Using the Eco-Map and Ecosystems Perspective to Guide Skilled Nursing Facility Discharge Planning.

Growing numbers of seniors across the United States require skilled nursing facility care after an inpatient hospital stay. Previous studies indicate that roughly 20 percent of all hospitalized Medicare beneficiaries are admitted to a skilled nursing facility following a qualifying hospital stay. Social workers address psychosocial problems, social support, networks, and healthcare needs during transitions in care, particularly discharge planning. Ecosystems perspective and the eco-map as a discharge planning tool is presented. Social workers can use these tools to examine the patient with respect to their transactional relationships with systems. This will further will facilitate provision of wrap-around services upon discharge.

The health-care experiences of families given the prenatal diagnosis of trisomy 18.

OBJECTIVE: The objective of this study was to examine parent-reported experiences in the health care system after receiving the prenatal diagnosis of trisomy 18 and to identify factors that contribute to satisfaction with care. STUDY DESIGN: Nineteen families who received the diagnosis between 2002 and 2005 were given semistructured telephone interviews. Of the 19 families, 11 continued the pregnancy while the remaining 8 chose induced abortion. Classical content analysis was utilized to identify themes among subject responses. RESULT: We identified several specific aspects of care as key in either being highly satisfied or dissatisfied: expressions of empathy from provider, continuity of care, communication, valuing the fetus and participation in medical decision-making. CONCLUSIONS: Aspects of care that were identified as reasons for dissatisfaction are potentially modifiable by training, education or team-based approaches. Further studies are necessary to determine how we can improve the quality of services during prenatal diagnosis.

The effect of the gonial angle, ramus length, age and gender on the temporomandibular opening index.

Linear mouth opening is often used to assess the limitation of mandibular movement. However, this has a number of limitations. It is dependent on variables such as age, gender and ramus length. A new measure of movement has been developed previously, called the temporomandibular opening index (TOI). Forty-two subjects who did not exhibit signs and symptoms of temporomandibular disorder (TMD) were recruited to this study. The relationship of age, gender, gonial angle, ramus length and the TOI was studied. Linear regression analysis showed that the TOI was not dependent on gender (P > 0.644), gonial angle (P > 0.327), ramus length (P > 0.248) and age (P > 0.690). The index may therefore be a better measure of mandibular movement.

Following treatment of myogenous TMD patients with the temporomandibular opening index: an initial report.

Limitation of mandibular movement is one of the cardinal signs of temporomandibular disorders (TMD), usually assessed by measurement of maximum voluntary mouth opening. A new measure of assessing mandibular mobility, the temporomandibular opening index (TOI), is less dependent on variables such as age, gender and ramus length. It has also been found to be useful to categorize patients. This study examined changes in TOI as treatment progressed in a group of myogenous TMD patients. Seven patients with myogenous TMD were included in the study and the TOI determined at 0 and 2 weeks, 1 and 6 months after initiation of treatment. Treatment outcome was assessed on a 4 point scale, 0=none, 1=mild, 2=moderate, and 3=severe. Headache, neckache, pain (joints and muscles) and joint sounds were assessed. Nine patients with no signs or symptoms of TMD were included to obtain a normal TOI. The mean TOI of the patient group was 16.4% (s.d.=11.2%) initially and 3.95% (s.d.=1.0%) at 6 months, while mean treatment scores changed from 12.57 (s.d.=3.05) to 1.43 (s.d.=1.90). The mean TOI of the control group was 3.63 (s.d.=0.74). A paired t-test showed that the TOI decreased significantly with time (P=0.02) while there was a concomitant decrease in treatment score (P=0.0003) over the same period. The TOI may be a useful method of following treatment of this group of myogenous TMD patients.

Federalism, entitlements, and discretionary grants: the fiscal context of national support for immunization programs.

This paper defines the appropriation and resource allocation structure of federal government programs that deliver vaccines to the public through state and local governments, with a special focus on the Centers for Disease Control and Prevention (CDC) Section 317 program. The paper places these programs in the context of the overall intergovernmental finance system of the United States, and the manner in which that system has responded to societal changes in other areas, such as unemployment insurance and environmental protection. The paper concludes that a changing environment for vaccine financing, and uncertain appropriations for state government immunization infrastructure, may have made the current CDC Section 317 program inadequate. Increased entitlement resources for federally funded vaccines have not been matched with increased and stable resources for the balance of program costs. To the contrary, funding provided to the Section 317 program has proven unstable, and its discretionary appropriations have proven vulnerable to both executive and legislative branch earmarking for such activities as overseas disease eradication or home state earmarking by congressional appropriations subcommittee members. In addition, the rigidity of some CDC program requirements makes it difficult for states to effectively use program funds. Consideration should be given to strengthening the Section 317 program and its relationships to other federal aid programs to ensure that adequate immunization protections are provided in all states to adequately protect all citizens.

The temporomandibular opening index (TOI) in patients with closed lock and a control group with no temporomandibular disorders (TMD): an initial study.

Mandibular movement may be assessed by measuring maximum mouth opening. This is a linear measurement from the maxillary to the mandibular incisal edge and is affected by gender, age and ramus length. It cannot be used to classify patients. The temporomandibular opening index (TOI) appears to be independent of these variables and has been shown to differ for different categories of patients with temporomandibular disorders (TMD). This study examined the TOI in a group of 11 patients with closed lock and a control group of 11 individuals with no signs or symptoms of TMD. The group with closed lock had a significantly different TOI from that of the control group (P < 0.001) according to the Mann-Whitney U-test. This suggests that the TOI may have greater diagnostic value than linear mouth opening.

Myogenous temporomandibular disorder patients and the temporomandibular opening index.

Limited mandibular movement is one of the cardinal signs of temporomandibular disorders, and is usually assessed by measurement of mouth opening. Linear measurement of mouth opening does not discriminate between diagnostic groups and has been shown to be influenced by gender, age and ramus length. A new temporomandibular opening index, however, can differentiate between diagnostic groups and is not influenced by the above variables. When patients with a myogenous temporomandibular disorder were examined, the temporomandibular opening index distinguished two subgroups, the first with values about the lower quartile and the second with values about the upper quartile. A similar identification of two subgroups was seen in electromyographic studies of myogenous temporomandibular disorder patients.

The long-term effect of oromaxillofacial trauma on the function of the temporomandibular joint.

Thirty patients with temporomandibular disorders (TMD) after trauma to the orofacial region were followed for 6 months. They were assessed at 10 days, 1 month, and 6 months. It was found that patients with combined fractures of the mandible and condyle showed more effects on function of the temporomandibular joint after 1 month than patients with condylar fracture only. This difference was not so apparent after 6 months. Patients with trauma but no fracture showed similar effects to those with non-condylar fractures. There was a tendency for arthrogenous patients to develop myogenous problems with time. A group of patients with TMD but no trauma, showed more favourable long-term response to conservative treatment. Long-term follow-up of these patients for TMD problems is recommended.

Comparison of a short examination procedure with an extensive diagnostic protocol for the diagnosis of temporomandibular disorders.

Eighty-nine patients who complained of temporomandibular disorders were examined using a short and long examination procedure. Seventy were females and 19 males. Mean age of the group was 31.53 years, with a range from 11 to 73 years. The agreement between the two examination procedures was tested using the Kappa statistic. This gave a value of 0.876 (P<0.001). This allowed rejection of the hypothesis that the agreement found between the two procedures was due to chance alone.

A mouth opening index for patients with temporomandibular disorders.

Limitation of mouth opening is an important sign of temporomandibular disorders. It is usually measured linearly from the incisal edge of the maxillary incisors to the incisal edge of the mandibular incisors. This measurement has been queried. A new measure of mouth opening, the opening index is suggested. It was shown that the mean opening index differs for groups of patients with a myogenous or arthrogenous temporomandibular joint problem.

The effect of parafunction on condylar asymmetry in patients with temporomandibular disorders.

This study was undertaken to examine the relationship between condylar asymmetry and parafunction in patients with temporomandibular disorders (TMD). Twenty-eight patients with TMD and parafunction and 30 patients with TMD but no parafunction were examined. A panoramic radiograph was obtained for each patient and from this the condylar asymmetry determined. The group with parafunction showed a significantly (P < 0.005) higher asymmetry index than did the group with no noticeable parafunction. Patients were grouped into the following age ranges: 10-19 years, 20-29 years, 30-39 years, and 40 + years. The mean asymmetry index was determined for each age range for both groups of patients. The group of patients with TMD and parafunction had a higher mean asymmetry index in all the age ranges studied. This suggests that muscle hyperactivity may be a factor in the increased asymmetry found in patients with TMD.

Temporomandibular joint dysfunction in children: evaluation of treatment.

Thirty-eight pediatric patients with temporomandibular joint (TMJ) dysfunction were diagnosed and treated. The etiology for the TMJ dysfunction was trauma in 30 (79%) patients, degenerative joint disease in two (5%) patients, growth disturbances in two (5%) patients and tumor in one (3%) patient. In three (8%) patients the etiology was unclear. The treatment modalities were: non-invasive therapy in 19 (50%) patients, occlusal therapy in 10 (26%) patients and surgical treatment in nine (24%) patients. The reported symptoms of temporomandibular joint dysfunction using the Helkino anamnestic index revealed that, at the initial examination, eight (21%) reported mild symptoms and 30 (79%) severe symptoms. One year later, 33 (87%) reported no symptoms, four (10%) mild symptoms and one (3%) severe symptoms. These differences were significant (P < 0.05-0.01). Maximum mouth opening 1 year after treatment as compared to the initial examination increased (P < 0.05) in all three treatment modalities. Deviation of the mandible on opening, 1 year after treatment as compared to the initial examination, decreased (P < 0.05) in all three treatment modalities. No differences were found between the modalities in both the maximum mouth opening or deviation of the mandible. TMJ dysfunction in children can be effectively treated by non-surgical treatment modalities. Surgery should be considered only when the non-surgical therapies were ineffective.

Condylar asymmetry and handedness in patients with temporomandibular disorders.

The relationship between condylar asymmetry and handedness of dentate patients with temporomandibular disorders was investigated. A group of 28 patients (22 females and 6 males) was studied. The mean age was 28.29 years, with a range from 10 to 54 years. The association between handedness and the sign of the condylar asymmetry index was examined using Fisher's exact test. No difference was found between sign and handedness (P > 0.05). This suggests that handedness does not affect the asymmetry index in this group of patients.

Ehlers-Danlos syndrome, fibromyalgia and temporomandibular disorder: report of an unusual combination.

An unusual case of temporomandibular disorder in the presence of both fibromyalgia and Ehlers-Danlos syndrome is presented. Some of the problems in treating these patients are discussed. It is suggested that early conservative treatment of the temporomandibular disorder with a stabilization splint and physical therapy is effective, and this approach should be attempted before any surgical intervention is chosen.

Condylar asymmetry measurements in patients with an Angle's Class III malocclusion.

Condylar asymmetry/age relationships were investigated in a group of 23 dentate patients with an Angle's Class III malocclusion and no signs or symptoms of temporomandibular disorders and no prior orthodontic treatment. Condylar asymmetry was determined from panoramic radiographs. A graph of age versus asymmetry index was then plotted. There was no significant correlation between age and the asymmetry index in these patients (R2 = 0.019). This is similar to results obtained for a group of patients with a Class I occlusion who were included as controls, and similar to a group of patients with an Angle's Class II division 2 malocclusion investigated previously.

Temporomandibular joint dysfunction in children.

Sixteen pediatric patients with temporomandibular joint (TMJ) dysfunction were successfully diagnosed following appropriately selected imaging methods. The role of radiography in diagnosis of TMJ dysfunction is essential in distinguishing between the osteogenic and non-osteogenic etiologies. Computed tomography (CT) was found to be a valuable imaging method, with advantages over plain film radiography. The treatment modalities considered were: non-invasive therapy, occlusal therapy and surgical treatment. The treatment of choice was dependent on the osteogenic or non-osteogenic etiology. Surgery was considered only when the non-invasive or occlusal therapies were ineffective.

Condylar asymmetry and age in patients with an Angle's Class II division 2 malocclusion.

The relationship of age to condylar asymmetry varies for different groups of patients with temporomandibular disorders. Those with a problem of myogenous origin show a parabolic curve, while those with an arthrogenous problem show a linear relation. A group of control subjects with no signs or symptoms of temporomandibular disorders showed no correlation between age and asymmetry index. A group of 17 patients with no signs or symptoms of temporomandibular disorders but with Angle's Class II Division 2 malocclusions and deep overbite, was studied for an age-condylar asymmetry relationship. Only patients with a maximum of one missing tooth, other than third molars, were included. As a control, a group of 22 individuals with an Angle's Class I occlusion was considered. The same exclusion criteria as above was applied to this group. Age-asymmetry indicies were plotted for both groups. No correlation between age and asymmetry index was found in either group (coefficients of determination 0.054 and 0.002, respectively). This may support the conclusion that Angle's Class II Division 2 malocclusion with deep overbite is not a major factor in the aetiology of these disorders.

The condylar asymmetry-age relationship in determining myogenous or arthrogenous origin of pain in patients with temporomandibular disorders.

The relation of age to asymmetry index of the condyles of the temporomandibular joint differs for groups of patients with a myogenous and arthrogenous origin of pain. It was decided to investigate if this has clinical diagnostic significance. Twenty-eight patients complaining of temporomandibular disorders (TMD) were included in this study. All were dentate with a maximum of five missing teeth including third molars allowed. Condylar asymmetry was measured according to the method of Habets, and this was used to compute the expected patient age for both curves. The patient was assigned to the group with computed age closest to true age. The association between category derived from graphs and that from clinical diagnosis was studied. There was agreement clinically and graphically in 25 of 28 patients. The Kappa statistic to explore the agreement between the two methods gave a value of 0.78, which allows rejection of the hypothesis that agreement was based on chance alone.

The relation of age and handedness to condylar asymmetry in a group of edentulous patients with a temporomandibular disorder of arthrogenous origin.

A group of edentulous patients with a temporomandibular disorder of arthrogenous origin was found to have a mean asymmetry index of 7.38%. This was lower than a group with a disorder of myogenous origin, but higher than a control group of non-patients. A graph of age vs. asymmetry index showed no correlation, in keeping with similar results found in a group of patients with a disorder of myogenous origin.