Coronary angiographic findings for out-of-hospital cardiac arrest survivors presenting with nonshockable rhythms and no ST elevation post resuscitation.

BACKGROUND: Recent guidelines suggest that coronary angiography (CAG) should be considered for out-of-hospital cardiac arrest (OHCA) survivors, including those without ST elevation (STE) and without shockable rhythms. However, there is no prospective data to support CAG for survivors with nonshockable rhythms and no STE post resuscitation. METHODS: This was a re-analysis of the PEARL study (randomized OHCA survivors without STE to early CAG versus not). Patients were subdivided by initial rhythm as nonshockable (Nsh) vs shockable (Sh). The primary outcome was coronary angiographic evidence of acute culprit lesion, with secondary outcomes being survival to hospital discharge and neurological recovery. RESULTS: The PEARL study included 99 patients with OHCA from a presumed cardiac etiology, 24 with nonshockable and 75 with shockable rhythms. There was no difference in the frequency of CAG between the two groups [71% (Nsh) and 75% (Sh); p = 0.79], presence of CAD [81% (Nsh) and 68% (sh); p = 0.37, or culprit lesions identified in each group [50% (Nsh) and 45% (Sh); p = 0.78. Nonshockable patients had worse discharge survival [33% (Nsh) vs 57% (Sh); p = 0.04] and those survived, had worse neurological recovery [30% (Nsh) vs 54% (Sh); p = 0.02] compared to shockable patients. CONCLUSIONS: OHCA survivors presenting with nonshockable rhythms and no STE post resuscitation had similar prevalence of culprit coronary lesions to those with shockable rhythms. CAG may be considered in patients with OHCA without STE regardless of initial presenting rhythm. There was no benefit of emergent CAG both in shockable and non-shockable rhythms.

Intracranial Perishunt Catheter Fluid Collections with Edema, a Sign of Shunt Malfunction: Correlation of CT/MRI and Nuclear Medicine Findings.

Fluid collections with edema along the intracranial tract of ventriculoperitoneal shunt catheters in adults are rare and are more frequently seen in children. The imaging appearance of these fluid collections is frequently confusing and presents a diagnostic dilemma. We present 6 cases of adult patients noted to have collections with edema along the tract of ventriculoperitoneal shunt catheters. To our knowledge, there are no previous studies correlating the CT/MR imaging findings with nuclear medicine scans in this entity. We hypothesized that when seen in adults, the imaging findings of a CSF-like fluid collection around the intracranial ventriculoperitoneal shunt catheter on CT/MR imaging may suggest areas of CSF accumulation with interstitial edema. It is important to recognize this rare ventriculoperitoneal shunt complication in adults to prevent misdiagnosis of an abscess or cystic tumor.

MRONJ risk reduction pathway - 360 degree survey.

Introduction Bisphosphonates and denosumab reduce the risk of skeletal events in some malignancies (for example, breast, myeloma). These drugs carry a significant risk of a difficult-to-manage side effect of medication related osteonecrosis of the jaw (MRONJ). Preventive dental screening and treatment reduces the incidence of MRONJ. A managed clinical network (MCN) has been used to provide a MRONJ risk reduction pathway. A 360 degree survey was undertaken to assess the effectiveness of the pathway.Aim The aim of the 360 degree survey was to evaluate if this preventive pathway fulfilled its aims based on patient and stakeholder responses.Method A multidisciplinary, cross-service, cross-health board MRONJ preventive pathway has been developed. A 360 degree feedback survey of patients and other stakeholders was undertaken.Results Overall, this survey revealed high levels of satisfaction across patients, oncologists, community dental services, general dental services, and hospital managers.Conclusion Alternative ways of delivering MRONJ preventive pathways can be developed and assessed using iterative stakeholder feedback aided by a robust clinical governance framework.

Improving the quality of endodontic record keeping through clinical audit.

Introduction Record keeping is an essential part of day-to-day practice and plays an important role in treatment, audit and dento-legal procedures. Creating effective endodontic records is challenging due to the scope of information required for comprehensive notes. Two audits were performed to assess the standards of endodontic record keeping by dentists in a restorative dentistry department and students on an endodontic MSc course.Methods Fifty sets of departmental records and 10 sets of student records were retrospectively evaluated against the European Society of Endodontology 2006 guidelines. Results of the first cycle of both audits were presented to departmental staff and MSc students, alongside an educational session. Additionally, departmental guidelines, consent leaflets and endodontic record keeping forms were developed. Both audits were repeated using the same number of records, thus completing both audit cycles.Results The most commonly absent records included consent, anaesthetic details, rubber dam method, working length reference point, irrigation details and obturation technique. Almost all areas of record keeping improved following the second audit cycle, with some areas reaching 100% compliance when record keeping forms were used. Statistically significant improvements were seen in 24 of the 29 areas in the departmental audit and 14 of the 29 areas in the MSc audit (P = 0.05).Conclusions Significant improvements in endodontic record keeping can be achieved through the provision of education, departmental guidelines, consent leaflets and endodontic record keeping forms.

Safety and predictability of conscious sedation in dentistry -- a multi-centre regional audit: South and West Wales experience.

INTRODUCTION: There are no previously published reports of audits in conscious sedation from a group comprising the general dental services (GDS), community dental services (CDS) and hospital dental services (HDS). AIM: The main aim of this audit was to assess current practice within the group in relation to the safety and predictability of dental treatment undertaken with the aid of conscious sedation. METHODS: A total of nine centres collected data prospectively on 1,037 sedation episodes over the course of one year. Audit standards were locally agreed based on current evidence and local experience. They were set at a completion rate of 90% and an adverse incident rate of 2% or less. RESULTS: Based on the data collected, a completion rate of 92% and a minor adverse incident rate of 2.6% were recorded. CONCLUSIONS: The participating centres met the standards set locally for this audit. Current practice in the participating centres was found to be safe and predictable. The audit tool is being refined to improve the quality of data collection. Further research and service evaluation is recommended.

Absorptive clearance of DTPA as an aerosol-based biomarker in the cystic fibrosis airway.

Biomarkers providing in vivo quantification of the basic elements of cystic fibrosis (CF) lung disease are needed. A study was performed to determine whether the absorption of a small radiolabelled hydrophilic molecule (Indium-111 (In-)DTPA) would be increased in CF airways. DTPA clearance has been used previously to assess epithelial permeability and may also be useful for quantifying liquid absorption. The absorptive clearance rate of DTPA was quantified in 10 CF and 11 control subjects using a novel aerosol technique. Subjects inhaled an aerosol containing nonabsorbable technetium-99m sulfur colloid (Tc-SC) particles and In-DTPA. Tc-SC clearance from the lung is exclusively mucociliary, while In-DTPA is cleared by both absorption and mucociliary clearance. The difference between the In-DTPA and Tc-SC clearance rates estimates In-DTPA absorption. Tc-SC (mucociliary) clearance was similar in central and peripheral zones in CF and non-CF lungs. Total In-DTPA clearance was increased in both zones in CF lungs. The absorptive component of In-DTPA clearance was increased in the airway-dominated central lung zones in CF (42% x h( -1) versus 32% x h(-1), p = 0.03). The absorption of In-DTPA is increased in the CF airway. Further study is needed to understand the relative roles of fluid absorption, inflammation and other mechanisms potentially affecting epithelial permeability and DTPA absorption.

Management of patients on warfarin by general dental practitioners in South West Wales: continuing the audit cycle.

AIMS: To ascertain the current management protocols of patients on warfarin by general dental practitioners (GDPs) in South West Wales and to compare these findings with current guidelines and the results from a previous audit published in 2003. MATERIALS AND METHODS: A questionnaire similar to that used in the first audit was sent to 447 GDPs in South West Wales. In addition, questions were included on factors which might affect international normalised ratio (INR), the timing of pre-operative INR assessment and the risk of bleeding associated with implant surgery. GDPs' details were derived from the online GDC database of registered dental practitioners. Registered specialists and GDPs who practised only orthodontics were excluded. RESULTS: Of the 447 questionnaires distributed, 332 (74%) were returned. Eight percent (n = 26) of the respondents did not treat patients on warfarin. Two hundred and forty-seven respondents (74%) considered implant placement as a procedure with high risk of bleeding, with inferior dental block, sub-gingival restorations and sub-gingival debridement receiving a lower response (45%, 28% and 12%, respectively). When planning a high risk procedure, 206 respondents (63%) indicated they would seek advice from a cardiologist or general medical practitioner; none of the respondents would advise the patient to reduce their warfarin dose, while 1% indicated they would ask the patient to stop taking warfarin without seeking any medical opinion. A total of 278 respondents (84%) stated they would check the INR before treatment and of these, 214 (65%) indicated they would do so within 24 hours of treatment and 60 (18%) within 48 hours. Ten respondents said they would not normally check INR. One hundred and twelve respondents (34%) considered 2.5 as the safe upper INR limit for performing high risk procedures, 21 (6%) considered an INR of between 1 and 2 as the safe limit, 99 (30%) considered and INR of 3 as safe, 36 (10%) considered 3.5 as safe and 36 (10%) considered an INR of 4 as safe. Finally, 286 respondents (86%) considered drug interactions and 236 (71%) considered alcohol as significant influencing factors on INR. CONCLUSIONS: The findings demonstrate a broad change in practice towards the new recommendations produced in 2001 but also highlight that further education and support may be necessary, as well as greater consistency in published guidelines.

Evaluation of a system for grading the complexity of root canal treatment.

AIM: To evaluate the reproducibility of the Restorative Index of Treatment Need (RIOTN) system for grading the complexity of root canal treatment. METHODOLOGY: The RIOTN system of grading the complexity of root canal treatment was applied to all endodontic referrals to a department of restorative dentistry in a district general hospital within a period of one year. Grading was repeated in 60 randomly selected teeth and weighted kappa analysis was used to test for intra-observer as well as inter-observer agreement with a consultant in restorative dentistry and a vocational trainee (VT). RESULTS: In all, 152 patients were referred for root canal treatment of 186 teeth within the period of study. Weighted kappa for intra-observer agreement when categorising complexity was 0.636. Weighted kappa for inter-observer agreement with the consultant was 0.570 and that for agreement with the VT was 0.223. CONCLUSION: The RIOTN system of grading the complexity of root canal treatment was incomplete; with moderate to poor reproducibility.

Quantum lithography with classical light.

We show how to achieve subwavelength diffraction and imaging with classical light, previously thought to require quantum fields. By correlating wave vector and frequency in a narrow band, multiphoton detection process that uses Doppleron-type resonances, we show how to achieve arbitrary focal and image plane patterning with classical laser light at submultiples of the Rayleigh limit, with high efficiency, visibility, and spatial coherence. A frequency-selective measurement process thus allows one to simulate, semiclassically, the path-number correlations that distinguish a quantum entangled field.

Differential capacitance of liquid/liquid interfaces--a lattice gas model approach.

A lattice gas model formalism under mean field approximation is developed for the analysis of differential capacitance pertaining to liquid/liquid interfaces. The interfacial profiles for the two solvent mole fractions are chosen and ionic charge densities are estimated by minimizing the Helmholtz free energy. The dependence of the differential capacitance on various interaction energies, electrolyte concentrations and dielectric constants is indicated. The influence of the solvent density profile is analyzed and deviations from the predictions of Gouy-Chapman theory are pointed out.

An assessment of the management of patients on warfarin by general dental practitioners in South West Wales.

For anticoagulation therapy, warfarin is used to reduce the risk of thrombo-embolic events in patients with mechanical prosthetic heart valves, certain cardiovascular conditions, deep vein thrombosis (DVT) and hypercoagulable states.(1). The International Normalised Ratio (INR) is used as a measure of anticoagulation and is expressed as a ratio of the patient's prothrombin time (PT) to control prothrombin time. In a person with a normal PT, the INR is approximately 1. The therapeutic range is the value of INR or degree of anticoagulation required to prevent the development of serious thrombo-embolism and is normally maintained between 2.0 and 4.5. It is important to recognize that the INR is only valid for patients on well controlled anticoagulant therapy, ie where the level of anticoagulation is reasonably stable over a moderate length of time.(2).

Afferent loop syndrome: the role of Tc-99m mebrofenin hepatobiliary scintigraphy.

Afferent loop syndrome is caused by intermittent mechanical obstruction of the afferent loop of a gastrojejunostomy and may present early as an acute type or late as a chronic type. The authors describe two patients who were examined for a history of bilious vomiting after gastrojejunostomy, and who were thought to have afferent loop syndrome (chronic type) based on clinical findings. Results of routine investigations, such as upper gastrointestinal endoscopy, and ultrasonography were inconclusive. Findings from the barium meal follow-through studies were normal in the first patient and revealed a dilated duodenum in the second patient. Tc-99m bromotriethyl-iminodiacetic acid has been used to identify afferent loop obstruction as represented in these studies.

An audit of antibiotic prescribing by general practitioners in the initial management of acute dental infection.

A sub-regional audit showed a high rate of referral of acute dentoalveolar infections as emergencies. In Torbay Hospital alone, 21 patients required admission following such referrals in a period of 3 months. A questionnaire was therefore sent out to all general medical and general dental practitioners in the area covered by Torbay Hospital in order to survey their choice of antibiotics in the initial management of acute dentoalveolar infections. The results showed that the prescribing patterns of general medical practitioners differed significantly from those of general dental practitioners and that practitioners were reluctant to prescribe metronidazole as a first choice, even in patients allergic to penicillin. The authors conclude that awareness about the use of antibiotics, particularly among general dental practitioners, needs to be increased.