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.

Steven Johnson Syndrome and Toxic Epidermal Necrolysis in a burn unit: A 15-year experience.

INTRODUCTION: The diffuse epidermal exfoliation seen in Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) is similar to skin loss in second degree burns, and many of these patients are referred for treatment at burn centers. Treatment can differ markedly from center to center, and mortality can range from 25% to 70%, including a considerable morbidity. However, our experience over a 15-year period from 2000 to 2015 with 40 patients found a mortality rate of only 10% (4/40). The purpose of this paper is to discuss our treatment algorithm as a model for other centers treating SJS/TENs patients. METHODS: Records were reviewed for all patients admitted to the LAC+USC burn unit between 2000 and 2015 and 40 patients were identified with biopsy-proven SJS or TENS. These cases were reviewed for age, gender, initial and greatest TBSA, causative drug, pre-existing medical conditions, and morbidity and mortality. All data were entered into the SPSS statistical software package and all statistical analyses were performed using this program. RESULTS: Our treatment algorithm focused on early referral to a specialty burn unit, immediate discontinuation of the offending drug, fluid resuscitation, nutritional supplementation, and meticulous wound care. Average time to transfer to a burn unit was 3.36 days. Silver-releasing antimicrobial dressings were applied to the affected skin surface and changed every 3 days. Mupirocin coated petroleum gauze was used for facial involvement. Steroids were tapered and discontinued if initiated at an outside facility (58% of patients), and starting after 2001, all patients received a course of IVIG. All patients received fluid resuscitation and the majority received supplemental tube feedings (69%). Average length of total stay was 17.1 days and length of ICU stay 15.9 days. While 44% were transferred to another facility for further rehabilitative care, 37% of patients discharge to home. In patients discharged home with complete resolution of skin lesions, time to healing was an average of 14 days. DISCUSSION: With our 10% mortality rate in 40 patients, our study represents a relatively large study population while maintaining a relatively low mortality rate. The demographic data from our study largely aligns with the existing literature, and we therefore feel that our low mortality rate is due to our treatment algorithm, rather than to a less severe pathology in our patient population. This claim is supported by a standard mortality ratio of 1.68. This ratio proves a significantly improved mortality than would be expected based on disease severity on admission.

Palatal anaesthesia for the removal of maxillary third molars as practised by oral and maxillofacial surgeons in Australia and New Zealand.

BACKGROUND: Injections of local anaesthetic to the palate are well known to be poorly tolerated. The absolute requirement of a palatal injection for the removal of maxillary third molars has never been investigated. The aim of this study was to document the current practice of palatal anaesthesia for extraction of these teeth with local anaesthesia as practised by oral and maxillofacial surgeons. METHODS: A postal survey was sent via the ANZAOMS office to all oral and maxillofacial surgeons who were members of the Australian and New Zealand Association, a total of 131. A response rate of 64 per cent (n = 84) was achieved. The frequency of administration and the factors that determined the decision to administer a palatal injection were assessed, as well as the methods employed for reducing the injection discomfort. RESULTS: The majority (77 of the 84) "always" gave a palatal injection for the removal of maxillary third molars, four respondents administered an injection "most of the time", and two respondents "occasionally". Significantly, one respondent "never" gave a palatal injection. The majority (76 per cent) utilized at least one adjunct in order to reduce the discomfort of the injection. CONCLUSIONS: The results of this survey suggest that for removal of maxillary third molars the requirement of the poorly tolerated palatal injection may not be absolute as conventionally taught and demonstrates the need for further investigation.

Vitamin C and vitamin E supplement use and colorectal cancer mortality in a large American Cancer Society cohort.

Some recent epidemiological studies have suggested that use of vitamin C or vitamin E supplements, both of which are important antioxidants, may substantially reduce the risk of colon or colorectal cancer. We examined the association between colorectal cancer mortality and use of individual vitamin C and E supplements in the American Cancer Society's Cancer Prevention Study II cohort. We used proportional hazards modeling to estimate rate ratios among 711,891 men and women in the United States who completed a self-administered questionnaire at study enrollment in 1982, had no history of cancer, and were followed for mortality through 1996. During the 14 years of follow-up, 4404 deaths from colorectal cancer occurred. After adjustment for multiple colorectal cancer risk factors, regular use of vitamin C or E supplements, even long-term use, was not associated with colorectal cancer mortality. The combined-sex rate ratios were 0.89 [95% confidence interval (CI), 0.73-1.09] for 10 or more years of vitamin C use and 1.08 (95% CI, 0.85-1.38) for 10 or more years of vitamin E use. In subgroup analyses, use of vitamin C supplements for 10 or more years was associated with decreased risk of colorectal cancer mortality before age 65 years (rate ratio = 0.48; 95% CI, 0.28-0.81) and decreased risk of rectal cancer mortality at any age (rate ratio = 0.40; 95% CI, 0.20-0.80). Our results do not support a substantial effect of vitamin C or E supplement use on overall colorectal cancer mortality.

The recovered memories debate: how reliable is the scholarship?

The disputed issues that comprise the recovered memories controversy are so important that they deserve the most careful and intellectually honest scholarship that the academic and professional community can muster. Drawing partly on illustrative material from the recent Health Care Analysis paper by Goodyear-Smith et al. and associated commentaries, it is argued that the controversy is not being well served. The rules of scholarship are too often broken, with the result that the products are often superficial, containing what should have been readily avoided factual errors, and are sometimes even misleading.

ATP-stimulated degradation of endogenous proteins in cell-free extracts of BHK 21/C13 fibroblasts. A key role for the proteinase, macropain, in the ubiquitin-dependent degradation of short-lived proteins.

Baby hamster kidney (BHK) 21/C13 cell proteins, labeled with [35S]methionine, [14C]leucine or [3H]leucine in intact cells, were degraded in soluble, cell-free extracts by an ATP-stimulated process. The stimulatory effect of ATP appeared to require ATP hydrolysis and was mediated to a large extent by ubiquitin. Although the cell extracts contained endogenous ubiquitin, supplementation with exogenous ubiquitin increased ATP-dependent proteolysis by up to 2-fold. Furthermore, antibodies against the E1 ubiquitin conjugating enzyme specifically inhibited both conjugation of [125I]ubiquitin to endogenous proteins and ATP/ubiquitin-dependent proteolysis. Addition of purified E1 to antibody-treated extracts restored conjugation and proteolysis. Proteins containing the amino acid analogues canavanine and azatryptophan were also degraded in vitro by an ATP/ubiquitin-dependent process but at a rate up to 2-fold faster than normal proteins. These results indicate that soluble, cell-free extracts of BHK cells can selectively degrade proteins whose rates of degradation are increased in intact cells. Treatment of cell-free extracts with antibodies against the high molecular weight proteinase, macropain, also greatly inhibited the ATP/ubiquitin-dependent degradation of endogenous proteins. Proteolysis was specifically restored when purified macropain L was added to the antibody-treated extracts. Treatment of cell extracts with both anti-macropain and anti-E1 antibodies reduced ATP/ubiquitin-dependent proteolysis to the same extent as treatment with either antibody alone. Furthermore, proteolysis could be restored to the double antibody treated extracts only after addition of both purified E1 and macropain. These results provide strong evidence for an important role for macropain in the ATP/ubiquitin-dependent degradation of endogenous proteins in BHK cell extracts.

Development of glycerophosphate acyltransferase in guinea pig lung mitochondria and microsomes.

Development of mitochondrial and microsomal glycerophosphate acyltransferase in the fetal guinea pig lung was investigated. Mitochondrial and microsomal enzyme activity gradually increased from 45 days to 55 days of gestation. The specific activity in the microsomal fraction (8.2 nmol/min per mg protein) then declined until term, but increased again in the 24-h newborn from 2.5 to 6.1 nmol/min per mg protein. Glycerophosphate acyltransferase activity in the mitochondrial fraction declined after 55 days (3.5 nmol/min per mg) to a minimum level at 60 days (1.8 nmol/min per mg), but increased again in the 24-h newborn (4.0 nmol/min per mg). The specific activity of both mitochondrial and microsomal enzyme declined after 24 h after birth until adult levels were attained. Glycerophosphate acyltransferase activity in mitochondria and microsomes from adult lung was 0.8 and 2.0 nmol/min per mg, respectively. Microsomal enzyme activity was consistently inhibited (over 95%) throughout gestation and adulthood by exposure to any one of several proteinases: trypsin, chymotrypsin, papain, bromelain, pronase and nagarse. Although mitochondrial enzyme activity was also inhibited by these proteinases, there was a continuous increase in proteinase-resistant glycerophosphate acyltransferase activity between 45 days of gestation and term. In contrast, adult mitochondrial enzyme activity was stimulated by all the proteinases studied. These results suggest that early in gestation, glycerophosphate acyltransferase lies more exposed on the cytoplasmic side of the mitochondrial outer membrane and as gestation progresses it becomes embedded into the phospholipid bilayer.