An in vitro study of a custom-made device for thermoregulation of the mixing slab on the setting properties of zinc oxide eugenol impression paste.

Aim: The present study was aimed to investigate the functional relationship between the mixing temperature and properties of a commercially available zinc oxide eugenol impression paste (ZnOE paste). Settings and Design: In-vitro study. Materials and Methods: A custom-made simulated mixing device was indigenously designed to maintain different mixing temperatures, simulating cold, ambient, and hot weather. A commercially available ZnOE paste was mixed according to the manufacturer's instructions in the simulated mixing device at the temperatures ranging from 10°C to 50°C. Initial setting time and consistency were measured according to A. D. A. Specification No. 16 (n = 8). A stainless-steel die having 25, 50, and 75 µm lines was used for surface detail reproduction. Detail reproduction of the stone casts of the impressions was evaluated with a stereomicroscope at 30 magnification (n = 8). The shear bond strength of ZnOE paste to self-cure acrylic tray resin was measured by using the UTM at a crosshead speed of 0.5 mm/min (n = 8). Statistical Analysis Used: Data were analyzed by using one-way analysis of variance (ANOVA) and Tukey's post hoc tests at a confidence interval of 95% (alpha =0.05). Results: Initial setting time, consistency, and detail reproduction of the ZnOE paste were affected by the mixing temperature (P < 0.001). Mixing ZnOE paste at a lower temperature of 10°C and higher temperatures of 40°C and 50°C resulted in shorter initial setting time, thicker consistency, and poor detail reproduction. However, no significant difference was obtained in the shear bond strength among the different mixing temperatures evaluated (P > 0.05). Conclusion: Based on this in vitro study, it is advisable to perform the manipulation of ZnOE paste at a clinical/laboratory temperature of 30°C for optimum performance. The simulated mixing device used in this study can be an alternative for extreme climatic conditions.

Role of advanced imaging with cardiac computed tomography and MRI in atrial and ventricular ablation.

PURPOSE OF REVIEW: Increasing evidence supports the use of advanced imaging with cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) in the work-up of patients with arrythmias being considered for ablation. RECENT FINDINGS: Advances in imaging technology and postprocessing are facilitating the use of advanced imaging before, during and after ablation in patients with both atrial and ventricular arrhythmias.In atrial arrythmias, quantitative assessment of left atrial wall thickness on CCT and quantification of late gadolinium enhancement (LGE) on CMR identify patients more likely to develop recurrent atrial arrythmias following ablation. In addition, in patients with recurrent arrythmia post ablation, LGE CMR can potentially identify targets for repeat ablation.In ventricular arrythmias, qualitative assessment of LGE can aide in determining the optimal ablation approach and predicts likelihood of ventricular arrythmias inducibility. Quantitative assessment of LGE can identify conduction channels that can be targeted for ablation. On CCT, quantitative assessment of left ventricular wall thickness can demonstrate myocardial ridges associated with re-entrant circuits for ablation. SUMMARY: This review focuses on the utility of CCT and CMR in identifying key anatomical components and arrhythmogenic substrate contributing to both atrial and ventricular arrhythmias in patients being considered for ablation. Advanced imaging has the potential to improve procedural outcomes, decrease complications and shorten procedural time.

Association of chronic kidney disease and end-stage renal disease with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: Insights from the national inpatient sample of 36,065 procedures.

BACKGROUND: Left atrial appendage occlusion (LAAO) has emerged as an alternative strategy to oral anticoagulation for mitigating ischemic stroke risk in selected patients with atrial fibrillation (AF), but safety data in patients with significant kidney disease are limited. OBJECTIVE: To determine the association of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with procedural complications and in-hospital outcomes after LAAO in AF patients. METHODS: Data were extracted from National Inpatient Sample for calendar years 2015-2018. Watchman implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO. RESULTS: A total of 36,065 Watchman recipients were included in the final analysis. CKD (9.8%, n = 3545) and ESRD (3%, n = 1155) were associated with a higher prevalence of major complications and mortality in crude analysis compared to no CKD. After multivariate adjustment for potential confounders, CKD was associated with length of stay (LOS) >1 day (adjusted odds ratio [aOR] 1.355; 95% confidence interval [CI] 1.234-1.488), median cost >$24,663 (aOR 1.267; 95% CI 1.176-1.365), and acute kidney injury (aOR 4.134; 95% CI 3.536-4.833), while ESRD was associated with in-patient mortality (aOR 7.156; 95% CI 3.294-15.544). CONCLUSION: The prevalence of CKD and ESRD was approximately 13% in AF patients undergoing Watchman LAAO implantations. CKD was independently associated with prolonged LOS, higher hospitalization costs, and acute kidney injury, while ESRD was independently associated with in-patient mortality.

Short-term outcomes associated with inpatient ventricular tachycardia catheter ablation.

BACKGROUND: Utilization of catheter ablation of ventricular tachycardia (VT) has steadily increased in recent years. Exploring short-term outcomes is vital in health care planning and resource allocation. METHODS: The Nationwide Readmissions Database from 2010 to 2014 was queried using the ICD-9 codes for VT (427.1) and catheter ablation (37.34) to identify study population. Incidence, causes of 30-day readmission, in-hospital complications as well as predictors of 30-day readmissions, complications, and cost of care were analyzed. RESULTS: Among 11 725 patients who survived to discharge after index admission for VT ablation, 1911 (16.3%) were readmitted within 30 days. Paroxysmal VT was the most common cause of 30-day readmission (39.51%). Dyslipidemia, chronic kidney disease (CKD), previous CABG, congestive heart failure (CHF), chronic pulmonary disease, and anemia predicted increased risk of 30-day readmissions. The overall in-hospital complication rate was 8.2% with vascular and cardiac complications being the most common. Co-existing CKD and CHF and the need for mechanical circulatory support (MCS) predicted higher complication rates. Similarly increasing age, CKD, CHF, anemia, in-hospital use of MCS or left heart catheterization, teaching hospital, and disposition to nursing facilities predicted higher cost. CONCLUSION: Approximately one in six patients was readmitted after VT ablation, with paroxysmal VT being the most common cause of the readmission. A complication rate of 8.2% was noted. We also identified a predictive model for increased risk of readmission, complication, and factors influencing the cost of care that can be utilized to improve the outcomes related to VT ablation.

A rare cause of stroke after transcatheter aortic valve replacement: Retained foreign body.

The field of transcatheter aortic valve replacement (TAVR) has matured significantly with the outcome and durability data now supporting use in lower-risk patients. We present a preventable complication from early in our experience (5 years ago) that illustrates the importance of heart team communication and cautious multidiscipline cross-pollination during the formative years of a program. An 87-year old female developed confusion, slurred speech and left upper extremity weakness 1 day following TAVR with inconclusive findings on carotid artery duplex and transthoracic echocardiography. Subsequent CT-scan disclosed a linear, ring-like, structure in the ascending aorta. The foreign body (FB) was radiolucent and successfully snared via tactile sensation and anatomic landmarks informed by the CT. The extricated FB was the valvuloplasty balloon guard (BG) that was inadvertently introduced into the patient via ascending aortic large sheath access. The failure mode was traced back to the first time use of a new balloon system and unrecognized BG by the surgical physician and technician components of the Heart Team who took the lead role in device insertion due to the open chest access. Subsequently, the heart team made changes to mitigate similar future complications by sharing multidiscipline responsibility for all procedural steps and ensuring the use of all new adjuvant devices are preceded by a procedural pause and team consensus regarding device preparation and use. Additionally, the manufacturer addition of a radiopaque marker or flair on the valvuloplasty BG may be warranted.

The Intravenous Drug User with a Big Heart.

Infective endocarditis is a severe and now more frequently encountered condition given the rise of intravenous (IV) drug use. An IV drug user presented with septic shock and bacterial endocarditis. Upon imaging, a fistulous tract was discovered, communicating from the annulus of the infected mitral valve to a large left ventricular pseudoaneurysm (PA). Presence of valvular vegetation, heart failure, and PA are all independent factors of increased mortality rates. The sheer size of the PA placed this patient at a very high surgical risk, and she was deemed inoperable. She was discharged when stabilized on supportive medical therapy. However, she returned six weeks later in cardiogenic shock with multi-organ failure. Repeat imaging revealed that the PA had significantly increased in size. Despite optimal medical management, the patient's condition deteriorated, and she, unfortunately, succumbed to her illness.

Use of MitraClip for Postmyocardial Infarction Mitral Regurgitation Secondary to Papillary Muscle Dysfunction.

Papillary muscle rupture after acute myocardial infarction (AMI) is a dreadful complication and it is associated with five percent of deaths following AMI. Surgery is the recommended treatment of choice; however, it is usually deferred due to the high risk of mortality. MitraClip implantation using a transcatheter approach is an alternative option for patients with severe mitral regurgitation (MR) following AMI or those with high operative risk. We report a case of a 68-year-old male patient who developed severe MR secondary to AMI and underwent successful mitral valve repair using the MitraClip device.

Survival Analysis of Cancer Patients of Differing Payer Type in South West Virginia, Between 2000 and 2013.

Introduction The effect of insurance coverage on the health of at-risk populations is poorly understood in the Appalachian region of the United States. The goal of this study is to examine how different types of insurance coverage (Private Insurance, Medicare under 65, Medicare 65 or over, Medicaid and Self Pay) may influence cancer survival over time. This study analyzes colon, bladder, as well as combines anal, rectal, and esophageal cancers. Methods We systematically analyzed all West Virginia Cancer Registry patients between the years of 2000 and 2013 who was diagnosed with colon, bladder, anal, rectal, and esophageal cancers. Separate analysis examined colon (n = 927), bladder (n = 269), and combined anal, rectum, and esophageal cancers (n = 398). Cox proportional hazards models investigated the effect of insurance types on survival while controlling for age, sex, tobacco use, alcohol use, and cancer stage. Results Overall, tobacco use marginally significantly decreased colon cancer survival. Tobacco use had a suggestive relationship at hazards ratio at 1.150, 95% confidence interval: 0.9990-1.235, p = 0.052. The type of payer group did not alter survival. Older individuals tend to have a lower survival rate compared to those that are younger at the time of diagnosis. Also, late-stage cancer faced lower survival compared to those with early-stage cancer. Other results within stage groups corresponded to existing literature. Conclusion For the three differing cancer groupings, there was no significant survival difference for patients by insurance type. The effect of tobacco usage on colon cancer survival merits further research. The study design could be improved by considering more risk factors such as patient comorbidities that might affect patient care and survival.

Effect of Root Dentin Conditioning on the Pushout Bond Strength of Biodentine.

INTRODUCTION: Sodium hypochlorite (NaOCl) is the main irrigant to clean root canals. Decalcifying agents are advocated as additional means to condition the root dentin. The aim of this study was to evaluate the effect of alternating (EDTA) or continuous 1-hydroxyethane 1,1-diphosphonic (HEDP) chelation in conjunction with NaOCl irrigation on the pushout bond strength of Biodentine (Septodont, Saint Maur des Fosses, France). METHODS: Single root canals of 50 extracted, mature human teeth were divided into 5 groups (n = 10) and enlarged using rotary instruments. Canals were irrigated with 5 mL irrigant after each instrument and then with 5 mL after mechanical preparation as follows: 2.5% NaOCl during and then 2.5% NaOCl, 17% EDTA, or 17% EDTA followed by 2.5% NaOCl after preparation. Continuous chelation with 2.5% NaOCl/9% Dual Rinse HEDP (Medcem GmbH, Weinfelden, Switzerland) during and after preparation. The control group was irrigated with water during and after preparation. Canals were then filled with Biodentine. A horizontal section of 1.5-mm thickness was taken from the middle root third, and a pushout bond test was performed. Data were statistically analyzed using 1-way analysis of variance/Tukey honest significant different test. RESULTS: The pushout bond strength of Biodentine was significantly higher when the root canal was irrigated with 2.5% NaOCl/9% Dual Rinse HEDP (19.6 ± 2.3 MPa) than with NaOCl alone (15.5 ± 1.5 MPa) or the NaOCl/EDTA sequences (15.7 ± 2.2 MPa and 16.9 ± 2.9 MPa) (P < .05), which did not differ among each other (P > .05). The lowest pushout bond strength values were found with water irrigation (11.5 ± 0.5 MPa) (P < .05 to all other groups). CONCLUSIONS: Irrigation with 2.5% NaOCl/9% Dual Rinse HEDP significantly improved the pushout bond strength of Biodentine to the root canal dentin.

The Impact of the Drug Epidemic on the Incidence of Sepsis in West Virginia.

Introduction Drug abuse and overdoses are on the rise in West Virginia. Multiple socioeconomic and prescription-prescribing practices influenced this shift. The shifting burden of intravenous drug use to more rural areas has created unique challenges for patient access (medical attention, addiction education, rehabilitation), as well as created an avalanche of additional costs for hospital networks. Methods We analyzed sepsis cases from 2006 to 2015 to investigate whether different types of drug use have increased the odds of developing sepsis as compared to other forms of drug use. To investigate this aspect, the authors examined this relationship by using a logistical regression and a time series analysis of the total cases of drug use and infections. Results The initial analysis investigated the association between drug use and the number of sepsis cases at Charleston Area Medical Center from 2006 to 2015 using a time series analysis. Results suggest that there are similar relationships between sepsis and sedative usage (p=0.016) and sepsis by mixed/other drug (p= 0.020) use. For logistic regression (n=2284), the infection models of sepsis/skin, endocarditis/skin infection, and osteomyelitis/skin infection showed several exposures significantly increased the risk of different infections. A drug user with a positive urine test for opiates is 80.8 percent more likely to develop sepsis as compared to skin infections (p=0.001). The use of sedatives also significantly increased the odds of developing sepsis by 83.2 percent (p=0.002). Conclusion Sepsis left untreated will result in a high mortality rate. As illicit drug use increases, sepsis cases will increase. Further research is needed to understand the continued relationship between drug use and the incidence of sepsis. Based on the current evidence, sepsis appears to be slightly affected by drug use and seems to be influenced by sedatives and opiates but only at a marginal level.

Alternative Treatment Approach for Right Heart Masses.

The traditional therapeutic approach for heart masses has been surgical resection. For right-sided masses, percutaneous mechanical thrombectomy (PMT) is a viable treatment option which is being applied with increasing frequency. This newer treatment modality is less invasive, less expensive, and results in shorter hospital stays compared to cardiac surgery. We demonstrate below a case in which rheolytic PMT was utilized successfully, allowing the patient to be discharged the following day.

Current practices in cancer pain management in Asia: a survey of patients and physicians across 10 countries.

In order to implement more effective policies for cancer pain management, a better understanding of current practices is needed. Physicians managing cancer pain and patients experiencing cancer pain were randomly surveyed across 10 Asian countries to assess attitudes and perceptions toward cancer pain management. A total of 463 physicians (77.3% oncologists) with a median experience of 13 years were included. Medical school training on opioid use was considered inadequate by 30.5% of physicians and 55.9% indicated ≤ 10 h of continuing medical education (CME). Of the 1190 patients included, 1026 reported moderate-to-severe pain (median duration, 12 months). Discordance was observed between physician and patient outcomes on pain assessment with 88.3% of physicians reporting pain quantification, while 49.5% of patients claimed that no scale was used. Inadequate assessment of pain was recognized as a barrier to therapy optimization by 49.7% of physicians. Additional barriers identified were patients' reluctance owing to fear of addiction (67.2%) and adverse events (65.0%), patients' reluctance to report pain (52.5%), excessive regulations (48.0%) and reluctance to prescribe opioids (42.8%). Opioid use was confirmed only in 53.2% (286/538) of patients remembering their medication. Pain affected the activities of daily living for 81.3% of patients. These findings highlight the need for better training and CME opportunities for cancer pain management in Asia. Collaborative efforts between physicians, patients, policy makers, and related parties may assist in overcoming the barriers identified. Addressing the opioid stigma and enhancing awareness is vital to improving current standards of patient care.