Morphological assessment of the isthmus in mesial root canals of first mandibular molars / Avaliação morfológica do istmo nos canais radiculares mesiais dos primeiros molares inferiores

ABSTRACT Root canal morphology and its anatomical variations pose a great challenge to endodontists Aim The aim of this in silico study was to perform a qualitative and quantitative analysis of the threedimensional morphological characteristics of the isthmus in the mesial root canals of mandibular molars using microcomputed tomography (micro-CT) Material and Method Six hundred first mandibular molars were selected, including 317 with two mesial canals with isthmuses between the canals, and fully formed root. Isthmus morphology was determined in 3D longitudinal sections using Fan et al. (2010) classification. Root length, and the volume and area of apical and coronal level were measured. Additionally, the structural model index (SMI) of the canals were also assessed Results The prevalence of isthmuses in the mesial root canals was 32% type II, 29% type III, 22% type IV, and 17% type I. The root length was found to be 9.1±0.5 mm, the volume and area, of all root canal system, were 41.8±40.1 mm3 and 63.6±24.2 mm2 respectively. The isthmi volume and area alone were 11.06±9.03 mm3 and 30.02±11.02 mm2. The study confirmed that isthmuses are present in mesial canals of mandibular first molars, being more frequent in the apical third Conclusion The high prevalence of isthmuses with complex morphological features underscores the importance of using intracanal medications to disinfect areas unprepared by instruments.

RESUMO A morfologia do canal radicular e suas variações anatômicas representam um grande desafio para os endodontistas. O objetivo deste estudo ex vivo foi realizar uma análise qualitativa e quantitativa das características morfológicas tridimensionais do istmo nos canais mesiais de molares inferiores por meio de microtomografia computadorizada (micro-CT) Material e Método Foram selecionados 600 primeiros molares inferiores, incluindo 317 com dois canais mesiais com istmos e raiz totalmente formada. A morfologia do istmo foi determinada em cortes longitudinais 3D usando a classificação Fan et al. (2010). Foram mensurados o comprimento da raiz, o volume e a área apical e coronal e da cavidade pulpar. Adicionalmente, também foram avaliados o structure model index (SMI) dos canais Resultados A prevalência de istmos nos canais mesiais foi de 32% tipo II, 29% tipo III, 22% tipo IV e 17% tipo I. O comprimento da raiz foi de 9,1±0,5 mm, o volume e a área de todo o sistema de canais radiculares foram de 41.8±40.1 mm3 e 63.6±24.2 mm2, respectivamente. O volume e área do istmo isoladamente foram 11.06±9,03 mm3 e 30.02±11.02 mm2. O estudo confirmou que os istmos estão presentes em canais mesiais dos primeiros molares inferiores, sendo mais frequentes no terço apical Conclusão A alta prevalência de istmos com características morfológicas complexas ressalta a importância do uso de medicação intracanal para desinfecção de áreas não tocadas por instrumentos.

Enhancing debris removal in curved canals: a comparative evaluation of XP-endo Finisher and Passive Ultrasonic Irrigation.

OBJECTIVES: The study aimed to compare the efficacy of XP-endo Finisher and Passive Ultrasonic Irrigation (PUI) in removing hard tissue debris from curved canals. MATERIALS AND METHODS: Thirty-four mandibular molars with Vertucci's type II mesial canals were scanned in microcomputed tomography before and after preparation with HyFlex EDM, and accumulated hard tissue debris was quantified. Subsequently, the teeth were randomly divided into two groups according to the supplementary procedure: PUI with the Ultra-X insert or XP-endo Finisher. After the intervention, the specimens underwent another scanning. Two separate analyses were conducted, one for the total canal and another for the isthmus area. Unpaired and paired T-tests were used for inter- and intergroup comparisons, with a significance level set at 5%. RESULTS: Both supplementary methods reduced the amount of debris compared to the initial volume. Remarkably, the XP-endo Finisher achieved a significantly higher percentage of debris removal (71% for the total canal and 74% for the isthmus areas) compared to PUI (41% for the total canal and 52% for the isthmus area) (P < 0.05). CONCLUSIONS: Both supplementary approaches reduced the amount of hard tissue debris from canal preparation, still XP-endo Finisher showed a higher reduction compared to PUI (p < 0.05). CLINICAL RELEVANCE: None of the supplementary methods rendered canals completely free of hard tissue debris. However, the supplementary approach with XP-endo Finisher resulted in lower levels of hard tissue debris than PUI in curved canals with isthmuses.

Morphological assessment of the isthmus in mesial root canals of first mandibular molars.

Root canal morphology and its anatomical variations pose a great challenge to endodontists. Aim: The aim of this in silico study was to perform a qualitative and quantitative analysis of the threedimensional morphological characteristics of the isthmus in the mesial root canals of mandibular molars using microcomputed tomography (micro-CT). Material and Method: Six hundred first mandibular molars were selected, including 317 with two mesial canals with isthmuses between the canals, and fully formed root. Isthmus morphology was determined in 3D longitudinal sections using Fan et al. (2010) classification. Root length, and the volume and area of apical and coronal level were measured. Additionally, the structural model index (SMI) of the canals were also assessed. Results: The prevalence of isthmuses in the mesial root canals was 32% type II, 29% type III, 22% type IV, and 17% type I. The root length was found to be 9.1±0.5 mm, the volume and area, of all root canal system, were 41.8±40.1 mm3 and 63.6±24.2 mm2 respectively. The isthmi volume and area alone were 11.06±9.03 mm3 and 30.02±11.02 mm2. The study confirmed that isthmuses are present in mesial canals of mandibular first molars, being more frequent in the apical third. Conclusion: The high prevalence of isthmuses with complex morphological features underscores the importance of using intracanal medications to disinfect areas unprepared by instruments.

A morfologia do canal radicular e suas variações anatômicas representam um grande desafio para os endodontistas. O objetivo deste estudo ex vivo foi realizar uma análise qualitativa e quantitativa das características morfológicas tridimensionais do istmo nos canais mesiais de molares inferiores por meio de microtomografia computadorizada (micro-CT). Material e Método: Foram selecionados 600 primeiros molares inferiores, incluindo 317 com dois canais mesiais com istmos e raiz totalmente formada. A morfologia do istmo foi determinada em cortes longitudinais 3D usando a classificação Fan et al. (2010). Foram mensurados o comprimento da raiz, o volume e a área apical e coronal e da cavidade pulpar. Adicionalmente, também foram avaliados o structure model index (SMI) dos canais. Resultados: A prevalência de istmos nos canais mesiais foi de 32% tipo II, 29% tipo III, 22% tipo IV e 17% tipo I. O comprimento da raiz foi de 9,1±0,5 mm, o volume e a área de todo o sistema de canais radiculares foram de 41.8±40.1 mm3 e 63.6±24.2 mm2, respectivamente. O volume e área do istmo isoladamente foram 11.06±9,03 mm3 e 30.02±11.02 mm2. O estudo confirmou que os istmos estão presentes em canais mesiais dos primeiros molares inferiores, sendo mais frequentes no terço apical. Conclusão: A alta prevalência de istmos com características morfológicas complexas ressalta a importância do uso de medicação intracanal para desinfecção de áreas não tocadas por instrumentos.

[Remarks on the "Dignified death and palliative care" bill]. / Comentarios al proyecto de ley "Muerte digna y cuidados paliativos".

The Chilean House of Representatives is discussing the bill on "Dignified death and palliative care", which regulates the so-called medical assistance in dying or euthanasia. This paper will critically analyze the different aspects of the bill, particularly concerning four main dimensions, namely, the patient's condition at the time of requesting euthanasia; the doctor-patient relationship and respect for the autonomy of both parties; the idea of medicine involved in it; and the possible therapeutic alternatives to euthanasia. This critical analysis raises the need to discuss in more depth a project that has to do with such important decisions about our lives and that implies a radical change in the way of thinking and practicing medicine.

Comentarios al proyecto de ley "Muerte digna y cuidados paliativos" / Remarks on the "Dignified death and palliative care" bill

The Chilean House of Representatives is discussing the bill on "Dignified death and palliative care", which regulates the so-called medical assistance in dying or euthanasia. This paper will critically analyze the different aspects of the bill, particularly concerning four main dimensions, namely, the patient's condition at the time of requesting euthanasia; the doctor-patient relationship and respect for the autonomy of both parties; the idea of medicine involved in it; and the possible therapeutic alternatives to euthanasia. This critical analysis raises the need to discuss in more depth a project that has to do with such important decisions about our lives and that implies a radical change in the way of thinking and practicing medicine.

Disinfecting and Shaping Type I C-shaped Root Canals: A Correlative Micro-computed Tomographic and Molecular Microbiology Study.

INTRODUCTION: This ex vivo study compared the disinfection and shaping abilities of 2 preparation protocols in C-shaped canals. METHODS: Mandibular second molars with type I C-shaped canals were pair matched based on micro-computed tomographic (micro-CT) analysis and distributed into 2 groups. The canals were contaminated with a mixed bacterial culture and prepared using 2 protocols, both with 2.5% sodium hypochlorite irrigation: XP-endo Shaper (FKG Dentaire, La Chaux-de-Fonds, Switzerland) supplemented with XP-endo Finisher (FKG Dentaire) (XP-E) and BioRaCe (FKG Dentaire) supplemented with a Hedström file (Dentsply/Sirona, Tulsa, OK) (BR-Hed). Micro-CT scans and intracanal bacteriologic samples were taken before (scan #1 and sample 1) and after preparation (scan #2 and sample 2) and after the supplementary step (scan #3 and sample 3). Canal shaping was evaluated by micro-CT imaging, and disinfection was assessed by quantitative polymerase chain reaction. RESULTS: Micro-CT data from the XP-E (n = 21) and BR-Hed (n = 23) protocols revealed no significant differences between groups regarding shaping parameters (canal volume, surface area, structure model index, and prepared walls) after preparation and after the supplementary step (P > .05). All these parameters significantly increased after each preparation step (P < .05), except for structure model index changes after the XP-endo Finisher (P > .05). Bacteriologic data from the XP-E (n = 21) and BR-Hed (n = 22) groups showed that 14 (66.7%) and 10 (45.5%) S2 samples still had detectable bacteria, respectively. The corresponding figures for supplementary steps with the XP-endo Finisher and Hedström file were 11 (52.4%) and 10 (45.5%), respectively. Bacterial counts in sample 1 significantly decreased in samples 2 and 3 in both groups (P < .01). Intragroup comparison between sample 2 and sample 3 showed a 66% reduction in counts after using the Hedström file and 18% after using the XP-endo Finisher (P > .05 for both groups). The quantitative bacterial reduction was not different between groups (P > .05). CONCLUSIONS: The XP-endo Shaper and BioRaCe systems have similar disinfecting and shaping abilities in C-shaped canals. Supplementary steps with the Hedström file and the XP-endo Finisher were similarly effective in improving shaping, but this was not sufficient to enhance disinfection. About half of the cases, in both groups, still harbored detectable amounts of bacteria.

[Ethical guidelines for medical decision-making during COVID-19 pandemic in Chile]. / Orientaciones éticas para la toma de decisiones médicas en el contexto de la pandemia de COVID-19 en Chile.

The catastrophic emergency experienced by many countries with the COVID-19 pandemic emphasized the importance of bioethics for decision-making, both at the public health (equitable and effective policies) and at the clinical level. At the clinical level, the issues are the fulfillment of medical care demand with adequate health care teams, infrastructure, and supplies, and to cover critical care demands that surpass the available resources. Therefore, ethically correct approaches are required for the allocation of life sustaining resources. There are recommendations for the allocating life support during disasters based on multiple considerations, including ethical ones. However, the ethical criteria of existing guidelines are variable. Ethical principles usually considered are saving the greatest number of lives, saving the greatest number of years of life and the principle of the life cycle or the goal to give each individual equal opportunity to live through the various phases of life. However, the centrality of the human being and the search for the common good should be considered. Knowledge of public perspectives and moral benchmarks on these issues is essential. A successful assignment effort will require everyone's trust and cooperation. Decision making should be planned and discussed in advance, since in-depth deliberation will be extremely complex during the disaster. Our goal is to help the health care teams to wisely allocate resources in shortage periods.

Empatía y cuidado profesional: esbozos de una relación problemática / The role of empathy in professional care

Introducción: tres paradigmas actuales acerca del cuidado profesional en medicina sitúan a la empatía como la actitud básica necesaria para lograr un cuidar de otros que respete la dignidad de las personas atendidas en los servicios de salud. Sin embargo, los conceptos de empatía difieren en estos paradigmas, algo que parece ser reflejo de la confusión general que existe respecto a esta noción. Por otro lado, hay quienes critican el que se pretenda reducir a ella la actitud fundamental del cuidar de otros. Además de esto, existen formas de comprender la medicina que, eventualmente. Métodos: a partir de estos tres paradigmas de cuidado, se profundiza en las teorías acerca de la empatía más importantes de la actualidad. El método que se utiliza es de análisis filosófico de los datos provenientes de las formas de comprender el cuidado profesional. Resultados: existen formas muy distintas de comprender la noción de empatía no solo desde paradigmas que gravitan en torno al cuidado profesional, sino también dentro de la filosofía. Las comprensiones de la noción son incluso disímiles, lo que hace imposible avanzar en la enseñanza y en el diálogo con respecto a la posición de la empatía en el cuidado. Se propone la noción fenomenológica de empatía que la sitúa en la esfera de las facultades espirituales del sujeto. Conclusiones: la empatía es un elemento relevante del cuidado profesional, pero parece no poder situarse en el centro del mismo como actitud básica. Es una herramienta útil que podría ser enseñada y evaluada en la educación médica, siempre y cuando se trabaje con una noción unívoca de ella.

Introduction: Abstract Introduction: Three current paradigms of professional health services situate empathy as the fundamental attitude necessary to respects the dignity of those serve. However, current concepts of empathy differ widely in these paradigms, something that seems to reflect the general confusion regarding this notion. On the other hand, there are those who criticize the attempt to reduce to it to the fundamental attitude of caring for others. Methods: From these three paradigms of healthcare, the most important current theories of empathy will be treated. The method employs a philosophical analysis of the data coming from the ways of understanding professional care. Results: there are very different ways of understanding the notion of empathy not only in healthcare, 9 but in philosophy as well. The understanding of the notion varies greatly, making it impossible to reach consensus in teaching and dialogue with respect to the role of empathy in health care. The proposal is to use a phenomenological approach to empathy which places it in the sphere of the subject's spiritual faculties. Discussion: empathy is a relevant element of professional healthcare, but not central as a fundamental attitude. It is a useful tool that could be taught and evaluated in medical education, as long as it is applied with a common understanding.

Orientaciones éticas para la toma de decisiones médicas en el contexto de la pandemia de COVID-19 en Chile / Ethical guidelines for medical decision-making during COVID-19 pandemic in Chile

The catastrophic emergency experienced by many countries with the COVID-19 pandemic emphasized the importance of bioethics for decision-making, both at the public health (equitable and effective policies) and at the clinical level. At the clinical level, the issues are the fulfillment of medical care demand with adequate health care teams, infrastructure, and supplies, and to cover critical care demands that surpass the available resources. Therefore, ethically correct approaches are required for the allocation of life sustaining resources. There are recommendations for the allocating life support during disasters based on multiple considerations, including ethical ones. However, the ethical criteria of existing guidelines are variable. Ethical principles usually considered are saving the greatest number of lives, saving the greatest number of years of life and the principle of the life cycle or the goal to give each individual equal opportunity to live through the various phases of life. However, the centrality of the human being and the search for the common good should be considered. Knowledge of public perspectives and moral benchmarks on these issues is essential. A successful assignment effort will require everyone's trust and cooperation. Decision making should be planned and discussed in advance, since in-depth deliberation will be extremely complex during the disaster. Our goal is to help the health care teams to wisely allocate resources in shortage periods.

[Are residents and interns prepared for teaching? Perceptions of undergraduate and graduate medical students]. / ¿Están preparados los residentes e internos para enseñar? Percepción de estudiantes de medicina de pre y postgrado.

BACKGROUND: Every doctor is expected to be competent in teaching. There are few initiatives to prepare medical students for this role. AIM: To explore residents (graduate students) and interns (final year undergraduate students) perceptions of the importance of acquiring teaching skills and how prepared they feel to meet this role. To determine the importance that undergraduate students give to such teaching. MATERIAL AND METHODS: Residents and interns participated in focus groups, and completed the Medical Education Readiness Questionnaire (METRQ), 5th year medical students were also invited to complete it. RESULTS: Three hundred and seventy seven subjects answered the questionnaire. The perceived importance of having teaching skills was 6.1 +/-1.2 among residents and 5.7 +/- 1.6 among interns, in a scale 1 to 7. Their perception of their own preparation for teaching was 4.3 +/- 1.6 for both groups in the same scale. Students evaluated the preparation of the residents for teaching as 5.2 +/- 1.6 and that of the interns as 4.4 +/-1.7. Seventy-eight percent of 5th year medical students reported to learn more than two. 5 hours a week from residents. Fifty-nine percent of residents and 66% of interns reported to teach up to 2.5 hours per week to the same students. Focus groups participants agreed that teaching is an important role for a physician, and that to do it properly requires personal characteristics, along with teaching skills. They also found that the best opportunities to learn how to teach are during practical training. CONCLUSIONS. Our study contributes to the recognition of the teaching role of physicians and the need for teaching training among medical students.

¿Están preparados los residentes e internos para enseñar?: Percepción de estudiantes de medicina de pre y postgrado / Are residents and interns prepared for teaching?: Perceptions of undergraduate and graduate medical students

Background: Every doctor is expected to be competent in teaching. There are few initiatives to prepare medical students for this role. Aim: To explore residents (graduate students) and interns (final year undergraduate students) perceptions of the importance of acquiring teaching skills and how prepared they feel to meet this role. To determine the importance that undergraduate students give to such teaching. Material and Methods: Residents and interns participated in focus groups, and completed the Medical Education Readiness Questionnaire (METRQ), 5th year medical students were also invited to complete it. Results: Three hundred and seventy seven subjects answered the questionnaire. The perceived importance of having teaching skills was 6.1 ±1.2 among residents and 5.7 ± 1.6 among interns, in a scale 1 to 7. Their perception of their own preparation for teaching was 4.3 ± 1.6 for both groups in the same scale. Students evaluated the preparation of the residents for teaching as 5.2 ± 1.6 and that of the interns as 4.4 ±1.7. Seventy-eight percent of 5th year medical students reported to learn more than two. 5 hours a week from residents. Fifty-nine percent of residents and 66 percent of interns reported to teach up to 2.5 hours per week to the same students. Focus groups participants agreed that teaching is an important role for a physician, and that to do it properly requires personal characteristics, along with teaching skills. They also found that the best opportunities to learn how to teach are during practical training. Conclusions. Our study contributes to the recognition of the teaching role of physicians and the need for teaching training among medical students.

Conocimiento del síndrome de fibromialgia y afrontamiento en la enfermedad en pacientes clínicamente diagnosticados / Knowledge of fibromyalgia syndrome and coping with the disease in clinically diagnosed

Se examinó la información que personas diagnosticadas clínicamente con fibromialgia conocían sobre el síndrome y su asociación con el estilo de afrontamiento hacia la enfermedad. La muestra fue integrada por 175 personas diagnosticadas clínicamente con fibromialgia, quienes era apacientes ambulatorios de Medicina Física y Rehabilitación de la Clínica de la Seguridad Social en Lima. Fue utilizado el diseño descriptivo correlacional. Los instrumentos aplicados fueron: el inventario de afrontamiento en problemas de salud y lesiones, versión en español (2002) y el cuestionario de conocimiento del sindrome de fibromialgia construido para este estudio, los que fueron validados. Los resultados mostraron que no existe asociación entre las variables estudiadas en la muestra y que el 90% de pacientes no tenían información sobre fibromialgia, de los cuales la mayoria recurrió a la preocupación emocional y, en menos porcentaje, a la distracción como tácticas de afrontamiento a la enfermedad. Estilos de afrontamiento como: la preocupación a la distracción emocional y la distracción parecen ser manifestaciones válidas frente a un padecimiento crónico como la fibromialgia.

It was examined the information that people clinically diagnosed with fibromyalgia knew about the syndrome and its association with coping style to disease. The sample was composed of 175 persons clinically diagnosed with fibromyalgia, who were outpatients of Physical Medicine and Rehabilitations Service of Social Securyty Clinic in Lima. It was used the descriptive correlational desing. the instruments applied were: the inventory of coping in health problems and injuries, Spanish version (2002), and the knowledge questionnaire fibromyalgia syndrome contructed for this study; which were validated. The results showed no association between the variables studied in the sample and 90% of patients had no information about fibromyalgia, which most of them appealed to emotional distress and, in a less %, to distraction as tactic of coping against disease. Coping styles such as emotional distress and distaction seem to be valid demonstrations against a chronic condition like fibromyalgia.

[Frequency and assessment of symptoms in hospitalized patient with advanced chronic diseases: is there concordance among patients and doctors?]. / Frecuencia y pesquisa de síntomas en pacientes crónicos en fases avanzadas en un hospital clínico: ¿Existe concordancia entre pacientes y médicos?

BACKGROUND: Physicians tend to over or underestimate symptoms reported by patients. Therefore standardized symptom scoring systems have been proposed to overcome this drawback. AIM: To estimate the prevalence and the diagnostic accuracy of physical and psychological symptoms and delirium in patients admitted to an internal medicine service at a university hospital. MATERIAL AND METHODS: We studied 58 patients, 45 with metastasic cancer and 13 with other advanced chronic diseases. The following scales were used: the Confusion Assessment Method for the diagnosis of delirium; the Edmonton Symptom Assessment Scale (ESAS) for pain and other physical symptoms; the Hospital Anxiety and Depression Scale to assess anxiety and depression. The ESAS was simultaneously applied to patients without delirium and their doctors to assess the level of diagnostic concordance. RESULTS: Twenty two percent of patients had delirium. Among the 45 patients without delirium, 11 (25%) had at least eight symptoms and 39 (88.6%) had four symptoms. The prevalence of symptoms was very high, ranging from 22 to 78%. Pain, restlessness, anorexia and sleep disorders were the most common. The concordance between symptoms reported by patients and those recorded by doctor was very low, with a Kappa index between 0.001 and 0.334. CONCLUSIONS: In our sample of chronic patients, there is a very high frequency of psychological and physical symptoms that are insufficiently recorded by the medical team.

Frecuencia y pesquisa de síntomas en pacientes crónicos en fases avanzadas en un hospital clínico: ¿Existe concordancia entre pacientes y médicos? / Frequency and assessment of symptoms in hospitalized patient with advanced chronic diseases: Is there concordance among patients and doctors?

Physicians tend to over or underestimate symptoms reported by patients. Therefore standardized symptom scoring systems have been proposed to overcome this drawback. Aim: To estimate the prevalence and the diagnostic accuracy of physical and psychological symptoms and delirium in patients admitted to an internal medicine service at a university hospital. Material and Methods: We studied 58 patients, 45 with metastasic cancer and 13 with other advanced chronic diseases. The following scales were used: the Confusion Assessment Method for the diagnosis of delirium; the Edmonton Symptom Assessment Scale (ESAS) for pain and other physical symptoms; the Hospital Anxiety and Depression Scale to assess anxiety and depression. The ESAS was simultaneously applied to patients without delirium and their doctors to assess the level of diagnostic concordance. Results: Twenty two percent of patients had delirium. Among the 45 patients without delirium, 11 (25 percent) had at least eight symptoms and 39 (88.6 percent) had four symptoms. The prevalence of symptoms was very high, ranging from 22 to 78 percent. Pain, restlesness, anorexia and sleep disorders were the most common. The concordance between symptoms reported by patients and those recorded by doctor was very low, with a Kappa index between 0.001 and 0.334. Conclusions: In our sample of chronic patients, there is a very high frequency of psychological and physical symptoms that are insufficiently recorded by the medical team.