E-HEART score: A novel scoring system for undifferentiated chest pain in the emergency department.

OBJECTIVE: Cardiovascular disease is the leading cause of death worldwide. As there is an increase in the global burden of ischemic heart disease, there are multiple scoring systems established in the emergency department (ED) to risk stratify and manage acute coronary syndrome (ACS) in patients with chest pain. The objective of this study was to integrate point-of-care echo into the existing history, electrocardiogram, age, risk factors, and troponin (HEART) score and evaluate a novel scoring system, the echo HEART (E-HEART) score in risk stratification of patients presenting with undifferentiated chest pain to the ED. The E-HEART Score was also compared with existing traditional scoring systems for risk-stratifying acute chest pain. METHODS: A diagnostic accuracy study involving 250 patients with chest pain at the ED of a single tertiary care teaching hospital in India was conducted. The emergency physicians assessed the E-HEART score after integrating their point-of-care echo/focused echo findings into the conventional HEART score on presentation. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE) within 4 weeks of initial presentation. The accuracy of the E-HEART score was compared with other conventional risk stratification scoring systems such as the thrombolysis in myocardial infarction (TIMI), history, electrocardiogram, age, and risk factors, Troponin Only Manchester ACS (T-MACS), and HEART scores. RESULTS: A total of 250 patients with a median age of 53 years (42.25-63.00) were part of the study. Low E-HEART scores (values 0-3) were calculated in 121 patients with no occurrence of MACE in this category. Eighty-one patients with moderate E-HEART scores (4-6) were found to have 30.9% MACE. In 48 patients with high E-HEART scores (values 7-11), MACE occurred in 97.9%. The area under receiver operating characteristics (AUROC) of E-HEART score is 0.992 (95% confidence interval: 0.98-0.99), which is significantly higher than AUROC values for HEART (0.978), TIMI (0.889), T-MACS (0.959), and HEAR (0.861), respectively (P < 0.0001). At a cutoff of E-HEART score >6, it accurately predicted ACS with a sensitivity of 92% and a specificity of 99% with a diagnostic accuracy of 97%. CONCLUSION: The E-HEART score gives the clinician a quick and accurate forecast of outcomes in undifferentiated chest pain presenting to the ED. Low E-HEART scores (0-3) have an extremely low probability for short-term MACE and may aid in faster disposition from the ED. The elevated risk of MACE in patients with high E-HEART scores (7-11) may facilitate more aggressive workup measures and avoid disposition errors. E-HEART is an easily adaptable scoring system with improved accuracy compared to conventional scoring systems.

Efficacy of Neurectomy of Peripheral Branches of the Trigeminal Nerve in Trigeminal Neuralgia: A Critical Review of the Literature.

INTRODUCTION: Of the many chronic painful conditions, trigeminal neuralgia (TN) affecting the orofacial region needs the particular attention of physicians and surgeons, especially those specialising in the maxillofacial region. Treatment protocols for the management of classic TN include pharmacology and surgical intervention. Oral and maxillofacial surgeons have traditionally employed the peripheral neurectomy in the surgical management of TN. This review aims to evaluate the efficacy of peripheral neurectomy in the management of TN with regard to (a) the relief of symptoms in comparison with standard neurosurgical procedures and (b) the duration of pain relief and complications observed compared to standard neurosurgical procedures. METHODS: The review of the literature was done according to PRISMA guidelines and included randomised controlled trials, reviews and prospective clinical studies involving surgical procedures for the management of TN. The primary outcomes evaluated were (a) initial relief of pain, (b) duration of relief of pain, (c) complications observed with ablative procedures and (d) recurrence of symptoms. A total of 43 studies fulfilled the inclusion criteria. RESULTS: In a total of 7913 patients from the 43 studies, central procedures were found to have best results for both quality and duration of pain relief. Percutaneous and peripheral procedures were associated with increased recurrence rates. The consolidated rates of complication for peripheral, percutaneous and central procedures were 39.46, 65.42 and 10.41%, respectively. The use of peripheral neurectomy alone in the management of classic TN was observed in 10 studies. CONCLUSION: Peripheral neurectomy in TN is associated with lesser quality of pain relief in comparison with central neurosurgical procedures. It also provides only short- to medium-term pain relief. Most studies with the use of peripheral neurectomy involved only a small group of patients with short follow-up periods. Oral and maxillofacial surgeons must not consider the peripheral neurectomy as the first surgical option in the management of classic TN. Long-term results can be achieved better with appropriate central neurosurgical procedures and pharmacotherapy.

Maxillofacial Infections of Odontogenic Origin: Epidemiological, Microbiological and Therapeutic Factors in an Indian Population.

Odontogenic fascial space infections are commonly encountered by the oral and maxillofacial surgeon. A retrospective study of the epidemiological characteristics, microbiological analysis and treatment response to odontogenic infections treated in the oral and maxillofacial unit of a Dental school is presented. A retrospective analysis of case records of all odontogenic infections that reported to the oral and maxillofacial surgery unit in a Dental school over a period of 2 years was performed. Epidemiological data, microbiological profile and treatment responses were analysed. All data were subjected to statistical analysis using SPSS statistical package. Mann-Whitney U test, Kruskal-Wallis test and nonparametric tests were carried out. A total of 2,140 patients were included in this study. Mandibular third molars were the offending tooth in nearly 40 % of cases with 107 patients becoming symptomatic following a dental extraction procedure. All patients were treated with surgical incision and drainage, antibiotics and local wound care. More than 95 % cases needed intraoral incisions. Penicillin was the drug in most of the cases. The pterygomandibular space was the most commonly involved with 15 % reporting with multiple fascial space involvement. Microbiological analysis showed a predominance of aerobic gram positive organisms with Streptococcus sanguis most commonly isolated. Peptostreptococci and Propionibacterium were the common anaerobes isolated. More than 80 % of the strains isolated were sensitive to penicillin. The average length of stay was 6.3 days. Inadequate documentation with regards to referral patterns, antibiotic history was commonly observed in case records. Penicillin continues to remain the drug of choice for a vast majority of maxillofacial infections of odontogenic origin. A delay in reporting can lead to worsening of symptoms with consequent increase in surgical morbidity and costs of treatment. Preventive dental care remains the best option available to mitigate the consequences of poor oral hygiene. Poor awareness among patient population for regular dental reviews and oral hygiene maintenance emphasises the need for sensitisation and education programs.

A Comparative Study Between Bupivacaine with Adrenaline and Carbonated Bupivacaine with Adrenaline for Surgical Removal of Impacted Mandibular Third Molar.

OBJECTIVES: To compare the effectiveness of bupivacaine with adrenaline with that of carbonated bupivacaine with adrenaline on pain, onset of anesthesia and duration of anesthesia following surgical removal of impacted mandibular third molar. STUDY DESIGN: All the patients who underwent surgical removal of impacted mandibular third molar and who fulfilled our inclusion and exclusion criteria from 1st June 2013 to 30th June 2014 were included in our study. Patients who were diagnosed as having impacted mandibular third molar were randomly allocated to two groups namely group A (bupivacaine with adrenaline), group B (carbonated bupivacaine with adrenaline). Pain during deposition of local anesthetic, onset of anesthesia and duration of anesthesia were compared between the two groups. The collected data were subjected to statistical analysis by Chi Square test, Mann-Whitney U test. RESULTS AND CONCLUSION: The efficacy of carbonated bupivacaine with adrenaline is more compared with bupivacaine with adrenaline in decreasing pain on deposition of local anesthetic solution and in rapid onset of anesthesia. The duration of anesthesia for carbonated bupivacaine with adrenaline and bupivacaine with adrenaline had no significant difference. The use of carbonated bupivacaine with adrenaline will reduce the patient discomfort both intra-operatively and post-operatively.

Peripheral Osteoma of the Body of Mandible: A Case Report.

Osteoma is a slow growing benign tumor consisting of well differentiated compact or cancellous bone that increases in size by continuous growth. It can be of a central, peripheral, or extraskeletal type. The peripheral type arises from the periosteum and is rarely seen in mandible. Although completely curable with adequate surgical treatment, osteomas precede the clinical radiographic evidence of colonic polyposis/Gardner's syndrome. Therefore they may be sensitive markers for the disease. Recurrence of peripheral osteoma after surgical excision is extremely rare. However it is appropriate to provide both clinical and radiographic follow up after surgical excision of peripheral osteoma. This article describes the case of a 45 year old male who presented with painless swelling of the right body of mandible and resultant cosmetic facial disfigurement and functional impairment.

Comparision between neocone, alvogyl and zinc oxide eugenol packing for the treatment of dry socket: a double blind randomised control trial.

OBJECTIVES: To prospectively evaluate and compare the effectiveness of Neocone, Alvogyl and Zinc Oxide Eugenol (ZOE) intra alveolar dressings for the management of dry socket and to study the epidemiological factors associated with the condition. STUDY DESIGN: All the patients who underwent extraction of teeth and who fulfilled our inclusion and exclusion criteria from 1st January 2012 to February 28th 2013 were included in our study. Patients who were diagnosed to suffer from dry socket were randomly allocated to three groups namely Group A (Alvogyl), Group B (ZOE), Group C (Neocone). Pain relief and healing of the socket were compared between these groups. The collected data were subjected to statistical analysis by Chi Square test, Z test of proportionality. RESULTS AND CONCLUSION: Alvogyl is superior to the other two medications for providing initial pain relief. Neocone provides complete pain relief and the healing was fastest with Neocone. Neocone emerged as the most suitable dressing material for the management of dry socket by virtue of shorter time required for complete pain relief, fewer visits and faster clinical healing.

Bhawsar-karandikar stent: an aid to vestibuloplasty.

The loss of teeth and their replacement by artificial denture is associated with many problems. Pre-prosthetic surgical procedures are performed to provide a better anatomic environment and to create proper supporting structures for construction of dentures. Whenever inadequate vestibular depth is present in edentulous mouth, deepening of vestibule is considered to increase the retention and stability of denture. Deepening of vestibule without any addition of the bone is termed as vestibuloplasty. This article describes the ease and convenience of vestibuloplasty followed by the use of Bhawsar-Karandikar stent to maintain the soft tissue modifications. The study yielded promising results and patient acceptance.

Microflora in maxillofacial infections--a changing scenario?

PURPOSE: Advances in isolation and culturing techniques have brought the role of anaerobic bacteria-causing maxillofacial infections to the fore. Recent literature also favors the role of anaerobes in maxillofacial infections. A prospective clinical and microbiological study was designed to check the validity of such claims. PATIENTS AND METHODS: This study included 88 patients who fulfilled the inclusion criteria. Pus was obtained by aspirating the involved spaces and culture and sensitivity tests were performed to determine the microbes involved and their sensitivity to various antibiotics. RESULTS: Upon isolating the various organisms causing infection, it was found that 68.2% were aerobes, 13.6% were mixed infections, and 9.1% were anaerobes. Streptococcus and Peptostreptococcus species were the most common among aerobes and anaerobes, respectively. On determining sensitivity to penicillin, 81.3% were sensitive and 18.8% were resistant. Coagulase-negative Staphylococcus and Staphylococcus aureus were predominantly resistant to penicillin. CONCLUSION: Analysis of the results indicated no change in microflora-causing infections in the maxillofacial region and penicillin remains the drug of choice in treating these infections.

Schwannoma in masquerade.

Neurilemmoma is a rare nerve tumor seldom included in the list of differential diagnosis of soft tissue swelling in maxillofacial region. Arrival at a clinical diagnosis of schwannomas is rarely possible as there are hardly any characteristic clinical features to help in its and it is mostly established by histopathologic examination. We report an interesting case which had presentations similar to a sebaceous cyst but finally turned out to be a schwannomma.

Poliomyelitis causing TMJ ankylosis?--report of two intriguing cases.

INTRODUCTION: Temporomandibular joint (TMJ) ankylosis is one of the common diseases which affect the TMJ especially in children. We are reporting two rare cases of TMJ ankylosis which occurred along with poliomyelitis and which are not reported in literature so far. DISCUSSION: In this article, we discussed about the most probable causes which resulted in TMJ ankylosis in these patients.

Anterior chest wall abscess--an unusual complication of an odontogenic infection.

INTRODUCTION: A majority of odontogenic infections can be successfully managed with routine incision and drainage and empirical antibiotics. Sometimes an odontogenic infection may spread to contiguous spaces and descend along the neck causing significant morbidity and rarely even mortality. CASE REPORT: We report a case of an odontogenic infection which had an unusual spread to the anterior chest wall.

Peculiar presentation of bilateral temporalis muscle hypertrophy--report of a case and review of literature.

PURPOSE: Temporal hypertrophy is a rare clinical entity, especially the bilateral variety, whereas masseteric hypertrophy is a commonly occurring disorder. Very few bilateral cases are reported in literature. We are reporting a case with bilateral temporalis muscle hypertrophy with peculiar symptoms which is not reported so far in literature.

Atraumatic placement of circummandibular wires: a technical note.

Fractures of the mandible are relatively uncommon in children as compared to that of adults. When they occur, the problems associated with their management are complicated due to the presence of the tooth bud and potential growth disturbance. Various management protocols are discussed in the literature. Most authors agree that the ideal method is to use an acrylic splint because it is easy to place and reduces the risk to jaw growth. These splints are secured to the reduced jaw by circummandibular wiring, which is a relatively simple technique. The authors describe their experience with a new atraumatic technique for the placement of circummandibular wires using a 16 gauge intravenous cannula stillete.