Loss of idealism or realistic optimism? A cross-sectional analysis of dental hygiene students' and registered dental hygienists' professional identity perceptions.

OBJECTIVES: The dental hygiene profession in the U.S. is in the process of establishing a direct access model of care and contributing to the creation of the profession of a dental therapist. The objectives were to analyse the professional role perceptions of dental hygiene students and registered dental hygienists in these times of change. Specifically, it was explored whether dental hygiene students' current professional identities differ (i) from their expected future identities, and (ii) from dental hygienists' current and (iii) past identities. METHODS: Survey data were collected from 215 dental hygiene students concerning their present and future role perceptions, and from 352 registered dental hygienists concerning their present and past professional identity perceptions. RESULTS: Students' future professional identity perceptions were even more positive than their very positive current perceptions of their professional role components. Students' current perceptions of professional pride, professional ambition, work ethic and patient relations were more positive than dental hygienists' current perceptions of these professional role components. A comparison of students' current perceptions with dental hygienists' current and retrospective descriptions showed that students were more positive than dental hygienists in each case. CONCLUSIONS: The fact that dental hygienists had less positive role perceptions than dental hygiene students might lead to the conclusion that a loss of idealism occurs over the course of a professional lifespan. However, dental hygienists actually improved their role perceptions over time and students' future descriptions were more positive than their current descriptions, supporting the interpretation that realistic optimism dominates professional role perceptions in these times of change.

The impact of vitamin D status on periodontal surgery outcomes.

Vitamin D regulates calcium and immune function. While vitamin D deficiency has been associated with periodontitis, little information exists regarding its effect on wound healing and periodontal surgery outcomes. This longitudinal clinical trial assessed outcomes of periodontal surgery and teriparatide administration in vitamin-D-sufficient and -insufficient individuals. Forty individuals with severe chronic periodontitis received periodontal surgery, daily calcium and vitamin D supplements, and self-administered teriparatide or placebo for 6 wks to correspond with osseous healing time. Serum 25(OH)D was evaluated at baseline, 6 wks, and 6 mos post-surgery. Clinical and radiographic outcomes were evaluated over 1 yr. Placebo patients with baseline vitamin D deficiency [serum 25(OH)D, 16-19 ng/mL] had significantly less clinical attachment loss (CAL) gain (-0.43 mm vs. 0.92 mm, p < 0.01) and probing depth (PPD) reduction (0.43 mm vs. 1.83 mm, p < 0.01) than vitamin-D-sufficient individuals. Vitamin D levels had no significant impact on CAL and PPD improvements in teriparatide patients at 1 yr, but infrabony defect resolution was greater in teriparatide-treated vitamin-D-sufficient vs. -deficient individuals (2.05 mm vs. 0.87 mm, p = 0.03). Vitamin D deficiency at the time of periodontal surgery negatively affects treatment outcomes for up to 1 yr. Analysis of these data suggests that vitamin D status may be critical for post-surgical healing. (ClinicalTrials.gov number, CT00277706).

Saliva/pathogen biomarker signatures and periodontal disease progression.

The purpose of this study was to determine the role of saliva-derived biomarkers and periodontal pathogens during periodontal disease progression (PDP). One hundred human participants were recruited into a 12-month investigation. They were seen bi-monthly for saliva and clinical measures and bi-annually for subtraction radiography, serum and plaque biofilm assessments. Saliva and serum were analyzed with protein arrays for 14 pro-inflammatory and bone turnover markers, while qPCR was used for detection of biofilm. A hierarchical clustering algorithm was used to group study participants based on clinical, microbiological, salivary/serum biomarkers, and PDP. Eighty-three individuals completed the six-month monitoring phase, with 39 [corrected] exhibiting PDP, while 44 [corrected] demonstrated stability. Participants assembled into three clusters based on periodontal pathogens, serum and salivary biomarkers. Cluster 1 members displayed high salivary biomarkers and biofilm; 71% [corrected] of these individuals were undergoing PDP. Cluster 2 members displayed low biofilm and biomarker levels; 76% [corrected] of these individuals were stable. Cluster 3 members were not discriminated by PDP status; however, cluster stratification followed groups 1 and 2 based on thresholds of salivary biomarkers and biofilm pathogens. The association of cluster membership to PDP was highly significant (p < 0.0007). [corrected] The use of salivary and biofilm biomarkers offers potential for the identification of PDP or stability (ClinicalTrials.gov number, CT00277745).

Early onset neonatal bacterial infections.

The evaluation of a neonate with suspected sepsis is one of the most common, most demanding, and most important tasks of the pediatrician or neonatologist. This review summarizes the difficulties in the prompt diagnosis of neonatal sepsis and the appropriate utilization of screening laboratory tests of blood, urine, and cerebrospinal fluid in this setting. The appropriate utilization of these laboratory tests requires careful consideration of the inherent limitations and appreciation of the sensitivity and specificity of these tests for the diagnosis of early onset bacteremia and sepsis.

Seasonal respiratory viral infections. Impact on infants with chronic lung disease following discharge from the neonatal intensive care unit.

OBJECTIVE: To determine the frequency and severity of acute respiratory infections in infants with bronchopulmonary dysplasia following discharge from the neonatal intensive care unit. DESIGN: A prospective cohort study of 30 oxygen-dependent children who were younger than 2 years (mean age, 9.8 months; range, 3 to 24 months) were studied from September 1990 through April 1991. MEASUREMENTS/RESULTS: During the study, 101 (90.2%) of 112 visits for illness were prompted by new or worsening respiratory symptoms. Diagnoses included upper respiratory tract infection (30.4%), otitis media (26.0%), pneumonia (11.1%), acute exacerbation of bronchopulmonary dysplasia (10.4%), reactive airway disease (9.6%), and bronchiolitis (5.9%). Among these children, an increase in the fraction of inspired oxygen was necessary during 43% of visits. Ten children were hospitalized on 25 occasions for a mean of 37.6 hospital days per child (range, 1 to 107 days), and mean length of stay for each hospitalization was 15 days (median, 6 days). Five children were admitted to the pediatric intensive care unit. Respiratory viruses isolated included respiratory syncytial virus (n = 7), parainfluenza 3 virus (n = 3), and adenovirus (n = 2). No isolates of influenza A or B were detected. Anthropometrics at study entry and study end were converted to z scores as descriptors of weight for age, height for age, and weight for height. Growth improved during the 8 months of the study; however, overall, the children were leaner at study end than at study entry. CONCLUSIONS: In children with bronchopulmonary dysplasia, respiratory viral infections led to significant morbidity, which included long and frequent hospitalizations during the peak of the respiratory viral season. Although weight and linear growth increased throughout the study, patients were leaner at study conclusion than at study entry.

Neonatal pulmonary insufficiency caused by adenovirus infection successfully treated with extracorporeal membrane oxygenation.

Two infants with fulminant early-onset sepsis syndrome and respiratory failure are described. Adenovirus was isolated from cultures from both patients. Complications during pregnancy and respiratory failure that required tracheal intubation at birth suggested congenital infection. Both infants were successfully treated with extracorporeal membrane oxygenation.

Enteric infectious disease in neonates. Epidemiology, pathogenesis, and a practical approach to evaluation and therapy.

There are many bacterial and viral pathogens that have been associated with enteric disease during the newborn period. These pathogens have widely different mechanisms of action on the intestinal epithelium and are associated with a spectrum of clinical findings. Infected infants can be asymptomatic, have gastroenteritis, or have a fulminant sepsis picture. To determine therapy and institute appropriate infection control measures requires the ability to recognize the clinical syndrome and correctly interpret laboratory results. All of these principles can be applied to the premature infant in the neonatal intensive care nursery as well as the full-term infant at home.

Selective intrapartum prophylaxis for group B streptococcus colonization: management and outcome of newborns.

OBJECTIVE: Intrapartum antibiotic prophylaxis (IAP) in mothers with group B streptococcus (GBS) colonization presents difficult neonatal management decisions. IAP was instituted in response to an increased incidence of early-onset GBS sepsis (EOGBSS), and a study was conducted to evaluate the outcome of these newborns. METHODS: A study was undertaken at Truman Medical Center-East, a county hospital with a level 1 nursery. During the 20-month study period, prenatal GBS cultures were obtained on all mothers in their third trimester of pregnancy. At time of delivery, GBS-positive women who had at least one risk factor were to receive IAP. Risk factors included fever and/or amnionitis, premature labor, and prolonged rupture of membranes defined as > 6 hours. Screening laboratory tests were performed on all newborns whose mothers received IAP. Only the newborns with positive screening laboratory tests or symptoms of sepsis received further laboratory evaluation and antibiotic treatment. RESULTS: During the study, 2040 mothers gave birth to 2054 newborns. Three hundred thirty-two mothers (16.3%) were colonized with GBS and 122 (37.0%) had at least one risk factor. IAP was given to 70 GBS-positive mothers. Thirty-three (27%) GBS-positive mothers with risk factors did not receive IAP for logistical reasons. Eleven full-term newborns had EOGBSS: For case newborns, the mean duration of ruptured membranes was 13.7 hours (range 2.5 to 28 hours). Vertical transmission occurred as follows: Cutaneous colonization was found in 33 (12.5%) newborns born to 261 mothers who received no IAP, and symptomatic EOGBSS was diagnosed in 9 (3.4%). Mothers who received one dose (n = 43) had three (6.9%) newborns with GBS colonization and two (4.7%) asymptomatic newborns with EOGBSS: No newborns born to 28 mothers who received two doses IAP had GBS colonization or were ill. Cutaneous vertical transmission was reduced (P = .03). Newborns born to GBS-positive mothers with one or more risk factors who received IAP had significantly less EOGBSS (P < .05) than those who did not receive IAP. CONCLUSIONS: Selective IAP was administered safely to 21% of GBS-positive women, or 3.5% of all deliveries. IAP prevented EOGBSS when it could be given to GBS-positive mothers with a risk factor. Accurate identification of mothers with GBS colonization and their risk factors is essential for effective use of IAP. Earlier institution of IAP after rupture of membranes may reduce the risk of EOGBSS and the need for extensive infant evaluation.

Early onset Haemophilus influenzae sepsis in the newborn infant.

Neonatal sepsis caused by Haemophilus influenzae is characterized by an early onset syndrome associated with pneumonia, shock and neutropenia. Over a 30-month period 13 infants referred to this hospital had early onset H. influenzae sepsis. Obstetric complications included preterm labor (92%), prolonged rupture of membranes > 12 hours (63%), maternal fever (64%), chorioamnionitis (43%), vaginal discharge (44%) and premature rupture of membranes (15%). All 13 infants were symptomatic at delivery and 7 required immediate intubation. Pneumonia and respiratory distress were the prominent clinical findings. H. influenzae was isolated from infant blood, maternal blood, placenta and genital tract. Isolates were predominantly non-type b, beta-lactamase-negative. A study to determine the prevalence of H. influenzae colonization of the genital tract among women attending clinic at the hospital with the most cases showed a rate of 0.3%. Perinatal risk factors and clinical findings in the infants are similar to disease caused by other organisms associated with early onset sepsis.

Outbreak of early onset group B streptococcal sepsis.

During January and August, 1990, 23 cases of early onset Group B Streptococcus (GBS) disease occurred in a Kansas City, MO, hospital with an attack rate of 14/1000 live births, compared with an annual rate of 1.2 cases/1000 live births for 1988 through 1989. Case infants were compared with controls matched by birth weight, race, maternal age and day of delivery and to a second group of infants of mothers colonized with GBS to identify risk factors and consider intervention strategies during the outbreak. The presence of multiple serotypes among the invasive strains suggested that the outbreak was not caused by a common source. Case mothers were more likely than control mothers to have chorioamnionitis, intrapartum fever or rupture of membranes > 12 hours, and premature case infants were more likely to have a history of rupture of membranes before onset of labor. Multiparous mothers of case infants were more likely to have a history of spontaneous abortion (odds ratio, 6.7; 95% confidence interval, 1.0 to 45.9). No single factor could explain the increase in GBS disease. If intrapartum antibiotic prophylaxis had been used for selected GBS carriers based on presence of either rupture of membranes > 12 hours, intrapartum maternal fever or preterm labor, 7.4% of all deliveries would have received antibiotics and 73% of cases could potentially have been prevented. We conclude that identification of colonized mothers with perinatal risk factors and use of intrapartum antibiotics could be expected to prevent substantial disease during an outbreak of early onset GBS disease.

X;6 translocation in a child with congenital acute lymphocytic leukemia.

A case of congenital acute lymphoblastic leukemia (ALL) displayed an X;6 translocation. This is the third reported case of ALL with an X;6 translocation. In addition, two of the three ALL cases occurred during infancy, at ages 2 months and newborn, and both translocations involved the band q15-16 region of chromosome 6. Anomalies of the long arm of chromosome 6, mainly interstitial and terminal deletions, have been reported as a recurrent karyotypic event in a significant number of ALL cases. The molecular basis and propensity of an X;6 rearrangement in this case of congenital ALL is unclear and merits further investigation. The similarities in this case and the other infant ALL case cited suggest that an X;6 rearrangement with a breakpoint in bands q15-16 of chromosome 6 is characteristic of a form of congenital ALL.

Humoral immune responses to gag and env proteins from human immunodeficiency virus type 1 in hemophiliac patients.

Solid-phase enzyme immunoassays using recombinant gag and env proteins were developed to study humoral immune responses to HIV infection in a cohort of 105 hemophiliac patients. Thirteen patients with ARC or AIDS and 92 asymptomatic patients were studied. A cross-sectional study showed a wide range of antibody responses to gag and env proteins; however, the differences between the ARC/AIDS and asymptomatic patients were statistically significant for both antigens (P less than .0004). In a longitudinal study, antibody levels in sera from 11 asymptomatic patients with gag antibody log units less than or equal to 1.5 were compared to levels in sera from 10 ARC/AIDS patients and 8 asymptomatic patients with gag antibody greater than 1.5. These patient groups were followed for comparable periods of time (67.1-71.7 mo). The asymptomatic patients with low gag antibody and the ARC/AIDS patients showed a similar pattern of antibody response to gag protein overtime. In hemophiliac patients with HIV-1 infection a low titer of antibody to gag protein is not invariably associated with clinical deterioration and is not a useful serologic marker of impending progression to AIDS.

Monoclonal antibody assay for detection of double-stranded RNA and application for detection of group A and non-group A rotaviruses.

Fastidious viruses are generally detected in human body fluids by means of immunoassay or nucleic acid hybridization systems. These approaches can be difficult to apply to the detection of viruses which display variations in antigenic or genetic composition. Rotaviruses are examples of viruses which can display such variations. Recently identified antigenic variants, designated as non-group A rotaviruses, cannot be detected by immunoassays or nucleic acid hybridization assays which utilize reagents directed at group A rotavirus strains. The incomplete understanding of the extent of antigenic and genetic variation has inhibited the development of assay systems for all of the non-group A rotaviruses and has limited the study of their role in human disease. While rotaviruses display genetic variation, they all contain a genome which consists of double-stranded RNA. We utilized a monoclonal antibody to devise a sensitive assay for the measurement of double-stranded RNA and applied it to the detection of a wide range of rotaviruses. We found that the assay could detect double-stranded RNA from as few as 10 PFU of standard strains of group A rotaviruses. The assay system was also capable of detecting double-stranded RNA from several strains of group B rotaviruses isolated from calves, rats, and pigs at levels below those at which viral RNA could be visualized by means of polyacrylamide gel electrophoresis. When applied to the detection of double-stranded RNA in serial stools shed by rotavirus-infected children, the assay system was capable of detecting double-stranded RNA in samples in which antigen could not be detected by immunoassay. The specific nature of the double-stranded RNA detected by this assay system could be determined by the elution of the nucleic acids from the monoclonal antibody and the reaction of the RNA with specific nucleotide probes. The measurement of double-stranded RNA offers a potential method for the sensitive detection of a wide range of rotaviruses and other members of the family Reoviridae.

Should we expand the TORCH complex? A description of clinical and diagnostic aspects of selected old and new agents.

Physicians faced with a newborn infant with signs and symptoms of perinatal infection must consider a multitude of diseases, and may need to embark on a complex differential diagnosis. As stated by Alford in 1967, "neonatal diagnoses of infections acquired in utero, natally and postnatally, are inherently difficult." Twenty years later, this statement is still true. In this review, the diagnostic problems encountered in the evaluation of a suspected perinatal infection have been discussed, as have the complexities of the evaluation process for the original four TORCH agents, as well as for three additional agents. From our point of view, the usefulness of the TORCH acronym has been to focus attention on perinatal infections. Its main drawback has been the resultant overuse of TORCH titers ignoring the complexity of the diagnostic process. Ideally, the TORCH concept serves two functions. It continues to remind us of the multiplicity of pathogens that can cause perinatal infection, and it underscores the need for thorough diagnostic evaluation for these challenging infections. We believe that this is an appropriate expansion of the TORCH complex, and we anticipate that this expanded TORCH complex will continue to grow.

Risk of adverse outcomes of pregnancy after human parvovirus B19 infection.

Human parvovirus B19 (B19) infection during pregnancy has been associated with fetal deaths. We conducted several studies to develop data needed to make recommendations for preventing fetal death associated with infection. In the first study, after an outbreak of B19 infection, specimens of cord blood from 47 infants with congenital anomalies, 10 with suspected intrauterine infection, and gestational age-matched controls were tested for IgG and IgM antibodies to B19. None had evidence of recent infection. Next, 192 women with unknown exposure to B19 who had stillbirths or spontaneous abortions were studied. Two patients and two controls had evidence of recent B19 infection. In a second case-control study of women who had stillbirths after outbreaks of erythema infectiosum in area schools, none of the 20 patients or 26 controls were IgM positive at the time of delivery. The rate of infection, as demonstrated by IgM positivity, among 267 pregnant control subjects was approximately 1%. These studies suggest that among pregnant women unselected for exposure to B19, neither infection nor stillbirths are common.

Hemolytic-uremic syndrome: a population-based study in Washington, DC and Baltimore, Maryland.

A population-based study of hemolytic-uremic syndrome (HUS) revealed that 20 child residents of Washington, DC and Baltimore, Maryland were hospitalized with HUS from January 1979 through September 1983. The number of cases peaked during the summer and fall; none occurred during the winter. Incidence of hospitalized cases was higher in Whites and girls than in Blacks or boys, and the average annual incidence was 1.08 cases/100,000 children less than 5 year old. This study demonstrates that HUS is not unique to the West Coast, as previously suggested.

Community outbreak of thyrotoxicosis: epidemiology, immunogenetic characteristics, and long-term outcome.

Between January and March 1984, the first community outbreak of transient thyrotoxicosis in the United States was documented in a seven-county area of southeastern Nebraska; 36 of the total 49 patients resided in York County (2.4 cases per 1,000 population). The median age of patients was 36 years, range six to 82 years; 51 percent were women. By definition, all patients were symptomatic, visited a physician, and had a newly identified elevated serum concentration of thyroxine or triiodothyronine of unknown cause. None had a goiter or a painful thyroid gland. Low 131I uptake measurements were found in all nine patients studied. Six patients were hospitalized; none died. Investigation of all 12 household contacts of eight selected patients revealed five additional persons with thyrotoxicosis and four with asymptomatic hyperthyroxinemia. A case-control study revealed that illness was associated with a significantly higher frequency of a reported recent respiratory viral-like condition. In another case-control study, the HLA-DR3 antigen was present in more case subjects (39 percent) than control subjects (14 percent). In addition, a significantly higher proportion of patients than control subjects purchased beef from one of the three supermarkets in York Country. Concomitant with the outbreak, the supermarket implicated in the outbreak purchased an unusually large quantity of beef (7,000 pounds) from a nonregular supplier in Nebraska, which had reportedly instituted the practice of trimming gullets (a procedure that removes the muscles from bovine larynx for beef) about three months earlier. Thus, it is concluded that the Nebraska outbreak, like one in Minnesota that occurred 18 months later, probably resulted from patients having eaten ground beef that was contaminated with bovine thyroid gland. This form of thyrotoxicosis, perhaps misdiagnosed as painless thyroiditis in the past, probably represents a previously under-recognized public health problem.