The monitoring of gingival crevicular fluid volume during orthodontic treatment: a longitudinal randomized split-mouth study.

UNLABELLED: This randomized split-mouth study was aimed at evaluating whether an orthodontic appliance per se or orthodontic tooth movement can induce detectable changes in gingival crevicular fluid (GCF) volume, and thus whether GCF volume is a predictable biomarker for tissue remodelling incident to orthodontic tooth movement. MATERIALS AND METHODS: Sixteen healthy orthodontic patients (7 females and 9 males; mean age, 17.7 years; range, 13-27 years) with the need for extraction of the first upper premolars were enrolled. One randomly chosen maxillary canine was subjected to a distalizing force by a 0.017 × 0.025 inch titanium-molybdenum alloy archwire and considered as the test tooth (TT). The contralateral canine, which was not subjected to any force but was included in an orthodontic appliance, was used as a control (CT). GCF sampling was performed at both mesial and distal sites of the CTs and TTs at baseline, immediately before applying the orthodontic appliance, and after 1 hour, 24 hours, and 7, 14, and 21 days. A Periotron was used to measure the GCF volume. A modest but significant increase in the GCF volume over time was seen in both the CTs (mesial sites) and the TTs (both mesial and distal sites) with no differences between the experimental teeth. Subclinical tissue inflammation consequent to the placement of the orthodontic appliance might be responsible for these GCF volume changes. The GCF volume does not appear to be a reliable biomarker for tissue remodelling during orthodontic treatment.

Implementing organizational systems to measure outcome-related processes of end-stage renal disease care.

The process to implement a continuous quality improvement program for the patient with end-stage renal disease requires a basic understanding of the complex medical and often psychological circumstances that affect these patients. The organizational elements require, therefore, a recognition and integration of functions from all those involved in delivering care. This includes the medical, nursing, social work, dietary, and technical staff. In the development and establishment of the quality assessment and improvement program at Our Lady of Lourdes Medical Center, experience has identified certain basic elements to use in the organizational and functional aspects of the system to achieve a measurable level of success. The primary element in establishing such a program begins with the commitment at the highest level of the organizational structure. Selection of leadership whose responsibility is to provide education and direction of staff participants should follow. Through leadership, education, and early staff involvement, physician support is gained that provides the operational elements for a successful program. A multidisciplinary team, representative of the various aspects of care, can then develop a quality assessment and improvement plan that establishes clinical indicators used to measure various quality components. A data collection and review process is the next phase of implementation of the organizational system to measure the various types of outcome and/or processes of care. The process is one of continued education based on outcome data for all staff members involved in care.

Effect of intradialytic parenteral nutrition on mortality rates in end-stage renal disease care.

Several studies have now demonstrated that low serum albumin and/or low protein catabolic rates correlate with increased risk of death in the chronic hemodialysis patient. A study involving 81 patients receiving thrice-weekly hemodialysis treatments and who had either a low serum albumin and/or protein catabolic rate was conducted to compare the effect of intradialytic parenteral nutrition (IDPN) on mortality rates. Fifty patients received IDPN and 31 patients did not. Thirty-eight of the patients were black (47%), 34 were white (42%), and 9 were Hispanic (11%). The study included 33 diabetic patients (41%), 20 of whom received IDPN. Nondiabetic patients received an average of 725 kcal/hemodialysis treatment and diabetic patients received an average of 670 kcal/hemodialysis treatment. The average length of treatment was 9 months. The results of the study revealed a better survival rate (64% v 52%) for patients treated with IDPN. Using Cox analysis, the IDPN-treated group had a significantly better survival rate (P < 0.01). Serum albumin increased by 12% in the survivors. There was no difference in survival when considered separately for diabetic and nondiabetic patients who received IDPN (mortality rate for diabetics: 50% for treated patients and 54% for untreated patients; mortality rate for nondiabetics: 26% for treated patients and 44% for untreated patients). However, the nondiabetic treated patients had the lowest mortality rates. In conclusion, correction of hypoalbuminemia by IDPN significantly reduced mortality rates overall.

Two cases of water-melon stomach and a review of the literature.

We report two cases of "water-melon stomach", which is a peculiar form of gastric antral vascular ectasia, characterized by a specific and striking endoscopic aspect. It is observed in a context of chronic iron deficiency anemia and gastrointestinal blood loss, particularly in elderly female patients. The clinical endoscopic, histologic, pathogenic and therapeutic aspects are described, with review of the literature.

Factors affecting survival of hemodialysis patients utilizing urea kinetic modeling. A critical appraisal of shortening dialysis times.

The objective of this study was to analyze risk factors affecting mortality rates (MR) in hemodialysis patients undergoing shortened dialysis time who were regularly kinetically modeled. Over a 14-month period, 180 in-center hemodialysis patients, 54% male, 46% female, 57% Black, 39% Caucasian, and 4% Hispanic, treated with rapid high efficiency dialysis (RHED = 2-3 h, 3 times/week) and conventional dialysis (3-4 h, 3 times/week) were studied. Median patient age was 56.7 years (16-84 years) and dialysis care ranged from 6 months to 18 years (mean +/- SD = 4.0 +/- 4.2 years). The patients underwent monthly urea kinetic modeling. The dialysis prescription was based upon normalizing Kt/V between 0.8 and 1.2 and the protein catabolic rate (PCRn) between 0.9 and 1.1. Thirty-three percent of the patients received recombinant human erythropoietin (r-HuEPO). The effects of various covariates, including primary diagnosis, post/predialysis BUN ratios, creatinine, albumin, calcium, phosphate, cholesterol, hemoglobin, r-HuEPO, Kt/V, and PCRn were analyzed using analysis of variance, chi 2 and linear discriminant function (DF) statistical methods. Several significant factors emerged as influencing outcome. The DF analysis produced a highly statistically significant (p < 0.0001) model to predict mortality based upon certain laboratory and dialysis parameters. Further, the linear DF correctly predicted mortality rate in 86% of cases. The results of the analysis revealed an overall mortality rate of 15.6%; hospitalization rates (HR) were 1.4 +/- 1.8 times/year. Length of dialysis time, i.e., dialysis times between 2 and 4 h, when adjusted for Kt/V has no correlation with MR or HR. Variables associated with survival were higher post/predialysis BUN ratios, normal Kt/V (0.8-1.2), normal albumin levels (> 3.5 g/dl), higher postdialysis BUN, creatinine, and cholesterol levels, and use of r-HuEPO. The use of r-HuEPO when analyzed by DF significantly improved MR, 8.3% as opposed to 19.2%. It is concluded that urea kinetic modeling permits shortening dialysis times without affecting mortality or hospitalization rates, and that low postdialysis BUN, post/predialysis BUN ratios, creatinine, and albumin values are correlated with a lower chance of survival.

[Isotopic method in the demonstration of diaphragmatic defects in a case of pleural effusion associated with cirrhosis: apropos of a case]. / Mise en évidence par méthode isotopique de défects diaphragmatiques en cas d'épanchement pleural associé à une cirrhose: à propos d'un cas.

A 62-year-old woman presented with massive right-sided hydrothorax associated with cirrhosis of the liver. Chest scintigraphy after intraperitoneal injection of labelled tracer showed movement of the tracer from the peritoneal to the pleural cavity. Medical therapy and thoracocentesis were successful in this case.

Mandibular growth and third molar impaction in extraction cases.

The position of mandibular third molars was studied in 60 patients from the pedodontic and orthodontic departments at the Federal University of Rio de Janeiro. All individuals received orthodontic treatment with an edgewise appliance following the extraction of first premolars. Examination of superimposed pretreatment and posttreatment cephalometric radiographs led to the observation that mandibular growth is directly related to the positioning of mandibular third molars. Third molar impactions were more likely to occur in cases with a predominance of vertical growth. The larger ascending ramus, the diminution in total length of the mandible and the larger mesial inclination of the crowns also seem to be indicative of third molar impaction.

End-stage renal disease and the practice of nephrology.

Data from a national survey of 336 nephrologists who provide dialysis care on capitation reimbursement show differences in practice activity associated with the proportion of patients with end-stage renal disease (ESRD). On the average, ESRD patients account for 53% of patients seen by these physicians. Nephrologists who have the majority of their visits with ESRD patients average more than 120 patient encounters per week, approximating the practice workloads of primary care physicians. Nephrologists spend comparable amounts of time providing treatment for ESRD and non-ESRD patients in the same settings, schedule additional office visits for facility dialysis patients, and provide treatment and advice for problems not related to dialysis. Whereas care for acute renal failure patients is primarily based on consultations and involves a narrow focus, treatment for ESRD involves the provision of comprehensive primary medical care by nephrologists to their patients being treated with dialysis.

Case-mix and treatment in end-stage renal disease: hemodialysis v peritoneal dialysis.

The University of Southern California School of Medicine conducted a nationwide survey of 336 nephrologists to obtain demographic and clinical data on 6,411 patients with end-stage renal disease (ESRD). Patient demographic data, along with ESRD etiology and comorbid conditions noted by the physician, were compared across various modalities of dialysis. Characteristics of the treatment provided were differentiated by the mode of dialysis and the location of the patient encounter. Results of the analysis show that patients on peritoneal dialysis are more likely to be female and have higher rates of diabetes compared with hemodialysis (HD) patients. Statistically, patients on intermittent peritoneal dialysis are older, more likely to be black, and have a higher incidence of cardiovascular conditions. Continuous ambulatory peritoneal dialysis patients have greatest problem severity and require more physician time and more complex services, whereas home HD patients require the greatest number of diagnostic tests and therapeutic procedures. Hospital inpatient care shows greater case-mix severity and more intensive treatment, but this does not differ by the mode of dialysis. Finally, patients of freestanding dialysis facilities are more likely to have hypertensive renal disease, whereas patients at hospital-based facilities are older, more likely to be seen in the hospital, have more urgent and severe problems during dialysis rounds, and require more physician time, more complex services, and more diagnostic tests and therapeutic procedures.

Cardiac work demands and left ventricular function in end-stage renal disease.

Cardiac hemodynamics were assessed by right and left heart catheterizations in nine patients on hemodialysis. Results showed increased stroke work index and left ventricular work indices. Left ventricular end-diastolic pressure was elevated in all patients (markedly so in five) and did not fall with occlusion of arteriovenous communications. Cardiac output was significantly elevated, but fell to normal postocclusion. Myocardial oxygen consumption, indirectly assessed by tension time and pressure rate indices, appeared increased. Six patients died: four from complications attributed to myocardial failure without infarction, one from transplant-related complications, and one from bacterial meningitis. Five had increased cardiac weights at autopsy, but none showed infarction. This study suggests that increased cardiac work is present in chronic renal failure. Myocardial mass increases result in increased myocardial oxygen demand; however, the increased oxygen requirements may not be met because of reduced erythrocyte mass. Persistance of pressure-volume overload and severe anemia are conducive to myocardial failure.