The Spectrum of Histological Findings in Oral Biopsies

Aim: To undertake a retrospective analysis of the use of a diagnostic pathology service, to determine the source of oral biopsies submitted for histological analysis, and to examine the range and frequencies of histologically diagnosed oral lesions in an Irish population. Methods: A retrospective analysis was carried out on all oral biopsies submitted for histological analysis to an oral and maxillofacial diagnostic pathology service from June to December 2015. Results: In total 724 oral biopsies were submitted. The majority of diagnoses were benign (80.3%) and the remaining diagnoses were made up of malignancies (6.7%) and potentially malignant disorders (PMDs), histologically characterised by epithelial dysplasia (13%). Less than 1% of biopsies were submitted from general dentists in primary care. Conclusion: This study showed that oral biopsies are not submitted from the primary care setting, but rather from hospital-based specialist units or referral-based specialist practitioners. There was a broad range of histological diagnoses, the majority of which were benign.

Dentist's views on incorporating oral health collaborative practice into primary medical care in Ireland.

BACKGROUND: In order to address the burden of oral disease, the dental profession needs to engage in collaborative practice with medical professionals. The aim of this study was to explore dentists' views on incorporating oral health collaborative practice into primary medical care in Ireland. SETTING: Dublin Dental University Hospital, Ireland. PARTICIPANTS: Dentists with backgrounds in oral surgery, oral medicine, paediatric dentistry, special care dentistry, prosthodontics, primary care dentistry, hospital dentistry and public dental health. All participants were working in, or had worked in, Dublin Dental University Hospital for a minimum of six months full-time equivalent within the previous 5 years. METHODS: Semi-structured qualitative interviews were undertaken in five phases, transcribed verbatim and thematically analyzed. RESULTS: A total of 17 participants were recruited. After 14 interviews, no new themes were emerging and data saturation was achieved. Eleven codes were identified and organized into four themes; (i) the relative importance of oral health to systemic health, (ii) the role of dentistry in the overall health care team, (iii) oral health interprofessional education and training, (iv) opportunities for oral health collaborative practice. CONCLUSION: Dentists felt that the best way to achieve effective oral health collaborative practice with primary medical care would be to educate medical professionals on how to identify the significant risk factors for oral disease, how to promote oral health and how to facilitate access to primary dental care for their patients.

Incorporating Oral Health as Part of Routine Diabetes Care in Ireland.

Diabetes mellitus is a common disorder of glucose metabolism that is increasingly prevalent in the Irish population. It is associated with a range of complications leading to substantial morbidity and mortality. A less well-recognized complication of diabetes is periodontal disease. This is a chronic inflammatory disease affecting the periodontium, the specialized group of tissues that surround and support the teeth, including the gingiva (gums) and alveolar bone. Periodontal disease affects patients with diabetes with a greater prevalence and incidence than non-diabetic patients, and can itself exert negative effects on glucose control in people with diabetes. The National Clinical Programme for Diabetes in Ireland aims to reduce the morbidity and mortality associated with diabetes, which includes the development and dissemination of guidelines supporting integrated care. Based on the bidirectional relationship between diabetes mellitus and periodontal disease, we recommend that an oral health evaluation, as well as any necessary onward referral, be incorporated into the Irish recommendations for routine diabetes care, as part of the National Clinical Programme.

Chemical Structures of Plant Hydrolyzable Tannins Reveal Their in Vitro Activity against Egg Hatching and Motility of Haemonchus contortus Nematodes.

The use of synthetic drugs against gastrointestinal nematodes of ruminants has led to a situation where resistance to anthelmintics is widespread, and there is an urgent need for alternative solutions for parasite control. One promising approach is to use polyphenol-rich bioactive plants in animal feeds as natural anthelmintics. In the present work, the in vitro activity of a series of 33 hydrolyzable tannins (HTs) and their hydrolysis product, gallic acid, against egg hatching and motility of L1 and L2 stage Haemonchus contortus larvae was studied. The effect of the selected compounds on egg and larval structure was further studied by scanning electron microscopy. The results indicated clear relationships between HT structure and anthelmintic activity. While HT size, overall flexibility, the types and numbers of functional groups, together with the linkage types between monomeric HTs affected the activity differently, the optimal structure was found with pentagalloylglucose.

Up-regulation of alternate co-stimulatory molecules on proinflammatory CD28null T cells in bronchiolitis obliterans syndrome.

Bronchiolitis obliterans syndrome (BOS) is associated with lack of immunosuppression of T cell proinflammatory cytokines and increased T cell granzyme B. Repeated antigen-driven proliferation down-regulates T cell CD28. We hypothesized that down-regulation of CD28 and up-regulation of alternate co-stimulatory molecules (CD134, CD137, CD152 and CD154) on T cells may be associated with BOS. Co-stimulatory molecules, granzyme B, perforin and intracellular cytokines were measured by flow cytometry on T cells from stable lung transplant patients (n = 38), patients with BOS (n = 20) and healthy controls (n = 10). There was a significant increase in the percentage of CD4/28(null) and CD8/28(null) T cells producing granzyme B, interferon (IFN)-γ and tumour necrosis factor (TNF)-α in BOS compared with stable patients. Down-regulation of CD28 was associated with steroid resistance and up-regulation of CD134, CD137, CD152 and CD154 on CD4(+) T cells and CD137 and CD152 on CD8(+) T cells. There was a significant correlation between increased CD28(null) /CD137 T cells producing IFN-γ, TNF-α with BOS grade (r = 0·861, P < 0·001 for CD28(null) /CD137 IFN-γ/CD8) and time post-transplant (r = 0·698, P < 0·001 for CD28(null) /CD137 IFN-γ/CD8). BOS is associated with down-regulation of CD28 and up-regulation of alternate co-stimulatory molecules on steroid-resistant peripheral blood proinflammatory CD4(+) and CD8(+) T cells. Therapeutic targeting of alternate co-stimulatory molecules on peripheral blood CD28(null) T cells and monitoring response using these assays may help in the management of patients with BOS.

Increased levels of T cell granzyme b in bronchiolitis obliterans syndrome are not suppressed adequately by current immunosuppressive regimens.

Bronchiolitis obliterans syndrome (BOS) is characterized by persistent alloreactive, infective and non-specific epithelial injury, loss of epithelial integrity and dysregulated repair. We have reported increased apoptosis of epithelial cells collected from the large airway in lung transplant recipients. As part of the alloreactive response, T cells induce apoptosis of target epithelial cells by secreting granzyme b. We hypothesized that granzyme b would be increased in lung transplant patients with acute rejection and BOS and that commonly used immunosuppressive agents would fail to suppress this serine protease adequately. We investigated intracellular T cell granzyme b in blood, bronchoalveolar lavage (BAL) and large airway brushing (23 controls, 29 stable transplant, 23 BOS, 28 acute rejection, 31 infection) using flow cytometry and assessed the effect of clinically relevant concentrations of cyclosporin A, tacrolimus, methylprednisolone and a protease inhibitor, gabexate mesilate, on in vitro granzyme b production. Granzyme b was increased significantly in all compartments of all transplant groups compared to controls. Surprisingly, granzyme b was even higher in patients with BOS than in patients with acute rejection. In longitudinal analysis in three patients, blood granzyme b increased prior to or at the onset of BOS. In vitro, methylprednisolone and gabexate mesilate had no effect and cyclosporin A and tacrolimus only a moderate effect on production of granzyme b by CD8(+) T cells. Increased T cell granzyme b production may contribute to BOS pathogenesis and is not curtailed by current immunosuppressants. Longitudinal investigation of granzyme b in blood may provide an adjunctive non-invasive method for predicting BOS/OB.

Alcohol drinking problems among New York City residents after the September 11 terrorist attacks.

Recent studies have shown an increase in alcohol use in New York City in the months after the September 11 terrorist attacks; thus far there have been no studies documenting changes in drinking problems. In 2002, a random digit dial phone survey was conducted of residents of New York City. This study provided us with estimates of the prevalence of alcohol drinking problems among residents of New York City 6 months after September 11 compared with the 6 months before September 11. Among 1,570 adults, the prevalence of drinking problems was 3.7% in the 6 months before September 11 and 4.2% in the 6 months after September 11. The incidence of drinking problems among those without drinking problems before September 11 was 2.2%. Persons with incident drinking problems were more likely than those without to report symptoms consistent with posttraumatic stress disorder (17.4% vs. 0.4% in those without drinking problems and 1.4% in nondrinkers), and depression (23.5% vs 5.6% vs. 4.9%, respectively) after September 11. After a disaster, a link between drinking problems and posttraumatic stress disorder or depression should be assessed.

The urban built environment and overdose mortality in New York City neighborhoods.

Accidental drug overdose continues to be a substantial cause of mortality for drug users. Characteristics of the neighborhood built environment may be important determinants of the likelihood of drug overdose mortality independent of individual-level factors. Using data from the New York City Office of the Chief Medical Examiner, we conducted a multilevel case control study using data on accidental overdose deaths as cases and non-overdose accidental deaths as controls. We used archival data from the New York City Housing and Vacancy Survey and the Mayor's Office of Operations to assess characteristics of neighborhood external (e.g. dilapidation of buildings) and internal (e.g. quality of utilities in houses) built environment. Multilevel analyses were used to assess the relations between the neighborhood built environment and the likelihood of overdose death. Six out of the eight characteristics of the external environment studied and three out of the six characteristics of the internal environment studied were significantly associated with the likelihood of fatal drug overdose in multilevel models after adjusting for individual-level (age, race, sex) and neighborhood-level (income, drug use) variables. Deterioration of the built environment, particularly the external environment, is associated with an increased likelihood of fatal accidental drug overdose. Disinvestment in social resources, psychosocial stressors, neighborhood differences in response to a witnessed overdose, and differences in vulnerability to the adverse consequences of drug use in different neighborhoods may explain the observed associations.

Adolescent archaics or adult moderns? Le Moustier 1 as a model for estimating the age at death of fragmentary supraorbital fossils in the modern human origins debate.

This study documents and examines selected implications of the adolescent supraorbital anatomy of the Le Moustier 1 Neandertal. Le Moustier's supraorbital morphology conforms to that expected of an adolescent Neandertal but indicates that significant development of the adult Neandertal torus occurs late in ontogeny. As the best preserved adolescent from the Late Pleistocene, Le Moustier 1's anatomy is used to help distinguish adolescent from adult anatomy in two cases of fragmentary supraorbital fossils, the Vindija late Neandertals and KRM 16425 from Klasies River Mouth (South Africa). It has been suggested that the modern-like aspects of the Vindija and Klasies supraorbital fossils are a function of developmental age rather than evolution. Although Le Moustier 1's anatomy does indicate that two of the Vindija fossils are adolescent; these two fossils have already been excluded from studies that demonstrate transitional aspects of the Vindija adult supraorbitals. Results of an analysis of KRM 16425 in light of Le Moustier 1 are more ambiguous. KRM 16425 is clearly not a Neandertal, but its morphology suggests that it may be an adolescent form of such late archaic Africans like Florisbad or Ngaloba. Both the Vindija and Klasies River Mouth cases highlight the need to be wary of confusing adolescent anatomy with modernity.

Preterm birth among African American and white women: a multilevel analysis of socioeconomic characteristics and cigarette smoking.

STUDY OBJECTIVE: Research shows that neighbourhood socioeconomic factors are associated with preterm delivery. This study examined whether cigarette smoking and individual socioeconomic factors modify the effects of neighbourhood factors on preterm delivery. DESIGN: Case-control study. SETTING: Moffit Hospital in San Francisco, California. PARTICIPANTS: 417 African American and 1244 white women, including all preterm and a random selection of term deliveries 1980-1990, excluding non-singleton pregnancies, congenital anomolies, induced deliveries, and women transported for special care. US census data from 1980 and 1990 were used to characterise the women's neighbourhoods, defined as census tracts. RESULTS: Cigarette smoking increased the risk of preterm delivery among both African American (OR=1.77, 95% confidence intervals (CI) (1.12 to 2.79)) and white women (OR=1.25, 95% CI (1.01 to 1.55)). However, cigarette smoking did not attenuate or modify the association of neighbourhood factors with preterm delivery. Among African American women, having public insurance modified the relation between neighbourhood unemployment and preterm delivery; among women without public insurance, the risk of preterm delivery was low in areas with low unemployment and high in areas with high unemployment, while among women with public insurance the risk of preterm delivery was highest at low levels of neighbourhood unemployment. CONCLUSIONS: Cigarette smoking was associated with preterm delivery, especially among African Americans. Adverse neighbourhood conditions had an influence on preterm delivery beyond that of cigarette smoking. The effects of some neighbourhood characteristics were different depending on individual socioeconomic status. Examining socioeconomic and behavioural/biological risk factors together may increase understanding of the complex causes of preterm delivery.

A comparison of insulin lispro and buffered regular human insulin administered via continuous subcutaneous insulin infusion pump.

This study compared glycemic control achieved with insulin lispro or buffered regular human insulin in patients with Type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) using an external insulin pump. In this 24-week multicenter, randomized, two-way crossover, open-label trial, 58 patients on CSII with adequate glycemic control received either insulin lispro or buffered regular human insulin for 12 weeks, followed by the alternate treatment for another 12 weeks. Efficacy and safety measures included hemoglobin A(1c) (HbA(1c)) at baseline and endpoint, home blood glucose monitoring, hypoglycemia, and frequency of pump catheter occlusion. Patients consumed a standard test meal on three occasions, with determinations of fasting, 1- and 2-h postprandial glucose values. Insulin lispro use was associated with a significantly lower HbA(1c) than was buffered regular human insulin (7.41+/-0.97 vs. 7.65+/-0.85 mmol/l; P=.004). Fasting serum glucose values before the test meal were similar between the two therapies. The 1-h (11.16+/-4.29 vs. 13.20+/-4.68 mmol/l; P=.012) and 2-h (9.64+/-4.10 vs. 12.53+/-4.64 mmol/l; P=.001) postprandial glucose concentrations were significantly lower during treatment with insulin lispro. No differences between treatments were observed in basal or bolus insulin doses, weight gain, or the incidence and rate of hypoglycemia, hyperglycemia, or pump occlusions. When used in external pumps, insulin lispro provides better glycemic control than buffered regular human insulin with a similar adverse event profile.

Needle exchange programs and experience of violence in an inner city neighborhood.

OBJECTIVE: To assess the association between proximity to a needle exchange program (NEP) and experience of violence in an inner city neighborhood. METHODS: A cross-sectional survey of residents of Harlem, New York City provided data for this study. We used geocoding to obtain the distance between respondents and the nearest NEP. Respondents reported violence they were aware of or had personally experienced in their neighborhood. Multiple logistic regression analyses assessed the relation between violence and distance from the nearest NEP. RESULTS: Among 220 respondents, 50.1% were African American, 39.0% were Latino, 44.7% were male, and the mean age was 44.5 years. In separate age-, race-, sex-, and income-adjusted logistic regression models, there was no significant association between (1) reporting a fight and distance from the nearest NEP (odds ratio [OR] = 1.05, p =.89); (2) robbery in the neighborhood in the previous 6 months and distance from the nearest NEP (OR = 1.13, p =.71); (3) ever having experienced violence and distance from the nearest NEP (OR = 0.72, p =.52); or (4) ever having been robbed by drug users and distance from the nearest NEP (OR = 1.05, p =.91). CONCLUSIONS: There was no consistent association between living close to NEPs and violence reported by residents of Harlem in this study. This study suggests that NEPs do not adversely affect rates of violence in their vicinity.

Multicenter phase II study of gemcitabine in previously untreated patients with advanced epithelial ovarian cancer.

Gemcitabine has activity in advanced ovarian cancer, with responses in platinum-resistant disease. This study assessed the activity of gemcitabine in previously untreated patients with advanced epithelial ovarian cancer. All patients had histologically verified invasive epithelial ovarian cancer, International Federation of Gynecology and Obstetrics (FIGO) stage III/IV disease and no prior chemotherapy. Patients received gemcitabine 1250 mg/m(2) on days 1, 8 and 15 of a 28-day cycle. Radiological response was assessed after two cycles. Between December 1992 and October 1995, 35 patients were enrolled. Of 33 evaluable patients, there was one complete response and five partial responses, for an overall response rate of 18% (95% confidence interval 7-36%). Forty-two percent of patients had a greater than 50% decrease in their CA-125 levels. Of the 25 patients who received platinum-based chemotherapy following treatment with gemcitabine, 12 achieved an overall response rate of 48%. Toxicity was mild, with two episodes of WHO grade 4 neutropenia (not associated with fever) and two episodes of grade 4 thrombocytopenia (not associated with bleeding). Gemcitabine has single-agent activity for poor-prognosis patients with advanced ovarian cancer. Similar results with subsequent platinum-based therapy indicate a lack of cross-resistance. This, combined with gemcitabine's favorable toxicity profile, warrants testing in comparative trials.

Prevalence, incidence, and correlates of chlamydia and gonorrhea among young adult injection drug users.

PURPOSE: To measure prevalence, incidence, and correlates of chlamydia and gonorrhea among injection drug users (IDUs). METHODS: Participants (n = 2129; 63% male, 52% white, ages 18-30 years) in five US cities were tested for chlamydia and gonorrhea by urine LCR assay and completed a standardized questionnaire about demographics and recent sexual behavior. Logistic regression identified correlates of prevalent infection; incidence rates were calculated from 6-month follow-up data. RESULTS: Chlamydia prevalence was 5.2% and did not differ by gender. Gonorrhea prevalence was 0.2% among men and 2.0% among women, P < .001. Among men, younger age [OR (95% CI): 0.89 (0.83-0.96)], age at sexual debut [0.91 (0.83-0.99)], and African American race [2.92 (1.53-5.59)] were associated with chlamydia. Among women, age at sexual debut [1.16 (1.02-1.31)] and commercial sex [1.96 (1.03-3.74)] were associated with chlamydia, and with gonorrhea [1.27 (1.04-1.56)] and [5.17 (1.66-16.11)], respectively. At 6 months, the cumulative incidence of chlamydia was 1.7% among men and 4.4% among women, P = .03; no men and 1.3% of women tested positive for gonorrhea, P = .01. IMPLICATIONS: Prevalence and correlates of chlamydia and gonorrhea were similar to other samples, suggesting that screening criteria need not be modified for IDU populations. The number of behavioral correlates identified was limited; perhaps unmeasured sexual-network-level factors play a role in determining sexually transmitted disease (STD) prevalence.

Epipen as an alternative to glucagon in the treatment of hypoglycemia in children with diabetes.

OBJECTIVE: Fear of a severe hypoglycemic reaction is a major obstacle to achieving near-normal plasma glucose levels. Although parenteral glucagon is effective in treating these reactions, it is cumbersome to use, causes severe nausea, and is impractical in the school setting. Epinephrine is available as a premixed injection (Epipen) that may be used by all care providers. Using Epipen to treat hypoglycemia may be an effective, safe, and easy-to-use alternative to glucagon. RESEARCH DESIGN AND METHODS: Ten children (age 11.7 +/- 2.4 years) with type 1 diabetes were studied on two occasions. After an overnight equilibration period, hypoglycemia was induced via an insulin pump (1 mU x kg(-1) x min(-1)). At a blood glucose level of 2.8 mmol/l, either glucagon (1 mg) or epinephrine (0.3 mg), in random order, was administered intramuscularly and responses were monitored. RESULTS: Plasma free insulin concentrations were similar in both studies. Plasma glucose levels increased by 1.7 +/- 0.2 mmol/l (mean +/- SEM) in 10 min and by 2.6 +/- 0.2 mmol/l in 15 min with administration of glucagon and were not consistently increased with administration of epinephrine (P < 0.01). Peak glucagon concentrations after administration of glucagon were >60-fold higher than basal concentrations. After administration of epinephrine, peak epinephrine levels were 20-fold higher than basal concentrations. CONCLUSIONS: Epinephrine does not seem to be an adequate substitute for glucagon in the treatment of severe hypoglycemia. The effectiveness of glucagon in reversing hypoglycemia and its side effects of nausea and vomiting are likely related to the markedly supraphysiologic plasma levels achieved with the standard intramuscular dose.

Using a primary nurse manager to implement DCCT recommendations in a large pediatric program.

PURPOSE: This study was conducted to determine whether recommendations from the Diabetes Control and Complications Trial (DCCT) could be implemented in a large pediatric population using a diabetes clinical nurse specialist program coordinator dedicated to intensive management. METHODS: Patients' charts were reviewed to examine HbA1c levels from before the results of the DCCT were published and again 1 year after the recommendations were implemented. Patients who met the following criteria (N = 124) were enrolled: type 1 diabetes, less than 18 years old, followed at Yale for 1 year prior to the results of the DCCT and 1 year after, and HbA1c level recorded in the medical chart. RESULTS: HbA1c levels were significantly lower 1 year after implementing the DCCT protocol; 3 years later these same patients improved even further as evidenced by another decrease in HbA1c levels. The patients were taking more insulin (more Ultralente and regular insulin and less NPH) and had an increased number of injections at both the 1-year and 3-year follow-up points. CONCLUSIONS: The DCCT protocol can be implemented in a large population of pediatric patients with the help of a nurse who is dedicated and available to the patients for ongoing adjustments and provides creative ways to overcome the barriers to achieving normoglycemia.

Designing compliance programs that foster ethical behavior.

The federal government continues to expand its initiatives to uncover healthcare fraud, waste, and abuse. It is therefore more important than ever that healthcare organizations have an effective compliance program in place. The organization should have a compliance officer with adequate authority and staff to carry out the compliance program's functions. The program should include an ethics code, an internal hotline that employees can use to report compliance concerns, and education and training for all employees. In addition, the program should be audited periodically to ensure its viability. To be successful, a compliance program also needs the support of the healthcare organization's senior management.

Elevated ambulatory blood pressure in 20 subjects with Williams syndrome.

Previous studies report conflicting frequencies of hypertension in cohorts of patients with Williams syndrome (WS). We studied blood pressure (BP) in WS using 24-hour ambulatory BP monitoring. This technique reliably measures day- and nighttime BP in a subject's natural environment and provides better prognostic information on long-term risks of hypertension than casual BP determinations. Twenty WS subjects evaluated through a multidisciplinary WS clinic and 35 age and gender-matched controls were studied. We found that WS subjects had significantly higher ambulatory BP than controls. After controlling for age, sex, and weight, the diagnosis of WS added approximately 10 mmHg to mean daytime and nighttime BPs. Hypertension, as defined by elevated mean daytime BP, was present in 40% of WS subjects versus 14% of controls (P < 0.05); among the children studied this difference was even more dramatic with 46% of WS children versus 6% of control children classified as hypertensive (P = 0.01). We also demonstrated normal diurnal BP variation but no evidence of a "white coat" effect or increased BP variability. Interestingly, parental reporting of a history of infantile hypercalcemia was strongly associated with the presence of hypertension (P = 0.008). Our data demonstrate that both children and adults with WS have higher mean BP and higher frequency of hypertension than healthy controls. Thus, elevated BP readings in the office setting should not be dismissed but require more thorough assessment.

Love songs.

The demands of medical technology, of tubes and meds, often overshadow the caring and giving that are the very core of nursing. Patients like Alice--and her husband--help reaffirm the values that led me into the profession.