Emergency department visits for infectious oral conditions in Massachusetts, 2014 through 2018

BackgroundThe authors aimed to measure population-based preventable emergency department (ED) visits related to infectious oral conditions (IOCs) in Massachusetts and to examine the associated sociodemographic factors to support prevention efforts.MethodsA statewide retrospective analysis of ED visits related to IOCs in Massachusetts from 2014 through 2018 was conducted using a Center for Health Information and Analysis database. The authors described patients' characteristics, dental diagnoses frequencies, emergency severity, lengths of stay, associated treatment, and costs. Multilevel logistic regression was used to assess factors associated with IOC visits.ResultsIOC visits in 2014 through 2018 were 1.2% (149,777) of the total ED visits, with an estimated cost of $159.7 million. There was an annual decline in the prevalence of IOC visits from 2014 through 2018. After adjusting for sociodemographic factors, odds of IOC were higher among males (adjusted odd ratio [AOR], 1.26; 95% CI, 1.24 to 1.27), non-Hispanic Blacks compared with non-Hispanic Whites (AOR, 1.03; 95% CI, 1.02 to 1.06), people residing in dental health care professional shortage areas (AOR, 1.06; 95% CI, 1.04 to 1.07), public insurance beneficiaries (AOR, 1.90; 95% CI, 1.87 to 1.93), or uninsured (AOR, 2.60; 95% CI, 2.54 to 2.66) compared with privately insured.ConclusionsThere was an annual decline in the prevalence of IOC visits from 2014 through 2018. Higher odds of IOC visits were associated with young adults, Black patients, uninsured people, public insurance beneficiaries, and people who reside in dental health care professional shortage areas.Practical ImplicationsThe authors provided statewide data to support proposed policies to improve oral health care in Massachusetts. IOCs are mostly preventable, but well-coordinated care between medicine and dentistry is integral for prevention.     

Imaging diagnosis

The diagnosis of hepatocellular carcinoma (HCC) is based on imaging examinations in combination with clinical and laboratory findings. Despite technological advances, imaging cirrhotic patients remains a challenging issue because nonmalignant hepatocellular lesions, such as dysplastic nodules, mimic a small HCC. One of the key pathologic factors for differential diagnosis that is reflected in imaging appearances is the vascular supply to the lesion. It is accepted that imaging techniques may establish the diagnosis of HCC in nodules larger than 2 cm showing characteristic arterial hypervascularization. In lesions ranging from 1 to 2 cm, biopsy is still recommended, although a negative response can never be used to rule out malignancy completely. Although ultrasonography is widely accepted for HCC surveillance, spiral computed tomography (CT) or dynamic magnetic resonance imaging is required for diagnostic confirmation and intrahepatic tumor staging. These examinations have replaced invasive procedures, such as lipiodol CT, but remain relatively insensitive for the detection of tiny HCC lesions and tumor vascular invasion into peripheral portal vein branches.     

Continuing Orthohantavirus Circulation in Deer Mice in Western Montana

Hantavirus pulmonary syndrome (HPS) is an often-fatal disease caused by New World hantaviruses, such as Sin Nombre orthohantavirus (SNV). In the US, >800 cases of HPS have been confirmed since it was first discovered in 1993, of which 43 were reported from the state of Montana. The primary cause of HPS in the US is SNV, which is primarily found in the reservoir host Peromyscus maniculatus (deer mouse). The reservoir host covers most of the US, including Montana, where multiple studies found SNV in local deer mouse populations. This study aimed to check the prevalence of SNV in the deer mice at popular recreation sites throughout the Bitterroot Valley in Western Montana as compared to previous studies in western Montana. We found high prevalence (up to 20%) of deer mice positive for SNV RNA in the lungs. We were unable to obtain a SNV tissue culture isolate from the lungs but could passage SNV from lung tissue into naïve deer mice. Our findings demonstrate continuing circulation of SNV in western Montana.     

Australian and New Zealand 1997 thrombolysis audit

Objectives : To describe patterns of revascularization techniques in acute myocardial infarction in Australasia, particularly time to thrombolysis, site of delivery, patient demographics, revascularization rates and outcomes. Methods : Seventy‐four Australasian emergency departments were surveyed. Data from 1997 were obtained on number of acute myocardial infarction patients, age, gender, time to revascularization, intracranial haemorrhage rate, mortality, location and rate of revascularization and angioplasty. Grouped data were analysed. Results : Thirty‐three hospitals responded (44.6%). Many others could not supply data. Of 2930 acute myocardial infarction patients, 29% received thrombolysis and 5% angioplasty. Tertiary hospitals thrombolysed more in coronary care units (24.2% versus 8.8%), while non‐tertiary hospitals used emergency departments more (16.2% versus 5.9%). Average emergency department door‐to‐needle time was 49.4 min (median 38.6) versus 63.9 min (median 66.8) in coronary care units. More patients had streptokinase than tissue‐type plasminogen activator. Inferior myocardial infarction accounted for 58% of cases. Primary angioplasty commenced on average 61.5 min (median 69.2) after arrival. Conclusions : Australasian revascularization procedure rates, times, mortality and intracranial haemorrhage rates are similar to internationally published values. Thrombolysis starts sooner if given in emergency departments. Hospitals thrombolysing patients in coronary care units should consider emergency department thrombolysis if median times are greater than 50 min.     

Spectral Doppler of the Hepatic Veins in Pulmonary Hypertension

Pulsed‐wave Doppler interrogation of the hepatic veins (HVs) provides a window to right heart hemodynamics and function. Various pathologies that involve the right heart are manifested on the HV Doppler depending on the location and severity of the involvement and its hemodynamic consequences. Pulmonary hypertension (PHTN), a common finding on echocardiographic studies, imparts changes on the HV Doppler that are important to recognize. In this article, we provide a review of the main abnormalities that are encountered on the HV Doppler in patients with PHTN.     

Access to dental care in Alabama for children with special needs: parents' perspectives

BACKGROUND: Access to dental care and delivery of quality dental health services are important for children with special needs. The authors surveyed parents of children with special needs in Alabama to determine their perceptions of access and barriers to dental care for their children. METHODS: The authors sent a questionnaire to 2,057 parents of children aged 3 to 13 years with special needs--cleft lip and/or palate; cerebral palsy, or CP; spina bifida; or epilepsy/seizure disorders--who were listed in a database provided by Children Rehabilitation Services of Alabama. The authors conducted univariate and multivariate analyses to calculate odds ratios and 95 percent confidence intervals. RESULTS: The overall response rate was 38 percent (N = 714). Eighty-five percent of respondents reported that their children had received some form of routine dental care. However, 35 percent of respondents reported they had had problems finding dentists willing to treat their children. Among those with problems, significant barriers to dental care included their children's having Medicaid insurance, poor oral health or CP, as well as a shortage of dentists with training in the care of children with special needs. CONCLUSIONS AND PRACTICE IMPLICATIONS: While the majority of respondents said their children had access to dental care, one-third said their children had problems receiving this care. Many of these problems can be ameliorated. Increasing providers' participation in the Medicaid program and improving their knowledge about, empathy for and training in the care of children with special needs is essential in improving access to dental care for this population.     

Effect of Lymph Node Dissection on the Prognosis of Thymic Carcinomas and Thymic Neuroendocrine Tumors

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Pheochromocytoma: Positive predictive values of mildly elevated urinary fractionated metanephrines in a large cohort of community‐dwelling patients

The diagnostic utility of different thresholds of elevated urinary fractionated metanephrine (UFM) for pheochromocytoma‐paraganglioma (PPGL) was evaluated in 10 164 community‐dwelling subjects (2012‐2017). Levels were ≥1.5× the upper normal limit (UNL) in 276 subjects (2.7%) and ≥2×UNL in 138 (1.4%). PPGL was subsequently diagnosed in 59 (mean age 51.9 ± 14.3, 64% female); 58 (98.3%) with UFM ≥ 2×UNL. Positive predictive values (PPV) were 42% for UFM ≥ 2×UNL, 55% for UFM ≥ 2.5×UNL, and 69% for UFM ≥ 3×UNL. The main reason for PPGL screening (52.5%) was adrenal incidentaloma. Mean (median) metanephrine/normetanephrine levels were 6.7 ± 9×UNL (3 × UNL) and 6.1 ± 8.9×UNL (2.5 × UNL). Six patients (10.2%) had an extra‐adrenal tumor (one malignant paraganglioma); one had bilateral pheochromocytoma. Only one patient presented with the “classic triad” (headache, palpitations, sweating). In conclusion, after excluding obvious reasons for false‐positive results, thorough diagnostic assessment for PPGL is justified in all subjects with UFM ≥ ×2UNL. The PPV of milder UFM elevations is very low.