Predicting Dental Caries in Young Children in Primary Health Care Settings.

Young children need increased access to dental prevention and care. Targeting high caries risk children first helps meet this need. The objective of this study was to develop a parent-completed, easy-to-score, short, accurate caries risk tool for screening in primary health care settings to identify children at increased risk for cavities. A longitudinal, prospective, multisite, cohort study enrolled (primarily through primary health care settings) and followed 985 (out of 1,326) 1-y-old children and their primary caregivers (PCGs) until age 4. The PCG completed a 52-item self-administered questionnaire, and children were examined using the International Caries Detection and Assessment Criteria (ICDAS) at 12 ± 3 mo (baseline), 30 ± 3 mo (80% retention), and 48 ± 3 mo of age (74% retention). Cavitated caries lesion (dmfs = decayed, missing, and filled surfaces; d = ICDAS ≥3) experience at 4 y of age was assessed and tested for associations with questionnaire items using generalized estimating equation models applied to logistic regression. Multivariable analysis used backward model selection, with a limit of 10 items. At age 4, 24% of children had cavitated-level caries experience; 49% were female; 14% were Hispanic, 41% were White, 33% were Black, 2% were other, and 10% were multiracial; 58% enrolled in Medicaid; and 95% lived in urban communities. The age 4 multivariable prediction model, using age 1 responses (area under the receiver operating characteristic curve = 0.73), included the following significant (P < 0.001) variables (odds ratios): child participating in public assistance programs such as Medicaid (1.74), being non-White (1.80-1.96), born premature (1.48), not born by caesarean section (1.28), snacking on sugary snacks (3 or more/d, 2.22; 1-2/d or weekly, 1.55), PCG cleaning the pacifier with juice/soda/honey or sweet drink (2.17), PCG daily sharing/tasting food with child using same spoon/fork/glass (1.32), PCG brushing their teeth less than daily (2.72), PCG's gums bleeding daily when brushing or PCG having no teeth (1.83-2.00), and PCG having cavities/fillings/extractions in past 2 y (1.55). A 10-item caries risk tool at age 1 shows good agreement with cavitated-level caries experience by age 4.

Reporter bacteriophage T7NLC utilizes a novel NanoLuc::CBM fusion for the ultrasensitive detection of Escherichia coli in water.

Rapid detection of bacteria responsible for foodborne diseases is a growing necessity for public health. Reporter bacteriophages (phages) are robust biorecognition elements uniquely suited for the rapid and sensitive detection of bacterial species. The advantages of phages include their host specificity, ability to distinguish viable and non-viable cells, low cost, and ease of genetic engineering. Upon infection with reporter phages, target bacteria express reporter enzymes encoded within the phage genome. In this study, the T7 coliphage was genetically engineered to express the newly developed luceriferase, NanoLuc (NLuc), as an indicator of bacterial contamination. While several genetic approaches were employed to optimize reporter enzyme expression, the novel achievement of this work was the successful fusion of the NanoLuc reporter to a carbohydrate binding module (CBM) with specificity to crystalline cellulose. This novel chimeric reporter (nluc::cbm) bestows the specific and irreversible immobilization of NanoLuc onto a low-cost, widely available crystalline cellulosic substrate. We have shown the possibility of detecting the immobilized fusion protein in a filter plate which resulted from a single CFU of E. coli. We then demonstrated that microcrystalline cellulose can be used to concentrate the fusion reporter from 100 mL water samples allowing a limit of detection of <10 CFU mL-1E. coli in 3 hours. Therefore, we conclude that our phage-based detection assay displays significant aptitude as a proof-of-concept drinking water diagnostic assay for the low-cost, rapid and sensitive detection of E. coli. Additional improvements in the capture efficiency of the phage-based fusion reporter should allow a limit of detection of <10 CFU per 100 mL.

Features of prescription drug monitoring programs associated with reduced rates of prescription opioid-related poisonings.

BACKGROUND: The United States is in the midst of an opioid epidemic. In addition to other system-level interventions, all states have responded during the crisis by implementing prescription drug monitoring programs (PDMPs). This study examines associations between specific administrative features of PDMPs and changes in the risk of prescription opioid-related poisoning (RxORP) over time. METHODS: This longitudinal, observational study utilized a 'natural experiment' design to assess associations between PDMP features and risk of RxORP in a nationally-representative population of privately-insured adults from 2004 to 2014. Administrative health claims data were used to identify inpatient hospital admissions and emergency department visits related to RxORP. Generalized estimating equation Poisson regression models were used to examine associations between specific PDMP features and changes in relative risk (RR) of RxORP over time. RESULTS: In adjusted analyses, states without PDMPs experienced an average annual increase in the rate of RxORP of 9.51% over the study period, while states with operational PDMPs experienced an average annual increase of 3.17%. The increase in RR of RxORP over time in states with operational PDMPs was significantly less than increases in states without PDMPs. States with specific features, including those that monitored more schedules or required more frequent data reporting, experienced stronger protective effects on the RR of RxORP over time. CONCLUSION: This study examined associations between specific PDMP features and RxORP rates in a nationally-representative population of privately-insured adults. Results of this study may be used as empirical evidence to guide PDMP best practices.

Covalent immobilization of lysozyme on ethylene vinyl alcohol films for nonmigrating antimicrobial packaging applications.

The objective of this study was to develop a new antimicrobial film, in which lysozyme was covalently attached onto two different ethylene vinyl alcohol copolymers (EVOH 29 and EVOH 44). The EVOH surface was modified with UV irradiation treatment to generate carboxylic acid groups, and lysozyme was covalently attached to the functionalized polymer surface. Surface characterization of control and modified films was performed using attenuated total reflectance Fourier transform infrared spectroscopy (ATR-FTIR) and dye assay. The value of protein loading after attachment on the surface was 8.49 µg protein/cm(2) and 5.74 µg protein/cm(2) for EVOH 29 and EVOH 44, respectively, after 10 min UV irradiation and bioconjugation. The efficacy of the EVOH-lysozyme films was assessed using Micrococcus lysodeikticus. The antimicrobial activity of the films was tested against Listeria monocytogenes and was similar to an equivalent amount of free enzyme. The reduction was 1.08 log for EVOH 29-lysozyme, 0.95 log for EVOH 44-lysozyme, and 1.34 log for free lysozyme. This work confirmed the successful use of lysozyme immobilization on the EVOH surface for antimicrobial packaging.

Covalent attachment of lactase to low-density polyethylene films.

Polymer films to which bioactive compounds such as enzymes are covalently attached offer potential for in-package processing of food. Beta-galactosidase (lactase) was covalently attached to surface-functionalized low-density polyethylene films. A two-step wet chemical functionalization introduced 15.7 nmol/cm2 primary amines to the film surface. Contact angle, dye assays, X-ray photoelectron spectroscopy, and appropriate protein assays were used to characterize changes in film surface chemistry after each step in the process of attachment. Glutaraldehyde was used to covalently attach lactase to the surface at a density of 6.0 microg protein per cm2 via reductive amination. The bond between the covalently attached lactase and the functionalized polyethylene withstood heat treatment in the presence of an ionic denaturant with 74% enzyme retention, suggesting that migration of the enzyme into the food product would be unlikely. The resulting polyethylene had an enzyme activity of 0.020 lactase units (LU)/cm2 (approximately 4500 LU/g). These data suggest that enzymes that may have applications in foods can be covalently attached to inert polymer surfaces, retain significant activity, and thus have potential as a nonmigratory active packaging materials.

Asthma prevalence, cost, and adherence with expert guidelines on the utilization of health care services and costs in a state Medicaid population.

OBJECTIVE: To provide a descriptive analysis of asthma prevalence and costs in a Medicaid population and gauge the degree of adherence with expert guidelines for asthma medication management from the National Asthma Education and Prevention Program. DATA SOURCES: Kentucky Medicaid administrative data for 1996. STUDY DESIGN: A cross-sectional retrospective analysis was used to determine adherence with asthma medication guidelines and utilization of asthma-related health care services and costs. Multivariate logistic regression was used to determine the relationship between nonadherence with the guidelines and utilization of health care services. PRINCIPAL FINDINGS: Of the 530,000 Medicaid recipients, 24,365 (4.6 percent) were identified as having asthma. Average annual asthma-related costs ($616) accounted for less than 20 percent of total health care costs ($3,645). Nonadherence to the guidelines was prevalent. Less than 40 percent of the patients received a prescription for a rescue medication, and fewer than 10 percent of the patients who received daily inhaled short-acting beta-2 agonists were regular users of inhaled steroids. Nonadherence to the guidelines was associated with an increased risk of an asthma-related hospitalization (odds ratio = 1.5, p < .05). CONCLUSIONS: Guideline nonadherence was widespread and associated with an increase in exacerbations of asthma that resulted in hospitalizations. Asthma prevalence and utilization of health care services in a Medicaid population were similar to previous estimates reported nationally and in health maintenance organizations.

Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma.

BACKGROUND: We assessed the role and importance of continuity of care in predicting the perceptions of the physician-patient relationship held by patients with asthma. METHODS: We analyzed the 1997 statewide probability survey of adult Kentucky Medicaid recipients. The participants included 1726 respondents with 2 or more visits to a physician's office, clinic, or emergency department in the previous 12 months. Of these, 404 reported having asthma. The respondents used 5-point single-item scales to rate continuity of care, provider communication, and patient influence over treatment. RESULTS: Multivariate linear regression analyses were used to assess the contribution of continuity of care to provider communication and patient influence in the presence of control variables. Those variables included age, sex, education, race, number of visits, general health, health improvement, and life satisfaction. For persons with asthma, continuity of care was the only variable that significantly contributed to the provider communication model (P = .01) and the only variable other than life satisfaction that contributed to the patient influence model (P < .05 for each). For patients who did not have asthma, continuity of care was one of several variables contributing significantly (P < .05) to the provider communication and patient influence models. CONCLUSIONS: Particularly for patients with asthma, continuity of care was linked to patient evaluations of their interaction with the physician. Because of this, changes in health care systems that promote discontinuity with individual physicians may be particularly disruptive for patients with chronic diseases.

Medicaid managed care and provider consolidation.

In the thrust toward constructing economic value, health care provider firms have been consolidating at a marked rate. Medicaid managed care programs have been rapidly emerging with the objectives of containing health care costs and improving services for beneficiaries. However, there are concerns that the trend toward achieving market efficiency through merger is largely incongruent with the economic and health value objectives of Medicaid managed care programs in the states. Discordance among value objectives arises primarily because of inefficient and market concentrating horizontal merger strategies employed by firms and disruptions in quality of care that occur during the transition to integrated health care systems. By promoting vertical integration strategies and filling in the quality gaps created by an active merger environment, Medicaid offices advance state objectives of cost containment and quality while recognizing that providers operate in a complex and competitive environment that necessitates consolidation for organizational survival.

Endoscopic evaluation of the esophagus in infants and children immediately following intraoperative use of transesophageal echocardiography.

OBJECTIVE: Intraoperative transesophageal echocardiography (TEE) has evolved as an essential technique for use during pediatric cardiac surgery; however, few studies have evaluated the safety of TEE in children. This series reports endoscopic examination of the esophagus following intraoperative TEE in pediatric patients. METHODS: Fifty children undergoing congenital heart surgery underwent flexible esophagoscopy that was performed after completion of their heart surgery and after the removal of the transesophageal echo probe. The patients' ages ranged from 4 days to 10 years old, and their weight ranged from 3.0 to 39.8 kg, with a mean weight of 12.6 kg. RESULTS: Thirty-two of 50 patients (64%) had abnormal results shown on esophageal examinations; this occurred more frequently in the subset of patients weighing < 9 kg. No long-term feeding or swallowing difficulties were noted in any of the 48 patients who survived. CONCLUSIONS: Intraoperative TEE in infants and children frequently caused mild mucosal injury. Care must be exercised in the insertion and manipulation of the probes.

Detrimental effects of standard medical therapy in congenital diaphragmatic hernia.

OBJECTIVE: To evaluate the impact of a nonstandard ventilation strategy on survival in congenital diaphragmatic hernia (CDH). BACKGROUND: Despite recent advances, including nitric oxide, CDH remains an unsolved problem with a mortality rate of 35% to 50%. Hyperventilation and alkalization remain common therapies. METHODS: In 1992, the authors prospectively abandoned hyperventilation and alkalization. Patients are lightly sedated and ventilated with the lowest pressure providing adequate chest movement, and the rate is set to patient comfort. Nitric oxide and extracorporeal membrane oxygenation (ECMO) are reserved for life-threatening instability. Surgical repair is delayed 1 to 5 days. Sixty consecutive patients are compared with 29 previous patients treated with hyperventilation and alkalization, 13 before and 16 after the availability of ECMO. RESULTS: Overall, 47 of 60 patients (78%) in study era 3 survived compared with 2 of 13 (15%) in the hyperventilation era and 7 of 16 (44%) in the hyperventilation/ECMO era (p < 0.0001). The disease severity and the incidence of associated anomalies did not differ between groups. To compare management strategies, patients who had treatment withheld because of lethal associated conditions were then removed from analysis. Peak inspiratory pressure and arterial pH were lower (p < 0.0001) and Paco2 was higher (p < 0.05) in era 3 than in the previous eras. The rate of pneumothorax (1.9%) decreased (p < 0.0001). In era 3, survival was 47 of 53 (89%) treated patients, and 23 of 25 inborn patients with isolated CDH survived (92%). CONCLUSIONS: Nonstandard ventilatory support of patients with CDH has led to significantly improved survival rates. This study sets a survival benchmark and strongly suggests the negative effects of hyperventilation and alkalization.

Assessing quality of care via HEDIS 3.0. Is there a better way?

Patients, employers, and third-party payers are all calling for improved measures of health care quality. This has led to the development of "report cards," assessments that are many times applied not just to health plans but also to providers. One attempt at creating a standardized set of quality and effectiveness measures is the Health Plan Employer Data and Information Set (HEDIS). The HEDIS measures are based primarily on analyses of administrative data sets. Problems with HEDIS measures, including the probability that plans will use different data collection methods and a lack of risk adjustment, may result in incorrect conclusions about the quality of care delivered by various providers. An alternative method of standardized surveys is proposed that will overcome many of the limitations of the current HEDIS measures, provide outcome rather than process data, and provide data for developing interventions to improve quality.

Gastrointestinal myoelectric activity in a child with gastroschisis and ileal atresia.

Gastroschisis is frequently associated with intestinal atresia and alterations in gastrointestinal function. The authors studied gastric and small bowel myoelectric activity in a child who had a complex course and prolonged inability to tolerate oral intake after staged repair of gastroschisis and an associated ileal atresia. The child remained unable to tolerate oral intake after repair of the atresia and was reexplored 3 months later to rule out a partial small bowel obstruction, with simultaneous placement of serosal electrodes on the stomach and proximal small bowel. Persistent gastric dysrhythmias were observed postoperatively, and the child was unable to tolerate gastrostomy tube feedings. Abnormalities were also seen in small bowel motility, including retrograde propagation of activity fronts of the migrating myoelectric complex. However, the intestine converted to a fed myoelectric pattern with tube feedings, and the child was subsequently able to tolerate feedings via a tube placed directly into the small bowel. The authors conclude that myoelectric recordings via implanted electrodes are safe and feasible in children, and may give information regarding underlying motility alterations. The ultimate clinical role of myoelectric recordings in treating children with suspected motility disorders will require further study.

Exposing the circumflex coronary artery: the heartflip technique.

A method to expose the circumflex coronary artery in its course in the atrioventricular groove is introduced. No special equipment or assistance is required. This method also can be applied to expose the obtuse marginal branches of the circumflex coronary artery. Adverse effects have not been observed.

Unilateral pulmonary agenesis, esophageal atresia, and distal tracheoesophageal fistula.

A small-for-gestational-age, premature infant with the combination of unilateral pulmonary agenesis, esophageal atresia, and distal tracheoesophageal fistula was treated successfully by early gastrostomy and delayed fistula division with esophagoesophagostomy. Only 2 other successfully treated cases have been reported previously. Both were full-term infants treated with early division of the tracheoesophageal fistula and esophagoesophagostomy. Gestational age, size, and associated medical problems need to be considered when planning operative therapy for these babies.

Long-term complications of laparotomy in Hodgkin's disease.

OBJECTIVE: The authors determined the incidence of complications in 133 patients who had undergone staging laparotomy with splenectomy before treatment for Hodgkin's disease (stages I-IV). METHODS AND MATERIALS: Medical records were reviewed, and the patients or their relatives were interviewed. Median follow-up after laparotomy was 15.7 years (range = 2.5-28 years). RESULTS: Ten episodes of overwhelming postsplenectomy infection (OPSI) were documented in nine patients (6.8%). None of 25 patients who received pneumococcal vaccine before splenectomy developed OPSI. Patients with advanced (stages III-IV) or recurrent Hodgkin's disease were at higher risk of OPSI than those with early disease, and those who received combined modality oncologic therapy were at greater risk than those receiving less intensive treatment. Surgical complications included small bowel obstruction in 13 patients (9.8%), necessitating repeat laparotomy in 9 patients (6.8%), atelectasis in 17 patients, abscess in 3 patients, and 1 wound dehiscence. No deaths occurred as a result of surgical complications. Causes of death in the 29 patients who died included Hodgkin's disease (12 patients), acute treatment-related morbidity (1 patient), leukemia (5 patients), bone marrow failure (3 patients), solid malignancy (2 patients), intercurrent disease (4 patients), unknown causes (1 patient), and OPSI (1 patient). CONCLUSION: With presplenectomy pneumococcal vaccination and modern surgical techniques, the long-term risks of laparotomy with splenectomy are acceptable if knowledge of the pathologic extent of abdominal Hodgkin's disease would alter treatment regimens.

Progress in childhood cancer care in Florida. 1970-1992.

Pediatric cancer has been a priority in Florida since 1970. That year physicians established a statewide network of children's tumor programs, the Florida Association of Pediatric Tumor Programs (FAPTP), which has grown from the initial two programs to 10 in 1992 and now maintains a registry with follow-up to monitor incidence and other indicators. State-of-the-art care is provided through affiliation with the Pediatric Oncology Group. The incidence of pediatric cancer in Florida is equivalent to national rates, but the number of children followed in 1991 had grown to approximately 2,000. The number receiving care has increased an average of 13% annually since 1981. Services for these patients should be reviewed on a continuing basis to assure access to specialized programs.

Pseudomembranous colitis following resection for Hirschsprung's disease.

Enterocolitis is the most common cause of significant morbidity and death in Hirschsprung's disease. Although most cases respond to nasogastric decompression, antibiotics, and colonic evacuation, some children have an unusually fulminant or protracted clinical course. Four cases are reported of pseudomembranous colitis (PMC) that developed 1 to 18 months (mean, 8 months) after definitive surgery for Hirschsprung's disease (Soave endorectal pull-though, 2; Duhamel procedure, 2). While all children presented with fever, abdominal distention, and diarrhea, indistinguishable from typical Hirschsprung's enterocolitis, the clinical course was fulminant in two cases, both of whom died of septic shock. Postmortem examination in both showed extensive colonic pseudomembranes despite identification of Clostridium difficile toxin and subsequent vancomycin therapy (initiated late in the clinical course). Two children in the series had protracted hospitalizations and eventually required diverting enterostomy despite recognition of C difficile toxin and treatment with enteral vancomycin, in one child necessitating multiple courses of antibiotic therapy. Awareness of the virulence of PMC associated with Hirschsprung's disease (even after definitive resection) should prompt submission of stool specimens from any child who presents with enterocolitis for both C difficile culture and toxin levels. On the basis of our experience it is our policy to initiate a prompt course of vancomycin by rectal lavage or nasogastric tube in all children with Hirschsprung's enterocolitis, pending culture results, in view of the significant morbidity and mortality exemplified by cases in this review.

Diagnosis of acute diffuse pulmonary infiltrates in immunosuppressed patients by open biopsy of the lung.

Herein is a review of the results of open biopsies of the lung performed upon immunosuppressed patients between the years 1982 and 1988. The goal was to assess the safety and value of the procedure on a group of patients who are many times in extremis because of multiorgan failure. Obtaining the correct diagnosis and establishing treatment poses a challenge. The study includes 74 patients. Fifty-four had malignant tumors; 20 had various diseases associated with immunosuppression. The biopsy was obtained from the left side in 65 instances. An adequate thoracotomy was done to permit exploration of the thoracic cavity and obtain a representative sample of tissue. The mortality rate related to the operation was 1.4 percent and the complication rate was 11.0 percent. Forty-six percent of the infiltrates were the result of infection. In 42 percent, a change in treatment was made. Thirty-two percent survived and were discharged from the hospital. Patients with adverse drug reaction, with nonspecific pneumonitis and with bacterial infection had a favorable prognosis and benefited most from open biopsy of the lung.