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Understanding consumer expectations is important if orthodontists are to be successful in marketing their elective services. The purpose of this study was to examine the relationship between consumer outcome expectations and treatment variables, including cost of treatment and malocclusion severity. The subjects were parents of patients recruited from 9 private orthodontic practices in southwestern Pennsylvania who were entering a single comprehensive phase of orthodontic treatment, characterized by a full fee and complete fixed appliances. The parents completed a questionnaire regarding outcome expectations for their child's orthodontic treatment. Pretreatment orthodontic study models of each child were evaluated with the peer assessment rating. The results of this study suggest that orthodontic consumers have very high outcome expectations. Also, the parents of patients with severe overall malocclusions, overjet, or midline deviations have expectations that exceed probable treatment outcomes. Orthodontists should consider that consumers seeking their services have increased expectations not related to the treatment outcomes.

Aim: To determine the relationship between treatment need assessment scores of orthodontists, general practitioners, and pediatric dentists., Study Design: Observational., Sample: Ten general dental practitioners, 18 orthodontists and 15 pediatric dentists reviewed 137 dental casts and recorded their opinion on whether orthodontic treatment was needed., Results: We found a high level of agreement between pediatric dentists, orthodontists and general practitioners (Kappa range 0.86-0.95). Between the groups, the amount of agreement was lower., Conclusions: Orthodontists, general dental practitioners, and pediatric dentists in this sample exhibit high levels of agreement on orthodontic treatment need.

Objective: The Oral Health Science Institute at the University of Pittsburgh has completed a cross-sectional epidemiologic study of 406 subjects with type 1 diabetes and 268 control subjects without diabetes that assessed the associations between oral health and diabetes. This report describes the prevalence of dry-mouth symptoms (xerostomia), the prevalence of hyposalivation in this population, and the possible interrelationships between salivary dysfunction and diabetic complications., Study Design: The subjects with diabetes were participants in the Pittsburgh Epidemiology of Diabetes Complications study who were enrolled in an oral health substudy. Control subjects were spouses or best friends of participants or persons recruited from the community through advertisements in local newspapers. Assessments of salivary function included self-reported xerostomia measures and quantification of resting and stimulated whole saliva flow rates., Results: Subjects with diabetes reported symptoms of dry mouth more frequently than did control subjects. Salivary flow rates were also impaired in the subjects with diabetes. Regression models of potential predictor variables were created for the 3 self-reported xerostomia measures and 4 salivary flow rate variables. Of the medical diabetic complications studied (ie, retinopathy, peripheral and autonomic neuropathy, nephropathy, and peripheral vascular disease), only neuropathy was found to be associated with xerostomia and decreased salivary flow measures. A report of dry-mouth symptoms was associated with current use of cigarettes, dysgeusia (report of a bad taste), and more frequent snacking behavior. Xerogenic medications and elevated fasting blood glucose concentrations were significantly associated with decreased salivary flow. Resting salivary flow rates less than 0.01 mL/min were associated with a slightly higher prevalence of dental caries. Subjects who reported higher levels of alcohol consumption were less likely to have lower rates of stimulated salivary flow., Conclusions: Subjects with type 1 diabetes who had developed neuropathy more often reported symptoms of dry mouth as well as symptoms of decreased salivary flow rates. Because of the importance of saliva in the maintenance and the preservation of oral health, management of oral diseases in diabetic patients should include a comprehensive evaluation of salivary function.

Background: Anastomotic leak from cervical esophagogastric anastomoses is a serious problem after esophagectomy. We explored the efficacy of partial or total mechanical anastomoses accomplished with the endoscopic linear cutting and stapling device as an alternative to hand-sewn anastomotic techniques., Methods: During a 42-month period, 93 patients undergoing either transhiatal esophagectomy or a three-incisional approach to esophagectomy underwent either hand-sewn (n = 43), partial mechanical (n = 16), or totally mechanical (n = 34) cervical esophagogastric anastomoses. The occurrence of postoperative anastomotic leak and the development of postoperative anastomotic stricturing requiring dilation therapy were analyzed between these groups using chi2., Results: All patients survived esophagectomy and were available for postoperative follow-up. Anastomotic leak developed in 10 patients (23%) with hand-sewn, 1 patient (6%) with partial mechanical, and 1 patient (3%) with total mechanical anastomoses (p < 0.05). Anastomotic stricture development paralleled the occurrence of anastomotic leak rate with 25 patients (58%) with hand-sewn, 3 patients (19%) with partial mechanical, and 6 patients (18%) with total mechanical anastomoses experiencing strictures requiring dilation therapy (p < 0.05)., Conclusions: These results suggest that partial or mechanical cervical esophagogastric anastomoses created with the endoscopic stapling device may be superior to hand-sewn anastomotic techniques.

Background: Vascular endothelial growth factor (VEGF) plays an important role in tumor growth and metastasis. We investigated the prognostic significance of VEGF overexpression, intratumoral microvessel density (MVD), and angiolymphatic invasion in stage Ia-b non-small cell lung cancer (NSCLC)., Methods: Eighty-five patients undergoing complete surgical resection of pathologic stage Ia-b NSCLC were evaluated. The mean and median clinical follow-up were 37.1 and 39.0 months (range, 30-44 months), respectively. Paraffin-embedded tumor specimens were stained with VEGF and CD31 (a specific endothelial marker) using immunohistochemical methods. VEGF staining was evaluated, by combining both percentage of positive tumor cells and staining intensity, as low (negative and < 20% of tumor cells showing weak positivity), or high (> 20% of tumor cells showing strong positivity). CD31 staining was expressed as MVD per high power field at 400x magnification. Angiolymphatic invasion was expressed as either presence or absence., Results: Low VEGF expression was seen in 25 (29%) patients, and high VEGF expression was seen in 60 (71%) patients. The survival rate in patients with low VEGF expression was significantly higher (80%) than that in those with high VEGF expression (48%, P = .018). The mean MVD in the low VEGF group was 23.7 +/- 5.7 vs. 34.4 +/- 9.3 in the high VEGF group (P = .001). Patients with high MVD also had a significantly lower survival rate than did those with low MVD count (46% vs. 73%, P = .0053). Age, sex, tumor type, and tumor differentiation were not found to be associated with overall survival. The presence of angiolymphatic invasion and T2 stage (i.e., tumor size > 3 cm) were associated with decreased survival. High VEGF expression, tumor size, and angiolymphatic invasion emerged as three independent factors predicting worsening prognosis using multivariate analysis., Conclusion: High VEGF expression within stage I NSCLC is closely associated with high intratumoral angiogenesis and poor prognosis. Immunohistochemical evaluation of T stage and VEGF expression along with examination of angiolymphatic invasion perioperatively may aid in predicting prognosis. Adjuvant therapies aimed at retarding tumor angiogenesis may be considered for stage I NSCLC patients with high VEGF levels.

Background: Diabetes is a chronic metabolic disease known to affect oral disease progression. The authors surveyed health behaviors essential for preventing dental and periodontal diseases and maintaining oral health is a population of adult patients with type 1 (insulin-dependent) diabetes. The goals of this study were to assess these patients' oral health behaviors, access to dental care and need for improved health education., Methods: As part of a dental and periodontal examination, 406 subjects with type 1 diabetes completed a questionnaire regarding their oral health attitudes, behaviors and knowledge. The authors also evaluated 203 age-matched nondiabetic control subjects., Results: The authors found that diabetic subjects' tobacco use and oral hygiene behaviors were similar to those of the nondiabetic control subjects. Diabetic subjects, however, more frequently reported the cost of dental care as a reason for avoiding routine visits. Most of these subjects were unaware of the oral health complications of their disease and the need for proper preventive care., Conclusions: Patients with diabetes appear to lack important knowledge about the oral health complications of their disease. The results of this survey did not indicate improved prevention behaviors among the subjects with diabetes compared with nondiabetic control subjects., Clinical Implications: Dentists have an opportunity and the responsibility to promote good oral health behaviors such as regular dental examinations, proper oral hygiene and smoking cessation that may significantly affect the oral health of their diabetic patients.

Purpose: Video-assisted surgical approaches to esophageal achalasia continue to be explored by many surgeons involved in the management of this motor disorder. We report our experience with thoracoscopic and laparoscopic esophagomyotomy to more clearly define the efficacy and safety of these approaches., Patients: Over 73 months, 58 patients with achalasia underwent thoracoscopic myotomy (n = 19) alone or laparoscopic myotomy (n = 39) with partial fundoplication (anterior = 15; posterior = 24). Mean age was 47.2 years and average length of symptoms was 60 months. Primary symptoms were as follows: dysphagia, 100%; pulmonary abnormalities, 22%; weight loss; 47%, and pain, 45%. Mean esophageal diameter was 6 cm and tortuosity was present in 16% (9/58) of patients. Prior management consisted of dilation (n = 47), botulinum toxin injection (n = 8), and prior myotomy (n = 1)., Methods: In the operating room all patients underwent endoscopic examination and evacuation of retained esophageal contents. The esophagomyotomy was extended 4 cm superiorly and inferiorly to 1 cm beyond the lower esophageal sphincter. Thoracoscopic and laparoscopic procedures were completed in all patients without conversion to an open operation. Mean operative time was 183 minutes (+/-58.1) and hospital stay averaged 2.3 days (+/-0.8). There was no operative mortality. The 1 operative complication was a perforation that was identified during the operation and repaired thoracoscopically., Results: Symptoms improved in 97% of patients. Mean dysphagia scores (range 0-10) decreased from 9.8 +/- 1.6 before the operation to 2.0 +/- 1.5 after the operation (P <.001) at a mean follow-up of 6 months. Postoperative reflux symptoms developed in 5% (1/19) of the thoracoscopy group and 8% (4/39) of the laparoscopy group. Nine patients have persistent or recurrent dysphagia (16%). Seven patients have successfully undergone Savary dilation, and 2 required esophagectomy to manage recalcitrant dysphagia., Conclusion: At this intermediate term analysis, video-assisted approaches for management of achalasia are a reasonable alternative to extended medical therapy or open operations.

Background: Recent research suggests that osteopenia may be a predisposing factor for periodontal tissue destruction. If so, then a relationship should exist between measures of systemic bone mineral density and periodontal tissue destruction. The purpose of the present cross-sectional study was to evaluate the association between systemic bone mineral density and the clinical signs of periodontal tissue destruction in a large population of elderly dentate women., Methods: A total of 292 dentate women (average age 75.5 years) were randomly selected for a cross-sectional periodontal substudy from participants at the Pittsburgh Field Center of the Study of Osteoporotic Fractures (SOF), a prospective study of a cohort of elderly women (age > or =65 years at baseline) to determine risk factors for fractures. Bone mineral density (BMD) was measured using single photon absorptiometry (radius, calcaneus) and dual energy x-ray absorptiometry (hip, spine). Oral health examinations, including periodontal probings and an assessment of bleeding on probing, were made using an NIDR probe at 3 buccal sites of all teeth. Multiple regression models were used to assess the association between bone mineral density and measures of periodontal disease status while controlling for potential confounders. Periodontal status variables examined included: average loss of periodontal attachment (LOA); number of sites with at least 4 mm LOA; number of sites with at least 6 mm LOA; number of sites with bleeding on probing; and deepest probing depth per person., Results: This study found no statistically significant association between the 5 indicators of periodontal disease and measures of systemic BMD at 8 anatomic sites after controlling for age, smoking, and number of remaining natural teeth. Some suggestive findings support a weak association between generalized osteopenia and periodontal disease., Conclusions: Systemic osteopenia is, at best, only a weak risk factor for periodontal disease in older non-black women.

Background: The periodontal disease status of 320 dentate adults, diagnosed 23.7 years previously with Type 1 insulin dependent diabetes mellitus, was evaluated. These patients had been monitored at 2-year intervals as part of a large University of Pittsburgh longitudinal study assessing the medical complications associated with insulin dependent diabetes., Methods: During one of their regularly scheduled medical examinations, a group of 320 adult dentate subjects (mean age of 32.1 years) received a periodontal examination as part of a comprehensive oral health assessment. The oral health assessment collected data regarding demographics, oral health behaviors, tooth loss, coronal and root caries, salivary functions, and soft tissue pathologies. For the periodontal assessments, 3 facial sites (mesial, midcervical, distal) of the teeth in the right maxillary/left mandibular or left maxillary/right mandibular quadrants were evaluated for calculus, bleeding on probing (BOP) and loss of gingival attachment (LOA)., Results: Attachment loss was significantly greater for older patients whereas BOP and calculus levels were relatively constant across age categories. Univariate analyses of factors possibly related to extensive periodontal disease (LOA > or =4 mm for at least 10% of sites examined) indicated an association with older age; lower income and education; past and current cigarette smoking; infrequent visits to the dentist; tooth brushing less than once per day; older age of onset; longer duration of diabetes; and the diabetic complication of neuropathy. A multivariate regression model of all possibly significant factors found current cigarette use (odds ratio [OR] = 9.73), insulin dependent diabetes onset after 8.4 years of age (OR = 3.36), and age greater than 32 years (OR = 3.00) explained the majority of the extensive periodontal disease in this group of diabetic patients., Conclusions: Management and prevention of extensive periodontal disease for Type 1 diabetic patients should include strong recommendations to discontinue cigarette smoking.

Background: Hepatocyte growth factor (HGF) is a cytokine that is released after injury. It is a paracrine factor that is produced by mesenchymal cells; epithelial and endothelial cells respond to HGF through its receptor, the c-met protein. Hepatocyte growth factor induces cell growth and cell movement and is also highly angiogenic. Evidence from breast cancer patients suggests that HGF is a negative prognostic indicator for breast cancer and is associated with invasive disease., Methods: We measured the HGF content in tumor tissue from 56 non-small cell lung cancer patients using the Western blot technique. The amount of HGF in tumor extracts was quantitated by densitometry after transfer of proteins to nitrocellulose and exposure to antibodies. Survival curves were generated based on clinical information obtained for each patient., Results: Our data indicate that HGF is also a negative prognostic indicator in lung cancer. As in the study of breast cancer patients, HGF was associated with recurrence and poor survival; the relative risk was seen to increase with increasing HGF tumor content. At levels of HGF greater than 100 units, the relative risk was 10, compared with that in patients with an HGF level of 1 unit. Node-negative patients with an elevated HGF tumor content had a significantly poorer outcome than node-positive patients with a low HGF tumor content. The same relationship was observed if the patients were stratified by stage: elevated HGF was associated with stage I patients whose disease recurred and who died of their disease, and stage I patients with elevated HGF had a worse survival than higher stage patients with a low level of HGF., Conclusions: These results suggest that elevated HGF may predict a more aggressive biology in non-small cell lung cancer patients. The level of HGF may be useful as an indicator of high risk in early stage lung cancer patients.

Objectives: To determine if survival and recurrence rates for patients with squamous cell carcinoma of the tongue correlate with the degree of dendritic cell (DC) infiltration of the primary tumor or adjacent tongue tissue and if there is an association between tumor or nodal stage and DC infiltration., Design: Hospital and office medical records were reviewed to obtain 5-year follow-up data. Original pathology specimens were recut and stained for the cell surface markers S100 and CD 1a. The number of DCs present in the specimens was quantified microscopically and compared statistically with patient outcome and staging., Setting: A university hospital., Patients: All patients who underwent resection of primary squamous cell carcinoma of the tongue from January 1, 1987, through December 31, 1990, for whom 5-year follow-up data and original pathology specimens were available (N=43)., Main Outcome Measures: Time to recurrence, death, or both., Results: Patients who had greater numbers of CD1a-positive DCs adjacent to tumor had improved survival (P=.02) and decreased recurrence rates (P=.06). The other subpopulations of DCs examined were not associated with survival or recurrence. In addition, the number of CD 1a-positive DCs in peritumoral epithelium decreased as the tumor stage increased (P=.01) and if nodal metastases were present (P=.05)., Conclusions: Dendritic cells are antigen-presenting cells that are thought to play a major role in the antitumor immune response. The CD1a surface antigen has been shown to mediate T-cell interactions. The association between CD1a-positive peritumoral DCs and patient outcome suggests an important function for this cell population.

Clinical and histopathological features do not reliably distinguish between benign and malignant pheochromocytomas. Additional markers that might be useful prognostic indicators in the pathological assessment of these tumors are sought. Immunohistochemical expression of MIB-1, Bcl-2, cathepsin B, cathepsin D, basic fibroblast growth factor (bFGF), c-met, and type IV collagenase were studied on formalin-fixed tissue from 33 nonconsecutive cases of pheochromocytoma, selected on the basis of reliable long-term follow-up, to determine associations with malignancy. The study group included 33 patients, 19 men and 14 women, with a mean age of 45 years, including five cases of neurofibromatosis (NF), three familial, and one MEN IIb. Mean follow-up was 63.2 months. Ten patients were determined to have malignant pheochromocytomas by the presence of metastatic disease. Features found to be associated with malignancy included MIB-1 labeling index (5% vs 1%) (P = .0009), male gender (90% vs 43%) (P = .008), extra-adrenal location (40% vs 9%) (P = .03), tumor weight (481 g vs 124 g) (P = .05), and young age (38 years vs 49 years) (P = .05). None of the five cases with NF were malignant (P = .04). S-100 positivity showed a significant (P = .02) but nonlinear association with benign tumors. Absent S-100 correlated with greater tumor weight. Malignancy was not associated with right versus left side or bilaterality, although bilateral tumors were smaller. C-met, bFGF, cathepsin B, cathepsin D, and collagenase were strongly expressed in most tumors and were not predictive of outcome, nor was bcl-2, which was variably expressed. Using multiple logistic regression with malignancy as the dependent variable, MIB-1 continued to show a significant association with malignancy (P = .005) independent of any association with sex, age, or extra-adrenal location. Using a cutoff value of MIB-1 labeling of greater than 3% yielded a specificity of 100% and a sensitivity of 50% in predicting malignancy.

Objectives: To assess the effect of cardiopulmonary bypass on allograft function and recipient survival in double-lung transplantation., Methods: Retrospective review of 94 double-lung transplantations., Results: Cardiopulmonary bypass was used in 37 patients (CPB); 57 transplantations were accomplished without bypass (no-CPB). Bypass was routinely used for patients with pulmonary hypertension (n = 27) and for two recipients undergoing en bloc transplantation. Cardiopulmonary bypass was required in eight (12.3%) of the remaining 65 patients. Mean ischemic time was longer in the CPB group (346 vs 315 minutes, p = 0.04). The CPB group required more perioperative blood (11.4 vs 6.0 units, p = 0.01). Allograft function, assessed by the arterial/alveolar oxygen tension ratio, was better in the no-CPB group at 12 and 24 hours after operation (0.54 vs 0.39 at 12 hours, p = 0.002; and 0.63 vs 0.38 at 24 hours, p = 0.001). The CPB group had more severe pulmonary infiltrates at both 1 and 24 hours (p = 0.005). Diffuse alveolar damage was more common in the CPB group (69% vs 35%, p = 0.002). Median duration of intubation was longer in the CPB group (10 days) than in the no-CPB group (2 days, p = 0.002). The 30-day mortality rate (13.5% vs 7.0% in the CPB and no-CPB groups) and 1-year survival (65% vs 67%, CPB and no-CPB) were not significantly different., Conclusions: In the absence of pulmonary hypertension, cardiopulmonary bypass is only occasionally necessary in double-lung transplantation. Bypass is associated with substantial early allograft dysfunction after transplantation.

Objective: The oral health of an adult population previously diagnosed with juvenile onset insulin dependent-diabetes was comprehensively assessed. The goal of this exploratory cross-sectional evaluation was to described the characteristics related to partial tooth loss edentulism in subjects with Type 1 diabetes mellitus., Methods: An adult population of 406 Type 1 diabetes mellitus subjects, who had been monitored for 6-8 years as part of a University of Pittsburgh longitudinal study of medical complications associated with diabetes, received an oral health examination for missing teeth, edentulism, coronal and root caries, periodontal status, and oral health behaviors., Results: Of the 406 subjects evaluated, 204 had no missing teeth, 186 had partial tooth loss (1-27 missing teeth), and 16 were edentulous. Patients who had partial tooth loss or who were edentulous were generally older; had lower incomes and levels of education; and had higher rates of nephropathy, neuropathy, retinopathy, and peripheral vascular disease. A logistic regression model found partial tooth loss to be significantly associated with extensive periodontal disease in remaining teeth (OR = 7.35), a duration of diabetes longer than 24 years (OR = 5.32), not using dental floss (OR = 2.37), diabetic neuropathy (OR = 2.29), household income less than $20,000 (OR = 2.21), multiple coronal caries and fillings (OR = 1.98), and bleeding on probing (OR = 1.82)., Conclusions: Although the majority of these adult Type 1 diabetes patients had serious medical complications associated with their diabetes, the possible impact of diabetes mellitus on oral health should be included in their overall management.

The purpose of this study was to compare the reliability and validity of three occlusal indexes of orthodontic treatment need in predicting the opinion of treatment need of a panel of 18 orthodontists. A set of 160 study casts representing all types of malocclusion was used. The casts were scored with the following occlusal indexes: the Index of Orthodontic Treatment Need (IOTN), the Handicapping Labio-Lingual Deviations index (HLD), and the Handicapping Malocclusion Assessment Record (HMAR modified). The diagnostic accuracy or validity of each index was calculated using the mean opinion of the orthodontic raters as a "gold standard". Receiver Operating Characteristic curves were plotted for each index. The overall diagnostic accuracy, as determined by percent area under the curve, was similar for each index: IOTN 98.6%; HLD 96.1%; HMAR 96.6%. The score optimizing the sensitivity and specificity relationship for each index was as follows: IOTN (dental health component) 4; HLD 13; HMAR 12. These results indicate that the three occlusal indexes provided valuable information for determining orthodontic treatment need.

Endocrine tumors of the pancreas are slow-growing lesions, yet one-third to one-half will metastasize. It is generally accepted that histopathologic features do not reliably predict metastatic potential or outcome. We investigated whether proliferative activity, as determined by MIB-l labeling, correlated with tumor type, metastasis, or patient survival. Formalin-fixed sections of pancreatic endocrine tumors were immunohistochemically stained for the MIB-l antibody against Ki-67 using the avidin-biotin complex technique. Labeling index (LI) was determined by counting 1000 consecutive tumor cells in an area of greatest staining intensity at x400 and expressed as a percentage. The study group included 37 patients, including 10 gastrinomas, 9 insulinomas, 4 glucagonomas, 2 VlPomas, and 12 nonfunctioning tumors. Twenty-one patients had metastases, primarily to regional lymph nodes and the liver. Five patients had MEN I. MIB-1 LI was significantly greater in the nonfunctioning tumors (mean 20S%) than in the functioning tumors (mean 51%) (p = 0.01). LI for functional tumors (insulinomas 64%, glucagonoma 44%, gastrinomas 32%, VlPomas 32%) were similar to each other, MIB-1 was significantly higher in those tumors that metastasized (mean 15.6%) compared to those that did not (mean 31%), (p = 0.04). All tumors with MIB-1 LI >10% developed metastases. Logistic regression showed that MIB-1 was a significant predictor of metastases (p = 0.003) after adjusting for functional status. MIB-1 LI also correlated with outcome in that those patients with MIB-1 LI >/=10% had a mean survival of 19 mo compared to 72 mo for those with levels <10% (p = 0.0001). Results of the proportional hazards model showed that MIR-1 remained a significant (p = 0.03) and independent predictor of survival times after adjustment for tumor size and functional status. Higher MIB-1 LI values were significantly associated with shorter survival times. In conclusion, MIB-1 LI appears to be a useful indicator of metastatic potential and is predictive of outcome in PET.

Background: We have developed a safe, simple, and easily performed standardized exercise oximetry outpatient test to assess patients undergoing lung resections. We studied its ability to predict outcome after pneumonectomy in 46 consecutive patients over a 5-year period., Methods: Room air oximetry is initially performed at rest. The patient then begins to exercise on a stair-stepper apparatus (Stamina Stepper), which provides uniform resistance to stepping. Oxygen saturation values are noted at 10, 20, and 30 steps, equivalent to climbing three flights of stairs. Group 1 consisted of the patients who either had a resting saturation less than 90%, or desaturation greater than or equal to 4% during exercise. Group 2 consisted of all patients who had a preoperative forced expiratory volume in 1 second of 60% or less. Group 3 consisted of all patients who had a predicted postoperative forced expiratory volume in 1 second of 40% or less. Group 4 consisted of patients who had a predicted postoperative diffusing capacity of 40% or less., Results: There were four deaths (8.6%), 12 patients (26%) remained in the intensive care unit 4 or more days, and 11 patients (23%) suffered major morbidity. Desaturation during exercise (group 1) significantly predicted longer intensive care unit stay (p = 0.0002) and incidence of major morbidity (p < 0.0001). Groups 2, 3, and 4 were not significantly predictive of either longer intensive care unit stay or major morbidity., Conclusions: Standardized exercise oximetry performed in the outpatient facility is highly predictive of major morbidity and prolonged intensive care unit stay after pneumonectomy.

Mutations in the K-ras gene are often identified in lung tumors and are implicated in the development of lung cancer. We used a sensitive method to analyze low-fraction mutations occurring in codon 12 of the K-ras gene in 114 primary lung tumors, including 77 adenocarcinomas, 31 squamous cell carcinomas and 6 adenosquamous carcinomas, which had previously been shown to be negative for codon 12 K-ras mutation in a first screening using less sensitive methods. Sixteen of these tumors were found to contain a low-fraction mutation, including 9 mutations among the adenocarcinomas, six mutations among the squamous cell carcinomas and one mutation among the adenosquamous carcinomas. Our study also showed that the occurrence of low-fraction mutation was associated with a positive smoking history, as was previously found for the occurrence of high-fraction mutation. Patients with low-fraction mutations were younger (mean age 58.8 years) than those with either high-fraction mutations (63.2 years) or no mutation (66 years). Patients with low-fraction mutations were more often stage 1 (8 of 10) than patients with either high fraction mutations (22 of 44) or no mutation (33 of 71). Moreover, the overall survival was better for the group with a low-fraction mutation than both the high-fraction mutation group and the group with no K-ras mutation, but due to small sample size, the difference was not statistically significant. Our results suggest that using highly sensitive methods of K-ras mutant detection in tumor DNA could obscure differences between patients in whom the mutation is found throughout the tumor, those in whom the mutation is only present in a small subpopulation and those who have no mutation.

Background: The role of nonanatomic wedge resection in the management of stage I (T1 N0 M0) non-small-cell lung cancer continues to be debated against the present gold standard of care--anatomic lobectomy., Methods: We analyzed the results of 219 consecutive patients with pathologic stage I (T1 N0 M0) non-small-cell lung cancer who underwent open wedge resection (n = 42), video-assisted wedge resection (n = 60), and lobectomy (n = 117) to assess morbidity, recurrence, and survival differences between these approaches., Results: There were no differences among the three groups with regard to histologic tumor type. Analysis demonstrated the wedge resection groups to be significantly older and to have reduced pulmonary function despite a higher incidence of treatment for chronic obstructive pulmonary disease when compared with patients having lobectomy. The mean hospital stay was significantly less in the wedge resection groups. There were no operative deaths among patients having wedge resection; however, a 3% operative mortality occurred among patients having lobectomy (p = 0.20). Kaplan-Meier survival curves were nearly identical at 1 year (open wedge resection, 94%; video-assisted wedge resection, 95%; lobectomy, 91%). At 5 years survival was 58% for patients having open wedge resection, 65% for those having video-assisted wedge resection, and 70% for those having lobectomy. Log rank testing demonstrated significant differences between the survival curves during the 5-year period of study (p = 0.02). This difference was a result of a significantly greater non-cancer-related death rate by 5 years among patients having wedge resection (38% vs 18% for those having lobectomy; p = 0.014)., Conclusion: Wedge resection, done by open thoracotomy or video-assisted techniques, appears to be a viable "compromise" surgical treatment of stage I (T1 N0 M0) non-small-cell lung cancer for patients with cardiopulmonary physiologic impairment. Because of the increased risk for local recurrence, anatomic lobectomy remains the surgical treatment of choice for patients with stage I non-small-cell lung cancer who have adequate physiologic reserve.

Background: Panel-reactive antibody (PRA) is commonly used before thoracic organ transplantation to estimate a potential recipient's degree of humoral sensitization., Methods: To assess the influence of an elevated PRA on survival and the incidence of rejection in pulmonary transplantation, the records of 247 patients that underwent single or double lung transplantation were reviewed., Results: Twenty-one of 247 patients (8.5%) had PRA values greater than 10%. Survival of this population was not significantly different from that of patients with low PRA levels: 74% (low PRA) vs 65% (elevated PRA) at 1 year and 58% in both groups at 3 years. The acute rejection rates (episodes/first 100 days) for the elevated and low PRA groups were 2.1 and 1.9, respectively (p = NS). Obliterative bronchiolitis developed in 38.9% of the high and 31.2% of the low PRA groups (p = NS). Six of 247 patients had a retrospective positive lymphocytotoxic cross-match result; three had PRA values greater than 10%. Patients with a positive cross-match result experienced similar survival and incidence of rejection as the remainder of the population. Among 957 patients evaluated for lung transplantation, 16 (1.7%) had a PRA (with dithiothreitol) greater than 15%. All had a history of pregnancy, blood transfusion, connective tissue disease, or previous transplantation., Conclusions: Humoral sensitization is uncommon in the lung transplantation population. A modestly elevated PRA does not predict survival or the development of acute rejection or bronchiolitis obliterans. PRA testing before lung transplantation should be reserved for those patients with specific risk factors for humoral sensitization.

We have shown previously that hepatocyte growth factor (HGF), which is produced by lung fibroblasts, is a potent mitogen and motogen for both normal and neoplastic bronchial epithelium, and that expression of the HGF receptor, the c-met proto-oncogene protein, is uniformly found in the human bronchial epithelium and in non-small cell lung carcinomas (NSCLCs; P. Singh-Kaw et al., Am. J. Physiol., 268: L1012-L1020, 1995). Yamashita et al. have reported an association of HGF with poor survival in invasive ductal carcinoma of the breast (Cancer Res., 54: 1630-1633, 1994). There are few prognostic markers for lung cancer, and the high recurrence rate for stage I lung cancer suggests the frequent presence of undetectable tumor burden in such patients. Criteria are needed to evaluate these patients for risk of recurrence. We have now evaluated whether HGF present in resectable lung tumors has prognostic significance. In this study, 56 primary NSCLCs, mainly adenocarcinomas, were examined for presence of HGF by quantitative Western blot. These tumors consisted of tissue from 34 stage I patients, 9 stage II patients, and 13 stage IIIa patients who underwent curative resection for primary NSCLC. Extracts of whole tumor tissue were analyzed after separation of proteins by electrophoresis and transfer of proteins to nitrocellulose membranes. Immunoreactive (ir)-HGF was visualized by reaction with a polyclonal anti-HGF antiserum and quantitated by densitometry. Lung tumor content of ir-HGF varied widely among individuals. Median ir-HGF content in tumor extracts was 15.3 ng/40 microg of tumor protein; mean ir-HGF was 27.2 ng/40 microg of tumor protein. The median and mean ir-HGF were both significantly higher in tumor tissue from patients who suffered a recurrence during the follow-up period compared with those with no evidence or residual disease; this was true of all patients (P = 0.0001) and stage I patients analyzed separately (P = 0.002). Analysis of survival curves indicated that ir-HGF levels higher than the median were associated with poor overall survival (P < 0.03). Univariate analysis showed three factors related to poor overall survival in this set of patients: ir-HGF, tumor (T) status (a measure of primary tumor size and extent), and age. Nodal (N) status and stage were only marginally related to overall survival, most likely because the majority of the patients in the study were stage I. N status, stage, and T status were related to disease-free survival, however. Multivariate Cox analysis showed that ir-HGF, T status, and age independently had a negative impact on overall survival. ir-HGF was a strong independent negative prognostic indicator (P = 0.0001) with a relative risk of 1.022 per unit of ir-HGF (ng/40 microg of protein). This demonstrates that, in this group of patients, the relative risk of ir-HGF content increased continuously as ir-HGF increased, and exceeded 10 at units of ir-HGF of 100 or more. In comparison, in this group of patients, the relative risk of a T status greater than 1 was 4.75 and that of age greater than 65 was 3.95. The combined negative effect of a T status greater than 1 and elevated ir-HGF on survival was also highly pronounced (P < 0.005). In addition, elevated ir-HGF had a negative impact on survival when patients were stratified by stage or N status. Stage I patients with high ir-HGF values had a worse outcome than stage II or stage IIIa patients with low ir-HGF values. Elevated ir-HGF was strongly associated with poor outcome for resectable NSCLC patients as a group, and also identified stage I patients with poor outcome, indicating that it could be a useful indicator of risk of relapse and death in patients who have early lung cancer. The impact of elevated ir-HGF was especially prominent in patients whose T status was greater than 1, suggesting that patients with both risk factors who are stag

Introduction: Opinions differ regarding differences between totally muscle-sparing thoracotomy and standard lateral thoracotomy approaches to pulmonary resection with respect to operative time, postoperative pain and morbidity, and occurrence of chronic postthoracotomy pain syndromes and subjective shoulder dysfunction., Methods: Three hundred thirty-five consecutive patients undergoing muscle-sparing thoracotomy (n = 148) or lateral thoracotomy (n = 187) to accomplish lobectomy for stage I lung cancer during a 40-month period were evaluated. Local rib resection was not employed, and two chest tubes were routinely used after operation in both thoracotomy groups. Epidural analgesia use was similar after operation in the two groups (muscle-sparing thoracotomy 38%, lateral thoracotomy 38%). The postoperative hospital courses and patient functional statuses at 1 year were examined., Results: Demographic analyses demonstrated no differences between groups in age, sex, or association of significant comorbid medical illness. Although the operative time required for muscle-sparing thoracotomy was shorter, there were no differences between thoracotomy approaches in any of the other primary acute postoperative variables analyzed (chest tube duration, length of hospital stay, postoperative narcotic requirements, and postoperative mortality). The frequencies of chronic pain and shoulder dysfunction assessed 1 year after operation were also similar between thoracotomy groups., Conclusions: The relative efficacies and rates of occurrence of acute or chronic morbidity are equivalent after muscle-sparing thoracotomy and standard lateral thoracotomy. Although muscle-sparing thoracotomy may possibly be performed more expediently, it appears that the singular advantage of muscle-sparing thoracotomy over standard lateral thoracotomy involves the preservation of chest wall musculature in case rotational muscle flaps should be needed later.

Immunohistochemical expression of p53, bcl-2, CD44 standard (CD44S), and the v6 isoform of CD44 (CD44v6) proteins were studied in 14 typical carcinoid tumors (TCs), 11 atypical carcinoids (ACs), and eight small cell carcinomas (SCLCs) in an attempt to use these markers of mutational events and cellular adhesion to discriminate neoplasms demonstrating neuroendocrine differentiation. p53 and bcl-2 overexpression were associated with more aggressive neuroendocrine cell types. p53 nuclear staining was weakly positive in 21% of the TCs, whereas strong nuclear staining was seen in 64% of the ACs and 88% of the SCLCs (P = 0.0047). bcl-2 was present in 21% of the TCs, 91% of the ACs, and 100% of the SCLCs (P = 0.0001). In contrast, CD44S and CD44v6 were inversely correlated with more aggressive types of neuroendocrine tumors. CD44S expression was moderate to strong in all of the TCs and 91% of the ACs but in only 37% of the SCLCs (P = 0.0018). There was no correlation between expression of these markers and tumor size or nodal status, although loss of CD44v6 was associated with lymph node metastases in the TC group only. In the spectrum of neuroendocrine tumors of the lung, p53 and bcl-2 overexpression correlates with more aggressive histologic cell types. The decreasing CD44S expression in AC and SCLC is similar to findings in cancer of the colon and in non-small cell carcinoma of the lung, where loss of CD44S is associated with poor prognosis. In AC and SCLC, but not in cancer of the colon, loss of CD44v6 correlates with more aggressive neoplasms and might correlate with lymph node metastases in TCs.

The K-ras mutation is one of the most common genetic alterations found in human lung cancer. To evaluate the prognostic value of ras gene alterations in lung cancer in a U.S. population, we have screened 173 human lung tumors, which included 127 adenocarcinomas, 37 squamous carcinomas, and 9 adenosquamous carcinomas, for mutations in the K-ras gene using the combination of the PCR and denaturing gradient gel electrophoresis. Forty-three tumors contained K-ras mutations. Of these, 41 were identified among the adenocarcinomas (32%), 1 among the squamous carcinomas (2.7%), and 1 among the adenosquamous carcinomas (11%). Forty of these mutations were found in codon 12 and consisted of 24 G to T transversions, 12 G to A transitions, 2 G to C transversions, and 1 double GG to TT mutation. Two other G to T transversions were found in codon 13, and 1 A to C transversion was found in codon 61. The data showed that gender did not seem to affect the incidence and the types of the K-ras mutations or amino acid changes. Examination of the mutations in adenocarcinomas in relation to overall survival showed no difference in adenocarcinomas with K-ras mutations compared with K-ras-negative adenocarcinomas. However, the substitution of the wild-type GGT (glycine) at codon 12 with a GTT (valine) or a CGT (arginine) showed a strong trend (P = 0.07) toward a poorer prognosis compared with wild-type or other amino acid substitutions. Substitution of the wild-type glycine for aspartate (GAT) showed a strong trend (P = 0.06) for a better outcome than the valine or arginine substitution. Although these trends will require larger patient populations for verification, these data suggest that the prognostic significance of K-ras mutations may depend on the amino acid substitution in the p21(ras) protein.

The etiologic relevance of craniofacial structure to obstructive sleep apnea syndrome (OSAS) is controversial yet the premise of a causal association serves to justify many treatments. A qualitative and quantitative analysis of the literature was performed to examine the foundation for any relationship between craniofacial structure and OSAS. A MEDLINE search and investigation of the published and unpublished literature on diagnostic imaging and OSAS was toxonomically arranged. Each sample study was evaluated by using the following criteria: (a) appropriate control group, (b) "blinding" of evaluators, (c) reliability measured, (d) random assignment of treatment, and (e) "success" was defined adequately in efficacy studies. Morphologic variables were combined among studies and compared with controls drawn from either the same patient pool as the OSAS group, or matched for gender, age, and body mass index. Analysis revealed 32 review articles, 16 case reports, and 95 sample studies. Only seven sample studies drew a control group from the same patient pool, whereas five used matched controls. Only one of these studies satisfied all the qualitative criteria. Of the treatment efficacy studies, 10 defined outcome adequately. However, none of these met all the qualitative criteria. The most consistent, strong effect sizes with the highest potential diagnostic accuracies were for mandibular plane to hyoid, mandibular plane angle, and mandibular body length. Only mandibular body length demonstrated a clinically significant association with and diagnostic accuracy for OSAS. However, since this variable's controls were selected from the literature, possible explanations for a positive association include methodologic differences between studies, varying magnification factors, and morphologic differences.

Health services research (HSR) in the Department of Veterans Affairs (VA) is one way in which to study the oral health care delivered to aging veterans and to ensure the most effective and efficient methods of meeting their oral health needs. This article details the current resources and infrastructure within VA dentistry that could be used to support a dental HSR agenda, followed by recommendations for improvements. The Department of Veterans Affairs' current situation regarding dental HSR is as follows: Dental health services research within VA needs expansion. Staff dentists have neither the training nor the incentives to conduct dental HSR. Dental clinic administrators are discouraged from being supportive of research due to the high clinical work-load requirements present at most dental services. Dental service affiliations with universities are not structured to support HSR. The HSR personnel outside of the dental services do not have the time nor the inclination to engage in dental HSR. Few recruitment and training initiatives are used to increase the number of VA dental health services researchers. Although funding sources exist that could be used to support dental HSR, the lack of trained and interested research personnel prevents full use. The Department of Veterans Affairs data collection in dentistry are inadequate to support dental HSR. If the required changes occur, VA is uniquely situated to be the largest contributor to dental HSR in the United States and to act as a catalyst for improving dental HSR throughout the nation. Recommendations for improvement of VA dental HSR are as follows: Restructure the Dental Activity System to include detailed diagnostic and treatment data as part of an integrated computerized patient record. Develop and implement a strategic plan with a detailed timeline for increasing dental HSR in VA. Recruit staff dentists with formal research training and provide them protected research time and resources to conduct meaningful research. Develop academic affiliations with centers of excellence in dental HSR. Develop full-time equivalent employee positions dedicated to research at the proposed Veterans Service Areas level. Develop incentives to increase collaboration with non-VA health services researchers in addressing VA issues. Develop dental HSR training programs modeled after the Career Development Program, Dental-Geriatric Fellowship, and Dentist-Scientist Programs that will permit VA to become a leader in dental HSR training. Develop mechanisms to ensure adequate and sustained funding for dental HSR projects. Ensure that dissemination techniques are effective and result in improvements in operational effectiveness and quality of care.

Background: A prospective clinical trial was undertaken to compare the efficacy of tacrolimus (FK 506) versus cyclosporine as the primary immunosuppressive agent after lung transplantation., Methods: Between October 1991 and May 1994, 133 single-lung and bilateral-lung recipients were randomized to receive either cyclosporine (n = 67) or tacrolimus (n = 66). The two groups were similar in age, sex, and underlying disease., Results: One-year and 2-year survival rates were similar in the two groups, although the trend was toward increased survival with tacrolimus. Acute rejection episodes per 100 patient-days were fewer (p = 0.07) in the tacrolimus group (0.85) than in the cyclosporine group (1.09). Obliterative bronchiolitis developed in significantly fewer patients in the tacrolimus group (21.7%) compared with the cyclosporine group (38%) (p = 0.025), and there was greater freedom from obliterative bronchiolitis over time for patients receiving tacrolimus (p < 0.03). Significantly more cyclosporine-treated patients (n = 13) required crossover to tacrolimus than tacrolimus-treated patients to cyclosporine (n = 2) (p = 0.02). The switch to tacrolimus controlled persistent acute rejection in 6 of 9 patients. The overall incidence of infections was similar in the two groups, although bacterial infections were more common with cyclosporine (p = 0.0375), whereas the risk of fungal infection was higher with tacrolimus (p < 0.05)., Conclusions: This trial demonstrates the advantage of tacrolimus in reducing the risk of obliterative bronchiolitis, the most important cause of long-term morbidity and mortality after lung transplantation.

The authors studied the attitudes of 1,000 U.S. dentists toward the treatment of HIV-positive patients. Using a random-sample mail survey, they measured dentists' professional attitudes toward treating HIV/AIDS patients, fear of contagion and negative emotions toward HIV-positive patients. The results indicate that 68 percent of the respondents would treat an HIV-positive patient, even if the possibility for a legitimate referral exists.

A random sample of U.S. dentists was surveyed with a mailed questionnaire to determine the number of splints that they fabricated over the preceding year for bruxers, patients with myofascial pain-dysfunction syndrome and patients with TM joint pain. The results indicate that a significant number of dentists treat these disorders with dental splints. Estimates are provided for the dental profession's yearly splint output for each disorder.

The Peer Assessment Rating (PAR) index is a British occlusal index that measures the severity of dental malocclusion and has been used in several investigations that have evaluated the effectiveness of orthodontic treatment provision in Europe. As part of its development, the PAR index was validated for malocclusion severity, by using the opinions of a panel of 74 dentists and orthodontists. The present investigation was carried out to validate the PAR index, by using the opinion of an American panel of orthodontists. Eleven orthodontists examined a sample of 200 sets of study casts and rated them for malocclusion severity and perceived treatment difficulty. Multiple regression techniques were used to evaluate the predictive power of the components of malocclusion on the panel's scores. Weightings were calculated from the partial regression coefficients and, when these weightings were applied to the PAR index, the association between the panel's opinion and the PAR index scores was increased.

Numerous indices have been proposed to help the clinician decide how much maxillary expansion will be required to alleviate crowding. The purpose of this investigation was to examine the validity of Pont's index, Schwarz's analysis and McNamara's rule of thumb. Records of 40 patients (20 females and 20 males) were selected from 155 consecutive pretreatment records. The discrepancy between actual intermolar/interpremolar widths and the index-generated widths were correlated against measures of crowding, and linear regressions were computed. Statistical analysis revealed that (1) males had more significant correlations between arch width and crowing than females, (2) interpremolar widths were more strongly correlated than intermolar widths, (3) Pont's index and McNamara's rule of thumb overestimated required arch width by 2.5 mm to 4.7 mm and 2.7 mm to 3.7 mm respectively, and (4) Schwarz's analysis overestimated interpremolar width by 2.5 mm to 4.3 mm but was reasonably accurate for intermolar width in males. The results suggest that these indices potentially overestimate the arch expansion required to alleviate crowding.

Objectives: This study assessed knowledge, attitudes, and behaviors related to the treatment of HIV-infected patients by Department of Veterans Affairs (VA) dental personnel., Methods: A questionnaire was mailed to all VA dentists, hygienists, and EFDA assistants and completed anonymously in May 1991. Descriptive results are reported along with comparisons between the findings from this study and a similar VA survey conducted in 1988, as well as several national surveys of non-VA dentists., Results: Nearly all VA respondents reported participation in some type of continuing education on HIV and infection control. They also reported high compliance with recommended infection control procedures. Furthermore, the findings suggest that VA dentists and hygienists have a high willingness to treat HIV-infected patients, far exceeding that expressed by non-VA dentists. However, a high level of anxiety related to occupational exposure to HIV seems to exist. Most respondents perceived a higher risk of HIV infection from commonly encountered occurrences in the workplace than actually exists based on current knowledge., Conclusions: While efforts to further reduce the risk of infection and improve care should continue, future efforts also should be directed toward reducing the anxiety of VA dental personnel in the treatment of infectious patients.

This study investigated the association of patient and provider characteristics on dental implant performance and survival probabilities. The outcomes of interest in this study were implant failures and peri-implant tissue health status. Univariate and bivariate statistics were used to describe the study population and to assess association of outcomes with patient and facility characteristics. Data were gathered from the period 1985 through January 1, 1990, from the Department of Veterans Affairs Dental Implant Registry. Logistic regression models were used to relate the outcomes with independent variables. Results showed that implant survival is associated with (1) the medical status of the patient, (2) the surface coating material of the implant, and (3) implant surgical and healing complications. Peri-implant soft tissue health was associated with (1) patient's use of tobacco, (2) surface coating of implants, and (3) implant provider's experience.

Objectives: To determine attitudinal predictors of health-care providers' willingness to treat HIV-infected patients. We also tested the hypothesis that differences between dental and medical students in their expressed desire to treat HIV-infected patients result from differences in their clinical exposure to bloodborne pathogens and their clinical training., Design: A cross-sectional design was used to administer a self-report questionnaire format to preserve subject anonymity., Methods: A questionnaire was used to assess attitudes, knowledge, and behavior associated with the care of HIV-infected patients. Both bivariate statistics and logistic regression techniques were used to determine factors related to the desire to treat HIV-infected patients., Results: Compared with dental students, medical students expressed a greater desire to treat HIV-infected patients. However, the attitudinal predictors of a desire to treat were similar across both groups. The two most important predictors were the degree to which respondents perceived a personal risk of HIV exposure and their sense of professional obligation to treat all patients. Furthermore, knowledge levels were unrelated to desire to treat., Conclusions: These results suggest that educational interventions aimed simply at increasing a provider's knowledge of HIV may not be effective in changing behavior.

The Department of Veterans Affairs (VA) operates the largest, integrated health care system in the United States of America. The projected need for long-term-care in the VA health care system parallels an expected increase in need for care in the United States, but precedes the need for care in the general population by 25-30 yr. The VA's Office of Dentistry, in an effort to estimate the resource requirements of this swelling group of veterans, initiated in 1986-7 an oral health survey of long-term care patients. The overall goals were to describe the oral health status of VA nursing home care units (NHCU) residents and to develop a methodology for estimating future dental health services utilization. This study describes the oral health status of the study population. Demographic and oral health data were collected for 650 long-term care residents of six VA NHCUs between October 1986 and July 1987. Data were collected on sociodemographic status, medical history, dental caries, periodontal diseases, oral soft tissue pathology, and the presence of dental prostheses. Caries and periodontal disease were evaluated using the United States National Institute of Dental Research Survey of Employed Adults and Seniors protocols. The oral health status of the population is described using DMF and ESI indices, the prevalence of oral lesions, levels of tooth loss, oral hygiene scores, and the status of existing dentures. Findings show moderate levels of untreated dental caries and periodontal disease and significant tooth loss which increased with age. A need for preventive therapy, restorative dentistry, conservative periodontal therapy, and prosthodontic care was evident.(ABSTRACT TRUNCATED AT 250 WORDS)

Purpose: To examine how medical students' attitudes and intentions toward the treatment of persons infected with human immunodeficiency virus (HIV) changed as the students progressed through medical school., Method: Similar 44-item self-administered questionnaires, to be completed anonymously, were given to 394 medical students at the University of Michigan Medical School in February 1989, when the students were in their first or second years, and to 378 of the same students in February 1991, when they were in their third or fourth years. Seven subscale variables were created, and their effects on students' willingness to treat HIV-infected patients were assessed. Bivariate statistics and logistic regression were used to relate the dependent and independent variables., Results: In 1989, 201 (51%) of the students responded; in 1991, 208 (55%) responded. The students showed a high--but declining--degree of willingness to care for patients infected with HIV or at high risk of infection. Homophobic attitudes decreased, but so did the students' intentions to follow infection-control guidelines. The students who expressed a career interest in surgery specialties indicated less willingness to provide care for HIV-infected patients, presumably because these students felt that they would be at a higher risk of exposure., Conclusion: Overall, the students' responses indicated that over the two years of the study they became more restrictive in their attitudes toward HIV-positive patients, felt less personal obligation toward caring for these patients, and were less likely to use appropriate infection-control methods to ensure their own safety.

This investigation evaluates the influence of several process variables upon the number of attendances required to complete orthodontic treatment provided by the hospital service of England and Wales. The hospital records and study casts of 1630 patients were collected from 17 District General Hospital Departments. The study casts were analysed with the Peer Assessment Rating. The following information was collected from the hospital records; the patients' sex, the number of attendances required to complete treatment, the type of treatment provided and the operator. The data were analysed with multiple regression techniques. It appeared that the number of attendances was influenced by the pretreatment malocclusion severity, the type of treatment, the experience of the operator and the department from which the treatment was delivered.

This double-blind, controlled clinical trial assessed the anxiety relief provided by oral triazolam given before intravenous sedation. Twenty-two healthy adults undergoing third-molar surgery with intravenous sedation were enrolled in this study. Subjects were randomly assigned to receive either 0.25 mg of triazolam p.o. or an identically appearing placebo 45 to 60 min before venipuncture. Immediately before test drug administration, subjects completed the Corah Anxiety Scale, a Visual Analog Scale (VAS) assessing state anxiety, and the Interval Scale of Anxiety Response (ISAR). The VAS and ISAR were repeated immediately before venipuncture. Intravenous sedation medications consisted of fentanyl, midazolam, and methohexital. At 24 hr, assessments of the venipuncture and global experience were obtained. Results indicated that the characteristics of the triazolam and placebo patients were similar at baseline. With triazolam pretreatment, both the VAS and ISAR scores decreased significantly. Dose requirements for conscious sedation medications were decreased in the triazolam group. Patients rated the venipuncture experience significantly less unpleasant when pretreated with triazolam, and global ratings of the overall surgical experience favored triazolam. An oral-intravenous combination sedation technique using 0.25 mg of triazolam may have a significant therapeutic advantage for outpatient oral surgery.

This study examined endosseous cylinder implant survival, defined as the unqualified presence of the implant in the mouth at the end of the observation period, in 598 consecutive VA patients, with a total of 2098 implants. Data were taken from the Department of Veterans Affairs (VA) Dental Implant Registry, which has maintained longitudinal data on the survival of individual dental implants in VA patients since 1987. The maximum time of observation in any one patient was 2040 days (5.6 yr). Survival analysis by use of life-table methods was carried out on both an implant- and a patient-specific basis. Implant cases were accrued randomly, and therefore a random censoring model was used. A correlated binomial model was used for assessment of the degree of within-patient clustering of implant removals. Results showed that the implant-specific survival rate during the longest time interval (5.6 yr) was 89.9%; the patient-specific implant survival rate during the same time was 78.2%. Among implants which were removed, the mean time to removal was 292 days. The hazard function, which describes the probability of implant loss as a function of time, decreased steadily throughout the observation period. The correlated binomial model suggested a clustering of removals within patients with multiple implants (rho = 0.11, p = 0.0001). The odds of having a second implant removed were 1.3 times greater if the patient had already had one implant removed. This study suggests that when implants fail, they do so soon after placement, and the likelihood of failure decreases steadily from implantation through the first five years post-surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of the paper is to relate standard epidemiologic and statistical methods for measures of disease occurrence to the description of prevalence proportions and incidence rates of dental diseases. No new concepts are introduced, but the choice of the unit of analysis of numerator and denominator is discussed, and the biological interpretation of the within-patient correlation coefficient is discussed.

The intention to treat HIV-infected persons and correlates of those intentions were examined in a cross-sectional sample of 1st- and 2nd-year medical students (n = 201). An anonymous questionnaire measured knowledge of HIV transmission, intention to provide medical care to HIV-infected persons, comfort in performing a physical examination on patients from subgroups with high HIV prevalence, level of homophobia, professional altruism, and personal perceived risk of HIV infection. Intention to provide medical care was considered as the dependent variable. All variables except perceived personal risk were found to be significantly related to the intention to provide medical care although knowledge showed the weakest relationship (Odds Ratio = 2.14). The presence of professional altruism and the presence of homophobia were associated with a significant increase in the effect of knowledge on increasing the intention to treat. Results of this report support other studies that showed that factors other than knowledge play a role in clinical decision making regarding patients with AIDS.

Dental personnel planning is important in formulating policy in dental education, dental public health programs, and dental care delivery systems. The purpose of this literature review is to illustrate the use of dentist-to-population ratios, need-based models, and demand-based models in the determination of appropriate supply of dental personnel. A historical perspective is provided that demonstrates how political manipulation and subjectivity have characterized the use of these models by organized dentistry, the federal government, and others. The lack of pertinent data and the inability to predict economic, social, political, and epidemiologic trends weaken the applicability of each model in determining future personnel levels. Considering the long-term consequences of the use of each model in personnel planning, caution is urged in using any of the presently available models.

Tooth loss in adults over age 35 usually is attributed to periodontal diseases. However, certain adult populations are known to have high caries rates. It is not clear to what extent caries contributes to tooth loss in adults. This pilot study examined the causes of tooth loss in a veteran population residing in an 800-bed, primarily long-term care facility. The study retrospectively reviewed 572 patients' dental records and documented causes for dental extractions. Of the sample population, 168 teeth were extracted in 51 patients who had 860 teeth present before treatment. Mean age of the patients undergoing extractions was 57.7 years, lower than the sample population of 60.1 years. Of the 168 teeth extracted, 105 (63%) were attributed to caries and 33 (20%) were documented as root tips, suggesting the presence of root caries. Fifty-five (33%) were extracted due to periodontal disease and six (4%) were extracted for prosthodontic reasons. Of the maxillary teeth, 67 percent were extracted for caries and 25 percent of periodontal reasons. Caries accounted for 57 percent and periodontal disease accounted for 42 percent of the mandibular teeth extracted. The order in which teeth were most frequently extracted was maxillary anteriors, mandibular anteriors, maxillary and mandibular premolars, and maxillary and mandibular molars. This study supports the recent work of authors who have found caries contributing significantly to tooth loss in adult populations.