A review of drugs that contribute to bleeding risk in general dental practice

The risk of postoperative bleeding is a daily concern for many general dental practitioners. A thorough medical and medication history must be taken to consider all risk factors, particularly drugs, that contribute to bleeding risk. While the risk from drugs such as aspirin, warfarin and clopidogrel are well known, the extent to which new antiplatelet agents and direct oral anticoagulants affect bleeding risk is less well understood. In addition, there are drugs other than antithrombotics, such as antidepressants and complementary medicines that also impair haemostasis. The aim of this paper is to provide dentists with an updated overview of the drugs commonly encountered in general dental practice that can contribute to a patient's postoperative bleeding risk.

Functional testosterone: biochemical assessment of hypogonadism in men--report from a multidisciplinary workshop hosted by the Ontario Society of Clinical Chemists

OBJECTIVES

In 2004, the Ontario Society of Clinical Chemists (OSCC) held an invitational multidisciplinary workshop to establish the most reliable, cost-effective approach to the biochemical assessment of hypogonadism in men.

METHODS

Specialists across Canada in clinical biochemistry, endocrinology, family medicine and urology were invited to participate in this workshop which included individual presentations and a consensus component addressing two challenge statements: 1) 'Determinations for total testosterone (TT) are equivalent to those for bioavailable testosterone (BAT) or calculated BAT (cBAT) or free testosterone (FT) (by analogue radioimmunoassay or equilibrium dialysis) or calculated FT (cFT)'; 2) 'There is no good evidence that borderline low testosterone concentrations in men should be treated'. The main outcomes were to identify what agreement exists in Canada, what issues were still controversial, and what research remains to be addressed.

RESULTS

Six recommendations based on expert opinion addressed these main themes: investigate with morning total testosterone (TT) followed by repetition and reflexive testing of sex hormone binding globulin (SHBG) if testosterone is 8-15 nmol/L with automatic calculation of cBAT; discontinue the use of analogue free testosterone assays; and definitive methods and standards must be available to ensure standardized results.

CONCLUSIONS

Total testosterone is a reliable marker for the initial investigation of men presenting with symptoms of hypogonadism; cBAT is a reasonable follow-up test in patients with equivocal biochemical or consistent symptomatic findings.

Cervical cancer--the impact of clinical presentation, health and race on survival

This study evaluated the association of race, comorbid illness, insurance status, and other prognostic factors on treatment and survival of patients with invasive carcinoma of the cervix, using as its methodology a retrospective study of patients with invasive carcinoma of the cervix treated from 1991 to 1998 at the University of Maryland. Of 161 such patients, 153 met the study criteria. Of these 153 women, 83 (54%) were African Americans and 70 (46%) were white. The mean (+/- SE) age of African American women was 52 +/- 1.8 years and that of white women was 50 +/- 1.8 years. African American women were more likely to present with stages II-IV disease (P = 0.01) and, as a consequence, underwent radiation therapy rather than surgery (P = 0.04). The survival of African American women with stage I-II disease was significantly lower than for white women. In the final regression model, stage III-IV disease (hazard ratio 3.2, 95% (CI 1.7, 6.1) African American race, (hazard ratio 1.9; 95% CI 1.0, 3.3) and comorbid illnesses (hazard ratio 2.3; 95% CI 1.3-4.0) were associated with poor survival. Adverse outcomes of African American women with cervical cancer persist after adjustment for stage of disease and other factors and are particularly apparent in stage I-II disease. The role of comorbid illness is deserving of further study.

Military medical modeling and simulation in the 21st century

As we enter the 21st century, military medicine struggles with critical issues. One of the most important issues is how to train medical personnel in peace for the realities of war. In April, 1998, The General Accounting Office (GAO) reported, "Military medical personnel have almost no chance during peacetime to practice battlefield trauma care skills. As a result, physicians both within and outside the Department of Defense (DOD) believe that military medical personnel are not prepared to provide trauma care to the severely injured soldiers in wartime. With some of today's training methods disappearing, the challenge of providing both initial; and sustainment training for almost 100,000 military medical personnel is becoming insurmountable. The "training gap" is huge and impediments to training are mounting. For example, restrictions on animal use are increasing and the cost of conducting live mass casualty exercises is prohibitive. Many medical simulation visionaries believe that four categories of medical simulation are emerging to address these challenges. These categories include PC-based multimedia, digital mannequins, virtual workbenches, and total immersion virtual reality (TIVR). The use of simulation training can provide a risk = free realistic learning environment for the spectrum of medical skills training, from buddy-aid to trauma surgery procedures. This will, in turn, enhance limited hands on training opportunities and revolutionize the way we train in peace to deliver medicine in war. High-fidelity modeling will permit manufacturers to prototype new devices before manufacture. Also, engineers will be able to test a device for themselves in a variety of simulated anatomical representations, permitting them to "practice medicine".

Defining mechanisms of action of interleukin-11 on the progression of radiation-induced oral mucositis in hamsters

Oral ulcerative mucositis is a common toxicity associated with drug and radiation therapy for cancer. It impacts on quality of life and economic outcomes, as well as morbidity and mortality. Mucositis is often associated with dose limitations for chemotherapy or is a cause for dose interruption for radiation. The complexity of mucositis as a biological process has only been recently appreciated. It has been suggested that the condition represents a sequential interaction of oral mucosal cells and tissues, pro-inflammatory cytokines and local factors such as saliva and the oral microbiota. The recognition that the pathophysiology of mucositis is a multifactorial process was partially suggested by the observation that interleukin-11 (IL-11), a pleotropic cytokine, favorably altered the course of chemotherapy-induced mucositis in an animal model. In the current study, we evaluated a series of biologic and morphologic outcomes to determine their roles and sequence in the development of experimental radiation-induced mucositis and to evaluate the effects of IL-11 in attenuating them. Our results suggest that IL-11 favorably modulates acute radiation-induced mucositis by attenuating pro-inflammatory cytokine expression. Data are also presented which help define the pathobiological sequence of mucositis.

Breast cancer screening and African American women: fear, fatalism, and silence

PURPOSE/OBJECTIVES

To explore the beliefs, attitudes, and practices related to breast cancer and breast cancer screening among low- and middle-income African American women.

DESIGN

Qualitative study using focus group methodology.

SAMPLE/SETTING

26 African American women, age 40-65, selected from three employment groups, recruited from a community-based center and a local teacher's union in a moderate-sized urban area.

METHODS

Three 90-minute focus group discussions exploring breast cancer beliefs, attitudes, and practices were audiotaped, transcribed verbatim, and analyzed using thematic context analysis techniques.

FINDINGS

When breast cancer was discussed, fear was the predominant feeling expressed in all groups. This fear was a primary reason not to engage in breast cancer screening. Unemployed women and service workers emphasized the role of violence in causing breast cancer, whereas teachers discussed injury and sex as causing breast cancer. All participants stressed that breast cancer is seldom discussed within the African American community. Teachers added that this secrecy within the African American community leads to breast cancer being viewed as a white woman's disease.

CONCLUSIONS

Despite initiatives promoting breast cancer awareness. African American women still hold misconceptions regarding the etiology of breast cancer and fatalistic perspectives regarding breast cancer outcomes, perhaps because breast cancer is discussed infrequently. Because pain, fear, and fatalism were discussed in all groups, future research should address the influence of these factors to increase screening behaviors.

IMPLICATIONS FOR NURSING PRACTICE

Because unemployed women, service workers, and teachers differed in their beliefs about breast cancer and breast cancer screening, nurses must be mindful of the need to tailor Interventions to address the needs of both low- and middle-income African American women.

'Epiphyseal dysgenesis' in Laurence-Moon-Biedl-Bardet syndrome

Ten patients with Laurence-Moon-Biedl-Bardet syndrome were investigated. They all belonged to one large family within which several intermarriages had taken place. We found that, apart from the already described abnormalities, these patients suffered from dysgenesis of the following epiphyses: vertebrae, proximal femur, proximal tibia, capitellum, tarsal navicular, and the distal epiphysis of the first metatarsal. The degree of polydactyly, a prominent feature of this syndrome, varied from patient to patient, ranging from a wide fifth metatarsal or metacarpal to a complete sixth digit. As in other epiphyseal dysgenesis, a pseudoepiphysis of the distal first metacarpal was present. One patient (the eldest) was tetraparetic due to severe spinal stenosis.

Supernatant from stored red cells activates neutrophils

Bioreactive substances including cytokines and lipids accumulate during storage of red blood cells (RBCs) but their clinical importance is uncertain. The goal of this study was to evaluate the effect of stored RBC supernatant on neutrophil activity in vitro. Packed RBCs (PRBCs) were collected and divided into two aliguots, one leukodepleted and the other nonleukodepleted. Plasma supernatant from PRBCs were collected on days 1, 8, 15, 29 and 35 and its effect on neutrophil expression of CD11b, CD16 and oxidative burst was measured by flow cytometry. Levels of tumour necrosis factor alpha (TNF alpha) and interleukin-8 (IL8) were also measured. The supernatant from PRBC units stored for greater than 15 days activated and primed neutrophils as evidenced by an increase CD11b and CD16 expression and oxidative burst. The greatest effect was seen in the oldest concentrates (35-day-old) (P < 0.008). Leukodepletion abrogated the effects of stored supernatant on CD11b and CD16 expression (P < 0.02) but did not reduce priming of the neutrophil oxidative burst (P > 0.1). Very low levels of IL8 and TNF alpha were detected in stored supernatants. Stored PRBC supernatant contains substances which directly enhance neutrophil expression of adhesion protein CD11b, CD16 and prime neutrophil oxidative burst. The exceedingly low level of IL8 and TNF alpha found in this study suggests that other factors may play a more important role in neutrophil priming and activation.

L-malate transport and proton symport in vesicles prepared from Pseudomonas putida

In vesicles from glucose-grown Pseudomonas putida, L-malate is transported by nonspecific physical diffusion. L-Malate also acts as an electron donor and generates a proton motive force (delta p) of 129 mV which is composed of a membrane potential (delta psi) of 60 mV and a delta pH of 69 mV. In contrast, vesicles from succinate-grown cells transport L-malate by a carrier-mediated system with a Km value of 14.3 mM and a Vmax of 313 nmol X mg protein-1 X min-1, generate no delta psi, delta pH, or delta p when L-malate is the electron donor, and produce an extravesicular alkaline pH during the transport of L-malate. A kinetic analysis of this L-malate-induced proton transport gives a Km value of 16 mM and a Vmax of 667 nmol H+ X mg protein-1 X min-1. This corresponds to a H+/L-malate ratio of 2.1. The failure to generate a delta p in these vesicles is considered, therefore, to be consistent with the induction in succinate-grown cells of an electrogenic proton symport L-malate transport system.

D-glucose and D-gluconate transport in vesicles from Pseudomonas putida

Vesicles prepared from glucose-grown cells of Pseudomonas putida (ATCC, 12633) retain glucose oxidase (GOX) and gluconate dehydrogenase (GADH) activity and actively transport D-glucose, 2-deoxy-D-glucose (2DOG), 3-deoxy-3-fluoro-D-glucose (3FG), and D-gluconate by saturable processes. The transport of these substrates is stimulated by the addition of L-malate or reduced phenazine methosulphate (PMS). Vesicles prepared from succinate-grown cells of P. putida lose their capacity to transport D-glucose, 2DOG, and 3FG by a saturable process. The transport and accumulation of D-gluconate, however, is retained with a KX value of 65 microM and a Vmax of 1.0 nmol . mg protein-1 . min-1. The rate of D-gluconate transport is stimulated by the addition of reduced PMS of L-malate with a reduction in the KX value to 42.0 microM. Respirometric studies with these vesicles indicate the presence of an active GOX and L-malate dehydrogenase but a defective GADH. Thus a reductase activity is detected in the presence of D-gluconate and either 2,6-dichloroindophenol (DCIP) or ferricyanide, as measured by a decrease in absorbance at 500 and 420 nm, respectively. Measurements on these vesicles with the oxygen electrode, however, indicate that no electron transfer from GADH to oxygen occurs. This is in contrast to the results with glucose-grown vesicles or with L-malate or D-glucose as substrates in the succinate-grown vesicles. A comparison between glucose and gluconate oxidase activity in native and detergent-treated vesicles is made. The significance of these results in relation to the presence of a glucose carrier in P. putida and other pseudomonads is presented.

Simultaneous determination of serum cholesterol and triglycerides after preliminary column chromatography

An isopropanolic extract of serum can be made suitable for the simultaneous estimation of cholesterol and triglycerides by passing it through a commercially-available chromatographic column containing activated metallic oxides in which alumina predominates. No centrifugation step nor phase separation is required. Use of the purified extract allows existing methods to be simplified and shortened without loss of reproducibility or stability. Results compare well with those obtained by traditional methods.