Understanding Adult Vaccination in Urban,Lower-Socioeconomic Settings: Influence of Physician and Prevention Systems

PURPOSE Vaccination rates for pneumococcal polysaccharide vaccine (PPV) and influenza vaccine are relatively low in disadvantaged urban populations. This study was designed to assess which physician and practice characteristics might explain differences in rates across physicians.METHODS PPV and influenza vaccination rates were determined for 2,021 patients aged 65 years and older receiving care from 30 physicians in 17 practices surveyed about their office systems for providing adult immunizations. Hierarchical linear modeling (HLM) analyses were used to examine the relationships among vaccination rates, patient-level characteristics, and physician variables.RESULTS Overall, the weighted PPV vaccination rate was 60.0% and varied widely across physicians (range, 11%–98%). At the patient level in HLM, patient race (P=.01) and age (P = .02), but not neighborhood income, were associated with PPV status. By linking physician survey data with PPV rates, we found the best pair of physician variables to be “reported time spent with patients for a well visit” (P = .01) and “use of enhanced immunization documentation” (P=.10). The overall influenza vaccination rate was 51.9% (range, 22%–96%). Patient race (P=.003) and age (P = .002) were associated with influenza vaccination. The pair of physician variables with the strongest association with influenza vaccination was “use of standing orders” (P <.001) and “average observed physician examination room time,” regardless of visit type (P=.02).CONCLUSIONS Vaccination rates vary widely in urban settings and are associated with practice characteristics such as time spent with patients and, for influenza vaccine, use of standing orders.     

Sensate lateral arm flap for defects of the lower leg

Ideally, reconstruction of lower extremity soft tissue defects includes not only an esthetically pleasing 3-dimensional shape and solid anchoring to the underlying structures to resist shear forces, but should also address the restoration of sensation. Therefore, we present a prospective study on defect reconstruction of the lower leg and ankle to evaluate the role of sensate free fasciocutaneous lateral arm flap and the impact of sensory nerve reconstruction. Thirty patients were allocated randomly to the study group (n = 15) that obtained end-to-side sensate coaptation using the lower lateral cutaneous brachial nerve to the tibial nerve using the epineural window technique, or to the control group reconstructed without nerve coaptation. At 1-year follow-up the patients were evaluated for pain sensation, thermal sensibility, static and moving 2-point discrimination, and Semmes-Weinstein monofilament tests. Data from both groups were compared and statistically analyzed with the Mann-Whitney U test and the Fisher exact test. Flaps of the study group reached a static and moving 2-point discrimination and Semmes-Weinstein monofilament tests nearly equal to the contralateral leg area and significantly better than flaps of the control group. Donor damage morbidity of the tibial nerve did not occur. To our point of view resensation should be carried out by end-to-side neurorrhaphy to the tibial nerve because of the superior restoration of sensibility.     

Identification of a Ca<Superscript>2+</Superscript>-Sensing Receptor in Rat Trigeminal Ganglia,Sensory Axons,and Tooth Dental Pulp

Extracellular Ca²⁺ regulates dentin formation, but little information is available on this regulatory mechanism. We have previously reported that sensory denervation reduces dentin formation, suggesting a role for sensory nerves in tooth mineralization. The G protein-coupled Ca²⁺-sensing receptor (CaR) is expressed in dorsal root ganglia and perivascular sensory nerves in mesenteric arterioles, and activation of these receptors by Ca²⁺ has been shown to induce vascular relaxation. The present study determined CaR expression in tooth dental pulp (DP), sensory axons, and trigeminal ganglion (TG) as well as the effect of increased [Ca²⁺]_e or a calcimimetic on tooth blood flow. The distribution of CaR, studied by immunochemistry, RT-PCR, and Western blot, indicates abundant expression of CaR in sensory axons in the jaws, TG, and DP. Restriction analysis of PCR products with specific endonucleases showed the presence of CaR message in TG and DP, and Western blotting indicates the expression of mature and immature forms of the receptor in these tissues. Pulpal blood flow, measured by laser-Doppler flowmetry, increased by 67% ± 6% (n = 12) following receptor stimulation with 5 mM Ca²⁺, which was completely inhibited by 5 μM IBTx, a high-conductance K_Ca channel blocker indicating a mechanism involving hyperpolarization. NPS R-467 (10 μM) increased blood flow by 85% ± 18% (n = 6), suggesting regulation through the CaR. Our results suggest that the CaR is present in sensory nerves, DP, and TG and that an increase in Ca²⁺ in the DP causes vasodilatation, which may contribute to accumulation of Ca²⁺ during dentin mineralization.     

Long-term sickness absence and disability pension with psychiatric diagnoses: a population-based cohort study

Sickness absence certified with psychiatric diagnoses is increasing in many Western countries. A substantial proportion of the sickness absentees never return to work, but ends up with a permanent disability pension (DP). This study investigated the incidence of long-term sickness absence (LTSA) with different psychiatric diagnoses, and tested predictors of the transition to permanent DP. A special objective was to explore previously reported gender differences, using a population-based cohort study. The population at risk of LTSA was 106,674 occupational active men and 89,356 women in a Norwegian county in 1994; 314 women and 203 men with LTSA >8 weeks, certified with a psychiatric diagnosis, were followed to the end of 1999, with DP as the endpoint. Diagnoses on sickness certificates, age, gender and income were used as explanatory variables in Cox regression analysis. Annual incidence of LTSA with a psychiatric diagnosis was 7.0/1000/year for women and 3.8/1000 for men; 72% of the women and 50% of the men had a diagnosis indicating depression. During follow-up, 32% of the men and 25% of the women obtained DP. Increasing age, male gender, low income and a diagnosis of psychosis or "other" increased the DP risk. Separate analysis for men indicated a different effect of age and a larger role of serious mental illness. The study verified that women more often than men had LTSA with psychiatric diagnoses, especially with depression. Men were at higher risk of transition to DP, and the study suggested some possible explanations.     

Severe respiratory dysfunction in a patient with relapsing polychondritis: should we treat the saddle nose deformity?

SUMMARY: We report a case of surgical correction of a saddle nose deformity, causing severe ventilation restrictions in a 42-year-old man diagnosed with relapsing polychondritis. Relapsing polychondritis is an autoimmune disorder, in which antibodies to type II collagen cause an inflammatory destruction of cartilage. If septal cartilage of the nose is involved, destruction leads to collapse of the dorsum of the nose, causing a saddle nose deformity. Patients suffer from a ventilation disorder of varying degree depending on the response to or onset of immunosuppressive therapy. In the described patient, the destruction of the nasal septum, in addition to unstable tracheal cartilage, caused a severe restriction in ventilation, with total collapse of the internal nasal valves during forced inspiration. To improve the function of the external airways the patient underwent surgery to reconstruct the nasal septum. Although cartilage grafts are the state of the art to reconstruct the nasal septum, we used a bone graft from the iliac crest, because the autoimmune polychondritis precludes cartilage grafting due to expected cartilage destruction. At follow up 2 years postoperatively no signs of bone resorption or deterioration of the improved airway were observed. We conclude that the use of bone grafts is a promising method to restore and improve ventilation disorders caused by a saddle nose deformity in relapsing polychondritis.     

Osteoporosis in COPD outpatients based on bone mineral density and vertebral fractures

One of the extrapulmonary effects of chronic obstructive pulmonary disease (COPD) is osteoporosis. Osteoporosis is characterized by a low bone mineral density (BMD) and microarchitectural deterioration. Most studies in COPD patients use dual‐energy X‐ray absorptiometry (DXA) only to determine osteoporosis; therefore, microarchitectural changes without a low BMD are missed. The aim of this study was to determine the prevalence and correlates of osteoporosis in COPD patients based on DXA, spinal X‐rays, and combinations thereof. DXA and spinal X‐rays were obtained and pulmonary function tests, body composition, 6‐minute walking distance, medical history, and medication use were assessed in 255 clinically stable COPD outpatients of a large teaching hospital in the Netherlands. Half of all patients had radiologic evidence of osteoporosis. Combining the results of DXA with spinal X‐rays augmented the proportion of COPD patients with osteoporosis compared with both methods separately. The prevalence of osteoporosis was not significantly different after stratification for Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) stage. Most patients with osteoporosis did not receive pharmacologic treatment. Age, body mass index (BMI), and parathyroid hormone (PTH) level were significant independent correlates for osteoporosis. Chest physicians should be aware of the high prevalence of osteoporosis in patients with COPD, even in the presence of a low GOLD score, as well as especially in elder COPD patients with a low BMI and/or an increased PTH level. © 2011 American Society for Bone and Mineral Research.