Randomized clinical trial of an enhanced recovery after surgery programme versus conventional care in laparoscopic Roux-en-Y gastric bypass surgery.

Background: Enhanced recovery after surgery (ERAS) programmes have led to a decreased duration of hospital stay in several surgical fields, but have not been fully tested in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity. This study aimed to investigate an ERAS programme versus standard care in these patients. Methods: Between January 2013 and July 2014, patients undergoing LRYGB were randomized to ERAS or conventional care. The primary outcome was functional hospital stay, defined as the time between end of surgery and when predefined discharge criteria (pain adequately controlled, fever and postoperative nausea and vomiting (PONV) absent, full liquid diet tolerated, mobilized and feeling fit for discharge) were met. Secondary outcomes were total length of hospital stay, 30-day complication and mortality rates, duration of surgery, time spent on the recovery ward and health-related quality of life. Results: A total 220 patients were randomized to ERAS (110 patients) or conventional (110) care. Patients in the ERAS group had shorter functional hospital stay (17·4 versus 20·5 h; P < 0·001), quicker pain control, tolerated liquid diet earlier, had earlier control of PONV, mobilized sooner and were comfortable with discharge sooner than those receiving conventional care. Total length of hospital stay, duration of surgery, time spent on the recovery ward, health-related quality of life, complication and readmission rates did not differ between the study groups. There were no deaths. Conclusion: Patients under ERAS care recovered faster after LRYGB surgery than those receiving conventional care, with no increase in readmission and postoperative morbidity rates. Registration number: NTR3853 (http://www.trialregister.nl/).

Strongly reduced penetration of atomic deuterium in radiation-damaged tungsten.

Radiation-damaged tungsten is exposed to high-flux, low-energy deuterium plasmas at self-bias conditions. We observe that the fraction of deuterium that penetrates is only 10(-5)-10(-7) of the plasma flux and strongly dependent on the local surface temperature. We propose that deuterium does not directly penetrate bulk tungsten but that it thermalizes at the surface, where it forms a protective chemisorbed layer. We find an energy barrier of 1-2 eV between the surface and bulk, causing the influx of deuterium to be low as compared to the number of defects and leading to slow filling of the damaged layer.

Finding and using dental evidence and tools at the point of care.

Trusted chair-side dental information is available in multiple formats and from numerous online Web sites to aid in the evidence-based treatment decision-making process.

Expression of receptors for insulin and leptin in the ventral tegmental area/substantia nigra (VTA/SN) of the rat.

Recent studies have demonstrated that the metabolic hormones insulin and leptin can modulate behavioral performance in reward-related paradigms. However, specific anatomical substrate(s) within the CNS for these effects remain to be identified. We hypothesize that midbrain dopamine neurons, which have been implicated to be critical in the mediation of motivational and reward aspects of stimuli, contribute to these behavioral effects of insulin and leptin. As one approach to evaluate this hypothesis, we used double-labeling fluorescence immunohistochemistry to determine whether the midbrain dopamine neurons express insulin receptors or leptin receptors. Extensive co-expression of tyrosine hydroxylase (a marker for dopamine neurons) with both the insulin receptor and the leptin receptor was observed in the ventral tegmentum and substantia nigra. These findings suggest that midbrain dopamine neurons are direct targets of insulin and leptin, and that they participate in mediating the effects of these hormones on reward-seeking behavior.

ERP analysis of cognitive sequencing: a left anterior negativity related to structural transformation processing.

A major objective of cognitive neuroscience is to identify those neurocomputational processes that may be shared by multiple cognitive functions vs those that are highly specific. This problem of identifying general vs specialized functions is of particular interest in the domain of language processing. Within this domain, event related brain potential (ERP) studies have demonstrated a left anterior negativity (LAN) in a range 300-700 ms, associated with syntactic processing, often linked to grammatical function words. These words have little or no semantic content, but rather play a role in encoding syntactic structure required for parsing. In the current study we test the hypothesis that the LAN reflects the operation of a more general sequence processing capability in which special symbols encode structural information that, when combined with past elements in the sequence, allows the prediction of successor elements. We recorded ERPs during a non-linguistic sequencing task that required subjects (n = 10) to process special symbols possessing the functional property defined above. When compared to ERPs in a control condition, function symbol processing elicits a left anterior negative shift between temporal and spatial characteristics quite similar to the LAN described during function word processing in language, supporting our hypothesis. These results are discussed in the context of related studies of syntactic and cognitive sequence processing.

Assessing the effectiveness of direct digital radiography barrier sheaths and finger cots.

BACKGROUND: Effective cross-contamination prevention is critical for direct digital radiography, or DDR, sensors, which are not sterilizable; however, current manufacturers' recommendations for standard precautions are limited to the use of plastic barrier sheaths, which are commonly known to tear or leak. The authors sought to determine the incidence of digital radiography barrier-sheath leakage, with and without additional latex finger cot protection, as measured by a water pressure test. METHODS: Four hundred plastic barrier sheaths were randomly assigned to four groups based on intraoral radiograph positioning device use and supplemental barrier protection with a latex finger cot. Sheaths were carefully placed to cover DDR sensors for a single intraoral use, gently removed from the sensors and tested for leakage through a water pressure technique. RESULTS: Perforations occurred in 44 to 51 percent of plastic sheaths after a single radiographic exposure. However, only up to 6 percent of the plastic sheaths that were covered by a latex finger cot leaked during the water pressure test. CONCLUSIONS: At least 44 percent of the plastic barrier sheaths leaked after a single intraoral radiographic exposure. Use of a latex finger cot over the plastic sheath significantly reduced leakage to no more than 6 percent. CLINICAL IMPLICATIONS: Latex finger cots used in conjunction with the standard plastic sheaths that cover DDR sensors may more effectively prevent cross-contamination than do plastic sheaths alone. Dentists who use DDR sensors during highly invasive dental procedures such as dental implant surgery are encouraged to consider supplemental barrier protection for these delicate, expensive and nonsterilizable sensors to prevent patient cross-contamination.

Comparison of diagnostic accuracy of digital imaging by using CCD and CMOS-APS sensors with E-speed film in the detection of periapical bony lesions.

OBJECTIVE: The purpose of this study was to compare E-speed Plus film and digital imaging with a charge-coupled device (CCD) sensor and a complementary metal-oxide semiconductor active pixel sensor (CMOS-APS) in the detection of periapical bone lesions. STUDY DESIGN: Periapical lesions were created in the cortical and trabecular bone of 10 dried human mandibles. Seventy radio-graphic images and 140 digital images were evaluated by 6 endodontists and 2 radiologists. Receiver operating characteristics curves and analysis of variance were used for statistical analysis.Results. No statistically significant differences were found between film, CCD, and CMOS-APS systems. Lesion detection occurred with significantly greater accuracy in cortical bone than in trabecular bone, as well as when the cortical plate was involved. CONCLUSIONS: That no differences were found between the two sensors lends support for the use of CMOS-APS sensors, which require less system power and may have longer life spans than CCD sensors. Digital imaging required 50% less radiation than film to obtain the same diagnostic information.

Effect of rotational speed on nickel-titanium file distortion.

Separation of instruments while performing root canals is something that has plagued all practitioners. The purpose of this study was to evaluate the effect of rotational speed on nickel-titanium file distortion and separation. Forty extracted human molars were instrumented with Profile (Dentsply Tulsa Dental Products, Tulsa, OK) ISO .04 rotary nickel-titanium instruments at 166.67 or 333.33 rpm. The instruments were evaluated after instrumentation for separation and/or distortion. The results of this study were statistically significant and indicate that file distortion and/or separation is four times as likely to occur at 333.33 rpm vs. 166.67 rpm.

Inflammatory cervical root resorption following segmental orthognathic surgery. A case report.

An unusual case of bilateral inflammatory external/internal root resorption developed in the maxillae of a 28 year-old female approximately 4 years following routine segmental orthognathic surgery. The patient experienced dental pain in a tooth adjacent to a segmental osteotomy cut 8 months postsurgery, however, the tooth later became asymptomatic. A definitive diagnosis of inflammatory cervical root resorption was not established until nearly 4 years later on routine dental examination. The external/internal resorptive lesions were located 4 to 6 mm apical to the connective tissue attachment on 3 of the 4 tooth roots adjacent to osteotomy cuts. Two of the affected teeth required non-surgical root canal therapy due to pulpal communication with the resorptive defects. The lesions were accessed by flap surgery, thoroughly debrided, and obturated with an intermediate restorative material until definitive restorative therapy could be completed. All sites healed uneventfully and the patient has been closely observed for approximately 2 years without symptoms or recurrence of the resorptive lesions. Dental health care providers should be alert to the possible occurrence of inflammatory root resorption in sites adjacent to osteotomy cuts over extended periods of time. Routine radiographic examination may be beneficial in the postoperative management of the segmental orthognathic surgery patient.

Infectious transient dental-related paresthesia.

Three instances of paresthesia in the oral cavity were resolved by nonsurgical endodontic therapy. Resolution of the condition supports the theory that pressure caused by an expanding infection and the associated inflammatory response result in paresthesia.

Stromal cells from subcutaneous adipose tissue seeded in a native collagen/elastin dermal substitute reduce wound contraction in full thickness skin defects.

BACKGROUND: Dermal substitutes seeded with cultured fibroblasts have been developed to improve dermal regeneration in full thickness wounds. Because of cell cultivation, 3 weeks are required before patients can be treated with these autologous adipose tissue. This substitute is easily fabricated within hours, which allows immediate treatment of full thickness defects. EXPERIMENTAL DESIGN: Porcine full thickness wounds were substituted with native collagen/alpha-elastin hydrolysate matrices. One group of matrices was left unseeded as negative control. The second was seeded with cultured dermal fibroblasts as positive control. The third was seeded with a stromal-vascular-fraction of adipose tissue, and the fourth was seeded with a stromal fraction with few vascular fragments (SF). All substitutes were covered with split skin mesh grafts and were protected against dehydration and infection with a microporous polyether urethane membrane. For 8 weeks, weekly biopsies were taken, myofibroblasts and fibroblasts were counted, thickness of the granulation tissue band was measured, and wound contraction and histology were evaluated. RESULTS: Negative control and stromal-vascular-fraction substitutes were invaded by high numbers of myofibroblasts and fibroblasts. They did not reduce wound contraction, and scar tissue was formed. SF substitutes reduced the accumulation of myofibroblasts and fibroblasts and prevented the formation of granulation tissue. As a result, dermal regeneration improved, and wound contraction was less than by the other substitutes. CONCLUSIONS: Adipose tissue cell isolates included vascular fragments containing endothelial cells. Seeded in dermal substitutes, these vascular fragments induced hypergranulation tissue formation and caused wound contraction. SF substitutes contained few endothelial cells. As a result, the contraction arresting effect of the seeded stromal cell fraction was effective. Our concept of a cellular dermal substitute seeded with stromal cells from adipose tissue is feasible and allows immediate treatment of full thickness skin defects.

A case report of severe external resorption.

External root resorption is a multifactorial process with many causes. Except for transient surface resorption, it is usually considered an irreversible process. Treatment can arrest or retard the resorptive process. Many factors that have been associated with this process include physiologic resorption, local factors, systemic conditions, and idiopathic resorption. This case report documents a 29-year-old white male who suffered a motor vehicle accident and dental trauma nine years ago. The accident resulted in the lateral displacement of the maxillary right canine. The maxillary right lateral incisor, right central incisor and left central incisors were avulsed. The right central incisor was never recovered from the accident site. The other teeth were replanted 90 minutes after the accident and rigidly splinted for six months. They then received root canal treatment, approximately one month after the splint was removed (seven months from time of the trauma). On annual examination, the patient complained of a loose maxillary fixed prosthesis. He was diagnosed with severe external resorption on the right lateral and left central incisors, and severe external replacement resorption on the right canine. This case report reviews the current trends in the treatment of avulsed teeth and the resorptive process.

Effect of three obturation techniques on the filling of lateral canals and the main canal.

The three-dimensional obturation of the root canal system is widely accepted as a key factor for successful endodontic therapy. The purpose of this study was to evaluate the obturation of lateral canals and the main canal using three gutta-percha sealer techniques: cold lateral condensation, warm lateral condensation, and warm vertical condensation. Sixty epoxied blocks with five lateral canals placed at varying angles from the main canal were used. Each experimental group was treated by a board-certified endodontist with training and clinical experience in that obturation technique. There was no statistically significant difference (p < 0.05) between the obturation techniques in the ratio of the void area to the gutta-percha-plus-sealer area for the main canal. There was significantly (p < 0.001) more sealer in the lateral canals for the two lateral condensation techniques. The warm obturation techniques had significantly (p < 0.001) more gutta-percha in the lateral canals.

Rapid removal of sealer following root canal treatment.

A case of acute exacerbation following nonsurgical root canal treatment is presented. Clinical symptoms of acute inflammation superimposed on chronic inflammation were initiated, presumably from root canal treatment and overfilling of AH-26. Unusually rapid removal of the root canal sealer overfilling was observed. Possible mechanisms of resolution, including inflammation and immune response, were discussed.

Vertical extrusion: literature review and report of a case.

To date, the scientific literature has documented, primarily, successful methods and techniques of treatment involving vertical extrusion. The purpose of this article is to review the literature and report on a case that demonstrates the multidisciplinary approach required to successfully manage a reversible complication involving the restoration of an adult maxillary central incisor that had sustained an oblique crown-root fracture.

Conservative treatment of persistent periradicular lesions using aspiration and irrigation.

Aspirating the unknown contents of a bony cavity and saline irrigation of a body wound are both basic surgical techniques. These two techniques have been combined in treating persistent periradicular pathosis in two cases. The cases demonstrate significant bony healing of extensive periradicular defects after the use of the combined procedure. Both cases were nonresponsive to nonsurgical root canal treatment. The use of aspiration and irrigation may initiate healing in cases of uninfected apical cysts which heretofore would require surgical intervention. The conservative nature of these procedures has advantages of reduced treatment time, avoidance of iatrogenic problems, and elimination of some conventional apical surgery.

Preserving the maxillary anterior alveolar ridge contour using hydroxylapatite.

Although this procedure is not necessarily indicated for all patients, it is an alternative to subsequent soft tissue, osseous, or synthetic grafting procedures. The combination of extraction, hydroxylapatite graft, and acid-etched replacement is an alternative treatment that reduces patient treatment time.

Osteomyelitis of the maxilla with associated vertical root fracture and Pseudomonas infection.

Osteomyelitis of the maxilla is not often found. A rare case of this condition secondary to a chronic vertical root fracture of a maxillary lateral incisor, with Pseudomonas aeruginosa as the primary pathogen, is presented. Interesting features of this case report are the occurrence of osteomyelitis in the maxilla, the rare isolate of P. aeruginosa, and the clinical problems associated with the diagnosis of vertical root fractures. The combination of surgical, endodontic, and antimicrobial therapy used is described.