The dental care of the psychiatric patient

The dental care of the psychiatric patient requies careful observatio and history taking. Medications used in the treatment of psychiatric illnesses demand care in treatment planning and prescibing. The nature and sequellae of many psychiatric conditions have a direct bearing on the clinical picture presented by the patient and the success of dental care. Implementation of care must have a significant component of flexibility in terms of treatment outcomes and the time and method of providing treatment. Particular emphasis must be placed uppon the establishment of effective oral hygiene programmes. The psychiatric patient suffers not only from a socially debilitating disease but also from society's opprobrium. With a modicum of effort, the dental profession can rise above that.     

Restorative dental care of the geriatric patient

Dental care of the elderly generally does not form a major area of study in the undergraduate curriculum, and seldom forms the main attraction at dental conferences. All too often treatment of the elderly is considered to be a backwater of prosthetic dentistry and little attention is paid to the restorative needs of this rapidly growing section of society. The aim of this paper is to identify the dental needs of an ageing population, and to focus the attention of the profession on these needs as well as to explore certain myths and prejudices associated with the treatment of patients in senescence.     

Perioperative treatment of the diabetic patient

The diabetic patient is frequently undergoing surgery for the underlying disease and its complications. Before referring the patient to surgery the diabetologist should carefully evaluate the presence of complications, cardiovascular, renal and neurologic disorders in particular. Generally no problems are posed by patients with NIDDM undergoing elective surgery. For more demanding patients and for those with IDDM the most effective and ready treatment is the continuous intravenous infusion of glucose, insulin and potassium. With this regimen, it is possible to perform major surgery in diabetics with a lower risk.     

Recent advances in the treatment of type II diabetes mellitus

Diabetes mellitus needs to be managed early to prevent the onset and progression of complications. Diet and exercise may not be sufficient to achieve and maintain good glycemic control. Currently, no pharmacologic agent addresses all of the fundamental abnormalities in the pathogenesis of type II diabetes mellitus. However, the newer agents do not exacerbate the hyperinsulinemia that often occurs with type II diabetes, and they may help reduce the risk of cardiovascular disease that is associated with high insulin levels. Two of these agents, metformin and acarbose, have recently become available in the United States for the treatment of type II diabetes. With the availability of agents that differ in their mechanisms of action and side effect profiles, regimens can be individualized to address the variety of pathophysiologic abnormalities in type II diabetes. For this purpose, agents can be used alone or in combination.     

Impact of a diabetes electronic management system on the care of patients seen in a subspecialty diabetes clinic

Journal clubs are a time-honored method of teaching literature appraisal skills in many residency programs. A questionnaire was completed by 57 hand surgery fellowship directors and 91 hand fellows to define the role of the journal club in hand fellowship training. We sought to identify definitive characteristics of hand surgery journal clubs and assess their strengths and weaknesses. One hundred forty-eight of 164 (90%) directors and fellows responded, yielding information on 57 of 58 accredited hand fellowships. Forty-nine of 57 (86%) responding fellowships have a journal club. The majority of clubs meet monthly for 1 to 2 hours, usually within the hospital. The primary purpose is to familiarize both fellows and attendings with the current literature. Most often, fellows choose the articles, which are most commonly original research and review articles. Usually, faculty presides, and residents and fellows present. Increased faculty participation was the most frequently suggested improvement. The great majority of those surveyed felt that their journal club was successful and was an important part of the fellowship training. We conclude that journal clubs have a high perceived value by participants, and recommend the journal club to all hand surgery communities, with or without fellowship involvement.     

Effect of intensive treatment on diabetic nephropathy in patients with type I diabetes

We evaluated the long-term effect of an intensive treatment of diabetic nephropathy (anti-hypertensive drugs, low protein diet, multiple insulin injections to achieve a good metabolic control) on glomerular filtration rate (GFR) and albumin excretion rate (AER). Fourteen type I diabetic patients (mean age 45 +/- 9.5 years, mean duration of diabetes 23.5 +/- 7.3 years, 8 males/6 females) with glomerular filtration rate < 70 ml/min-1/1.73 m2 and albumin excretion rate > 30 micrograms/min were treated intensively for 36 months. This intensive treatment consisted of multiple insulin injections, antihypertensive therapy with ACE inhibitors and a low-protein diet (0.8 g/kg body wt/day.) Renal function was evaluated as GFR and AER. HbA1c mean value decreased significantly from 8.7 +/- 0.8% to 6.5 +/- 0.5% (P < 0.0002). GFR rose from 58 +/- 12 ml/min-1/1.73 m2 to 84 +/- 11 ml/min-1/1.73 m2 (P < 0.0008). AER decreased from 208 micrograms/min (range: 73 to 500) to 63.8 micrograms/min (range 15 to 180; P < 0.05). Systolic and diastolic blood pressure decreased respectively from 144 +/- 26 mm Hg to 120 +/- 15 mm Hg and from 89 +/- 9 mm Hg to 75 +/- 8 mm Hg (P < 0.01). We obtained a rise of GFR and a reduction of proteinuria after three years of this treatment. We suggest that this intensive treatment in all patients with early stage diabetic nephropathy may be effective in slowing the progression to renal failure.     

Fitting the treatment to the patient: recent advances in the practice of electroconvulsive therapy

Traditionally it has been thought that a grand mal seizure is both necessary and sufficient for the maximum efficacy of ECT. Recent important research, however, has demonstrated that both the electrical dosage above the seizure threshold, i.e. the suprathreshold dosage, and the electrode placement (unilateral or bilateral) determine the efficacy of this treatment, as well as the degree of cognitive impairment. This article reviews the development of these significant concepts and suggests specific practical recommendations for incorporating these into contemporary ECT practice.     

Toe amputation in the diabetic patient

BACKGROUND: We considered whether it is more practical to amputate the toe of a diabetic patient with osteomyelitis and good circulation or to treat the patient with antibiotics for a prolonged period. METHODS: We undertook a retrospective study of 141 diabetic patients who had undergone a toe-ray amputation for proven or documented osteomyelitis. RESULTS: The mean ankle/brachial index of all patients was 0.81 (range, 0.68 to 1.14); the mean functional days lost on antibiotic therapy was 39 (range, 7 to 84 days). The cost of 6 to 8 weeks of preoperative antibiotic therapy was $900 to $2240 (mean, $1440). CONCLUSIONS: Diabetic patients with good circulation and osteomyelitis of the toe may benefit from prompt toe amputation.     

Chronic pain: primary care treatment of the older patient

The prevalence of chronic diseases associated with pain increases with age, and pain prevalence appears to increase with the level of functional dependence. Chronic pain in older patients is associated with sleep disorders, impaired physical and social function, and increased healthcare utilization. Symptoms of pain, anxiety, and depression are often associated and may intensify each other. Because a complete resolution of chronic pain is unlikely, it is important to establish early in therapy the level of pain that the patient would find acceptable. The goal of therapy is to treat chronic pain while minimizing side effects and optimizing the patient's functional status.     

Impact of lipid and ACE inhibitor therapy on cardiovascular disease and metabolic abnormalities in the diabetic and hypertensive patient

We examined the effect of 1,1-dichloroethylene (1,1-DCE) on microsomal cytochrome P450 (P450) enzymes in rat liver and kidney. Rats were treated intraperitoneally with 1,1-DCE daily for 4 days, at doses of 200, 400, and 800 mg/kg. Among the P450-dependent monooxygenase activities in liver microsomes, testosterone 2alpha-hydroxylase (T2AH), which is associated with CYP2C11 activity, was remarkably decreased by 800 mg/kg 1,1-DCE. The level relative to control activity was < 10%. Furthermore, immunoblotting showed that 1,1-DCE (> or = 400 mg/kg) significantly decreased CYP2C11/6 protein levels in liver microsomes. In addition, 7-methoxyresorufin O-demethylase (MROD), 7-ethoxycoumarin O-deethylase (ECOD), benzphetamine N-demethylase (BZND), chlorzoxazone 6-hydroxylase (CZ6H), and testosterone 6beta-hydroxylase (T6BH) activities were significantly decreased by the highest dose of 1,1-DCE (by 40-70%). However, the activities of other P450-dependent monooxygenases, namely 7-ethoxyresorufin O-deethylase (EROD), 7-benzyloxyresorufin O-debenzylase (BROD), aminopyrine N-demethylase (APND), erythromycin N-demethylase (EMND), lauric acid omega-hydroxylase (LAOH), and testosterone 7alpha-hydroxylase (T7AH) were not affected by 1,1-DCE at any dose. Immunoblotting showed CYP1A1/2, CYP2B1/2, CYP2E1, and CYP3A2/1 protein levels were significantly decreased by 60-66% by 1,1-DCE (800 mg/kg), whereas that of CYP4A1/2 was not affected by any dose of 1,1-DCE. By contrast, among the P450-dependent monooxygenase activities in kidney microsomes, only CZ6H activity was increased by 1,1-DCE (1.6-fold at 800 mg/kg). Also, it was observed that 1,1-DCE (800 mg/kg) significantly increased CYP2E1 protein levels by immunoblotting (approximately 1.5-fold). These results suggest that 1,1-DCE changes the constitutive P450 isoforms in the rat liver and kidney, and that these changes closely relate to the toxicity of 1,1-DCE.     

Cerebral blood flow in the diabetic patient

Asthma affects about 1 in 10 children. The condition is characterized by acute respiratory distress brought on by environmental factors. The condition is treated with medications aimed to reduce reaction to stimulants by the airway. Dental management involves attention to the status of the patient and awareness of stimulants of the reactive airway. Clinical recommendations are provided.     

Recent advances in the treatment of laryngitis

A 74-year-old woman was admitted to the hospital because of persistent nocturnal coughing and abnormal shadows on chest x-ray films. The films showed cavities in the right upper lobe and small nodular shadows in the right upper, lower, and left upper lung fields. Examination of a specimen obtained by transbronchial lung biopsy showed nonspecific inflammatory changes. An open-lung biopsy was done. Histopathological examination showed evidence of diffuse aspiration bronchiolitis and actinomyces. Actinomyces is a member of the endogenous flora of the oral mucous membranes. Our diagnosis was diffuse aspiration bronchiolitis caused by micro-aspiration of oro-pharyngeal secretions during sleep.     

Intensive care of the pregnant diabetic

Over the last 2 years at Metropolitan Hospital Medical Center 245 diabetic women have been seen on the obstetric service. This complication of pregnancy comprises 7.9 per cent of 3,076 deliveries, resulting in an over-all uncorrected perinatal mortality rate of 2.9 per cent. We believe that early detection and strict rigid control of diabetes is the key to improved perinatal outcome. This article presents the classification, diagnosis, and management which have led to these results.