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D. Treslott, M.S., Ph.D.

Medical Instructor, Mercer University School of Medicine

Effect of carbamazepine on pain scores of unipolar depressed patients with chronic pain: a trial of off-on-off-on design. Diagnosis of metachromatic leukodystrophy, Krabbe disease, and Farber disease after uptake of fatty acid-labeled cerebroside sulfate into cultured skin fibroblasts. Morphometric study of the jejunal mucosa in various childhood enteropathies with special reference to intraepithelial lymphocytes. Ginseng supplementation does not change lactate threshold and physical performances in physically active Thai men. Journal of the Medical Association of Thailand = Chotmaihet thangphaet Vol 90; 2007: 1172-9. Effects of bromocriptine mesylate on the composition of the mammary secretion in non-breast-feeding women. A biopsy-based quick test in the diagnosis of duodenal hypolactasia in upper gastrointestinal endoscopy. Urinary sialyloligosaccharides in adult type sialidosis: occurrence of two positional isomers. Does low lactose milk powder improve the nutritional intake and nutritional status of frail older Chinese people living in nursing homes? Relationship of urinary sodium/potassium excretion and calcium intake to blood pressure and prevalence of hypertension among older Chinese vegetarians. Relationship between lactose digestion, gastrointestinal transit time and symptoms in lactose malabsorbers after dairy consumption. Poor predictability of lactose malabsorption from clinical symptoms for Chilean populations. Lactose malabsorption in Greek adults: correlation of small bowel transit time with the severity of lactose intolerance. Low-dose lactose, fructose and sorbitol malabsorption and intolerance does not often coexist in normal adults [abstract]. Coincidental malabsorption of lactose, fructose, and sorbitol ingested at low doses is not common in normal adults. Honey may have a laxative effect on normal subjects because of incomplete fructose absorption. Evaluation of pharmacological aids on physical 240 performance after a transmeridian flight. Low serum 25-hydroxyvitamin D concentrations and secondary hyperparathyroidism in middle-aged white strict vegetarians. Gastrointestinal dysfunction in a community sample of subjects with symptoms of irritable bowel syndrome. Milk, milk products and lactose intake and ovarian cancer risk: a meta-analysis of epidemiological studies. Disaccharidases and histology of duodenal mucosa in congenital lactose malabsorption. Impact of digestion and absorption in the weaning period on infant feeding practices. Correlation of lactase activity, lactose tolerance and milk consumption in different age groups. Characterization of human intestinal lactase and hetero-beta-galactosidases of infants and adults. Lactose malabsorption is associated with early signs of mental depression in females: a preliminary report. Chronic diarrhoea in infants and young children: causes, clinical features and outcome. Absence of increased fecal blood loss in adult volunteers after oral administration of conventional tablets and osmotic tablets of albuterol. Adult-type hypolactasia is not a predisposing factor for the early functional and structural changes of atherosclerosis: the Cardiovascular Risk in Young Finns Study.

The rising intraosseous pressure, vascular stasis, small-vessel thrombosis and periosteal stripping 2 Infection (a) (b) Sequestrum Pathology Acute haematogenous osteomyelitis shows a characteristic progression marked by inflammation, suppuration, bone necrosis, reactive new bone formation and, ultimately, resolution and healing or else intractable chronicity. Some of the bone may die, and is encased in periosteal new bone as a sequestrum (c). Bacterial toxins and leucocytic enzymes also may play their part in the advancing tissue destruction. With the gradual ingrowth of granulation tissue the boundary between living and devitalized bone becomes defined. Pieces of dead bone may separate as sequestra varying in size from mere spicules to large necrotic segments of the cortex in neglected cases. Macrophages and lymphocytes arrive in increasing numbers and the debris is slowly removed by a combination of phagocytosis and osteoclastic resorption. A small focus in cancellous bone may be completely resorbed, leaving a tiny cavity, but a large cortical or cortico-cancellous sequestrum will remain entombed, inaccessible to either final destruction or repair. Initially the area around the infected zone is porotic (probably due to hyperaemia and osteoclastic activity) but if the pus is not released, either spontaneously or by surgical decompression, new bone starts forming on viable surfaces in the bone and from the deep layers of the stripped periosteum. This is typical of pyogenic infection and fine streaks of subperiosteal new bone usually become apparent on x-ray by the end of the second week. With time this new bone thickens to form a casement, or involucrum, enclosing the sequestrum and infected tissue. If the infection persists, pus and tiny sequestrated spicules of bone may discharge through perforations (cloacae) in the involucrum and track by sinuses to the skin surface. If the infection is controlled and intraosseous pressure released at an early stage, this dire progress can be halted. The bone around the zone of infection becomes increasingly dense; this, together with the periosteal reaction, results in thickening of the bone. In some cases the normal anatomy may eventually be reconstituted; in others, though healing is sound, the bone is left permanently deformed. If healing does not occur, a nidus of infection may remain locked inside the bone, causing pus and sometimes bone debris to be discharged intermittently through a persistent sinus (or several sinuses). The infection has now lapsed into chronic osteomyelitis, which may last for many years. Acute osteomyelitis in infants the early features of acute osteomyelitis in infants are much the same as those in older children. However, a significant difference, during the first year of life, is the frequency with which the metaphyseal infection spreads to the epiphysis and from there into the adjacent joint. In the process, the physeal anlage may be irreparably damaged, further growth at that site is severely retarded and the joint will be permanently deformed. Following Trueta (1957) it has long been held that, during the first 6­9 months of life, small metaphyseal vessels penetrate the physeal cartilage and this permits the infection to spread into the cartilaginous epiphysis. Others have disagreed with this hypothesis (Chung, 1976), but what is indisputable is that during infancy osteomyelitis and septic arthritis often go together. Another feature in infants is an unusually exuberant periosteal reaction resulting in sometimes bizarre new bone formation along the diaphysis; fortunately, with longitudinal growth and remodelling the diaphyseal anatomy is gradually restored. Acute osteomyelitis in adults Bone infection in the adult usually follows an open injury, an operation or spread from a contiguous focus of infection. True haematogenous osteomyelitis is uncommon and when it does occur it usually affects one of the vertebrae. A vertebral infection may spread through the end-plate and the intervertebral disc into an adjacent vertebral body. If a long bone is infected, the abscess is likely to spread within the medullary cavity, eroding the cortex and extending into the surrounding soft tissues. Periosteal new bone formation is less obvious than in childhood and the weakened cortex may fracture. If the bone end becomes involved there is a risk of the infection spreading into an adjacent joint. Children the patient, usually a child over 4 years, presents with severe pain, malaise and a fever; in neglected cases, toxaemia may be marked. The parents will have noticed that he or she refuses to use one limb or to allow it to be handled or even touched. There may be a recent history of infection: a septic toe, a boil, a sore throat or a discharge from the ear. Typically the child looks ill and feverish; the pulse rate is likely to be over 100 and the temperature is raised.

Cholestyramine: Cholestyramine may increase the clearance of oral corticosteroids. Cyclosporine: Increased activity of both cyclosporine and corticosteroids may occur when the two are used concurrently. Digitalis glycosides: Patients on digitalis glycosides may be at risk of arrhythmias due to hypokalemia. Aspirin should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. The clearance of salicylates may be increased with concurrent use of corticosteroids. Carcinogenesis, Mutagenesis, Impairment of Fertility No adequate studies have been conducted in animals to determine whether corticosteroids have a potential for carcinogenesis or mutagenesis. Pregnancy: Teratogenic Effects: Pregnancy Category C Corticosteroids have been shown to be teratogenic in many species when given in doses equivalent to the human dose. Corticosteroids should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Infants born to mothers who have received corticosteroids during pregnancy should be carefully observed for signs of hypoadrenalism. Nursing Mothers Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. Because of the potential for serious adverse reactions in nursing infants from corticosteroids, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use the efficacy and safety of corticosteroids in the pediatric population are based on the well-established course of effect of corticosteroids which is similar in pediatric and adult populations. In order to minimize the potential growth effects of corticosteroids, pediatric patients should be titrated to the lowest effective dose. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. Dermatologic: Acne, allergic dermatitis, cutaneous and subcutaneous atrophy, dry scaly skin, ecchymoses and petechiae, edema, erythema, hyperpigmentation, hypopigmentation, impaired wound healing, increased sweating, rash, sterile abscess, striae, suppressed reactions to skin tests, thin fragile skin, thinning scalp hair, urticaria. Gastrointestinal: Abdominal distention, bowel/bladder dysfunction (after intrathecal administration), elevation in serum liver enzyme levels (usually reversible upon discontinuation), hepatomegaly, increased appetite, nausea, pancreatitis, peptic ulcer with possible subsequent perforation and hemorrhage, perforation of the small and large intestine (particularly in patients with inflammatory bowel disease), ulcerative esophagitis. Musculoskeletal: Aseptic necrosis of femoral and humeral heads, calcinosis (following intra-articular or intra-lesional use), Charcot-like arthropathy, loss of muscle mass, muscle weakness, osteoporosis, pathologic fracture of long bones, postinjection flare (following intra-articular use), steroid myopathy, tendon rupture, vertebral compression fractures. Neurologic/Psychiatric: Convulsions, depression, emotional instability, euphoria, headache, increased intracranial pressure with papilledema (pseudotumor cerebri) usually following discontinuation of treatment, insomnia, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychic disorders, vertigo. Ophthalmic: Exophthalmoses, glaucoma, increased intraocular pressure, posterior subcapsular cataracts. The following adverse reactions have been reported with the following routes of administration: Intrathecal/Epidural: Arachnoiditis, bowel/bladder dysfunction, headache, meningitis, parapareisis/paraplegia, seizures, sensory disturbances. Ophthalmic: Increased intraocular pressure, infection, ocular and periocular inflammation including allergic reactions, residue or slough at injection site, temporary/permanent visual impairment including blindness. However, in certain overwhelming, acute, life-threatening situations, administration in dosages exceeding the usual dosages may be justified and may be in multiples of the oral dosages. It Should Be Emphasized that Dosage Requirements Are Variable and Must Be Individualized on the Basis of the Disease Under Treatment and the Response of the Patient. If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly. Although this method of treatment will ameliorate symptoms, it is in no sense a cure and the hormone has no effect on the cause of the inflammation. In order to obtain the full antiinflammatory effect, it is important that the injection be made into the synovial space. Employing the same sterile technique as for a lumbar puncture, a sterile 20 to 24 gauge needle (on a dry syringe) is quickly inserted into the synovial cavity. The injection site for each joint is determined by that location where the synovial cavity is most superficial and most free of large vessels and nerves. Suitable sites for intra-articular injection are the knee, ankle, wrist, elbow, shoulder, phalangeal, and hip joints. Since difficulty is not infrequently encountered in entering the hip joint, precautions should be taken to avoid any large blood vessels in the area. Treatment failures are most frequently the result of failure to enter the joint space.

Examples of evidence to demonstrate compliance may include: Description and schedule of rotations, including supervising faculty Rotation/Experience objectives Self-Study: Provide above items in appendix. Exhibit 10 is suggested or cross-reference with Standard 2-11 Resident Evaluations On-Site: Have evaluations available for review by visiting committee 2-13 Residents must gain experience in teaching orofacial pain. Describe how the residents participate in the collection of history and clinical data, diagnostic assessment, treatment planning, treatment and presentation of treatment outcome. Examples of evidence to demonstrate compliance may include: Documentation of treatment planning sessions/conferences where treatment outcomes are discussed On-Site: Have documentation available for review by the visiting committee Documentation of Chart reviews On-Site: Have documentation available for review by the visiting committee Case simulations On-Site: Have available for review by the visiting committee Records of resident clinical activity (such as case logs) including procedures performed in each area described above On-Site: Have records available for review by the visiting committee Patient records On-Site: Have records available for review by the visiting committee Resident evaluations On-Site: Have evaluations available for review by the visiting committee 2-15 the program must provide instruction in the principles of practice management. Describe the intended outcomes of instruction either in terms of goals and objectives for resident training or competencies and proficiencies the instruction in this area is intended to enable the resident to: Examples of evidence to demonstrate compliance may include: Course outlines Self-Study: Provide the outlines in the appendix 2-16 Structured patient care conferences must be held at least every other week. These conferences should be attended by residents and faculty representative of the disciplines involved. Examples of evidence to demonstrate compliance may include: Conference schedules Self-Study: Provide schedules in the appendix 2-17 Residents must be given assignments that require critical review of relevant scientific literature. Intent: Residents are expected to have the ability to critically review relevant literature as a foundation for 185 lifelong learning and adapting to changes in oral health care. This should include the development of critical evaluation skills and the ability to apply evidence-based principles to clinical decision-making. Describe how residents learn to identify and critically review scientific literature. Describe a typical literature review assignment and provide an example in the appendix. Residents participate in the following: (check all that apply) Journal Club Literature Reviews Development of Journal Abstracts Examples of evidence to demonstrate compliance may include: Evidence of experiences requiring literature review Self-Study: Provide examples of experiences in the appendix Program Length 2-18 the duration of the program must be at least two consecutive academic years with a minimum of 24 months, full-time or its equivalent. Is the program at least two consecutive academic years with a minimum of 24 months, full-time or its equivalent? Examples of evidence to demonstrate compliance may include: Program schedules Self-Study: Provide schedules in the appendix Curriculum plan Self-Study: Provide curriculum plan in the appendix or cross-reference with Standard 2-1 2-19 Where a program for part-time residents exists, it must be started and completed within a single institution and designed so that the total curriculum can be completed in no more than twice the duration of the program length. Intent: Part-time residents may be enrolled, provided the educational experiences are the same as those acquired by full-time residents and the total time spent is the same. Where deficiencies are noted, corrective actions must be taken; and c) maintains a personal record of evaluation for each resident that is accessible to the resident and available for review during site visits. If evaluations are not conducted at least two times a year, please explain any activities underway to address this situation. Self-Study Analysis: 187 Is the program director board certified or educationally qualified in orofacial pain? Does the program director have a full-time appointment in the sponsoring institution with a primary commitment to the orofacial pain program? Responsibility Program administration Development and implementation of curriculum plan Ongoing evaluation of program content, faculty teaching, and resident performance Evaluation of resident training and supervision in affiliated institutions and off-service rotations Maintenance of records related to the educational program Resident selection Preparing graduates to seek certification by the American Yes No 1. Provide data regarding faculty responsibilities and qualifications (Exhibits 11 and 12 are suggested for presenting this information) 2. Describe how the teaching staff members are oriented to the philosophy and objectives of the In the event of a change in program personnel, how is program continuity ensured? Assess the adequacy of the size and time commitment of the teaching staff Examples of evidence to demonstrate compliance may include: Full and part-time faculty rosters Self-Study: Provide above items in the appendix. Program and faculty schedules Completed BioSketch of faculty members with major responsibilities to the program (Exhibit 13) Criteria used to certify a non-specialist faculty member as responsible for a specialty teaching area Self-Study: Provide above items in the appendix Documentation that non-specialist faculty members are responsible for a specialty teaching area On-Site: Prepare the above items for review by the visiting committee 3-4 A formally defined evaluation process must exist that ensures measurements of the performance of faculty members annually. Include the frequency of evaluations, who performs the evaluation, whether it is documented, and whether written performance evaluations are shared with individual faculty. Examples of evidence to demonstrate compliance may include: 189 Faculty files On-Site: Prepare the above items for review by the visiting committee Performance appraisals Self-Study: Provide a blank faculty performance evaluation form if utilized On-Site: Prepare above items for review by visiting committee 3-5 A faculty member must be present in the clinic for consultation, supervision, and active teaching when residents are treating patients in scheduled clinic sessions. Intent: this standard does not preclude occasional situations where a faculty member cannot be available. Faculty members should contribute to an ongoing resident and program/curriculum evaluation process. Describe how it is ensured that a faculty member is present in the dental clinic for consultation, supervision, and active teaching when residents are treating patients in scheduled clinic sessions. Provide a monthly faculty clinic schedule in the appendix; include only one page if the schedule remains the same for all 12 months. Examples of evidence to demonstrate compliance may include: Faculty clinic schedules Self-Study: Provide the schedules in the appendix 3-6 Adequate support staff, including allied dental personnel and clerical staff, must be consistently available to allow for efficient administration of the program.