Dental management of a patient fitted with subcutaneous Implantable Cardioverter Defibrillator device and concomitant warfarin treatment

Automated Implantable Cardioverter Defibrillators (AICD), simply known as an Implantable Cardioverter Defibrillator (ICD), has been used in patients for more than 30 years. An Implantable Cardioverter Defibrillator (ICD) is a small battery-powered electrical impulse generator that is implanted in patients who are at a risk of sudden cardiac death due to ventricular fibrillation, ventricular tachycardia or any such related event. Typically, patients with these types of occurrences are on anticoagulant therapy. The desired International Normalized Ratio (INR) for these patients is in the range of 2–3 to prevent any subsequent cardiac event. These patients possess a challenge to the dentist in many ways, especially during oral surgical procedures, and these challenges include risk of sudden death, control of post-operative bleeding and pain.This article presents the dental management of a 60 year-old person with an ICD and concomitant anticoagulant therapy. The patient was on multiple medications and was treated for a grossly neglected mouth with multiple carious root stumps. This case report outlines the important issues in managing patients fitted with an ICD device and at a risk of sudden cardiac death.     

Shared clinical decision making: A Saudi Arabian perspective

Objectives:

To determine preferences of patients regarding their involvement in the clinical decision making process and the related factors in Saudi Arabia.

Methods:

This cross-sectional study was conducted in a major family practice center in King Abdulaziz Medical City, Riyadh, Saudi Arabia, between March and May 2012. Multivariate multinomial regression models were fitted to identify factors associated with patients preferences.

Results:

The study included 236 participants. The most preferred decision-making style was shared decision-making (57%), followed by paternalistic (28%), and informed consumerism (14%). The preference for shared clinical decision making was significantly higher among male patients and those with higher level of education, whereas paternalism was significantly higher among older patients and those with chronic health conditions, and consumerism was significantly higher in younger age groups. In multivariate multinomial regression analysis, compared with the shared group, the consumerism group were more likely to be female [adjusted odds ratio (AOR) =2.87, 95% confidence interval [CI] 1.31-6.27, p=0.008] and non-dyslipidemic (AOR=2.90, 95% CI: 1.03-8.09, p=0.04), and the paternalism group were more likely to be older (AOR=1.03, 95% CI: 1.01-1.05, p=0.04), and female (AOR=2.47, 95% CI: 1.32-4.06, p=0.008).

Conclusion:

Preferences of patients for involvement in the clinical decision-making varied considerably. In our setting, underlying factors that influence these preferences identified in this study should be considered and tailored individually to achieve optimal treatment outcomes.Patients and physicians assume different and varying roles in the medical consultation process. This could determine the extent of involvement of the patient and the physicians in the clinical decision making process and patient care management. In one extreme, the physician assumes the responsibility of the clinical decision with no or very little joint deliberation with the patient. This is known as the “paternalistic” approach.1,2 In the other extreme, the informed medical decision approach means that the clinical decision is made by patients and potential others, including family members, after obtaining all needed medical information that could enable the patient to make on appropriate decision. This is known as the “consumerism” approach to clinical decision-making.3,4 Shared decision making is probably at the center of this spectrum, in which patients and physicians exchange information, discuss the details of the medical problems, explore available treatment options, and conclude together an agreed treatment plan.5 The provision of health care that is consistent with the preferences of patients may improve the patients’ satisfaction and health outcomes.6,7 The practice of shared clinical decision-making was encouraged as it respects patients’ autonomy, values, and commitment to the agreed health plan and continuity of care.8 The relevant literature shows that most patients prefer to be offered information on their medical conditions, available options of treatment, and future plan of care.1,3,9 However, the extent of the involvement of patients in the process of decision making is variable and influenced by issues related to the patients status of their illnesses, and types of decisions under consideration.10,11 Patients of younger age, women, and with higher levels of education have been found to prefer an active role and to share this process. In addition, preferences of patients may change with time and different stages of the sickness.11,12 The complexity of this process is further compounded by the fact that patient views and attitudes towards involvement in medical decision making are influenced significantly by certain underlying cultural aspects. This necessitates a sensitive and individual approach for each patient.13 This study aims to explore preferences of patients from Saudi Arabia regarding their involvement in medical decision making, and to explore factors that may affect these preferences.     

Serum lipids and chronic hepatitis C genotype 4: interaction and significance

Background &; aim. Metabolic abnormalities are common in chronic hepatitis C infection (CHC). However, the genotypic differences of these disarrangements in patients infected with CHC genotype 4 (HCV-4) and its association with liver histology and viral loads remain unknown.Material and methods. We consecutively enrolled 183 HCV-4 patients and 106 healthy matched controls; to compare metabolic profiles and assess pattern of association of HCV RNA levels as well as histological factors with the serum lipid profile.Results. HCV-4 infection is associated with higher homeostasis model assessment of insulin resistance (HOMA-IR) index, despite that, a favourable lipid pattern, consisting of an elevation in HDLC and a reduction in serum cholesterol (TC), LDL-C and triglyceride (TG) levels, in comparison with normal matched adults. Significant fibrosis was independently associated with HOMA-IR, portal/periportal inflammation grade, serum cholesterol and age. Univariate association was elucidated between lower LDL-C and TC and Metavir activity score and between higher TG and TC and steatosis. In multivariate analysis, severe hepatitis activity, milder hepatic fibrosis, and triglyceride levels are associated with higher HCV RNA levels.Conclusion. HCV-4 is associated with wide metabolic changes. A proportional relationship is found between serum lipid profiles and hepatitis C viral load and liver histology in patients with HCV-4.     

Irrigation endoscopic discectomy: a novel percutaneous approach for lumbar disc prolapse

Purpose

The purpose of this study is to present a new endoscopic procedure, aiming to achieve the success rate equivalent to microsurgical discectomy, while addressing the drawbacks and limitations of other percutaneous techniques.

Methods

A series of 43 patients with uncontained lumbar disc herniation underwent surgery with irrigation endoscopic discectomy (IED). The endoscope and instruments are placed directly over the surface of the lamina through two posterior skin portals 5 mm each without any muscle retraction or dilatation. Pump irrigation is used for the opening of a potential working space. The rest of the procedure is performed endoscopically like the standard microsurgical discectomy.

Results

Outcome according to modified Macnab criteria was excellent in 78 %, good in 17 %, and poor in 5 % of patients. VAS for leg pain dropped from 78 preoperatively to 7, and the Oswestry Low-Back Pain Disability Questionnaire dropped from 76 to 19. The mean time for postoperative ambulation was 4 h, hospital stay was 8 h, and for return to work was 7 days.

Conclusions

Preliminary clinical experience with IED shows it to be as effective as microsurgical discectomy, and in comparison to other percutaneous procedures addressing noncontained herniations, a reduction in the cost, technical difficulty and surgical invasiveness has been demonstrated.     

Sleep Apnea: Is Routine Preoperative Screening Necessary?

Background

Because perioperative complications of unrecognized obstructive sleep apnea (OSA) can be severe, many bariatric surgery programs routinely screen all patients. However, many obese non-bariatric surgery patients do not get screened. We wanted to evaluate the need for routine preoperative OSA screening.

Methods

Morbidly obese patients with a body mass index (BMI)?>?40 kg/m² undergoing bariatric surgery—all screened for OSA—were compared to morbidly obese orthopedic lower extremity total joint replacements (TJR) patients—not screened for OSA. Cardio-pulmonary complications were recorded.

Results

Eight hundred eighty-two morbidly obese patients undergoing either bariatric (n?=?467) or orthopedic TJR surgery (n?=?415) were compared. As a result of screening, 119 bariatric surgery patients (25.5 %) were newly diagnosed with OSA, bringing the incidence to 42.8 % (200/467). Orthopedic surgery group had 72 of 415 (17.3 %) patients with pre-existing OSA. The unscreened orthopedic patients had a 6.7 % (23/343) cardiopulmonary complications rate compared to 2.6 % (7/267) for screened bariatric surgery patients. This difference was not statistically significant when adjusted for age and comorbidity (p?=?0.3383).

Conclusion

Sleep apnea screening prior to bariatric surgery identifies an additional 25 % of patients as having OSA. In this study, unscreened morbidly obese patients did not have an increased incidence of cardiopulmonary complications after surgery compared to screened patients. Prospective randomized studies should be conducted to definitively assess utility and cost effectiveness of routine OSA screening of all morbidly obese patients undergoing surgery. Preoperative OSA screening may be safely omitted when randomizing patients for such a trial.     

Retention of fiber posts to the optimally and over-prepared dowel spaces

PURPOSE

To assess the retention of glass fiber post cemented with self-adhesive resin cement into optimum and over-prepared root canals following obturation in the presence of either eugenol (EB) or calcium hydroxide (CB)-based sealers.

MATERIALS AND METHODS

Roots of extracted premolars were endodontically-treated in 5 groups (n = 10). Roots of Group 1 (control) were left with no obturation and then optimally prepared to receive endodontic dowels. Other root canals were obturated with gutta-percha in the presence of either eugenol-based (Groups 2 and 4) or calcium hydroxide-based (Groups 3 and 5) sealer. Dowel spaces were prepared with optimal diameter in Groups 2 and 3, one size larger in Groups 4 and 5. Standardized fiber posts were luted to the prepared spaces using self-adhesive resin cement and itsretention was then tested on an universal testing machine. Both one-way ANOVA and Tukey''s HSD comparisons (α=0.05) were used to identifythe significance of inter-group retention differences. Scanning electron microscopy (SEM) of both optimally and over-prepared dowel spaces was also considered to figure the nature of their interior out.

RESULTS

The post retention was significantly higher to the non-obturated, optimally-prepared dowel spaces of Group 1 compared to the obturated, optimally-prepared ones of Groups 2 and 3. For each dowel space diameter, root canals obturated using CB of Groups 3 and 5 showed significantly higher dowel retention compared to those obturated using EB of Groups 2 and 4. Post retention to the over-prepared dowel spaces of Groups 4 and 5 was significantly higher than that recorded for the optimally-prepared ones of Groups 1-3. SEM images revealed traces of endodontic sealer and gutta-percha on the walls of the optimally-prepared dowel spaces.

CONCLUSION

Despite the adverse effect of endodontic sealers on the retention of fiber posts, the over-preparation of dowel spaces helps to improve the retention.     

Preparation,Characterization and Cytotoxic Activity of New Oleuropein Microemulsion Against HCT-116 Colon Cancer Cells

Pharmaceutical Chemistry Journal - The work was aimed to elucidate whether the nanoencapsulation of oleuropein would potentiate its anticancer activity against colon cancer or not. Oleuropein...