Governance, maternal well-being and early childhood caries in 3-5-year-old children.

BACKGROUND: This study assessed the direct, indirect and total effect of distal - political - risk indicators (affecting populations), and proximal risk indicators (affecting women) on the global prevalence of early childhood caries (ECC) in 3-5 year old children. METHODS: Data on global ECC prevalence were obtained from a prior study. Data for distal risk indicators (voice and accountability; political stability/absence of terrorism; control of corruption) were obtained from the World Bank Governance indicators, 2016. Data for proximal risk indicators (women's opportunity for leadership; percentage of female legislators, top officials and managers; basic employability status of women; ability of women to afford time off work to care for newborns; gross national income (GNI) per capita for females) were derived from the Human Development Index, 2016. Associations between variables were assessed with path analysis. RESULTS: Voice and accountability (ß = - 0.60) and GNI per capita for females (ß = - 0.33) were directly associated with a lower ECC prevalence. Political stability/absence of terrorism (ß =0.40) and higher percentage of female legislators, senior officials and managers (ß = 0.18) were directly associated with a higher ECC prevalence. Control of corruption (ß = - 0.23) was indirectly associated with a lower ECC prevalence. Voice and accountability (ß = 0.12) was indirectly associated with a higher ECC prevalence. Overall, voice and accountability (ß = - 0.49), political stability/absence of terrorism (ß = 0.34) and higher female GNI (ß = - 0.33) had the greatest effects on ECC prevalence. CONCLUSION: Distal risk indicators may have a stronger impact on ECC prevalence than do proximal risk indicators.. Approaches to control ECC may need to include political reforms.

Incidence and Outcomes of Heparin-Induced Thrombocytopenia in Patients Undergoing Vascular Surgery.

OBJECTIVE: The National Inpatient Sample (NIS) from years 2010 through 2012 was utilized to determine the incidence, predictive risk factors, and outcomes of heparin-induced thrombocytopenia (HIT) in patients undergoing vascular surgery. DESIGN: Retrospective population-based study. SETTING: Data from the National Inpatient Sample (NIS) (2011 through 2013) using specific International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure codes corresponding with vascular surgery. PARTICIPANTS: 425,379 hospital admissions in patients which underwent vascular surgery. Among these, 1,290 (0.31%) were diagnosed with HIT, and 17,765 (4.18%) were diagnosed with secondary thrombocytopenia. MEASUREMENTS AND RESULTS: The incidence of HIT is 0.3% in the vascular surgery population. The highest incidence is observed in thoraco-subclavian and vein reconstruction procedures. This study indicated that liver disease, endocarditis, chronic renal failure, congestive heart failure, atrial fibrillation, obesity, and female sex are associated with a higher incidence of HIT in this population. In vascular surgery patients, HIT can increase mortality by 3-fold and lead to severe complications such as acute renal failure, venous embolism, pulmonary embolism, and respiratory failure. CONCLUSION: The incidence of HIT in the vascular surgery population is similar to previously reported incidence in cardiac surgery patients. In the vascular surgery population, mortality increases 3-fold in patients with HIT versus those without any thrombocytopenia. Understanding the associated risk factors and complications will allow clinicians to make informed decisions and anticipate HIT and associated complications in certain high-risk populations.

In-Hospital Mortality with Use of Percutaneous Endoscopic Gastrostomy in Traumatic Brain Injury Patients: Results of a Nationwide Population-Based Study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a frequently performed invasive procedure that has been associated with high short-term mortality. Its use of special interest in traumatic brain injury (TBI) patients as nutrition support constitutes important issues in intensive care of this group. We used a national database to determine the incidence of, and factors associated with, in-hospital mortality among TBI patients undergoing PEG. METHODS: We conducted a retrospective study using the US nationwide inpatient sample to analyze data from all hospitalizations in 2008 with International Classification of Diseases, Ninth Revision, diagnostic and procedure codes identifying patients with TBI and hemorrhagic stroke who received PEG. Bivariate and multivariate logistic regression analyses were performed using demographic and clinical variables to identify predictors of in-hospital mortality in this patient population. Patients who did not undergo PEG were used as control. RESULTS: In-hospital mortality after PEG was 6% (95% CI, 0.05-0.76%) among the TBI population with 0.2% occurring in the first 7 days and 2% occurring in the first 14 days. These patients had a higher incidence of other trauma-related comorbidities and were classified as high-risk stratification based on SRRi score compared to the non-PEG group. Factors strongly predictive of in-hospital mortality were age >51 years, not receiving a PEG, and having a high comorbidity burden of >2. CONCLUSION: Understanding the rate of mortality associated with PEG in this patient population and identifying factors that increase and decrease the risk of death will improve patient selection for those most likely to benefit from this procedure.

Comparative evaluation of shock absorption ability of custom-fit mouthguards with new-generation polyolefin self-adapting mouthguards in three different maxillary anterior teeth alignments using Fiber Bragg Grating (FBG) sensors.

PURPOSE: Prevention of orofacial injuries is one of the biggest pre-occupations in sports dentistry. The custom-fitted mouthguard is considered the best choice for fit and protection when compared to over-the-counter commercial mouthguards. However, cost and time prohibit their mass production. It is therefore imperative to have an over-the-counter true mouth-formed mouthguard with comparable properties. The present in vitro experimental study was carried out to compare the shock absorption ability of EVA laminate mouthguards with self-adapting polyolefin material mouthguards in three different anterior teeth alignments. MATERIALS AND METHODS: Finite element analysis (FEA) was performed to simulate the stress distribution due to impact on the respective mouthguards. Customized pendulum device with three interchangeable standard size impact objects was used. Response of grating was monitored using a FBG interrogation system. Shift in wavelength for each impact was measured. Three standardized jaw models were subjected to a total of 72 impact strikes with three different balls on two specified sites by releasing the objects from two different heights H1 24 cm and H2 48 cm. RESULTS AND CONCLUSIONS: Two-way ANOVA was applied and comparative values computed. It was found that the percentage shock absorption ability of self-adapted polyolefin mouthguard was highly significant at <0.001 level in both regions. The influence of height on the shock absorption ability of both mouthguards was highly significant at P < 0.001. It was concluded that self-adapting polyolefin mouthguards fulfill similar protection requirement as custom-fit mouthguards and can be used for millions of athletes if properly fitted chairside by a dentist without requiring laboratory fabrication.

Shock absorption ability of laminate mouth guards in two different malocclusions using fiber Bragg grating (FBG) sensor.

PURPOSE: The majority of orofacial injuries affect the upper jaw, with the maxillary incisors being most prone to injury, often accounting for as many as 80% of all cases. Children with malocclusion in the anterior segment of the maxilla are more prone to traumatic injuries than those exhibiting normal occlusion, because most often the damaging force impacts directly against the maxillary anterior teeth. Hence, because of the difference of dissipation of the impact force because of the presence or absence of malocclusion, the mouthguard's shock absorption capacity would be influenced by certain factors. In the present study, a unique in vitro experiment utilizing fiber Bragg Grating (FBG) as distributed strain sensors was carried out to evaluate the shock absorption ability of laminate customized mouthguards in two different malocclusions compared with normal occlusion. MATERIAL AND METHODS: The impact was produced using a customized pendulum device with three interchangeable impact objects on typhodont models with two different malocclusions and normal occlusion from different heights. Response of gratings was monitored using an optical spectrum analyzer. Strain induced because each impact was determined from the Bragg's wavelength shifts for each grating. For every model, 12 impact strikes were measured using three different impact objects on the two specified sites by releasing the object from two different heights. RESULTS AND CONCLUSIONS: The laminated mouthguards showed significant variation in shock absorption ability when different malocclusions were compared. Hence, modifications in the original design of the laminated mouthguards should be considered for athletic competitors with malocclusion to provide adequate protection against impact. FBG sensor has shown the unique advantage of high sensitivity to strain measurement and can be used in further studies. The height of the impact is an important variable in determining the shock absorption ability of mouthguards.

ICU Delirium in Cardiac Patients.

Delirium is a prevalent complication in critically ill medical and surgical cardiac patients. It is associated with increased morbidity and mortality, prolonged hospitalizations, cognitive impairments, functional decline, and hospital costs. The incidence of delirium in cardiac patients varies based on the criteria used for the diagnosis, the population studied, and the type of surgery (cardiac or not cardiac). Delirium experienced when cardiac patients are in the intensive care unit (ICU) is likely preventable in most cases. While there are many protocols for recognizing and managing ICU delirium in medical and surgical cardiac patients, there is no homogeneity, nor are there established clinical guidelines. This review provides a comprehensive overview of delirium in cardiac patients and highlights its presentation, course, risk factors, pathophysiology, and management. We define cardiac ICU patients as both medical and postoperative surgical patients with cardiac disease in the ICU. We also highlight current controversies and future considerations of innovative therapies and nonpharmacological and pharmacological management interventions. Clinicians caring for critically ill patients with cardiac disease must understand the complex syndrome of ICU delirium and recognize the impact of delirium in predicting long-term outcomes for ICU patients.

Use of continuous glucose monitor as a motivational device for lifestyle modifications to improve glycaemic control in patients with type 2 diabetes treated with non-insulin therapies.

The efficacy of continuous glucose monitors (CGM) to improve glycaemic control in individuals on intensive insulin therapy (basal and prandial) has been well established in several studies; however, there is limited evidence on its usage and efficacy in patients with type 2 diabetes (T2D) who are on non-insulin therapies. Lifestyle modifications and glucose monitoring are essential components of the management of T2D. We report a case that demonstrates the impact of CGM use as an effective tool for patient education and motivation to implement and adhere to lifestyle modifications in improving glycaemic control in a patient with long-standing poorly controlled T2D who was on oral glucose-lowering medications. CGM use is associated with high level of patient satisfaction which can improve quality of life and has the potential to reduce long-term complications related to poor glycaemic control. These observations emphasise the need to broaden the use of CGM in this patient population.

Fiber Bragg grating sensor for measurement of impact absorption capability of mouthguards.

BACKGROUND: There is no standard technique to monitor impact absorption capability of mouthguards. Earlier investigations have established that strain transferred to the teeth through mouthguard is a good indication of their efficiency. In the present study, a unique experimental scheme utilizing fiber Bragg gratings (FBGs) as distributed strain sensors is proposed and investigated to estimate impact absorption capability of custom-made mouthguard. The proposed methodology is useful due to advantages such as, very small size and flexibility for ease of bonding, self-referencing, and multiplexing capability of using FBG sensors. MATERIAL AND METHODS: Finite-element analysis was performed to simulate the stress distribution due to impact on the mouthguard. The FBGs were fabricated by exposing the core of photosensitive fiber to intense Ultra-Violet light through a 'phase mask'. One FBG sensor was bonded on the jaw model and another on the mouthguard surface at similar positions, so that both gratings are simultaneously affected by impact. Two different sets of the sensors were used, one for the anterior region and another for posterior region. The impact was produced using customized pendulum device with interchangeable impact objects i.e. cricket ball, hockey ball, and steel ball. Response of gratings was monitored using optical spectrum analyzer and strain induced due to each impact was determined from the Bragg wavelength shifts for each grating. RESULTS AND CONCLUSIONS: Strain induced due to impact was calculated from the Bragg wavelength shifts. Difference in the strain values for the two gratings is interpreted as impact energy absorbed by the mouthguard. The Bragg wavelength shifts (induced strain) for FBG bonded on the jaw model was much lower than the shift for FBG bonded on the mouthguard, indicating that most of the impact energy is absorbed by the mouthguard.

Clinical and Radiographic Success of Resin-bonded Strip Crowns in Primary Incisors with Varying Extents of Sound Tooth Structure Available for Bonding.

CONTEXT: First-time dental treatment for children is often sought due to carious, malformed, fractured, and discolored teeth. The strip crown represents a highly esthetic and popular option for the restoration of primary anterior teeth. However, there are limited data on the clinical success of these crowns based on the extent of surface area used for adhesion. AIMS SETTINGS AND DESIGN: This in vivo study aimed to assess the clinical, radiographic, and photographic performance of 66 composite strip crown restorations on primary anterior teeth for up to 15 months and compare the outcome based on the extent and surface area of tooth structure available. MATERIALS AND METHODS: The amount of surface area available in each group after removal of affected enamel was evaluated through 3D scanning of study casts and digital measurements. The teeth were thus grouped into three categories: group I with crown structure involvement up to the incisal one-third, group II with involvement up to the middle of the middle third, and group III with involvement up to the cervical one-third. STATISTICAL ANALYSIS USED: Kruskal-Wallis H test and Mann-Whitney U test were used for computation of mean scores for intra- and intergroup comparison, respectively. Scoring was done as per FDI clinical criteria on a scale of 1 to 5. RESULTS: Group III showed the highest mean scores at different time intervals and also the highest failure rate (52.38%), followed by group II (12%) and group I (5%). The overall retention rate observed for the strip crowns was 77.28% at the end of 15 months. CONCLUSION: Strip crowns should be considered for teeth that offer a minimum of half to two-thirds of the healthy tooth structure remaining. Further, longitudinal studies are required to add to the results of the final outcome of these restorations. KEY MESSAGES: A critical surface area value of <50 mm2 or less than half of the available sound tooth structure was found to be detrimental to the retention rate of these crowns in this study. It could therefore be suggested to consider strip crowns for teeth that offer a minimum of half to two-thirds of healthy tooth structure remaining. HOW TO CITE THIS ARTICLE: Grewal N, Jha S, Kaur N. Clinical and Radiographic Success of Resin-bonded Strip Crowns in Primary Incisors with Varying Extents of Sound Tooth Structure Available for Bonding. Int J Clin Pediatr Dent 2021;14(4):454-461.

Prevalence of Shape-related Developmental Dental Anomalies in India: A Retrospective Study.

AIM AND OBJECTIVE: The aim and objective of this study was to review the literature to analyze the prevalence of developmental dental anomalies regarding shape in India. BACKGROUND: Although there have been several studies investigating the prevalence of individual dental anomalies related to shape, only a few studies considered all subtypes and their distribution among genders, especially in India. RESULTS: An electronic search was made in the PUBMED database to review prevalence-based data on developmental dental anomalies related to shape in India up to December 2018. A diverse range of results regarding prevalence of developmental dental anomalies related to shape were seen in these studies due to vast regional, cultural, and ethnic diversities and various environmental factors affecting the tooth development. CONCLUSION: There is a necessity to conduct more study on shape-related dental anomalies because there are very limited studies regarding prevalence of concrescence, dilacerations, and accessory root and various associated factors. CLINICAL SIGNIFICANCE: Early diagnosis and timely management of these anomalies can prevent complications. The knowledge on identification and prevalence of dental anomalies helps the dental practitioners improve the treatment plan. The prevalence studies can be of utmost importance in the formulation of oral healthcare programs by using their data to analyze the intensity of dental anomalies. HOW TO CITE THIS ARTICLE: Goswami M, Bhardwaj S, Grewal N. Prevalence of Shape-related Developmental Dental Anomalies in India: A Retrospective Study. Int J Clin Pediatr Dent 2020;13(4):407-411.

Intraoperative Anesthesiology Management and Patient Outcomes for Surgical Revascularization for Moyamoya Disease: A Review and Clinical Experience.

BACKGROUND: Moyamoya disease (MMD) is a rare cerebrovascular condition, often presenting as a headache or stroke in adults. Anesthetic management of this illness may challenge providers because it can affect the long-term neurologic outcome and hospital length of stay (LOS) in patients with MMD. MATERIALS AND METHODS: A literature search was conducted to assess etiology and epidemiology, as well as existing reports of intraoperative management of MMD. Due to sparse findings, the search was expanded to include studies of the use of intraoperative anesthetic agents during other neurosurgical procedures. We also retrospectively reviewed all MMD cases from January 1, 2009, to December 31, 2015, at Memorial Hermann Hospital-Texas Medical Center, where intraoperative management involved craniotomy and surgical revascularization. Data were collected primarily on the use of several anesthetic agents. The LOS and any adverse events were also recorded for each case. The data were divided into two equivalent case cohorts: (1) January 1, 2009, to February 18, 2013, and (2) February 19, 2013, to December 31, 2015. RESULTS: Remifentanil use notably increased between the first and second time periods while fentanyl use decreased. Desflurane usage also demonstrated an observed increase when our two cohorts were compared. Additionally, there was a decrease in the mean LOS between the first and second periods of 3.9 and 3.3 days, respectively. CONCLUSION: Increasing use of remifentanil in MMD cases could be attributed to its ability to provide more stable hemodynamics during induction, maintenance, and emergence of anesthesia when compared with fentanyl. Lower systolic pressures, diastolic pressures, and heart rates were reported in patients receiving remifentanil over fentanyl.

Comparison of resorption rate of primary teeth treated with alternative lesion sterilization and tissue repair and conventional endodontic treatment: An in vivo randomized clinical trial.

BACKGROUND: Complete pulpectomy and elimination of wide range of microorganisms from infected primary root canals is not possible through conventional endodontic procedures. Thus, lesion sterilization and tissue repair (LSTR) therapy employing 3Mix tri-antibiotic paste have been used as an alternative endodontic modality for infected primary teeth. AIM: This study aims to evaluate the root resorption rate of endodontically treated mandibular primary molars with conventional endodontic treatment or LSTR therapy and to compare it with their healthy contralateral teeth. MATERIALS AND METHODS: Fifty carious first and second primary mandibular molars from 25 healthy children aged 7-10 years were treated with two different endodontic procedures using LSTR Therapy and conventional endodontic treatment. The resorption rate of these teeth with healthy contralateral teeth was compared clinically and radiographically at 3, 6, 12 and 36 months using Chi-square test. RESULTS: At 12 months, clinically, there was no difference in the outcomes of both groups but radiographically, statistically significant difference (P < 0.001) in root resorption between treated teeth and their controls in both the groups was observed. At 36 months, interradicular bone resorption around the crown of succedaneous teeth and their delayed eruption was noted in LSTR group. CONCLUSIONS: LSTR therapy could be a viable treatment modality for infected/nonvital primary molars with poor prognosis and intended to be maintained for shorter duration in the oral cavity as natural space maintainers.

Surface remineralization potential of nano-hydroxyapatite, sodium monofluorophosphate, and amine fluoride containing dentifrices on primary and permanent enamel surfaces: An in vitro study.

BACKGROUND: Organic amine fluorides and nano-hydroxyapatite dentifrices have shown remineralization potential in various studies. However, there is a lack of direct comparison between amine fluoride and nano-hydroxyapatite with conventional inorganic fluorides as sodium monofluorophosphate. AIM: The aim of the study is to evaluate remineralizing efficacy of the three dentifrices on both primary and permanent enamel surfaces. METHODS: Enamel sections were obtained from 40 sound molars - 20 primary and 20 permanent molars. Five enamel slabs were prepared from these extracted molars stored in artificial saliva, wherein one slab acted as control, second as demineralized (negative control), and other three slabs were brushed with sodium monofluorophosphate, amine fluoride, and nano-hydroxyapatite dentifrices, respectively, twice daily for 21 days. Scanning electron microscopy- Energy dispersive spectroscopy (SEM-EDS) analysis for surface morphology and calcium and phosphorus content and Vickers surface microhardness (SMH) values were evaluated at baseline, after demineralization, and postapplication of the experimental agents. RESULTS: Highly significant changes in calcium phosphorus ratio and SMH values were seen in enamel slabs treated with nano-hydroxyapatite and amine fluoride dentifrice as compared to sodium monofluorophosphate in both primary and permanent teeth. Surface morphology of enamel slabs treated with amine fluoride most closely resembled natural enamel morphology, while sodium monofluorophosphate-treated surfaces showed globular pattern of remineralization. Deposition of a separate highly mineralized layer over existing surface was seen in nano-hydroxyapatite-treated surfaces. CONCLUSIONS: Nano-hydroxyapatite exhibited highest remineralization potential in terms of mineral gain followed by amine fluoride and sodium monofluorophosphate dentifrice.

Dentin dysplasia type 1 - clinical management dilemmas: A case report of first-generation sufferers.

Dentine Dysplasia is a rare genetic condition. The treatment options and dilemmas associated with the condition remain undiscovered so far. This article highlights the variations in traits and challenges faced in the treatment of the cases.

Trends and Outcomes of Early Versus Late Percutaneous Endoscopic Gastrostomy Placement in Patients With Traumatic Brain Injury: Nationwide Population-based Study.

BACKGROUND: Oral intake for traumatic brain injury (TBI) patients is often not an option because of facial trauma, swallowing dysfunctions, altered consciousness, etc. These patients often require percutaneous endoscopic gastrostomy (PEG) placement for nutrition support. To date, there is lack of studies examining the relationship between the timing of PEG placement and patient outcome in the TBI group. METHODS: We conducted a population-based study in a retrospective cohort of TBI patients undergoing PEG, using the national inpatient sample for years 2011 to 2013. RESULTS: A total of 96,625 patients were identified for TBI and 3343 of those patients received PEG. TBI patients who undergo an early or late PEG placement had a higher rate of in-hospital mortality, when compared with patients with a standard timing of PEG placement. Late PEG was preferably placed in patients with higher Charlson index and trauma-related comorbidities, and these patients had a higher incidence of complications, that is, sepsis, urinary tract infection, acute respiratory distress syndrome/pneumonia, and deep vein thrombosis/pulmonary embolism. When stratified by mortality-risk groups, early PEG was associated with higher rates of in-hospital mortality while standard PEG was associated with best mortality outcomes in low-mortality-risk group and moderate-mortality-risk group. CONCLUSIONS: The results of this study suggest that if a PEG placement is indicated for a TBI patient, a standard (7 to 14 d) timing may be associated with better patient outcomes. However, secondary to limitations associated with the use of administrative databases, further prospective studies are needed to establish clear guidelines regarding the optimal timing of placing PEG in TBI patients.

Status of oral health awareness in Indian children as compared to Western children: a thought provoking situation (a pilot study).

A study was conducted to evaluate the level of oral health awareness in a selected sample of Indian children and a selected sample of western children residing in Amritsar city of Punjab. Children were evaluated on the basis of a standardized questionnaire developed by WHO, for health awareness in children. Final results revealed the level of awareness in both the groups and the practical application of their knowledge about dental health in day to day life.

Comparative evaluation of enamel remineralization potential of processed cheese, calcium phosphate-based synthetic agent, and a fluoride-containing toothpaste: An in situ study.

BACKGROUND: Enamel remineralization potential of variety of products has been established, but there is a lack of evidence of comparison of remineralization potential of natural versus synthetic products. AIM: The aim of this study was to compare the enamel remineralization potential of saliva, cheese, casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)-based synthetic agent, and fluoride toothpaste. DESIGN: In situ study was carried out on sixty individuals who wore an intraoral appliance containing demineralized enamel slabs for each agent. One out of six slabs was kept as a control so as to record the baseline values (neither subjected to demineralization nor remineralization). Experimental agents were applied on the designated enamel slabs on day 1, 4, 7, and 10 with a crossover wash out period of 7 days. Quantitative values of mineral content of slab were measured using energy dispersive X-ray and qualitative changes in surface topography of slab were seen under scanning electron microscope at ×20K magnification. RESULTS: Highly significant changes from baseline values were seen in calcium and phosphorus content of slabs treated with cheese and CPP-ACP-based agent whereas levels of fluoride were significantly higher in enamel slabs treated with fluoride-containing toothpaste. CONCLUSION: Cheese is an organic, economical, and user-friendly option over prescribed synthetic agents. A synergistic effect of fluoride-containing toothpaste with intake of cheese could be a good enamel remineralization protocol.

The relationship between minute ventilation and end tidal CO2 in intubated and spontaneously breathing patients undergoing procedural sedation.

BACKGROUND: Monitoring respiratory status using end tidal CO2 (EtCO2), which reliably reflects arterial PaCO2 in intubated patients under general anesthesia, has often proven both inaccurate and inadequate when monitoring non-intubated and spontaneously breathing patients. This is particularly important in patients undergoing procedural sedation (e.g., endoscopy, colonoscopy). This can be undertaken in the operating theater, but is also often delivered outside the operating room by non-anesthesia providers. In this study we evaluated the ability for conventional EtCO2 monitoring to reflect changes in ventilation in non-intubated surgical patients undergoing monitored anesthesia care and compared and contrasted these findings to both intubated patients under general anesthesia and spontaneously breathing volunteers. METHODS: Minute Ventilation (MV), tidal volume (TV), and respiratory rate (RR) were continuously collected from an impedance-based Respiratory Volume Monitor (RVM) simultaneously with capnography data in 160 patients from three patient groups: non-intubated surgical patients managed using spinal anesthesia and Procedural Sedation (n = 58); intubated surgical patients under General Anesthesia (n = 54); and spontaneously breathing Awake Volunteers (n = 48). EtCO2 instrument sensitivity was calculated for each patient as the slope of a Deming regression between corresponding measurements of EtCO2 and MV and expressed as angle from the x-axis (θ). All data are presented as mean ± SD unless otherwise indicated. RESULTS: While, as expected, EtCO2 and MV measurements were negatively correlated in most patients, we found gross systematic differences across the three cohorts. In the General Anesthesia patients, small changes in MV resulted in large changes in EtCO2 (high sensitivity, θ = -83.6 ± 9.9°). In contrast, in the Awake Volunteers patients, large changes in MV resulted in insignificant changes in EtCO2 (low sensitivity, θ = -24.7 ± 19.7°, p < 0.0001 vs General Anesthesia). In the Procedural Sedation patients, EtCO2 sensitivity showed a bimodal distribution, with an approximately even split between patients showing high EtCO2 instrument sensitivity, similar to those under General Anesthesia, and patients with low EtCO2 instrument sensitivity, similar to the Awake Volunteers. CONCLUSIONS: When monitoring non-intubated patients undergoing procedural sedation, EtCO2 often provides inadequate instrument sensitivity when detecting changes in ventilation. This suggests that augmenting standard patient care with EtCO2 monitoring is a less than optimal solution for detecting changes in respiratory status in non-intubated patients. Instead, adding direct monitoring of MV with an RVM may be preferable for continuous assessment of adequacy of ventilation in non-intubated patients.

Evaluating the Adjuvant Effect of Dexamethasone to Ropivacaine in Transversus Abdominis Plane Block for Inguinal Hernia Repair and Spermatocelectomy: A Randomized Controlled Trial.

BACKGROUND: The transversus abdominis plane (TAP) block is a relatively straightforward regional technique used for postoperative analgesia in patients undergoing abdominal surgeries. Various adjuvants have been used in past to prolong the duration of action of analgesia in peripheral nerve blocks. Several studies investigating the analgesic efficacy of dexamethasone added to local anesthetic agents, such as bupivacaine, have shown promising results. However, there are few studies comparing the efficacy of dexamethasone with ropivacaine. OBJECTIVES: To determine if the addition of dexamethasone 8 mg to ropivacaine 0.2% in a TAP block would prolong the analgesic effect when compared with ropivacaine 0.2% alone after inguinal hernia repair and spermatocelectomy. STUDY DESIGN: A randomized, double blinded, placebo-controlled, prospective study. SETTING: Teaching hospital. METHODS: A total of 82 patients undergoing inguinal hernia repair or spermatocelectomy were enrolled in the study, of which 41 patients received TAP block with ropivacaine with saline, and the other 41 received ropivacaine with dexamethasone immediately following surgery. Both the proceduralist (resident) and the patient were blinded to the solution used. Visual analog pain scores (0 - 10) were obtained pre-block and immediately post block. Our primary endpoint was visual analog pain score at 12 hours, with 24 and 48-hour pain scores as the secondary endpoints. RESULTS: The averaged pre-block pain score was 7.6 ± 1.7 in the saline group and 7.7 ± 2.2 in the dexamethasone group. There was an improvement in the pain scores from the baseline, at 12 hours after the administration of the block in both the groups. Although the dexamethasone group had a greater change in pain score (-3.2) than the saline group (-2.2), the difference between the 2 groups was not statistically significant (0.08). We did not observe significant differences in change from baseline at 24 hours and 48 hours between the 2 groups (P value = 0.74 and 0.44, respectively). LIMITATIONS: We did not assess the total dose of analgesics used during the surgery with the assumption that the effect of intraoperative analgesics should wear off by the time we collect the 12-hour pain score. We did not control for the expertise of the provider that performed the block, as some of the providers may have been junior residents with limited experience and expertise in the area. Additionally, we were unable to include postoperative opioid consumption due to concerns of inconsistencies during patient reporting and data quality. CONCLUSIONS: In conclusion, we could not show a statistically significant prolongation of analgesia for TAP blocks with ropivacaine when dexamethasone was added, though there was a one point drop in pain score at 12 hours post block when dexamethasone was added to the block solution. This decrease in pain scores at 12 hours may still be beneficial to patient satisfaction given the low side effect profile of dexamethasone. As ropivacaine has a lower pH than other local anesthetic agents, further well designed studies are needed to investigate the combination of this drug with more alkaline drugs like corticosteroids. KEY WORDS: Regional anesthesia, transversus abdominis plane, dexamethasone, ropivacaine.