Dental Abscess to Septic Shock: A Case Report and Literature Review.

Sepsis is a leading cause of death in the United States, with a mortality rate in excess of 215,000 deaths per year. It may lead to septic shock, a complex pathophysiological process with microbial and host response events that progress to multisystem derangement. There is poor documentation of the relationship between dental infection and septic shock, with only a few case reports of septic shock secondary to dentoalveolar abscess. Presented is a case of sepsis/septic shock in a 23-year-old man with signs and symptoms of pulpal necrosis, acute apical abscess, and canine space infection that rapidly progressed to an altered mental state, hyperthermia, tachycardia, hypotension, acute respiratory failure, diarrhea, renal insufficiency, lactic acidosis, leukocytosis, and hyperglycemia. Once septic shock develops, the mortality rate is nearly 50%. Early antimicrobial intervention is associated with surviving severe sepsis, making it critical for dentists to understand local factors leading to the crisis and the signs and symptoms of the sepsis-septic shock continuum.

Rabbit antithymocyte induction and dosing in deceased donor renal transplant recipients over 60 yr of age.

BACKGROUND: Antithymocyte globulin (rATG) is a commonly used induction agent in renal transplantation; however, data in older kidney recipients are limited. METHODS: We reviewed charts of 301 deceased donor renal transplants who received a protocol consisting of 3-7 doses of rATG and triple maintenance therapy. Outcomes of patients >60 yr of age (n = 45) were compared to those aged 18-59 yr (n = 256). RESULTS: Older recipients had more diabetics, were more likely to receive expanded criteria donor kidneys (p < 0.01), and over 30% were sensitized. Recipients >60 received less cumulative rATG (4.6 vs. 5.1 mg/kg; p < 0.01). Three-yr acute rejection was lower in the >60 group (2% vs. 16%, p < 0.01) although glomerular filtration rates were similar between groups. Actuarial graft survival was similar; however, patient survival in the >60 group at three yr was lower (80% vs. 95%; p = 0.02). Specifically, patients >60 with delayed graft function and rATG cumulative dosing >6 mg/kg had a survival of <50% by two yr. CONCLUSION: Recipients over 60 yr receiving rATG induction have acceptable renal function and a low risk of rejection; however, reduced survival was noted among those receiving >6 mg/kg. These data suggest that when used, lower cumulative dosages of rATG are preferable in the older recipient.

Diagnostic thinking and information used in clinical decision-making: a qualitative study of expert and student dental clinicians.

BACKGROUND: It is uncertain whether the range and frequency of Diagnostic Thinking Processes (DTP) and pieces of information (concepts) involved in dental restorative treatment planning are different between students and expert clinicians. METHODS: We video-recorded dental visits with one standardized patient. Clinicians were subsequently interviewed and their cognitive strategies explored using guide questions; interviews were also recorded. Both visit and interview were content-analyzed, following the Gale and Marsden model for clinical decision-making. Limited tests used to contrast data were t, chi2, and Fisher's. Scott's pi was used to determine inter-coder reliability. RESULTS: Fifteen dentists and 17 senior dental students participated in visits lasting 32.0 minutes (+/- 12.9) among experts, and 29.9 +/- 7.1 among students; contact time with patient was 26.4 +/- 13.9 minutes (experts), and 22.2 +/- 7.5 (students). The time elapsed between the first and the last instances of the clinician looking in the mouth was similar between experts and students. Ninety eight types of pieces of information were used in combinations with 12 DTPs. The main differences found in DTP utilization had dentists conducting diagnostic interpretations of findings with sufficient certainty to be considered definitive twice as often as students. Students resorted more often to more general or clarifying enquiry in their search for information than dentists. CONCLUSIONS: Differences in diagnostic strategies and concepts existed within clearly delimited types of cognitive processes; such processes were largely compatible with the analytic and (in particular) non-analytic approaches to clinical decision-making identified in the medical field. Because we were focused on a clinical presentation primarily made up of non-emergency treatment needs, use of other DTPs and concepts might occur when clinicians evaluate emergency treatment needs, complex rehabilitative cases, and/or medically compromised patients.