Indications of antibiotic prophylaxis in dental practice- Review

Antibiotics are frequently used in dental practice. Clinical and bacteriological epidemiological factors determine the indications of antibiotics in dentistry. Antibiotics are used in addition to appropriate treatment to aid the host defences in the elimination of remaining bacteria. It is indicated when there is evidence of clinical sign involvement and spread of infection. Antibiotics are prescribed in dental practice for treating odontoge nic infections, non-odontogenic infections, as prophylaxis against focal and local infection. Special care needs to be addressed to patients with organ transplants, poorly controlled diabetes and pregnancy. Antibiotics should be used only as an adjunct to dental treatment and never alone as the first line of care. The present paper reviews the indications of antibiotics in dental practice.     

Influence of preoperative patient education on the risk of dislocation after primary total hip arthroplasty

Objective

Dislocation is a well‐known complication after total hip arthroplasty (THA), and is the second‐highest cause of revision surgery. Our objective was to assess the effect of preoperative patient education on the occurrence of hip dislocation within 6 months after primary THA.

Methods

Between 1998 and 2007, we conducted a prospective cohort study at the Geneva University Hospital Department of Orthopaedic Surgery, including all primary THAs performed via an anterolateral transgluteal approach with the use of a 28‐mm diameter head. The preoperative education session was introduced in June 2002 and included advice on muscle strengthening exercises and postoperative restrictions of range of motion as a means of preventing dislocation. The main outcome was the incidence of dislocation within 6 months of surgery.

Results

A total of 597 patients who underwent 656 THAs between June 2002 and June 2007 participated in the education session, whereas 1,641 patients who underwent 1,945 procedures did not. Forty‐six dislocations occurred over the study period, 5 (0.8%) in participants and 41 (2.1%) in nonparticipants (absolute risk reduction 1.3%; 95% confidence interval [95% CI] 0.4, 2.3), with the time interval between surgery and dislocation being significantly shorter among participants (0.2 versus 1.2 months). Nonparticipants had a 2.8 times higher risk of dislocation than participants (unadjusted odds ratio [OR] 2.80; 95% CI 1.10, 7.13). Adjustment for age, sex, comorbidities, and prior surgery did not change the results (adjusted OR 2.79; 95% CI 1.09, 7.15).

Conclusion

Our findings suggest that participation in a preoperative patient education session may reduce the risk of dislocation within 6 months after THA.     

Health care expenditures after introduction of a gatekeeper and a global budget in a Swiss health insurance plan

STUDY OBJECTIVES: To assess whether the introduction of "managed care" (capitated budget and utilisation control by general practitioners) in a Swiss health insurance plan caused a selective disenrolment of plan members, and whether it achieved its goal of reducing health care expenditures. DESIGN: Controlled before-after analysis of health insurance claims. SETTING: Health insurance plan of the University of Geneva, Switzerland, which introduced managed care at the end of 1992, and comparison plan, which reimbursed health care expenditures without setting a budget or controlling access. PARTICIPANTS: Analysis of self selection: university plan members who accepted (3993) or refused (659) transfer to managed care. Analysis of change in expenditures: cohorts of persons continuously enrolled in the university (1575) and comparison (3384) plans in 1992 and 1993. MAIN RESULTS: During 1992, the year before the transformation of the university plan, persons who refused managed care had generated 35% higher expenditures than those who accepted managed care (p < 0.001). Between 1992 and 1993, expenditures per member decreased by 9% in the university cohort and increased by 11% in the comparison cohort (p = 0.004). Technical procedures (laboratory tests, physical therapy, drugs) decreased most in the university plan. No impact on hospital admissions was detected. CONCLUSIONS: Introduction of gatekeeping and budget management by physicians caused a favourable self selection process for the university plan. In addition, the managed care plan achieved a substantial decrease in overall health care expenditures in its first year of operation, chiefly by reducing outlays for technical procedures.

 

     

Risk of major bleeding in unselected patients with venous thromboembolism.

PURPOSE: To evaluate the risk of major bleeding in unselected patients given anticoagulant treatment (heparin overlapped and followed by oral anticoagulants) because of deep vein thrombosis (DVT) or pulmonary embolism (PE). SUBJECTS AND METHODS: We screened the database of 1590 outpatients suspected of DVT and PE in prospective diagnostic studies conducted in Geneva between 1992 and 1998. RESULTS: Four hundred and eleven of 1590 patients (26%) were anticoagulated for confirmed venous thromboembolism (PE, 300; DVT, 111). One patient was excluded because of concomitant thrombolytic therapy. Five (1.2%; 95% confidence interval, 0.4-2.8) of the remaining 410 patients experienced a major hemorrhagic event during the 3-month follow-up, including two fatal events. All bleedings occurred during the first month of therapy (heparin, two; oral anticoagulants, two; combined treatment, one) and the median age of the patients who bled was 80 years. At least one serious comorbid condition associated with higher bleeding risk was present in four patients and, in one case, the bleeding was clearly related to an excessive intensity of anticoagulation. CONCLUSION: The rate of bleeding events in this population of unselected outpatients is similar to that reported in controlled therapeutic trials. The hemorrhagic events occurred early in the course of anticoagulant therapy and concerned old patients mostly affected by at least one comorbid condition. Particular care should be used to avoid the risk of overtreatment.     

Platelet count at term pregnancy: a reappraisal of the threshold

OBJECTIVE: To assess the safety of a new platelet count threshold for the definition of maternal thrombocytopenia late in pregnancy. METHODS: A platelet count was performed in 6770 pregnant women late in pregnancy and in 6103 of their newborns as well as in a control group of 287 age-matched nonpregnant healthy women. RESULTS: The prevalence of maternal thrombocytopenia (platelet count less than 150 x 10(9)/L) was 11.6%. The mean platelet counts (248 compared with 213 x 10(9)/L) and 2.5th percentile (164 compared with 116 x 10(9)/L) were significantly higher in healthy nonpregnant women than in pregnant women. Among thrombocytopenic pregnant women, 621 (79%) had platelet counts between 116 and 149 x 10(9)/L; none (0%; 95% confidence interval 0, 0.6) had complications related to thrombocytopenia, and none of their newborns had severe thrombocytopenia (platelet count less than 20 x 10(9)/L). CONCLUSION: In healthy pregnant women, a platelet count over 115 x 10(9)/L late in pregnancy does not require further investigation during pregnancy and may be considered a safe threshold.     

Ortner's syndrome: - case series and literature review

More than a century ago, Ortner described a case of cardiovocal syndrome wherein he attributed a case of left vocal fold immobility to compression of the recurrent laryngeal nerve by a dilated left atrium in a patient with mitral valve stenosis. Since then, the term Ortner's syndrome has come to encompass any nonmalignant, cardiac, intrathoracic process that results in embarrassment of either recurrent laryngeal nerve-usually by stretching, pulling, or compression; and causes vocal fold paralysis. Not surprisingly, the left recurrent laryngeal nerve, with its longer course around the aortic arch, is more frequently involved than the right nerve, which passes around the subclavian artery.ObjectivesTo discuss the pathogenesis of hoarseness resulting from cardiovascular disorders involving the recurrent laryngeal nerve along with the findings of literature review.Materials and methodsThis paper reports a series of four cases of Ortner's syndrome occurring due to different causes.DesignCase study.ResultOrtner's syndrome could be a cause of hoarseness of voice in patients with cardiovascular diseases.ConclusionAlthough hoarseness of voice is frequently encountered in the Otolaryngology outpatient department, cardiovascular- related hoarseness is an unusual presentation. Indirect laryngoscopy should be routinely performed in all cases of heart disease.     

Overuse of mammography during the first round of an organized breast cancer screening programme

Objectives  We examined the frequency of mammography screening among women who had had a screening mammogram recently and therefore generally did not need to repeat the examination.
Methods  A population-based sample of 50- to 69-year-old women were surveyed immediately before and 8 months after they received an invitation to participate in the first round of screening of the newly organized mammography screening programme in Geneva, Switzerland. These women also received a booklet that included the recommendation to have screening mammograms at 2-year intervals.
Results  The baseline survey identified 660 women who had had a mammogram within the previous 12 months. Of these, 23.2% [95% confidence interval (CI), 20.0–26.6] had an opportunistic mammogram and 4.1% (95% CI, 2.7–5.9) had an organized mammogram during follow-up. Women who had had their last mammogram 6–12 months prior to baseline (vs. more recently), intended to have a mammogram within the next 6 months, wished to receive more information on mammography screening, and had a history of surgical breast biopsy were more likely to have an unnecessary screening mammogram (either organized or opportunistic) during follow-up. Compared with women who had an opportunistic mammogram, women who had an organized mammogram were more likely to be of lower socioeconomic status, to have made their own screening decision and to have anticipated the date of their next mammogram by no more than a few months.
Conclusions  Opportunistic mammography screening in excess of recommendation is common, and persists despite explicit advice about recommended screening frequency.     

17β-OESTRADIOL ENHANCES NITRIC OXIDE SYNTHASE ACTIVITY IN ENDOTHELIUM-DENUDED RAT AORTA

1. It has been suggested that oestrogen-produced vasodilatation is due to induction of endothelial nitric oxide synthase (NOS), but there are many reports of direct effects on vascular smooth muscle. In the present study, these processes were investigated in rat aorta isolated from ovariectomized rats. 2. Short-term treatment (10min) with 17β-oestradiol (10 μmol/L) produced a small attenuation of the phenylephrine (PE)-induced constriction, which was unaffected by the nitric oxide synthase inhibitor l-N 5(-1-iminoethyl)ornithine (NIO; 100μmol/L). Long-term treatment (6h) with 17β-oestradiol (10 μmol/L) did not affect acetylcholine-mediated vasorelaxation in endothelium-intact aortic rings, but did attenuate PE-induced constriction. This attenuation was also observed in endotheliumdenuded preparations after 17β-oestradiol (10 μmol/L for 6h) and was far greater than the acute effect of 17β-oestradiol (10 μmol/L). 3. The attenuation produced by 17β-oestradiol (10 μmol/L for 6 h) was significantly inhibited by concomitant treatment with cycloheximide (1 μmol/L), suggesting that protein synthesis was involved. NIO (100 μmol/L) also attenuated the effect, which suggests that the anti-constrictor effect of 17β-oestradiol occurs through the increased production of nitric oxide (NO). 17β-Oestradiol increased NO production, as assessed by the conversion of [³H]-arginine to [³H]-citrulline in rat aorta. These effects were prevented by cycloheximide and NIO. The anti-constrictor effect of oestrogen was blocked by the oestrogen receptor antagonist ICI 182780 (100nmol/L). 4. Western blotting using an antibody specific for inducible nitric oxide synthase (NOS) revealed that 17β-oestradiol (10 μmol/L for 24 h) treatment induced the formation of inducible NOS protein in the aorta, an effect blocked by cycloheximide. The results indicate that 17β-oestradiol can attenuate the vasoconstrictor effect of PE by a specific receptor-mediated process that involves induction of inducible NOS.