Patterns of rates of mortality in the Clinical Practice Research Datalink.

The Clinical Practice Research Datalink (CPRD) is a widely used data resource, representative in demographic profile, with accurate death recordings but it is unclear if mortality rates within CPRD GOLD are similar to rates in the general population. Rates may additionally be affected by selection bias caused by the requirement that a cohort have a minimum lookback window, i.e. observation time prior to start of at-risk follow-up. Standardised Mortality Ratios (SMRs) were calculated incorporating published population reference rates from the Office for National Statistics (ONS), using Poisson regression with rates in CPRD GOLD contrasted to ONS rates, stratified by age, calendar year and sex. An overall SMR was estimated along with SMRs presented for cohorts with different lookback windows (1, 2, 5, 10 years). SMRs were stratified by calendar year, length of follow-up and age group. Mortality rates in a random sample of 1 million CPRD GOLD patients were slightly lower than the national population [SMR = 0.980 95% confidence interval (CI) (0.973, 0.987)]. Cohorts with observational lookback had SMRs below one [1 year of lookback; SMR = 0.905 (0.898, 0.912), 2 years; SMR = 0.881 (0.874, 0.888), 5 years; SMR = 0.849 (0.841, 0.857), 10 years; SMR = 0.837 (0.827, 0.847)]. Mortality rates in the first two years after patient entry into CPRD were higher than the general population, while SMRs dropped below one thereafter. Mortality rates in CPRD, using simple entry requirements, are similar to rates seen in the English population. The requirement of at least a single year of lookback results in lower mortality rates compared to national estimates.

An analysis of the effect of a vent hole on excess cement expressed at the crown-abutment margin for cement-retained implant crowns.

PURPOSE: The labial margins of anterior implant-retained crowns are often positioned subgingivally for a superior esthetic appearance. One of the consequences of subgingival margins is the increased risk of leaving excess cement behind following cementation. This can lead to potential problems, including peri-implant inflammation, soft tissue swelling, soreness, bleeding or suppuration on probing, and bone loss. The purpose of this laboratory study was to investigate the effect of placement, location, and diameter of a vent hole on the amount of cement being expressed at the margin of an anterior implant abutment-retained crown. MATERIALS AND METHODS: Three implant crown copings were fabricated to fit on the same custom abutment. Three vent diameters (0.75, 1.25, and 1.65 mm) and three locations on the palatal surface of the coping (cervico-palatally, mid-palatally, inciso-palatally) were chosen for vent hole placement. For each test, the coping was cemented onto the abutment under standardized conditions. A preweighed thin coating of cement was applied to the fit surface of the coping. The amount of cement expressed at the margin and vent hole was measured by weight and calculated as a proportion of the amount of cement placed in the coping before seating. The procedure was completed 15 times for each variable. The results were statistically analyzed using univariate ANOVA with post hoc Bonferroni-adjusted independent samples t-tests. RESULTS: The presence of a vent hole influenced the proportion of cement expressed at the coping margin (p < 0.05). The location of a vent hole influenced the proportion of cement expressed at the coping margin (p < 0.05), with the exception of the mid-palatal and inciso-palatal positioning where there was no significant difference (p= 0.61) between groups. The diameter of the vent hole did not significantly influence the proportion of cement expressed at the coping margin (p= 0.096). CONCLUSIONS: When using anterior cement-retained implant crowns, the use of a 0.75-mm mid-palatal or inciso-palatal vent hole to minimize the amount of cement expressed at the margin during cementation should be considered.

A technique for post-orthodontic retention of maxillary anterior teeth in the restored dentition: A case report.

Retention is one of the most important factors in the long term success of orthodontic treatment. In the adult patient when orthodontic movement is part of an overall treatment plan involving other disciplines, the provision of permanent retention can he complicated. Several methods have been proposed in the literature to date, all with their own problems and risks. This case report presents a technique that may solve this problem for suitable patients in a way that is both non-invasive and has excellent long-term maintenance potential.

Acid suppression in healthy subjects following lansoprazole or pantoprazole.

AIM: To compare the effect of lansoprazole, 30 mg once daily, with that of pantoprazole, 40 mg once daily, for the inhibition of gastric acid secretion. METHODS: Two randomized, single-blind, two-way, crossover studies were conducted in 74 healthy male volunteers. Lansoprazole, 30 mg, or pantoprazole, 40 mg, was administered once daily for five consecutive days with at least a 2-week washout period between regimens. Ambulatory 24-h intragastric pH was recorded at baseline and on days 1 and 5 of each crossover treatment period. RESULTS: On day 1 in both studies, lansoprazole, 30 mg, produced significantly higher mean 24-h intragastric pH values when compared to pantoprazole, 40 mg (3.78 vs. 3.08, P < 0.001, and 3.97 vs. 3.20, P < 0.001, in the first and second studies, respectively). In both studies, lansoprazole, 30 mg, produced significantly greater proportions of time that the intragastric pH was above 3, 4 and 5 when compared with pantoprazole, 40 mg (P < 0.005 in all comparisons). By treatment day 5 in the first study, lansoprazole, 30 mg, continued to produce a higher mean 24-h intragastric pH (4.15 vs. 3.91, P=0.014) and a significantly greater percentage of time that the intragastric pH was above 4 (63% vs. 56%, P=0.017) and 5 (41% vs. 30%, P < 0.001) when compared with pantoprazole, 40 mg. In the second study, the effects on intragastric pH were comparable between the two treatment groups. Headache was the most commonly reported adverse experience (nine lansoprazole-treated subjects, seven in the first study and two in the second study; six pantoprazole-treated subjects, five in the first study and one in the second study). CONCLUSIONS: Lansoprazole, 30 mg once daily, produces a faster onset and greater degree of acid inhibition than pantoprazole, 40 mg once daily. The implications for these differences on symptom relief and healing of erosive oesophagitis should be explored.

Congestive heart failure secondary to diffuse organized biventricular mural thrombus following mitral valve replacement.

A 52-year-old woman underwent mitral valve replacement for progresive mitral regurgitation. Despite anticoagulation therapy, pulmonary thromboemboli occurred. Progressive heart failure developed and fatal intracerebral hemorrhage occurred four years after valve replacement. Autopsy findings revealed a normal-sized heart with minimal ventricular hypertrophy. However, there was extensive organized mural thrombosis involving both ventricles. Endocardial thickening by diffuse organized thrombosis is an uncommon but severe complication following prosthetic valve replacement and may result in intractable heart failure from endocardial rigidity.

Cholesteatoma of the middle ear and mastoid. A comparison of CT scan and operative findings.

High-resolution CT scanning accurately depicts the status of the structures of the temporal bone, allowing delineation of pathology prior to surgical exploration of ears with cholesteatoma. It provides information concerning location and extent of disease as well as possible anatomic variations and complications that may be encountered. The main advantages of CT scanning over polytomography are superior soft-tissue contrast resolution and improved spatial detail at a reduced radiation dose for the patient.

Massive amniotic fluid embolism: diagnosis aided by emergency transesophageal echocardiography.

A 36-year-old woman was hospitalized at term and in labor at 3-cm cervical dilatation. The early labor course was remarkable only for oxytocin augmentation and combined spinal-epidural analgesia. Eight hours after admission, tetanic uterine contractions ensued, followed by persistent fetal bradycardia. An emergency cesarean section was performed and a viable male infant was delivered. Intraoperatively, a placental abruption was identified, and disseminated intravascular coagulation and persistent hypotension developed despite resuscitative efforts. Transesophageal echocardiography revealed normal left ventricular contractility and gross enlargement of the right ventricle and main pulmonary trunk, consistent with acute right ventricular pressure overload and underloading of the left ventricle. Despite resuscitative efforts, the patient died three hours postoperatively. Autopsy showed extensive microvascular plugging of the pulmonary capillaries by fetal cells in all lung fields. This is a rare case of amniotic fluid embolism diagnosed in part and managed pre-mortem with transesophageal echocardiography and confirmed by autopsy findings.

Anesthetic-postoperative morphine regimens for cesarean section and postoperative oxygen saturation monitored by a telemetric pulse oximetry network for 24 continuous hours.

STUDY OBJECTIVE: To document the effects of compromised respiratory function on oxygen saturation (SpO2) after cesarean section via the telemetric pulse oximetry network (TPON) for 24 continuous hours. DESIGN: Prospective study. SETTING: Postpartum ward of a university hospital. PATIENTS: ASA physical status I or II parturients undergoing cesarean section. INTERVENTIONS: Healthy parturients were assigned to 1 of 3 anesthetic-postoperative morphine regimens as follows: general anesthesia-parenteral morphine as needed (GA/PM; n = 11); epidural anesthesia-parenteral morphine as needed (EA/PM; n = 15); epidural anesthesia-epidural morphine 4 to 5 mg (EA/EM; n = 10). MEASUREMENTS AND MAIN RESULTS: For 24 continuous hours after cesarean section, SpO2, heart rate, and plethysmogram every 10 seconds were recorded by the TPON computer. In addition, pain, somnolence, respiratory rate (RR), and side effects were recorded every 30 minutes to 2 hours. SpO2 less than 94% and less than 92% occurred least with GA/PM. The highest mean cumulative time of SpO2 between 95% and 90% occurred with EA/EM. The longest episode of SpO2 less than 92% and the lowest SpO2 for more than 1 minute also occurred with EA/EM. With all 3 regimens, SpO2 decreased to less than 80% for 20 to 30 seconds at a time, but the lowest SpO2 (less than 85%) for more than 1 minute occurred with EA/EM in 1 patient and was associated with somnolence that required treatment. With all 3 regimens, average RR was within normal limits, but mean RR was significantly lower with EA/EM than with GA/PM or EA/PM from the 8th to the 14th postoperative hours. Somnolence did not differ significantly among the 3 regimens. Pain score was significantly lower with EA/EM than with GA/PM or EA/PM for the first 20 hours. CONCLUSIONS: All 3 regimens risked low SpO2, with the EA/EM regimen having the highest risk but the best analgesia. Neither general nor epidural anesthesia combined with postoperative parenteral morphine influenced SpO2 postoperatively. In this study, the TPON provided a feasible method of detecting hypoxemia early on in the general ward setting.

Intrauterine pregnancy and aortic valve replacement.

Cardiopulmonary bypass (CPB) does not appear to cause excessive maternal risk, but the potential for fetal complications is of great concern. In general, operative intervention should be delayed until at least the second trimester. When this is not possible, ethical issues arise and a clash of maternal autonomy versus "fetal rights" ensues. This conflict is further complicated by maternal status changes that may accompany valvular disease or develop after CPB. The case described herein summarizes and discusses these conflicts.

Pain management for labor and delivery in the 90s.

Although variable, labor pain is among the most severe of pain syndromes, and has been described as severe to excruciating in 50 to 70 percent of primiparas. "Twilight sleep" or amnesia was commonly used in the first half of this century via potent intramuscular, intravenous and inhalational agents. Subsequently, epidural anesthesia, first caudal then lumbar was used which offered superior pain relief without clouding the sensorium. However, epidurals with local anesthetics also contributed to dense sensory and motor blocks which are not necessary for labor. Presently, both spinal and epidural opioids are used along with decreasing doses of local anesthetics, rendering the laboring patient a relatively pain-free labor but allowing her more mobility and control of her environment.

Cardiac output in women undergoing cesarean section with epidural or general anesthesia.

Cardiac output during cesarean section and for 24 hours after delivery was estimated by using a noninvasive ultrasonic Doppler technique and was compared between term pregnant patients who underwent either epidural or general anesthesia. Cardiac output peaked by 36.7% and 26.3% of baseline values at 15 and 30 minutes after delivery, respectively, with epidural anesthesia and by 28% and 17.2%, respectively, with general anesthesia. From 60 minutes to 24 hours after delivery, cardiac output in both groups remained elevated at preoperative levels. This study demonstrates a similar pattern of increase in cardiac output with epidural and general anesthesia and a return by 60 minutes to preoperative levels, which persisted for up to 24 hours after delivery. The applicability of this noninvasive technique can be extended in various circumstances during pregnancy, labor, delivery, and the postpartum period to further define cardiac output in pregnancy.

Direct sagittal CT in the evaluation of temporal bone disease.

The human temporal bone is an extremely complex structure. Direct axial and coronal CT sections are quite satisfactory for imaging the anatomy of the temporal bone; however, many relationships of the normal and pathologic anatomic detail of the temporal bone are better seen with direct sagittal CT sections. The sagittal projection is of interest to surgeons, as it has the advantage of following the plane of surgical approach. This article describes the advantages of using direct sagittal sections for studying various diseases of the temporal bone. The CT sections were obtained with the aid of a new head holder added to our GE CT 9800 scanner. The direct sagittal projection was found to be extremely useful for evaluating diseases involving the vertical segment of the facial nerve canal, vestibular aqueduct, tegmen tympani, sigmoid sinus plate, sinodural angle, carotid canal, jugular fossa, external auditory canal, middle ear cavity, infra- and supralabyrinthine air cells, and temporomandibular joint.

Pulmonary aspiration--effects of volume and pH in the rat.

To evaluate the effect of volume of aspirates with different pHs on mortality associated with pulmonary aspiration, hydrochloric acid solutions were injected into the tracheas of 336 Sprague-Dawley rats. The rats were divided randomly into 33 groups, were observed for 96 hr after aspiration, and were not resuscitated. Deaths were divided into two groups: early, less than 30 min after aspiration, and late, greater than 4 hr after aspiration. Late deaths, accounting for 22% of all fatalities, occurred exclusively in animals aspirating solutions with a pH less than 2.5. These late deaths indicated progressive lung damage as opposed to acute cardiorespiratory failure, which early deaths suggested. Low volume pulmonary aspirates (0.3 ml/kg) with extremely low pH (1.0) resulted in a high mortality rate (90%). Conversely, higher volume pulmonary aspirates (1.0-2.0 ml/kg) with a higher pH (greater than or equal to 1.8) resulted in a low mortality rate (14%). These data demonstrate an important interaction between pH and volume of aspirates: even low volumes have a high mortality rate if pH is very low, whereas if gastric fluid is effectively buffered, then much higher volumes than previously thought can be tolerated. This suggests that the routine use of nonparticulate antacids may be indicated in patients at risk from aspiration of stomach contents and should not be withheld because of concern of increasing gastric volume.

The effect of nitroglycerin on the gravid uterus in sheep and rabbits.

UNLABELLED: Clinical reports suggest that nitroglycerin (TNG) has an effect on the uterus that is detected by the obstetrician on palpation, but not obvious by measurement of uterine pressure. This study was designed to compare the effects of TNG on uterine compliance and tension. We used three sets of experiments to evaluate the effect of TNG on the uterus. In vivo experiments were conducted on laboring ewes and rabbits 2 h postpartum to measure the effect of TNG on active uterine tension. An in vitro experiment was also conducted by using isolated uterine strips from term pregnant rabbits to evaluate the effect of TNG on uterine compliance. TNG had no discernible effect on uterine intracavitary pressure or frequency of contraction in either laboring ewes or postpartum rabbits at doses that were sufficient to reduce the mean arterial pressure. TNG did, however, increase the compliance of uterine tissue from rabbits at term, whereas S-nitroso-N-acetylpenicillamine failed to produce a similar effect. Thus, the perceived relaxant effects of TNG may be caused by an increase in uterine compliance, which may facilitate efforts by the obstetrician to manipulate the uterus. While the mechanism of action remains unclear, it appears to be independent of nitric oxide. IMPLICATIONS: The administration of nitroglycerin may have a relaxant effect on the uterus. These experiments were conducted to elucidate the effect of nitroglycerin on the peripartum uterus by measuring active tension and compliance.