Examining the accuracy of caregivers' assessments of young children's oral health status

BackgroundCaregivers' perceptions of their young children's oral health status (OHS) are a strong determinant of whether the children visit a dentist. Our aims were to quantify the correlation between caregivers' assessments and their children's clinically determined restorative treatment needs, while investigating factors related to this association.MethodsOne hundred eight caregivers assessed their children's OHS by answering a question on the self-reported National Health and Nutrition Examination Survey III instrument. Children underwent clinical oral examinations at one of two study sites of the Carolina Oral Health Literacy Project: a dental school–based clinic and a community-based health clinic. Examiners recorded the children's clinical treatment needs by using a modification of the caries severity index. The authors quantified concordance between the two measures with use of the Spearman rank correlation (ρ) and Kendall τ rank correlation, whereas they assessed differences in sociodemographic factors and oral health literacy (OHL) levels by using a homogeneity χ² test (P < .2 criterion).ResultsThe concordance between caregivers' assessments and clinically determined OHS was lower for younger children (< 2 years, ρ = 0.29 versus = 2 years, ρ = 0.63 [homogeneity P = .03]), a pattern that was evident in the community clinic but not in the university clinic. Caregivers' age, education and OHL did not influence the accuracy of self-reports.ConclusionsFor children younger than 2 years, caregivers' assessments correlated poorly with clinical needs, which routinely were underestimated.Practice ImplicationsThese findings underscore the importance of preventive dental visits at a young age and the early establishment of a dental home.     

Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty

Objectives

We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care–sensitive conditions mortality that could be used for hospital pay‐for‐performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients.

Methods

We performed a cross‐sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST‐elevation myocardial infarction. We used multivariable logistic regression models to predict in‐hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non‐Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient‐level covariates. We then ranked each hospital on observed‐to‐expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models.

Results

The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19–1.36) and poor patients (aOR = 1.21, 95% CI = 1.12–1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C‐statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest‐performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest‐performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001).

Conclusions

Sociodemographic risk adjustment of emergency care–sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay‐for‐performance programs.

     

Relative Efficacy of Sacubitril-Valsartan,Vericiguat, and SGLT2 Inhibitors in Heart Failure with Reduced Ejection Fraction: a Systematic Review and Network Meta-Analysis

Cardiovascular Drugs and Therapy - Sacubitril/valsartan, vericiguat, and the sodium-glucose co-transporter-2 inhibitors (SGLT2i) dapagliflozin and empagliflozin proved effective in phase 3 trials...     

Oral L-arginine improves endothelial dysfunction in patients with essential hypertension

BACKGROUND: L-Arginine is a nitric oxide precursor, which augments endothelium-dependent vasodilatation in hypercholesterolemic humans and animals. Endothelium-dependent vasodilation is attenuated in patients with hypertension; however the effects of oral L-arginine on endothelial function of the conduit arteries in patients with essential hypertension have not previously been investigated. METHODS: In a prospective randomized double blind trial, 35 patients with essential hypertension received either 6 g L-arginine (18 subjects) or placebo (17 subjects). Patients were examined for flow-mediated endothelium-dependent dilatation of the brachial artery before and 1.5 h after administration of L-arginine or placebo. At the end of the protocol the nitrate-induced, endothelium-independent vasodilatation was evaluated. RESULTS: Two groups of L-arginine and placebo were similar regarding age, sex, blood lipids, smoking, diabetes, coronary artery disease, body mass index, intima-media thickness of the common carotid artery, clinics blood pressure and baseline brachial artery parameters. Administration of L-arginine or placebo did not change significantly heart rate, blood pressure, baseline diameter, blood flow or reactive hyperemia. L-Arginine resulted in a significant improvement of flow-mediated dilatation (1.7+/-3.4 vs. 5.9+/-5.4%, P=0.008) while placebo did not significantly change this parameter (3.0+/-2.7 vs. 3.1+/-2.2%, P=ns). The effect of L-arginine on flow-mediated dilatation was significantly different from the effect of placebo (P=0.05). L-Arginine did not significantly influence nitrate-induced dilatation (16+/-6.9 vs. 17.7+/-6.7%, P=ns). CONCLUSIONS: Oral administration of L-arginine acutely improves endothelium-dependent, flow-mediated dilatation of the brachial artery in patients with essential hypertension. The long-term effects of L-arginine in these patients require further investigation.     

Can premenstrual syndrome affect arterial stiffness or blood pressure?

ObjectiveWe tested the hypotheses that monthly fluctuations in markers of arterial stiffness and blood pressure hemodynamics differ between women with and without premenstrual syndrome. We also assessed hypertension prevalence and arterial stiffening in postmenopausal women with or without history of premenstrual symptoms.MethodsTwenty one pre-menopausal women with premenstrual syndrome and 15 women without were prospectively examined in three distinct phases of their menstrual cycle (menses, late follicular and luteal phase). Pulse-wave velocity and analysis were used to assess arterial stiffness and wave reflection indices, respectively. Endothelial function was evaluated by flow-mediated vasodilation. In a cross-sectional substudy, 156 postmenopausal women were assessed for possible associations between retrospectively reported PMS symptoms and hypertension.ResultsIn women with premenstrual syndrome, arterial stiffness significantly increased during the luteal and menses phase (late follicular: 6.48 ± 1.07, luteal: 7.1 ± 1.26, menstruation: 7.12 ± 1.19 m/s, p = 0.003), while blood pressure peaked at the menses phase. Significant interactions between PMS and changes in arterial stiffness and blood pressure but not endothelial function, were observed. Changes in PWV were significantly associated with concomitant changes in blood pressure, C-reactive protein and the severity of PMS symptoms. The prevalence of hypertension (20.9% vs. 40.9%, p = 0.041) and pulse-wave velocity values (8.64 ± 1.52 vs. 9.37 ± 1.1, p = 0.046) were higher in postmenopausal women with 7 or more reported PMS symptoms. Arterial stiffness differences remained significant after adjustment for confounding factors.ConclusionThese results imply that PMS may affect arterial stiffness and BP monthly variability. Whether PMS is associated with new onset hypertension later in life needs further evaluation.     

Prolonged treatment of Salmonella enterica serovar Typhimurium with commercial disinfectants selects for multiple antibiotic resistance, increased efflux and reduced invasiveness

OBJECTIVES: To study how disinfectants affect antimicrobial susceptibility and phenotype of Salmonella enterica serovar Typhimurium SL1,344. METHODS: Wild-type strain SL1,344 and its isogenic gyrA mutant were passaged daily for 7 days in subinhibitory concentrations, and separately for 16 days in gradually increasing concentrations of a quaternary ammonium disinfectant containing formaldehyde and glutaraldehyde (QACFG), an oxidizing compound blend (OXC), a phenolic tar acids-based disinfectant (TOP) and triclosan. The MICs of antimicrobials and antibiotics for populations and representative isolates and the proportion of cells resistant to the MICs for the wild-type were determined. Expression of acrB gene, growth at 37 degrees C and invasiveness of populations in Caco-2 intestinal epithelial cells were assessed. RESULTS: QACFG and triclosan showed the highest selectivity for variants with reduced susceptibility to chloramphenicol, tetracycline, ampicillin, acriflavine and triclosan. Populations treated with the above biocides had reduced invasiveness in Caco-2 cells, and altered growth kinetics. Resistance to disinfectants was observed only after exposure to gradually increasing concentrations of triclosan, accompanied with a 2000-fold increase in its MIC. Growth in OXC and TOP did not affect the MICs of antibiotics, but resulted in the appearance of a proportion of cells resistant to the MIC of acriflavine and triclosan for the wild-type. Randomly selected stable variants from all populations, except the one treated with TOP, over-expressed acrB. CONCLUSIONS: In vitro exposure to QACFG and triclosan selects for Salmonella Typhimurium cells with reduced susceptibility to several antibiotics. This is associated with overexpression of AcrAB efflux pump, but accompanied with reduced invasiveness.     

Selection of patients for ambulatory lumbar discectomy: results from four US states

Background contextThere is a persistent trend for more outpatient lumbar discectomies in the United States.PurposeTo investigate the characteristics of the patients selected for ambulatory procedures.Study designRetrospective cohort study.Patient sampleForty-seven thousand one hundred twenty-five patients who underwent outpatient and 102,592 patients undergoing inpatient lumbar discectomies and were were registered in the State Ambulatory Surgery Database (SASD) and State Inpatient Database (SID), respectively, for New York, California, Florida, and North Carolina from 2005 to 2008.Outcome measuresRate of outpatient procedures, 30-day readmissions, and hospital charges.MethodsWe performed a retrospective cohort study involving patients who underwent outpatient and inpatient lumbar discectomies and were registered in SASD and SID, respectively, for New York, California, Florida, and North Carolina from 2005 to 2008. Logistic regression models were used to demonstrate the association of socioeconomic factors with the odds of undergoing an outpatient procedure.ResultsMale gender (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.03–1.08), private insurance (OR, 1.93; 95% CI, 1.86–2.01), lower Charlson Comorbidity Index (OR, 4.04; 95% CI, 3.17–5.16), and higher volume hospitals (OR, 1.06; 95% CI, 1.04–1.08) were significantly associated with outpatient procedures. Higher income (OR, 0.83; 95% CI, 0.81–0.85), older age (OR, 0.996; 95% CI, 0.995–0.997), coverage by Medicaid (OR, 0.89; 95% CI, 0.83–0.96), African Americans (OR, 0.65; 95% CI, 0.60–0.70), and other minority races were associated with decreased odds of outpatient procedures. The rate of 30-day postoperative readmissions was higher among inpatients. Institutional charges were significantly lower for outpatient lumbar discectomies. The median charge for inpatient surgery was $24,273 as compared with $11,339 for the outpatient setting (p<.0001).ConclusionsAccess to ambulatory lumbar discectomies appears to be more common for younger, white, male patients, with private insurance and less comorbidities, in the setting of higher volume hospitals. Further investigation is needed in the direction of mapping these disparities for appropriate resource utilization.