Interventions for anesthetic success in symptomatic irreversible pulpitis: A network meta-analysis of randomized controlled trials

BACKGROUND: Local anesthetics alone or in combination with adjuncts, such as oral medications, have routinely been used for pain control during endodontic treatment. The best clinical choice amongst the vast numbers of agents and techniques available for pain control for irreversible pulpitis is unclear. This network meta-analysis combined the available evidence on agents and techniques for pulpal anesthesia in the maxilla and mandible, in order to identify the best amongst these approaches statistically, as a basis for future clinical trials.METHODS: Randomized trials in MEDLINE, DARE, and COCHRANE databases were screened based on inclusion criteria and data were extracted. Heterogeneity was assessed and odds ratios were used to estimate effects. Inconsistencies between direct and indirect pooled estimates were evaluated by H-statistics. The Grading of Recommendation, Assessment, Development, and Evaluation working group approach was used to assess evidence quality.RESULTS: Sixty-two studies (nine studies in the maxilla and 53 studies in the mandible) were included in the meta-analysis. Increased mandibular pulpal anesthesia success was observed on premedication with aceclofenac + paracetamol or supplemental 4% articaine buccal infiltration or ibuprofen+paracetamol premedication, all the above mentioned with 2% lignocaine inferior alveolar nerve block (IANB). No significant difference was noted for any of the agents investigated in terms of the success rate of maxillary pulpal anesthesia.CONCLUSION: Direct and indirect comparisons indicated that some combinations of IANB with premedication and/or supplemental infiltration had a greater chance of producing successful mandibular pulpal anesthesia. No ideal technique for maxillary anesthesia emerged. Randomized clinical trials with increased sample size may be needed to provide more conclusive data. Our findings suggest that further high-quality studies are required in order to provide definitive direction to clinicians regarding the best agents and techniques to use for mandibular and maxillary anesthesia for irreversible pulpitis.

Perioperative Hypothermia and shivering in women undergoing Caesarean section under Spinal anesthesia from a tertiary care hospital in Fiji islands - A Cross-sectional Study

Introduction@#Hypothermia and shivering have been known to occur with spinal anaesthesia intra-operatively. We carried out the present study to assess the incidence and associated factors of hypothermia and shivering amongst women undergoing Caesarean section under spinal anaesthesia.@*Methods@#A cross-sectional study was carried out amongst 300 pregnant women requiring spinal anaesthesia for Caesarean section with American Society of Anaesthesiology category I/II. The following details were captured for each eligible patient: demographics, foyer temperature, time spent in the foyer, patients calf (leg) temperature and pre-anaesthesia patient temperature, intra-operative axillary temperatures at 10, 30, 60 and 90 minutes after spinal anaesthesia depending on the duration of surgery, time spent in the operating theatre and the room temperature was documented. Any active or passive warming provided to the patients before and after spinal blockade was also documented. Other information collected include the details of drugs used in the spinal blockade, amount of IV fluids given, amount of ephedrine used, and the details of any blood products required intra-operatively.@*Results@#Out of the total 300 study participants, 63 (21%) patients received spinal anaesthesia for elective caesarean section while 237 (79%) women had emergency surgery. A total of 233/300 (77.7%) had perioperative hypothermia of which only 50/233 (21.5%) had shivering. Only 140 (46.7%) women were warmed during their caesarean delivery. Seventy two participants out of the total 135 (53.3%) who were warmed intra-operatively developed hypothermia while 116/156 (74.4%) of those who did not undergo any warming intra-operatively developed the same (P=0.0002). Average pre-anaesthesia temperature of patients who became hypothermic was lower than that of patients who maintained temperatures more than 36⁰C after spinal block (36.5 ±0.5 vs. 37.0 ±0.5; P=0.0001). Postoperative hypothermia was less common in those patient who were warmed inside OT than those who were not warmed (53.3% vs. 74.4%; P= 0.0002). There was a more significant difference in hypothermia between the patients who were actively warmed with a convection warmer and those who were not (26/75, 34.7% vs. 43/50, 86%; P= 0.0001). Only 21.6% of the hypothermic patients had shivering while 49.3% of the normothermic patients were noted to have shivering after spinal anaesthesia (P=0.0001).@*Conclusion@#Perioperative hypothermia is a major problem in women who have caesarean section under spinal anaesthesia at CWMH. Efforts directed toward routine temperature monitoring and aggressive maintenance of intraoperative normothermia in these women will very likely improve clinical outcomes and patient satisfaction.

Incidence, Types, Management and Outcomes of Congenital Heart Disease in the Paediatric Population at CWM Hospital

Introduction@#Congenital Heart Disease (CHD) refers to structural or functional heart disease present at birth. CHD continues to cause morbidity and mortality in Fiji. There is no published data on CHD in the Pacific in the last 15 years. Unpublished data by Mataika. R, 2012 (12) estimated the incidence of CHD at Colonial War Memorial Hospital (CWMH) was ~ 0.5% or 4.9/1000 live births. This study aims to collect and document data on the incidence, types, management and outcomes of CHD, a platform upon which decisions for policy and practice development for CHD screening and management in Fiji can be made.@*Method@#This is a five-year descriptive, retrospective, single-centre study at CWMH.@*Results@#The incidence of CHD was 5.8 per 1,000 with an uncorrected incidence of 7.2 per 1,000. Ventricular Septal defects (VSD) and Tetralogy of Fallot (TOF) were the most common acyanotic and cyanotic lesions respectively. The total number of cases of CHDs was 202 and 76 (39%) died within that period. Ninety-five percent of the deaths occurred within the first year of life. Sixty-five percent of these infant mortalities were known acyanotic CHD cases. Forty-six (23%) cases had corrective surgeries. Survival rate for surgery locally was 98%, compared to 100% for those cases that had surgery abroad.@*Conclusion@#This study highlights the mortality associated with congenital heart diseases in Fiji and the need for strengthening of surgical management strategies.

Anxiolytic, sedative, and hypnotic activities of aqueous extract of Morinda citrifolia fruit.

Morinda citrifolia (Indian mulberry or noni) fruit has been long used as a folk medicine for a wide range of health purposes as it is claimed to have analgesic, antiinfl ammatory, antioxidant, detoxifi er, and cell-rejuvenator properties. A recent study has revealed central nervous system suppressant nature of its extract. Hence, the present study has evaluated the anxiolytic, sedative, and hypnotic effects of the aqueous extracts of Morinda citrifolia in rodents in comparison to diazepam. Anxiety was assessed by ‘Isolation-induced aggression’ model, sedation by ‘Spontaneous locomotor activity using actophotometer’ and hypnotic activity by ‘Prolongation of ketamine-induced sleeping time’. Six male mice were used for each of the groups and postdose, all the six that received diazepam had shown an inhibition of aggression, whereas in the test group, fi ve of six mice and none in the control group had shown an inhibition of aggression (P = 0.0007). Similarly, for the sedative activity, the total number of spontaneous locomotor activity at 30 min following drug administration was found to be 364.67±10.74, 123.16±8.33, and 196.67±3.7, while at 60 min it was found to be 209±12.98, 49±5.78, and 92±2.5 (mean±SD) for the control, standard, and test groups of mice respectively (P < 0.001). Hypnotic activity was measured by prolongation of ketamine-induced sleeping time wherein the onset and duration of loss of righting refl ex were compared among each group of mice. The time in minutes for the onset in control, standard, and test groups was 4.01±0.22, 1.23±0.05, and 2.23±0.07, respectively. The duration of loss of righting refl ex was 44.23±0.59, 56.03±1.34, and 50.57±0.36, respectively. Both these were statistically signifi cant (P < 0.001). However, more clinical studies are needed to assess the long-term effects of the extract in humans.