A survey of prescribing practices by general dentists in Australia.

BACKGROUND: Numerous studies of dental antibiotic prescribing show that overprescribing is a worldwide occurrence. The aim of this study was to assess prescribing practices of general dentists in Australia for antibiotics, analgesics and anxiolytics and to determine the extent to which prescribing is in accordance with current guidelines. METHODS: A structured questionnaire was sent to 1468 dentists in Victoria and Queensland in July-August 2018. The questionnaire covered demographics, clinical conditions where dentists prescribe antibiotics, non-clinical factors which influence prescribing, and medicines for anxiolysis and pain relief. Responses were scored using a system based on the current Australian therapeutic guidelines. Logistic regression was used to determine the relative importance of independent variables on inappropriate prescribing. RESULTS: Three hundred eighty-two responses were received. Overall, 55% of overprescribing of antibiotics was detected, with a range of 13-88% on a routine or occasional basis depending on the scenario. Between 16 and 27% of respondents inappropriately preferenced analgesics over anti-inflammatories for dental pain; 46% of those who prescribed anxiolytic medicines did so inappropriately, with varying regimens and choices outside the guidelines. Years of practice was the main demographic factor influencing prescribing, with recent graduates (0-5 years) generally scoring better than their colleagues for antibiotic prescribing (p < 0.05). CONCLUSIONS: Future interventions could be directed towards the appropriate role and use of antibiotics, shortfalls in knowledge and appropriate choices of medicines for pain relief and anxiolysis. Given that the most overprescribing occurred for localised swellings (88%), this area could be focused on in continuing education as well as ensuring it is addressed in undergraduate teaching. Continuing education on the appropriate use of medicines can be targeted at more experienced dentists as well as patients, especially those who expect antibiotics instead of treatment. TRIAL REGISTRATION: University of Melbourne Human Ethics Sub-Committee; ID: 1750768.1 .

Preventing medication errors in dental practice: An australian perspective.

INTRODUCTION: Prescribing errors are a common type of medication error, even in dental practice. However, prescribing is a skill to which little attention is paid, as the profession is mostly focussed on performing dental procedures, eschewing the use of drugs, to treat dental conditions. Most dentists in Australia report learning little about prescribing during their university training, gaining these skills informally on the job after they graduate. Despite this, dentists are the second largest prescriber group in Australia and prescribe a wide variety of drugs including antibiotics, non-steroidal anti-inflammatory drugs, opioid analgesics, muscle relaxants and anxiolytics. OBJECTIVES: To summarise medication safety, medication and prescribing errors in the context of dental practice. DATA: The sources of medication and prescribing errors are reviewed. SOURCES: For this narrative review, pivotal concepts regarding sources of medication error and types of prescribing error are highlighted. The Swiss Cheese model of prescribing errors is also discussed, highlighting possible interventions when errors can be detected and averted. STUDY SELECTION: Case reports of prescribing error in dentistry in Australia are presented, highlighting examples of how dental prescribing is prone to error. CONCLUSIONS: Solutions lie in addressing the systems and processes in which dentists work. Examples include implementing forced functions such as checklists and electronic prescribing tools. CLINICAL SIGNIFICANCE: Dentists are the second largest prescriber group in Australia and prescribe a wide variety of drugs. As such, prescribing errors are common in dental practice. Solutions to reduce medication and prescribing errors lie in addressing the systems which govern dentistry, as well as implementing forced functions such as prescribing tools.

Outcomes to evaluate care for adults with acute dental pain and infection: a systematic narrative review.

OBJECTIVE: To identify outcomes reported in peer-reviewed literature for evaluating the care of adults with acute dental pain or infection.DesignSystematic narrative review. SETTING/PARTICIPANTS: Primary research studies published in peer-reviewed literature and reporting care for adults with acute dental pain or infection across healthcare settings. Reports not in English language were excluded. STUDY SELECTION: Seven databases (CINAHL Plus, Dentistry and Oral Sciences Source, EMBASE, MEDLINE, PsycINFO, Scopus, Web of Science) were searched from inception to December 2020. Risk of bias assessment used the Critical Appraisal Skills Programme checklist for randomised controlled trials and Quality Assessment Tool for Studies of Diverse Design for other study types. OUTCOMES: Narrative synthesis included all outcomes of care for adults with acute dental pain or infection. Excluded were outcomes about pain management to facilitate treatment, prophylaxis of postsurgical pain/infection or traumatic injuries. RESULTS: Searches identified 19 438 records, and 27 studies (dating from 1993 to 2020) were selected for inclusion. Across dental, pharmacy, hospital emergency and rural clinic settings, the studies were undertaken in high-income (n=20) and low/middle-income (n=7) countries. Two clinical outcome categories were identified: signs and symptoms of pain/infection and complications following treatment (including adverse drug reactions and reattendance for the same problem). Patient-reported outcomes included satisfaction with the care. Data collection methods included patient diaries, interviews and in-person reviews. DISCUSSION: A heterogeneous range of study types and qualities were included: one study, published in 1947, was excluded only due to lacking outcome details. Studies from dentistry reported just clinical outcomes; across wider healthcare more outcomes were included. CONCLUSIONS: A combination of clinical and patient-reported outcomes are recommended to evaluate care for adults with acute dental pain or infection. Further research is recommended to develop core outcomes aligned with the international consensus on oral health outcomes. PROSPERO REGISTRATION NUMBER: CRD42020210183.

Each for Equal: Gender Inequity in Dentistry in Australia.

OBJECTIVE: While there is an increasing number of women entering the dental profession, they are still underrepresented in leadership roles in major dental organizations, academia, and journal boards. Keynote and invited speaking roles in professional and scientific conferences recognize expertise and leadership and are key factors in career advancement and academic promotions. The aim of this study was to investigate gender differences in representation at dental continuing professional development (CPD) events and conferences in Australia. METHODS: An analysis of the gender of speakers was conducted with CPD and conference programs that are publicly available online from the federal and Victorian branches of the Australian Dental Association, the peak national body for dentists. RESULTS: The planned 2020 Victorian Branch CPD program featured 30 events, with a mean 2.5 speakers per event. There were 58 scientific presentations in the schedule, 22 (38%) of which were allocated to female speakers. Seven CPD events in 2020 included only female speakers, and 13 included only male speakers.The 37th and 38th Australian Dental Congresses featured 25% and 36% of female speakers, respectively. All keynote speakers were male for both events, and men accounted for 86% and 93% of international speakers. CONCLUSIONS: While women are approaching parity in local and state-level CPD events, there is a large discrepancy in the male-to-female speaker ratio for major national conferences. Suggestions to improve gender imbalance include having women on the convening committee and developing and implementing policies to address the imbalance. There has been significant progress in addressing gender inequity in dentistry, but gender-balanced leadership in major conferences still needs to be addressed. KNOWLEDGE TRANSFER STATEMENT: The findings of this study show that while women may be approaching parity with small continuing professional development events, they are still underrepresented as speakers in major conferences. It is recommended that active policies be implemented to reduce the imbalance to ensure gender-balanced leadership in one aspect of the dental profession in Australia.

Trends in Dental Medication Prescribing in Australia during the COVID-19 Pandemic.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic and subsequent restrictions on dental services have had a significant impact on the provision of dental care in Australia and around the world. OBJECTIVES: To investigate the impact of COVID-19 on medications prescribed by dentists under the Australian Pharmaceutical Benefits Scheme (PBS). METHODS: Data on the number of dental prescriptions dispensed for all medications listed on the PBS Dental Schedule, from January 2019 to June 2020, were extracted from publicly available data sets. Analysis of prescription trends was performed for 1) total medications, 2) each major medication class, and 3) individual medications. The number of prescriptions dispensed in each month from January 2020 to June 2020 was compared to the same month in 2019 to determine the relative (percentage) change, and z statistics were used to determine whether changes were statistically significant. RESULTS: There was a significant decrease in dental prescriptions in April 2020 compared to April 2019 (14,785, 18%; P < 0.05). Decreases in prescriptions for antibiotics (10,512, 16%; P < 0.05) and opioid analgesics (3,129, 18%; P < 0.05) were smaller compared to other major medication classes. There was a significant increase in June 2020, compared with June 2019, for prescriptions of amoxicillin with clavulanic acid (4,903, 20%; P < 0.05), tramadol (89, 46%; P < 0.05), and oxycodone (381, 73%; P < 0.05). CONCLUSION: Dental service restrictions during COVID-19 likely drove an unmet need for routine dental treatment, which had significant implications for public oral health following easing of restrictions. During the initial surge and subsequent lockdown, antibiotics and opioid analgesics may have been used an as alternative to routine operative treatment. Continued professional guidance is required to ensure dental prescribing remains evidence based during the pandemic period. KNOWLEDGE TRANSFER STATEMENT: The COVID-19 pandemic and subsequent restrictions on dental practice have had a profound impact on the provision of dental care in Australia and elsewhere in the world. In this context, population-level medication surveillance is important to identify and respond to changes in prescribing patterns that have arisen due to COVID-19 and restrictions on the provision of dental care. This research is particularly important for governments, regulators, and professional associations to ensure therapeutic guidelines and recommendations during the pandemic period remain relevant and evidence based.

Prescribing drugs of dependence in dentistry: a review of legal and regulatory considerations.

The misuse of drugs of dependence is a major public health issue in Australia, and prescribing of these medications by dentists has increased in recent years. While there has been much focus on the appropriate indications and clinical use of these medicines in dental practice, the legal requirements of prescribing are equally important. Dental practitioners need to be aware of their legal obligations, as inappropriate prescription practices may lead to regulatory or criminal prosecution. Although dentists hold registration through the National Scheme and there is nationally standardised scheduling of drugs in Australia, the legislation governing drug laws differs for each state and territory, especially when prescribing drugs of dependence. This article summarises the legislation governing the prescription of drugs of dependence in Australia that is relevant to dental practice, providing insights into how dentists might contribute to the appropriate, safe and legal use and management of these medications.

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.

Dental opioid prescribing rates after the up-scheduling of codeine in Australia.

The misuse of pharmaceutical opioids is a major public health issue. In Australia, codeine was re-scheduled on 1 February 2018 to restrict access; it is now only available on prescription. The aim of this study was to measure the change in dental opioid prescriptions, one year before and after the codeine re-scheduling in Australia and to assess dental prescribing rates of opioids for 2018 by population and by clinician. Data was extracted for dental opioids for the year immediately prior and after the codeine up-schedule (1 February 2017-31 January 2019) from the publicly-available national prescription database (Pharmaceutical Benefits Scheme). Descriptive statistics, T-tests and odds ratios were used to identify significant prescribing differences. Codeine, codeine/paracetamol, oxycodone and tramadol use increased significantly the year after the codeine restriction than the previous year (13.8-101.1%). Australian dentists prescribed 8.6 prescriptions/1,000 population in 2018, with codeine/paracetamol accounting for most prescriptions (96%). The significant increase in opioid prescribing highlights that Australian dentists may be contributing to the misuse of pharmaceutical opioids. Educational efforts should be targeted at the appropriate use of opioids and patient selection. Dentists should be added to the prescription monitoring system SafeScript so they can make informed decisions for patients who are potentially misusing opioids.

Oral manifestations of illicit drug use.

The use of illicit and misuse of licit drugs is a global public health problem, with illicit drug use being responsible for 1.8% of the total disease burden in Australia in 2011. Oral adverse effects associated with illicit drug use are well-established, with aggressive caries, periodontitis, bruxism, poor oral hygiene and general neglect documented. Other factors such as a high cariogenic diet and lifestyle, social and psychological factors compound the poorer oral health in illicit drug users. Literature has shown that the oral health-related quality of life among injecting drug users is poorer compared with the Australian general population and the overall quality of life of addicted people correlates with caries experience. Thus, the role of the dentist is imperative in managing the oral health of these individuals. Given their widespread recreational use, it is likely that dental practitioners will encounter patients who are regular or past users of illicit drugs. The aim of this article is to describe the prevalence and mechanism of action of commonly used illicit drugs in Australia, including cannabis, methamphetamine, cocaine and heroin and to inform dentists about the common orofacial presentations of their side effects to help with patient management.

Antibiotic resistance and relevance to general dental practice in Australia.

Antibiotic resistance is a well-established global public health crisis, with the use and misuse of antibiotics being the principal cause of bacterial resistance. Studies in both Australia and overseas have demonstrated that the dental prescribing of antibiotics is increasing and that dentists tend to prescribe antibiotics unnecessarily and for incorrect clinical indications. Dental practitioners in Australia also prefer to prescribe moderate to broad-spectrum antibacterial agents and make some inappropriate antibiotic prescribing choices. This review aims to inform dentists about the overall scope and development of bacterial resistance, approaches and challenges to reducing resistance and, ultimately, the role of dental prescribers in practising with optimal antibiotic stewardship.

Part 1. Current prescribing trends of antibiotics by dentists in Australia from 2013 to 2016.

BACKGROUND: Literature has shown dentists tend to overprescribe antibiotics and do not always prescribe in accordance with recommended guidelines. Unnecessary prescribing is one major factor that contributes to the development of antibiotic resistance. The aim of the present study was to assess the antibacterial prescribing patterns of dentists in Australia from 2013 to 2016. METHODS: Data on dental antibacterial prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) from 2013 to 2016 was accessed and prescribing trends analysed. The prescribing rates were standardized to the dose and population. RESULTS: There was a slight decrease in the dispensed use of most antibacterials from 2013 to 2016, but there was a significant increase in the dispensed use of amoxicillin/clavulanic acid of 11.2%. Amoxicillin was the most commonly dispensed antibiotic, accounting for approximately 65% of all antibacterials from 2013 to 2016, while phenoxymethylpenicillin accounted for only 1.4% of prescriptions in 2016. There were low but significant quantities of dispensed antibiotic prescriptions that do not fit with current guidelines. CONCLUSIONS: The data suggest that dentists in Australia are prescribing some antibiotics inappropriately and there is a preference for moderate- to broad-spectrum agents. The current PBS dental schedule is inconsistent with prescribing guidelines and may contribute to inappropriate prescribing.

Part 2. Current prescribing trends of dental non-antibacterial medicines in Australia from 2013 to 2016.

BACKGROUND: There is limited literature regarding dental prescribing preferences for medicines other than antibiotics. This study aimed to describe the prescribing trends of dispensed prescription medicines by dentists in Australia from 2013 and 2016 and assess adherence to current guidelines. METHODS: Data were accessed from the Department of Health of all dental prescriptions dispensed under the Pharmaceutical Benefits Scheme (PBS) from 2013 to 2016 and prescribing patterns were analysed. The prescribing rates were standardized to the dose and population. RESULTS: There was an overall increase in the standardized use of opioid analgesics by almost 30% over the time frame, with the combination paracetamol 500 mg plus codeine 30 mg tablet accounting for the majority of dispensed opioid prescriptions (96.2% in 2016). Dispensed benzodiazepine prescriptions increased by 14.6%. CONCLUSIONS: The increase in the consumption of opioids is concerning, suggesting that continuing education is required for dentists to better understand their limited role in managing dental pain and potential for abuse. The substantial increase in the dispensed use of benzodiazepines also requires further investigation and there were some drugs prescribed inappropriately and not in accordance with guidelines. Consideration could also be given to reviewing the drugs listed on the PBS for dental prescribing.

Restoration of shoulder abduction in brachial plexus avulsion injuries with double neurotization from the spinal accessory nerve: a report of 13 cases.

In upper (C5-C7) and total (C5-T1) root avulsion brachial plexus injury, a method of double neurotization from a single donor spinal accessory nerve to two target nerves (suprascapular nerve and axillary nerve) may be done, leaving donor nerves available for reconstruction procedures to restore other aspects of upper limb function. A mean range of shoulder abduction of 91° (SD 25°) was achieved through this procedure in our study of 13 cases, of which seven cases were C5-C7 root avulsion and six cases were C5-T1 root avulsion brachial plexus injuries. Six of the former group and three of the latter group achieved >90° shoulder abduction. The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries. LEVEL OF EVIDENCE: IV.

Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results.

Many operative and non-operative treatments of dorsal fracture dislocations of the proximal interphalageal (PIP) joint have been described. Return of good joint function requires anatomical reduction of the articular fragments and restoration of joint congruity and a stable functional arc of motion, with the fixation construct stable enough for early mobilization. To prevent recurrent dorsal subluxation, the attachments of the ligamentous palmar restraints and the bony buttress provided by the palmar lip of the middle phalanx base must be restored. Open reduction and internal interfragmentary screw fixation using 1.5 or 1.3mm screws was employed in 12 fingers in 10 patients with unstable dorsal fracture dislocations of the PIP joints of Schenck grades III and IV. At an average follow-up of 8.7 months, all patients in this series achieved good to excellent results and an average total active interphalangeal motion of 132 degrees (range 105 degrees -165 degrees). Additional benefits over non-operative techniques included improved patient comfort and simplified nursing care and therapy supervision.

Cerclage-wiring-assisted fixation of difficult hand fractures.

Difficult hand fractures with multiple butterfly fragments, multiple cortical splits or intraarticular extension continue to pose a challenge for optimal stable fixation that allows early postoperative mobilisation. In this study, we describe the use of cerclage-wire-assisted fixation of 17 difficult hand fractures in 16 patients. The cerclage wires helped to maintain the reduction, so providing sufficient initial stability for placement of a plate and screws. Stable fixation of the fracture was then accomplished without losing the reduction. One to three cerclages of stainless-steel wires were used for the preliminary fixation. Stable fixation was then accomplished by a bridging or neutralising plate technique. Postoperatively, the fixation was sufficiently stable to allow immediate mobilisation. With an average follow up of 44.5 months, all 17 fractures united without loss of reduction. At final follow-up, the average total active range of motion was 247 degrees (range 220-260 degrees ).

Anatomic reconstruction of the distal radioulnar ligaments: long-term results.

Chronic post-traumatic dynamic distal radioulnar joint instability following rupture of the distal radioulnar ligaments may cause disabling and progressive ulnar-sided wrist symptoms. We use a free tendon graft to anatomically reconstruct both dorsal and palmar distal radioulnar ligaments simultaneously. Nine patients who underwent this procedure between 1990 and 1997 were assessed using a modified Mayo Wrist Score. Following surgery, average wrist scores improved from 66 (95% CI, +/-3.0) to 92 (95% CI, 92+/-6.9) and were maintained in the long term (average score, 87 at 9 years). Joint stability was restored and maintained in seven of the nine patients, but two developed recurrent instability. Pain, grip strength and function were better following surgery in the short and long term. Range of supination and pronation decreased slightly from an average of 169 degrees pre-operatively to 155 degrees (90% of normal) in the long term. Long-term radiographs show no distal radioulnar or ulnocarpal joint osteoarthritis.

Severe upper limb complications from parenteral abuse of Subutex.

INTRODUCTION: Subutex is a sublingual formulation of buprenorphine that is used to treat opioid dependency. It may be abused parenterally with disastrous consequences. CLINICAL PRESENTATION: We present 4 cases of parenteral abuse of Subutex resulting in severe upper limb complications. TREATMENT: Two vascular complications were treated with combinations of anticoagulants, vasodilators, brachial plexus bock and iloprostol. One severe hand abscess required surgical debridement, and 1 median nerve injury required neurolysis. OUTCOME: All patients had a poor outcome. Both patients with vascular complications required multiple amputations, the patient with a thenar abscess had severely impaired thumb function, and the patient with median nerve injury has ongoing neuralgic pain, numbness and thenar weakness. CONCLUSION: The incidence of complications of parenteral abuse of Subutex is increasing in Singapore. These complications have a poor outcome despite adequate management, and are best prevented by education or legal means.

The prevention of neuroma formation by diathermy: an experimental study in the rat common peroneal nerve.

INTRODUCTION: There have been anecdotal reports of the efficacy of diathermy (electrocoagulation) in the prevention of neuroma formation. However, this has not been investigated in the laboratory. In this experiment involving 40 rats, diathermy was applied to the terminal proximal ends of transected rat common peroneal nerves to evaluate its effect on neuroma formation. MATERIALS AND METHODS: Monopolar and bipolar diathermy set at 45 W, applied for different durations (4 seconds and 10 seconds), were evaluated. Under histological control, the presence of neuroma formation and the diameter of the nerve ends were evaluated at 3 months. The contralateral common peroneal nerve in the same rat served as the control. The dorsal root ganglia of 2 rats in each group were also harvested for histological study. RESULTS: The incidence of neuroma formation was 30% in the group which received high-duration monopolar diathermy (10-second application), versus 90% in the control group (P <0.05). The mean diameter of the nerve ends was smaller at 0.51 mm [standard deviation (SD), 0.29] versus 0.85 mm (SD, 0.24) in the control (P <0.05). The incidence of neuroma formation was 30% in the group which received low-duration monopolar diathermy (4-second application), and 83% in the control group (P <0.05). The diameter was 0.43 mm (SD, 0.14) versus 0.85 mm (SD, 0.28) (P <0.05). High-duration bipolar diathermy applied for 10 seconds, showed a neuroma formation of 25% versus 100% in the control group (P <0.05). The diameter of the nerve ends was 0.48 mm (SD, 0.07) versus 0.79 mm (SD, 0.36) in the control group (P <0.05). The incidence of neuroma formation was 60% in the low-duration bipolar group, which received bipolar diathermy application for 4 seconds, and 90% in the control group (P = 0.25). The diameter of the nerve ends in the low-duration bipolar group was 0.52 mm (SD, 0.24) versus 0.76 mm (SD, 0.40). The incidence of neuroma formation and the difference in diameter in the low duration-bipolar group were both not statistically significant. CONCLUSION: This study demonstrates the effectiveness of monopolar diathermy in reducing the rate of neuroma formation. For bipolar diathermy, an application of 10 seconds was effective in reducing neuroma formation but an application of 4 seconds was not associated with a significant reduction in neuroma formation.

Audit of hypertension in general practice.

An audit of hypertension management was done in October 2004 in nine general practice (GP) clinics. Two structure, ten process and two outcome indicators were assessed. Results showed that targets were achieved in only four indicators, i.e., weight recording (89%), BP monitoring (85.8%), follow-up interval not exceeding 6 months (87.9%) and mean diastolic BP (73.9%). The other indicators (hypertension registry, reminder mechanisms for defaulters, recording of smoking, height, fundoscopy, monitoring of lipid profile, blood sugar, ECG, renal function and achievement of target mean systolic pressure) showed adequacy percentages varying from 22.1 to 68.7. Out of the 1260 patients assessed, 743 (59%) achieved a mean BP < or = 140/90 (or < or = 130/80 mmHg with diabetes mellitus / renal insufficiency) in the last 3 recorded readings. There was a vast difference between individual clinics. Reasons for not achieving targets were discussed and remedial measures for implementation were recommended.

The effect of preconditioning (ischemic and pharmacological) on myocardial necrosis following coronary artery bypass graft surgery.

OBJECTIVES: Ischemic preconditioning is known to protect the human heart from ischemic injury during coronary artery bypass graft (CABG) surgery but is not practised routinely. Adenosine A1 receptor agonists may confer protection in this setting by mimicking preconditioning. The aim of this study was to compare preconditioning, by ischemia or an adenosine A1 receptor agonist (GR79236X), with an established method of myocardial protection in CABG, namely intermittent cross-clamp fibrillation. METHODS: In this prospective double-blind study, 30 CABG patients were randomised to receive: (a) intermittent cross-clamp fibrillation (control), (b) pharmacological preconditioning (GR79236X), or (c) ischemic preconditioning (two 3-min periods of ischemia, each followed by 2 min of reperfusion). Surgery was performed under standardised conditions by one surgeon (WBP). The primary endpoint was cardiac troponin T release. RESULTS: Mean cardiopulmonary bypass time was 91+/-11.6 (S.D.) min. Mean ischemic time was 33+/-5.5 (S.D.) min with no inter-group difference. Mean troponin T at 72 h was highest in the control group (1.32+/-0.99 (S.D.) microg/l), similar in the GR79236X group (1.22+/-1.22 (S.D.) microg/l; P=0.85) and significantly reduced in the ischemic preconditioning group (0.58+/-0.40 (S.D.) microg/l; P=0.04). CONCLUSIONS: Ischemic preconditioning is superior to the other techniques at limiting myocardial necrosis during CABG. Pharmacological preconditioning may confer some benefit but this was not statistically shown using a specific adenosine A1 agonist (GR79236X).