Making clinical decisions for dental care: concepts to consider

Clinical decisions are often made with incomplete information, yet patient care decisions are made every day. Patients vary clinically, uncertainty exists in diagnostic and prognostic information, and many preventive and treatment alternatives have not been formally assessed for their effectiveness. Because scientific information will never answer all clinical questions, clinical decisions are partially based on probabilistic information.
This paper describes how to apply clinical decision making to diagnosing and managing dental caries and periodontal diseases. By using explicit information to quantify probabilities and outcomes, clinical decision making analyzes decisions made under uncertain conditions and the uncertain impact of clinical information.
Clinical decision making incorporates concepts for preventing, diagnosing and treating dental caries and periodontal diseases: risk assessment, evidence-based dentistry, and multiple oral health outcomes. This information can serve as a tool for clinicians to augment clinical judgment and expertise.     

Etanercept decreases tumor necrosis factor-α activity in chronic wound fluid

High levels of tumor necrosis factor-alpha (TNF-alpha), a pro-inflammatory cytokine, are present in the wound fluid of chronic nonhealing wounds. This leads to increased inflammation, cytokine expression, and ultimately results in impaired wound healing and tissue destruction. Etanercept is a recombinant fusion protein that consists of the soluble TNF receptor (p75) linked to the Fc portion of human IgG1. It is an effective inhibitor of TNF-alpha and has been shown to provide rapid and sustained improvement in rheumatoid arthritis by acting as a soluble receptor binding TNF-alpha and preventing its proinflammatory activities. Therefore, the aim of this study was to determine whether Etanercept could inhibit TNF-alpha activity in chronic wound fluid. Wound fluid was collected from the venous leg ulcers of 16 different patients. The effect of Etanercept on TNF-alpha activity was evaluated using both a TNF-alpha bioassay and an enzyme-linked immunoassay. Etanercept was found to reduce the cytotoxic effect of chronic wound fluid on L929 fibroblasts by approximately 30% and neutralized TNF-alpha binding in the enzyme-linked immunoassay by up to 80%. Direct application of Etanercept to chronic wounds may therefore reduce the inflammatory activity of TNF-alpha, which could reduce the chronicity of venous leg ulcers and thus aid in the healing of these wounds.     

Academic Degrees and Clinical Practice Characteristics: The University of Washington Physician Assistant Program: 1969-2000

CONTEXT: The physician assistant profession has been moving toward requiring master's degrees for new practitioners, but some argue this could change the face of the discipline. PURPOSE: To see if there is an association between physician assistants' academic degrees and practice in primary care, in rural areas, and with the medically underserved. METHODS: Surveys were sent to 880 graduates of the first 32 University of Washington physician assistant classes through 2000. Respondents noted their academic degree at program entry and the highest degree attained at any time up to the time of survey. Relationships between practice characteristics and academic degree levels were tested by unadjusted odds ratios and logistic regression after controlling for year of graduation and sex. RESULTS: Of the 478 respondents, 54% worked in primary care, about 30% practiced in nonmetropolitan communities, and 42% reported providing care for the medically underserved. Respondents with no degree (33% of total at entry, 24% at survey) were significantly more likely than degree holders to work in primary care and nonmetropolitan areas. Respondents with no degree at program entry were significantly more likely, and those with no degree at the time of the survey were marginally more likely, to self-report work with the medically underserved. CONCLUSION: Respondents with no academic degree are significantly more likely to demonstrate a commitment to primary, rural, and underserved health care. These findings may inform the national debate about the impact of required advanced degrees on the practice patterns of nonphysician providers.     

A new index for evaluating horizontal skeletal discrepancies and predicting treatment outcomes

The cephalometric measurement known as Wits appraisal (AOBO) was studied to determine its importance in diagnosis, treatment, and prediction of treatment success. The Wits appraisal is used primarily to identify unreliable ANB values (those that do not accurately reflect the degree of horizontal jaw discrepancy, ie, those that differ greatly from the AOBO value). Therefore, differences between AOBO and ANB also were evaluated. Because neither measurement alone can assess jaw discrepancies with total accuracy, they were combined, plotted on a scattergram, and divided into equal zones to create a new index of horizontal skeletal discrepancies and treatment predictability. Pretreatment values correspond to treatment difficulty, and posttreatment values correspond to the effectiveness of treatment. Treatment time for each zone also was evaluated. We were able to draw several conclusions from this study. First, combining AOBO and ANB values results in a more accurate measurement of treatment difficulty. These combined values also can be used to predict both treatment time and the success of treatment for horizontal discrepancies. Second, the AOBO value predicts variations in treatment time at each ANB value. Finally, adding ANB and AOBO values and then dividing the total yields zones that represent statistically significant differences in treatment times and percentages of success. The zones also correlate with the difference between AOBO and ANB measurements.     

Design of an intravenous oxygenator

The aim of this study was to design a new intravenous blood–gas exchange device and to estimate the design characteristics of the device with a dimensionless function by using a substance that can be used instead of bovine blood. In addition, the characteristics of oxygen transfer were estimated using empirical formulas and the reliability of the equations was ascertained by comparing their output with an experiment performed using bovine blood. The dimensionless function was derived using distilled water and bovine blood to estimate the oxygen transfer rate. Using the derived equations, the calculated oxygen transfer rates for bovine blood and distilled water were similar for Reynolds numbers ranging from 0.7 to 7.0. Therefore, it is possible to estimate the oxygen transfer rate in bovine blood, which is a non-Newtonian fluid, using distilled water, which is a Newtonian fluid. Moreover, it was possible to verify the related equations because the oxygen transfer rate could be estimated using the derived equations, according to the diameters of the various device modules.