Sedation or General Anaesthetic for Special Care Patients?

When faced with an anxious patient with complex needs who requires dental care, it can be difficult to decide on the most appropriate method to manage their pain and anxiety. There are a range of conscious sedation techniques that may be used, and on some occasions, general anaesthesia may be required. This paper describes the methods available and the factors influencing the decision-making process. The general dental practitioner (GDP) may not be able to offer care in their setting, but knowing more about the decision-making process and the information required to make that decision can help them guide patients and their families.

Multidisciplinary, patient-centred approach to improving compliance with venous thromboembolism (VTE) prophylaxis in a district general hospital.

Hospital-acquired venous thromboembolism (VTE) accounts for an estimated 25 000 preventable deaths per annum in the UK and is associated with significant healthcare costs. The National Institute for Health and Care Excellence guidelines on the prevention of VTE in hospitalised patients highlight the clinical and cost-effectiveness of VTE prevention strategies. A multidisciplinary quality improvement team (MD QIT) based in a district general hospital sought to improve compliance with VTE prophylaxis prescription to greater than 85% of patients within a 3-month time frame. Quality improvement methodology was adopted over three cycles of the project. Interventions included the introduction of a 'VTE sticker' to prompt risk assessment; educational material for medical staff and allied healthcare professionals; and patient information raising the awareness of the importance of VTE prophylaxis. Implementation of these measures resulted in significant and sustained improvements in rates of risk assessment within 24 hours of admission to hospital from 51% compliance to 94% compliance after cycle 2 of the project. Improvements were also observed in medication dose adjustment for the patient weight from 69% to 100% compliance. Dose adjustments for renal function showed similar trends with compliance with guidelines improving from 80% to 100%. These results were then replicated in a different clinical environment. In conclusion, this project exemplifies the benefits of MD QITs in terms of producing sustainable and replicable improvements in clinical practice and in relation to meeting approved standards of care for VTE risk assessment and prescription. It has been demonstrated that the use of educational material in combination with a standardised risk assessment tool, the 'VTE sticker', significantly improved clinical practice in the context of a general medical environment.

Dentistry and Parkinson's disease: learnings from two case reports.

Parkinson's disease is one of the most common conditions affecting the older generation. It is a progressive neurological condition presenting with motor, non-motor and behavioural symptoms that may impact upon oral health. Protecting and maintaining oral health for these individuals is paramount to their comfort, function and quality of life. To do so requires an individualised care plan considering the current stage and progression of their condition, access to care, ability to safely tolerate treatment and oral prostheses, their supporting network, and their own wishes. This paper reviews the current literature on Parkinson's disease and discusses two case reports of patients at differing stages of the condition. It emphasises the importance of a multidisciplinary approach, reasonable adjustments and the use of various techniques and skills within a dentist's armamentarium.

The role of nutritional research in the success of human space flight.

The United States has had human space flight programs for >50 y and has had a continued presence in space since 2000. Providing nutritious and safe food is imperative for astronauts because space travelers are totally dependent on launched food. Space flight research topics have included energy, protein, nutritional aspects of bone and muscle health, and vision issues related to 1-carbon metabolism. Research has shown that energy needs during flight are similar to energy needs on Earth. Low energy intakes affect protein turnover. The type of dietary protein is also important for bone health, plant-based protein being more efficacious than animal protein. Bone loss is greatly ameliorated with adequate intakes of energy and vitamin D, along with routine resistive exercise. Astronauts with lower plasma folate concentrations may be more susceptible to vision changes. Foods for space flight were developed initially by the U.S. Air Force School of Aerospace Medicine in conjunction with the U.S. Army Natick Laboratories and NASA. Hazard Analysis Critical Control Point safety standards were specifically developed for space feeding. Prepackaged foods for the International Space Station were originally high in sodium (5300 mg/d), but NASA has recently reformulated >90 foods to reduce sodium intake to 3000 mg/d. Food development has improved nutritional quality as well as safety and acceptability.

Noninvasive assessment of preclinical atherosclerosis.

Initially considered as a semipermeable barrier separating lumen from vessel wall, the endothelium is now recognised as a complex endocrine organ responsible for a variety of physiological processes vital for vascular homeostasis. These include the regulation of vascular tone, luminal diameter, and blood flow; hemostasis and thrombolysis; platelet and leucocyte vessel-wall interactions; the regulation of vascular permeability; and tissue growth and remodelling. The endothelium modulates arterial stiffness, which precedes overt atherosclerosis and is an independent predictor of cardiovascular events. Unsurprisingly, dysfunction of the endothelium may be considered as an early and potentially reversible step in the process of atherogenesis and numerous methods have been developed to assess endothelial status and large artery stiffness. Methodology includes flow-mediated dilatation of the brachial artery, assessment of coronary flow reserve, carotid intima/media thickness, pulse wave analysis, pulse wave velocity, and plethysmography. This review outlines the various modalities, indications, and limitations of available methods to assess arterial dysfunction and vascular risk.

Validity of the Eating Attitude Test among Exercisers.

Theory testing and construct measurement are inextricably linked. To date, no published research has looked at the factorial validity of an existing eating attitude inventory for use with exercisers. The Eating Attitude Test (EAT) is a 26-item measure that yields a single index of disordered eating attitudes. The original factor analysis showed three interrelated factors: Dieting behavior (13-items), oral control (7-items), and bulimia nervosa-food preoccupation (6-items). The primary purpose of the study was to examine the factorial validity of the EAT among a sample of exercisers. The second purpose was to investigate relationships between eating attitudes scores and selected psychological constructs. In stage one, 598 regular exercisers completed the EAT. Confirmatory factor analysis (CFA) was used to test the single-factor, a three-factor model, and a four-factor model, which distinguished bulimia from food pre-occupation. CFA of the single-factor model (RCFI = 0.66, RMSEA = 0.10), the three-factor-model (RCFI = 0.74; RMSEA = 0.09) showed poor model fit. There was marginal fit for the 4-factor model (RCFI = 0.91, RMSEA = 0.06). Results indicated five-items showed poor factor loadings. After these 5-items were discarded, the three models were re-analyzed. CFA results indicated that the single-factor model (RCFI = 0.76, RMSEA = 0.10) and three-factor model (RCFI = 0.82, RMSEA = 0.08) showed poor fit. CFA results for the four-factor model showed acceptable fit indices (RCFI = 0.98, RMSEA = 0.06). Stage two explored relationships between EAT scores, mood, self-esteem, and motivational indices toward exercise in terms of self-determination, enjoyment and competence. Correlation results indicated that depressed mood scores positively correlated with bulimia and dieting scores. Further, dieting was inversely related with self-determination toward exercising. Collectively, findings suggest that a 21-item four-factor model shows promising validity coefficients among exercise participants, and that future research is needed to investigate eating attitudes among samples of exercisers. Key PointsValidity of psychometric measures should be thoroughly investigated. Researchers should not assume that a scale validation on one sample will show the same validity coefficients in a different population.The Eating Attitude Test is a commonly used scale. The present study shows a revised 21-item scale was suitable for exercisers.Researchers using the Eating Attitude Test should use subscales of Dieting, Oral control, Food pre-occupation, and Bulimia.Future research should involve qualitative techniques and interview exercise participants to explore the nature of eating attitudes.

Effect of dietary sodium on fluid/electrolyte regulation during bed rest.

BACKGROUND: A negative fluid balance during bed rest (BR) is accompanied by decreased plasma volume (PV) which contributes to cardiovascular deconditioning. HYPOTHESIS: We hypothesized that increasing dietary sodium while controlling fluid intake would increase plasma osmolality (POSM), stimulate fluid conserving hormones, and reduce fluid/electrolyte (F/E) losses during BR; conversely, decreasing dietary sodium would decrease POSM, suppress fluid conserving hormones, and increase F/E losses. METHODS: We controlled fluid intake (30 ml x kg(-1) x d(-1)) in 17 men who consumed either a 4.0 +/- 0.06 g x d(-1) (174 mmol x d(-1)) (CONT; n = 6), 1.0 +/- 0.02 g x d(-1) (43 mmol x d(-1)) (LS; n = 6), or 10.0 +/- 0.04 g x d(-1) (430 mmol x d(-1)) (HS; n = 5) sodium diet before, during, and after 21 d of 6 degrees head-down BR. PV, total body water, urine volume and osmolality, POSM, and F/E controlling hormone concentrations were measured. RESULTS: In HS subjects, plasma renin activity (-92%), plasma/urinary aldosterone (-59%; -64%), and PV (-15.0%; 6.0 ml x kg(-1); p < 0.05) decreased while plasma atrial natriuretic peptide (+34%) and urine antidiuretic hormone (+24%) increased during BR (p < 0.05) compared with CONT. In LS, plasma renin activity (+166%), plasma aldosterone (+167%), plasma antidiuretic hormone (+19%), and urinary aldosterone (+335%) increased with no change in PV compared with CONT (p < 0.05). Total body water did not change in any of the subjects. CONCLUSIONS: Contrary to our hypothesis, increasing dietary sodium while controlling fluid intake during BR resulted in a greater loss of PV compared with the CONT subjects. Reducing dietary sodium while controlling fluid intake did not alter the PV response during BR compared with CONT subjects.

History of nutrition in space flight: overview.

Major accomplishments in nutritional sciences for support of human space travel have occurred over the past 40 y. This article reviews these accomplishments, beginning with the early Gemini program and continuing through the impressive results from the first space station Skylab program that focused on life sciences research, the Russian contributions through the Mir space station, the US Shuttle life sciences research, and the emerging International Space Station missions. Nutrition is affected by environmental conditions such as radiation, temperature, and atmospheric pressures, and these are reviewed. Nutrition with respect to space flight is closely interconnected with other life sciences research disciplines including the study of hematology, immunology, as well as neurosensory, cardiovascular, gastrointestinal, circadian rhythms, and musculoskeletal physiology. These relationships are reviewed in reference to the overall history of nutritional science in human space flight. Cumulative nutritional research over the past four decades has resulted in the current nutritional requirements for astronauts. Space-flight nutritional recommendations are presented along with the critical path road map that outlines the research needed for future development of nutritional requirements.

Water and energy dietary requirements and endocrinology of human space flight.

Fluid and energy metabolism and related endocrine changes have been studied nearly from the beginning of human space flight in association with short- and long-duration flights. Fluid and electrolyte nutrition status is affected by many factors including the microgravity environment, stress, changes in body composition, diet, exercise habits, sleep cycles, and ambient temperature and humidity conditions. Space flight exposes astronauts to all these factors and consequently poses significant challenges to establishing dietary water, sodium, potassium, and energy recommendations. The purpose of this article is to review the results of ground-based and space flight research studies that have led to current water, electrolyte, and energy dietary requirements for humans during space flight and to give an overview of related endocrinologic changes that have been observed in humans during short- and long-duration space flight.

Mood changes following exercise.

26 participants completed a mood measure to assess anger, confusion, depression, fatigue, tension, and vigor immediately before and immediately after two exercise sessions. Analysis showed significant mood enhancement for each exercise session. Follow-up univariate results indicated that Depressed mood scores were reduced significantly and Fatigue scores increased significantly following the first exercise session. Scores after the second exercise session indicated that Depressed mood decreased significantly. There was no interaction. Results lend support for the notion that exercise reduces depressed mood scores. It is suggested that researchers should consider the mechanisms that produce changes in mood following exercise.

Predictive effectiveness of mood measures.

The present study compared the predictive effectiveness of mood states and the Positive and Negative Affect Schedule models of mood. 38 junior high school students completed the Brunel University Mood Scale to assess anger, confusion, depression, fatigue, tension, and vigor and the PANAS 5 min. before a fitness test. Performance was self-referenced by comparing fitness test scores with a previous best score assessed four weeks earlier. Participants who equaled or bettered their previous best score were classified as Successful. Those who did not match their previous score were classified as Unsuccessful. Discriminant function analysis indicated that 31 participants (81.6%) could be correctly classified as Successful or Unsuccessful based on preperformance Brunel Mood scores. Discriminant function coefficients indicated that Confusion, Fatigue, and Vigor contributed significantly to the discrimination. For the Positive and Negative Affect Schedule, discriminant function analysis indicated that 26 participants (68.4%) could be correctly classified as Successful or Unsuccessful, with Negative Affect and Positive Affect contributing significantly to the discrimination. Summarizing negative mood into a single factor may lead to a substantial loss of information. Research on mood and performance relationships should use the mood dimensions assessed in the Brunel University Mood Scale rather than the Positive and Negative Affect Schedule.

Performance satisfaction and postcompetition mood among runners: moderating effects of depression.

This study examined the influence of postcompetition depressed mood on the intensity of other mood dimensions assessed by the Profile of Mood States and relationships between mood and satisfaction with performance. 195 distance runners completed the Brunel Mood Scale which is a 24-item measure assessing anger, confusion, depression, fatigue, tension, and vigor, and a Performance Satisfaction questionnaire immediately after running a 10-mi. race. To examine the proposed moderating effect of depression, participants were separated into a No-depression group of 133 and a Depressed Mood group of 62. Multivariate analysis of variance indicated that the Depressed Mood group reported significantly higher scores on Anger, Contusion, Fatigue, and Tension and lower Vigor scores than the No-depression group t ratios indicated that poorer performance was associated with higher Depression scores. Standard multiple regression to predict Performance Satisfaction scores from postcompetition scores on Anger, Confusion, Fatigue, Tension, and Vigor in the No-depression group indicated that only 1% (Adj. R2=.01, p>.05) of the variance was explained. By contrast, in the Depressed Mood group, the same mood dimensions predicted 27.5% of the variance in Performance Satisfaction scores (Adj. R2=.275, p<.01) with Anger (Beta=.63, p<.001), and Confusion (Beta=.44, p<.05) being significant predictors. Present findings support the notion that depressed mood is related to the intensity of other mood dimensions assessed by the Profile of Mood States and moderates relationships between those scores and performance satisfaction.