Conservative Posterior Tooth Restorations

Conservative restorations for posterior teeth (noncrowns) are in a significant evolution, as tooth-colored restorations are showing strong competition for traditional silver amalgam and gold alloy restorations. Resin restorations (direct and indirect inlays and onlays, and directly placed) are major preferences, but porcelain inlays and onlays are favored also. Dentists are advised to inform their patients about the availability of the various types of restorations discussed in this paper. This education will stimulate discussion about their choices and will provide optimum patient satisfaction with the result.     

A Hyperkinetic Heart in Uncomplicated Active Acromegaly

Cardiac function was studied by echocardiography in 12 patients with active acromegaly and in 12 age- and sex-matched healthy control subjects. None of the patients had cardiovascular diseases or other endocrine diseases than acromegaly. The patients had a mean age of 39±5 years and were short-term acromegalic with a mean duration of disease of 6±3 years. Mean left ventricular mass was 163±43 g/m² in the acromegalic group versus 120±24 g/m² in the control group. Preload (the diastolic diameter of the left ventricle) was within normal limits, while afterload (end-systolic meridional wall stress) was significantly decreased in the acromegalic group. Myocardial contractility assessed as fractional shortening of the left ventricle was 39.9±3.6% in the acromegalic group versus 32.9±5.1% in the control group, and cardiac output was increased by 52% in the acromegalic group because of increased heart rate and stroke volume. We suggest that augmented peripheral blood flow is responsible for the condition of cardiac hyperkinesia in short-term acromegaly and involved in the development of hypertension, which is a frequent complication of long-term acromegaly.     

Differences in Referral Rates from General Practice

There are many unexplained differences in the rates at whichgeneral practitioners make referrals to other medical specialists.This study investigated 17 586 referrals from 141 general practitionersto specialists in seven specialties in Ringkjøbing countyin Denmark. As an expression of the referral rate, a referralindex was estimated for every general practitioner. The referralindex was the number of referrals to the specialist per 1000patients per year, including children, standardized for ageand sex to the average population in Ringkjøbing county.The following six variables were evaluated in relation to thereferral index: specialists in the local area, doctors per practice,consultations per general practitioner per year, patients registered,consultations per 1000 patients per year standardized for ageand sex, and supplementary procedures per consultation. Stepwisemultiple regression analysis was used. The study showed thatthe referral index rose both with a better access to specialistand with an increasing number of consultations per practitionerper year. The referral index fell with increased numbers ofpatients registered. No correlation was found between the referralindex and number of supplementary procedures per consultation,number of doctors per practice and number of consultations per1000 patients per year.     

Excessive Hypercalcaemia and Mixed Connective Tissue Disease

ABSTRACT A 23-year-old female with extreme hypercalcaemia was treated with calcitonin, mitramycin and parathyroidectomy and normocalcaemia was achieved after 4 weeks. Nevertheless, the patient later died of cutaneous necrosis, impaired circulation and multiple organ failure. Serum immunoreactive parathyroid hormone was in the normal range and parathyroid tissue normal. Mixed connective tissue disease was diagnosed on the basis of high titers of antibody to extractable nuclear antigen, moderately elevated levels of antibody to nuclear antigen and only marginal elevation of anti-double standed DNA. The role of Cl. difficile toxin in the blood and an acinic cell tumour is unclear.     

SPINAL ANAESTHESIA IN YOUNG PATIENTS USING A 29-GAUGE NEEDLE: TECHNICAL CONSIDERATIONS AND AN EVALUATION OF POSTOPERATIVE COMPLAINTS COMPARED WITH GENERAL ANAESTHESIA

One hundred patients aged 18–49 yr, undergoing electivearthroscopy of the knee joint, were allocated randomly to eitherspinal anaesthesia using a 29-gauge spinal needle or generalanaesthesia. Dural puncture was considered difficult in 18%of the patients receiving spinal anaesthesia. In three patients(6%) it was necessary to supplement the spinal anaesthetic withgeneral anaesthesia. Spinal and general anaesthesia were otherwiseuneventful in all patients. The incidence of postoperative headachewas similar in the two groups. One patient developed post duralpuncture headache following spinal anaesthesia. This headachewas of short duration and disappeared without treatment. Spinalanaesthesia caused more backache than general anaesthesia, otherwisethe frequency of postoperative complaints was the same or lower.Ninety-six percent of the patients receiving spinal anaesthesiawould prefer the same anaesthetic for a similar procedure inthe future ^*Department of Anaesthesiology, Hvidovre University Hospital,DK-2650 Hvidovre, Copenhagen, Denmark     

Cryptic structural lesions in refractory partial epilepsy: MR imaging and CT studies

Results of contrast material-enhanced computed tomography (CT) and T2-weighted spin-echo magnetic resonance (MR) imaging were correlated with pathologic findings in 25 patients treated surgically for refractory partial epilepsy. Of 12 lesions present, ten (83%) were detected by MR imaging and seven (58%) by CT scanning. Of nine low-grade gliomas, eight were detected by MR imaging and four by CT scanning. One posttraumatic scar and one case of temporal lobe atrophy were better demonstrated by MR imaging. A small, thrombosed arteriovenous malformation was the only lesion detected by CT scanning but not by MR imaging. No lesions were detected in 13 patients with mild gliosis and one patient with a 1.2-cm grade 1 astrocytoma. Although more sensitive than CT for detection of structural lesions in patients with refractory partial epilepsy, MR imaging resulted in a 25% false-negative diagnostic rate when a repetition time of 2,000 msec and echo time of 60 msec were used. Multi-echo imaging with at least one long echo time may be needed to increase the sensitivity of MR imaging in these patients.     

CONTINUOUS SUBCUTANEOUS PUMP INFUSION OF SOMATOSTATIN ANALOGUE SMS 201-995 VERSUS SUBCUTANEOUS INJECTION SCHEDULE IN ACROMEGALIC PATIENTS

Diurnal serum GH patterns were determined in 10 acromegalic patients before treatment, after 3 d continuous s.c. pump infusion and then after 3 d with three equal daily s.c. injections in both instances totalling 100 μg/24 h. Subcutaneous injections (33 μg) induced impressive suppression of serum GH lasting 3-6 h in eight patients followed by escape to pretreatment values before the next injection. In contrast, continuous infusion resulted in greater and more stable 24 h suppression to the levels reached at the nadir between injections. Suppression of mean 24 h serum GH below 5 ng/ml was achieved by pump treatment in four patients, while two patients had mean values between 5 rig/ml and 10 ng/ml. In four patients occasional or all levels were above 10 ng/ml (24 h average 12.4-102 ng/ml) implying either that adequate suppression by the SMS 201-995, was impossible during the 3 d pump infusion period, or that the dose administered was inadequate. Carbohydrate tolerance was unaffected in either regimen, indicating that reduction in insulin antagonistic hormones balanced inhibition of insulin release. Interestingly, and in contrast to somatostatin, SMS 201-995 did not inhibit TSH release. No untoward effects were observed at the moderate dosage and blood clinical chemistry was unchanged. Fairly constant diurnal serum SMS 201-995 values were obtained during pump infusion, while levels undulated inversely with serum GH during injection treatment. Average diurnal serum somatostatin-C immunoreactivity (all patients) decreased from 496 ± 129 (mean ± SD) to 385 ± 100 ng/ml ( P < 0 003) during pump treatment and did not decrease further during the following 3 d injection treatment (363 ± 76 ng/ml).     

THIOPENTONE SENSITIVITY IN YOUNG AND ELDERLY WOMEN

Induction and maintenance doses of thiopentone were smallerin eight elderly women than in eight younger women. Mean venousanaesthetic concentrations were 34% less (P = 0.02) in the elderly.For each patient an "expected maintenance dose" was calculatedfrom serum clearance and the area under the curve during theanaesthesia. In the elderly the average expected dose was equalto the dose given, but in the younger patients the dose givenwas greater than the expected (P<0.02). In younger women,but not in the elderly, a high cardiac output was accompaniedby the need for a relatively high maintenance dose if a certainserum concentration was to be maintained. Cardiac output wasequally reduced in both patient groups (30–40%). Afterinduction the heart rate was reduced in the elderly during theentire period of anaesthesia and always more than in the younger.No correlation was found between serum concentration of thiopentoneand haemodynamic effects.     

INFLUENCE OF AGE AND SEX ON THE PHARMACOKINETICS OF THIOPENTONE

Thiopentone was given to eight women and eight men (60–79yr). The disappearance of thiopentone from the venous bloodwas described by a three-compartment open model. The only significantdifference between the sexes was a higher initial venous concentrationin males. The dose (mg kg ^–1) for induction was 70% ofthe value (P<0.05) previously reported for a comparable groupof younger men and women (20–40 yr). The volumes of distributionV₂ and V₃ were larger in the elderly (P<0.05). The terminalhalf-lives were increased with advancing age (from 75% to 100%on average) (P0.01). The clearance value was 50% greater inthe older women than in a group of young women. For all groupsa significant correlation between initial drug concentrationand k₁₂ supported the hypothesis that the redistribution rateconstant k₁₂ is the predominant factor in the pharmacokineticprofile of a dose of thiopentone sufficient to obtund the eyelashreflex.