Regional variation in hospitalisation and mortality in heart failure: comparison of England and Lombardy using multistate modelling

Heart failure (HF) is a common, serious chronic condition with high morbidity, hospitalisation and mortality. The healthcare systems of England and the northern Italian region of Lombardy share important similarities and have comprehensive hospital administrative databases linked to the death register. We used them to compare admission for HF and mortality for patients between 2006 and 2012 (n = 37,185 for Lombardy, 234,719 for England) with multistate models. Despite close similarities in age, sex and common comorbidities of the two sets of patients, in Lombardy, HF admissions were longer and more frequent per patient than in England, but short- and medium-term mortality was much lower. English patients had more very short stays, but their very elderly also had longer stays than their Lombardy counterparts. Using a three-state model, the predicted total time spent in hospital showed large differences between the countries: women in England spent an average of 24 days if aged 65 at first admission and 19 days if aged 85; in Lombardy these figures were 68 and 27 days respectively. Eight-state models suggested disease progression that appeared similar in each country. Differences by region within England were modest, with London patients spending more time in hospital and having lower mortality than the rest of England. Whilst clinical practice differences plausibly explain these patterns, we cannot confidently disentangle the impact of alternatives such as coding, casemix, and the availability and use of non-hospital settings. We need to better understand the links between rehospitalisation frequency and mortality.     

Sealing ability of a new polydimethylsiloxane-based root canal filling material

We tested the null hypothesis that there is no difference in the sealing ability of GuttaFlow, RoekoSeal, and AH26 in root canals. Sixty extracted mandibular premolars were filled with AH26 (lateral compaction), RoekoSeal, or GuttaFlow (modified single-cone). The sealing ability of the root canal fillings was measured weekly (4 weeks) by using a glucose penetration model. Kruskal-Wallis test revealed significant differences in glucose penetration between the experimental groups at weeks 1, 2, 3, and 4. Whereas GuttaFlow showed the highest amount of leakage at all times, AH26 showed the lowest. There was no significant difference between RoekoSeal-filled and AH26-filled root canals throughout the experimental period. AH26 showed better sealing ability in root canals than GuttaFlow.     

The pharmacokinetics and cardiovascular effects of high-dose articaine with 1:100,000 and 1:200,000 epinephrine

OBJECTIVES: The authors conducted a randomized, double-blind, two-way crossover clinical trial to compare the pharmacokinetics and cardiovascular effects of 11.9 milliliters of 4 percent articaine hydrochloride (HCl) plus 1:100,000 epinephrine (A100) with those of 11.9 mL of 4 percent articaine HCl plus 1:200,000 epinephrine (A200). METHODS: During two testing sessions, the authors administered injections of A100 and A200 over a seven-minute period (in one-cartridge doses unless otherwise noted): maxillary right first molar infiltration, maxillary left first molar infiltration, maxillary right first premolar infiltration, maxillary left first premolar infiltration, right inferior alveolar injection, left inferior alveolar injection, right long buccal infiltration (one-half cartridge) and left long buccal infiltration (one-half cartridge). They analyzed venous blood samples for articaine levels. They used noninvasive acoustic tonometry to measure a variety of cardiovascular parameters over a two-hour period. RESULTS: Plasma concentration curves of articaine over time were similar for both solutions, with peak concentrations and times to maximum concentration being 2,037 nanograms per milliliter and 22 minutes for A100 and 2,145 ng/mL and 22 minutes for A200. At the 10-minute point, the mean systolic blood pressure and heart rate were significantly elevated (P < .05) with A100 versus A200. CONCLUSIONS: Maximum dose recommendations for the A100 solution also can be applied to the A200 solution. A200 produces less cardiovascular stimulation than does A100. CLINICAL IMPLICATIONS: A200 is as safe as A100, and may be preferable to A100 in patients with cardiovascular disease and in those taking drugs that reportedly enhance the systemic effects of epinephrine.     

Understanding and managing patients with chronic pain

The specialty of oral and maxillofacial surgery has had at its core the foundations of anesthesia and pain and anxiety control. This article attempts to refamiliarize the reader with clinical pearls helpful in the management of patients with chronic pain conditions. The authors also hope to highlight the interplay of chronic pain and psychology as it relates to the oral and maxillofacial surgery patient. To that end, the article outlines and reviews the neurophysiology of pain, the definitions of pain, conditions encountered by the oral and maxillofacial surgeon that produce chronic pain, the psychological impact and comorbidities associated with patients experiencing chronic pain conditions, and concepts of multimodal treatment for patients experiencing chronic pain conditions.     

The development of a dental diagnostic terminology

There is no commonly accepted standardized terminology for oral diagnoses. The purpose of this article is to report the development of a standardized dental diagnostic terminology by a work group of dental faculty members. The work group developed guiding principles for decision making and adhered to principles of terminology development. The members used an iterative process to develop a terminology incorporating concepts represented in the Toronto/University of California, San Francisco/Creighton University and International Classification of Diseases (ICD)-9/10 codes and periodontal and endodontic diagnoses. Domain experts were consulted to develop a final list of diagnostic terms. A structure was developed, consisting of thirteen categories, seventy-eight subcategories, and 1,158 diagnostic terms, hierarchically organized and mappable to other terminologies and ontologies. Use of this standardized diagnostic terminology will reinforce the diagnosis-treatment link and will facilitate clinical research, quality assurance, and patient communication. Future work will focus on implementation and approaches to enhance the validity and reliability of diagnostic term utilization.     

A prospective multicenter evaluation of 1,583 3i implants: 1- to 5-year data

PURPOSE: The purpose of this prospective multicenter study was to evaluate the efficacy of 3i threaded implants for the treatment of edentulous patients in a 1- to 5-year period. This article reports the total data and global results of 3 threaded designs of 3i implants: self-tapping, ICE, and Osseotite. MATERIALS AND METHODS: A total of 1,583 implants (619 ICE, 545 Osseotite, and 419 self-tapping) were placed between 1995 and 1999 in 528 patients at 13 European clinical centers. The average age of the patients was 53.6 years. Clinical and radiographic evaluations were performed annually for up to 5 years. RESULTS: Of the total implants, 707 were placed in the maxilla and 876 in the mandible. A total of 1,162 implants were placed in posterior segments. Forty-eight implants were lost to follow-up and 55 were failures. The most frequent prosthetic indication was the short-span fixed prosthesis (440 cases), followed by 172 single-tooth replacements, 56 long-span prostheses, and 4 overdentures. Radiographic evaluation after 6, 12, and 24 months of implant loading showed, respectively, mean crestal bone loss of 0.04 +/- 1.3 mm, 0.12 +/- 1.6 mm, and 0.2 +/- 1.7 mm. A cumulative survival rate of 96.5% was observed 5 years after implant placement, with 97.2% survival in the maxilla and 95.8% in the mandible. The survival rate was similar in anterior (96.7%) and posterior (96.5%) segments. DISCUSSION: A total of 55 failures were reported in this study with 47 early failures and 8 late failures. The rate of late failures is of utmost importance for the restorative dentist. CONCLUSION: This clinical study gives evidence of very high success rates using 3 threaded designs of 3i implants.     

Preemptive rofecoxib and dexamethasone for prevention of pain and trismus following third molar surgery *

Objective The goal of this preliminary randomized prospective clinical trial was to compare the analgesic efficacy and the reduction in trismus of preoperative rofecoxib, intraoperative dexamethasone, and both rofecoxib and dexamethasone following third molar extraction surgery. Study design Thirty-five subjects requiring surgical removal of at least 1 partial bony impacted mandibular third molar were invited to participate in this double-blind and double-dummy placebo-controlled clinical trial. Subjects were randomly assigned into 1 of 4 treatment groups: (1) placebo po preoperatively and placebo IV intraoperatively; (2) rofecoxib 50 mg po preoperatively and placebo IV intraoperatively; (3) placebo po preoperatively and dexamethasone10 mg IV intraoperatively; and (4) rofecoxib 50 mg po preoperatively and dexamethasone 10 mg IV intraoperatively. Subjects completed a diary assessing postoperative pain onset and intensity using categorical and visual analogue scales. Interincisal opening was assessed 1, 2, 3, and 7 days postoperatively using a Therabite ruler. Results This randomized controlled clinical trial enrolled 35 subjects. Two subjects did not meet the inclusion criteria and 4 did not return completed diaries. The mean age of the remaining 29 subjects (11 males, 18 females) was 22.8 years (+/- 0.6 year). The active treatments tended to delay the need for initial pain medication. When compared to other active treatments and to placebo, the combination of preoperative rofecoxib and intraoperative dexamethasone significantly reduced initial pain intensity ( P < .05). Baseline interincisal opening was 52.6 mm (+/- 6.2). The greatest decrease in interincisal opening was 43.3% for the placebo group at 24 hours. Preoperative rofecoxib alone showed a decrease in interincisal opening of 42.3% ( P = ns) at 24 hours. Intraoperative dexamethasone alone showed a decrease in the interincisal opening of 24.1% of baseline ( P < .05 vs placebo). The group receiving the combination of rofecoxib and dexamethasone showed a decrease in interincisal opening of 23.7% of baseline ( P < .05 vs placebo). Conclusions The results of this trial indicate that the use of intraoperative dexamethasone is an effective therapeutic strategy for limiting trismus following surgical removal of impacted third molars. The combination of preoperative rofecoxib 50 mg and intraoperative dexamethasone 10 mg was most effective in minimizing pain and trismus following third molar surgery.