32,8% e ulceração ocorreu em 46,3% dos casos. Elastose solar foi moderada a severa em 31,8%. Mutação BRAF V600E foi detectada em 18,6% e nenhuma mutação NRAS e KIT foi detectada. Expressão de BRAF V600E, PTEN e p53 ocorreram em 32,3%, 87% e 80%, respectivamente. Mutação BRAF V600E teve associação significativa com sítio, idade e expressão de BRAF V600E, mas não com a expressão de PTEN. A expressão de p53 teve associação significativa com recidiva sistêmica. Conclusão: A prevalência da mutação BRAF V600E foi baixa comparada às populações caucasianas mais estudadas com diferenças no padrão do melanoma cutâneo mutado BRAF V600E. A expressão de p53 foi mais prevalente do que a encontrada na literatura se apresentando como fator de bom prognóstico

Introduction: Cutaneous melanoma has a multifactorial etiology. BRAF, NRAS, KIT, PTEN and TP53 are important genes involved in the pathogenesis of melanoma. Objective: To characterize the clinicalpathological and molecular profile of primary cutaneous melanoma in the state of Ceará, Brazil. Method: Demographic and clinical-pathological data were collected. Skin phototype was determined according to Fitzpatrick (1988) and solar elastosis was classified according to LANDI et al. (2006). BRAF V600E, NRAS Q61L and KIT V559A mutation screening was performed by RT-PCR and immunohistochemistry to evaluate BRAF V600E (mutated), PTEN and p53. Results: Of the 156 assessed melanomas, female gender, phototype II and trunk tumor location predominated. Breslow was greater than 4mm in 32.8% and ulceration occurred in 46.3% of the cases. Solar elastosis was moderate to severe in 31.8%. The BRAF V600E mutation was detected in 18.6% and no NRAS and KIT mutations were detected. BRAF V600E, PTEN and p53 expression occurred in 32.3%, 87% and 80% of cases, respectively. The BRAF V600E mutation was significantly associated with site, age and BRAF V600E expression, but not with PTEN expression. p53 expression showed a significant association with systemic relapse. Conclusion: The BRAF V600E mutation prevalence was low when compared to the most frequently studied Caucasian populations, with differences observed in the mutated BRAF V600E cutaneous melanoma pattern. p53 expression was more prevalent than that found in the literature, showing a good prognostic factor

Delivering HIV care in challenging operating environments: the MSF experience towards differentiated models of care for settings with multiple basic health care needs.

INTRODUCTION: Countries in the West and Central African regions struggle to offer quality HIV care at scale, despite HIV prevalence being relatively low. In these challenging operating environments, basic health care needs are multiple, systems are highly fragile and conflict disrupts health care. Médecins Sans Frontières (MSF) has been working to integrate HIV care in basic health services in such settings since 2000. We review the implementation of differentiated HIV care and treatment approaches in MSF-supported programmes in South Sudan (RoSS), Central African Republic (CAR) and Democratic Republic of Congo (DRC). METHODS: A descriptive analysis from CAR, DRC and RoSS programmes reviewing methodology and strategies of HIV care integration between 2010 and 2015 was performed. We describe HIV care models integrated within the provision of general health care and highlight best practices and challenges. RESULTS: Services included provision of general health care, with out-patient care (range between countries 43,343 and 287,163 consultations/year in 2015) and in-patient care (range 1076-16,595 in 2015). By the end of 2015 antiretroviral therapy (ART) initiations reached 12-255 patients/year. A total of 1101 and 1053 patients were on ART in CAR and DRC, respectively. In RoSS 186 patients were on ART when conflict recommenced late in 2013. While ART initiation and monitoring were mostly clinically driven in the early phase of the programmes, DRC implemented CD4 monitoring and progressively HIV viral load (VL) monitoring during study period. Attacks to health care facilities in CAR and RoSS disrupted service provision temporarily. Programmatic challenges include: competing health priorities influencing HIV care and need to integrate within general health services. Differentiated care approaches that support continuity of care in these programmes include simplification of medical protocols, multi-month ART prescriptions, and community strategies such as ART delivery groups, contingency plans and peer support activities. CONCLUSIONS: The principles of differentiated HIV care for high-quality ART delivery can successfully be applied in challenging operating environments. However, success heavily depends on specific adaptations to each setting.

Oral Health-related quality of life in pediatric patients with cystic fibrosis.

PURPOSE: To compare the oral health-related quality of life (OHRQoL) of 8- to 12-year-old children and 13- to 17-year-old adolescents diagnosed with cystic fibrosis (CF). MATERIALS AND METHODS: Participants were recruited from a Midwest CF center. Parents provided demographic information and their assessment of the child's health. Patients completed the Child Oral Health Impact Profile (COHIP). RESULTS: Thirty-nine child-parent pairs participated. Fifty four percent of the patients were male, 87% Caucasian, and 56% adolescent, with 66% of families reporting an annual income of over $100,000. Excellent or very good health, including oral health, was reported by 67% of the patients. Individuals taking 10 or more medications reported better OHRQoL while Caucasians reported better oral health and total scores than other races. Adolescents had poorer total COHIP, social-emotional well-being, and self-image scores. CONCLUSION: Although most patients reported good or excellent oral health, adolescents reported a poorer OHRQoL than younger patients.

Impact of HIV-associated conditions on mortality in people commencing anti-retroviral therapy in resource limited settings.

OBJECTIVES: To identify associations between specific WHO stage 3 and 4 conditions diagnosed after ART initiation and all cause mortality for patients in resource-limited settings (RLS). DESIGN, SETTING: Analysis of routine program data collected prospectively from 25 programs in eight countries between 2002 and 2010. SUBJECTS, PARTICIPANTS: 36,664 study participants with median ART follow-up of 1.26 years (IQR 0.55-2.27). OUTCOME MEASURES: Using a proportional hazards model we identified factors associated with mortality, including the occurrence of specific WHO clinical stage 3 and 4 conditions during the 6-months following ART initiation. RESULTS: There were 2922 deaths during follow-up (8.0%). The crude mortality rate was 5.41 deaths per 100 person-years (95% CI: 5.21-5.61). The diagnosis of any WHO stage 3 or 4 condition during the first 6 months of ART was associated with increased mortality (HR: 2.21; 95% CI: 1.97-2.47). After adjustment for age, sex, region and pre-ART CD4 count, a diagnosis of extrapulmonary cryptococcosis (aHR: 3.54; 95% CI: 2.74-4.56), HIV wasting syndrome (aHR: 2.92; 95%CI: 2.21 -3.85), non-tuberculous mycobacterial infection (aHR: 2.43; 95% CI: 1.80-3.28) and Pneumocystis pneumonia (aHR: 2.17; 95% CI 1.80-3.28) were associated with the greatest increased mortality. Cerebral toxoplasmosis, pulmonary and extra-pulmonary tuberculosis, Kaposi's sarcoma and oral and oesophageal candidiasis were associated with increased mortality, though at lower rates. CONCLUSIONS: A diagnosis of certain WHO stage 3 and 4 conditions is associated with an increased risk of mortality in those initiating ART in RLS. This information will assist initiatives to reduce excess mortality, including prioritization of resources for diagnostics, therapeutic interventions and research.

Dental and oral care for chronically ill children and adolescents.

Dental care is the most unmet health care need of children and adolescents who have chronic conditions and diseases. Because advances in therapy and medical technology have extended the lives of this population, it is very likely that these children will seek care in general dental practices. It is extremely important for dental practitioners to be knowledgeable about their patients' history and medical treatment to deliver care safely. This article reviews four chronic diseases of childhood (asthma, cystic fibrosis, cancer, and sickle cell disease) and discusses recommendations for oral and dental treatment.

Maxillary melanotic neuroectodermal tumor of infancy.

The melanotic neuroectodermal tumor of infancy (MNTI) is a rare benign neoplasm of neural crest origin most commonly found in the anterior region of the maxilla. The tumor almost always develops during the first year of life, although in some cases it can be present at birth. MNTI's present as a rapidly growing, painless expansile, partly pigmented mass. They are usually unencapsulated, with a tendency to occur as a single lesion. Local excision is the treatment of choice and is usually curative. Main sites for recurrences are the maxilla (57%) and the skull/brain (28.6%). Malignant transformation has been noted in approximately 6.5% of all cases and in 2% of maxillary tumors. The case of a 3-month old boy who presented with a loose primary maxillary left central incisor is discussed. The diagnostic and clinico-pathological features as well as tumor management and importance of a timely diagnosis are reviewed.

An overview of chronic oral graft-vs-host disease following pediatric hematopoietic stem cell transplantation.

Hematopoietic stem cell transplant (HSCT) is the treatment of choice for many hematologic, genetic, oncologic, and immunologic diseases. It is also one of the most aggressive treatments among the different cancer therapies, however, and is associated with severe conditioning-related toxicity, profound neutropenia, a high level of prophylactic immunosuppression and graft-vs-host disease (GVHD). Even with GVHD prophylaxis, chronic GVHD remains a significant complication of HSCT and is a frequent reason for nonrelapse morbidity and mortality following allogeneic HSCT. It primarily targets the skin, gastrointestinal tract, and liver. Approximately 20% of patients who receive matched sibling transplants and 40% of matched unrelated donor recipients will develop chronic GVHD. Risk factors include: (1) history of acute GVHD; (2) hemotologic malignancy; (3) female donor to male recipient; (4) use of total body irradiation; (5) donor age of > or = 5 years; and (6) recipients >10 years of age. The purpose of this paper was to review the pathogenesis, prevention, and treatment of pediatric chronic graft-vs-host disease, with a focus on its oral manifestations and the dental management of affected children and adolescents.

Severe gingival recession and early loss of teeth in a child with chronic graft versus host disease: a case report.

Graft versus host disease (GVHD) occurs after a hematopoietic stem cell transplantation (HSCT) when the donor's immune system rejects the recipient's body, leading to significant morbidity and mortality. Increased numbers of chronic GVHD (c-GVHD) patients are likely to be seen by dental professionals because of the advances made in transplantation. The oral cavity may be the primary or the only site of c-GVHD and may have persistent lesions after resolution has occurred in other areas. Approximately 80% of patients with extensive c-GVHD present some type of oral involvement, including xerostomia, oral pain and lesions. Dental and oral care can be challenging for these patients. This paper discusses the manifestations and treatment of oral c-GVHD and presents the case history of a 15-month-old girl who developed severe oral GVHD with an unusual periodontal presentation and early loss of primary teeth.

Head and neck extramedullary disease as the initial presentation of acute myelogenous leukemia in a child.

The purpose of this paper was to describe a child with a noncontributory medical history who sought an emergency dental appointment due to a significant facial and neck swelling. The clinical and radiographic exams revealed no odontogenic infection, and the patient was subsequently diagnosed with acute myelogenous leukemia by the hematology/oncology service. This report underscores the important role pediatric dentists can play in an early referral for further workup of a suspected malignancy, which may initially present as extramedullary disease in the head and neck.

Dental care of the pediatric cancer patient.

Although the rate for childhood cancer has remained relatively stable for the past 2 decades, there have been drastic declines in mortality due to early diagnosis and improvements in therapy. Now over 75% of children diagnosed with cancer survive more than 5 years. The pediatric dental professional plays an important role in the prevention, stabilization, and treatment of oral and dental problems that can compromise the child's health and quality of life before, during, and after the cancer treatment. This manuscript discusses recommendations for the dental care of the pediatric oncology patient.

Self-injurious behavior as a challenge for the dental practice: a case report.

Patients who present self-injurious behavior (SIB) can be considered a treatment challenge in the dental office or hospital setting. Oral structures can play various roles in the process of self injury. In this paper, the authors report a case of SIB in the form of cheek-biting on an adolescent with a history of hydrocephalus and developmental delay, which was successfully treated with a modified standard maxillary orthodontic retainer. Early detection and intervention in SIB cases in patients with developmental disabilities influence the successful outcome of the therapeutic interventions, enhancing the patient's quality of life.