Qun Xiang

Medications prescribed in emergency departments for nontraumatic dental condition visits in the United States.

Background:Prior research has documented factors associated with nontraumatic dental condition (NTDC) visits to emergency departments (EDs), but little is known about the care received by patients in EDs for NTDC visits. Objective:We examined national trends in prescription of analgesics and antibiotics in EDs for NTDC visits in the United States. Research Design:We analyzed data from the National Hospital Ambulatory Medical Care survey from 1997 to 2007. We used a multivariable logistic regression model to examine factors associated with receiving analgesics and antibiotics for NTDC visits in EDs. Results:Overall 74% received at least 1 analgesic, 56% received at least 1 antibiotic, and 13% received no medication at all during NTDC visits to EDs. The prescription of medications at EDs for NTDC visits steadily increased over time for analgesics (odds ratio=1.11/y, P<0.0001) and antibiotics (odds ratio=1.06/y, P<0.0001). In the multivariable analysis, self-pay patients had significantly higher adjusted odds of receiving antibiotics, whereas those with nondental reasons for visits and children (0–4 y) had significantly lower adjusted odds of receiving a prescription for antibiotics in EDs for NTDC visits. Children (0–4 y), adults (53–72 y), and older adults (73 y and older) had lower adjusted odds (P<0.001) of receiving analgesics. Conclusions:Nationally, analgesic and antibiotic prescriptions for NTDC visits to EDs have increased substantially over time. Self-pay patients had significantly higher odds of being prescribed antibiotics. Adults over 53 years and especially those 73 years and older had significantly lower odds of receiving analgesics in EDs for NTDC visits.

Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States.

Objective We examined trends and patient characteristics for non-traumatic dental condition (NTDC) visits to emergency departments (EDs), and compared them to other ED visit types, specifically non-dental ambulatory care sensitive conditions (non-dental ACSCs) and non-ambulatory care sensitive conditions (non-ACSCs) in the United States. Methods We analyzed data from the National Hospital Ambulatory Medical Care survey (NHAMCS) for 1997 to 2007. We performed descriptive statistics and used a multivariate multinomial logistic regression to examine the odds of one of the three visit types occurring at an ED. All analyses were adjusted for the survey design. Results NTDC visits accounted for 1.4% of all ED visits with a 4% annual rate of increase (from 1.0% in 1997 to 1.7% in 2007). Self-pay patients (32%) and Medicaid enrollees (27%) were over-represented among NTDC visits compared to non-dental ACSC and non-ACSC visits (P < 0.0001). Females consistently accounted for over 50% of all types of ED visits examined. Compared to whites, Hispanics had significantly lower odds of an NDTC visit versus other visit types (P < 0.0001). Blacks had significantly lower odds of making NDTC visits when compared to non-dental ACSC visits only (P < 0.0001). Compared to private insurance enrollees, Medicaid and self-pay patients had 2–3 times the odds of making NTDC visits compared to other visit types. Conclusion Nationally, NTDC visits to emergency departments increased over time. Medicaid and self-pay patients had significantly higher odds of making NDTC visits.

PTPH1 cooperates with vitamin D receptor to stimulate breast cancer growth through their mutual stabilization

Tyrosine phosphorylation is tightly regulated by protein tyrosine kinases (PTKs) and protein tyrosine phosphatases (PTPs), and has a critical role in malignant transformation and progression. Although PTKs have a well-established role in regulating breast cancer growth, contribution of PTPs remains mostly unknown. Here, we report that the tyrosine phosphatase PTPH1 stimulates breast cancer growth through regulating vitamin D receptor (VDR) expression. PTPH1 was shown to be overexpressed in 49% of primary breast cancer and levels of its protein expression positively correlate with the clinic metastasis, suggesting its oncogenic activity. Indeed, PTPH1 promotes breast cancer growth by a mechanism independent of its phosphatase activity, but dependent of its stimulatory effect on the nuclear receptor VDR protein expression and depletion of induced VDR abolishes the PTPH1 oncogenic activity. Additional analyses showed that PTPH1 binds VDR and increases its cytoplasmic accumulation, leading to their mutual stabilization and stable expression of a nuclear localization-deficient VDR abolishes the growth-inhibitory activity of the receptor independent of 1,25-dihydroxyvitamin D3. These results reveal a new paradigm in which a PTP may stimulate breast cancer growth through increasing cytoplasmic translocation of a nuclear receptor, leading to their mutual stabilization.

Prescription of opioid and nonopioid analgesics for dental care in emergency departments: Findings from the National Hospital Ambulatory Medical Care Survey

OBJECTIVES The aim of this study was to examine trends and associated factors in the prescription of opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics by emergency physicians for nontraumatic dental condition (NTDC)-related visits. Our secondary aim was to investigate whether race/ethnicity is a possible predictor of receiving a prescription for either type of medication for NTDC visits in emergency departments (EDs) after adjustment for potential covariates. METHODS We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997-2000 and 2003-2007, and used multinomial multivariate logistic regression to estimate the probability of receiving a prescription for opioid analgesics, nonopioid analgesics, or a combination of both, compared with receiving no analgesics for NTDC-related visits. RESULTS During 1997-2000 and 2003-2007, prescription of opioid analgesics and combinations of opioid and nonopioid analgesics increased, and that of no analgesics decreased over time. The prescription rates for opioid analgesics, nonopioid analgesics, opioid and nonopioid analgesic combinations, and no analgesics for NTDC-related visits in EDs were 43 percent, 20 percent, 12 percent, and 25 percent, respectively. Majority of patients categorized as having severe pain received prescriptions for opioids for NTDC-related visits in EDs. After adjusting for covariates, patients with self-reported dental reasons for visit and severe pain had a significantly higher probability of receiving prescriptions for opioid analgesics and opioid and nonopioid analgesic combinations. CONCLUSIONS Prescription of opioid analgesics increased over time. ED physicians were more likely to prescribe opioid analgesics and opioid and nonopioid analgesic combinations for NTDC-related visits with reported severe pain.

Cone structure in subjects with known genetic relative risk for AMD.

Purpose Utilize high-resolution imaging to examine retinal anatomy in patients with known genetic relative risk (RR) for developing age-related macular degeneration (AMD). Methods Forty asymptomatic subjects were recruited (9 men, 31 women; age range, 51 to 69 years; mean age, 61.4 years). Comprehensive eye examination, fundus photography, and high-resolution retinal imaging using spectral domain optical coherence tomography and adaptive optics were performed on each patient. Genetic RR scores were developed using an age-independent algorithm. Adaptive optics scanning light ophthalmoscope images were acquired in the macula extending to 10 degrees temporal and superior from fixation and were used to calculate cone density in up to 35 locations for each subject. Results Relative risk was not significantly predictive of fundus grade (p = 0.98). Only patients with a high RR displayed drusen on Cirrus or Bioptigen OCT. Compared to an eye with a grade of 0, an eye with a fundus grade equal to or greater than 1 had a 12% decrease in density (p < 0.0001) and a 5% increase in spacing (p = 0.0014). No association between genetic RR and either cone density (p = 0.435) or spacing (p = 0.538) was found. Three distinct adaptive optics scanning light ophthalmoscope phenotypical variations of photoreceptor appearance were noted in patients with grade 1 to 3 fundi. These included variable reflectivity of photoreceptors, decreased waveguiding, and altered photoreceptor mosaic overlying drusen. Conclusions Our data demonstrate the potential of multimodal assessment in the understanding of early anatomical changes associated with AMD. Adaptive optics scanning light ophthalmoscope imaging reveals a decrease in photoreceptor density and increased spacing in patients with grade 1 to 3 fundi, as well as a spectrum of photoreceptor changes, ranging from variability in reflectivity to decreased density. Future longitudinal studies are needed in genetically characterized subjects to assess the significance of these findings with respect to the development and progression of AMD.

Racial/ethnic disparities in provision of dental procedures to children enrolled in Delta Dental insurance in Milwaukee, Wisconsin

OBJECTIVES Most studies on the provision of dental procedures have focused on Medicaid enrollees known to have inadequate access to dental care. Little information on private insurance enrollees exists. This study documents the rates of preventive, restorative, endodontic, and surgical dental procedures provided to children enrolled in Delta Dental of Wisconsin (DDWI) in Milwaukee. METHODS We analyzed DDWI claims data for Milwaukee children aged 0-18 years between 2002 and 2008. We linked the ZIP codes of enrollees to the 2000 U.S. Census information to derive racial/ethnic estimates in the different ZIP codes. We estimated the rates of preventive, restorative, endodontic, and surgical procedures provided to children in different racial/ethnic groups based on the population estimates derived from the U.S. Census data. Descriptive and multivariable analysis was done using Poisson regression modeling on dental procedures per year. RESULTS In 7 years, a total of 266,380 enrollees were covered in 46 ZIP codes in the database. Approximately, 64 percent, 44 percent, and 49 percent of White, African American, and Hispanic children had at least one dental visit during the study period, respectively. The rates of preventive procedures increased up to the age of 9 years and decreased thereafter among children in all three racial groups included in the analysis. African American and Hispanic children received half as many preventive procedures as White children. CONCLUSION Our study shows that substantial racial disparities may exist in the types of dental procedures that were received by children.

Nontraumatic dental condition-related visits to emergency departments on weekdays, weekends and night hours: findings from the National Hospital Ambulatory Medical Care survey.

Objective To determine whether the rates of nontraumatic dental condition (NTDC)-related emergency department (ED) visits are higher during the typical working hours of dental offices and lower during night hours, as well as the associated factors. Methods We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997 through 2007 using multivariate binary and polytomous logistic regression adjusted for survey design to determine the effect of predictors on specified outcome variables. Results Overall, 4,726 observations representing 16.4 million NTDC-related ED visits were identified. Significant differences in rates of NTDC-related ED visits were observed with 40%–50% higher rates during nonworking hours and 20% higher rates on weekends than the overall average rate of 170 visits per hour. Compared with 19–33 year olds, subjects < 18 years old had significantly higher relative rates of NTDC-related ED visits during nonworking hours [relative rate ratio (RRR) = 1.6 to 1.8], whereas those aged 73 and older had lower relative rates during nonworking hours (RRR = 0.4; overall P = 0.0005). Compared with those having private insurance, Medicaid and self-pay patients had significantly lower relative rates of NTDC visits during nonworking and night hours (RRR = 0.6 to 0.7, overall P < 0.0003). Patients with a dental reason for visit were overrepresented during the night hours (RRR = 1.3; overall P = 0.04). Conclusion NTDC-related visits to ED occurred at a higher rate during nonworking hours and on weekends and were significantly associated with age, patient-stated reason for visit and payer type.

Rural–urban differences in dental service use among children enrolled in a private dental insurance plan in Wisconsin: analysis of administrative data

BackgroundStudies on rural–urban differences in dental care have primarily focused on differences in utilization rates and preventive dental services. Little is known about rural–urban differences in the use of wider range of dental procedures. This study examined patterns of preventive, restorative, endodontic, and extraction procedures provided to children enrolled in Delta Dental of Wisconsin (DDWI).MethodsWe analyzed DDWI enrollment and claims data for children aged 0-18 years from 2002 to 2008. We modified and used a rural and urban classification based on ZIP codes developed by the Wisconsin Area Health Education Center (AHEC). We categorized the ZIP codes into 6 AHEC categories (3 rural and 3 urban). Descriptive and multivariable analysis using generalized linear mixed models (GLMM) were used to examine the patterns of dental procedures provided to children. Tukey-Kramer adjustment was used to control for multiple comparisons.ResultsApproximately, 50%, 67% and 68 % of enrollees in inner-city Milwaukee, Rural 1 (less than 2500 people), and suburban-Milwaukee had at least one annual dental visit, respectively. Children in inner city-Milwaukee had the lowest utilization rates for all procedures examined, except for endodontic procedures. Compared to children from inner-city Milwaukee, children in other locations had significantly more preventive procedures. Children in Rural 1-ZIP codes had more restorative, endodontic and extraction procedures, compared to children from all other regions.ConclusionsWe found significant geographic variation in dental procedures received by children enrolled in DDWI.

Differences in Utilization of Dental Procedures by Children Enrolled in Wisconsin Medicaid And Delta Dental Insurance Plans

BACKGROUND Few studies have directly compared dental procedures provided in public and private insurance plans for enrollees living in dental health professional shortage areas (DHPSAs). We examined the rates for the different types of dental procedures received by 0-18-year-old children living in DHPSAs and non-DHPSAs who were enrolled in Medicaid and those enrolled under Delta Dental of Wisconsin (DDW) for years 2002 to 2008. METHODS Medicaid and DDW dental claims data for 2002 to 2008 was analyzed. Enrollees were divided into DDW-DHPSA and non-DHPSA and Medicaid-DHPSA and non-DHPSA groups. Descriptive and multivariable analyses using over-dispersed Poisson regression were performed to examine the effect of living in DHPSAs and insurance type in relation to the number of procedures received. RESULTS Approximately 49 and 65 percent of children living in non-DHPSAs that were enrolled in Medicaid and DDW received at least one preventive dental procedure annually, respectively. Children in DDW non-DHPSA group had 1.79 times as many preventive, 0.27 times fewer complex restorative and 0.51 times fewer endodontic procedures respectively, compared to those in Medicaid non-DHPSA group. Children enrolled in DDW-DHPSA group had 1.53 times as many preventive and 0.25 times fewer complex restorative procedures, compared to children in Medicaid-DHPSA group. CONCLUSIONS DDW enrollees had significantly higher utilization rates for preventive procedures than children in Medicaid. There were significant differences across Medicaid and DDW between non-DHPSA and DHPSA for most dental procedures received by enrollees.

The effect of suturing on force for dislodgement of tracheostomy tubes: medial versus lateral sutures.

U decannulation of a tracheostomy is a lifethreatening complication. Tube displacement occurs at a rate of 0% to 7% and is particularly problematic in the early postoperative period, generally described as the first 7 days to 14 days following tracheostomy placement. It is during this period that the tracheocutaneous tract is forming and reinsertion of an accidentally decannulated tube can be difficult and may result in the formation of a false passage and the need for orotracheal intubation. Factors associated with tube dislodgement include obesity, postoperative swelling, length of the tube, frequent patient repositioning, and method of securing the tube. Several methods are described for tube security including the use of ties or tapes around the neck and suturing the plastic flange to the neck in various manners. Some surgeons decline to place sutures on the flange to prevent a false appearance of a secure tracheostomy that is less prone to accidental decannulation. Another concern with a sutured tracheostomy tube is that dislodgement might occur with the tube being held in the subcutaneous tissue by the sutures, delaying recognition of accidental dislodgement. This could potentially occur with a tracheostomy tube that has been dislodged into the subcutaneous tissue but appears to remain tightly secured to the neck, thus delaying a diagnosis of decannulation. Suturing the flange of a tracheostomy to the neckdecreases the incidence of early decannulation in children. Because of the wide variation in techniques in securing a tracheostomy, we attempted to objectively determine what role suturing played in addition to the tracheostomy ties. In addition, we sought to determine if placing sutures at the lateral margin of the tracheostomy flange is different from placing them medially. We hypothesized that medially placed sutures require more force for the same excursion of the tracheostomy tube.