Oral health knowledge and practices in the Kaski District of Nepal.

INTRODUCTION: Oral disease is a widespread problem in Nepal. However, up-to-date information on oral health is limited and oral health initiatives may be shaped by assumptions about insufficient oral health knowledge. Furthermore, the influence of socio-demographic factors on oral health in Nepal remains unclear. This study aims to explore the relationship between demographic background and oral health knowledge, attitudes and behaviors in rural Nepal. METHODS: Secondary analysis of data from a community-based survey on oral health knowledge, beliefs, practices, and access to care among residents ages 12 and above across 4 rural villages in Nepal's Kaski District (Total number = 3,243). Chi-square tests were performed to examine associations among oral health knowledge, attitudes and behaviors and demographic characteristics. RESULTS: Participants reported a baseline knowledge of oral health; 92.4% knew about the recommended tooth-brushing regimen. Participants with higher education and younger age demonstrated better oral health knowledge. Misconceptions about dental treatment causing blindness (23.1%), deafness (11.6%), and mental health problems (14.9%) were reported across all groups. CONCLUSION: Numerous factors besides knowledge likely determine individual oral health behavior. Future interventions should consider community-based outreach programs and dental care delivery through community Health Posts to build trust in dental care, build on existing knowledge and community experiences, and improve access to preventative care. Up-to-date understanding of oral health knowledge and practices and sociocultural influences on oral health behavior will better focus interventions and policy decisions.

The relationship of the infrapatellar branches of the saphenous nerve to arthroscopy portals and incisions for anterior cruciate ligament surgery. An anatomic study.

The purposes of this study were 1) to carefully define the anatomic distribution of the infrapatellar branches of the saphenous nerve, 2) to provide the surgeon with reliable parameters for where the nerve is most commonly encountered, and 3) to provide specific surgical recommendations to minimize the risk of nerve injury. To accomplish these goals, we dissected 20 cadaveric, fresh-frozen, matched-pair knees. Calipers were used to measure the distance from the nerve to three clinically relevant and easily reproducible landmarks: the inferior pole of the patella, the medial border of the patella at its midpoint, and a point 2 cm medial to the patellar ligament at the level of the joint line. Distances were recorded with the knees in extension and in 90 degrees of flexion to examine the effect of dynamic knee motion on nerve position. We consistently found two main trunks of the nerve that traverse the knee primarily in a medial to lateral but somewhat proximal to distal direction. Because of this, we recommend that incisions for arthroscopy portals be made in a horizontal fashion to decrease the likelihood of nerve injury. Measured from both the inferior pole of the patella and the medial border of the patella, the nerve moved distally with knee flexion. We therefore recommend that incisions across the anterior aspect of the knee be made with the knee in flexion. In 8 of our 20 specimens, the nerve was actually found at the landmark located 2 cm medial to the patellar ligament. This is an extremely high-risk area and should be avoided if possible.

A simple effective splinting technique for the mallet finger.

We describe an inexpensive, simple, and effective technique for the closed treatment of mallet fingers. This technique splints the mallet finger in 0 degrees of extension. It is simple, readily reproducible, and easy to use, requiring materials that are readily available to any physician. Thirty-seven patients, ages 21 to 65 years, presented with a closed mallet finger injury at day zero to 5 months after injury. Ten of these patients had a fracture. All were treated with this splinting technique. We report excellent results in 35 of 37 patients, who recovered either complete or near-complete active extension. Our results compare favorably with results from other techniques and splints.

Lossy (15:1) JPEG compression of digital coronary angiograms does not limit detection of subtle morphological features.

BACKGROUND: Development of the "all-digital" cardiac catheterization laboratory has been slowed by substantial computer archival and transfer requirements. Lossy data compression reduces this burden but creates irreversible changes in images, potentially impairing detection of clinically important angiographic features. METHODS AND RESULTS: Fifty image sequences from 31 interventional procedures were viewed both in the original (uncompressed) state and after 15:1 lossy Joint Photographic Expert's Group (JPEG) compression. Experienced angiographers identified dissections, suspected thrombi, and coronary stents, and their results were compared with those from a consensus panel that served as a "gold standard." The panel and the individual observers reviewed the same image sequences 4 months after the first session to determine intraobserver variability. Intraobserver agreement for original images was not significantly different from that for compressed images (89.8% versus 89.5% for 600 pairs of observations in each group). Agreement of individual observers with the consensus panel was not significantly different for original images from that for compressed images (87.6% versus 87.3%; CIs for the difference, -4.0%, 4.0%). Subgroup analysis for each observer and for each detection task (dissection, suspected thrombus, and stent) revealed no significant difference in agreement. CONCLUSIONS: The identification of dissections, thrombi, and coronary stents is not substantially impaired by the application of 15:1 lossy JPEG compression to digital coronary angiograms. These data suggest that digital angiographic images compressed in this manner are acceptable for clinical decision-making.

Compression of digital coronary angiograms does not affect visual or quantitative assessment of coronary artery stenosis severity.

Digital coronary angiographic techniques are now widely used in many cardiac catheterization laboratories. However, the full potential of digital imaging technology remains to be achieved because of its enormous storage and exchange requirements. Compression of digital imaging data allows a reduction in the volume of data so that storage and transmission are more efficient and cost-effective. Three angiographers reviewed the original and compressed formats of 96 coronary angiographic sequences in a blinded fashion to assess coronary lesion severity. Compression was achieved using the Joint Photographic Experts Group (JPEG) standard, which resulted in a compression ratio of approximately 15:1. The original format was reviewed in a blinded fashion a second time to assess for intraobserver variability of similar formats. Lesion severity was graded in quartiles. Coronary stenosis >50% was considered "significant." In parallel, the reproducibility of quantitative coronary angiographic (QCA) measurements of coronary artery dimensions was also evaluated. For the visual assessment of lesion severity in the compressed versus original formats, kappa=0.52, suggesting moderate agreement. When lesions were assessed as significant versus "insignificant," however, kappa=0.88, suggesting excellent agreement. In the 2 separate readings of the original data formats, kappa=0.44 for assessment of lesion severity by quartiles and kappa=0.72 for lesions assessed as significant versus insignificant. Analysis of the compressed versus original data sets using QCA resulted in an excellent correlation for the measurement of lesion severity (r=0.99). The correlation was equally strong when the original format was analyzed sequentially (r=0.98). Lossy JPEG (15:1) compression is a valid means for reducing storage and exchange requirements of coronary angiographic data. The variability in assessing lesion severity between the original and compressed formats is comparable to the reported variability in visual assessment of lesion severity in sequential analysis of cine film.

Application of quantitative coronary angiography in a cineless environment: in vivo assessment of a fully automated system for clinical use.

The accuracy and precision of a fully automated quantitative coronary angiography (QCA) algorithm for use in a cineless environment were determined in phantom studies and in an in vivo canine preparation. Imaging studies of 118 coronary segments in six anesthetized dogs were compared with measurements of the diameters of casts of the canine coronary arteries produced in physiologic conditions. Regression analysis of phantom vessel diameters against QCA measurements revealed slopes of 0.94 to 0.96 and r values > 0.99. The results of the in vivo studies showed good correlation with the coronary cast diameter measurements, with a slope of 0.969 and an r value of 0.987 for the sets of measurements. The high degree of accuracy obtained in a model representative of the clinical situation demonstrates that QCA methods can be applied reliably in the clinical arena with current digital imaging technology and without cinefilm.

Which media are most likely to solve the archival problem?

The clinical application of quantitative methods for coronary arteriography remains limited, due in large part to the absence of a suitable replacement for cinefilm as the procedure record. The extension to the clinical environment of the validated objective methods which have found such widespread acceptance in clinical research studies is difficult to implement if the time-consuming and variable process for digitization of selected cinefilm frames is required. In addition, the complete integration of the angiographic procedure record with other patient records and procedures stored in a digital data format requires that the angiographic data eventually be converted to a digital format as well. Replacement of cinefilm requires that the media chosen for the task provide at least the same capabilities and preferably improved functions as those provided by cinefilm as a display, transport, and archival media. The demanding set of requirements imposed on the replacement options include high capacity, high acquisition rate, high transfer rate, application in a distributed environment, portability between institutions, and low expense. A true digital solution should also provide immediate access to the results of the angiographic procedure, transfer of image data over digital networks, multiple-user viewing capability, and quantitative analysis on a routine basis for all patients. In fact, a single media may not provide all the capabilities listed above but, rather, different media may need to be used for specialized tasks, i.e. the solution for archival may not be the same that will be employed as the portable patient record. Separation of the archival function from the acquisition/display and portable transfer functions increases the likelihood that cinefilm can be replaced in the imminent future by reducing the demands on a single media. Among the archival options available today are: (1) magnetic disks; (2) analog laser optical disks; (3) digital laser optical disks; (4) digital file-based magnetic tape; (5) digital video magnetic tape. In evaluating each of these alternatives, an accounting is required of how each meets the archival requirements along with an approximate breakdown of cost and readiness for implementation as a clinical solution today.

Ejection load changes in aortic stenosis. Observations made after balloon aortic valvuloplasty.

To investigate complementarity and competitiveness between the intrinsic and extrinsic components of the total left ventricular systolic load, hemodynamic data from 18 elderly subjects with severe aortic stenosis were analyzed before and after balloon dilation of the stenosed aortic valve. Multisensor micromanometric pressure measurements allowed calculation (simplified Bernoulli equation) of the ejection velocity and aortic input impedance spectra. Despite a 32% increase in the aortic valve area (from 0.56 +/- 0.04 to 0.74 +/- 0.05 cm2 [mean +/- SEM], p < 0.01), the peak left ventricular systolic pressure fell by only 12% (from 189 +/- 10 to 167 +/- 8 mm Hg, p < 0.01). This was accompanied by an increase in the impedance at the same cardiac output. In a subset of patients (n = 9) in whom the peak aortic systolic pressure rose after valvuloplasty (from 115 +/- 10 to 128 +/- 12 mm Hg, p < 0.01), a 40% increase in the aortic valve area was accompanied by a marked increase in the aortic input impedance. In this subset, the steady component of the aortic input impedance increased by 24% (from 960 +/- 96 to 1,188 +/- 134 dyne.sec/ml, p < 0.05), and the characteristic impedance increased by 25% (from 106 +/- 13 to 132 +/- 19 dyne.sec/ml, p < 0.05). Because of an increased aortic impedance acutely following the procedure, the total left ventricular systolic load after balloon dilation of the stenotic valve was only slightly decreased despite a significant increase in aortic valve area. This represents an example of complementarity and competitiveness between the intrinsic and extrinsic components of the total systolic ventricular load. It may explain why improvement in left ventricular performance may be modest acutely following balloon aortic valvuloplasty.

Quantitative and qualitative coronary angiographic analysis: review of methods, utility, and limitations.

Coronary angiography continues to be the pivotal study in the diagnosis and treatment of ischemic cardiac disease. Although angiographic equipment and imaging techniques have advanced over the past three decades, the analysis of coronary angiograms, by visual estimated percent diameter stenosis, has remained unchanged in most clinical catheterization laboratories. Rapid, computerized angiographic analysis systems are now available that remedy the inherent imprecision and inaccuracies plaguing visual coronary analysis. Despite its advantages, successful QCA is quite dependent on meticulous attention to radiographic and angiographic technique, even more so than with visual analysis. Although the available QCA systems can reproducibly and accurately define the site and degree of coronary stenosis, they cannot routinely determine whether an obstruction is flow limiting. Several methods, some based on extrapolations of quantitative measures alone, and others based on digital subtraction angiography, have been developed to determine the physiologic impact of a given coronary lesion. Recent observations have demonstrated, however, that even if the physiologic consequences of an obstruction are known, the prognosis of the lesion over time cannot be predicted. The qualitative, morphologic characteristics of a lesion are as, or more, important than the quantitative lesion attributes in determining an atheroma's behavior and stability, and hence, qualitative descriptors should be incorporated into QCA analyses. Although not currently available, future QCA systems will provide, by automated analysis, reproducible and accurate measures of absolute obstruction, physiologic data describing the flow limiting characteristics of a lesion, and qualitative, morphologic lesion descriptors. Implementation of these systems should provide more consistent and accurate prognostic and pathophysiologic information, thereby helping to refine and more effectively direct therapeutic interventions in coronary artery disease.

Pitfalls in the determination of absolute dimensions using angiographic catheters as calibration devices in quantitative angiography.

Using catheter outer diameter as a scaling device, quantitative coronary arteriography allows the precise and objective measurement of change in absolute dimensions of coronary arteries after mechanical or pharmacologic intervention. Because of variable density in the wall of the catheter, automated systems might vary in the determination of the outer catheter diameter. To examine this premise, catheters in a variety of French sizes from 6 manufacturers were injected with radiographic contrast and used as scaling devices for arterial phantoms of known geometric dimension. Radiographic diameters of the catheters were determined by applying the quantitative coronary arteriographic algorithm to the catheters using a calibration grid in the same field of view. The varying composition of the catheters resulted in differing x-ray attenuation and, subsequently, automated edge-detection algorithms varied widely in determining the actual catheter diameter to be used as a scaling factor. For instance, a Lucite "artery" with a minimal luminal diameter of 1.50 mm (image calibrated using the micrometer-determined outside diameter of a Baxter 8Fr guiding catheter) resulted in a quantitative angiographic diameter of 2.03 mm (overestimation by 35%). If the diameter of a similar size Shiley catheter was used to calibrate the image, a luminal diameter of 1.60 mm was determined: a difference of 0.43 mm based solely on differences in scaling catheter attenuation. These data suggest that a specific "fingerprint" for each catheter material and catheter French size exists, rendering generalizations about catheter size questionable. These observations are important for quantitative angiography where many brands and sizes of angiographic catheters are being used clinically.(ABSTRACT TRUNCATED AT 250 WORDS)

Further evaluation of collagen shields as a delivery system for 5-fluorouracil: histopathological observations.

Collagen shields are a potential delivery system for antifibroblast drugs such as 5-fluorouracil after filtration surgery. To determine whether collagen shields produce histologic evidence of inflammation when implanted subconjunctivally, shields were implanted into four rabbit eyes and six guinea pig eyes and retained for 7 or 14 days. Two rabbit eyes and two guinea pig eyes served as controls. Seven days after implantation in the rabbit eyes foreign-body giant cells were present at the surface of the shield, and early deposition of connective tissue was evident around the shield. The inflammatory response at 14 days was similar but more intense. In the guinea pig eyes the collagen shields induced substantially less inflammation, and there was marked shield degradation at 14 days. The results suggest that the inflammatory response in rabbits may be species specific and that collagen shields may be of value as a drug-delivery system for antifibroblast drugs in other species.

Sequence determination and comparison of the exfoliative toxin A and toxin B genes from Staphylococcus aureus.

The DNA encoding the exfoliative toxin A gene (eta) of Staphylococcus aureus was cloned into bacteriophage lambda gt11 and subsequently into plasmid pLI50 on a 1,391-base-pair DNA fragment of the chromosome. Exfoliative toxin A is expressed in the Escherichia coli genetic background, is similar in length to the toxin purified from culture medium, and is biologically active in an animal assay. The nucleotide sequence of the DNA fragment containing the gene was determined. The protein deduced from the nucleotide sequence is a polypeptide of 280 amino acids. The mature protein is 242 amino acids. The DNA sequence of the exfoliative toxin B gene was also determined. Corrections indicate that the amino acid sequence of exfoliative toxin B is in accord with chemical sequence data.

Modulation of specific [3H]phenytoin binding by benzodiazepines.

We have shown that diazepam (ED50 2.4 microM), flunitrazepam (ED50 10.2 microM) and Ro5-4864 (ED50 5 microM) are able to enhance both total and specific [3H]phenytoin binding. Picrotoxin (IC50 1.43 microM) and chloride, either NaCl or KCl (IC50 42.4 microM) inhibit both the increase in total and specific binding of [3H]phenytoin, Ro15-1788 does not. The optimum time for this enhancement was 3-4 hours. While the ED50's for the benzodiazepines are high their order of potency suggests that an involvement of both the "peripheral type" benzodiazepine receptor and the GABA-chloride ionophore complex is likely. Clonazepam (IC50 23 microM), oxazepam (IC50 12 microM) chlordiazepoxide (IC50 35 microM) and Ro8682-10, a convulsant benzodiazepine (IC50 16 microM) all inhibit both total and specific [3H]phenytoin binding. These effects were not blocked by chloride ions, picrotoxin or Ro 15-1788, and reached equilibrium within 45 minutes. This order of potency also parallels that for the "peripheral' benzodiazepine receptor in rat brain. These data suggest the presence of a micromolar benzodiazepine receptor site which may play a role in the control of CNS excitability. Nitrazepam, medazepam, bromazepam and the tetralobenzodiazepines U38335, U42794, U43434, and U37834 had no effect on total or specific [3H]phenytoin binding nor on the actions of the other benzodiazepines described in concentrations up to 50 microM.

In situ molecular weight determination of rat brain [3H]phenytoin binding sites.

Using irradiation inactivation analysis of specific [3H]phenytoin binding to rat brain we have demonstrated that there are two different binding sites involved, with molecular weights of 73238 +/- 1535 (higher affinity site) and 108121 +/- 6935 (lower affinity site).

Specific binding of [3H]phenytoin in the human brain.

Competition between cold phenytoin and [3H]phenytoin binding was observed in normal human brain. Binding was observed in all areas examined. The highest number of sites was in the amygdala (a total of 717.71 fmol/mg protein) and the lowest in the Brodman area (BA) 4 of the motor cortex (153.91 fmol/mg protein) and cerebellar cortex (154.4 fmol/mg protein). In three areas, amygdala, cortex area BA 38 (inferior parietal lobe), and cortex area BA 8 (premotor cortex), two sets of binding sites were observed. In these areas the Kd for the higher affinity sites ranged from 35 to 116 nM, and for the lower affinity site, from 328 to 866 nM. In the four areas where only one binding site was observed the KdS ranged from 164 to 311 nM and the Scatchard plot was linear.

Enhancement of 3H-phenytoin binding by diazepam and (+)bicuculline.

3H-Phenytoin binding to the particulate fraction of rat wholebrain homogenate was studied using the filter assay technique. It was found that diazepam and (+)bicuculline methobromide caused a concentration-dependent enhancement of the total binding of 3H-phenytoin, whereas GABA and (-)bicuculline methobromide (the inactive bicuculline isomer) had no effect. In subsequent competition experiments (labelled versus unlabelled phenytoin), it was found that the presence of a potentiating concentration of diazepam transformed the biphasic phenytoin competition isotherm into a simple curve with a Hill coefficient of approximately one, and a Ki of 110 nM.

The complete amino acid sequence of staphylococcal enterotoxin C1.

This report presents the complete amino acid sequence of staphylococcal enterotoxin C1. It has a total of 239 amino acids and a calculated Mr = 27,500. Reaction of the native toxin with trypsin produced five peptides, designated A through E. Their structures were determined after further fragmentation with cyanogen bromide, trypsin, and chymotrypsin. Overlap peptides were prepared by cleavage at the two half-cystine residues, and by the reaction of enterotoxin C1 with hydroxylamine. The latter procedure was employed when it was found that one of the three asparaginyl-glycine loci in the toxin is refractory to direct sequencing. The sequence is compared to staphylococcal enterotoxin B. Extensive homology is found, particularly in the carboxyl-terminal region. However, the segment spanned by the disulfide bond in enterotoxin C1 is three residues shorter than the corresponding segment in the B variant.