Efficacy of oral diclofenac with or without codeine for pain control after invasive bilateral third molar extractions.

Postoperative pain and inflammation after oral surgery is mostly managed using non-steroidal anti-inflammatory drugs (NSAIDs). However, opioids combined with NSAIDs may improve pain management in patients, especially after traumatic oral surgery. Few studies have compared NSAIDs with and without opioid use after oral and maxillofacial surgery. This randomized, double-blind, cross-over study compared the clinical efficacy of either diclofenac (50mg) and codeine (50mg) or diclofenac alone (50mg) for the management of postoperative pain after invasive third molar surgery. Volunteers (n=46) who were scheduled to undergo the removal of symmetrically positioned lower third molars in two separate appointments were included. They reported significantly less postoperative pain at various time points within 24h after surgery and also consumed significantly less rescue medication (paracetamol (acetaminophen)) throughout the study when they took diclofenac combined with codeine than when they took only diclofenac. In conclusion, oral diclofenac with codeine was more effective for managing postoperative pain than diclofenac without codeine. It was expected that patients taking two pain medications after surgery would generally have less pain than when taking only one of the two medications. The prospective cross-over design of the present work makes this study distinct from many others.

Efficacy and Safety of 2% and 4% Articaine for Lower Third Molar Surgery.

This double-blind crossover randomized clinical trial compared the efficacy of 2 concentrations of articaine, 2% (A2) and 4% (A4), with 1:200,000 epinephrine, for lower third molar removal. During 2 separate appointments with either A2 or A4, both similarly positioned lower third molars in 46 volunteers were extracted. The following were evaluated: onset and duration of anesthetic action on soft tissues, intraoperative bleeding, hemodynamic parameters, postoperative analgesia, and mouth opening and wound healing during the 7th postoperative day, along with the incidence, type, and severity of adverse reactions. Nearly identical volumes of both anesthetic solutions were used for each appointment: 3.4 ± 0.9 mL ≈ 68 mg of articaine (A2) and 3.3 ± 0.8 mL ≈ 132 mg of articaine (A4). Statistical analysis indicated no differences in onset or duration of anesthetic action on soft tissues or duration of postoperative analgesia evoked by A2 and A4 anesthetic solutions (P > 0.05). The surgeon's rating of intraoperative bleeding was considered minimal throughout all surgery with both anesthetic solutions. While transient changes in blood pressure, heart rate, and oxygen saturation were observed, these factors were clinically insignificant and were uninfluenced by articaine concentration (P > 0.05). No systemic or local adverse reactions were observed in the preoperative and postoperative periods due to A2 or A4, but 1 case of bilateral paresthesia was observed. There were no significant differences between preoperative and postoperative (7th day) values of mouth opening and wound healing whether volunteers received A2 or A4 (P > 0.05). In conclusion, both A2 and A4, administered in equal volumes, were effective and safe during lower third molar surgery, and no significant differences were found between their efficacy and safety (ClinicalTrials.gov NCT02457325).

Condición de salud y cumplimiento de la guía clínica chilena para el cuidado del paciente diabético tipo / Health condition and compliance of the chilean clinical guideline for type 2 diabetic patients

Objetivo: Identificar condición de salud (CS) de los pacientes diabéticos tipo 2. Medir el cumplimiento de las atenciones de salud según guía clínica. Identificar variables asociadas a CS. Material y método: estudio de pre-valencia, abril 2010. Población: 1.100 pacientes DM2 controlados en Programa Cardiovascular, considerando criterios de inclusión, exclusión, consentimiento informado. Muestra: 340 por aleatorización simple (confianza 95 por ciento merma 10 por ciento). Recolección de datos realizada en CESFAM o visita domiciliaria por investigadoras e internas de enfermería entrenadas, con encuesta validada, exámenes, plantilla para información y ficha clínica. Para el análisis se utilizó estadística descriptiva, Chi2, Odds Ratios con IC (95 por ciento). Resultados: CS: descompensados (HbA1c>7 por ciento) 56.5 por ciento, patologías agregadas 97.9 por ciento, complicaciones 25 por ciento, mayor frecuencia retinopatía diabética. hombres mayor riesgo de amputación (p=0.003). Presión arterial >130/85 mm.hg. 58.2 por ciento, sobrepeso-obesidad 71.2 por ciento, autovalencia (adultos mayores) 23.1 por ciento. Cumplimiento recomendaciones ministeriales: controles/profesionales/año a lo menos cinco 41.5 por ciento, CESFAM adapta esta recomendación. Evaluación anual de: pie diabético 78 por ciento, fondo ojo 41,6 por ciento. Indicación régimen (nutricionista) último control 80 por ciento. Cinco controles profesionales/ año o más es protector de compensación de diabetes, IC (0.62-0.95), resto de recomendaciones y adaptación de éstas no se asocian a condición de salud (p > 0.05). Conclusiones: Los componentes de condición de salud están en general por sobre lo esperado. En ningún paciente se cumple en un 100 por ciento las recomendaciones de la guía clínica. Cinco o más controles profesionales anuales se asocian a compensación de la diabetes. Importante cumplir recomendaciones para mejorar control metabólico y disminuir/retrasar complicaciones para una mejor calidad de vida de pacientes.

Objectives: To determine compliance with Chilean clinical guideline and to measure their impact through evaluation of patient’s health condition (HC), to determine associations. Methods: prevalence study, April 2010. Population: 1,100 diabetic patients controlled in the Cardiovascular Program, considering criteria of inclusion, exclusion, informed consent. Sample: 340 randomized patients (Confidence level: 95 percent; Loss: 10 percent). Information was collected in an outpatient clinic and through home visits performed by researchers and trained senior nursing students, with a validated survey, exams, staff for file information. For the purposes of the analysis, descriptive statistics was used, Chi2, Odds Ratios with CI (95 percent). Results: HC: decompensation (HbA1c>7 percent 56.5 percent derived illnesses 97.9 percent, complications 25 percent, greater frequency of diabetic retinopathy. Males with greater risk of amputation (p=0.003). Blood pressure >130/85 mm. hg. 58.2 percent, overweight-obesity 71.2 percent, self-care (older adults) 23.1 percent. Compliance with clinical guideline: controls/professionals/year at least five 41.5 percent, CESFAM adapts this recommendation. Annual evaluation of: diabetic foot 78 percent, fundoscopy 41.6 percent. Regime indication (dietician) last control 80 percent. Five professional controls/year or more protect compensation for diabetes, IC (0.62-0.95), other recommendations and adaptation of recommendations are not associated with health status (p > 0.05). Conclusions: components of hC are better than expected. In none of the patients are the recommendations of the clinical guideline fulfilled in a 100 percent. 5 or more annual outpatient visits are associated to good metabolic control. Compliance with clinical guideline recommendations is important to improve metabolic control, to lessen complications and to improve patient’s quality of life.

Comparison of oral versus sublingual piroxicam during postoperative pain management after lower third molar extraction.

In this study, 53 patients received piroxicam, administered orally or sublingually, after undergoing removal of symmetrically positioned lower third molars, during two separate appointments. This study used a randomized, blind, cross-over protocol. Objective and subjective parameters were recorded for comparison of postoperative results for 7 days after surgery. Patients treated with oral or sublingual piroxicam reported low postoperative pain scores. The patients who received piroxicam orally took a similar average amount of analgesic rescue medication compared with patients who received piroxicam sublingually (p>0.05). Patients exhibited similar values for mouth opening measured just before surgery and immediately following suture removal 7 days later (p>0.05), and showed no significant differences between routes of piroxicam administration for swelling control during the second or seventh postoperative days (p>0.05). In summary, pain, trismus and swelling after lower third molar extraction, independent of surgical difficulty, could be controlled by piroxicam 20mg administered orally or sublingually and no significant differences were observed between the route of delivery used in this study.

The selective and non-selective cyclooxygenase inhibitors valdecoxib and piroxicam induce the same postoperative analgesia and control of trismus and swelling after lower third molar removal.

We compared the clinical efficacy of orally administered valdecoxib and piroxicam for the prevention of pain, trismus and swelling after removal of horizontally and totally intrabony impacted lower third molars. Twenty-five patients were scheduled to undergo removal of symmetrically positioned lower third molars in two separate appointments. Valdecoxib (40 mg) or piroxicam (20 mg) was administered in a double-blind, randomized and crossed manner for 4 days after the surgical procedures. Objective and subjective parameters were recorded for comparison of postoperative courses. Both agents were effective for postoperative pain relief (N = 19). There was a similar mouth opening at suture removal compared with the preoperative values (86.14 +/- 4.36 and 93.12 +/- 3.70% of the initial measure for valdecoxib and piroxicam, respectively; ANOVA). There was no significant difference regarding the total amount of rescue medication taken by the patients treated with valdecoxib or piroxicam (173.08 +/- 91.21 and 461.54 +/- 199.85 mg, respectively; Wilcoxon test). There were no significant differences concerning the swelling observed on the second postoperative day compared to baseline measures (6.15 +/- 1.84 and 8.46 +/- 2.04 mm for valdecoxib and piroxicam, respectively; ANOVA) or on the seventh postoperative day (1.69 +/- 1.61 and 2.23 +/- 2.09 mm for valdecoxib and piroxicam, respectively; ANOVA). The cyclooxygenase-2 selective inhibitor valdecoxib is as effective as the non-selective cyclooxygenase inhibitor piroxicam for pain, trismus and swelling control after removal of horizontally and totally intrabony impacted lower third molars.

The selective and non-selective cyclooxygenase inhibitors valdecoxib and piroxicam induce the same postoperative analgesia and control of trismus and swelling after lower third molar removal

We compared the clinical efficacy of orally administered valdecoxib and piroxicam for the prevention of pain, trismus and swelling after removal of horizontally and totally intrabony impacted lower third molars. Twenty-five patients were scheduled to undergo removal of symmetrically positioned lower third molars in two separate appointments. Valdecoxib (40 mg) or piroxicam (20 mg) was administered in a double-blind, randomized and crossed manner for 4 days after the surgical procedures. Objective and subjective parameters were recorded for comparison of postoperative courses. Both agents were effective for postoperative pain relief (N = 19). There was a similar mouth opening at suture removal compared with the preoperative values (86.14 ± 4.36 and 93.12 ± 3.70 percent of the initial measure for valdecoxib and piroxicam, respectively; ANOVA). There was no significant difference regarding the total amount of rescue medication taken by the patients treated with valdecoxib or piroxicam (173.08 ± 91.21 and 461.54 ± 199.85 mg, respectively; Wilcoxon test). There were no significant differences concerning the swelling observed on the second postoperative day compared to baseline measures (6.15 ± 1.84 and 8.46 ± 2.04 mm for valdecoxib and piroxicam, respectively; ANOVA) or on the seventh postoperative day (1.69 ± 1.61 and 2.23 ± 2.09 mm for valdecoxib and piroxicam, respectively; ANOVA). The cyclooxygenase-2 selective inhibitor valdecoxib is as effective as the non-selective cyclooxygenase inhibitor piroxicam for pain, trismus and swelling control after removal of horizontally and totally intrabony impacted lower third molars.

Analgesic and anti-inflammatory dose-response relationship of 7.5 and 15 mg meloxicam after lower third molar removal: a double-blind, randomized, crossover study.

Fifty patients were scheduled to undergo removal of symmetrically positioned lower third molars in two separate appointments. Meloxicam 7.5 or 15 mg was once daily administered in a double-blind, randomized and crossover manner after the surgery for 4 days. Objective and subjective parameters were recorded for comparison of postoperative courses. Patients treated with 7.5mg meloxicam who underwent osteotomy reported higher pain scores at 1.5, 3, 4, 10, 12 and 16 h (P<0.05) and ingested a greater amount of rescue analgesic medication (P<0.05) than those who did not require osteotomy. A higher percentage of patients who underwent osteotomy medicated with 7.5mg meloxicam needed rescue medication as compared to those who did not require osteotomy (P<0.05). There was a similar mouth opening at suture removal compared with preoperative values for both doses (P>0.05). There were no significant differences concerning swelling observed on the 2nd or 7th postoperative days in comparison with baseline (P>0.05) between the two doses. Pain, trismus and swelling after lower third molar removal not requiring osteotomy can be successfully controlled by a dose regimen of 7.5mg meloxicam once daily. For more aggressive extractions 15 mg meloxicam is advisable.

Diagnóstico microbiológico de la neumonía del adulto adquirida en la comunidad / Microbiologic diagnosis of community-acquired pneumonia in adults

Microbiological analysis allows us to identify the etiology of pneumonia and its in vitro susceptibility pattern. Antibiotic treatment directed against a known pathogen enables us to narrow antibacterial spectrum of action, and to reduce costs, drug adverse effects risk and antibiotic resistance. However it is unnecessary to perform extended microbiological studies in all patients with community acquired pneumonia (CAP). Etiological studies must be based in pneumonia severity, epidemiological risk factors and clinical response to empirical treatment. Routine microbiological analysis for ambulatory patients is not recommended. In patients with persistent cough and worsening in their general conditions, a sputum sample must be obtained to perform an acid-fast smear and Mycobacterium culture. The risk of complications and death of patients hospitalized with CAP justifies basic microbiological exploration (sputum Gram staining and culture, blood cultures, pleural fluid culture) intending to obtain a more accurate etiology of pulmonary infection and to guide specific antibiotic treatment. Paired serum samples obtained to document atypical pathogen infections (Mycoplasma pneumoniae, Chlamydia pneumoniae) and urine sample to detect Legionella pneumophila antigenuria are recommended in all CAP severely ill patients that are admitted to ICU, in those not responding to betalactamic drug treatment and in selected patients with specific epidemiological risks. A microbiological study would be useful in management of patients with severe CAP pneumonia outbreaks with clinical-epidemiological particular characteristics, and in-patients with empirical antimicrobial treatment failure

Los exámenes microbiológicos permiten identificar el agente causal de la neumonía y su patrón de sensibilidad a antimicrobianos. El tratamiento anti infeccioso dirigido contra un patógeno conocido permite reducir el espectro de acción de los fármacos, los costos, el riesgo de reacciones adversas y de la resistencia antimicrobiana. Sin embargo, no es necesario realizar estudios microbiológicos extensos a todos los pacientes con neumonía adquirida en la comunidad (NAC). Los estudios deben estar guiados por la gravedad de la neumonía, los factores de riesgo epidemiológico y la respuesta al tratamiento empírico. No se recomienda realizar investigaciones microbiológicas rutinarias en los pacientes manejados en el medio ambulatorio. En pacientes con tos persistente y compromiso de su estado general, se debe obtener muestras de expectoración para baciloscopia y cultivo de Koch. El riesgo de complicaciones y muerte de los enfermos hospitalizados por NAC justifica la realización de exámenes microbiológicos básicos (tinción de Gram y cultivo de expectoración, hemocultivos, cultivo de líquido pleural) que intentarán precisar el agente causal de la infección pulmonar y orientar el tratamiento antimicrobiano específico. Se recomienda obtener muestras de suero pareadas para la pesquisa de patógenos atípicos (Mycoplasma pneumoniae, Chlamydia pneumoniae) y una muestra de orina para la detección de Legionella pneumophila en todos los pacientes con NAC grave admitidos a la UCI, en aquellos que no responden a agentes b-lactámicos y en pacientes seleccionados con riesgo epidemiológico específico. El estudio microbiológico podría ser útil en el manejo de pacientes con NAC grave, brotes de neumonía con características clínico-epidemiológicas particulares, y en pacientes con fracaso del tratamiento antimicrobiano empírico

Is it useful to add an anticholinergic treatment to beta 2-adrenergic medication in acute asthma attack?

The aim of our study was to determine whether the combination of an anticholinergic treatment with a beta 2-adrenergic medication is a more effective treatment for acute asthma attack than the two treatments individually. The association of salbutamol-ipratropium was compared to treatment with salbutamol and ipratropium alone. It was a prospective double-blind study in children with acute asthma attack, participating as outpatients. Their clinical history and characteristics of bronchial obstruction were recorded on a standard form. Afterwards, they were included in one of the three following study groups: group one, 100 micrograms/inh salbutamol; group two, 20 micrograms/inh ipratropium; group three, 100 micrograms/inh of salbutamol plus 20 micrograms/inh ipratropium. There were 40 patients in each group, with Tal score +/- 5 and PEF < 80% of the predicted value. They were evaluated at the beginning (0 min), and at 15, 30, 45, 60, 80, 100 and 120 min. Each patient was treated with two inhalations of the study medication and was then evaluated for variations in Tal score. The mean age was 7.3 years; Tal score was 5.6, 5.6 and 6.0 at 0 min (p > 0.05). Decrease in Tal score after 15 min meant p < 0.01 for salbutamol-ipratropium and salbutamol vs. ipratropium. At 30 min p < 0.05 for salbutamol-ipratropium vs. salbutamol, and at 45 min p < 0.01 for salbutamol-ipratropium vs. salbutamol. PEF at 0 min was 70.9%, 71.3% and 68.6% (p > 0.05) increasing after 15 min. At 30 min p < 0.05 for salbutamol-ipratropium vs. salbutamol, and p < 0.01 vs. ipratropium. At 45 min p < 0.01 for salbutamol-ipratropium vs. salbutamol and ipratropium. A total 4.7 doses of salbutamol were needed to improve the asthma attack, 5.3 of ipratropium and 3.7 of salbutamol-ipratropium, with p < 0.01 for salbutamol-ipratropium vs. salbutamol and ipratropium. We conclude that the combination of salbutamol and ipratropium is more effective than each medication alone in treating acute asthma attacks in pediatric patients.