Long-term alliance for pathology equipment and technology acquisition: a paradigm shift for improved quality and efficiency.

OBJECTIVE: Personnel costs are the largest single budget item in the clinical laboratory, other major expenses being equipment, analyzers, blood and blood components, and cost of day-to-day consumables. This report describes our experience with developing a long-term relationship with a single major vendor as a paradigm shift from the traditional multiple vendors, multiple contracts, and recurrent extended negotiations. Our objective was to develop a long-term approach for replacement of effete equipment and upgrades to operations in a pathology and laboratory medicine department in collaboration with vendors providing equipment and services. METHODS: Major vendors were invited to visit the department to analyze the workload and workflow and suggest integrated solutions to meet the goals of the department. Multiple iterations of the proposals were evaluated, and a recommendation made to the medical center leadership. The vendor, the medical center, and the department jointly developed a 15-year partnership plan to improve the operations of pathology services. The agreement encompasses a range of management and performance criteria for both sides. The salient items discussed were laboratory staffing, turnaround time, workload change, test insourcing, reference laboratory costs, and scholarly productivity and teaching. RESULTS: The agreement reduced laboratory staffing by 21%, eliminated stat tests by reducing the turnaround time for routine tests to less than 45 minutes for 90% of tests, with an increase of 9.1% in the number of tests, Cost avoidance in salary and reference laboratory costs was $3,424,136/year against an expected target of $2 million in total savings, despite not including cost avoidance from promoting appropriate use of laboratory testing for inpatients and increase in revenue from increase in ambulatory testing. Vizient score in laboratory utilization improved from the 94th to 76th percentile. Scholarly output increased by more than 100%. CONCLUSION: This model of a long-term alliance with a chosen vendor led to improvements in quality and efficiency.

Timing of Referrals to a Down Syndrome Parent Group by Race.

The Down Syndrome Association of Central Ohio (DSACO) is a nonprofit organization that supports families, promotes community involvement, and encourages lifetime opportunities for people with Down syndrome. Methods: At DSACO, ongoing efforts for quality improvement included: a Medical Advisory Committee in 2016, the creation of resources groups for Latino families in 2017, for Somali families from 2018 to 2019, and for African American families in fall 2018, presentations at birth hospitals, and close tracking of referrals from hospitals when an infant with Down syndrome is born. In addition, the timing of referrals, either "early" (on the day of birth or the first day after birth) or "late" (2 or more days after birth), were tracked and plotted in p charts. Results: From January 2017 to April 2021, DSACO received 167 referrals; of these, a median of 65% was received "early." When analyzing all referrals to DSACO, no special cause was seen over the time studied. When evaluating the timing of referral to DSACO by race, referrals for 78% of White families were early (105/135 referrals). In comparison, referrals for 9% of minority families were early (3/32 referrals). Conclusions: The timing of DSACO referral differed by race. Outreach efforts did not change referral timing but led to a more diverse DSACO membership. Future study is needed to confirm if there is racial disparity in the timing of referrals to resources nationally and to understand the barriers in referring diverse families to Down syndrome nonprofit organizations.

Searching for the "Active Ingredients" in Physical Rehabilitation Programs Across Europe, Necessary to Improve Mobility in People With Multiple Sclerosis: A Multicenter Study.

BACKGROUND: Physical rehabilitation programs can lead to improvements in mobility in people with multiple sclerosis (PwMS). OBJECTIVE: To identify which rehabilitation program elements are employed in real life and how they might affect mobility improvement in PwMS. METHODS: Participants were divided into improved and nonimproved mobility groups based on changes observed in the Multiple Sclerosis Walking Scale-12 following multimodal physical rehabilitation programs. Analyses were performed at group and subgroup (mild and moderate-severe disability) levels. Rehabilitation program elements included setting, number of weeks, number of sessions, total duration, therapy format (individual, group, autonomous), therapy goals, and therapeutic approaches. RESULTS: The study comprised 279 PwMS from 17 European centers. PwMS in the improved group received more sessions of individual therapy in both subgroups. In the mildly disabled group, 60.9% of the improved received resistance training, whereas, 68.5% of the nonimproved received self-stretching. In the moderately-severely disabled group, 31.4% of the improved, received aerobic training, while 50.4% of the nonimproved received passive mobilization/stretching. CONCLUSIONS: We believe that our findings are an important step in opening the black-box of physical rehabilitation, imparting guidance, and assisting future research in defining characteristics of effective physical rehabilitation.

Estimating the cost of school sealant programs with minimal data.

OBJECTIVE: Develop methodology to estimate the annual cost of resources used by school sealant programs (SSPs) and demonstrate its use. METHODS: We used existing literature and expert opinion to identify SSP cost components and the most appropriate units for their measurement (e.g., per operator) and collection frequency (e.g., per day). For equipment and reusable instruments, costs were sufficiently homogenous across SSPs that we could provide default per unit cost estimates (2016 US$) that SSPs can use in lieu of collecting their own data. We also provide default costs for supply items such that SSPs can estimate total supply costs with program-specific information on sealant material used, as well as number of: sealant stations, operators, service delivery days, children screened/sealed, and number of teeth sealed. For the remaining three categories (labor, mileage, and administrative), costs varied substantially by SSP and required us to develop and pilot collection logs for program-specific data. RESULTS: The annual cost per sealant station ranged from $584 to $797 depending on program characteristics. For a hypothetical SSP that staffed each of two stations with two operators (hygienist and assistant) compensated at the national rate, hourly labor costs would equal $77.97. Assuming this SSP used disposable instruments, light-cured sealants and delivered sealants (3 per child) to 60 percent of the 3,390 children screened over 100 service days, infection control/supply costs per child would equal $5.30. CONCLUSION: This methodology allows SSPs to estimate costs with minimal data collection and time.

Rheological and sensory behaviors of parboiled pasta cooked using a microwave pasteurization process.

Pasta hydration and cooking requirements make in-package microwave pasteurization of pasta a processing challenge. The objective of this study was to assess instrumental and sensory attributes of microwave-treated pasta in comparison to conventionally cooked pasta. Fettuccine pasta was parboiled for 0, 3, 6, 9, or 12 min, pasteurized by microwaves at 915 MHz, then stored under refrigeration for 1 week. Pastas were evaluated by a trained sensory panel and with rheometry. Total pasta heat treatment affected both rheological and sensory behaviors; these differences were attributed to ultrastructure differences. Significant nonlinear behavior and dominant fluid-like behavior was observed in all pastas at strains >1%. Sensory results suggested microwave pasteurization may intensify the attributes associated with the aging of pasta such as retrogradation. A clear trend between magnitude of heat treatment and attribute intensity was not observed for all sensory attributes tested. The microwave pasta with the longest parboil time showed rheological behavior most similar to conventionally cooked pasta. Principal component analysis revealed that no microwave-treated pasta was similar to the control pasta. However, pasta parboiled for 9 min before microwave treatment had the greatest number of similar sensory attributes, followed by pasta parboiled for 6 or 12 min. Further study is needed to determine overall consumer acceptance of microwave-treated pasta and whether the differences in sensory and rheological behavior would impact consumer liking. PRACTICAL APPLICATIONS: The results of this study may be applied to optimize microwave pasteurization processes for cooked pasta and similar products, such as rice. The measurement and analysis procedures can be used to evaluate processing effects on a variety of different foods to determine overall palatability.

A School-Based Dental Program Evaluation: Comparison to the Massachusetts Statewide Survey.

BACKGROUND: School-based dental programs target high-risk communities and reduce barriers to obtaining dental services by delivering care to students in their schools. We describe the evaluation of a school-based dental program operating in Chelsea, a city north of Boston, with a low-income and largely minority population, by comparing participants' oral health to a Massachusetts oral health assessment. METHODS: Standardized dental screenings were conducted for students in kindergarten, third, and sixth grades. Outcomes were compared in bivariate analysis, stratified by grade and income levels. RESULTS: A greater percentage of Chelsea students had untreated decay and severe treatment need than students statewide. Yet, fewer Chelsea third graders had severe treatment need, and more had dental sealants. There was no significant difference in the percentage of Chelsea students having severe treatment need or dental sealants by income level. CONCLUSIONS: Students participating in our program do not have lower decay levels than students statewide. However, they do have lower levels of severe treatment need, likely due to treatment referrals. Our results confirm that school-based prevention programs can lead to increased prevalence of dental sealants among high-risk populations. Results provide support for the establishment of full-service school-based programs in similar communities.

Effect of Antidepressant Switching vs Augmentation on Remission Among Patients With Major Depressive Disorder Unresponsive to Antidepressant Treatment: The VAST-D Randomized Clinical Trial.

IMPORTANCE: Less than one-third of patients with major depressive disorder (MDD) achieve remission with their first antidepressant. OBJECTIVE: To determine the relative effectiveness and safety of 3 common alternate treatments for MDD. DESIGN, SETTING, AND PARTICIPANTS: From December 2012 to May 2015, 1522 patients at 35 US Veterans Health Administration medical centers who were diagnosed with nonpsychotic MDD, unresponsive to at least 1 antidepressant course meeting minimal standards for treatment dose and duration, participated in the study. Patients were randomly assigned (1:1:1) to 1 of 3 treatments and evaluated for up to 36 weeks. INTERVENTIONS: Switch to a different antidepressant, bupropion (switch group, n = 511); augment current treatment with bupropion (augment-bupropion group, n = 506); or augment with an atypical antipsychotic, aripiprazole (augment-aripiprazole group, n = 505) for 12 weeks (acute treatment phase) and up to 36 weeks for longer-term follow-up (continuation phase). MAIN OUTCOMES AND MEASURES: The primary outcome was remission during the acute treatment phase (16-item Quick Inventory of Depressive Symptomatology-Clinician Rated [QIDS-C16] score ≤5 at 2 consecutive visits). Secondary outcomes included response (≥50% reduction in QIDS-C16 score or improvement on the Clinical Global Impression Improvement scale), relapse, and adverse effects. RESULTS: Among 1522 randomized patients (mean age, 54.4 years; men, 1296 [85.2%]), 1137 (74.7%) completed the acute treatment phase. Remission rates at 12 weeks were 22.3% (n = 114) for the switch group, 26.9% (n = 136)for the augment-bupropion group, and 28.9% (n = 146) for the augment-aripiprazole group. The augment-aripiprazole group exceeded the switch group in remission (relative risk [RR], 1.30 [95% CI, 1.05-1.60]; P = .02), but other remission comparisons were not significant. Response was greater for the augment-aripiprazole group (74.3%) than for either the switch group (62.4%; RR, 1.19 [95% CI, 1.09-1.29]) or the augment-bupropion group (65.6%; RR, 1.13 [95% CI, 1.04-1.23]). No significant treatment differences were observed for relapse. Anxiety was more frequent in the 2 bupropion groups (24.3% in the switch group [n = 124] vs 16.6% in the augment-aripiprazole group [n = 84]; and 22.5% in augment-bupropion group [n = 114]). Adverse effects more frequent in the augment-aripiprazole group included somnolence, akathisia, and weight gain. CONCLUSIONS AND RELEVANCE: Among a predominantly male population with major depressive disorder unresponsive to antidepressant treatment, augmentation with aripiprazole resulted in a statistically significant but only modestly increased likelihood of remission during 12 weeks of treatment compared with switching to bupropion monotherapy. Given the small effect size and adverse effects associated with aripiprazole, further analysis including cost-effectiveness is needed to understand the net utility of this approach. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01421342.

Microwave Pasteurization of Cooked Pasta: Effect of Process Parameters on Texture and Quality for Heat-and-Eat and Ready-to-Eat Meals.

Pasta presents a challenge to microwave processing due to its unique cooking requirements. The objective of this study was to determine the effects of microwave processing on pasta physicochemical and mechanical properties. Fettuccine pasta was parboiled for selected times, then pasteurized using a Microwave Assisted Pasteurization System and stored under refrigeration for 1 wk. Samples were analyzed using microscopy, mechanical testing, and chemical analyses after storage. While no significant differences were observed for free amylose among fresh samples, samples parboiled for ≤6 min had significantly higher free amylose, suggesting reduced starch retrogradation. Increased heat treatment increased degree of protein polymerization, observed in microstructures as increased gluten strand thickness and network density. Firmness and extensibility increased with increased parboil time; however, extension data indicated an overall weakening of microwave-treated pasta regardless of total cooking time. Overall, microwave pasteurization was shown to be a viable cooking method for pasta.

Responsiveness and clinically meaningful improvement, according to disability level, of five walking measures after rehabilitation in multiple sclerosis: a European multicenter study.

BACKGROUND: Evaluation of treatment effects on walking requires appropriate and responsive outcome measures. OBJECTIVES: To determine responsiveness of 5 walking measures and provide reference values for clinically meaningful improvements, according to disability level, in persons with multiple sclerosis (pwMS). METHODS: Walking tests were measured pre- and postrehabilitation in 290 pwMS from 17 European centers. Combined anchor- and distribution-based methods determined responsiveness of objective short and long walking capacity tests (Timed 25-Foot Walk [T25FW] and 2- and 6-Minute Walk Tests [2MWT and 6MWT] and of the patient-reported Multiple Sclerosis Walking Scale-12 [MSWS-12]). A global rating of change scale, from patients' and therapists' perspective, was used as external criteria to determine the area under the receiver operating characteristic curve (AUC), minimally important change (MIC), and smallest real change (SRC). Patients were stratified into disability subgroups (Expanded Disability Status Scale score ≤4 [n = 98], >4 [n = 186]). RESULTS: MSWS-12, 2MWT, and 6MWT were more responsive (AUC 0.64-0.73) than T25FW (0.50-0.63), especially in moderate to severely disabled pwMS. Clinically meaningful changes (MICs) from patient and therapist perspective were -10.4 and -11.4 for MSWS-12 (P < .01), 9.6 m and 6.8 m for 2MWT (P < .05), and 21.6 m (P < .05) and 9.1 m (P = .3) for 6MWT. In subgroups, MIC was significant from patient perspective for 2MWT (10.8 m) and from therapist perspective for MSWS-12 (-10.7) in mildly disabled pwMS. In moderate to severely disabled pwMS, MIC was significant for MSWS-12 (-14.1 and -11.9). CONCLUSIONS: Long walking tests and patient-reported MSWS-12 were more appropriate than short walking tests in detecting clinically meaningful improvement after physical rehabilitation, particularly the MSWS-12 for moderate to severely disabled pwMS.

Calculating averted caries attributable to school-based sealant programs with a minimal data set.

OBJECTIVES: We describe a methodology for school-based sealant programs (SBSP) to estimate averted cavities, (i.e., difference in cavities without and with SBSP) over 9 years using a minimal data set. METHODS: A Markov model was used to estimate averted cavities. SBSP would input estimates of their annual attack rate (AR) and 1-year retention rate. The model estimated retention 2+ years after placement with a functional form obtained from the literature. Assuming a constant AR, SBSP can estimate their AR with child-level data collected prior to sealant placement on sealant presence, number of decayed/filled first molars, and age. We demonstrate the methodology with data from the Wisconsin SBSP. Finally, we examine how sensitive averted cavities obtained with this methodology is if an SBSP were to over or underestimate their AR or 1-year retention. RESULTS: Demonstrating the methodology with estimated AR (= 7 percent) and 1-year retention (= 92 percent) from the Wisconsin SBSP data, we found that placing 31,324 sealants averted 10,718 cavities. Sensitivity analysis indicated that for any AR, the magnitude of the error (percent) in estimating averted cavities was always less than the magnitude of the error in specifying the AR and equal to the error in specifying the 1-year retention rate. We also found that estimates of averted cavities were more robust to misspecifications of AR for higher- versus lower-risk children. CONCLUSIONS: With Excel (Microsoft Corporation, Redmond, WA, USA) spreadsheets available upon request, SBSP can use this methodology to generate reasonable estimates of their impact with a minimal data set.

Quality of reporting in economic evaluations of interventions to prevent dental caries needs improvement.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Systematic review of publications on economic evaluations of caries prevention programs. Marino RJ, Khan AR, Morgan M. Caries Res 2013;47(4):265-72. REVIEWERS: Susan O. Griffin, PhD, Kari Jones, PhD PURPOSE/QUESTION: The purpose of this study was to review the literature on economic evaluations of interventions for the prevention of dental caries with the intention of describing the characteristics (e.g., intervention evaluated, type of economic evaluation, and year of publication) of these studies and to assess their quality. The quality of economic evaluation was assessed using a checklist developed by Drummond et al.(1) This review did not present economic findings for individual studies or synthesize findings across studies. SOURCE OF FUNDING: Grant from Borrow Foundation (UK). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. TYPE OF STUDY/DESIGN: Systematic review of study characteristics and quality LEVEL OF EVIDENCE: Not applicable STRENGTH OF RECOMMENDATION GRADE: Not applicable.

An analysis of the New York University Emergency Department Algorithm's suitability for use in gauging changes in ED usage patterns.

BACKGROUND: The Emergency Department Algorithm (EDA) developed at New York University uses administrative discharge data to distill hundreds of International Classification of Diseases-9 codes for emergency department (ED) visits into 4 categories, making it attractive to researchers and policy makers. The EDA has been used to analyze patterns of ED visits in a wide variety of locations and populations. However, there are concerns regarding the validity and use of the EDA for research and policy. OBJECTIVE: To explain the findings of previous EDA users that it appears to lack sensitivity in detecting changes in ED utilization patterns. STUDY DESIGN: Mathematical simulation was used to analyze and explain the performance of the EDA in detecting differences in utilization patterns across hypothetical ED populations. Sensitivity analysis was used to illustrate the magnitude of changes in EDA outputs relative to changes in ED populations using a national sample of actual ED patients. RESULTS: The vast majority of possible EDA outputs are clustered so tightly as to show no significant change in outputs between different hypothetical populations. Sensitivity analysis shows that changes in EDA outputs are not nearly as great as the magnitude of the input differences across real-world populations. CONCLUSIONS: The EDA categorizes a very large variety of ED visits into a relatively small group of outputs. Its operating characteristics suggest that the EDA is insufficiently sensitive to changes in ED utilization patterns to be useful in assessing interventions to change them. This finding should caution potential users to consider the EDA's limitations before using it.

Association of health information technology and teleintensivist coverage with decreased mortality and ventilator use in critically ill patients.

BACKGROUND: Little evidence exists to support implementing various health information technologies, such as telemedicine, in intensive care units. METHODS: A coordinated health information technology bundle (HITB) was implemented along with remote intensivist coverage (RIC) at a 727-bed academic community hospital. Critical care specialists provided bedside coverage during the day and RIC at night to achieve intensivist coverage 24 hours per day, 7 days per week. We evaluated the effect of HITB-RIC on mortality, ventilator and vasopressor use, and the intervention length of stay. We compared our results with those achieved at baseline. RESULTS: A total of 954 control patients who received care for 16 months before the implementation of HITB-RIC and 959 study patients who received care for 10 months after the implementation were included in the analysis. Mortality for the control and intervention groups were 21.4% and 14.7%, respectively. In addition, the observed mortality for the intervention group was 75.8% (P < .001) of that predicted by the Acute Physiology and Chronic Health Evaluation IV hospital mortality equations, which was 29.5% lower relative to the control group. Regression results confirm that the hospital mortality of the intensive care unit patients was significantly lower after implementation of the intervention, controlling for predicted risk of mortality and do-not-resuscitate status. Overall, intervention patients also had significantly less (P = .001) use of mechanical ventilation, controlling for body-system diagnosis category and severity of illness. CONCLUSION: The use of HITB-RIC was associated with significantly lower mortality and less ventilator use in critically ill patients.

Exploring four-handed delivery and retention of resin-based sealants.

BACKGROUND: To date, no trials have been published that examine whether four-handed delivery of dental sealants increases their retention and effectiveness. In the absence of comparative studies, the authors used available data to explore the likelihood that four-handed delivery increased sealant retention. METHODS: The authors examined data regarding the retention of autopolymerized resin-based sealants from studies included in systematic reviews of sealant effectiveness. The explanatory variable of primary interest was the presence of a second operator. To examine the unique contribution of four-handed delivery to sealant retention, the authors used linear regression models. RESULTS: Eleven of the 36 studies from systematic reviews met explicit criteria and were included in this analysis. The high level of heterogeneity among studies suggested that multivariate analysis was the correct approach. According to the regression model, the presence of a second operator increased retention by 9 percentage points. CONCLUSIONS: For this group of studies, four-handed delivery of autopolymerized sealants was associated with increased sealant retention. CLINICAL IMPLICATIONS: Using four-handed delivery to place resin-based sealants may increase retention.

Perceived disability, fatigue, pain and measured isometric muscle strength in patients with post-polio symptoms.

BACKGROUND AND PURPOSE: Several years after the acute polio illness, patients may develop new post-polio symptoms. The purpose of the present study was to evaluate patients with post-polio symptoms with regard to perceived fatigue, functional ability, muscle strength, pain and with regard to measured physical fitness and isometric muscle strength. In addition, the relationship between the results of these subjective and objective measurements was investigated. METHOD: This was a prospective cross-sectional study in which 32 patients with post-polio symptoms were included. Main outcome measures were the Fatigue Severity Scale (FSS), the Disability Rating Index (DRI), pain intensity, pain distribution, self-reported and measured muscle strength and oxygen uptake. RESULTS: A marked reduction in isometric muscle strength compared to normal data, high scores in fatigue, widespread pain, low oxygen uptake and difficulties in performing some daily activities were found. Self-reported general muscle strength, pain intensity and pain distribution correlated significantly with patients' perceived fatigue and function at the activity level. There was no significant correlation between self-reported and measured results except for that found between isometric muscle strength in the legs and patients' perceived general muscle strength and oxygen uptake. CONCLUSIONS: Evaluation of pain intensity, pain distribution, perceived muscle strength, fatigue and ability to perform daily tasks reveals important aspects of health status in patients with post-polio symptoms. Reduction in isometric muscle strength was not reflected in those tests or in reported symptoms, and should be monitored independently using a sensitive assessment tool. Accurate screening of isometric muscle strength in isolated muscle groups contributes to therapeutic management in making a functional diagnosis at the level of body function and structure when designing specific training programmes and in motivating patients. An evaluation combining self-reports with sensitive muscle strength measures provide supplementary information and is appropriate for evaluating these patients in physiotherapy practice.

Impact of increasing Medicaid dental reimbursement and implementing school sealant programs on sealant prevalence.

UNLABELLED: We examined the impact of two financing strategies--increasing Medicaid dental reimbursements and providing school sealant programs--on dental sealant? prevalence (number of children with at least one sealant) among 7- to 9-year-olds in Alabama and Mississippi counties from 1999 to 2003. METHODS: We used Medicaid claims data in a linear regression model. We regressed number of children sealed per county onto eligible children, median family income, dentist-to-population ratio, and indicator variables for reimbursement increase, presence of community health center (CHC) or school sealant program, and interaction between reimbursement increase and presence of school program or CHC. We also calculated the average incremental cost per sealant from increasing the Medicaid reimbursement rate and then disaggregated it into cost to provide additional sealants and cost to provide the same number of sealants under the higher rate. RESULTS: Increasing the sealant reimbursement rate was associated with a 102 percent increase and a 39 percent increase in sealant prevalence in Mississippi and Alabama, respectively. Introducing school sealant programs more than doubled sealant prevalence in both states. In Mississippi, 85 percent of the average incremental cost from implementing the higher reimbursement rate was due to providing new sealants and 15 percent was due to paying a higher rate for sealants that likely would have been delivered at the old rate. CONCLUSION: Depending on supply and demand conditions in dental markets, both strategies can be effective in increasing sealant prevalence.

Speech characteristics of patients with pallido-ponto-nigral degeneration and their application to presymptomatic detection in at-risk relatives.

PURPOSE: This report describes the speech characteristics of individuals with a neurodegenerative syndrome called pallido-ponto-nigral degeneration (PPND) and examines the speech samples of at-risk, but asymptomatic, relatives for possible preclinical detection. METHOD: Speech samples of 9 members of a PPND kindred were subjected to perceptual characterization. Speech deterioration patterns were reported for 2 participants followed longitudinally at 6-month intervals. Cross-sectional findings were reported for 3 participants at various stages of disease. Longitudinal and cross-sectional findings were used to guide the examination of 4 at-risk, but asymptomatic, participants. RESULTS: Results revealed a progressive mixed dysarthria with hypokinetic, spastic, and flaccid features. It was characterized primarily by vocal tremor and high-frequency vocal flutter, speaking rate abnormalities most often in the direction of slowing, and a tendency toward monopitch. Dysarthria progression was marked by exacerbation and increasing severity of early features, progressive decrease in spontaneous speech output, verbal perseverations, and eventual mutism. Results for at-risk participants revealed preclinical speech abnormalities that preceded other motor signs. Speech results were examined in light of available autopsy findings for site of lesion associations. CONCLUSION: The dysarthria of PPND is an early harbinger of disease onset. It has a mixed presentation, with hypokinetic, spastic, and flaccid features.

Estimated impact of competing policy recommendations for age of first dental visit.

OBJECTIVE: To compare levels of dental utilization and untreated dental decay among children aged 1 to 3 years that are likely to occur under 2 potential guidance policies: (1) pediatricians refer all toddlers to dentists for screening (consistent with American Academy of Pediatric Dentistry and the American Dental Association recommendations; DENT), and (2) pediatricians receive training in caries risk assessment, screen toddlers, and refer at-risk children to dentists (consistent with American Academy of Pediatrics recommendations; PED). METHODS: Using decision analysis, we estimated the impact of PED and DENT assuming alternately unlimited dental capacity for Medicaid-insured patients and fixed Medicaid dental capacity. Results With unlimited capacity, if DENT were implemented, then dental utilization is estimated to increase from 27% under the status quo to 65% and untreated decay to decrease from a mean of 0.60 surfaces to 0.52 surfaces per child. If PED were implemented, then dental utilization and untreated decay would decrease from status quo levels to an estimated 11% and 0.47 surfaces, respectively, assuming that diagnostic sensitivity and specificity both equaled 1; they would decrease to 13% and 0.53 surfaces, respectively, if sensitivity equaled 0.76 and specificity equaled 0.95. With fixed capacity, under DENT, untreated decay is estimated to increase to 0.63 surfaces because low-risk private-pay patients would crowd out at-risk Medicaid-insured children, whereas under PED, untreated decay would still be less than under the status quo. CONCLUSIONS: Implementing PED will decrease untreated decay under most plausible scenarios, whereas switching to DENT will increase the burden of disease if Medicaid dental capacity is limited.

Safety and efficacy of botulinum toxin type B (Myobloc) in adductor spasmodic dysphonia.

This single-site, open-label, dose-finding study evaluated the safety and efficacy of botulinum toxin type B (BoNT-B; Myobloc) for the treatment of adductor spasmodic dysphonia (AdSD) in 13 patients. Three patients received a total of 50 U (25 U per vocal fold); the same three subsequently received 100 U, and then 10 more received 200 U. The primary measure of efficacy was the patient's rating of the change in the severity of spasms on a scale from -3 to +3. There were seven secondary measures of efficacy, including blinded ratings of the sound of voice recorded on audiotape. At Week 8 after injection, spasms improved in 0 of 3 patients who received 50 U, 1 of 3 patients who received 100 U, and 8 of 10 patients who received 200 U. The mean (+/- standard deviation [SD]) score for the change in spasm severity at Week 8 in the 200 U group was 1.4 (+/-1.2) points (P = 0.004). All seven secondary measures also showed improvement. Breathiness was the most common side effect but was mild in intensity and of short duration. We conclude that BoNT-B is safe and effective for the treatment of adductor spasmodic dysphonia.