Specialist Officers Research Articles

Ouvindo Crianças Sobre Sentidos e Significados Atribuídos ao TDAH

Resumo Cada vez mais, fenômenos de ordem cultural, social, econômica, política e comportamental são transformados em questões médicas e individuais. Logicamente, se o problema é do indivíduo, poder-se-ia tratá-lo e curá-lo, ignorando-se, assim, todo o vasto contexto problemático de desigualdades, de exclusão, de padrões e normas, de competitividade e de homogeneidade em que estamos inseridos. Na tentativa de aprofundar esse tema, o presente estudo investiga a produção de significados e sentidos por crianças/estudantes, diagnosticadas com Déficit de Atenção com ou sem hiperatividade. O estudo foi realizado com quatro estudantes entre 7 e 14 anos de idade e seus responsáveis. Como resultados, pode se destacar que todos os diagnósticos surgiram a partir de queixas oriundas da escola que levaram os familiares a buscar ajuda nos consultórios de especialistas. É necessário repensar práticas que proporcionem um desenvolvimento sem excluir a diversidade e nem patologizar a singularidade.

A Study on Job Satisfaction

Background: A study was carried out to assess the job satisfaction of medical officers of the armed forces. Methods: Medical officers having a minimum of five service, stationed in a large cantonment having a tertiary care service hospital were administered anonymously the scale developed by bray field and Roth to assess job satisfaction. A total of 64 medical officers (22 administrative cadre, 26 specialists), participated in the study. Results: Overall there was a low level of job satisfaction among the medical officers. There was no significant difference in the level of job satisfaction in the three groups. Only 3 each of administrative cadre and specialist officers were in the higher satisfied group. The most common factor stated (91.5% of the respondents), as contributing towards job satisfaction was an opportunity for self-development. Others in decreasing frequency were job security (51.6%), prestige of organization (38.5%), nature of work (28.8%).

Exploration of infertile couples' support requirements: a qualitative study.

Due to high prevalence of infertility, increasing demand for infertility treatment, and provision of high quality of fertility care, it is necessary for healthcare professionals to explore infertile couples' expectations and needs. Identification of these needs can be a prerequisite to plan the effective supportive interventions. The current study was, therefore, conducted in an attempt to explore and to understand infertile couples' experiences and needs. This is a qualitative study based on a content analysis ap- proach. The participants included 26 infertile couples (17 men and 26 women) and 7 members of medical personnel (3 gynecologists and 4 midwives) as the key informants. The infertile couples were selected from patients attending public and private infertility treatment centers and private offices of infertility specialists in Isfahan and Rasht, Iran, during 2012-2013. They were selected through purposive sampling method with maximum variation. In-depth unstructured interviews and field notes were used for data gathering among infertile couples. The data from medical personnel was collected through semi-structured interviews. The interview data were analyzed using conventional content analysis method. Data analysis revealed four main categories of infertile couples' needs, including: i. Infertility and social support, ii. Infertility and financial support, iii. Infertility and spiritual support and iv. Infertility and informational support. The main theme of all these categories was assistance and support. The study showed that in addition to treatment and medical needs, infertile couples encounter various challenges in different emotional, psychosocial, communicative, cognitive, spiritual, and economic aspects that can affect various areas of their life and lead to new concerns, problems, and demands. Thus, addressing infertile couples' needs and expectations alongside their medical treatments as well as provision of psychosocial services by development of patient-centered approaches and couple-based interventions can improve their quality of life and treatment results and also relieve their negative psychosocial consequences.

Factors associated with resistant hypertension in a large cohort of hypertensive patients: the Pol-Fokus study.

Patients with resistant hypertension (RHT) are at high risk for coronary artery disease (CAD) and cerebrovascular disease (CVD), compared with the general hypertensive population. The aim of the study was to evaluate factors associated with RHT in a large sample of hypertensive patients under the care of general practitioners and specialists in Poland. We included 12 375 patients (mean age, 64.0 ±12.3 years; age range, 18-98 years; women, 59%) with hypertension treated for at least 1 year. Patients were divided into 3 groups: with controlled hypertension, uncontrolled hypertension (not fulfilling the criteria for RHT), and RHT. Controlled hypertension, uncontrolled hypertension, and RHT were found in 47.3%, 27.9%, and 24.7% of the patients, respectively. The RHT rate was higher in patients visiting specialist offices (29.8%) and in patients with diabetes (32.5%), CAD (31.5%), CVD (33.3%), and impaired renal function (31.9%). Patients with RHT were characterized by the highest rate of high (23.5%) and very high (60.5%) added cardiovascular risk. An underuse of preferred antihypertensive drug combinations and aldosterone antagonists in patients with uncontrolled hypertension and RHT was observed. In a multivariate analysis, RHT was independently associated with male sex, higher pulse pressure, metabolic syndrome, diabetes, CAD, CVD, diseases requiring treatment with nonsteroidal anti-inflammatory drugs and an estimated glomerular filtration rate of less than 60 ml/min/1.73 m2. The vast majority of patients with RHT carry a high or very high cardiovascular risk. In addition, the underuse of preferred antihypertensive drug combinations and aldosterone antagonists has been observed.

Skin Testing for IgE Mediated Disease can be Done Safely in The Family Practice Office

Background: Aeroallergen skin testing for assessing allergic disease has been in use for well over 100 years. Initially, trepidation to the use of skin puncture testing (SPT) occurred because of reported morbidity and mortality. SPT has most frequently been utilized in the specialist office due to fear of adverse reactions. Methods: Analysis of 156,335 SPT tests (morbidity and mortality) allowed equivalency testing versus superiority testing to show 95% confidence level. The ninety-five percent confidence interval around the 11.5/100,000 SPT is (11.3-11.7/100,000). Results: The literature documents 1 death from SPT from 1990 to 2001 and 1 death from 1945 to 1987. These 2 reported deaths have been contrasted with 0 deaths in 125,295 SPT patients reviewed in a primary care setting utilizing United Allergy Service protocols (UAS). Systemic reactions (SR) occurred in only 18 patients. The SR rate amongst subspecialists has been reported as a 0.015-0.023% SR per 100,000 SPT. Statistically, this result is not significantly different from the UAS SR rate of 0.0115% without associated anaphylaxis or deaths. Conclusion: Based on the findings evident in this study, SPT is safely performed in the primary care (PC) office and allows for a larger percentage of the symptomatic population to be assessed. The observed SR rate of 11.5/100,000 SPT was statistically similar to the lowest published rate of 15/100,000 SPT (p=0.45) and statistically lower than the highest published rate of 23/100,000 SPT (p=0.02). These data suggest that SPT is as safe in the (PC) office as it is in the specialist office.

Comparison of a MEMS-Based Handheld OCT Scanner With a Commercial Desktop OCT System for Retinal Evaluation.

The goal of this study was to evaluate the ability of our handheld optical coherence tomography (OCT) scanner to image the posterior and anterior structures of the human eye, and especially the individual layers of the retina, and to compare its diagnostic performance with that of a fixed desktop commercial ophthalmic OCT system. We compared the clinical imaging results of our handheld OCT with a leading commercial desktop ophthalmic system (RTVue) used in specialist offices. Six patients exhibiting diabetes-related retinal pathology had both eyes imaged with each OCT system. In both sets of images, the structural irregularities of the retinal layers could be identified such as retinal edema and vitreomacular traction. Our handheld OCT system can be used to identify relevant anatomical structures and pathologies in the eye, potentially enabling earlier screening, disease detection, and treatment. Images can be acquired quickly, with sufficient resolution and negligible motion artifacts that would normally limit its diagnostic use. Following screening and early disease detection in primary care via our optimized handheld OCT system, patients can be referred to a specialist for treatment, preventing further disease progression. While many primary care physicians are adept at using the ophthalmoscope, they can definitely take advantage of more advanced technologies.

The Measure of a Doctor's Heart

Over the many years that I worked as a doctor in a major New York City hospital, I noticed a peculiar phenomenon occurring with my patients. Most of the vast number of ill or injured people who passed into and out of my care melted into one long blur as those years rolled by, while certain individuals continued to live in my memory as clearly as on the day I first met them. Only now, as I approach the end of my career, do I understand why this has been so. The reason does not involve personal preferences, nor does it reflect the degree of challenge that different patients presented, or any other such variable that would naturally set some apart from others. It involves another dynamic entirely, which I believe is this: those patients who remain alive in my memory are the ones who mark the measure of my doctor's heart. Katherine, Lily, and Nestor are three who do this for me, and their stories make clear what I mean. I came to know Katherine when I was a still-wet-behindthe-ears third-year medical student doing my monthlong clinical rotation in Internal Medicine, and she won me to her cause immediately. A slender, probably once-attractive, auburn-skinned woman in her late thirties, Katherine lay confined to bed in Room 301A on the medical ward with the most disturbing disease I had ever seen. Her diagnosis was faradvanced scleroderma, a condition in which a person's immune system becomes confused. Instead of producing antibodies that defend against outside invaders, it produces antibodies that attack the person's own connective tissues, those strong and marvelously flexible tissues that give our skin its suppleness and that form the bulwark of our muscles, our blood vessels, and all our internal organs. The attacking antibodies rob these connective tissues of their marvelous elasticity, making them grow stiff and hard and resistant to movement. Unfortunately, modern medicine has not yet learned how to stop this grim process. Once started, the disease can progress slowly or more rapidly, affecting its victim in merely a few places, or spreading through the person's entire body, as it was doing in Katherine's case. Katherine had begun to develop the early signs of scleroderma a decade earlier. A feeling of tightness in her skin, together with a shiny appearance, began first on her fingers and toes, and then also appeared on her elbows and knees. She had seen other patients whose condition was more advanced than hers in her specialist's office, and she knew what was coming. As time went on, the disease progressed, steadily gaining ground with its leathery unyieldingness, eventually closing in so fully all around her that she could do nothing but lie stiff and motionless in bed. She was encased in a body that would one day become her coffin.

Statin therapy for cholesterol control

ease is undeniable in patients who have known cardiovascular disease, risk factors, or those who are in the primary prevention area,” said Nihar Desai, MD, MPH, Assistant Professor in the Division of Cardiovascular Medicine at Yale School of Medicine. “Statins are the cornerstone of lipid-lowering therapy for the reduction of cardiovascular disease.” In a population so widely affected by heart disease, lipid management requires an all-hands-on-deck approach on the part of health care providers. Pharmacists play a crucial role. Three recent studies on statins provide new fi ndings on adherence, drug interactions, and potentially dangerous adverse effects. Frequently a patient’s fi rst point of contact with the health care system, pharmacists can counsel patients on whether their complaints are statin-related, educate patients and prescribers on interactions and recommendations, and send a message consistent with that of other health care providers about the importance of adherence.

Interventional Pain Management for Failed Back Surgery Syndrome

Patients who suffer from the condition known as failed back surgery syndrome (FBSS) present to the offices of physicians, surgeons, and pain specialists alike in overwhelming numbers. This condition has been defined as persistent back and/or leg pain despite having completed spinal surgery. As lumbar surgery continues to grow in prevalence, so will the number patients suffering from FBSS. It is important for physicians treating this population to expand their knowledge of FBSS etiologies and appropriate diagnostic imaging modalities, combined with confirmatory diagnostic injections, and proper technique for interventional pain procedures. In doing so, the physician may adequately be prepared to manage these complex cases in the future, ideally with the support of stronger evidence. Management begins with a systematic evaluation of common FBSS etiologies such as new-onset stenosis, recurrent herniated nucleus pulposus (HNP), epidural fibrosis, pseudarthrosis, and others. History and physical may be supplemented by imaging including X-ray, magnetic resonance imaging, or computed tomography myelography. Certain diagnoses may be confirmed with diagnostic procedures such as intra-articular injections, medial branch blocks, or transforaminal nerve root blocks. Once an etiology is determined, a multidisciplinary approach to treatment is most effective. This includes exercise or physical therapy, psychological counseling, medication, and interventional procedures. The most invasive treatment option, short of revision surgery, is spinal cord stimulation. This intervention has a number of studies demonstrating its efficacy and cost-effectiveness in this population. Finally, revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.

Association of Military Deployment of a Parent or Spouse and Changes in Dependent Use of Health Care Services

U.S. Armed Forces members and spouses report increased stress associated with combat deployment. It is unknown, however, whether these deployment stressors lead to increased dependent medication use and health care utilization. To determine whether the deployment of Army active duty members (sponsors) is associated with changes in dependent health care utilization. A quasi-experimental, pre-post study of health care patterns of more than 55,000 nonpregnant spouses and 137,000 children of deployed sponsors and a comparison group of dependents. Changes in dependent total utilization in the military health system, and separately in military-provided and purchased care services in the year following the sponsors' deployment month for office visit services (generalist, specialist); emergency department visits; institutional stays; psychotropic medication (any, antidepressant, antianxiety, antistimulant classes). Sponsor deployment was associated with net increased use of specialist office visits (relative percent change 4.2% spouses; 8.8% children), antidepressants (6.7% spouses; 17.2% children), and antianxiety medications (14.2% spouses; 10.0% children; P<0.01) adjusting for group differences. Deployment was consistently associated with increased use of purchased care services, partially, or fully offset by decreased use of military treatment facilities. These results suggest that emotional or behavioral issues are contributing to increased specialist visits and reliance on medications during sponsors' deployments. A shift to receipt of services from civilian settings raises questions about coordination of care when families temporarily relocate, family preferences, and military provider capacity during deployment phases. Findings have important implications for the military health system and community providers who serve military families, especially those with children.

Diagnosis and treatment of grass pollen‐induced allergic rhinitis in specialized current clinical practice in Spain

Allergic rhinitis (AR) is the leading cause of consultation at the allergy specialist's office, but detailed, reliable, and validated clinical data on this condition are limited. This study was designed to define the clinical features, diagnostic methods, and therapeutic approaches of patients with AR induced by grass pollen in Spain. Two hundred twelve specialists participated in a multicenter, observational, epidemiologic, questionnaire-based study. Each investigator had to recruit at least two patients consulting for the first time and with a diagnosis of AR induced by grass pollen. Five hundred twenty-four patients (52% men; mean age, 29.3 years) with grass pollen-induced rhinitis (mean disease duration, 8.7 years) were recruited. Just 18.4% of patients reported that their symptom status had improved since the beginning of the condition, 89.4% had moderate-severe rhinitis (Allergic Rhinitis and Its Impact on Asthma classification) and 35.1% had concomitant bronchial asthma. For 52.1% of patients, control of symptoms with previous drug treatment was poor. Most of the patients were polysensitized to other pollens (sensitization to olive tree pollen, 57.1%). Oral antihistamines (97.3%) and nasal corticosteroids (82.3%) were the most frequently prescribed drugs and 43.1% of patients received specific immunotherapy. The clinical profile for the majority of Spanish patients consulting an allergy specialist for AR induced by grass pollen corresponds to a young adult with a lengthy moderate-severe rhinitis, often accompanied by bronchial asthma. Their symptoms progressively worsen and rhinitis is poorly controlled by symptomatic treatment. Oral antihistamines and nasal corticosteroids are the most frequently used therapeutic approaches and less than one-half receive specific immunotherapy.

The Impact of Psychological Consequences of Rape on Rape Case Attrition: The Police Perspective

This paper examines whether the psychological sequelae of rape relate to rape case attrition by leading police to see the victim as less reliable. A mixed methods approach with two linked studies, one qualitative and one quantitative, was used. In Study 1, the qualitative study, interviews with 12 specialist police officers were analysed using Framework Analysis. In Study 2, the quantitative study, 76 specialist officers completed an online questionnaire to assess the generalisability of Study 1’s findings. In Study 1, officers’ perceptions of victims clustered into three stereotypes, which we label “the real victim”, “the mad discloser”, and “the bad discloser”. Victims who exhibited signs of shame, self-blame, and post-traumatic stress reactions which impeded their ability to give a coherent account of the rape were perceived as less reliable “mad” or “bad” victims. The findings of Study 2 supported these results. Although police interview strategies have improved in recent years, there is evidence that signs of trauma and shame in the victim are sometimes misinterpreted as signs of lying. This may affect attrition by impacting on victim-officer relationships. Further training on recognising trauma and understanding its consequences is recommended both for specialist officers and front-line staff.

New daily-persistent headache

Chronic daily headache (CDH) is a descriptive term that encompasses 4 different headache disorders, each of which is characterized by frequent headaches. Primary CDH subtypes of long duration (i.e., 4 hours or more) are chronic migraine, chronic tension-type headache, hemicrania continua, and new daily-persistent headache (NDPH). NDPH, while not as common as chronic migraine or chronic tension-type headache, is common enough to be part of the general neurologist's practice, and is seen often in the headache specialist's office. First described in 1986,1 it gained acceptance when it was placed within the Silberstein-Lipton (S-L) criteria for chronic daily headache in 1994.2 The critical feature of the original description and the subsequent S-L description was the onset: daily headache starts abruptly without a background of frequent or worsening headache. Unfortunately, its diagnosis using International Classification of Headache Disorders (ICHD)–II3 criteria has been mired in controversy based on 2 separate issues: 1) the disparate descriptions of the degree …

Screening Effectiveness for Hepatitis A and B in Chronic Hepatitis C Patients with Chronic Kidney Disease

Purpose: The Advisory Committee on Immunization Practices (ACIP) recommends immunization of all patients with chronic liver disease (CLD) against hepatitis A (HAV) and those CLD patients with risk factors for hepatitis B (HBV) against the latter. Studies have reported underutilization of HAV and HBV vaccination in CLD patients, leading to adverse health outcomes. Screening and immunization becomes much more important in chronic hepatitis C (CHC) patients with chronic kidney disease (CKD) because CKD stage 5 patients are at high risk of acquiring HBV through dialysis. Our aim was to determine how effectively CHC patients with CKD are screened for HAV and HBV antibodies and receive vaccination at our institution. Methods: The Department of Gastroenterology at Wayne State University maintains a Hepatitis C registry, which is a database of over 3000 hepatitis C patients seen in the hepatitis clinic at Harper hospital between January 1995 and present. Retrospective chart reviews were undertaken and a final sample of 123 CHC patients with CKD was obtained. Data on demographics and immunization status was analyzed using SPSS version 17.0. Results: The mean age of patient population was 50 with a range of 26 to 83. 119 (96%) patients were African-American and 5 (4%) were Caucasians. Seventy six (61 %) patients were males. Out of 123 patients, HBV and HAV status was known for 105 and 77 patients respectively. Nineteen (15.4%) patients were infected with HBV, 23 (18.7%) had evidence of vaccination and 18 (14.6 %) had immunity as a result of previous exposure. 45 (36.6%) patients were found to be susceptible. Out of 77 patients who had been tested for HAV, 34 (44%) patients had evidence of immunization. Forty three (55.8%) patients were found to be susceptible. Conclusion: Despite multiple visits to clinic, only 62% CHC patients with CKD had been tested for anti-HAV. Out of these, 55.8 % were susceptible, most of who were referred back to the primary care because of insurance reasons. Follow-up of vaccination status was incompletely documented. Screening effectiveness was much better for HBV (85 %), half of whom were susceptible to HBV however, had incomplete follow-up of vaccination. A previous study found that patients who were susceptible to HAV and HBV were much more likely to receive vaccines if they were seen in specialist offices than the patients seen in primary care offices. Better communication between primary care personnel and specialists, with explicit understanding of which office will assume responsibility for immunization and accurate record keeping of immunization history may reduce vaccine underutilization in patients with chronic liver disease and improve health outcomes.

How Can I Ethically Handle Referrals to a Specialist Against Whom There Are Allegations of Unethical Behavior?

Q As a general dentist in a small community, there are a limited number of specialists to whom I can refer patients. I am aware, through a number of sources I believe to be credible, that a particular specialist allegedly is engaged in unethical treatment of female patients. This same dentist recently was disciplined by the professional licensing board for previous related, although not identical, inappropriate conduct. Neither the state board nor society peer review and ethics committees have yet taken any action related to these new allegations. Until these bodies act on these new allegations, I am uncomfortable in referring patients to this specialist. The only other option for this specialty care involves patients' traveling between 40 and 80 miles. Is it ethical for me not to refer patients to this particular practitioner, and how do I respond if patients ask why I am referring them to a specialist so far away rather than the specialist in our town?

The Relationship of Periodontal Disease to Diseases and Disorders at Distant Sites: Communication to Health Care Professionals and Patients

The body of research defining relationships among periodontal disease and certain systemic diseases and disorders has been expanding, and questions have been raised regarding what information should be conveyed to health care professionals and patients. Representatives from dentistry, medicine, the academic community and the insurance industry convened a two-day workshop July 23 and 24, 2007. The workshop participants achieved general consensus on a number of issues, including the need for greater cooperation between the health care professions. This cooperation should translate into improved clinical care as physicians refer patients for dental care, and dentists are proactive in regard to the general health of their patients. Communication to health care professionals requires a multifaceted approach that includes publication of research findings in medical and dental journals, cooperation among professional organizations and initiatives at the local level such as presentations at medical grand rounds. Dental schools should play a role in their health science centers. Communication with patients may improve through the use of targeted informational brochures in the offices of medical specialists, appropriate media campaigns and efforts led by local dental organizations. It is too early to provide specific recommendations regarding the treatment of periodontal disease to improve specific health outcomes, but dentists can become advocates for a general health promotion and disease prevention message. The lifestyles approach includes an improved diet, smoking cessation, appropriate hygiene practices and stress reduction. These strategies can improve oral and general health outcomes.

A Conversation with IAYT President Matthew Taylor

Matthew J. Taylor, PT, PhD, RYT was elected president of the board of directors for IAYT in February 2008. He has 27 years of clinical experience in physical therapy and is a leader in integrating Yoga with Western approaches to rehabilitation and therapy. He received his Masters of Physical Therapy degree from Baylor University in 1981, and served as a physical therapist and active duty Army Medical Specialist officer in the United States Army from 1980 through 1988. In 1988, he left the military and opened a private physical therapy practice in Galena, Illinois. In 1995, he expanded his physical therapy practice into an integrated clinic and health club. He became a certified, advanced-level Integrative Yoga Therapy therapist in 1998, and in 2006, he completed his PhD in transformational learning and change thorough the California Institute of Integral Studies. In 2003, he founded the Dynamic Systems Rehabilitation (DSR) clinics in Scottsdale, AZ. The clinic offers therapy and wellness services that integrate classical Yoga, physical therapy, and modern transformation learning theory. He has been an IAYT board member since February 2007 and is IAYT's representative for the Academic Consortium for Complementary and Alternative Health Care. Matt sat down with us to discuss his perspective on Yoga therapy, IAYT, and some possibilities for the future of both.

Use it or Lose it: The Medicare Low Vision Demonstration Project

The Low Vision Demonstration Project is now one year old. This project constitutes a unique and pivotal opportunity for vision rehabilitation professionals. If it succeeds, it will open up significant opportunities for funding and provision of services. But, if it fails, it could represent another nail in the coffin of specialized services. The question now is whether professionals in the field of visual impairment and blindness will step up to the plate to ensure that this project is successful. The achievements of the project have been encouraging so far, but there are a number of significant weaknesses, and there is still much to do. This column offers a progress report on the project and examines its serious implications. Although some reports have appeared in previous issues of the Journal of Visual Impairment & Blindness (JVIB) (see, for example, the Comment entitled Medicare Coverage for Orientation and Mobility Services, by Lorraine Lidoff, which appeared in October 2005; and the special report that appeared in the From the Field department of the August 2006 issue), let me first provide an overview of the project for anyone who is not familiar with it. SCOPE OF THE PROJECT Begun on April 1, 2006, the Low Vision Demonstration Project is a five-year project established to help deliver services in a new manner and evaluate the utilization of funding for vision rehabilitation services by a new set of providers who had not previously been covered by Medicare: certified low vision therapists, orientation and mobility (OM however, the demonstration project also covers vision rehabilitation training that may be provided in the eye care specialist's office or at a qualified agency. Because the project is funded by Medicare, service providers are obliged to follow its requirements, which may differ from customary procedures in vision rehabilitation. Specifically, all services must be preceded by a written plan of care, with specific goals and a statement of the location at which the services are to be provided, which must be approved by the supervisory physician and reviewed every 30 days. The service provider must detail the training provided and the progress made by the patient. Training is limited to nine hours total, to be provided within 90 consecutive days, and cannot be extended. Vision rehabilitation services are billed in 15-minute increments. For this demonstration project, six different sites in four states and two cities throughout the United States have been selected: Atlanta, Georgia; Kansas; New Hampshire; the five boroughs of New York, New York; North Carolina; and Washington State. The patient must reside in one of these six areas, and the supervising eye care specialist must have his or her practice in one of the six sites. The patient must have a corrected visual acuity in his or her best eye of 20/70 or worse, or have a documented central scotoma, a general constriction of the visual fields, or bilateral hemianopia. Qualifying patients must show a medical necessity for the services rendered, be capable of progress, and be able to derive a benefit. …

The Long War

Vincent Cannistraro is the former head of counterterrorism operations and analysis for the Central Intelligence Agency. He served in the National Security Council as director for intelligence programs during the Reagan administration and currently heads Cannistraro Associates, a security consultancy located in McLean, Virginia. Philip Giraldi is a former CIA counterterrorism specialist and military intelligence officer who served eighteen years in Turkey, Italy, Germany, and Spain. He is currently a partner in Cannistraro Associates.

Oral health‐related quality of life of periodontal patients

The purpose of this study was to assess the oral health-related quality of life of patients presenting to a periodontal specialist by means of six questions, and to assess the perceived oral health by means of one question. Self-assessments of oral health were associated with clinical characteristics. Logistic regression models were used to associate self-assessments with clinical characteristics in a cross-sectional study. On the six-item questionnaire, close to 20% (295/1480) of the patients reported that teeth, gums or dentures had an impact fairly often or very often on one or more items (eating, relaxing, avoiding going out, feeling self-conscious, pain or discomfort). On the single question requesting a self-assessment of oral health, 42% (628/1468) rated their oral health as fair or poor. Both common oral health-related quality of life problems and worse perceived oral health were associated with having more than eight teeth with>5 mm periodontal pockets (odds ratio=1.45, 95% confidence interval=1.01-2.08; and odds ratio=2.83, 95% confidence interval=2.08-3.84, respectively), compared with patients who had fewer than three teeth with>5 mm periodontal pockets. Oral health-related problems in patients presenting to a periodontal specialist office negatively affect their quality of life. If some of the findings of this study can be confirmed in other studies, it could change the perception of chronic periodontitis as a silent disease.