Cardiac murmurs: echocardiography in the assessment of patients requiring antibiotic prophylaxis for dental treatment.

BACKGROUND: Traditionally patients who indicate that they have a heart murmur or who indicate that they have had rheumatic fever are given antibiotic prophylaxis for dental treatment. This is commonly done without further assessment of the patient's actual endocarditis risk. Echocardiography is a non-invasive method of assessing cardiac valve function and haemodynamics. METHODS: Consecutive patients who were referred to a private practice oral and maxillofacial surgeon for dentoalveolar surgery and indicated that they had a cardiac problem and usually had antibiotic prophylaxis, were evaluated. Those with a clear indication for prophylaxis, for example had prosthetic heart valves or previous infective endocarditis, received antibiotic prophylaxis. Where there was uncertainty, they were referred for an echocardiogram, and if abnormal, a formal cardiology review. RESULTS: Three hundred and seventy patients out of approximately 20 000 (1.85 per cent) indicated that they had a cardiac murmur and usually received antibiotic prophylaxis for dental treatment between 1 February 1997 and 1 February 2005. Two hundred and sixty-two (71 per cent) were female and 108 (29 per cent) were male; age range 0.7 to 98 years, average 37.6 years. Two hundred and seventy (72 per cent) had normal hearts with no indication for antibiotic prophylaxis. Of the 100 (28 per cent) patients with abnormal findings, they were on average older; 49.5 years, range 0.7 to 87 years. Of these, 50 (14 per cent) met current indications for antibiotic prophylaxis. CONCLUSION: Patients who present for dental treatment indicating that they require antibiotic prophylaxis for cardiac condition need to be fully evaluated. In this study only 50 of 370 patients (14 per cent) required antibiotic prophylaxis. The remaining 320 (86 per cent) would have no benefit but a risk of adverse reaction to the antibiotic.

A re-assessment of the effect of thyrotrophin (TSH) on the tibial plate bioassay for growth hormone (GH).

The claim has been made that thyrotrophin (TSH) can augment the action of growth hormone (GH) to stimulate growth of the epiphysial cartilage plate of the hypophysectomized rat's tibia. The TSH induces its effect via secretion of thyroid hormones which in turn enhance the stimulatory action of GH. If this is true then the employment of the tibia test, whose endpoint is the increase in thickness of the epiphysial cartilage plate in response to GH present either in crude pituitary extracts or relatively purified preparations, which also are likely to contain modest or appreciable quantities of TSH, requires further examination. The present study utilized various fractions of crude pituitary extracts from intact and thyroidectomized rats that respectively contained appreciable quantities of GH or essentially no GH. Fractional aliquots of pituitary extracts from thyroidectomized rats were administered concomitantly with graded doses of exogenous GH to hypophysectomized rats to determine the point at which TSH in the extracts was sufficiently able to stimulate significant tibial plate growth when compared to recipients given GH alone. Purified GH and TSH were also administered in various doses to hypophysectomized recipients in a further attempt to delineate the dose range at which TSH augments the action of GH to promote significant chondrogenesis of the epiphysial plate. The results indicate that the enhancement of the GH effect on the cartilage plate by TSH was evident only when quantities above 100 microng bovine GH were co-administered with 100 mU bovine TSH. As little as 40 mU TSH augmented the growth effect of 400 microng GH on the cartilage plate, demonstrating that smaller quantities of TSH could potentiate larger quantities of GH. These data, therefore, suggest that extracts equivalent to not more than one-half of a normal adult rat's anterior pituitary gland should be administered to hypophysectomized rats for bioassay of GH. Fractions of glands greater than this may contain sufficient amounts of TSH to augment the appreciable quantities of GH already present.