Specialist paediatric dentistry in Sweden 2008 – a 25‐year perspective

International Journal of Paediatric Dentistry 2010; 20: 313–321 Background. Paediatric dentistry in Sweden has been surveyed four times over the past 25 years. During this period postgraduate training, dental health, and the organization of child dental care have changed considerably. Aim. To investigate services provided by specialists in paediatric dentistry in Sweden in 2008, and to compare with data from previous surveys. Design. The same questionnaire was sent to all 30 specialist paediatric dental clinics in Sweden that had been used in previous surveys. Comparisons were made with data from 1983, 1989, 1996 and 2003. Results. Despite an unchanged number of specialists (N = 81 in 2008), the number of referrals had increased by 16% since 2003 and by almost 50% since 1983. There was greater variation in reasons for referrals. The main reason was still dental anxiety/behaviour management problems in combination with dental treatment needs (27%), followed by medical conditions/disability (18%), and high caries activity (15%). The use of different techniques for conscious sedation as well as general anaesthesia had also increased. Conclusions. The referrals to paediatric dentistry continue to increase, leading to a heavy work load for the same number of specialists. Thus, the need for more paediatric dentists remains.     

Differential Effect of Biventricular and Right Ventricular DDD Pacing on Coronary Flow Reserve in Patients With Ischemic Cardiomyopathy

CRT and Coronary Flow Reserve. Background: Cardiac resynchronization therapy (CRT) has become a mainstay in heart failure management. There are also indications that upgrading of existing pacemakers to CRT systems may be of benefit. The aim of this study was to assess the effect of biventricular (BiV), compared with right ventricular (RV), pacing, on coronary flow reserve (CFR), in patients with ischemic cardiomyopathy. Methods and Results: From our database of heart failure patients implanted with BiV pacemakers, 20 patients (10 responders and 10 non‐responders to CRT) were randomly selected. Left anterior descending artery coronary flow reserve was measured invasively, under BiV and RV pacing, using intracoronary adenosine to induce hyperemia. In all the 20 patients, there was a significant difference in the pairwise comparison between CFR recorded during BiV and RV pacing (mean difference 0.15, 95% confidence interval 0.07–0.23, P = 0.001). When comparing responders to non‐responders, there was a significant difference as to the effect of BiV, compared with RV, pacing on CFR: mean difference (BiV minus RV CFR) was 0.26 ± 0.06 (95% confidence interval 0.13–0.39; P = 0.002), while in non‐responders the difference was 0.04 ± 0.03 (95% confidence interval ?0.02 to 0.10; P = 0.168). Conclusion: BiV pacing is overall associated to higher CFR, compared with RV DDD pacing. This difference is almost exclusively attributable to the beneficial effect of CRT on coronary flow reserve in CRT‐responders. This effect may contribute to the beneficial action of resynchronization in the failing heart and can be viewed in the context of reports of the usefulness of upgrading RV pacemakers to CRT systems. (J Cardiovasc Electrophysiol, Vol. 21, pp. 1233‐1239, November 2010)     

Double Reactivity Against Actin and α-Actinin Defines a Severe Form of Autoimmune Hepatitis Type 1

Anti-filamentous actin antibodies characterize autoimmune hepatitis type 1 (AIH-1). Recently, the binding domain of alpha-actinin on actin was shown to be a predominant epitope. To test this reactivity, an anti-alpha-actinin enzyme-linked immunosorbent assay was developed, and positivity confirmed by Western blot. Anti-alpha-actinin antibody was found in 21/50 (42%) of AIH-1 patients, compared with 52/401 (12.9%) of liver disease control patients, and with 6/200 (6%) of blood donors. Anti-filamentous and anti-alpha-actinin activities were found specifically together in 66% of anti-filamentous-positive AIH-1 patients. This combination of specificities reflected clinical and histological disease activity, short duration and absence of treatment. Finally, using an actin-alpha-actinin complex assay, the binding of anti-filamentous actin to alpha-actinin-binding domain on actin was demonstrated, as well as that of anti-alpha-actinin on the actin-binding domain of alpha-actinin. Thus, the frequent combination of anti-filamentous and anti-alpha-actinin antibodies seems to be the hallmark of activity in AIH-1.     

Silent Cerebral Events/Lesions Related to Atrial Fibrillation Ablation: A Clinical Review

Brain magnetic resonance imaging (MRI) has identified a high incidence of cerebral ischemia in asymptomatic patients after atrial fibrillation (AF) ablation (silent). Detection of cerebral ischemic events on MRI is based on acute hyperintense lesions on diffusion‐weighted imaging. In the literature, the incidence is related to specifications of MRI and depends on the definition applied. In comparative studies, silent cerebral events (SCE, diffusion‐weighted MRI [DWI] positive only) appear to be approximately 3 times more common compared to using a definition of silent cerebral lesions (SCL; without fluid attenuated inverse recovery sequence [FLAIR] positivity). Whereas the FLAIR sequence may turn positive within days after the ischemic event, SCE definition is highly sensitive for early phases of ischemic brain damage. SCE/SCL appear to represent cerebral ischemic infarcts and determine the “embolic fingerprint” of a specific ablation technology and strategy used. The optimum time point for detecting SCE is early after AF ablation (24–72 hours), whereas detection of SCL can only be performed within the first 2–7 days (due to delay of FLAIR positivity). Different technology‐, procedure‐, and patient‐related parameters have been identified to play a role in the multifactorial genesis of SCE/SCL. In recent years, evidence has been gathered that there may be differences of SCE/SCL rates depending upon the ablation technology used, but small patient numbers and a large number of potential confounders hamper all studies. As major findings of recent studies, mode of periprocedural and intraprocedural anticoagulation has been identified as a major predictor for incidences of SCE/SCL. Whereas procedural characteristics related to higher SCE/SCL‐rates may be modified, unchangeable patient‐related factors should be taken into account for future individualized risk assessment. Novel ablation devices introduced into the market should be tested for their potential embolic fingerprint and refinements of ablation procedures to reduce their embolic potential should be prompted. The knowledge of “best practice” in terms of low SCE/SCL rates has prompted changes in work‐flow, which have been implemented into ablation procedures using novel ablation devices. So far, no study has linked SCE/SCL to neuropsychological decline and the low number of AF‐ablation‐associated events needs to be weighted against the multitude of preexisting asymptomatic MRI‐detected brain lesions related to the course of AF itself. Future studies are needed to evaluate if more white matter hyperintensities due to AF may be prevented by AF ablation (producing only a small number of SCE/SCL).     

Impact of long‐term treatment with low‐dose inhaled corticosteroids on the bone mineral density of chronic obstructive pulmonary disease patients: Aggravating or beneficial?

Background and objective: Chronic obstructive pulmonary disease (COPD) is characterized by a low‐level systemic chronic inflammatory activity that is responsible for many of the disease's extra‐pulmonary manifestations, including osteoporosis and fragility fractures. These manifestations are also well‐documented side‐effects of oral corticosteroids. It was hypothesized that low levels of inhaled corticosteroids, due to their anti‐inflammatory properties and their low circulating levels, might preserve the bone mineral density (BMD) of COPD patients. Methods: Two hundred and fifty‐one male ex‐smokers with COPD patients grouped on the basis of their diffusion capacity value as predominantly bronchitic or predominantly emphysematic and 313 male controls with similar age and smoking history were enrolled in the study. Each of the patient's categories was randomized into two separate subgroups. Patients enrolled in subgroups B_neg(n = 91, 36%) and E_neg(n = 37, 14.7%) were treated with long‐acting β2‐agonists and anticholinergics, while subgroups B_ICS(n = 87, 35%) and E_ICS(n = 38, 15.1%) were additionally receiving low‐dose inhaled corticosteroids. Patients and controls were evaluated by clinical examination, lung function testing and BMD measurement every 6 months for 4 years. Results: According to the findings, emphysematic patients demonstrated an increased rate of BMD loss compared with bronchitic patients (P = 0.01). Furthermore, a reduction of the annual BMD loss in bronchitic patients on inhaled corticosteroids (P = 0.02) was measured, without a corresponding benefit for the emphysematics (P = not significant). Conclusions: Long‐term administration of low‐dose inhaled corticosteroids decelerates the annual BMD loss in bronchitic patients, possibly by reducing both pulmonary and systemic chronic inflammation caused by COPD.     

Disorders of the Autonomic Nervous System in Patients With Brugada Syndrome: A Pilot Study

Autonomic Disorders in Brugada Syndrome . Introduction: The aim of this study was to examine autonomic disorders in patients with Brugada syndrome by performing a cardiac sympathetic innervation evaluation, a head‐up tilt‐test (HUT) and heart rate variability (HRV) analysis. Methods and Results: We enrolled 20 patients with Brugada syndrome (mean age 42.5 ± 8.8 years), 9 with spontaneous and 11 with an induced type 1 electrocardiogram (ECG) in the setting of symptoms and 20 age‐matched controls. All subjects underwent a HUT with parallel measurements of plasma catecholamines and cortisol, a ¹²³I‐metaiodobenzylguanidine single photon emission tomography, and HRV evaluation. Ten control subjects participated in the innervation portion of the study. The tilt‐test with clomipramine challenge was positive in 15 of 20 (75%) patients (7 spontaneous, 8 induced) and in 1 in controls (P < 0.01). A sympathoadrenal imbalance was shown in positive tests. The pattern of innervation in all groups was heterogenic and similar to controls with a trend towards lower measurements in patients with a spontaneous type 1 ECG and a positive HUT. HRV analysis did not reveal any significant differences during day and night. Four patients (20%) had sustained ventricular arrhythmias during a follow‐up of 31.1 ± 8.6 months, but no correlations with innervation or response to tilting were found. Conclusion: A high susceptibility to vasovagal syncope was observed in patients with Brugada syndrome, which could be disease‐related symptoms. Conversely, sympathetic innervation was observed to follow a physiological, heterogenic pattern; however, these factors did not have prognostic value for life‐threatening arrhythmias. (J Cardiovasc Electrophysiol, Vol. pp. 773‐780, July 2010)     

全肘关节置换术治疗类风湿性关节炎的疗效评价——三种假体的比较研究

背景：据我们所知，英文文献中只有两篇关于当前所用的肘关节假体的比较研究，因假体效果的比较是非常困难的。更好的了解不同假体的疗效对于指导选择合适的假体是很有意义的。 方法：我们将采用肘关节置换治疗的风湿性关节炎患者根据假体类型的不同分为三组，即Souter—Strathclyde组、Kudo组和Coonrad—Morrey组。每组包括33个肘关节。所有手术均由一名医生或由他指导下完成。术后随访没有进行翻修手术的病例，随访时间Souter—Strathclyde组平均为61个月，Kud0组为67个月，Coonrad—Morrey组为68个月。临床功能评价包括疼痛缓解程度和屈曲程度。用生命曲线表评价假体生存率，翻修手术和假体松动的影像学表现作为终结点。 结果：各组在年龄、性别和随访时间方面有可比性。三组病例疼痛均得到缓解。三组中肘关节活动度的改善程度也很相似，但固定屈曲畸形和最大屈曲角度并未有显著改变。翻修术的原因主要有感染、脱位和无菌性松动。Coonrad—Morrey假体比其他二组生存率高。以翻修手术或影像学显示假体松动分别作为终结点，假体五年生存率Souter-Strathclyde组为85％和81％，Kudo组为93％和82％，Coonrad-Morrey组为90％和86％。而Coonrad—Morrey组影像学显示假体松动率较低。此组中16％的尺骨假体周围出现局灶型骨溶解，而其中一半的病例能发展为真正的松动。 结论：这三种假体在缓解疼痛和提高肘关节活动范围方面是相似的。我们相信Coonrad—Morrey假体的铰链装置可预防脱位，并不增加松动的危险。 可信水平：治疗性研究，Ⅲ级，进一步可信度参见作者介绍。