Diagnostic criteria for temporomandibular disorders (DC/TMD): interexaminer reliability of the Finnish version of Axis I clinical diagnoses.

Recently, updated diagnostic criteria for temporomandibular disorders (DC/TMD) were published to assess TMD in a standardised way in clinical and research settings. The DC/TMD protocol has been translated into Finnish using specific cultural equivalency procedures. To assess the interexaminer reliability using the Finnish translations of the DC/TMD-FIN Axis I clinical diagnostic assessment instruments. Reliability assessment data were collected during a 1-day DC/TMD Examiner Training Course at the University of Turku, Finland, in collaboration with the International DC/TMD Training and Calibration Center in Malmö University. Clinical TMD examinations according to the Finnish pre-final version of the DC/TMD Axis I assessment protocol were performed by four experienced TMD specialists on altogether 16 models. Kappa coefficient, overall percentage agreement (%A) as well as positive (PA) and negative (NA) agreements were used to define the reliability. Myofascial pain with referral, headache attributed to TMD and disc displacement (DD) without reduction without limited opening showed excellent kappa values (range 0·87-1·00). Fair-to-good reliability was observed for diagnoses of myalgia (k = 0·67), arthralgia (k = 0·71) and DD with reduction (k = 0·64). The PA was high for all pain-related diagnoses and DD without reduction without limited opening (medians ≥83%), and acceptable for DD with reduction (median 67%). The NA was high (medians ≥87%) for all DC/TMD diagnoses, except for myalgia which showed acceptable NA (median 75%). The %A was high for all assessed diagnoses (medians >85%). The findings of this study showed DC/TMD-FIN Axis I to demonstrate sufficiently high reliability for pain-related TMD diagnoses.

Long-term effectiveness of a prefabricated oral appliance for myofascial pain.

The long-term effectiveness of a prefabricated oral appliance (R) was compared with a stabilisation appliance (S) in patients with myofascial pain. Sixty-five patients diagnosed with myofascial pain at two centres for Stomatognathic Physiology in Sweden and Finland were included in a randomised controlled trial using Research Diagnostic Criteria for Temporomandibular Disorders, with history questionnaires and clinical examinations performed by blinded examiners at baseline and at 6- and 12-month follow-ups. Patients were randomly assigned either to the R or the S group. Treatment outcome was measured according to IMMPACT for four chronic pain outcome domains: pain intensity, overall improvement, physical functioning and emotional functioning. Physical functioning was classified for Graded Chronic Pain severities and assessed by the Jaw Functional Limitation scale. Emotional functioning composed of scores of non-specific physical symptoms and depression. There were no differences between groups at baseline. At both follow-ups, all outcome domains showed significant within-group improvement, without significant differences between groups. At 12 months, 72% of all patients reported a 30% reduction in worst pain and 63% of the patients a 50% reduction in worst pain. Overall improvement 'better' to 'symptom-free' was observed in 81% in the R and 64% in the S group at the 12-month follow-up. Graded Chronic Pain, Functional Limitation of the Jaw, non-specific physical symptoms and depression showed statistically significant reduction at 12-month follow-up. Results support the hypothesis that the effectiveness of the prefabricated appliance is similar to that of the stabilisation appliance in the long-term when treating patients with myofascial pain.

Salivary cortisol and IgA levels in patients with myofascial pain treated with occlusal appliances in the short term.

In many studies, the endocrinological response of individuals to different kinds of stresses has been tested. There seems to be widespread agreement that stress, depression, disability and dysfunctional illness behaviors are critical aspects of patients suffering from symptoms like pain, arising out of temporomandibular disorders (TMD). We aimed to explore treatment-induced changes in salivary cortisol, IgA and flow rate values in TMD patients suffering from myofascial pain. Temporomandibular disorders patients (n = 39) were randomized into two groups and treated with two different occlusal appliances. Perceived stress regarding family, work, economy, relationships, general health and stress in general was evaluated at baseline according to a verbal scale. Paraffin-stimulated saliva samples were collected before treatment and during follow-up at 6 and 10 weeks. Flow rate was measured immediately after the saliva collection while salivary cortisol and IgA were determined from samples stored at -70 degrees C. No clear association between reported stress and cortisol or IgA values could be observed at baseline. At 10 weeks follow-up, 92% of the patients felt 'better, much better, symptom-free' and no difference was found between the two appliance groups. Cortisol, IgA and flow rate values showed no systematic between appliance groups' differences. All salivary parameters showed interindividual differences but stayed intra-individually on a similar level throughout the study and no statistically significant changes could be observed when comparing before and after treatment levels. To conclude, there were no treatment-induced changes in saliva parameters despite successful appliance therapy in myofascial pain patients.

Complications of diagnostic and therapeutic ERCP.

BACKGROUND AND AIMS: In the era of magnetic resonance cholangiopancreaticography (MRCP) and laparoscopic biliary surgery, indications for endoscopic retrograde cholangiopancreaticography (ERCP) should be profoundly considered in the light of ERCP related complication rate. MATERIAL AND METHODS: To evaluate the frequency of complications associated with diagnostic and therapeutic ERCP, all endoscopic procedures from 1991 to 1996 were retrospectively reviewed. RESULTS: A total of 813 cannulations were performed on 590 patients. Endoscopic sphincterotomy (EST) was performed on 223 patients out of 230 attempted. Common bile duct stones were removed from 134 patients, an endoscopic stent was inserted in 69 patients and a benign stricture was dilated in 11 patients. After diagnostic ERCP, the complication rate was 1.8% with no mortality, after EST the complication rate was 9.1% with a mortality rate of 0.9%. Pancreatitis was the most common complication with a rate of 1.5% after diagnostic ERCP and 3.9% after EST. In three patients the pancreatitis was severe and resulted in the deaths of two of them. Other complications were haemorrhage after EST (2.6%), duodenal wall or bile duct perforation (0.7% of the cannulations and 2.2% of EST) and cholangitis (0.6% of all cannulations). All of these patients survived. CONCLUSION: Complication rates were comparable with large series from clinics specialised in endoscopic procedures.

Spontaneous recovery of post partus liver necrosis in a patient listed for transplantation.

The patient was a young previously healthy woman, who after a normal grosses, during delivery got severe abdominal pain. The liver function tests were highly pathological and the patient became anuric and developed first grade of encephalopathy. In computer tomography, 90% of the liver parenchyma was damaged and liver biopsy showed necrosis. The patient had fulminant hepatic failure including hepatorenal syndrome and was put on the Scandiatransplant high urgent waiting list for a liver transplant. No suitable liver was found. After eight days, the general situation of the patient was better and the liver function tests started to improve. She was taken off the waiting list. Twenty-seven days after delivery the patient was discharged in good condition. At check up six months later the patient was feeling well and the clinical tests were normal.

Hereditary breast cancer in Finnish women.

OBJECTIVE: To estimate the incidence of hereditary breast cancer seen in one Finnish hospital and to study the characteristics of the disease. DESIGN: Retrospective questionnaire and study of Finnish Cancer Registry. SETTING: University hospital, Finland. SUBJECTS: All 669 patients operated on for breast cancer 1986-90. MAIN OUTCOME MEASURES: Type of breast cancer and morbidity in hereditary compared with other forms of breast cancer. The definition of hereditary breast cancer requires that at least three first degree relatives, inclusive of the proband, have breast cancer. RESULTS: Of the 669 patients 495 answered the questionnaire. Ten patients (2%) were classified as having hereditary breast cancer. The remaining 485 patients had other types of breast cancer by definition. Of those that were not hereditary 89 (18%) were classified as having familial breast cancer. Of the 495 patients 396 (80%) were classified as sporadic. The mean age of the patients at onset of the disease was 56 years in the hereditary group, 55 years in the familial group, and 57 years in the sporadic group. One patient (10%) in the hereditary, five (6%) in the familial, and 17 patients (4%) in the sporadic group had bilateral disease. Ductal carcinoma was most common in all groups of patients with breast cancer. CONCLUSION: There were no statistical differences in this series in the age at onset, incidence of bilateral disease, stage, and histopathology among the groups, although bilateral and lobular cancer were seen more often in the group with hereditary breast cancer.

Good long-term results in patients surviving severe acute pancreatitis.

Thirty-seven patients treated for severe acute pancreatitis were investigated a mean of 6.2 years after the attack; 30 were found to be in good condition and 24 were working normally. Two-thirds of previously heavy drinkers had either reduced their intake considerably or become abstainers. The main complication observed on follow-up was diabetes mellitus, which affected 20 patients and required insulin treatment in nine. Of the remaining patients, four were taking oral antidiabetic agents and seven were on a strict diabetic diet. Before severe acute pancreatitis none had been diabetic. All patients who underwent resection of the pancreas developed diabetes. In 21 of 24 patients with over or imminent diabetes, pancreatitis had been primarily alcoholic in origin. Polyneuropathy, as diagnosed by clinical signs and/or neurophysiological tests, was observed in six patients, all of them heavy drinkers. It is concluded that patients with severe acute pancreatitis have a high chance of returning to normal activity and productive work. These results serve to encourage all those involved to persist with the exacting work involved in treating such patients.

Pancreatic surgery, not pancreatitis, is the primary cause of diabetes after acute fulminant pancreatitis.

Acute fulminant pancreatitis is associated with significant morbidity and mortality. To examine the outcome of conservative and surgical treatment of this disorder, 36 patients who survived an initial episode were restudied after a mean of six years. Fifty three per cent had developed diabetes mellitus, half of whom required insulin therapy. Pancreatic resection was associated with a 100% frequency of diabetes, while only 26% of those treated with peritoneal lavage developed this (p less than 0.001). Insulin secretion and sensitivity were assessed using the hyperglycaemic glucose clamp technique. First phase insulin secretion was impaired in surgically treated patients (mean (SEM) 14 (5) microU/ml x 10 minutes) compared with conservatively treated patients and control subjects (144 (66) and 87 (12) microU/ml x 10 minutes, respectively; p less than 0.05). Second phase and 'maximal' insulin secretion were also impaired among the surgically treated patients compared with the conservatively treated patients and the controls. Insulin sensitivity was reduced among the surgically treated patients (2.88 (58) mg/kg.minute) when compared with conservatively treated patients and healthy control subjects (5.87 (1.02) and 6.45 (0.66) mg/kg.minute; p less than 0.05). Pancreatic resection is associated with a very high frequency of diabetes compared with peritoneal lavage, and these results favour conservative treatment of active fulminant pancreatitis whenever possible.

Spinal anaesthesia with hyperbaric tetracaine: effect of age and body mass.

To discover the influence of age and body mass on spinal analgesia with hyperbaric tetracaine, 60 patients (17-82 years) were administered a subarachnoid injection of 15 mg tetracaine in 3 ml of 5% glucose. The patients were in the lateral position during the injection and in the supine position thereafter. The maximal spread of analgesia (mean T4, range T1-T11) did not correlate with age or body mass. Any variable studied was not significantly different for the different age groups. In 29 patients (48%) the block required supplementation with fentanyl or general anaesthesia (five patients). Tourniquet-induced pain occurred in eight patients (28% of patients with tourniquet). Decreases in systolic arterial blood pressure, greater than 30% of the preanaesthetic value, correlated with the level of analgesia and were more frequent in patients over 50 years (P less than 0.01). Severe hypotension and bradycardia with transient serious changes in QRS-complexes occurred in one patient (analgesia level, T3). In conclusion, 15 mg of hyperbaric tetracaine provided a relatively high sensory spinal blockade without correlating with age or body mass. Supplementation of analgesia during surgery was needed in almost half of the patient material.