Researchers have discovered that our friendly gut bacteria, vital partners in fermenting and processing our everyday food, turn on us in times of stress such as major surgery, cancer chemotherapy or bowel disease and seize the opportunity to create havoc and kill our other probiotic bacteria.

Swimmer’s Ear, infections from wearing contact lenses, and puncture wounds in children’s feet which turn septic are all caused by the common bacteria Pseudomonas aeruginosa, which is widely found in soil, water and sewage. While only 3% of people normally harbour this organism in their intestines, during hospitalization for critical illness, more than 50% of patients end up with this bacteria. Most of the time Pseudomonas aeruginosa lives within our guts in peaceful co-existence when we have plenty of food and good health. But in times of stress such as during hospital stays they rapidly turn on us and become concerned only for their own survival. Patients infected with Pseudomonas aeruginosa have a high fatality rate approaching 40%.

“Since most hospital acquired infections develop from bacteria we already have in our guts, working out how to shield them from the stress molecules we produce may be a more effective treatment than trying to use antibiotics to kill them”, says medical researcher Professor Olga Zaborina from the University of Chicago, USA.

The scientists have discovered for the first time that these bacteria have a highly sophisticated sensing apparatus which recognises and intercepts chemical compounds we produce during stress such as endorphin hormones, immune system molecules such as interferon, and signals produced by damaged and oxygen starved tissues like adenosine.

“This means that the bacteria have evolved a way of taking advantage of any opportunity through their highly refined ‘sense and respond circuits’ which can identify the very molecules we humans use to respond to stress or illness”, says Professor Zaborina. “This virulence circuitry is so clever that P. aeruginosa can recognise our weakness, communicate this information to other bacteria, and simultaneously release compounds which kill our normal probiotic gut bacteria”, giving them home field advantage right off the bat.

Currently over-using antibiotics in hospitals is causing major problems with the spread of antibiotic resistance amongst bacteria. Even ordinary environmental bacteria have evolved a highly sophisticated mechanism to become resistant to antibiotics, enabling them to kill badly stressed and weak patients. Intestinal bacteria such as P. aeruginosa are a particular problem because they form a protective slime, called a biofilm, which stops antibiotics from killing them. Even within the slime they can still sense and respond to a host’s stress chemicals, causing infections.

The only treatments available until now have been a ‘take no prisoners’ approach using antibiotics which kill several types of bacteria including the normal, protective, probiotic bacteria in our guts, further weakening the patient.

“If we do not find a strategy to contain intestinal bacteria rather than eliminating them, which helps spread resistance, we will soon run out of effective antibiotics”, says Professor Zaborina. “We know of many diseases caused or complicated by intestinal bacteria such as Inflammatory Bowel Disease, infectious diarrhoea, or cancer treatments such as chemotherapy and bone marrow transplants”.

“Yet in all these cases specific bacterial strains responsible for the problem cannot always be identified, because the species are difficult to culture”, says Professor Zaborina. In addition it is not just the mere presence of the strains in the intestine that may be threatening, but rather the state of their virulence, which is not routinely examined clinically. “Exposing the Dr Jekyll and Mr Hyde nature of intestinal bacteria is a key to understanding how they behave. We cannot afford to ignore their will to survive during stress”.

The scientists suggest that in future paying better attention to the needs of our gut bacteria, especially when someone is sick, dehydrated, starved or stressed, could help to reduce the need for antibiotics and lead to a lower hospital acquired infection rate.

About the SOCIETY FOR GENERAL MICROBIOLOGY

The SGM has been established for over 50 years, promoting and supporting the art, science and significance of microbiology and associated subjects worldwide.

SOCIETY FOR GENERAL MICROBIOLOGY
Marlborough House
Basingstoke Road, Spencers Wood
Reading
RG7 1AG
socgenmicrobiol

On the occasion of the World Kidney Day 2007, on March 8th, The “American Journal of Nephrology” has published an article focusing on chronic kidney disease (CKD) as a global public health problem, and the urgent need for all countries to have a public health policy for CKD.

The message of World Kidney Day 2007 is that kidney disease is common, harmful and treatable. Until recently, decision makers in public health and biomedical science had viewed CKD as uncommon, without consequences and untreatable until the stage of kidney failure. The public health mandate is now clear: No country can afford to overlook the burden of CKD. The article outlines risk factors and strategies to come to grips with this problem.

In both developed and developing nations, a consistent picture is emerging of increased risk for CKD among people with cardiovascular disease (CVD) risk factors or established CVD. On the other hand, the most important adverse outcomes of CKD include not only complications of decreased glomerular filtration rate and progression to kidney failure, but also an increased risk of CVD. Most guidelines for CVD risk factor conditions and for CVD now recommend testing for CKD as well as different treatments for people found to have CKD compared to treatments for people without CKD.

In principle, a surveillance program for CKD stages 4-5 would enable all countries to monitor the magnitude and the care of this high-risk, high-cost population, and possibly to reduce the risk of progression to kidney failure, and reduce the cost of dialysis and transplantation. A surveillance program for patients with CKD stage 3 would reach many more people and might also be an effective way to lower rates of CVD and death, especially among the elderly with CVD risk factors or CVD.

Strong, effective public health care policies focusing on prevention, detection and treatment of these common chronic diseases including investment in basic and clinical research may also reduce the risk of developing CKD.

About S. KARGER AG

With over a century of experience in connecting the world of biomedical science, Karger publishes nearly 80 scientific, peer-reviewed journals and 150 serial and non-serial books and supplement issues annually for a global scientific readership.

S. KARGER AG
Allschwilerstrasse 10
P.O Box
CH-4009 Basel

karger

A new study reveals the true costs of the increase in maternal obesity and how it is impinging on service delivery in the NHS.

It was carried out by The Centre for Food, Physical Activity and Obesity Research at the University of Teesside with 33 healthcare professionals based in the North East of England recruited for the study.

The results are published in this month’s BJOG: An International Journal of Obstetrics and Gynaecology.

Previous studies have concentrated on the effects of obesity on pregnant women and the subsequent public health risks.

The findings of this study uncover 5 recurrent themes relating to maternal obesity: booking appointments, equipment, care requirements, complications and restrictions and current and future management of care. The main points are summarised below.

Equipment

Obese patients require specialised equipment for surgical deliveries including theatre tables and scales. Other equipment such as specially modified ward beds, chairs and wheelchairs are required. The costs of these, though considered less-expensive, are cumulative.

Care requirements

More guidance is required in antenatal and postnatal care provision as obese women have higher levels of maternal morbidity and a higher dependency on care. The risks involved include misdiagnosing conditions such as high blood pressure and determining fetal size. There is more demand for one-to-one specialist care, specifically, for a consultant obstetrician to be available at the time of birth rather than a registrar. All those interviewed also agreed that multidisciplinary care (MCD) is needed, with dietetic and physiotherapy services working with maternity units when caring for an obese patient. Given these extra demands, there are further implications on waiting times and staff resources.

Complications and restrictions

Obesity results in problems for the mother throughout the antenatal period. Common problems include deep vein thromboses (DVT), incontinence, diabetes and pre-eclampsia. Problems extend into the labour stage such as the need for increase pain relief and reduced mobility for women during labour. Complications during delivery for the baby include fetal distress and birth trauma. Postnatal problems for obese mothers include increased support for breastfeeding, and a higher rate of infection because of the slower rate of healing in obese women.

Maternal obesity also reduces patient choice. There are restrictions for pool and, in some cases, home births. Given the higher incidence of emergency interventions, emergency caesareans are usually carried out for obese patients.

Better and more consistent maternal nutrition guidelines are needed. Pregnant women that are obese need to be informed about the appropriate weight gain and made aware about the issues surrounding their condition and how to manage the potential risks to mother and baby if weight is not controlled.

Healthcare professionals agreed that consistency of tone is required in the way obese women are communicated to given the difficulties and emotions involved. There is a need to strike a balance between providing information and doing it sensitively so patient dignity is maintained. Similarly, obese mothers need to realise that they must take responsibility by managing their body weight sensibly.

Lead researcher Nicola Heslehurst said the research team was alerted to the growing problem by anecdotal evidence from midwives and other staff in maternity units in the region who were getting extremely concerned about the apparent increase in the number of women who were obese at the start of their pregnancy. “Doctors and midwives in the region have expressed concerns about the increase in complications that can arise when mums are obese. One of the problems is that sometimes you can’t see the ultrasound scan of the baby properly in obese pregnant women and this can lead to clinical problems as well as being upsetting for the parents who are not able to see a picture of their baby”

Professor Carolyn Summerbell, who heads up the University of Teesside’s Centre for Food, Physical Activity and Obesity Research, said: “We’re not trying to blame or stigmatize obese pregnant mothers and we would certainly not recommend that overweight mums-to-be go on crash diets. But our initial findings show reasons for concern with obese pregnant mothers, and there is a lack of weight management guidance and support readily available for them”.

Prof. John Wilkinson said “Until the late 1980s the height and weight of pregnant women was regularly monitored. But this became unfashionable in recent years as it was felt this caused unnecessary concern and worry to women who had gained a couple of extra pounds. But our study recommends that a routine system of monitoring the height and body weight of pregnant mothers is extended to all maternity units. This will allow comparisons between different social groups, ages and whether the mothers were having their first child and whether they were in employment. It will also enable us to judge the effectiveness of health promotion activities aimed at pregnant mothers.”

Dr Judith Rankin, Associate Director of the Regional Maternity Survey Office (RMSO) and a partner in the study, said: “This research will help to inform the NHS about the changes needed to the way service delivery is carried out and how the information is collected.”

Professor Philip Steer, editor-in-chief of BJOG said, “Over the years, the obesity problem has slowly crept up on us and now has the potential to assume epidemic proportions if we are not careful.”

“Based on the findings of this piece of research, we know the economic and social impacts of maternal obesity. Action is needed to ensure that the problem is dealt with immediately, with the sensitivities of all involved carefully considered. Much forward planning and co-ordination is required and public education campaigns should focus on a healthy lifestyle agenda, starting in our primary schools. We need to nip this in the bud or maternity services will suffer as a result.”

TEESSIDE UNIVERSITY
Middlesbrough
Tees Valley
TS1 3BA
tees.ac

Reforms are urgently needed to improve the health needs of people in the last phase of life, say doctors in this week’s BMJ.

Our health care systems do not reliably meet the needs of people living with serious illness in the last phase of life, write Sydney Dy and Joanne Lynn, two palliative care doctors based in the United States.

Even though contrary evidence is all around us, we use language – and build health care systems – as if disability and ill health were aberrations, rather than an expected phase that lasts months or years nearer the end of most of our lives, they say.

Yet only a few per cent of people in developed countries now die suddenly. Traditional hospital and surgical services no longer match most patients’ serious chronic illnesses, a fact that calls for substantial restructuring.

And since the numbers of people living with serious chronic conditions in old age will double within the next two decades in the United States and many other countries, finding sustainable ways to improve comfort and meaningfulness in this last phase of life has become a priority.

Patients coming to the end of life tend to follow one of three trajectories, with different priorities and needs, they explain. For example, patients with a short period of decline most need continuity of care and aggressive symptom management. Those with chronic organ system failure most need disease management and advance planning, while those with long-term dementia or frailty most need support services rather than intensive treatment.

Customising and reengineering care to match the needs, rhythms, and situations of these three trajectories offers a promising way to improve outcomes for patients sick enough to die, they say. If a community can build a care system that reliably serves patients in each trajectory in their area, then almost everyone there could count on good care in the last phase of life. This might create a reliable care system for this fragmented and inefficient part of the health care picture.

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Getting services right for those sick enough to die BMJ Volume 334 pp 511-13

Contact: Emma Dickinson

BMJ-British Medical Journal

Research in Wales has demonstrated that the Incredible Years parenting programme, an evidence-based programme developed at the University of Washington, Seattle, is very effective in reducing the likelihood of children going on to develop behavioural problems in the UK.

The study is published on bmj and is the first of its kind to demonstrate the effectiveness of the programme in a community setting.

Antisocial behaviour in young people is a growing problem. Around 5-10% of UK and US children aged 5-15 years present with clinically significant conduct disorders and the problem is highest in socially disadvantaged areas. Left untreated, up to 40% of children with early difficulties develop subsequent conduct disorder, including drug misuse, criminal and violent behaviour.

So researchers in North Wales set out to determine whether the Incredible Years programme, which teaches and develops parenting skills, could help prevent a child from developing conduct disorders.

The programme was delivered by existing Sure Start staff across North and Mid Wales. Sure Start is a government strategy aimed at providing parenting support for young children and their families in high-risk communities.

More than 150 parents from socially disadvantaged areas took part. All had children aged 3 and 4 years at risk of conduct disorder. Parents were either placed on the programme (12 weekly group sessions) or were put on a waiting list (controls).

Child behaviour and parenting skill were assessed at the start of the study and six months later both by parent report and by direct blind observation. Parents were also asked to self-rate their own feelings of depression, stress and ability to cope.

Children on the programme showed significantly reduced antisocial and hyperactive behaviour, and increased self-control, compared to control children. Parents reported a reduction in stress and depression levels and improved parenting skills.

The authors say this study holds “important lessons for the UK government because, unlike the disappointing results from the national evaluation of Sure Start, it shows that choosing an evidence-based programme … can achieve remarkable outcomes in high risk children whose parents generally fail to engage with services.”

They conclude: “It is important that Government commission effective services for high-risk conduct disordered children. They deserve evidence-based programmes, as do the public, who pay a high price for services and for the other costs of antisocial behaviour.”

In a separate paper, the researchers looked at the cost-effectiveness of the programme. Costs were measured from a public sector perspective including health, special educational and social services, and these were considered against the outcome of improved child behaviour based on parent report using the Eyberg Child Behaviour Index (ECBI), a commonly used measure of child behaviour and the primary outcome measure reported in the main study.

They calculated that it would cost ВЈ1344 to bring the average child on the programme to below the clinical cut-off point and ВЈ5486 to bring the child with the highest ECBI score to below the clinical cut-off point. The programme also appeared to be more cost effective in children at highest risk of developing conduct disorder.

This parenting programme involves a modest additional cost and demonstrates strong clinical effect, suggesting it would represent good value for money for public spending, they conclude.

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A pragmatic randomized controlled trial and cost effectiveness analysis of a parenting intervention in Sure Start services for children at risk of developing conduct disorder BMJ Online First

Contact: Emma Dickinson

BMJ-British Medical Journal

Calls made on cellular phones have no negative impact on hospital medical devices, dispelling the long-held notion that they are unsafe to use in health care facilities, according to Mayo Clinic researchers.

In a study published in the March issue of Mayo Clinic Proceedings, researchers say normal use of cell phones results in no noticeable interference with patient care equipment. Three hundred tests were performed over a five-month period in 2006, without a single problem incurred.

Involved in the study were two cellular phones which used different technologies from different carriers and 192 medical devices. Tests were performed at Mayo Clinic campus in Rochester.

The study’s authors say the findings should prompt hospitals to alter or abandon their bans on cell phone use. Mayo Clinic leaders are reviewing the facility’s cell phone ban because of the study’s findings, says David Hayes, M.D., of the Division of Cardiovascular Diseases and a study author.

Cell phone bans inconvenience patients and their families who must exit hospitals to place calls, the study’s authors say.

The latest study revisits two earlier studies that were done ‘in vitro’ (i.e., the equipment wasn’t connected to the patients), which also found minimal interaction from cell phones used in health care facilities. Dr. Hayes says the latest study bolsters the notion that cells phones are safe to use in hospitals.

Other Technology-Related Proceedings Articles Explore Concerns for Patients

Two other pieces in the March issue of Mayo Clinic Proceedings also address whether technological devices interfere with patient care equipment. Unlike the cellular phone study, the other reports detail technological devices that caused patient care equipment to malfunction.

A letter to the editor published in the journal details the first known case of a portable CD player causing an abnormal electrocardiographic (ECG) recording within a hospital setting. The recording returned to normal when the CD player, which the patient was holding close to the ECG lead, was turned off.

Technology also can threaten implantable rhythm devices such as pacemakers and defibrillators outside the hospital setting, according to a journal report. The report outlines two cases of retail stores’ anti-theft devices causing people’s heart devices to malfunction.

The anti-theft devices are commonly placed near store exits and entrances, triggering an alarm if customers leave with merchandise that was not purchased. In two instances in Tennessee, customers with a pacemaker and an implantable cardiac defibrillator experienced adverse reactions after nearing anti-theft devices.

The devices triggered the adverse reactions, sending both patients to emergency rooms for evaluation. The report’s authors recommend that the anti-theft devices be placed in areas of stores where customers won’t linger — away from vending machines or displays of sale merchandise, for instance — to help avoid future episodes.

Store employees also should be trained to move a customer who has collapsed near an anti-theft device when medically advisable, says J. Rod Gimbel, M.D, of East Tennessee Heart Consultants, and an author of the report. If they aren’t moved, they could experience recurring life-threatening malfunction to their implantable device, as did one patient who was described in the report.

“Simply moving the person away from the anti-theft device may save their life,” Dr. Gimbel says.

Though Gimbel’s report outlines only two cases of anti-theft devices causing implantable heart devices to malfunction, he asserts that similar instances are likely underreported, qualifying the problem as a potentially widespread public safety issue.

“Many times with public safety issues we wait until something bad occurs before we act,” Dr. Gimbel says. “Here’s an opportunity where we can make our knowledge public and head off future problems.”

In an accompanying editorial, John Abenstein, M.D., of Mayo Clinic’s Department of Anesthesiology, addresses the journal reports relating to the impact of technological devices on patient care equipment.

Dr. Abenstein says the risk of some technological devices upsetting the function of patient care equipment in hospitals appears to be small. The Food and Drug Administration(FDA) should take a more explicit stand on the matter, he says, so that health care facility policies can be altered when appropriate.

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Other authors of the cell phone study are Jeffrey Tri, Rodney Severson, and Linda Hyberger, all of Mayo Clinic Rochester. The other author of the anti-theft device report is James Cox Jr., M.D., of the University of Tennessee Medical Center-Knoxville.

A peer-review journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 80 years and has a circulation of 130,000 nationally and internationally. Articles are available online at mayoclinicproceedings/.

Contact: Traci Klein

Mayo Clinic

On March 13 and 14 a National Research Council committee will hold a meeting to gather information on the capacity of public transit to move people to or from critical locations in times of emergency in the 38 largest urbanized areas in the U.S. Public safety planners, national security coordinators, and representatives for the disabled will provide input to the committee, which will use the information in its development of a congressionally mandated report on this topic.

DETAILS:

The meeting will run from 9 a.m. to 5:30 p.m. on March 13 and from 8 a.m. to 1:30 on March 14 in Room 105 of the National Academies’ Keck Center, 500 Fifth St., N.W., Washington, D.C. More information is available online at www8.nationalacademies/cp/projectview.aspx?key=48703.

PARTICIPANTS INCLUDE:

* JOHN BENISON, chief, Policy Division, Office of Civil Rights, U.S. Department of Transportation

* JOSEPH KAMMERMAN, homeland security coordinator, D.C. Department of Transportation

* DONALD LUMPKINS, program specialist, Technical Assistance Division, U.S. Department of Homeland Security

* DAVID SCHNEIDER, equal opportunity specialist, Office of Civil Rights, Federal Transit Administration

* KATHERINE SIGGERUD, director, physical infrastructure issues, U.S. Government Accountability Office

* BRIAN WOLSHON, associate professor, Department of Civil and Environmental Engineering, Louisiana State University

* ROBERT YOUNG, public safety planner, Metropolitan Washington Council of Governments

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Contact: Maureen O’Leary

The National Academies

BioAlliance Pharma SA (Paris:BIO), a company dedicated to the treatment and supportive care of cancer and AIDS patients, announced positive preliminary results from the first Phase I trial of fentanyl Lauriad®.

This first randomized, single-centre trial in healthy volunteers has evaluated the pharmacokinetics of a single application of 2 different innovative muco-adhesive formulations of fentanyl Lauriad®. The fentanyl was detected in the plasma soon after the application of each formulation and plasma concentrations remained stable over the next 24 hours, with low intersubject variability, especially for one of the two formulations that will be used for subsequent clinical development. Both muco-adhesive buccal formulations displayed a good local safety profile. These preliminary results suggest that a single daily application of fentanyl Lauriad® may provide effective relief of severe chronic pain in cancer patients. The company is planning to perform a second pharmacokinetic repeated-dose study by the end of the year.

“The success of this first Phase I clinical trial with fentanyl Lauriad® relies on our original know-how in mucosal drug delivery”, explained Dominique Costantini, BioAlliance Pharma’s President and CEO. “The Lauriad® technology has been extended to fentanyl and enables molecules which can cross the mucosa to remain in the body for long periods. This is a very important step on the path to clinical development for fentanyl Lauriad®”.

About this first Phase I trial of fentanyl Lauriad®

This clinical trial was performed in healthy volunteers who were successively administered two innovative formulations one week apart according to a randomized design. The objective was to obtain stable fentanyl plasma concentrations over several hours. Fentanyl has already been shown to be systemically absorbed through the mucosal route leading to the development of fentanyl-based treatments for severe, acute pain. With the patented Lauriad® formulation, fentanyl is rapidly and continuously released in the oral mucosa and systemically absorbed. This concept of a sustained release addresses the treatment of cancer chronic pain.

Source
BioAlliance Pharma

Good sleep in later life reduces the risk of falls and depression, is essential for maintaining activity and performance levels, and reduces challenging behaviour encountered in dementia sufferers. A multi-disciplinary research project headed by the University of Surrey in collaboration with the Universities of Loughborough and Bath and King’s College London will address practice and policy relevant issues arising from the nature, impact and management of the sleep-wake balance in later life. It will extend and ‘join up’ strategically targeted areas of sleep research relevant to understanding and improving autonomy, active ageing, and quality of later life.

Professor Sara Arber of the University of Surrey Department of Sociology who will lead the research commented, “Sleep problems in later life are widespread and adversely affect quality of life, but remain under acknowledged and little researched. Our research will find out the ‘real life’ experiences of poor sleep among older people, and identify strategies for improving sleep and reducing reliance on sleeping pills.”

This 4 year research project is funded by a ВЈ2.3 million grant from the Economic and Social Research Council (ESRC)1 as part of the New Dynamics of Ageing Research Programme. Academic partners from six disciplines and four institutions, together with five non-academic partners, will achieve these objectives through research within eight inter-linked work packages (see somnia.surrey.ac).

A range of methods will be used to improve understanding of disrupted sleep and use of sleep medication in later life, including secondary analysis of existing large databases, and in-depth research with older people in the community and care homes. Interventions will be conducted to evaluate the effects of ‘blue-enriched’ light on quality of sleep in the community and care homes, evaluate a supported self-management programme for insomnia among chronically ill patients in general practice, and evaluate newly-developed sensor-devices to improve sleep. A user-friendly information and advice website on sleep will be developed, and a sleep education module will be prepared for the DIPEx website (dipex).

About SURREY UNIVERSITY

Surrey is a truly international university, drawing its students and staff from 140 countries around the globe, focusing its research and teaching on the real word, whilst fully recognising its responsibilities to the region it serves. We offer high-calibre teaching, a world-class research base, a thriving postgraduate community and a high quality of life in a beautiful campus setting. At the same time we have a strong eye for innovation and enterprise and are at the forefront of developments in teaching and research.

SURREY UNIVERSITY
Guildford
Surrey
GU2 7XH
surrey.ac

Poor dental health is a common medical problem for homeless people and a social stigma indicating poverty and alienation. A new thesis from Karolinska Institutet in Sweden presents unique research into homelessness and dental health.

“Homeless people associate oral health with feelings of human dignity,” says Patricia De Palma, dentist and author of a new doctoral thesis on homelessness and dental health. “If dental care is made more accessible, it could be an important link between homelessness and a tolerable life.”

The formal account of the dental health of the homeless the first ever makes depressing reading. The 147 homeless people included in the study had an average of 18 teeth each, eight less than the average Swede. Seventy per cent of the homeless had no toothbrush, and their remaining teeth were often in such a poor state that they had to be removed. Many found it difficult to chew and ingest food.

Using in-depth interviews, Patricia De Palma has also examined homeless people’s thoughts about dental care and dental health. The interviews, which were conducted both before and after dental treatment, show that dental care can achieve much more than healthy teeth.

“Many of those who’d lost teeth talked about a changed personal image,” she says. “They felt stared-at, amputated. After treatment, however, they felt that they had grown as people and become a little more normal.”

Despite the universal right to state-subsidised dental care, homeless people are effectively denied access to it, according to Patricia De Palma.

“We have the world’s best dental care in Sweden, but only for those who can pay,” she says. “This is unacceptable. The national health insurance and national dental insurance must be coordinated to make sure no one falls through the net.”

Since 2002, Patricia De Palma has been running a dental surgery in Stockholm for homeless people.

Thesis: Oral health among a group of homeless individuals from the dental professional’s and patient’s perspective.

About the KAROLINSKA INSTITUTET
KAROLINSKA INSTITUTET
SE-171 77 Stockholm
info.ki.se/index_se.html