Solubility evaluation of different root canal sealing materials.

AIM: To evaluate the solubility of five different root canal sealers (AH Plus Jet, RealSeal SE, MTA Fillapex, Tubli-Seal, and Acroseal) in chloroform, eucalyptol and Endosolv-E solvents. MATERIALS AND METHODS: Ninety root canal sealer samples were prepared and then divided into three groups for immersion in a solvent for 2, 5 or 10 minutes. The mean values of the root canal sealers' dissolution in the solvents were obtained by the difference between the preimmersion original weight and the post-immersion weight on a digital analytical scale. Data were statistically analyzed by a Kruskal-Wallis test with a Bonferroni correction. RESULTS: Chloroform was a more effective solvent than eucaly-ptol or Endosolv E for all root canal sealers, except for RealSeal SE, at all time points (p < 0.003). RealSeal SE was the least soluble sealer in all solvents at all time points. CONCLUSION: Chloroform demonstrated a superior ability over other solvents in dissolving canal sealing materials, and eucaly-ptol was found to be the least effective solvent in this study. CLINICAL SIGNIFICANCE: This study can help to the clinicians about which solvent should be preferred for solving the filling materials in retreatment cases.

D-ribose aids heart failure patients with preserved ejection fraction and diastolic dysfunction: a pilot study.

OBJECTIVES: The incidence of heart failure continues to escalate with >550,000 newly diagnosed patients annually worldwide. More than half of the patients with heart failure have preserved ejection fraction or isolated diastolic dysfunction, for which no current effective therapies for diastolic dysfunction exist. Every cell requires adequate levels of high energy phosphates to maintain integrity and function. Previous studies have demonstrated that diastolic function is energy dependent and supplemental D-ribose has shown to improve diastolic dysfunction. This study investigated what role D-ribose might play in congestive heart failure patients with preserved systolic function and diastolic dysfunction. METHODS: A total of 11 patients, New York Heart Association class II-IV, with clinical symptoms, normal left ventricular systolic function and echocardiographic evidence of diastolic dysfunction were enrolled after meeting inclusion criteria. Each patient received oral D-ribose (5 g/dose) for 6 weeks. Echocardiographic evaluation, cardiopulmonary metabolic testing and subjective questionnaire assessment were performed at baseline, 6 weeks and at 9 weeks (3 weeks after discontinuing D-ribose). RESULTS: An improvement in their tissue Doppler velocity (E'), which was maintained at 9 weeks, was demonstrated in 64% of the patients. Five patients showed an improvement in their ratio of early diastolic filling velocity (E) to early annulus relaxation velocity (E'). There was no appreciable difference in these measurements during valsalva or with leg raising and handgrip exercises. Four patients also had an improvement in their maximum predicted VO2 values; two demonstrated a worsening effect and no differences were noted in the remaining patients. Subjective assessment revealed a benefit in only one patient, worsening symptoms in one patient and no change in the remaining cohort. CONCLUSIONS: This pilot study revealed some beneficial trends with D-ribose even with this small cohort size. However, future investigations are necessary to further substantiate these observed benefits.

Aortic root bentall graft disarticulation following repair of type a aortic dissection.

A 47-year-old man presented with chest pain and was found to have an ascending aortic dissection. He underwent aortic arch resection and replacement with a hemishield tube graft with a valve conduit, better known as the Bentall technique. Five months later he presented with shortness of breath. A transesophageal echocardiogram revealed near-complete dehiscence of the mechanical valve conduit and a periaortic root abscess. He underwent removal of the conduit and placement of a homograft aortic root and valve. One month later he developed rigors. A transthoracic echocardiogram showed worsening systolic function and a periaortic hematoma or abscess. Serial transthoracic echocardiograms revealed increasing size in the periaortic echogenic free space and subsequent evidence of flow from the left ventricle into the periaortic space. He was determined not to be a surgical candidate and discharged to hospice in fair condition. He subsequently expired.

Transthoracic impedance cardiography: a noninvasive method of hemodynamic assessment.

Impedance cardiography technology, along with recent advances in the impedance cardiography (ICG) device, has become a provocative but not yet proven noninvasive alternative to invasive hemodynamic measurements. The results from stroke volume and cardiac output measurements by ICG show reasonably accurate correlation to the values calculated from direct measurements from pulmonary artery catheters. ICG may be a useful adjunct to clinical judgment for heart failure patients. The available data would not yet support supplanting invasive hemodynamic assessment in the critical care setting with ICG. Future studies and advances in technology are expected to improve impedance cardiography, thus broadening its clinical applications. Ongoing research must confirm the precise benefits of this information for ICG monitoring to become a standard assessment in heart failure.

Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management.

Pulmonary hypertension (PH) is common in the critical care setting, and may be a target for specific therapy. Moderate degrees of pulmonary hypertension are most often the consequence of acute or chronic heart failure, hypoxemia, or acute pulmonary embolism, and may be relatively rapidly reversible. The consequences of more severe forms of PH, both acute and chronic, can include hypotension; low cardiac output; right heart failure with congestion of the liver, gut, and kidneys; and varying degrees of hypoxemia, each of which can lead to death or severe disability. We review the physiology, definitions, classification, pathogenesis, diagnostic tools, and algorithms for diagnosis and specific treatments for the various causes of PH as seen in the critical care setting.

Improvement in hyponatremia during hospitalization for worsening heart failure is associated with improved outcomes: insights from the Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Chronic Heart Failure (ACTIV in CHF) trial.

BACKGROUND: Hyponatremia predicts poor outcome in patients with acute heart failure syndromes. This study evaluated the relationship between baseline serum sodium, change in serum sodium, and 60-day mortality in hospitalized heart failure patients. METHODS: A post-hoc analysis of the ACTIV in CHF trial was performed. ACTIV in CHF randomized 319 patients hospitalized for worsening heart failure to placebo or one of three tolvaptan doses. Cox proportional hazards regression-analysis was used to explore the relationship between baseline hyponatremia, sodium change during the hospitalization, and 60-day mortality. RESULTS: Hyponatremia was observed in 69 patients (21.6%). After covariate adjustment, baseline hyponatremia was a statistically significant predictor of 60-day mortality (P = 0.0016). Follow-up serum sodium data were available in 68 patients. At hospital discharge, 45 of 68 (66.2%) hyponatremic patients had improvements in serum sodium levels (> or = 2 mmol/l). Hyponatremic patients with a serum sodium improvement had a mortality rate of 11.1% at 60 days post discharge, compared with a 21.7% mortality rate in those showing no improvement. After covariate adjustment, change in serum sodium was a statistically significant predictor of 60-day mortality (HR: 0.736, 95% CI: 0.569-0.952 for each 1-mmol/l increase in serum sodium from baseline). CONCLUSIONS: Serum sodium improvements during hospitalization for heart failure were associated with improved survival at 60 days.

Cardiac hemodynamic and coronary angiographic characteristics of patients being evaluated for liver transplantation.

With improved survival after liver transplantation (LT), the referral of older candidates has increased. The increasing demand for, and the decreased supply of, liver donors makes careful preoperative cardiac risk assessment imperative. There is a paucity of information regarding the cardiac characteristics of patients being referred for LT in the current era. This study aimed to describe the cardiac hemodynamic and coronary angiographic characteristics of a cohort of patients with end-stage liver disease without known coronary artery disease (CAD) being evaluated for LT. One hundred sixty-one consecutive patients aged>or=45 years with end-stage liver disease who were referred for right- and left-sided cardiac catheterization as part of a liver transplant evaluation were identified. There was a high prevalence of atherosclerotic risk factors; half had hypertension or diabetes, and more than half had >or=2 coronary risk factors other than age. There was a high prevalence of CAD, with 26% having unknown moderate to severe coronary narrowing. Patients with moderate to severe CAD were older, were more likely to be men, and were more likely to have hypertension or diabetes mellitus. Right- and left-sided filling pressures were elevated, suggesting abnormalities in left ventricular diastolic compliance. In conclusion, this study showed a high prevalence of coronary risk factors and unknown moderate to severe CAD in patients with end-stage liver disease being referred for LT.

Reassessment of dobutamine, dopamine, and milrinone in the management of acute heart failure syndromes.

The appropriate role of intravenous inodilator therapy (inotropic agents with vasodilator properties) in the management of acute heart failure syndromes (AHFS) has long been a subject of controversy, mainly because of the lack of prospective, placebo-controlled trials and a lack of alternative therapies. The use of intravenous inodilator infusions, however, remains common, but highly variable. As new options emerge for the treatment of AHFS, the available information should be reviewed to determine which approaches are supported by evidence, which are used empirically without evidence, and which should be considered inappropriate. For these purposes, we reviewed data available from randomized controlled trials on short-term, intermittent, and long-term use of intravenous inodilator agents (dobutamine, dopamine, and milrinone) in AHFS. Randomized controlled trials failed to show benefits with current medications and suggested that acute, intermittent, or continuous use of inodilator infusions may increase morbidity and mortality in patients with AHFS. Their use should be restricted to patients who are hypotensive as a result of low cardiac output despite a high left ventricular filling pressure.