Association of Patient Belief About Success of Antibiotics for Appendicitis and Outcomes: A Secondary Analysis of the CODA Randomized Clinical Trial

Importance

A patient's belief in the likely success of a treatment may influence outcomes, but this has been understudied in surgical trials.

Objective

To examine the association between patients' baseline beliefs about the likelihood of treatment success with outcomes of antibiotics for appendicitis in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial.

Design, Setting, and Participants

This was a secondary analysis of the CODA randomized clinical trial. Participants from 25 US medical centers were enrolled between May 3, 2016, and February 5, 2020. Included in the analysis were participants with appendicitis who were randomly assigned to receive antibiotics in the CODA trial. After informed consent but before randomization, participants who were assigned to receive antibiotics responded to a baseline survey including a question about how successful they believed antibiotics could be in treating their appendicitis.

Interventions

Participants were categorized based on baseline survey responses into 1 of 3 belief groups: unsuccessful/unsure, intermediate, and completely successful.

Main Outcomes and Measures

Three outcomes were assigned at 30 days: (1) appendectomy, (2) high decisional regret or dissatisfaction with treatment, and (3) persistent signs and symptoms (abdominal pain, tenderness, fever, or chills). Outcomes were compared across groups using adjusted risk differences (aRDs), with propensity score adjustment for sociodemographic and clinical factors.

Results

Of the 776 study participants who were assigned antibiotic treatment in CODA, a total of 425 (mean [SD] age, 38.5 [13.6] years; 277 male [65%]) completed the baseline belief survey before knowing their treatment assignment. Baseline beliefs were as follows: 22% of participants (92 of 415) had an unsuccessful/unsure response, 51% (212 of 415) had an intermediate response, and 27% (111 of 415) had a completely successful response. Compared with the unsuccessful/unsure group, those who believed antibiotics could be completely successful had a 13-percentage point lower risk of appendectomy (aRD, -13.49; 95% CI, -24.57 to -2.40). The aRD between those with intermediate vs unsuccessful/unsure beliefs was -5.68 (95% CI, -16.57 to 5.20). Compared with the unsuccessful/unsure group, those with intermediate beliefs had a lower risk of persistent signs and symptoms (aRD, -15.72; 95% CI, -29.71 to -1.72), with directionally similar results for the completely successful group (aRD, -15.14; 95% CI, -30.56 to 0.28).

Conclusions and Relevance

Positive patient beliefs about the likely success of antibiotics for appendicitis were associated with a lower risk of appendectomy and with resolution of signs and symptoms by 30 days. Pathways relating beliefs to outcomes and the potential modifiability of beliefs to improve outcomes merit further investigation.

Trial Registration

ClinicalTrials.gov Identifier: NCT02800785.

Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department

INTRODUCTION

In the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED.

METHODS AND ANALYSIS

This protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016-2017.

ETHICS AND DISSEMINATION

All sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.

Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs

In March 2000 the Plastic Surgery Unit of our 600-bedded district general hospital agreed to be the pilot ward for the introduction of a new standard of hand hygiene, emphasizing the use of alcohol gel on socially clean hands between clinical contact with patients. Hand hygiene practice of healthcare workers (HCWs) was observed using Formic forms. The data from completed forms were scanned into an Excel database, and results fed back to HCWs in graphical form. The case notes of patients newly affected by methicillin-resistant Staphylococcus aureus (MRSA), likely to have been acquired as inpatients, were reviewed for one year before and after this performance feedback of hand hygiene. The cost of teicoplanin use (for MRSA infections) was also determined for the two periods. There was a significant reduction in the number of patients newly affected by MRSA (P<0.05), and in the use of teicoplanin, suggesting that performance feedback of hand hygiene reduces nosocomial MRSA infection rates and antibiotic use.

Staphylococcus aureus in the oral cavity: a three-year retrospective analysis of clinical laboratory data

OBJECTIVE

A retrospective analysis of laboratory data to investigate the isolation of Staphylococcus aureus from the oral cavity and facial area in specimens submitted to a regional diagnostic oral microbiology laboratory.

METHODS

A hand search of laboratory records for a three-year period (1998-2000) was performed for specimens submitted to the regional diagnostic oral microbiology laboratory based at Glasgow Dental Hospital and School. Data were collected from forms where S. aureus was isolated. These data included demographics, referral source, specimen type, methicillin susceptibility and clinical details.

RESULTS

For the period 1998-2000, there were 5,005 specimens submitted to the laboratory. S. aureus was isolated from 1,017 specimens, of which 967 (95%) were sensitive to methicillin (MSSA) and 50 (5%) were resistant to methicillin (MRSA). The 1,017 specimens were provided from 615 patients. MRSA was isolated from 37 (6%) of patients. There was an increasing incidence of S. aureus with age, particularly in the >70 years age group. The most common specimen from which MSSA was isolated was an oral rinse (38%) whilst for MRSA isolates this was a tongue swab (28%). The clinical condition most commonly reported for MSSA isolates was angular cheilitis (22%). Erythema, swelling, pain or burning of the oral mucosa was the clinical condition most commonly reported for MRSA isolates (16%). Patients from whom the MSSA isolates were recovered were most commonly (55%) seen in the oral medicine clinic at the dental hospital, whilst patients with MRSA were more commonly seen in primary care settings such as nursing homes, hospices and general dental practice (51%).

CONCLUSION

In line with more recent surveys, this retrospective study suggests that S. aureus may be a more frequent isolate from the oral cavity than hitherto suspected. A small proportion of the S. aureus isolates were MRSA. There were insufficient data available to determine whether the S. aureus isolates were colonising or infecting the oral cavity. However, the role of S. aureus in several diseases of the oral mucosa merits further investigation.

Reduction in intracanal bacteria during root canal preparation with and without apical enlargement

AIM

To compare in vitro intracanal bacterial reduction using nickel-titanium rotary instruments with and without apical enlargement.

METHODOLOGY

Thirty-eight palatal roots of maxillary molar teeth, with mature apices were subdivided according to lengths and then randomly assigned to two experimental and one control groups. The roots were sterilized and then reinfected with Enterococcus faecalis, which served as a bacteriological marker. All roots in the experimental groups were prepared in a step-down sequence with engine-driven GT rotary files at 350 rpm. In experimental group A (n = 16) additional apical enlargement to ISO size 35 was performed. In group B (n = 16) a serial step-back technique was followed with no apical enlargement. This was combined in groups A and B with irrigation with NaOCl and EDTA. In the control group (group C, n = 6) irrigation only was carried out, with no mechanical preparation. Samples were then taken from the root canals to determine the numbers of remaining bacteria.

RESULTS

In groups A and B, 15 (94%) and 13 (81%) specimens were rendered bacteria-free, respectively. In the control group C none of the specimens were bacteria-free. There was a significant difference (P < 0.001) in the antibacterial effects of experimental and control regimens. There was, however, no significant difference (P = 0.276) between the preparation methods used in the experimental groups.

CONCLUSIONS

There was no significant difference in intracanal bacterial reduction when Ni-Ti GT rotary preparation with NaOCl and EDTA irrigation was used with or without apical enlargement preparation technique. It may therefore not be necessary to remove dentine in the apical part of the root canal when a suitable coronal taper is achieved to allow satisfactory irrigation of the root canal system with antimicrobial agents.

A study of blood contamination of Siqveland matrix bands

AIMS To use a sensitive forensic test to measure blood contamination of used Siqveland matrix bands following routine cleaning and sterilisation procedures in general dental practice.

MATERIALS AND METHODS

Sixteen general dental practices in the West of Scotland participated. Details of instrument cleaning procedures were recorded for each practice. A total of 133 Siqveland matrix bands were recovered following cleaning and sterilisation and were examined for residual blood contamination by the Kastle-Meyer test, a well-recognised forensic technique.

RESULTS

Ultrasonic baths were used for the cleaning of 62 (47%) bands and retainers and the remainder (53%) were hand scrubbed prior to autoclaving. Overall, 21% of the matrix bands and 19% of the retainers gave a positive Kastle-Meyer test, indicative of residual blood contamination, following cleaning and sterilisation. In relation to cleaning method, 34% of hand-scrubbed bands and 32% of hand-scrubbed retainers were positive for residual blood by the Kastle-Meyer test compared with 6% and 3% respectively of ultrasonically cleaned bands and retainers (P < 0.001).

CONCLUSIONS

If Siqveland matrix bands are re-processed in the assembled state, then adequate pre-sterilisation cleaning cannot be achieved reliably. Ultrasonic baths are significantly more effective than hand cleaning for these items of equipment.

Vascular endothelial growth factor gene therapy in ischaemic rat skin flaps

Gene therapy with the complementary DNA (cDNA) of the angiogenic cytokine vascular endothelial growth factor (VEGF) has emerged as a promising strategy in the treatment of myocardial and lower-limb ischaemia. The objective of this study was to determine whether these principles could be applied to a recognised model of skin-flap ischaemia. Plasmid vectors including the cDNA of green fluorescent protein (GFP) and one of three VEGF isoforms (A165, B167 or B186) were constructed, and their base sequences confirmed. GFP expression was used as a marker of successful in vitro transfection of human endothelial cells with each plasmid. The plasmids were then administered subcutaneously to rat abdominal skin flaps surgically rendered ischaemic, and the percentage of viable tissue was assessed at 1 week. Angiograms of the flaps and histological preparations of flap tissue were assessed for evidence of angiogenesis. The survival of flaps treated with VEGF A165 or B167 cDNA was significantly greater than that of controls (P < 0.05). The survival of flaps treated with VEGF B186 cDNA was greater than that of controls, but statistical significance was not reached. Angiograms and microvessel density counts failed to produce evidence of angiogenesis. With improved delivery strategies, VEGF may have a role in the management of surgical ischaemia.

Molecular identification of microorganisms from endodontic infections

A relatively wide range of bacteria have been isolated from root canals using standard culture techniques. However, only 50% of the bacteria in the oral cavity are cultivable (S. S. Socransky et al., Arch. Oral Biol. 8:278-280, 1963); hence, bacterial diversity in endodontic infections is underestimated. This study used a PCR-based 16S rRNA gene assay, followed by cloning and sequencing of 16S rRNA amplicons from a small subset of samples to assess the diversity of bacteria present in infected root canals. A total of 41 clinical samples from 15 de novo and 26 refractory cases of endodontic infections were assessed. Of these samples, 44% were positive by culture and 68% were positive by PCR. Eight samples were selected for further analysis. Of these, the two de novo cases yielded sequences related to those of the genera Enterococcus, Lactobacillus, Propionibacterium, and Streptococcus and two clones were related to previously uncultivated bacteria, while the sinus-associated, de novo case yielded sequences related to those of the genera Lactobacillus, Pantoea, Prevotella, and Selenomonas. The five refractory cases produced clones which were related to the genera Capnocytophaga, Cytophaga, Dialister, Eubacterium, Fusobacterium, Gemella, Mogibacterium, Peptostreptococcus, Prevotella, Propionibacterium, Selenomonas, Solobacterium, Streptococcus, and Veillonella and two clones representing previously uncultivated bacteria. The phylogenetic positions of several clones associated with the Clostridiaceae and Sporomusa subgroups of the Firmicutes grouping are also shown. This study demonstrates that molecular techniques can detect the presence of bacteria in endodontic infections when culture techniques yield a negative result and can be used to identify a wider range of endodontic-infection-related bacteria including the presence of previously unidentified or unculturable bacteria.

A review of therapeutic angiogenesis and consideration of its potential applications to plastic and reconstructive surgery

The use of exogenous agents to stimulate the growth of new blood vessels into ischaemic tissue is a potentially revolutionary therapy in a wide variety of clinical specialties. Therapeutic angiogenesis research has been mostly confined to ischaemia of the heart and the lower limb. There has been relatively little research into the potential applications of the technique to plastic, reconstructive and burns surgery. In this paper, relevant published work is reviewed and potential applications of therapeutic angiogenesis to our specialty are considered.

The microflora associated with extra-oral endosseous craniofacial implants: a cross-sectional study

Infection of soft tissues surrounding extra-oral craniofacial endosseous implants is a common clinical problem. The aim of this study was to analyse the microflora associated with such implants, in both health and disease. Eighteen patients with a total of 49 implants were studied. Each patient was seen on two occasions for both a clinical examination and for collection of microbiological samples, using swabs and paper points, from the peri-abutment soft tissues. Specimens were cultured on blood agar and on agars selective for staphylococci and yeasts. Isolates were identified and selective antibiotic susceptibility testing undertaken. No single organism emerged as a predominant cause of peri-abutment skin infection but Staphylococcus aureus, Gram-negative bacilli and yeasts were all present as potential pathogens in this context. Culture and sensitivity results should therefore guide the treatment of these infections.

Pyoderma gangrenosum following breast reconstruction

Pyoderma gangrenosum is an unusual cause of skin necrosis following surgery, particularly in those without an associated systemic condition. There have been reports of the condition in this context but not in relation to breast reconstruction. We present a case of pyoderma gangrenosum following latissimus dorsi flap reconstruction of a breast.

The application of Ontario human rights legislation to the practice of occupational medicine

Although human rights legislation has important implications for occupational physicians, these implications may be overlooked in the practice of occupational medicine in other countries where human rights legislation may be different. The potential for significant oversights becomes greater as organizations continue to centralize international business support functions, such as occupational health services, operating from a single site. Human rights legislation has important implications with respect to policy decisions upon which an occupational physician has influence. This includes decisions about whether to conduct drug and alcohol testing; the performance of medical examinations; evaluating issues related to health and safety concerns of pregnant employees; and the need to work accommodate those with handicaps as defined by human rights legislation. This article examines the application of the Ontario human rights legislation in these areas.

A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap

OBJECTIVES

The temporomandibular joint is occasionally encountered in extirpative surgery of the head and neck. It presents a difficult management issue. Little has been reported on functional outcomes after resection and reconstruction of the temporomandibular joint.

DESIGN

A retrospective analysis consisting of chart reviews and phone interviews was performed on 17 patients who underwent fibular free flap reconstruction of the temporomandibular joint from 1993 to 1998.

RESULTS

Mean follow-up in surviving patients (10) was 41.3 months. Mean age of the group was 62; male-to-female ratio was 11:6. Average hospital stay was 11.6 days. Four patients had no radiation therapy, 2 had preoperative and 11 had postoperative treatment. Five patients had one osteotomy, seven had two, one had three, and one had four. Ten patients could chew, one could not, and none were recorded for the remaining. Diet consisted of regular food for two patients, soft food for seven, full liquids for four, and tube feeds for four. Cosmesis was judged as excellent by eight patients, acceptable by two, and unacceptable by two. Five patients did not describe cosmesis. Most patients stated that bony contour was excellent, but that the soft tissue defect was noticeable. Speech was judged as intelligible by seven and moderately understandable by one. Nine patients did not describe speech. Two patients had postoperative displacement of the fibular head out of the fossa.

CONCLUSION

Primary reconstruction of the temporomandibular joint with microvascular fibular flaps is a viable and effective means of restoring function. The majority of patients are able to resume oral feeds, obtain excellent or pleasing cosmetic results, and maintain intelligible speech.

Prevention of yeast spoilage in feed and food by the yeast mycocin HMK

The yeast Williopsis mrakii produces a mycocin or yeast killer toxin designated HMK; this toxin exhibits high thermal stability, high pH stability, and a broad spectrum of activity against other yeasts. We describe construction of a synthetic gene for mycocin HMK and heterologous expression of this toxin in Aspergillus niger. Mycocin HMK was fused to a glucoamylase protein carrier, which resulted in secretion of biologically active mycocin into the culture media. A partial purification protocol was developed, and a comparison with native W. mrakii mycocin showed that the heterologously expressed mycocin had similar physiological properties and an almost identical spectrum of biological activity against a number of yeasts isolated from silage and yoghurt. Two food and feed production systems prone to yeast spoilage were used as models to assess the ability of mycocin HMK to act as a biocontrol agent. The onset of aerobic spoilage in mature maize silage was delayed by application of A. niger mycocin HMK on opening because the toxin inhibited growth of the indigenous spoilage yeasts. This helped maintain both higher lactic acid levels and a lower pH. In yoghurt spiked with dairy spoilage yeasts, A. niger mycocin HMK was active at all of the storage temperatures tested at which yeast growth occurred, and there was no resurgence of resistant yeasts. The higher the yeast growth rate, the more effective the killing action of the mycocin. Thus, mycocin HMK has potential applications in controlling both silage spoilage and yoghurt spoilage caused by yeasts.

Plant low-molecular-weight phospholipase A2S (PLA2s) are structurally related to the animal secretory PLA2s and are present as a family of isoforms in rice (Oryza sativa)

Recently, we purified to homogeneity and characterized a low-molecular-weight calcium-dependent phospholipase A2 (PLA2) from developing elm seed endosperm. This represented the first purified and characterized PLA2 from a plant tissue. The full sequences of two distinct but homologous rice (Oryza sativa) cDNAs are given here. These encode mature proteins of 1 19 amino acids (PLA2-I, preceded by a 19 amino acid signal peptide) and 128 amino acids (PLA2-II. preceded by a 25 amino acid signal peptide), and were derived from four expressed sequence tag (EST) clones. Both proteins were homologous to the N-terminal amino acid sequence of the elm PLA2. They contained twelve conserved cysteine residues and sequences that are likely to represent the Ca(2+)-binding loop and active-site motif, which are characteristic of animal secretory PLA2s. A soluble PLA2s activity was purified 145 000-fold from green rice shoots. This had the same biochemical characteristics as the elm and animal secretory PLA2s. The purified rice PLA2 consisted of two proteins, with a molecular weight of 12 440 and 12 920, that had identical N-terminal amino acid sequences. This sequence was different from but homologous to the PLA2-I and PLA2-II sequences. Taken together, the results suggest that at least three different low-molecular-weight PLA2s are expressed in green rice shoots. Southern blot analysis suggested that multiple copies of such genes are likely to occur in the rice and in other plant genomes.

Fluoride release, microbial inhibition and microleakage pattern of two orthodontic band cements

OBJECTIVES

To compare, in vitro, the fluoride release, microbial inhibition and microleakage pattern of a conventional glass ionomer cement (Ketac-Cem) and an acid-modified composite (Ultra Band-Lok) for band cementation.

METHODS

Fluoride release was measured from cement discs (3.0 mm diameter and 1.5 mm thick) at regular intervals over 40 days using a potentiometric method. Microbial inhibition was determined for each cement using an agar diffusion test against one of four different strains of Streptococcus mutans. Thirty pairs of banded third molars (15 banded pairs for each cement) were thermocycled and microleakage determined by a dye penetration method. The depth of microleakage was assessed by an index applied by two examiners independently to photographic records taken of the mid-buccal aspect of each tooth.

RESULTS

The cumulative and daily fluoride release for days 5, 15 and 40 were significantly greater for Ketac-Cem than for Ultra Band-Lok (all p < 0.05). After the initial set, the anti-microbial activity was significantly greater for Ketac-Cem than for Ultra Band-Lok over the following 24 h period for all four strains of S. mutans (all p < 0.05). There was no significant difference between the two cement groups for microleakage at the cement/enamel interface (p = 0.66) but a borderline significance was detected for microleakage at the cement/band interface (p = 0.051).

CONCLUSIONS

The fluoride release and anti-microbial activity of Ketac-Cem were greater than that of Ultra Band-Lok. There was no significant difference in microleakage between the cements at the cement/enamel interface but a borderline difference existed between the cements at the cement/band interface.

Barriers to the use of a diagnostic oral microbiology laboratory by general dental practitioners

OBJECTIVE

To identify barriers on the use of diagnostic microbiology facilities in general dental practice.

DESIGN

A cross-sectional survey using a postal questionnaire.

SETTING

Primary/secondary care interface between the diagnostic oral microbiology laboratory, University of Glasgow Dental Hospital and School, Glasgow and dental practitioners within the surrounding health boards, 1998.

SUBJECTS

All GDPs (797) within Argyll and Clyde, Ayrshire and Arran, Lanarkshire and Greater Glasgow Health Boards.

MAIN OUTCOME MEASURES

The responses were expressed as both absolute and relative frequencies.

RESULTS

Responses were received from 430 (55%). The most frequent reason for failure to use the service was lack of information, with more than half of the respondents claiming to be unaware of the facility. Lack of request forms and sampling equipment were also viewed as barriers to using the service.

CONCLUSIONS

The laboratory is failing to successfully communicate its role in addressing the growing burden of antibiotic resistance in the community and must be more proactive in encouraging appropriate use and increasing accessibility of the service to GDPs.

Smoking cessation, physicians, and medical office staff. Clinical tobacco intervention in Prince Edward Island

OBJECTIVE

To assess attitudes and self-reported behaviours of physicians and medical office staff in Prince Edward Island concerning clinical tobacco intervention (CTI).

DESIGN

Mail survey of PEI primary care physicians and their medical office staff. Most surveys were not mailed back but picked up in person by research staff.

SETTING

Primary care settings in PEI.

PARTICIPANTS

All active primary care physicians in PEI identified in the Canadian Medical Association database and medical office staff. Respondents included 63/88 (71.6%) physicians and 59/88 (67.0%) medical office staff. Fifty-seven physicians and medical office staff surveys overlapped.

MAIN OUTCOME MEASURES

Attitudes and self-reported behaviours in CTI.

RESULTS

More than 70% of the time, 68.3% of physicians reported asking new patients about their smoking behaviour and 66.7% reported that they listen to and acknowledge patients' feelings and fears about stopping smoking. Close to half (43.3%) of physicians reported thinking about or planning to do more CTI. Physicians and medical office staff reported that staff had limited involvement in methods to cue smoking interventions. Only half (50.8%) of physicians reported that their offices are well set up to identify smokers and to help them quit smoking. Offices were well set up for CTI if physicians perceived that office staff had an active role in CTI and if follow-up visits were frequently arranged.

CONCLUSIONS

This study identified apparent opportunities for improving CIT, particularly in the areas of physician training, involvement of medical office staff, and awareness of billing codes. This could improve the quality of preventive care for patients in PEI.

Comparison of potency of inhaled beclomethasone and budesonide in New Zealand: retrospective study of computerised general practice records

OBJECTIVE

To determine whether inhaled budesonide and beclomethasone are equipotent in the treatment of asthma in primary care.

DESIGN

Retrospective study of computerised clinical records from 28 general practices in New Zealand.

SUBJECTS

5930 patients who received 16 725 prescriptions for inhaled budesonide or beclomethasone from 1 July 1994 to 30 June 1995.

SETTING

General practices on the database of the Royal New Zealand College of General Practitioners Research Unit. Linked information from secondary care was available for a subset of the practices.

MAIN OUTCOME MEASURE

Mean prescribed daily inhaled corticosteroid dose.

RESULTS

The daily prescribed dose was higher for patients receiving inhaled budesonide (mean 979 microg) than beclomethasone (mean 635 microg), a difference of 344 microg (95% confidence interval 313 to 376 microg). This difference was consistent in all age bands and with different types of inhalation device. Evidence of systematic prescribing of higher doses of budesonide to patients with more severe asthma was not found.

CONCLUSIONS

In primary care in New Zealand evidence suggests that budesonide is less potent than beclomethasone. Consideration of validated, established, and other possible markers of asthma severity did not support confounding by severity as a reason for the higher prescribed doses of budesonide. Pending further epidemiological evaluation, international asthma guidelines may need to be modified on the equivalence of inhaled corticosteroid doses. Furthermore, the comparative potency of newly developed inhaled steroids in clinical trials will need to be confirmed in appropriately designed epidemiological studies based in general practice.

Polymicrobial coronal leakage of super EBA root-end fillings following two methods of root-end preparation

The aim of this study was to compose in vitro coronal leakage of a super EBA root-end filling material after two root-end cavity preparation techniques. A mixed anaerobic microbial marker was used. Forty-five extracted human teeth with straight, single root canals were prepared chemo-mechanically to a size 40 master apical file. The teeth were divided into experimental groups (35 teeth) and control groups (10 teeth). Forty teeth (35 experimental teeth and five negative control teeth) were obturated by lateral condensation of cold gutta-percha with Tubliseal EWT sealer. The remaining five teeth were not obturated and served as positive controls. These teeth were stored for 6 months in artificial saliva. The apical 3-4 mm of each root was resected perpendicular to the long axis of the root and a root-end cavity prepared to a depth of 3 mm using either a size 008 rosehead burr or an ultrasonic retroprep tip. Freshly mixed EBA cement was placed into the root-end cavity. The entire root surface of each tooth, except the cutting surface of the apical end, was sealed with nail varnish. The coronal part of each root canal was sealed with the cut end of a tube and placed in a bottle containing sterile Brain Heart Infusion Broth (BHIB). A marker consisting of Anaerobic streptococci and Fusobacterium nucleatum in BHIB was placed in each coronal chamber at 7-day intervals and daily observations were made for bacterial growth in the apical chamber for 60 days. All positive control teeth exhibited bacterial leakage within 48 h, whilst the apical chamber of negative control teeth remained uncontaminated throughout the test period. Fifty-nine percent (n = 10) of the specimens prepared with a burr showed leakage after 90 days, whilst only 22% (n = 4) of the ultrasonically prepared group showed leakage after the same time. The group prepared with ultrasonic tips showed statistically significant less specimens with leakage (P < 0.05) than the group prepared with burrs.

Coronal leakage of obturated root canals after long-term storage using a polymicrobial marker

This in vitro study investigated the effect of long-term storage on the coronal leakage of a microbial marker on teeth root filled with lateral condensation of cold gutta-percha and one of two sealers. Sixty single-rooted teeth were prepared chemomechanically to a size 40 master apical file. The teeth were divided into two groups of 20 teeth each and obturated with gutta-percha using either Apexit or Tubliseal EWT sealer. The teeth were stored for 6 months in artificial saliva and tested for leakage using a marker consisting of S. sanguis and P. intermedia. The teeth were checked for bacterial leakage daily for 90 days. All positive control teeth leaked after 24 h, while the negative control teeth remained uncontaminated throughout the test period. Leakage reached the apex through the experimental teeth at the earliest at 17 days and at latest at 88 days. Fifty percent and 70% of the specimens of the Apexit and Tubliseal EWT groups respectively showed leakage at 90 days. There was no statistically significant difference (p > 0.05) between the two groups.

An evaluation of microbial coronal leakage in the restored pulp chamber of root-canal treated multirooted teeth

This in vitro study investigated the effect of a resin-reinforced glass ionomer lining material on the coronal leakage of a mixed obligate microbial marker in maxillary molars obturated with lateral condensation of cold gutta-percha and Tubliseal sealer, after 2 years' storage. Forty maxillary first molars were prepared chemomechanically to a size 30-40 master apical file. The teeth were divided into an experimental group (30 teeth) and control group (10 teeth). In the experimental group, the floor of pulp chamber and the root-canal opening of 15 teeth were covered with Vitrebond as a lining; the remaining 15 teeth received no lining. These teeth were tested for leakage using a microbiological marker consisting of anaerobic streptococci and Fusobacterium nucleatum. The teeth were checked daily for bacterial leakage for 60 days. All positive control teeth leaked within 48 h, while the negative control teeth remained uncontaminated throughout the test period. The teeth restored with Vitrebond liner showed no leakage whilst 60% of the specimens with no Vitrebond liner showed leakage after 60 days.

A computerized adaptive testing system for speech discrimination measurement: the Speech Sound Pattern Discrimination Test

A computerized, adaptive test-delivery system for the measurement of speech discrimination, the Speech Sound Pattern Discrimination Test, is described and evaluated. Using a modified discrimination task, the testing system draws on a pool of 130 items spanning a broad range of difficulty to estimate an examinee's location along an underlying continuum of speech processing ability, yet does not require the examinee to possess a high level of English language proficiency. The system is driven by a mathematical measurement model which selects only test items which are appropriate in difficulty level for a given examinee, thereby individualizing the testing experience. Test items were administered to a sample of young deaf adults, and the adaptive testing system evaluated in terms of respondents' sensory and perceptual capabilities, acoustic and phonetic dimensions of speech, and theories of speech perception. Data obtained in this study support the validity, reliability, and efficiency of this test as a measure of speech processing ability.

Coronal leakage in teeth root-filled with gutta-percha and two different sealers after long-term storage

This in vitro study investigated the effect of long-term storage on the coronal leakage of a microbial marker in teeth root-filled with lateral condensation of cold gutta-percha and one of two sealers. Sixty single-rooted teeth were prepared chemomechanically to a size 40 master apical file. The teeth were divided into two groups of 20 teeth each and obturated with gutta-percha using either Apexit or Tubliseal EWT sealer. The teeth were stored for 6 months in artificial saliva and tested for leakage using a marker consisting of Anaerobic streptococci and Prevotella intermedia. The teeth were checked for bacterial leakage daily for 90 days. All positive control teeth leaked within 48 hours, while the negative control teeth remained uncontaminated throughout the test period. Leakage in the experimental teeth started at times varying from 10 to 71 days; 30% and 75% of the specimens of the Apexit and Tubliseal EWT groups respectively showed leakage at 90 days. The Tubliseal EWT group showed significantly more leakage (p < 0.05) than the Apexit group.

Identifying hazardous or harmful alcohol use in medical admissions: a comparison of audit, cage and brief mast

Two hundred and forty new medical inpatients received Alcohol Use Disorders Identification Test (AUDIT), CAGE and brief Michigan Alcoholism Screening Test (brief MAST) questionnaires. Sensitivities when identifying weekly drinkers of > 14 units (women) or > 21 units (men) were 93, 79 and 35%, respectively (P < 0.001). Sensitivities to > 21 units (women) or > 28 units (men were 100%, 94% and 47%. Routine screening of medical admissions with the AUDIT (cut-off score 8) is recommended.

The effect of smear layer on microbial coronal leakage of gutta-percha root fillings

The aim of this in vitro study was to determine the effect of removal of the smear layer on canal obturation as measured by penetration of bacteria from a coronal direction. One hundred and twenty extracted human teeth with straight, single root canals were decoronated. The canals were prepared using the modified double-flared technique with balanced force under copious irrigation. The apical matrix was prepared to size 40 and apical patency subsequently confirmed with a size 15 file. The teeth were divided randomly into experimental groups (80 teeth) and control groups (40 teeth). The root canals of 40 experimental and 20 control teeth were rinsed with 40% citric acid and 2% NaOCl to remove the smear layer before obturation. In experimental groups, 20 teeth with smear layer intact and 20 teeth with smear layer removed were obturated with lateral condensation of cold gutta-percha and Apexit sealer. A further 20 teeth with smear layer intact and 20 teeth with smear layer removed were obturated with the Trifecta technique with the same sealer. In control groups, 10 teeth with smear layer intact and 10 teeth with smear layer removed were obturated with lateral condensation of cold gutta-percha and Apexit sealer. These teeth were completely sealed both coronally and apically to serve as negative controls. The remaining 20 teeth with either smear layer intact or smear layer removed were not obturated and served as the positive controls. The root surface of each tooth was sealed with nail varnish. The cut end of a polypropylene tube was sealed around the coronal part of each root canal so that bacteria placed therein could move only through the obturated canal space. Each root was placed in a glass bottle containing sterile Todd-Hewitt Broth (THB) and aliquots of 0.5 ml of THB were injected into the polypropylene tube. The model system was centrifuged at 168 g. An innoculum of Streptococcus sanguis in THB was placed in each coronal chamber at 5-day intervals and daily observations were made for bacterial growth in the apical reservoir for 90 days. All positive control teeth showed bacterial penetration within 24 h, while the negative control teeth remained uncontaminated throughout the test period. Leakage through the experimental teeth was variable ranging from 7 to 86 days. There was no statistical significant difference (P > 0.05) in leakage between the obturated canal when the smear layer was either removed or intact.

An in vitro study of the coronal leakage of two root canal sealers using an obligate anaerobe microbial marker

The aim of this in vitro study was to investigate the coronal leakage of obligate anaerobes into root canals obturated with lateral condensation of cold gutta-percha with two root canal sealers. Sixty extracted human teeth with straight, single root canals were prepared using the modified double-flared technique with balanced force under copious irrigation until the master apical file was size 40. The teeth were divided randomly into experimental groups (40 teeth) and control groups (20 teeth). In the experimental groups, 20 teeth were obturated with lateral condensation of cold gutta-percha and AH26 sealer and 20 teeth were obturated with the same technique using TubliSeal EWT sealer. In the control groups, 10 teeth were obturated with the same technique either with AH26 or TubliSeal EWT sealer. These teeth were completely sealed to serve as negative controls. The remaining 10 teeth were not obturated and served as positive controls. The root surface of each tooth was sealed with nail varnish except the apical 2 mm. The coronal part of each root canal was sealed with the cut end of polypropylene tube and placed in a glass bottle containing sterile Fastidious Anaerobe Broth (FAB). Aliquots of 0.5 mL of FAB were injected into the polypropylene tube and the model system was centrifuged at 168 g. An inoculum of Fusobacterium nucleatum in FAB was placed in each coronal chamber at 7-day intervals and daily observations were made for bacterial growth in the apical reservoir for 12 weeks. All positive control teeth showed bacterial leakage within a week, while the negative control teeth remained uncontaminated throughout the test period. All the experimental teeth exhibited leakage of bacterial metabolites within 12 weeks, ranging from 1 to 12 weeks. The mean time for complete leakage in the AH26 and the TubliSeal EWT groups was 8.4 and 8.2 weeks respectively. There was no statistically significant difference (P > 0.05) in leakage between the AH26 and the TubliSeal EWT groups.

An evaluation of the Nd:YAG laser in periodontal pocket therapy

The aim of this study was to determine whether the Nd:YAG laser energies of 50 and 80 mJ at 10 pulses per second (pps) were capable of improving the clinical parameters associated with periodontal disease. These energy settings were chosen as previous work indicated that higher values would damage root surfaces and that 80 mJ had an in-vitro bactericidal effect. Eighty periodontally affected sites in teeth scheduled for extraction from 11 patients with adult periodontitis were randomly placed in one of the following four treatment groups: 1. laser treatment at 50 mJ, 10 pps for 3 minutes; 2. laser treatment at 80 mJ, 10 pps for 3 minutes; 3. scaling and 4. untreated control. Probing depth, bleeding on probing (BOP), plaque index, gingival index and gingival crevicular fluid (GCF) volume were measured at baseline and week 6. Baseline subgingival microbiological samples were collected, then repeated immediately after treatment and at week 6 to assess the total anaerobic colony forming units (CFU). Only the scaling group showed a significant reduction in pocket depth and BOP (P < 0.001). The microbial samples taken immediately after scaling and laser at 80 mJ and 10 pps treatments showed a significant reduction in total CFU compared with the baseline (P < 0.01), which was sustained only in the scaling group until week 6. Electron microscopy did not reveal any heat damage on the root surfaces. This study demonstrated that application of Nd:YAG laser pulses of 50 mJ and 80 mJ failed to improve the clinical and microbiological parameters of periodontal disease.

Yes, minister, Canadians need strong tobacco-control legislation now!

At a meeting with federal health minister Diane Marleau on Nov. 16, 1995, the CMA and other health organizations were told that the minister plans to propose comprehensive measures to limit the manufacture, sale and marketing of tobacco products. On Dec. 11, 1995, the minister announced a "Blueprint on Tobacco Control," which outlined the scope of her plan to introduce tobacco legislation in the spring. On the basis of adamant support for tobacco control from all levels of the organization, the CMA urges the minister to move quickly. It also advocates regulating tobacco as a hazardous product in the meantime. Physicians can take a wide variety of actions to intervene with patients and add their voice to antitobacco lobbying efforts in 1996.

Failure of the legal system to enforce drunk driving legislation effectively

STUDY OBJECTIVE

To evaluate the investigation and prosecution of drunk drivers and identify reasons for system failure.

DESIGN

Prospective data collection on all drivers with an elevated blood alcohol level who were treated at a Level I trauma center between January 1 and June 30, 1991.

SETTING

Level I trauma center/university medical center serving a population of 1.8 million.

INTERVENTIONS

Prospective data collection, interviewing ambulance squad members, investigating police, and results of prosecution.

MEASUREMENTS AND MAIN RESULTS

Of 321 drivers, 78 had ethanol levels of more than 100 mg/dL; nine were between 50 and 100 mg/dL. All drivers had rapid transport to a trauma center for severe injury or high-risk injury mechanism. Police reports were accessible for 84 of 87 drivers; all drivers were believed to be at fault. The crashes resulted in five deaths and 74 other victims requiring hospitalization. Six of the intoxicated drivers died. Police requests for blood alcohol levels were made for 28 drivers, one of whom died. The remaining 59 drivers had no legal blood alcohol level drawn. Although the greater the distance from our center (more rural), the less likely were requests for ethanol levels, but there were many "no requests" from nearby cities. Of the 28 drivers on whom legal alcohol levels were drawn, eight escaped central registration with the highway safety commission, which records any and every traffic violation within New Jersey. Of the remaining 20, eight were not prosecuted (excluding one death), including one repeat offender. One committed a later "driving while intoxicated" offense and was then prosecuted. The remaining 11 were all convicted; five were repeat offenders.

CONCLUSION

Reasonable cause is required for legal blood alcohol requests. Our data demonstrated that this is difficult when the driver is unavailable for questioning. However, once legal blood alcohol levels have been obtained, inadequate legal follow-up leads to nonprosecution. Once officially charged, conviction appears certain, but even this punishment and re-education fail to change behavior in many of these drivers.

Pathogenesis of SIVmac251 after atraumatic inoculation of the rectal mucosa in rhesus monkeys

Intrarectal inoculation of rhesus monkeys with low doses of SIVmac led to a prolonged clinical and virological latency that was not observed for high intrarectal doses or for intravenous inoculation. Animals infected intrarectally with low virus doses remained negative for serum antibody responses to SIV for at least one year even though they readily transferred SIV to naive recipients via transfusion of whole blood.

New hydroxyethylamine HIV protease inhibitors that suppress viral replication

The synthesis of analogues of AcSerLeuAsn[Phe-HEA-Pro]IleValOMe (1, JG-365; where HEA stands for the hydroxyethylamine unit 2), a tight-binding inhibitor of HIVP, are reported. Systematic modification of the P3 and P3' regions of the inhibitors has led to smaller HIVP inhibitors that inhibit viral replication in HIV-infected and SIV-infected cell cultures. Six aliphatic and/or aromatic derivatives were prepared by replacing residues in the P3 regions of BocLeuAsn[Phe-HEA-Pro]IleValOMe. Aromatic side chains at P3 gave better inhibitors than aliphatic side chains. The better inhibitors in this series contained a beta-naphthylalanine or a biphenyl unit at P3. A second series of HIVP inhibitors were obtained by converting the P3 group into acyl groups. CbzAsn[Phe-HEA-Pro]IlePheOMe and Qua-Asn-[Phe-HEA-Pro]-Ile-Phe-OMe (where Qua = quinolin-2-ylcarbonyl) are potent HIVP inhibitors with Ki values equal to 1.0 and 0.1 nM, respectively. The inhibition constants were determined by using the continuous fluorometric assay developed by Toth and Marshall. The activities of the protease inhibitors for inhibition of SIV replication were determined in vitro using CEM x 174 cells. Inhibition of HIV infection was determined essentially as reported by Pauwels and co-workers. The anti-HIV assay was carried out in culture using CEM cells (a CD4+ lymphocyte line) infected with virus strain HTLV-IIIb with a multiplicity of infection of 0.1. Several analogues inhibited the cytopathic effect at concentrations of 0.1-0.8 microgram/mL. These results establish that good inhibitors of HIV protease that inhibit viral replication in infected lymphocytes in in vitro cell assays can be obtained from JG-365 when the AcSerLeu unit is replaced by aromatic acyl derivatives.

Pseudoaneurysm of the inferior gluteal artery

Aneurysms of the inferior gluteal artery are uncommon, and have not previously been described in detail in the radiologic literature. The authors report the findings of computed tomography and angiography for a patient with a pseudoaneurysm of the inferior gluteal artery who was successfully treated by embolization alone.

Are gamma delta T cells important for the elimination of virus-infected cells?

Rhesus monkeys (Macaca mulatta) gamma delta T cells were identified using a monoclonal antibody. The relative representation of gamma delta T lymphocytes in the peripheral blood, lymph nodes, and spleen resembles that of Homo sapiens. The analysis of function and specificity revealed further significant similarities between the simian and human gamma delta T-cell systems. Since both human and monkey gamma delta T lymphocytes can effectively lyse cells infected with immunodeficiency viruses, it is possible that the primate gamma delta T-cell systems contribute to antiviral immunosurveillance.

Control of intraocular pressure with apraclonidine hydrochloride after cataract extraction

We conducted a randomly assigned, double-masked, controlled clinical trial to assess the efficacy of 1% apraclonidine hydrochloride in controlling postoperative intraocular pressure increases in patients undergoing extracapsular cataract extraction. Apraclonidine hydrochloride was given either one hour preoperatively or immediately after uncomplicated, extracapsular cataract extraction with posterior chamber intraocular lens implantation and compared with artificial tears given immediately postoperatively. Those who received apraclonidine hydrochloride preoperatively had significantly lower mean intraocular pressure at the first postoperative reading (P = .0005). After preoperative and postoperative apraclonidine hydrochloride, the mean early postoperative intraocular pressure was 19.8 mm Hg and 32.0 mm Hg, respectively, and 27.6 mm Hg after artificial tears. No patient who received preoperative apraclonidine hydrochloride had an intraocular pressure increase to 30 mm Hg or higher postoperatively. Nine of 20 patients (45%) who received postoperative apraclonidine hydrochloride and eight of 18 patients (44%) who received postoperative artificial tears had an increase of intraocular pressure to 30 mm Hg or higher in the early postoperative period. These differences were also highly significant (P = .0005).

Oral candidosis in the elderly in long term hospital care

A total of 137 patients in long term hospital care were interviewed and examined to determine the prevalence, nature and most important causes of oral candidosis in the hospitalized elderly. Oral candidal infection as determined by the imprint culture technique was present in 47% of patients with a further 31% being carriers of Candida. The prevalence of chronic atrophic candidosis in denture wearers was 38%, while 26% of all patients had angular cheilitis, 67% of which had an infective etiology. Microbiologic examination strongly indicated the upper denture as the major source of infection in those with dentures despite the existence of a ward policy which should have encouraged good oral and denture hygiene.

Bacteraemia following incision and drainage of dento-alveolar abscesses

Twenty-five patients undergoing routine incision and drainage of dento-alveolar abscesses were screened for bacteraemia during the procedure. In 13 patients, the abscesses were aspirated with a needle prior to incision and drainage, while needle aspiration was omitted in the remaining 12. A blood sample was taken from all individuals immediately before the surgical procedures and at one-minute intervals for a period of 5 minutes after surgery. Needle aspiration of pus resulted in a significant reduction (P less than 0.05) in the bacteraemic episodes (0 out of 13) during subsequent surgery as compared with incision and drainage, without aspiration (3 out of 12). Bacteraemia appeared to be transient, although in one case it was detected at 5 minutes. It is concluded that bacteraemic episodes occur during incision and drainage of dento-alveolar abscesses and this may be reduced by aspiration of the abscess contents prior to incision and drainage. In addition, the aspirates could serve as excellent microbiological samples, uncontaminated with salivary flora. The need for antibiotic cover in at risk patients, however, needs to be established by further studies.

The microbiology of periapical granulomas

Of the 16 periapical granulomas studied, 14 (88%) yielded a positive growth when homogenized and cultured. The concentration of colony-forming units per milliliter of the suspension ranged from 10(1.3) to 10(4.0) (mean 10(2.2)). A total of 47 isolates comprising 26 (55%) facultative anaerobes and 21 (45%) strict anaerobes were obtained. The organisms most commonly cultured were Veillonella species (15%), Streptococcus milleri (11%), Streptococcus sanguis (11%), Actinomyces naeslundii (11%), Propionibacterium acnes (11%), and Bacteroides species (10%). Most of the organisms (96%) were sensitive to either amoxicillin, clindamycin, or tetracycline, whereas only 45% were sensitive to metronidazole.

Increased sensitivity for rapid detection of cytomegalovirus by shell vial centrifugation assay using mink lung cell cultures

A comparative study was made of various human and non-human cell cultures to determine their sensitivity for cytomegalovirus (CMV) as detected by the production of CMV early antigen using the shell vial centrifugation assay. Mink lung cell cultures, frequently used for detection of herpes simplex virus in clinical specimens, were found to be significantly more sensitive to infection by CMV than other cell cultures tested. Using the shell vial centrifugation assay, the mink lung cell cultures were more sensitive than human diploid fibroblasts for the detection of the Davis strain of human CMV and CMV from clinical specimens.