Arterial dissection as a cause of intracranial stenosis: A narrative review

Intracranial artery dissection (IAD) is an underdiagnosed, non-atherosclerotic cause of stroke with various clinical manifestations. To identify all the potential studies investigating the epidemiology, risk factors, symptoms, radiology findings, and treatment methods of IAD, we conducted a literature search screening PubMed, SCOPUS, EMBASE, and BIREME. According to the results of several studies, IAD is the major cause of ischemic stroke in at least one-third of the cervical-cranial artery dissection (CCAD) cases presenting with ischemic stroke. Mechanical causes are associated with cervical artery dissections (CAD) in up to 40 % of the cases. However, the risk factors for IAD are still not completely understood. Antithrombotic therapy with either antiplatelet or classic anticoagulants is the mainstay of treatment for preventing further thromboembolic complication after a stroke. Endovascular or surgical treatment options can be considered when medical therapies are not effective or when there is a high rate of recurrence or increased risk of bleeding. The observational studies have shown that these methods are very effective in preventing recurrence and significantly improving morbidity and mortality in patients with ruptured dissections. Clinical trials are required to establish the best option for each mechanism of ischemic lesion.

Clinical approach to urinary incontinence: a comparison between internists and geriatricians

To compare the initial approach and pattern of practice between internists and geriatricians in treating urinary incontinence. A retrospective chart review of 300 consecutive charts of elderly patients over the age of 65, seen by either internists (IM) or Geriatricians (GERI) for urinary incontinence at the Cleveland Clinic Florida was performed. The clinical approaches to the management of urinary incontinence were compared between IM and GERI groups by using a Student's t test. The mean age for these patients was 77 y for the IM group and 79 y for the GERI group. Majority of patients suffered from two chronic illnesses. We found that geriatricians performed more initial work up such as urodynamic testing before referring, while internists obtained more referrals to gynecologist with special interest in urologic disorders (currently called urogynecologist) without initial workup. IM and GERI groups equally prescribed medications for incontinence. However, the GERI group recommended Kegel exercises more frequently. This study showed that geriatricians manage urinary incontinence more extensively by performing more initial work up including urodynamics and providing initial behavioral therapy (Kegel exercise and toilet schedule) before referring to specialists. Perhaps geriatricians feel more comfortable treating urinary incontinence as shown by their lower frequency of referrals and are therefore more comfortable than internists at addressing this medical issue. On the contrary, the internist did the initial evaluation but preferred to get a referral perhaps due to less familiarity with urinary incontinence.

Implant position record and implant position cast: minimizing errors, procedures and patient visits in the fabrication of the milled-bar prosthesis

This article describes a new rationale and method involved in the fabrication of a patient detachable prosthesis supported by a milled bar. This simple procedure improves prosthesis retention. The overdenture is processed directly over a milled bar, which provides an intimate relation between the bar and the acrylic resin denture base to create resistance against rotational and lateral forces acting on the prosthesis. Incorporating simple and predictable attachments, with low maintenance needs, controls resistance to dislodgment along the path of insertion of the prosthesis. The concepts used in the fabrication of the milled bar include an implant position record (IPR) and an implant position cast (IPC) to reduce the need for time-consuming procedures, such as sectioning the cast bar and soldering it to make it fit the abutments. This procedure also reduces the number of patient visits required of the completion of the prosthesis.

Face-bow record without a third point of reference: theoretical considerations and an alternative technique

Accurate mounting of dental casts is achieved by transferring the tridimensional spatial relationship of the maxillary arch to an articulator. A face-bow is used to transfer this relationship to the articulator, usually by relating the face-bow to a plane of reference. The most common reference plane is the Frankfort plane, which has been assumed to be horizontal when the patient is in the natural head position. The axis-orbitale plane has also been considered horizontal and used as reference. However, it has been shown that both planes are not horizontal, and mounting a maxillary cast according to these planes can result in an inaccurate mounting. This article describes an alternative procedure for face-bow transfer without a plane of reference, and uses the angular relationship between the occlusal plane and the condylar path to mount the maxillary cast on the articulator. The elimination of a reference plane, to which relate the functional determinants of occlusion, avoids an additional source of error during the mounting procedure.

Procedure to prevent cast breakage during separation from elastomeric impressions

This article describes a quick and simple procedure for removing dental stone casts from elastomeric impressions. Frequently, dental stone casts break at the time of separation because of the rigidity of the impression material. The materials used in this technique are inexpensive and easy to use. When this method is properly used, it simplifies the removal of the cast from the impression, decreasing the chance of fracture of the cast.

Long-term reinforced fixed provisional restorations

Extensive prosthodontic treatment often requires fabrication of long-term provisional restorations. Numerous materials and techniques have been described for prolonged insertion of interim restorations. This article describes a procedure for fabrication of long-term reinforced heat-processed provisional restorations based on a diagnostic wax-up. Reinforced heat-processed provisional restorations reduced flexure, which minimizes progressive loss of cement and diminished the possibility of recurrent decay. Occlusal stability and vertical dimension were maintained because of greater wear resistance. Occlusion, tooth contours, and pontic design developed in the provisional restoration were duplicated in the definitive restoration. The use of a matrix from a diagnostic wax-up facilitated fabrication of the prosthesis, and made the procedure less time-consuming and more predictable.

Functional impairment among elderly women with osteoporotic vertebral fractures

Back pain is a significant cause of functional impairment in elderly women with vertebral fractures. To determine the degree of functional impairment due to painful osteoporotic vertebral fractures, investigators compared 75 white women with a mean age of 77 (+/- 7.2) years who had a mean number of 2.8 (+/- 0.87) vertebral fractures with 83 white women with a mean age of 74 (+/- 6.5) years who had no vertebral fractures. These patients were seen within a 2-year period. The Katz Activities of Daily Living scale was used to assess the patients' functional status. All patients underwent a comprehensive evaluation that included a detailed history and a physical examination. Bone density was evaluated in most of the patients and the evaluation revealed osteoporosis in all of the patients with vertebral fractures. The women with vertebral fractures were found to be more significantly dependent in the following activities of daily living: bathing, toileting, dressing, transfer, and continence. These findings have important nursing implications for rehabilitation of the elderly with this condition.

Caudal epidural blocks for elderly patients with lumbar canal stenosis

OBJECTIVE

To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS).

DESIGN

This study was a descriptive, prospective study with a 10-month follow-up.

PARTICIPANTS AND SETTING

Thirty patients, 76 +/- 6.7 years of age, with leg discomfort with or without back pain and with LCS documented by magnetic resonance imaging (MRI) within 1 year of the study, were recruited from the outpatient clinic of the Cleveland Clinic Florida. None of the subjects had received CEB or surgery for their leg discomfort and none had relief of pain by analgesics alone.

MEASUREMENTS AND INTERVENTIONS

Subjects received a total of three doses of 0.5% Xylocaine with 80 mg Depo-Medrol into the caudal epidural space through the sacral hiatus at weekly intervals. The Roland 5-point pain rating scale was utilized before and at 2-month intervals up to 10 months after the CEB was administered. MRI was used to identify the degree of LCS.

RESULTS

The degree of LCS on admission was moderate in 66.7% (n = 20) of the patients, mild in 23.3% (n = 7), and severe in the remaining 10% (n = 3). Patients had LCS involving 2.4 +/- 0.49 lumbar vertebrae. The degree of LCS is directly correlated with the pain level before CEB. After CEB, the pain level changed from 3.43 +/- 0.82 to 1.5 +/- 0.86 (P < 0.0000), with a significant relief of pain up to 10 months (the end of observation). The duration of pain relief ranged from 4 to 10 months (P < 0.0001).

CONCLUSION

CEB offers significant pain relief and appears to be a reasonable therapeutic option among elderly patients with LCS. This alternative seems particularly important among patients with poor response to drug therapy and who are either poor surgical risks or who have refused surgery.

Continuous compared with intermittent tube feeding in the elderly

The methods of continuous (C) and intermittent (I) nasogastric tube feedings in 60 patients, 54 men and 6 women, with a mean age of 72 +/- 9 years were compared in terms of number of complications, staff time used, and caloric intake. Patients were randomly assigned between these two methods and followed for 7 days. Diarrhea, aspiration pneumonia, clogged tubes, and self-extubation were observed in both groups. Diarrhea was significantly more frequent (96% of 30 patients) in the I group than the C group (66% of 30 patients) (p < .008). Furthermore, diarrhea was more prolonged (4 days or more) in 64% of 30 patients in the I group than the C group (4 days or more) in 58% of 30 patients (p < .02). However, clogged tubes occurred 3 times more often in the C group (p < .01). Self-extubation and aspiration pneumonia tend to be more frequent in the I group but the difference was not significant. The average time used by staff nurses in the maintenance of NGT feedings was not significantly longer in the I group (48.45 +/- 11 min/patient per day) than the C group (46.46 +/- 11 min/patient per day). In the C group the mean calories recommended were 2248 +/- 36 kcal/day but the actual caloric intake was only 1465 +/- 281 kcal/day, a deficiency of 783 +/- 291 kcal/day. The recommended calorie count for the I group was 2021 +/- 5 kcal/day but the amount delivered was only 1226 +/- 254 kcal/day, which resulted in a deficit of 795 +/- 259 kcal/day.(ABSTRACT TRUNCATED AT 250 WORDS)