Predicting medical emergency team calls, cardiac arrest calls and re-admission after intensive care discharge: creation of a tool to identify at-risk patients.

We aimed to develop a predictive model for intensive care unit (ICU)-discharged patients at risk of post-ICU deterioration. We performed a retrospective, single-centre cohort observational study by linking the hospital admission, patient pathology, ICU, and medical emergency team (MET) databases. All patients discharged from the Alfred Hospital ICU to wards between July 2012 and June 2014 were included. The primary outcome was a composite endpoint of any MET call, cardiac arrest call or ICU re-admission. Multivariable logistic regression analysis was used to identify predictors of outcome and develop a risk-stratification model. Four thousand, six hundred and thirty-two patients were included in the study. Of these, 878 (19%) patients had a MET call, 51 (1.1%) patients had cardiac arrest calls, 304 (6.5%) were re-admitted to ICU during the same hospital stay, and 964 (21%) had MET calls, cardiac arrest calls or ICU re-admission. A discriminatory predictive model was developed (area under the receiver operating characteristic curve 0.72 [95% confidence intervals {CI} 0.70 to 0.73]) which identified the following factors: increasing age (odds ratio [OR] 1.012 [95% CI 1.007 to 1.017] P <0.001), ICU admission with subarachnoid haemorrhage (OR 2.26 [95% CI 1.22 to 4.16] P=0.009), admission to ICU from a ward (OR 1.67 [95% CI 1.31 to 2.13] P <0.001), Acute Physiology and Chronic Health Evaluation (APACHE) III score without the age component (OR 1.005 [95% CI 1.001 to 1.010] P=0.025), tracheostomy on ICU discharge (OR 4.32 [95% CI 2.9 to 6.42] P <0.001) and discharge to cardiothoracic (OR 2.43 [95%CI 1.49 to 3.96] P <0.001) or oncology wards (OR 2.27 [95% CI 1.05 to 4.89] P=0.036). Over the two-year period, 361 patients were identified as having a greater than 50% chance of having post-ICU deterioration. Factors are identifiable to predict patients at risk of post-ICU deterioration. This knowledge could be used to guide patient follow-up after ICU discharge, optimise healthcare resources, and improve patient outcomes and service delivery.

Unhealthy behaviours for self-management of HIV-related peripheral neuropathy.

The prevalence of peripheral neuropathy is frequent in HIV disease and is often associated with antiretroviral therapy. Unhealthy behaviours, particularly substance-use behaviours, are utilized by many HIV-positive individuals to manage neuropathic symptoms. As part of a larger study on self-care for symptoms in HIV disease, this study analyzed the prevalence and characteristics of unhealthy behaviours to self-manage peripheral neuropathy in HIV disease. Sociodemographic and disease-related correlates and unhealthy behaviours were examined in a convenience sample of 1,217 respondents who were recruited from data collection sites in several US cities, Puerto Rico, Colombia, and Taiwan. Results of the study indicated that respondents with peripheral neuropathy (n=450) identified a variety of unhealthy self-care behaviours including injection drug use, oral drug use, smoking cigarettes and alcohol ingestion. Specific unhealthy behaviours that participants reported to alleviate peripheral neuropathy included use of marijuana (n=67), smoking cigarettes (n=139), drinking alcohol (n=81) and street drugs (n=30). A subset of those individuals (n=160), who identified high levels of neuropathy (greater than five on a scale of 1-10), indicated significantly higher use of amphetamines and injection drug use in addition to alcohol use and cigarette smoking. For participants from Norway, substance use (using alcohol: 56%) was one of the most frequent self-management strategies. Implications for clinical practice include assessment and education of persons with HIV for self-care management of the complex symptom of peripheral neuropathy.

Symptom management and self-care for peripheral neuropathy in HIV/AIDS.

Peripheral neuropathy is the most common neurological complication in HIV and is often associated with antiretroviral therapy. As part of a larger study on self-care for symptoms in HIV disease, this study analyzed the prevalence and characteristics of peripheral neuropathy in HIV disease, sociodemographic and disease-related correlates and self-care strategies. A convenience sample of 1,217 respondents was recruited from data collection sites in several US cities, Puerto Rico, Colombia and Taiwan. Results of the study indicated that respondents with peripheral neuropathy (n=450) identified 20 self-care behaviors including complementary therapies, use of medications, exercise and rest and/or elevation of extremities. Ratings of frequency and effectiveness were also included. An activities checklist summarized into five categories of self-care behaviors including activities/thoughts, exercise, medications, complementary therapies and substance was used to determine self-care behaviors. Taking a hot bath was the most frequent strategy used by those with peripheral neuropathy (n=292) and received the highest overall rating of effectiveness of any self-management strategies included in this study at 8.1 (scale 1-10). Other self-care strategies to manage this symptom included: staying off the feet (n=258), rubbing the feet with cream (n=177), elevating the feet (n=236), walking (n=262), prescribed anti-epileptic agent (n=80), prescribed analgesics (n=84), over-the-counter medications (n=123), vitamin B (n=122), calcium supplements (n=72), magnesium (n=48), massage (n=156), acupuncture (n=43), reflexology (n=23) and meditation (n=80). Several behaviors that are often deemed unhealthy were included among the strategies reported to alleviate peripheral neuropathy including use of marijuana (n=67), cigarette smoking (n=139), drinking alcohol (n=81) and street drugs (n=30).

Effect of a gonadotropin releasing hormone analog on cerebral hemodynamics in premenopausal women.

BACKGROUND: Impaired reactivity of cerebral blood vessels is associated with increased risk of stroke. Female sex hormones have vasoactive effects in a number of vascular beds but their effects upon the cerebral circulation are not well understood. Ultrasound techniques allow us to examine the ability of intracranial vessels to dilate in response to a pharmacological stimulus (the carbonic anhydrase inhibitor acetazolamide). We studied intracranial hemodynamics in a group of premenopausal women before and after induction of a temporary hypoestrogenic state. METHODS: We examined middle cerebral artery mean flow velocity, common and internal carotid artery pulsatility index and cerebrovascular reactivity to acetazolamide (CVR) in a group of women undergoing treatment for menstrual disorders. Volunteers underwent ultrasound examination during the follicular phase of the menstrual cycle and after completing treatment with gonadotropin releasing hormone (GnRH, goserelin 3.6 mg) administered subcutaneously every 28 days for 12 weeks. The study was conducted in a prospective, single-blind fashion and analyzed using parametric comparisons of means to examine change in intracranial hemodynamic parameters between pre- and postmenopausal states. RESULTS: Twelve premenopausal women aged 37.2+/-7 years and without overt vascular disease completed the protocol. GnRH reduced serum estrogen concentration (215.6+/-122 pg/ml vs. 82.4+/-12 pg/ml, p=0.0047) but this was not associated with a change in CVR (145+/-19% and 146+/-14% for follicular and post-GnRH studies, respectively (p=0.6). No significant changes in blood pressure, internal carotid or middle cerebral artery pulsatility or mean flow velocity were observed between time points. CONCLUSION: Neither resting cerebral hemodynamics nor reactivity of cerebral resistance vessels to a potent vasodilatory stimulus changed when the circulating concentration of estradiol was artificially decreased using a GnRH agonist. Induction of a hypoestrogenic state does not appear to influence cerebral vasodilatory capacity in the short term.

The effect of HRT on cerebral haemodynamics and cerebral vasomotor reactivity in post-menopausal women.

BACKGROUND: Cerebral vasomotor reactivity (CVR) is an index of cerebrovascular dilatory capacity which can readily be assessed using trans-cranial Doppler ultrasound. Impaired CVR is associated with elevated risk of stroke. We performed a randomized, double-blind placebo-controlled trial to investigate the effect of two HRT preparations upon CVR. METHODS: We examined middle cerebral artery mean flow velocity (MFV), internal carotid artery pulsatility index (PI) and CVR to an i.v. acetazolamide bolus using ultrasound in three groups of post-menopausal women randomized to oral estradiol 1 mg+norethisterone 0.5 mg (group N), estradiol 1 mg+dydrogesterone 5 mg (group D) or placebo (group P). The MFV, PI and CVR were measured before and after 3 months treatment. RESULTS: Thirty-eight post-menopausal women were recruited (N=12, D=14, P=12); mean (SE) age was 56.7 (4) years. Neither HRT preparation affected CVR [% (SE) change from baseline N +4.2 (11); D +3.8 (5.5); P +4.0 (3.8); all comparisons P = NS]. PI was significantly reduced in recipients of dydrogesterone [% (SE) change from baseline D -5.4% (4.6); N +12.3 (6.9); P +11.6 (6.9). P=0.025]. Middle cerebral artery velocity was significantly increased following dydrogesterone treatment compared with placebo [% (SE) change from baseline D +6.8 (3.4) N +3.9 (4.2) P -4.6% (3.4) P=0.03 for D versus P]. CONCLUSION: HRT did not alter CVR. The reduced PI and increased MFV suggest HRT-induced intracranial vasodilatation, which is more apparent in dydrogesterone recipients. Differences may exist between progestogens with regard to changes in intracranial haemodynamics.

Self-care management for neuropathy in HIV disease.

Peripheral neuropathy is the most common neurological complication in HIV and is often associated with antiretroviral therapy. As part of a larger study on self-care for symptoms in HIV disease, this study analyzed the prevalence and characteristics of peripheral neuropathy in HIV disease, the self-care strategies, and sources of information for self-care utilized by the sample. A convenience sample of 422 respondents was recruited from an Internet web-based site developed by the University of California, San Francisco International HIV/AIDS Research Network and from five geographic data collection sites (Boston, New York City, San Francisco and Paterson in the USA, and Oslo, Norway). Results of the study indicated that respondents with peripheral neuropathy identified 77 self-care behaviours including complementary therapies, use of medications, exercise and rest and/or elevation of extremities. Sources of information included health care providers, informal networks and media sources.

Scottish consortium for development and education in dental primary care.

A national consortium for dental primary care in Scotland has been formed as a result of integrated planning by groups involved in managing and delivering postgraduate dental education in Scotland. In 1998 a partnership was formed with representatives from the Scottish Council for Postgraduate Medical and Dental Education (SCPMDE) and the three Scottish dental institutions at Dundee, Edinburgh and Glasgow Universities. The principal aim of the Consortium is to promote evidence-based dental care through postgraduate education and research. The activities of the Consortium will provide a broadly based adjunct to current postgraduate provision with partner institutions contributing in different ways. Since its inception the Consortium has focused on two main areas: 'Higher Training' for Primary Care. Scottish Dental Practice Based Research Network.

An in vitro and in vivo evaluation of various implant-cleaning instruments.

OBJECTIVE: The surface roughness caused by four implant scalers (Premier/Hawe-Neos, Advanced Implant Technologies, Hu-Friedy, and Nobel Biocare) on a titanium abutment was assessed in a standardized in vitro situation, and operators were asked to evaluate the clinical usefulness of each instrument. METHOD AND MATERIALS: Twenty-four evaluators scored scanning electron micrographs of abutment surfaces scaled for 15 minutes with each instrument. Twelve operators used each instrument on at least three implant recall patients and scored each for ease of access; efficacy in deposit removal; overall convenience; distance reached subgingivally; scaling time per abutment; and overall preference. RESULTS: The Advanced Implant Technologies scaler created a significantly rougher surface than all other instruments. The Premier/Hawe-Neos and Advanced Implant Technologies instruments were significantly preferred in most categories by the operators. There was no statistically significant difference in scaling time per abutment. CONCLUSION: The Premier/Hawe-Neos instrument combines operator acceptance with less damage to the abutments, and, of the instruments tested, is the scaler of choice.

Customized emergence profile in the implant crown--a new technique.

As single-tooth replacement becomes an accepted part of daily practice, demands for optimum esthetics in implant-supported crowns increase. Most healing abutments and transfer copings are round and do not simulate the normal cross section of anterior teeth, resulting in unnatural sulcular form around implant abutments. This article presents a simple and economical method to develop and reproduce an optimum emergence profile in the implant crown using standard Nobelpharma components.

Smoking and implant failure--benefits of a smoking cessation protocol.

This prospective study reviews the early outcomes of 223 consecutive Brånemark implants placed in 78 patients by one operator. Patients were divided into three groups: nonsmokers (NS); smokers who followed a smoking cessation protocol (SQ); and smokers who continued to smoke (SNQ). There was a statistically significant difference between failure rates in the NS and SNQ groups (P < .005) and between the SQ and SNQ groups (P < .05), but none between the NS and SQ groups. It is concluded that the smoking cessation protocol described shows considerable promise in improving success rates for osseointegration in smokers who follow it.

The effects of spiramycin and/or scaling on advanced periodontitis in humans.

It has long been questioned whether antibiotics, used as a supplement to traditional therapy, provide any lasting benefit in the treatment of chronic periodontitis. This study was designed to evaluate Spiramycin as an adjunct to scaling and root planing in the treatment of advanced chronic periodontitis. In total, 193 patients with advanced periodontitis were recruited in seven centres using selection criteria previously described. After undergoing thorough scaling and root planing, all patients randomly received either Spiramycin, 1,500,000 international units, twice per day (IU, bid) for 14 days (96 patients), or a visually-identical placebo capsule (97 patients). The clinical parameters measured were plaque index, crevicular fluid level, probing depths, bleeding on probing and attachment level changes. Data was recorded at baseline, two-, eight-, 12- and 24-weeks visits. A total of 189 patients completed the study (96 placebo, 93 Spiramycin). Statistically significant differences in probing depth, favoring Spiramycin, were seen at two weeks (p < 0.0125), eight weeks (p < 0.0020), 12 weeks (p < 0.0032) and 24 weeks (p < 0.0075). Spiramycin also produced a significant improvement in attachment level at 12 weeks (p < 0.0146). All other clinical parameters showed no difference between drug and placebo. This study shows that Spiramycin, as an adjunct to thorough scaling and root planing, provides a statistically significant improvement in probing depths for up to 24 weeks when compared with scaling and root planing alone. Both longer studies and microbiologic evaluations are necessary to determine whether a more lasting benefit is possible.

The association between the failure of dental implants and cigarette smoking.

This paper reviews the outcome of 2,194 Brånemark implants placed in 540 patients by one of the authors over a 6-year period. The overall failure rate of 5.92% is consistent with other studies; however, when patients were subdivided into smokers and nonsmokers, it was found that a significantly greater percentage of failures occurred in smokers (11.28%) than in nonsmokers (4.76%) (P < .001). These differences were significant for all areas except the posterior mandible. While failure rates decreased with increasing implant length, failure rates for each implant length were consistently higher in smokers than in nonsmokers. The possible mechanisms of failure in smokers are discussed, and a protocol for cessation of smoking around the time of surgery is proposed.

Custom stent fabrication for free gingival grafts around osseointegrated abutment fixtures.

The Branemark system of osseointegrated dental implants offers a viable treatment alternative for patients whose conventional prostheses have not been successful. However, the unkeratinized, loosely attached nature of the oral mucosa through which the fixtures may pass often presents a region of easy trauma. A free gingival graft of keratinized tissue from the hard palate can be substituted for these tissues. The success of the graft is dependent upon early healing and protection of the recipient site. This protection can be accomplished by fabrication and use of a custom acrylic resin tissue stent extended beyond the borders of the surgical site.