In vivo evaluation of clinical performance of Cention N and glass ionomer cement in proximal restorations of primary molars

INTRODUCTION

Restoring a proximal lesion in primary tooth has met with many challenges which has led to evolution of many materials. An alternative to Glass Ionomer Cements which has fluoride releasing capacity, offers good bond strength and is esthetic have been long looked for.

AIM

This study aimed to compare the clinical performance of GIC and Cention N in proximal restorations of primary molars.

MATERIALS AND METHODOLOGY

A prospective study was conducted on 154 primary molars in patients aged between 5 and 8 years using a split-mouth design. Patients were divided into two groups. Control group restored with GIC and study group received Cention N. Both groups were assessed at baseline 3, 6 and 9 months according to Ryge criteria and data was statistically analysed using Fisher's Exact.

RESULTS

Statistically significant difference was found between GIC and Cention N restorations for color match at baseline and color stability at 3 months (P < 0.001), while the other parameters did not show any significant difference among the two restorative materials.

CONCLUSION

Cention N can be used as a suitable alternative to GIC for restoring Class II restorations in primary molars.

The flashfm approach for fine-mapping multiple quantitative traits

Joint fine-mapping that leverages information between quantitative traits could improve accuracy and resolution over single-trait fine-mapping. Using summary statistics, flashfm (flexible and shared information fine-mapping) fine-maps signals for multiple traits, allowing for missing trait measurements and use of related individuals. In a Bayesian framework, prior model probabilities are formulated to favour model combinations that share causal variants to capitalise on information between traits. Simulation studies demonstrate that both approaches produce broadly equivalent results when traits have no shared causal variants. When traits share at least one causal variant, flashfm reduces the number of potential causal variants by 30% compared with single-trait fine-mapping. In a Ugandan cohort with 33 cardiometabolic traits, flashfm gave a 20% reduction in the total number of potential causal variants from single-trait fine-mapping. Here we show flashfm is computationally efficient and can easily be deployed across publicly available summary statistics for signals in up to six traits.

Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion-Dry and Wet Conditions

Objective

The aim of this study was to assess the effectiveness and reliability of magnification, DIAGNOdent in detection of smooth surface white spot lesions.

Study design

Three hundred children aged 5–10 years were examined by two examiners for presence of smooth surface white spot lesions using naked eye and magnifying loupes in wet and dry conditions followed by DIAGNOdent analysis. Data was analysed using Cohen's kappa coefficient, Friedman test and Paired t test. Accuracy was assessed by sensitivity and positive predicted values.

Results

Significant difference was found between naked eyes and magnifying loupes with and without air drying. While insignificant difference was found between DIAGNOdent and loupes.

Conclusion

Magnifying loupes with air drying is an effective method in detection of smooth surface white spot lesion.

Clinical significance

With the increased knowledge about the pathogenesis of dental caries and its ability to be remineralisable if detected early, makes it all the more important for the clinician to be vigilant in detection of early lesion to prevent the avoidable restorative approach for the same. Incorporation of magnification to routine dental examination by general dentist can help in early diagnosis and treatment of dental decay. This could prevent further progression of dental caries and reduces the incidence of tooth decay

How to cite this article

Gupta N, Sandhu M, et al. Comparison of Visual Examination and Magnification with DIAGNOdent for Detection of Smooth Surface Initial Carious Lesion—Dry and Wet Conditions. Int J Clin Pediatr Dent 2019;12(1):37–41.

Split-mouth Randomised Clinical Trial on the Efficacy of GIC Sealant on Occlusal Surfaces of Primary Second Molar

PURPOSE

To evaluate the clinical performance of high viscosity GIC sealant applied with or without additional light curing in children with early childhood caries (ECC).

MATERIALS AND METHODS

A split-mouth clinical trial was conducted in a total of 111 3- to 5-year-old children with ECC. 180 pairs of non-carious primary second molars were selected and divided into two groups: study and control. On the basis of the application technique, selected teeth in the study group were further allotted to group A (sealant application with additional light curing) and group B (sealant application without additional light curing). Caries incidence was observed for 1 year in the anatomical pits and grooves, along with sealant retention and marginal discolouration at various intervals over the 1-year period.

RESULTS

Group A (GIC sealant with additional light curing) (44.2%) showed sealant retention similar to that of group B (GIC sealant without additional light curing) (43.0%) (p = 0.885). Caries incidence was significantly higher in the control group (26%) than the sealant groups (1%) (p < 0.001). No marginal discolouration adjacent to the sealant was observed in either anatomical grooves or pits in both sealant groups for the duration of the study.

CONCLUSION

Retention and caries prevention by high-viscosity GIC sealant applied with or without additional light curing was found to be similar. At the 12-month assessment, mean dmfs scores and caries incidence in primary second molars were higher in the control than in both study groups.

Emerging Understanding of Emotional Intelligence of Teenagers

Aim

Emotional intelligence (EI) is the ability to use emotions effectively and productively. It is becoming increasingly clear that these skills are one of the primary foundations for better performance of students in classrooms and in the society as well and EI provides the basis for competencies important "in almost every job." So we accessed the EI of teenagers as a guide of their academic score.

Study design

We analyzed the correlation of academic score to the EI of teenagers in regular schools and part-time unconventional coaching institute using the Bar-On Emotional Quotient questionnaire.

Results and conclusion

The results of our study showed that empathy and self-actualization were highly developed in students of regular conventional school than those attending part-time unconventional coaching institute. The academic score had a significantly positive correlation with empathy, whereas a significantly negative correlation with interpersonal relations. Empathy, interpersonal relation, and impulsive control were significantly higher in females than males. Therefore by inculcating and working toward development of EI in the young generation, we can hope to achieve a more positive environment.

How to cite this article

Sekhri P, Sandhu M, Sachdev V. Emerging Understanding of Emotional Intelligence of Teenagers. Int J Clin Pediatr Dent 2017;10(3):289-292.

Evaluation of Remineralization Potential of Beverages modified with Casein Phosphopeptide-Amorphous Calcium Phosphate on Primary and Permanent Enamel: A Laser Profiler Study

Purpose

To assess the erosive potential of carbonated beverages and the remineralization potential of beverages with added casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) paste on primary and permanent enamel.

Materials and methods

A total of 32 primary and 32 permanent enamel specimens were immersed for 5, 10, and 30 minutes, respectively, in beverages, i.e., Coke, Sprite, Mirinda, and Mountain Dew, with and without added 0.2% CPP-ACP. Samples were profiled before immersion and after immersion under laser profiler.

Results

Coke was found to be highly erosive at it caused significant enamel erosion at both 10 and 30 minutes of immersion (p < 0.05) for both primary and permanent enamel. The 30-minute immersion caused significant amount of reminerali-zation over primary enamel in all groups, whereas permanent enamel remineralization was significant in Sprite and Mountain Dew at 30 minutes in all the groups (p < 0.05).

Conclusion

This study demonstrated that enamel erosion occurred after immersion in carbonated beverages. Remineralization of enamel was observed after immersion in beverages modified with CPP-ACP paste. Primary enamel was susceptible to remineralization compared with permanent enamel. Within the limitations of this in vitro study, the application of CPP-ACP paste may enhance the remineralization after an erosive challenge and thus offer some protection for patients who are at risk for erosion.

How to cite this article: Rai N, Sandhu M, Sachdev V, Sharma R. Evaluation of Remineralization Potential of Beverages modified with Casein Phosphopeptide-Amorphous Calcium Phosphate on Primary and Permanent Enamel: A Laser Profiler Study. Int J Clin Pediatr Dent 2018;11(1):7-12.

The effect of different root canal sealers on the fracture resistance of endodontically treated teeth-in vitro study

Background:

The aim of this study was to compare the in vitro effects of four different root canal sealers on the fracture resistance of endodontically treated teeth.

Materials and Methods:

Seventy-five freshly extracted human mandibular premolars were used for the study. Teeth were divided into five groups based on type of root canal sealers used. Gutta-percha was used for all the samples: Group I: AH Plus root canal sealer, Group II: MTA Fillapex root canal sealer, Group III: Apexit root canal sealer, Group IV: Conventional zinc oxide-eugenol (ZOE) sealer, Group V: Control (unobturated teeth). The teeth were embedded in acrylic resin blocks and fracture force was measured using a universal testing machine (Asian Test Equipments). Data obtained were statistically evaluated using one-way ANOVA and post hoc test (Tukey's test). All groups showed statistically significant result (P < 0.05).

Results:

Group I and Group II showed higher resistance to fracture than other three groups. There was comparable difference in fracture force between Group I and Group II. Moreover, there was no statistically significant difference between Group III and Group IV and between Group IV and Group V.

Conclusion:

Based on this in vitro study, resin-based sealer was more effective as compared to other sealers and the control group. However, no significant differences were observed between ZOE and control group.

Early Eruption of Maxillary Pre Molar with Turner's Hypoplasia in a 5-Year-Old Boy

Early eruption of permanent maxillary premolar appears to be a unique finding, at such an early chronological age. Untimely eruption of permanent maxillary premolar is discussed in a 5-year-old male patient. On intra oral examination grossly carious primary maxillary first molar (tooth number 54,64) were reported. The erupting teeth presented with a hypomineralized cusp tip. Extraction following space maintainer in 64 region was given. Pediatric dentist should consider these kinds of rarities in eruption pattern while examining a pediatric patient.

Collaborative meta-analysis of individual participant data from observational studies of Lp-PLA2 and cardiovascular diseases

BACKGROUND

A large number of observational epidemiological studies have reported generally positive associations between circulating mass and activity levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) and the risk of cardiovascular diseases. Few studies have been large enough to provide reliable estimates in different circumstances, such as in different subgroups (e.g., by age group, sex, or smoking status) or at different Lp-PLA2 levels. Moreover, most published studies have related disease risk only to baseline values of Lp-PLA2 markers (which can lead to substantial underestimation of any risk relationships because of within-person variability over time) and have used different approaches to adjustment for possible confounding factors.

OBJECTIVES

By combination of data from individual participants from all relevant observational studies in a systematic 'meta-analysis', with correction for regression dilution (using available data on serial measurements of Lp-PLA2), the Lp-PLA2 Studies Collaboration will aim to characterize more precisely than has previously been possible the strength and shape of the age and sex-specific associations of plasma Lp-PLA2 with coronary heart disease (and, where data are sufficient, with other vascular diseases, such as ischaemic stroke). It will also help to determine to what extent such associations are independent of possible confounding factors and to explore potential sources of heterogeneity among studies, such as those related to assay methods and study design. It is anticipated that the present collaboration will serve as a framework to investigate related questions on Lp-PLA2 and cardiovascular outcomes.

METHODS

A central database is being established containing data on circulating Lp-PLA2 values, sex and other potential confounding factors, age at baseline Lp-PLA2 measurement, age at event or at last follow-up, major vascular morbidity and cause-specific mortality. Information about any repeat measurements of Lp-PLA2 and potential confounding factors has been sought to allow adjustment for possible confounding and correction for regression dilution. The analyses will involve age-specific regression models. Synthesis of the available observational studies of Lp-PLA2 will yield information on a total of about 15 000 cardiovascular disease endpoints.

Shear Bond Strength of Self-etching Adhesives to Cavities Prepared by Diamond Bur or Er,Cr:YSGG Laser and Effect of Prior Acid Etching

PURPOSE

To compare and evaluate shear bond strength of self-etching adhesives bonded to cavities prepared by diamond bur or Er,Cr:YSGG laser and the effect of prior acid etching on shear bond strength.

MATERIALS AND METHODS

Ninety-six caries-free human premolars were selected and divided into 2 groups depending on mode of cavity preparation (48 teeth each). Cavities were prepared with Er,Cr:YSGG laser in group 1 and diamond burs in an air-turbine handpiece in group 2. Groups 1 and 2 were further subdivided into three subgroups of 8 teeth each, which were bonded with sixth- or seventh-generation adhesives with or without prior acid etching, followed by restoration of all samples with APX Flow. These samples were subjected to shear bond strength testing. In addition, the surface morphology of 24 samples each from groups 1 and 2 was evaluated using SEM. Data were analyzed using the Shapiro-Wilk test, one- and two-way ANOVA, the t-test, and the least significant difference test, which showed that the data were normally distributed (p > 0.05).

RESULTS

The shear bond strength of adhesives in cavities prepared by Er,Cr:YSGG laser was significantly higher than in diamond bur-prepared cavities (p < 0.05). SEM analysis showed a smear-layer-free anfractuous surface on laser-ablated teeth, in contrast to conventional bur-prepared teeth.

CONCLUSIONS

The Er,Cr:YSGG laser-ablated surface proved to be more receptive for adhesion than those prepared by diamond bur irrespective of the bonding agent used. Seventh-generation adhesives yielded higher shear bond strength than did sixth-generation adhesives. Prior acid etching decreased the shear bond strength of self-etching adhesives.

Double-Blind Crossover Study to Compare Pain Experience During Inferior Alveolar Nerve Block Administration Using Buffered Two Percent Lidocaine in Children

PURPOSE

Buffering of anesthetic solutions has been suggested to reduce pain on injection and onset of anesthesia. The purpose of this study was to assess the reduction in pain on injection during inferior alveolar nerve block administration in children.

METHODS

A double blind crossover study was designed where 30 six- to 12-year-old patients received two sessions of inferior alveolar nerve block scheduled one week apart. Two percent lidocaine with 1:200,000 epinephrine was given during one appointment, and a buffered solution was given during the other. Pain on injection was assessed using the sound, eye, and motor (SEM) scale, and the time to onset was assessed after gingival probing. The Heft-Parker visual analogue scale (HP-VAS) was self recorded by the patient after administration of local anesthesia.

RESULTS

When tested using Mann-Whitney analysis, no significant differences were found between the SEM scores (P=0.71) and HP-VAS scores (P=0.93) for the two solutions used. Student's t test was used to assess the difference in the onset of anesthesia, which was also found to be statistically insignificant (P=0.824).

CONCLUSION

Buffered lidocaine did not reduce the pain on injection or time to onset of anesthesia for inferior alveolar nerve block in children.

Comparative Evaluation of Obturating Techniques in Primary Teeth: An in vivo Study

Aim: The present study was undertaken to compare two methods of obturation in primary teeth by using lentulospirals and pressure syringe, radiographically.

Materials and methods: Sixty teeth in subjects with mean age of 5.88 ± 1.58 years were obturated randomly using two different obturating techniques, i.e. group I: Thirty teeth obturated with pressure syringe, and group II: Thirty teeth obturated with lentulospiral. Quality of obturation and presence or absence of voids were assessed by taking radiographs after obturation was done using both the techniques. Results of quality of obturation were statistically analyzed using Chi-square test and Mann-Whitney’s test, whereas voids were analyzed using Chi-square test.

Results: No statistically significant difference between the quality of obturation using pressure syringe or lentulospiral (p > 0.05) was observed. However, significantly higher number of voids were found for lentulospiral technique as compared to pressure syringe (p < 0.01).

Conclusion: Both the techniques were found to be equally efficient statistically, though lentulospiral produced more voids.

How to cite this article: Vashista K, Sandhu M, Sachdev V. Comparative Evaluation of Obturating Techniques in Primary Teeth: An in vivo Study. Int J Clin Pediatr Dent 2015;8(3): 176-180.

An in-vitro evaluation of the effect of 980 nm diode laser irradiation on intra-canal dentin surface and dentinal tubule openings after biomechanical preparation: Scanning electron microscopic study

Context:

Very recently, diode laser has been used for disinfecting the root canals in endodontic treatment and increasing its success rate and longevity utilizing the thermal effect of laser on surrounding tissues.

Aims:

The aim of this study is to evaluate the effect of 980 nm laser irradiation on intra-canal dentin surface – scanning electron microscopic (SEM) - in-vitro study.

Methods:

A total of 40 single-rooted freshly extracted permanent teeth were collected. Teeth were sectioned at the cemento-enamel junction using diamond disc. Root canals of all samples were prepared using hand ProTaper, which were randomly assigned into two groups (n = 20 each). Group 1: Receiving no treatment after biomechanical preparation; Group 2: 980 nm diode laser-treated root canals. Teeth were prepared for SEM analysis to check the size of intra-canal dentinal tubule openings.

Statistical Analysis Used:

Data were analyzed using SPSS V.16 software and compared using Levene's and independent t-test.

Results:

On statistical analysis, width of intracanal dentinal tubule openings in Group 1 (control) was significantly higher than those observed in Group 2 (diode laser-treated) (P < 0.001).

Conclusion:

This study showed that the application of 980 nm diode laser on intra-radicular dentin resulted in ultrastructural alterations resulting in melting of dentin.

A comparative evaluation of dermatoglyphics in different classes of malocclusion

Aim

To study associations of dermatoglyphic features with malocclusion in Indian children.

Materials and methods

A total of 237 children aged 12–16 years, who attended our outpatient clinic in a government medical college, were selected. Finger and palm prints were collected, and fingertip pattern frequencies, total ridge counts (TRCs), and atd angles (formed by the triradii below the first and last digits and that in the hypothenar region of the palm) were calculated. These parameters were analyzed with their Angle’s class of malocclusion using appropriate statistical tests. Dermatoglyphic parameters were examined and asymmetry analysis was conducted in subjects with different occlusion patterns.

Results

Although no fingerprint pattern was found to be specific for a particular class of occlusion, increased tendencies toward high frequencies of whorls in subjects with class II malocclusion and plain arches in those with class III malocclusion were observed. Significant differences in atd angle and TRC were observed among malocclusion types (p = 0.0001). Asymmetry scores did not differ significantly.

Conclusion

Dermatoglyphic analysis can be used as an indicator of malocclusion at an early age, thereby aiding the development of treatments aiming to establish favorable occlusion. Inheritance and twin studies, as well as those conducted in different ethnic groups, are required to examine these relationships further.

A Comparative Study of Biodegradation of Nickel and Chromium from Space Maintainers: An in vitro Study

Objective: The aim of the study was to compare and evaluate the in vitro biodegradation of nickel and chromium from space maintainers, made of three different companies, i.e (Dantaurum, Rocky mountain and Dtech) in artificial saliva.

Materials and methods: The study comprised of 30 space maintainers out of which 10 were fabricated using Dantaurum, 10 using Rocky mountain and 10 using Dtech band materials. Stainless steel wire (Dantaurum, Rocky mountain and Konark) was used for making loops and Leone solder and flux was used for soldering. Each group was further divided into four subgroups containing 1, 2, 3 and 4 space maintainers respectively. The space maintainers in each subgroup were placed in separate glass beakers containing 100 ml of artificial saliva at 37°C for 4 weeks. Salivary samples from each beaker was analyzed for nickel and chromium ions separately on days 1, 7, 14, 21 and 28 days using inductively coupled plasma-optical emission spectrophotometer.

Results: Total release of nickel and chromium from all band and loop space maintainers ranged from 0.020 to 1.524 ppm and 0.002 to 0.289 ppm respectively. The release of nickel and chromium between the groups and within the groups was not significant (p < 0.5).

Conclusion: There was no substantial release of nickel and chromium from space maintainers made of Dantaurum, Rocky mountain and Dtech which could cause any toxicity.

How to cite this article: Anand A, Sharma A, Kumar P, Sandhu M, Sachdeva S, Sachdev V. A Comparative Study of Biodegradation of Nickel and Chromium from Space Maintainers: An in vitro Study. Int J Clin Pediatr Dent 2015; 8(1):37-41.

Correlation between dental caries experience and mutans streptococci counts using saliva and plaque as microbial risk indicators in 3-8 year old children. A cross Sectional study

OBJECTIVES

Determination of the relative amounts of mutans streptococcus in both saliva and plaque and to study its correlation with dental caries in children.

STUDY DESIGN

The study comprised of 60 children aged 3-8 years divided into 2 groups (30 children in each): Group A- Children with more than 4 carious teeth and Group B- Children without caries. Saliva and plaque was collected from children of both the groups with the help of Dentocult SM strip test kit (Orion Diagnostic). Following incubation, mutans streptococcus scores (from 0 to 3) in each individual was evaluated and compared between both the groups.

RESULTS

On comparing the two groups, mean ± SD of saliva score and plaque score was 2.40 ± 0.675 and 2.40 ± 0.621 respectively in group A, whereas it was 0.60 ± 0.498 and 0.83 ± 0.531 in children of group B showing a significant correlation (p = < 0.001) between mutans streptococci scores in both saliva and plaque and dental caries experience.

CONCLUSIONS

There is a direct and strong co-relation between the salivary and plaque mutans streptococcus counts and caries activity in children aged 3-8 years. Key words:Mutans streptococci, dentocult, dental caries.

Targeting HER3 by interfering with its Sec61-mediated cotranslational insertion into the endoplasmic reticulum

There is increasing evidence implicating HER3 in several types of cancer. But the development of targeted therapies to inactivate HER3 function has been a challenging endeavor. Its kinase domain functions in allostery not catalysis, and the classical ATP-analog class of tyrosine kinase inhibitors fail to inactivate it. Here we describe a novel approach that eliminates HER3 expression. The small-molecule cotransin CT8 binds the Sec61 translocon and prevents the signal peptide of the nascent HER3 protein from initiating its cotranslational translocation, resulting in the degradation of HER3 but not the other HER proteins. CT8 treatment suppresses the induction of HER3 that accompanies lapatinib treatment of HER2-amplified cancers and synergistically enhances the apoptotic effects of lapatinib. The target selectivities of cotransins are highly dependent on their structure and the signal sequence of targeted proteins and can be narrowed through structure-function studies. Targeting Sec61-dependent processing identifies a novel strategy to eliminate HER3 function.

Supraclavicularis proprius muscle associated with supraclavicular nerve entrapment

Entrapment neuropathy of the supraclavicular nerve is rare and, when it occurs, is usually attributable to branching of the nerve into narrow bony clavicular canals. We describe another mechanism for entrapment of this nerve with the aberrant muscle; supraclavicularis being found during the routine dissection of an embalmed 82-year-old cadaver. Our report details a unique location for this rare muscular variation whereby the muscle fibres originated posteriorly on the medial aspect of the clavicle before forming a muscular arch over the supraclavicular nerve and passing laterally towards the trapezius and acromion. We recommend that in clinical instances of otherwise unexplained unilateral clavicular pain or tenderness, nerve compression from the supraclavicularis muscle must be borne in mind.

Circular enamel hypoplasia: a rare enamel developmental disturbance in permanent teeth

Circular enamel hypoplasia, a type of enamel hypoplasia is an extensive enamel disturbance that results in a demarcating line surrounding the crown of the injured teeth visible both clinically and radiographically that most frequently occurs as a result of trauma in children around the age of two years. Clinical features include poor aesthetics, dentin sensitivity, increased susceptibility to dental caries and malocclusion. Early radiographic diagnosis of such teeth is important for timely intervention and subsequent treatment.

Bayesian methods for meta-analysis of causal relationships estimated using genetic instrumental variables

Genetic markers can be used as instrumental variables, in an analogous way to randomization in a clinical trial, to estimate the causal relationship between a phenotype and an outcome variable. Our purpose is to extend the existing methods for such Mendelian randomization studies to the context of multiple genetic markers measured in multiple studies, based on the analysis of individual participant data. First, for a single genetic marker in one study, we show that the usual ratio of coefficients approach can be reformulated as a regression with heterogeneous error in the explanatory variable. This can be implemented using a Bayesian approach, which is next extended to include multiple genetic markers. We then propose a hierarchical model for undertaking a meta-analysis of multiple studies, in which it is not necessary that the same genetic markers are measured in each study. This provides an overall estimate of the causal relationship between the phenotype and the outcome, and an assessment of its heterogeneity across studies. As an example, we estimate the causal relationship of blood concentrations of C-reactive protein on fibrinogen levels using data from 11 studies. These methods provide a flexible framework for efficient estimation of causal relationships derived from multiple studies. Issues discussed include weak instrument bias, analysis of binary outcome data such as disease risk, missing genetic data, and the use of haplotypes.

Autoimmune hypothyroidism protects against breast cancer development in the elderly

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Background: An association between breast cancer and autoimmune hypothyroidism has been suggested. While a biological role for thyroid hormone in breast tumorigenesis has been demonstrated in vitro, epidemiological evidence is lacking. Methods: A retrospective, population-based cohort study was conducted to examine the risk of postmenopausal breast cancer (BRCA) in women with or without autoimmune hypothyroidism, identified on the basis of prescriptions for levothyroxine (LT4). Administrative health records were used to capture information on all women aged 66 and older living in Ontario, Canada at baseline (April 1, 1993 to March 31, 1996) and during a 10-year follow up. Propensity scores were used to create a matched cohort of LT4 and non-LT4 users. Cox proportional hazards modeling was used to evaluate the impact of LT4 use on the 5-year incidence of BRCA and benign breast disease, and on all-cause mortality rates among women diagnosed with breast cancer during follow-up. Results: LT4 users (N=89,093) and non-LT4 users (N=89,093) were well-matched with respect to baseline sociodemographics, estrogen use, comorbidity, and health care utilization, including the likelihood of receiving mammography or a breast biopsy. The 5-year incidence of BRCA was 0.86% in LT4 users compared to 0.97% in non-LT4 users (p=0.002). Adjustment for baseline characteristics did not alter these results (hazard ratio [HR] 0.86; 95% confidence interval [CI] 0.77–0.95; p= 0.004). Among women who developed BRCA, all cause mortality was significantly lower in LT4 users than in non-users (43.9% vs. 56.1%; adjusted HR 0.82; 95% CI 0.70–0.96; p= 0.01). The incidence of benign breast disease did not vary between groups. Conclusions: Elderly women with autoimmune hypothyroidism appeared to have a protective advantage in the incidence of BRCA and in mortality following a breast cancer diagnosis. These results suggest a biological role for thyroid hormone in the development of breast cancer, with a modulating effect of treated autoimmune hypothyroidism in promoting a less aggressive disease course. Further studies exploring the effect of thyroid hormone in breast cancer development are needed and may uncover novel therapeutic targets in the management of breast cancer in the future.

No significant financial relationships to disclose.

Role of duplex Doppler and power Doppler sonography in transplanted kidneys with acute renal parenchymal dysfunction

The limited work published on the comparison of power Doppler sonography (PDS) and duplex Doppler sonography (DDS) in the assessment of acute renal allograft dysfunction has shown contradictory results. We compared the role of DDS and PDS in renal transplant recipients developing acute renal parenchymal dysfunction and correlated these findings with kidney biopsy, which was taken as the gold standard. Thirty post-renal transplant patients with acute graft dysfunction underwent Doppler sonography, DDS and PDS using an HDI 5000 ATL machine. Patients who developed graft dysfunction as a result of vascular, obstructive or other non-parenchymal causes were excluded. All patients underwent an allograft biopsy within 72 h of the sonography. Based on the biopsy findings, 24 patients were categorized as having acute rejection, and six patients as having no rejection. The overall sensitivity, specificity and accuracy of DDS for evaluation of graft dysfunction were 54.17, 33.33, and 50.00%, respectively, and that for PDS were superior with 87.50, 33.30, and 76.67%, respectively. The low specificity can be partially attributed to the small number of cases without rejection in our study population. We conclude that PDS is superior to DDS in screening patients with acute parenchymal renal dysfunction post-transplant. However, a normal PDS examination does not exclude the presence of acute rejection. Power Doppler sonography is a useful screening test for diagnosing acute rejection but a renal allograft biopsy remains the gold standard for diagnosis of this condition.

Twenty-year comparison of tissue and mechanical valve replacement

OBJECTIVE

We sought to compare outcomes with tissue and St Jude Medical mechanical valves over a 20-year period.

METHODS

Valve-related events and overall survival were analyzed in 2533 patients 18 years of age or older undergoing initial aortic, mitral, or combined aortic and mitral (double) valve replacement with a tissue valve (Hancock, Carpentier-Edwards porcine, or Carpentier-Edwards pericardial) or a St Jude Medical mechanical valve. Total follow-up was 13,390 patient-years. There were 666 St Jude Medical aortic valve replacements, 723 tissue aortic valve replacements, 513 St Jude Medical mitral valve replacements, 402 tissue mitral valve replacements, 161 St Jude Medical double valve replacements, and 68 tissue double valve replacements. The mean age was 68 +/- 13.3 years (St Jude Medical valve, 64.5 +/- 12.9; tissue valve, 72.0 +/- 12.6).

RESULTS

There were no overall differences in survival between tissue and mechanical valves. Multivariable analysis indicated that the type of valve did not affect survival. Analysis by age less than 65 years or 65 years or older and presence or absence of coronary disease revealed similar long-term survival in all subgroups. The risk of hemorrhage was lower in patients receiving tissue aortic valve replacements but was not significantly different in patients receiving mitral valve or double valve replacements. Thromboembolism rates were similar for tissue and mechanical valve recipients. However, reoperation rates were significantly higher in patients receiving both aortic and mitral tissue valves. The reoperation hazard increased progressively with time both in patients receiving aortic and in those receiving mitral tissue valves. Overall valve complications were initially higher with mechanical aortic valves but not with mechanical mitral valves. However, valve complication rates later crossed over, with higher rates in tissue valve recipients after 7 years in patients undergoing mitral valve replacement and 10 years in those undergoing aortic valve replacement.

CONCLUSIONS

Tissue and mechanical valve recipients have similar survival over 20 years of follow-up. The primary tradeoff is an increased risk of hemorrhage in patients receiving mechanical aortic valve replacements and an increased risk of late reoperation in all patients receiving tissue valve replacements. The risk of tissue valve reoperation increases progressively with time.

Heart transplantation in patients seventy years of age and older: A comparative analysis of outcome

OBJECTIVE

Advanced age has traditionally been considered a contraindication for heart transplantation because of the reported adverse effect of increased age on long-term survival. However, as the field of transplantation continues to evolve, the criteria regarding the recipient's upper age limit have been expanded and older patients are being considered as potential candidates. We analyzed the outcome of heart transplantation in patients 70 years of age and older and compared these results with those in younger patients (<70 years) over a 4-year period.

METHOD

We retrospectively analyzed the results of 15 patients 70 years of age and older who underwent heart transplantation between November 1994 and May 1999 and compared them with results in 98 younger patients undergoing transplantation during the same period

RESULTS

The older age group had a higher preoperative left ventricular ejection fraction (P =.02), higher incidence of female donors (P =.02), and longer cardiac allograft ischemic time (P =.01). No differences were found regarding incidence of diabetes mellitus, donor age, donor/recipient weight ratio, and mismatch (<0.80). The 30-day or to-discharge operative mortality was similar in both groups (0% in the older vs 5.1% in younger patients). Actuarial survival at 1 year and 4 years was not statistically different between the older and younger patients (93.3% +/- 6.4% vs 88.3% +/- 3.3% and 73.5% +/- 13.6% vs 69.1% +/- 5.8%, respectively). The length of intensive care unit stay and total post-transplantation hospital stay, incidence of rejection, and incidence of cytomegalovirus infection were similar between the groups.

CONCLUSIONS

Heart transplantation in selected patients 70 years of age and older can be performed as successfully as in younger patients (<70 years of age) with similar morbidity, mortality, and intermediate-term survival. Advanced age as defined (> or =70 years) should not be an exclusion criterion for heart transplantation. The risks and benefits of transplant surgery should be applied individually in a selective fashion.

Can peer-comparison feedback improve patient functional status?

OBJECTIVE

To determine whether providing physicians with peer-comparison feedback can improve patient functional status.

STUDY DESIGN

Randomized, controlled, comparative study.

METHODS

Forty-eight primary care physicians at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California, were randomly assigned to an intervention group or a control group. All physicians were informed that their elderly patients (randomly selected patients aged 65 to 75) would be monitored. Physicians in the intervention group received aggregated peer-comparison feedback data (physician "report cards") on the functional status of their elderly patients. Physicians in the control group received only general information that their patients' functional status would be monitored. The effect of the intervention on patients' functional status was determined by comparing responses to surveys completed by the patients at baseline and after the intervention.

RESULTS

Patients in both the control and intervention groups had a statistically significant decrease in functional status, including decreases in their ability to complete daily activities and increases in pain. In addition, patients in the control group reported a significant decrease in social activities, physical fitness, and feelings. In the intervention group, patients also experienced a significant decrease in social support.

CONCLUSIONS

Educational interventions, including peer-comparison feedback, did not result in improvements in patient functional status. Research is desperately needed to identify interventions that can lead to improved health for elderly patients.

Physician education and report cards: do they make the grade? results from a randomized controlled trial

PURPOSE

We sought to determine whether tailored educational interventions call improve the quality of care, as measured by the provision of preventive care services recommended by the US Preventive Services Task Force, as well as lead to better patient satisfaction.

SUBJECT AND METHODS

We performed a randomized controlled study among 41 primary care physicians who cared for 1,810 randomly selected patients aged 65 to 75 years old at Kaiser Permanente Woodland Hills, a group-model health maintenance organization in southern California. All physicians received ongoing education. Physicians randomly assigned to the comprehensive intervention group also received peer-comparison feedback and academic detailing. Baseline and postintervention (2 to 2.5 years later) surveys examining the provision of preventive care and patient satisfaction were performed and medical records were reviewed.

RESULTS

Based on the results of patient surveys, there were significant improvements over time in the provision of preventive care in both the education and the comprehensive intervention groups for influenza immunization (79% versus 89%, P <0.01, and 80% versus 91%, P <0.01), pneumococcal immunization (42% versus 73%, P < 0.01 and 34% versus 73%, P < 0.01), and tetanus immunization (64% versus 72%, P <0.01, and 59% versus 79%, P <0.01). Mammography (90% versus 80%, P <0.01) and clinical breast examination (85% versus 79%, P <0.05) scores worsened in the education only group but not in the comprehensive intervention group. However, there were few differences in rates of preventive services between the groups at the end of the study, and the improvements in preventive care were not confirmed by medical record review. Patient satisfaction scores improved significantly in the comprehensive intervention group (by 0.06 points on a 1 to 5 scale, P = 0.02) but not in the education only group (by 0.02 points, P = 0.42); however, the improvement was not significantly greater in the comprehensive intervention group (P = 0.20).

CONCLUSION

A physician-targeted approach of education, peer-comparison feedback, and academic detailing has modest effects on patient satisfaction and possibly on the offering of selected preventive care services. The lack of agreement between patient reports and medical records review raises concerns about current methods of ascertaining compliance with guidelines for preventive care.

Actual failure rates: A method of assessing tissue valve reoperation rates

BACKGROUND

Patients older than age 70 with coronary disease undergoing mitral valve replacement have a limited survival rate, suggesting that few of these patients will require reoperation if they receive a tissue mitral valve. However, traditional actuarial analysis of valve durability censors patients who die before valve failure and doesn't reflect the lower frequency of reoperation in patient subgroups with limited survival rates.

METHODS

Actual or cumulative reoperation rates represent the rates of reoperation in patients without censoring for death and estimate the risk that the valve will fail before the patient dies. The actual rates of valve rereplacement were determined in 255 recipients of tissue mitral valves, categorizing patients by age and presence of coronary artery disease at 8 years after surgery and compared with standard actuarial estimates of valve durability.

RESULTS

Operative mortality rates were 17.5% for patients with coronary artery disease and 6.0% for those without (P <.001). At 8 years, the actual reoperation rates for patients younger than age 70 with and without coronary artery disease were 9.2% (n = 76) and 10% (n = 90), respectively. In patients older than age 70 without coronary artery disease the reoperation rate was 9.4% (n = 32). In contrast, the actual reoperation rate was only 1.7% (n = 58) in patients older than age 70 with coronary artery disease. This rate was significantly lower (P =.05) than the other groups. The difference in reoperation rates was not significant if standard actuarial analysis was used.

CONCLUSIONS

Actual reoperation rates are significantly lower in patients older than 70 years with CAD receiving mitral tissue valves than in younger patients or in patients without coronary artery disease. Calculation of actual reoperation rates provides a unique and clinically useful perspective in evaluating data on prosthetic valve reoperation rates.

Cardiac reoperations in octogenarians: analysis of outcomes

BACKGROUND

With the rapid growth of the elderly segment of the population, more octogenarians are referred for complex cardiac interventions, including reoperations. Data regarding the outcomes, quality of life, and long-term results after reoperative open-heart surgical procedures in octogenarians are scarce.

METHODS

We retrospectively studied 113 consecutive octogenarians (mean age, 83+/-2.6 years) who underwent reoperative cardiac procedures within a 13-year period. Coronary artery bypass grafting (CABG) was performed in 49 patients (CABG group), valvular procedures (aortic, mitral, or tricuspid valve, alone or in combination) in 35 (valve group), and combined CABG and valve intervention in 29 (combined CABG and valve group).

RESULTS

The 30-day mortality rate was 8% (4 of 49) for the CABG group, 9% (3 of 35) for the valve group, and 17% (5 of 29) for the combined CABG and valve group. One- and 5-year actuarial survival rates were, respectively, 85%+/-5% and 58%+/-10% for the CABG group, 78%+/-7% and 53%+/-12% for the valve group, and 69%+/-9% and 63%+/-10% for the combined CABG and valve group. Sixty-one percent of patients in the CABG group, 40% in the valve group, and 38% in the combined CABG and valve group were in New York Heart Association class I or II postoperatively at a mean follow-up time of 2.1+/-2.4 years. Similarly, 91%, 85%, and 80%, respectively, thought that they had an improved quality of life and were satisfied with their functional status.

CONCLUSIONS

Cardiac reoperations can be performed successfully in most octogenarians, although with an increased risk, particularly in the combined CABG and valve group. Long-term survival is acceptable with improved quality of life and functional status. However, it is possible that these results could be improved in this high-risk group of patients with earlier referral and surgical intervention, for the effective use of health care resources.

A prospective, multicenter study of a pneumonia practice guideline

OBJECTIVE

To study the effect of a length of stay practice guideline on patient outcomes.

DESIGN

A prospective, nonrandomized, interventional trial.

SETTING

Six geographically distributed hospitals.

PATIENTS

Two hundred forty-two consecutively hospitalized "low-risk" patients with pneumonia.

MEASUREMENTS AND RESULTS

One hundred fifty-two patients (63%) completed the mailed postdischarge survey and were included in the analysis. Data were prospectively collected for 85 patients from the baseline observation period (B) and 67 patients from the intervention period (I). During the I, case managers provided physicians with patient risk information based on guideline recommendations. There was no significant change in guideline compliance (B vs I: 76.5% vs 83.6%; p=0.32) or length of stay (B vs I: 3.5 days [95% confidence interval, 3.2 to 3.8] vs 3.6 days [95% confidence interval, 3.3 to 4.0]). Also, there were no statistically significant effects of the intervention on patient outcomes, care following hospital discharge, and patient satisfaction scores.

CONCLUSION

Patients in this study often had shorter lengths of stay than recommended by the practice guideline. This suggests that the external environment may have had a greater effect on physician behavior and length of stay than the practice guideline itself. Moreover, it demonstrates the importance of continuous assessment of physician practices immediately prior to, during, and after application of the clinical practice guideline.

Can practice guidelines safely reduce hospital length of stay? Results from a multicenter interventional study

BACKGROUND

Although practice guidelines about appropriate lengths of stay have been widely promulgated, their effects on patient outcomes are not clear. Our objective was to study the effects of length of stay practice guidelines on patient outcomes.

PATIENTS AND METHODS

We performed a prospective, nonrandomized, interventional trial in six geographically distributed hospitals, among consecutively hospitalized "low-risk" patients with total hip replacement, hip fracture, or knee replacement. Case managers provided physicians with patient risk information based on guideline recommendations. We measured length of stay, compliance with recommended guideline length of stay, health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction.

RESULTS

A total of 560 patients were included in the study. For patients with knee replacement, there was a statistically significant increase in practice guideline compliance (27% baseline versus 53% intervention, P <0.0001) and reduction in length of stay (5.2 days versus 4.6 days, P <0.001) when compared with the baseline period. For hip replacement patients, there similarly was an increase in practice guideline compliance (66% baseline versus 82% intervention, P = 0.01) and reduction in length of stay (5.1 days versus 4.8 days, P = 0.03). Significant reductions in length of stay were not observed for patients recovering after hip fracture despite a significant increase in guideline compliance. There were few statistically significant changes in patient outcomes related to reductions in lengths of stay, including health status, hospital readmission rates, return to emergency department, return to work and recreation, and patient satisfaction. For patients undergoing hip replacement, very short lengths of stay (shorter than the guideline recommendation) were associated with an increased rate of discharging patients to nursing homes and rehabilitation facilities (21% versus 7%, P = 0.01), and hip fracture patients with very short lengths of stay required more visits to the doctor after discharge (56% versus 25%, P = 0.04).

CONCLUSION

Reductions in lengths of stay were most often associated with no significant change in patient outcomes. However, very short lengths of stay were associated with increased intensity of care following discharge for patients undergoing hip surgery, indicating possible cost shifting (the cost incurred by transferring patients to rehabilitation facilities may have been greater than had the patients remained in the acute care hospital for an additional 1 or 2 days and been sent directly home). These results emphasize the importance of monitoring the effects of cost containment and other systematic efforts to change patient care at the local level.

Physicians' changing attitudes toward guidelines

The objective of the study was to measure the change in physicians' attitudes toward preventive care guidelines over a 2-year period. The study was conducted at a Southern California managed care medical group that was experiencing intense price competition. We analyzed individualized survey responses of 62 HMO primary care physicians over the study period. We found that physicians increasingly believed that clinical guidelines were being used for cost containment (first survey 71% vs second survey 92%, p < .005) and less for quality improvement (first survey 85% vs second survey 67%, p < .008) over time. These findings may create a barrier to physicians' adoption of practice guidelines.

Role of transabdominal pelvic ultrasound and computed tomography in the detection of bladder involvement in advanced cancer of the cervix

The imaging data of 125 advanced cancer cervix patients attending the Institute Rotary Cancer Hospital between June 1992 and June 1994 was reviewed. The aim of the study was to assess the role of transabdominal pelvic ultrasound (TAPUS) and computed tomography (CT) in the detection of bladder involvement. TAPUS was performed in 65 patients (group I) and CT in 60 patients (group II). With respect to clinical stage, both groups were comparable. Cystoscopy was performed in all patients and the findings were taken as the gold standard for comparison of imaging data. The sensitivity, specificity and accuracy of TAPUS were 65, 94 and 75%, respectively, while those for CT were 80, 92 and 85%, respectively. Results of the present study reveal that the accuracy of TAPUS is comparable to the accuracy of other imaging modalities in the detection of bladder involvement in cervical cancer and that it should be used more frequently in developing countries that deal with a large number of cervical cancer patients in view of its easy availability, low cost and absence of exposure to radiation.

Tropical pulmonary eosinophilia: a comparative evaluation of plain chest radiography and computed tomography

Plain chest radiography and computed tomography (CT) of the chest were performed on 10 patients with tropical pulmonary eosinophilia (TPE). Chest radiographs revealed bilateral diffuse lesions in the lungs of all the patients with relative sparing of lower lobes in one patient. However, computed tomography revealed bilateral diffuse lung lesions in all of the patients with relative sparing of lower lobes in three patients. In seven (70%) of the 10 patients, CT provided additional information. Computed tomography was found to be superior for the detection of reticulonodular pattern, bronchiectasis, air trapping, calcification and mediastinal adenopathy. No correlation was found between pulmonary function and gas exchange data using CT densities. There was also no correlation between the absolute eosinophil count (AEC) and the radiological severity of lesions. In six patients, high-resolution CT (HRCT) was performed in addition to conventional CT (CCT), and nodularity of lesions was better appreciated in these patients. It is concluded from this study that CT is superior to plain radiography for the evaluation of patients with TPE. However, more work needs to be done to substantiate the results of the present study.

Correlation of computed tomography with second-look laparotomy in ovarian carcinoma

BACKGROUND

Cancer of the ovary is the second commonest gynaecological malignancy after cancer of the cervix. Surgery followed by cisplatin-based chemotherapy is the standard treatment approach. In patients with persistent disease, second-look laparotomy offers an opportunity to debulk the tumour. This is usually followed by an alternative method of chemotherapy. We compared the findings at surgery (second-look laparotomy) with the preoperative computed axial tomography scan assessments.

METHODS

Thirty-seven patients with epithelial ovarian carcinoma were assessed with computed axial tomography scans of the abdomen and pelvis prior to undergoing a second-look laparotomy.

RESULTS

Tumour was correctly identified on computed axial tomography scan in 11 patients who had macroscopic evidence of cancer at laparotomy. In 6 patients, both computed axial tomography scan and surgery showed no disease recurrence. In the remaining 20 patients, there was a mismatch between the computed axial tomography scan and the surgical findings. In 16 of the 20 (80%) patients, computed axial tomography scans were negative but tumour was present. When the tumour was less than 1.5 cm in diameter it was missed in 8, and when equal to or greater than 1.5 cm, it was missed in 5 patients. These small tumour deposits were located in the retroperitoneal area, under the dome of the diaphragm, omentum or peritoneum, liver surface, and in the pouch of Douglas. In one case each, infiltration of the urinary bladder, sigmoid colon and rectum was also not detected. In 4 patients, computed axial tomography scans showed tumour when none was present.

CONCLUSION

Computed axial tomography scan cannot detect small nodules often present in ovarian cancer, and thus even if a computed axial tomography scan is normal it should not exclude a second-look laparotomy.

Influence of vein valves in the development of arteriosclerosis in venoarterial grafts in the rabbit

Coronary saphenous vein grafts in human beings have a more limited long-term patency rate than internal thoracic artery grafts, primarily because of more rapid development of arteriosclerosis. The factors responsible for this increased susceptibility are not completely understood. To test the hypothesis that vein valves may influence this process, we studied 48 hypercholesterolemic rabbits with jugular vein grafts interposed into the carotid arterial circulation. In 24 animals (group A), the vein segments did not contain a vein valve. In the other 24 animals (group B), a vein valve was present. Both groups were further divided in four subgroups of six to be put to death at 2, 4, 6, and 8 weeks after the operation. All animals were fed a 2% cholesterol diet. At postmortem examination, alternate 2 mm sections were either stained with hematoxylin and eosin for histologic and morphometric studies or frozen in liquid nitrogen for immunohistochemistry and in situ hybridization studies. Proliferating cell nuclear antigen immunostaining was used to study cell proliferation. Wall thickness of vein grafts increased with time. During the first 2 weeks intimal and medial thickening was primarily due to an increase in numbers of cells. Between 2 and 6 weeks further intimal and medial thickening occurred, but without additional increase in cell numbers. After 6 weeks, foam cells and lipid deposits started to appear. By 8 weeks, changes identical to those seen in arteriosclerotic plaques in human beings were evident. These changes developed sooner and with more intensity in group B animals (p < 0.01 to 0.001), and they developed faster and with more severity in segments of vein located distal to the valve than in the segments located proximal to the valve (p < 0.001). This is the first controlled experiment demonstrating that the presence of valves in the vein segments is associated with augmented and accelerated intimal changes leading to vein atheromatosis.

Role of radiotherapy in cavernous hemangioma liver

OBJECTIVE

To study the effectiveness of local radiotherapy for controlling cavernous hemangioma of liver.

METHODS

This is a retrospective analysis of four diagnosed cases of cavernous hemangiomas of the liver treated with radiotherapy. Hepatic irradiation was given in a tumor dose of 30 Gy in 15 fractions over 3 weeks period.

RESULTS

Three of the four cases showed a complete clinical regression of the liver lesions over a period of 8-14 months, but in one case there was only 75% regression of the mass at 12 months of follow up.

CONCLUSIONS

Localized radiotherapy is effective in the treatment of giant cavernous hemangiomas of the liver and a tumor dose of 30 Gy is optimum with minimal morbidity.