Multidisciplinary and Multistage Treatment of Complex Facial Trauma: Case Report

The improved performance of modern automobiles often results in higher driving speeds, rendering traffic accidents much more devastating. Many of our facially injured patients require multidisciplinary and multistage treatment, which is often both sophisticated and radical. We present a patient with complex facial trauma, discuss his injury characteristics and the multistage treatment performed, and review the literature.     

Structural determinants of A(3) adenosine receptor activation: nucleoside ligands at the agonist/antagonist boundary

Mutagenesis of the human A(3) adenosine receptor (AR) suggested that certain amino acid residues contributed differently to ligand binding and activation processes. Here we demonstrated that various adenosine modifications, including adenine substitution and ribose ring constraints, also contributed differentially to these processes. The ligand effects on cyclic AMP production in intact CHO cells expressing the A(3)AR and in receptor binding were compared. Notably, the simple 2-fluoro group alone or 2-chloro in combination with N(6)-substitution dramatically diminished the efficacy of adenosine derivatives, even converting agonist into antagonist. Other affinity-increasing substitutions, including N(6)-(3-iodobenzyl) 4 and the (Northern)-methanocarba 15, also reduced efficacy, except in combination with a flexible 5'-uronamide. 2-Cl-N(6)-(3-iodobenzyl) derivatives, both in the (N)-methanocarba (i.e., of the Northern conformation) and riboside series 18 and 5, respectively, were potent antagonists with little residual agonism. Ring-constrained 2',3'-epoxide derivatives in both riboside and (N)-methanocarba series 13 and 21, respectively, and a cyclized (spiral) 4',5'-uronamide derivative 14 were synthesized and found to be human A(3)AR antagonists. 14 bound potently at both human (26 nM) and rat (49 nM) A(3)ARs. A rhodopsin-based A(3)AR model, containing all domains except the C-terminal region, indicated separate structural requirements for receptor binding and activation for these adenosine analogues. Ligand docking, taking into account binding of selected derivatives at mutant A(3)ARs, featured interactions of TM3 (His95) with the adenine moiety and TMs 6 and 7 with the ribose 5'-region. The 5'-OH group of antagonist N(6)-(3-iodobenzyl)-2-chloroadenosine 5 formed a H-bond with N274 but not with S271. The 5'-substituent of nucleoside antagonists moved toward TM7 and away from TM6. The conserved Trp243 (6.48) side chain, involved in recognition of the classical (nonnucleoside) A(3)AR antagonists but not adenosine-derived ligands, displayed a characteristic movement exclusively upon docking of agonists. Thus, A(3)AR activation appeared to require flexibility at the 5'- and 3'-positions, which was diminished in (N)-methanocarba, spiro, and epoxide analogues, and was characteristic of ribose interactions at TM6 and TM7.     

Concordance for cognitive impairment: a study of 50 community-dwelling elderly female-female twin pairs

The present study sought to determine concordance of cognitive impairment among elderly female twins. Cognitive testing was performed by telephone interview in a sample of 100 female-female twins older than 65 years. The participants were 32 monozygotic (MZ) and 18 dizygotic (DZ) female twin pairs, all between the ages of 65 and 86 years; their mean age was 70.2 +/- 4.6 years. All were recruited from the Institute of Psychiatry Volunteer Twin Register (IPVTR). We used the Telephone Interview for Cognitive Status (TICS) and analyzed the modified total score. Correlation's of age and zygosity were computed in relation to score on cognitive interview, and differences between MZ twin pairs (n = 32) and DZ pairs (n = 18) were analyzed using the general linear model procedure. Five subjects of the 64 MZ females (7.8%) and one DZ female (2.4%) were found to be cognitively impaired. In no case was the second twin affected. No differences in cognitive score were found between MZ and DZ twin pairs. In both groups a highly significant correlation was found between age and lower score: R(2) = -0.32, P =.009. We conclude that aging-related impairment in cognitive testing did not differ between MZ and DZ elderly female twins. Although the overall sample size was relatively small and error variance may have been introduced by imprecise measures of zygosity, the present findings are suggestive of gender differences in cognitive performance that need further evaluation.     

Respiratory emergencies in the pediatric dental clinic: prevention and treatment

Emergency situations can occur in the Pediatric Dental Clinic. The purpose of this article is to focus on signs and symptoms of emergencies involving the airway, such as aspiration of foreign bodies, asthma attacks, obstruction of the airway as a consequences of physiological and pathological causes and sedation-induced apnea. Preventive and diagnostic tools, and protocols are presented, as well as a schematic flow chart of the management of airway obstruction due to foreign bodies. A new classification of risk factors that considers the parameters of sleep apnea risk, tonsil size, sedation level, patient's health status and dentist's qualification is also suggested.     

The reduction of broken appointment rates through an automated appointment confirmation system

Broken appointments continue to be an important productivity, quality assurance, and access gauge for private dental practices and academic dental centers. In November 2001, the University of Rochester Eastman Dental Center, an urban academic dental center, installed an automated confirmation system to address a high incidence of broken appointments. Following the installation of the system, the Eastman Dental Center experienced a marked decrease in the broken appointment rate. Over a twelve-month period, the center's overall broken rate declined from 23.42 percent to 19.17 percent. The general dentistry rate declined from 23.67 percent to 19.77 percent, and the pediatric dentistry rate declined from 29.42 percent to 25.25 percent.     

The long-term effect of specific type II 5alpha-reductase inhibition with finasteride on bone mineral density in men: results of a 4-year placebo controlled trial

PURPOSE: We determine the effect of long-term suppression of dihydrotestosterone with finasteride, a specific type II 5alpha-reductase inhibitor, on bone mineral density. MATERIALS AND METHODS: As part of a large (3,040 cases) 4-year, double-blind, placebo controlled trial designed to assess the long-term effects of finasteride in men with benign prostatic hyperplasia, 157 men 46 to 76 years old who were randomized to receive either 5 mg. finasteride or placebo underwent dual energy x-ray absorptiometry of the lumbar spine at baseline and at years 2, 3 and 4. RESULTS: Of 117 patients who had a baseline measurement and at least 1 additional measurement during the study baseline mean plus or minus standard deviation bone mineral density values were 1.12 +/- 0.17 gm./cm.2 in the finasteride group (63) and 1.10 +/- 0.17 gm./cm.2 in the placebo group (54). After 4 years bone mineral density was not different between treatment groups (finasteride 1.14 +/- 0.17 gm./cm.2 and placebo 1.13 +/- 0.18 gm./cm.2). Similar results were obtained for the 33 finasteride and 25 placebo treated patients who completed the study with year 4 bone mineral density measurements. CONCLUSIONS: These data demonstrate that long-term inhibition of type II 5alpha-reductase with finasteride does not adversely affect bone mineral density.     

Attitudes Toward Sexuality Among Nursing Home Residents

There is a paucity of data regarding sexuality among nursing home residents. The aim of the present study was to evaluate sexual attitudes in a group of independent residents in a large urban nursing home. Ten items covering different aspects of sexual attitude were scored by two board certified psychiatrists following a semistructured interview. The study was undertaken at a large 1,200-bed nursing home providing services to both healthy independent elderly as well as geriatric patients. Subjects were 31 volunteers: 15 men and 16 women (mean age: 82.4 and 74.1 years, respectively), who consented to participate. Participants were cognitively intact and living independently at the nursing home. Exclusion criteria were: a) current major psychiatric morbidity, b) drug or alcohol abuse, c) Geriatric Depression Scale (short version) score 5, and d) Clinical Dementia Rating >0. A hierarchy of basic functions was constructed wherein each function was graded on a 5-point Likert-like scale reflecting its endorsed importance. The majority (23/31) felt that sexuality should be openly discussed with the elderly by health professionals. Twenty-one of 31 expressed willingness to receive medical consultation and treatment for sexual dysfunction as needed and 20/31 expressed a similar attitude if their partner so needed. The hierarchy of needs was rated by the participants (men and women, respectively) as follows: Mood (4.4; 4.3), Memory (4.2; 4.2), Sleep (3.8; 3.9), Sex (3.5; 2.8), and Appetite (2.8; 2.6). Sex is graded as moderately important among nursing home residents, more so in males. The majority of residents expressed positive attitudes towards open discussion of sexual matters and willingness to accept therapeutic interventions when needed.     

Suicide amongst Alzheimer's disease patients: a 10-year survey

Suicide is a major public health problem with advancing age being one of the factors associated with increased risk. It has been suggested that most DSM axis-I disorders contribute to increased suicidal risk while dementia is one of the few exceptions. We conducted a 10-year retrospective analysis of all elderly patients suffering from dementia admitted to a large urban mental health center. Between 1991 and 2000 there were 1,551 admissions to our center who were 65 years or older. Of these, 341 were diagnosed (DSM-IV criteria) as suffering from dementia and 215/341 as suffering from Alzheimer's disease (AD). Sixteen AD patients (7.4% of all AD patients) were admitted immediately following a suicide attempt. The control group consisted of the next admission of an elderly AD patient matched for age and gender. The index group (suicidal patients) differed from controls in Clinical Dementia Rating scores (p = 0.017) and higher frequency of previous suicide attempts (p = 0.022). Lifetime psychopathology was not associated with higher rates of suicide attempts (p = 0.068). Physicians should be aware that suicide attempts are not rare in elderly AD patients. Higher level of daily functioning and previous suicide attempts are associated with increased suicidal risk.     

Attending to the thalamus: inhibition of return and nasal-temporal asymmetry in the pulvinar

Inhibition of return (IOR) is a mechanism whereby the attentional system favors novel locations by inhibiting already scanned ones. An important question is what the neural structures are involved. Recently, we studied a patient with damage to the superior colliculus (SC) and concluded that the SC generates IOR. However, it is possible that IOR is generated beyond the colliculus, for example, by the pulvinar. In this paper we tested three patients with unilateral damage to the pulvinar and demonstrated that the pulvinar is not necessary for IOR generation, providing additional support to the suggestion that the SC generates IOR. In addition, since we used monocular presentation, we were able to furnish behavioral evidence for nasal-temporal asymmetrical representation of visual input in the pulvinar.