Self-management in temporomandibular disorders: a systematic review of behavioural components.

The aim of this qualitative systematic review was to identify the behaviour change techniques most frequently employed in published temporomandibular disorder (TMD) self-management (SM) programmes. The reviewers matched the components of SM programmes into the relevant behaviour change technique domains according to the definitions of the behaviour change taxonomy (version 1). Electronic databases were searched for randomised controlled trials assessing an SM programme for TMD. Manual searches were also conducted for potentially important journals. Eligibility criteria for the review included: the type of study, the participants, the intervention utilised and the comparators/control. Fifteen randomised controlled trials with 554 patients were included in this review. The review concludes a minority of the available behaviour change techniques are currently employed in SM programmes. Other behaviour change techniques should be examined to see whether there is a theoretical underpinning that might support their inclusion in self-management programmes in TMD. Further trials are required to conclude that SM programmes are more effective than no treatment at all and or placebo. With more structured SM programmes, greater therapeutic benefits might be achieved, and certainly if SM programmes published in the literature define their components through use of the behaviour change taxonomy, it would be easier for clinicians to replicate efficacious programmes.

Self-management programmes in temporomandibular disorders: results from an international Delphi process.

Self-management (SM) programmes are commonly used for initial treatment of patients with temporomandibular disorders (TMD). The programmes described in the literature, however, vary widely with no consistency in terminology used, components of care or their definitions. The aims of this study were therefore to construct an operationalised definition of self-management appropriate for the treatment of patients with TMD, identify the components of that self-management currently being used and create sufficiently clear and non-overlapping standardised definitions for each of those components. A four-round Delphi process with eleven international experts in the field of TMD was conducted to achieve these aims. In the first round, the participants agreed upon six principal concepts of self-management. In the remaining three rounds, consensus was achieved upon the definition and the six components of self-management. The main components identified and agreed upon by the participants to constitute the core of a SM programme for TMD were as follows: education; jaw exercises; massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. This Delphi process has established the principal concepts of self-management, and a standardised definition has been agreed with the following components for use in clinical practice: education; self-exercise; self-massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. The consensus-derived concepts, definitions and components of SM offer a starting point for further research to advance the evidence base for, and clinical utility of, TMD SM.

DEEP Study: does EQ-5D-5L measure the impacts of persistent oro-facial pain?

The EQ-5D-5L is a generic quality of life (QOL) measure widely used throughout the world, which has the advantage that it allows health-state preferences to be elicited. The aim of this study was to examine whether: a) variation in the standardised reference period for EQ-5D-5L from 'today' to 'the last month' had a minimal clinically meaningful difference; (b) EQ-5D-5L had convergent validity with a multidimensional pain measure in quantifying the impacts of pain. As part of a larger study into the effectiveness and efficiency of care pathways for persistent orofacial pain (POFP) (http://research.ncl.ac.uk/deepstudy), participants with POFP (n = 100) completed two versions of the EQ-5D-5L at the same time with different reference periods ('today' vs. 'last month'). Participants also completed the first section of the West Haven-Yale Multidimensional Pain Inventory (v3) to assess convergent validity. Two-tailed nonparametric inferential statistics, intra-class correlation coefficients (ICC), and within-subject change scores were used to compare the two EQ-5D-5L versions. Convergent validity was assessed using Spearman's rho correlation coefficients. Health-state valuations were significantly different (P < 0.01), and there was good similarity between the two versions' ICC 0.86 (95% CI 0.79-0.91). The within-subject mean change was 0.03 (95% CI 0.01-0.06). For convergent validity, all relationships were significant (P < 0.05) and in the expected directions. EQ-5D-5L demonstrates sufficient convergent validity to be used with POFP, and a change in the standard reference period may be unnecessary if a multidimensional pain measure is also used.

Ruptured papillary muscle, a complication of myocardial infarction: clinical presentation, diagnosis, and treatment.

Ruptured papillary muscle due to myocardial infarction was encountered in 14 patients during the period 1975-1983. Five of the 14 patients had a history of angina pectoris and two had a history of prior myocardial infarction. Eleven patients with myocardial infarction developed additional pain due to myocardial ischemia and/or a murmur of mitral regurgitation and pulmonary edema within a week, 3 others had a prolonged course with intermittent pain due to myocardial ischemia and breathlessness for longer periods and then deteriorated. Thirteen of our 14 patients developed a murmur and all but one had pulmonary edema on the chest x-ray. Five patients had infarction patterns on the electrocardiogram, the remainder of the patients had only ST- and T-wave changes. Echocardiograms showed fine flutter and notching of the anterior mitral leaflets and vigorous contractions of the left ventricle. Only one patient was demonstrated to have a papillary muscle tip prolapsing into the left atrium on two-dimensional echocardiography. Twelve patients underwent surgery and 8 survived. Seven patients had single-vessel coronary disease, 4 involving the circumflex system and 3 involving the right coronary system. Four of the 7 patients with single-vessel coronary disease survived surgery. Five patients went to surgery with the intra-aortic balloon pump in place and only 3 survived. Three others had the pump inserted intraoperatively and 2 of these survived. Six of 9 patients who had mitral valve replacement and coronary bypass survived. Ejection fraction ranged from 40 to 79%. Surgical survival did seem to be related to the extent of papillary muscle rupture, with the best results occurring in the group with a small portion of the tip ruptured. Seven patients had a stormy clinical course and required surgery within 10 days of rupture. Four of these 7 survived. It seems reasonable to believe that these patients who often have small infarction and limited coronary disease have good potential for survival. Our approach has been to move toward surgery once the diagnosis is made to avoid the sudden deterioration that frequently occurs. The surgical mortality in this group remains in the 30 to 40% range.

Elimination of the chloride interference on the determination of arsenic using hydride generation inductively coupled plasma mass spectrometry.

In the determination of arsenic, attention has recently focused on the speciation of As(III) and As(V). Reversed-phase HPLC can be used to efficiently separate these two arsenic species. When inductively coupled plasma mass spectrometry is used for arsenic detection, an isobaric interference at m/z 75 is caused by the presence of chloride in the sample. These experiments describe the use of hydride generation in conjunction with a polypropylene-membrane gas-liquid separator to completely eliminate the transport of chloride to the plasma. A detection limit of 0.46 ppb for As(III) was achieved with this system. The chromatographic resolution of the system was not compromised by the addition of the gas-liquid separator. A determination of the arsenic content of a NIST urine sample was performed to demonstrate the effectiveness of the chloride elimination.

Echocardiographic criteria of the diagnosis of mitral-semilunar valve continuity.

A prospective echocardiographic study of 39 healthy adults with no history of heart disease was conducted to investigate the relationship between the anterior mitral valve leaflet (AMVL) and the posterior aortic root (PAR). The difference between the echocardiographic depth of the AMVL and the depth of the PAR with respect to the chest wall (CW) echoes was measured from both the third and fourth intercostal spaces in both the supine and left lateral positions. The results indicate that there were no statistically significant differences between the two depths in three of four measuring position postures. However, the best correlation between the depth of the AMVL had the PAR was obtained in the fourth ICS supine position. The echocardiographic difference between the CS-PAR and the CW-AMVL was less than or equal to 8 mm. in 90 per cent and less than or equal to 10 mm. in 97 per cent of our subjects in the fourth ICS. In the third intercostal space in the left lateral position, however, there was a statistically significant (P less than 0.01) difference in the two dimensions. In an individual subject, in any of the four possible positions, however, there were differences of up to 14 mm. in the two depths. The AMVL was found to be echocardiographically continuous with the PAR in all cases. An understanding of the normal AMVL-PAR relationship is becoming increasingly important, especially in regard to the application of echocardiography to the diagnosis of congenital heart disease, such as tetralogy of Fallot, double-outlet right ventricle, and transportation of the great vessels and of mitral regurgitation.

Myocardial infarction management with peripheral streptokinase.

The early management of myocardial infarction (MI) is undergoing a new evolution. Aggressive treatment and new invasive modalities have brought improved prognosis to these patients. Intracoronary administration of fibrinolytic agents is rapidly gaining wide acceptance. We report a pilot protocol for administration of peripheral intravenous (IV) versus direct intracoronary fibrinolytic agents in acute MI. Thirty patients with acute evolving MI were assigned consecutively to receive fibrinolytic therapy; 15 patients received intracoronary streptokinase and 15 received peripheral IV streptokinase at a dosage of 1.5 million units over a 30-minute period. Evaluation by clinical symptoms, ECG changes, and hemodynamic studies by angiography and radionuclide ventriculography indicated comparable and beneficial results for both groups. Patients assigned to the IV therapy were able to receive streptokinase therapy 1.5 hours earlier than those receiving intracoronary therapy, and they had a higher incidence of reperfusion. We conclude that IV streptokinase therapy may be preferable to intracoronary therapy in view of a higher reperfusion frequency, fewer complications, and greater ease of administration. With both treatment modalities, comparable improvement in left ventricular function was noted. Institutions that do not have invasive techniques available may well be the first to benefit from this method of myocardial salvage, and we encourage cooperation between emergency and cardiology departments.

Intravenous streptokinase in acute myocardial infarction.

Intravenous (IV) fibrinolytic therapy, a recent area of research, has a great deal of applicability in emergency medicine. We report our experience with 30 patients treated with this method. Thirty consecutive patients in the early stages of acute evolving myocardial infarction (AMI) were assigned to receive high-dose IV streptokinase, 1.5 million units over a 30-minute period. Patients presented to the treating hospital at a mean time of 1.21 +/- 1.08 hours, and treatment commenced at a mean time of 2.77 +/- 1.31 hours after the onset of symptoms. Using standard clinical criteria, 86.7% (n = 26) of the patients reperfused initially. Two, however, reoccluded within the first 48 hours, and their clinical symptoms of myocardial infarction reappeared. By clinical observation 80% (n = 24) of the patients reperfused, and myocardial salvage was observed. Twenty-four patients with clinical reperfusion and one additional patient had patency of the affected artery, yielding a reperfusion rate of 83.3% (n = 25) as judged by angiography within one week of AMI. Both patients who had reoccluded clinically also were found to be occluded on angiography. Clinical and angiographic methods yield very similar results for the judgment of reperfusion (80% vs 83%, respectively, with no significant difference, P not significant). The results of our study tend to confirm the efficacy of IV streptokinase as a valuable management tool for early myocardial infarction.

Role of cytochrome P450 enzyme induction in the metabolic activation of benzo[c]phenanthrene in human cell lines and mouse epidermis.

The environmental contaminant benzo[c]phenanthrene (B[c]Ph) has weak carcinogenic activity in rodent bioassays; however, the fjord region diol epoxides of B[c]Ph, B[c]Ph-3,4-diol 1,2-epoxides (B[c]PhDE), are potent carcinogens. To determine the role of cytochrome P450 isozymes in the activation of B[c]Ph in MCF-7 cells and the low activation of B[c]Ph in mouse skin, cells of the MCF-7 and the human hepatoma HepG2 cell lines were treated with the potent Ah receptor agonist 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) prior to exposure to B[c]Ph for 24 h. Mice were treated topically with 1 microg of TCDD or vehicle (control) for 73 h and then with 2 micromol of B[c]Ph for 24 h. In MCF-7 cells, TCDD exposure increased B[c]PhDE-DNA adduct levels more than 3-fold with a 10-fold increase in the (-)-B[c]PhDE-2-dA(t) adduct. Treatment of HepG2 cells with TCDD prior to B[c]Ph application did not increase B[c]PhDE-DNA binding. Total B[c]PhDE-DNA adducts increased 3-fold in TCDD-treated mouse epidermis: the majority of the increase resulted from (+)-B[c]PhDE-1-dA adducts. Analysis of P450 enzymes by Western blotting detected a large increase of P4501B1 but almost no increase in P4501A1 in MCF-7 cells exposed to 10 microM B[c]Ph for 24 or 48 h. In HepG2 cells, there were no detectable levels of P4501A1 or P4501B1 after treatment with 10 microM B[c]Ph for 24 h. In contrast, topical application of 2 micromol of B[c]Ph to mouse skin for 48 or 72 h increased P4501A1, but no P4501B1 was detected. As a measure of P450 activity, the metabolism of 7,12-dimethylbenz[a]anthracene (DMBA) was analyzed in microsomes prepared from MCF-7 and HepG2 cells exposed to 0.1% DMSO, 10 microM B[c]Ph, or 10 nM TCDD for 24 or 48 h and from mouse epidermis treated with 1 microg of TCDD, or vehicle control for 72 h, or 2 micromol of B[c]Ph for 48 h. The levels of DMBA metabolites were low or undetectable in microsomes from B[c]Ph-treated MCF-7 and HepG2 cells, but a metabolite pattern consistent with P4501A1 metabolism of DMBA was present in B[c]Ph-exposed mouse epidermal microsomes. TCDD-treated MCF-7 cells, HepG2 cells, and mouse epidermis had DMBA metabolism patterns characteristic of P4501A1 activity. Microsomes from TCDD-treated human cells formed a higher proportion of the proximate carcinogenic metabolite DMBA-3,4-dihydrodiol (16% of total identified metabolites) than TCDD-treated mouse epidermis (2%). In mouse epidermis, the weak ability of B[c]Ph to increase hydrocarbon-metabolizing activity and the increase in mainly P4501A1, leading to formation of the less carcinogenic stereoisomer B[c]PhDE-1, may explain the low carcinogenic activity of B[c]Ph. In a human mammary carcinoma cell line, treatment with B[c]Ph increases mainly P4501B1 and results in formation of a higher proportion of the more carcinogenic B[c]PhDE-2. This indicates that cells in which B[c]Ph treatment increases P4501B1 levels effectively activate B[c]Ph to potent carcinogenic metabolites.