The prescribing of antibiotics for endodontic infections by dentists in Turkey: a comprehensive survey.

AIM: To investigate the antibiotic prescribing patterns for endodontic infections based on the reports of Turkish dentists. METHODOLOGY: A survey consisting of 20 questions on general information and 13 questions on antibiotic prescribing patterns for endodontic cases was delivered to the e-mail addresses of general dentists and specialists via the database of the Turkish Dental Association. Collected data were analysed using Mc-Nemar-Bowker Test and multivariate ordinal logistic regression tests at the significance level of 0.05. RESULTS: A total of 1007 responses were obtained from 17 827 dentists. The majority of the participants were general dental practitioners (GDP, 80%) whilst 8% were Endodontists. Gender, clinical experience, affiliations and speciality were significant risk factors for antibiotic prescription (P < 0.05). GDPs prescribed antibiotics twice as much as all specialists and members of public hospitals prescribed antibiotics three times more than specialists and clinical academics (P < 0.05). Amoxicillin with clavulanic acid was the most prescribed antibiotic (90%), followed by Ornidazole (25%). Clindamycin was the drug of choice for the patients with penicillin allergy (59%). Infection and fever control (76%), prophylaxis (44%) and avoiding swelling and trismus during endodontic treatment (26%) were the most common reasons for antibiotic prescriptions. Completing a course of prescribed antibiotics was recommended by most (75%). Infective endocarditis, immunosuppression, artificial heart valve and mitral valve prolapse were the main causes of prophylaxis in descending order. Uncontrolled and extensive use of antibiotics by patients (62%) was mentioned as the most effective reason for antibiotic resistance. Up to 10% of participants prescribed antibiotics for symptomatic irreversible pulpitis, asymptomatic apical periodontitis with or without endodontic treatment (8, 12 and 11%, respectively). Up to 20% of dentists prescribed antibiotics for symptomatic apical periodontitis when the pulp was vital or necrotic (13 and 23%, respectively). Almost one third of the participants prescribed antibiotics for symptomatic apical periodontitis of previously treated teeth with or without radiographic lesions whilst 34% prescribed antibiotics for acute apical abscess with localized swelling without systemic involvement. CONCLUSIONS: The majority of dentists reported they prescribed antibiotics inappropriately. It is necessary to improve the knowledge of dentists about antibiotics and their indications in endodontics.

Constrictive pericarditis after renal transplantation: three case reports.

INTRODUCTION: Pericardial exposure can be see in chronic kidney disease, but constrictive pericarditis (CP) development, which is usually present with signs of right-sided heart failure is rare. In renal transplant recipients CP can lead to graft dysfunction and serious liver disease. We present herein 3 such CP patients. PATIENT 1: A 37-year-old male patient with end-stage renal disease (ESRD) due to membranoproliferative glomerulonephritis was on chronic hemodialysis (HD). He underwent living donor kidney transplantation in 1995. In 2006 he was admitted with complaints of shortness of breath, weakness, and abdominal distention. PATIENT 2: A 17-year-old male patient with ESRD due to vesicoureteral reflux had 6 months of HD and underwent living donor kidney transplantation in 2008. Six months after transplantation, he showed leg edema, massive ascites, hepatosplenomegaly, and pretibial edema. PATIENT 3: A 52-year-old male patient was 21 years after HD initiation when cadaveric donor kidney transplantation was performed in August 2011. Four months after transplantation, he presented with a shortness of breath and fatigue. Echocardiography revealed 2-3 degree aortic regurgitation and increased pericardial brightness. CONCLUSION: All patients underwent right-sided heart catheterization, leading to a diagnosis of constrictive pericarditis, requiring total pericardiectom. Pathological examination of the pericardium showed typical diffuse fibrosis.

Cardiomyopathy with alopecia and palmoplantar keratoderma (CAPK) is caused by a JUP mutation.

Inherited desmosomal cardiocutaneous syndromes are characterized by the quartet of woolly hair, palmoplantar keratoderma (PPK), skin fragility and cardiac abnormalities, which are caused by mutations in genes coding for desmosomal proteins. We describe a previously unrecognized autosomal recessive syndrome in a family with arrhythmogenic right ventricular cardiomyopathy associated with alopecia and PPK (named CAPK). Genetic investigation of the family led us to find a homozygous disease-causing mutation, p.R265H, in JUP which encodes plakoglobin, a well-described member of the desmosome complex. This study expands the clinical spectrum of disorders associated with germline mutations affecting desmosomal proteins by describing a novel phenotype.

Time-dependent decalcifying effects of endodontic irrigants with antibacterial properties.

The aim of this study was to investigate the extent of calcium ion (Ca(2+)) removal on root dentin after treatment with 1.25% NaOCl, 2.5% NaOCl, 5.25% NaOCl, 2% chlorhexidine (CHX), 2% iodine potassium iodide (IKI), and MTAD in 3 immersion time periods. Extracted human mandibular premolars were bisected longitudinally, and the root halves (n = 70) were isolated with nail varnish, leaving the root canal exposed. The specimens were immersed in the test solutions, during which the amount of Ca(2+) release into the solutions was determined at 5, 10, and 15 minutes by flame photometry. The decalcifying effect of 5%, 2.5%, and 1.25% NaOCl and 2% IKI significantly increased within time (P < .05), with 5% NaOCl extracting the greatest amount of Ca(2+) at all treatment times. For 2% CHX and distilled water, a significant increase in the amount of Ca(2+) extraction from root dentin was only evident at 10 minutes (P < .05) and did not change at 15-minute readings. Between the 5- to 10-minute and 10- to 15-minute intervals, the greatest amount of increase in the rate of Ca(2+) extraction from root dentin was observed in the 2.5% NaOCl group. At 15 minutes, 2% CHX and distilled water showed the least amount of change. Among the test solutions, MTAD extracted the least amount of Ca(2+) at 5 minutes.

Calcium loss from root canal dentin following EDTA, EGTA, EDTAC, and tetracycline-HCl treatment with or without subsequent NaOCl irrigation.

The aim of this study was to determine the extent of calcium removal on root canal dentin after 17% EDTA, 17% EGTA, 15% EDTAC, and 1% tetracycline-HCl treatment; with or without subsequent use of 2.5% NaOCl. Extracted single-rooted human teeth were bisected longitudinally and the root halves (n=100) were isolated with nail varnish, leaving the root canal exposed. The samples were immersed in the test solutions for 1 and 5 minutes, after which the amount of calcium ion (Ca(2+)) release into the solutions was determined by flame photometry. Regardless of treatment time, all single (treatment solution only) and combined (treatment solution with subsequent NaOCl application) irrigation regimens removed significantly more Ca(2+) than control treatment (distilled water). Compared with other groups, treatment with 17% EDTA and 17% EDTA + 2.5% NaOCl resulted in the maximum amount of Ca(2+) removal from root canal dentin (p<0.05). All combined-treatment groups except 17% EGTA + 2.5% NaOCl removed significantly more Ca(2+) than their single-treatment versions (p<0.05). Within each test group, extending the treatment time to 5 minutes resulted in significantly more Ca(2+) removal (p<0.05).

Angiographic and clinical follow-up after coronary implantation of the ACS Multilink Duet stent: a single center experience.

As a growing variety of coronary stents become available on the market and the results of randomised trials may be difficult to apply to less selected patients, detailed information about the immediate and long term results achieved with one device can be helpful for the interventional cardiologist. The purpose of the present study was to test the applicability, angiographic and clinical results of the ACS Multilink Duet coronary stent in a relatively unselected group of patients undergoing coronary angioplasty immediately and in the long term. From November 1998 to May 2000, 337 ACS Multilink Duet coronary stents were implanted in 285 patients in our clinic. Data were collected retrospectively from the catheterization laboratory records and patient charts. Restenotic lesions and chronic total occlusion stenting were excluded from analysis (45 patients and 60 stents were excluded leaving 240 patients, 262 lesions and 277 stents for analysis). In 3 cases (1%) the ACS Multilink Duet stent did not cross the lesion and another device was used. One patient (0.4%) died due to acute occlusion of the proximal left anterior descending artery and cardiogenic shock within 4 hours after the procedure. Three patients (1.25%) had subacute thrombosis and q wave myocardial infarction during the hospital course, while four additional patients, out of 197, in whom one month clinical data were available had myocardial infarction (2 q waves and 2 non-q waves) after hospital discharge in the first month (2.03%). After 6 months from the procedure angiographic follow-up data were available for 108 patients (45%), 111 lesions (42.4%) and 117 stents (40.4%). They had complex lesions, B2-C type accounting for 42.3% of the cohort, and lesions requiring 2.5 mm diameter stents were also included and constituted 11.1% of the study cohort. Restenosis occurred in 24 patients (21.4%) and in 25 stents (22.2%). Comparing the patients with and without restenosis, diabetes mellitus and complex lesion morphology (B2-C) were found to be more frequent in the restenosis group (p<0.01, p<0.01). Lesions suitable to stent with a stent diameter of 3.5 mm or more had less restenosis with respect to smaller diameters (p=0.022). For a single stent diameter restenosis rates, regarding the stent length were 14.2% for 8 mm and 13 mm, 18.6% for 18 mm, and 37.5% for 23 mm and 28 mm (p=not significant). The Multilink Duet stent, in a cohort of relatively unselected patients, has a high rate of applicability, an acceptable rate of subacute occlusion, and a low rate of restenosis.

Apical hypertrophic cardiomyopathy mimics acute coronary syndrome.

We present a case who was initially thought to have an acute coronary syndrome but who was later diagnosed to have an apical hypertrophic cardiomyopathy. Interestingly, the diagnosis could be established with left heart catheterization, not echocardiography.

Association between the severity of heart failure and the susceptibility of myocytes to apoptosis in patients with idiopathic dilated cardiomyopathy.

BACKGROUND: Bcl-2 proto-oncogene, an inhibitor of apoptosis and Bax proto-oncogene, an inducer of apoptosis play critical roles in the molecular circuit controlling apoptosis in cardiac muscle. The ratio of Bax to Bcl-2 proto-oncogene determines survival or death after an apoptotic stimulus. We speculated that susceptibility of myocytes to apoptosis determined as the Bax/Bcl-2 ratio might vary with the severity of heart failure. METHODS AND RESULTS: We studied immunohistochemically 108 endomyocardial biopsy specimens from 30 patients with idiopathic dilated cardiomyopathy (mild heart failure, n=14; moderate or severe heart failure, n=16) with the use of Bcl-2 and Bax monoclonal antibodies. The expression of each protein was determined semiquantitatively as the fraction of myocytes labeled with specific monoclonal antibodies using a digital morphometric analysis system. Patients with mild heart failure showed significantly increased Bax/Bcl-2 ratio than the patients with advanced heart failure (1.59+/-1.26 vs. 0.34+/-0.43, P=0.002). The expression of Bcl-2 was found to be independent of the severity of heart failure whereas the expression of Bax was significantly higher in patients with mild heart failure compared to the patients with moderate or severe heart failure (52.1+/-29.3 vs. 21.6+/-22.4%, P=0.005). Additionally, Bax/Bac-2 ratio was inversely correlated with the mitral E-interventricular septum distance, left ventricular end-systolic and end-diastolic diameter. CONCLUSION: The susceptibility of myocytes to apoptosis is significantly increased in the early phase of heart failure but it decreases with worsening of the disease due to depressed expression of Bax onco-protein. Increased myocyte susceptibility to apoptosis may have a role in the transition from mild heart failure to severe in patients with idiopathic dilated cardiomyopathy.

Exercise-induced myocardial ischemia in patients with coronary artery ectasia without obstructive coronary artery disease.

BACKGROUND: Aetiology, clinical significance and treatment options for coronary artery ectasia/aneurysm is not clear. OBJECTIVE: We sought to determine whether exercise can induce coronary ischemia in patients with coronary artery ectasia/aneurysm without significant coronary stenosis. METHODS: Coronary artery ectasia was defined as 1.5-2-fold, aneurysm as >2-fold luminal dilatation of the adjacent normal segment. The study patients could have irregularities with ectatic coronaries but they did not have stenotic lesions >50% with visual assessment of two blinded observers. Patients having coronary artery ectasia or aneurysm with prior myocardial infarction, dilated cardiomyopathy, valvular heart disease, bundle branch block, significant ST-T changes were excluded. The control group was formed from a well matched population of 32 patients with normal coronary arteries who have not performed a treadmill test before coronary angiography. The study group underwent a symptom limited treadmill test if they did not have one before coronary angiogram, all control patients underwent treadmill test. RESULTS: Thirty-three patients with coronary artery ectasia/aneurysm (ranging from one to three vessels) but without significant stenosis were derived from 4470 cardiac catheterization procedures between January 1998 and July 2000. In the study group, 17 of the patients had positive treadmill tests with respect to five patients in the control group (P = 0.004). In subgroup analysis, diffuse ectasia/aneurysm (involving 2-3 vessels) was found to be strongly related with ischemia (P = 0.005) with respect to local disease. CONCLUSION: Coronary artery ectasia/aneurysm may lead to exercise induced ischemia, especially in the diffuse form.

Heart rate variability in hypertrophic obstructive cardiomyopathy: association with functional classification and left ventricular outflow gradients.

BACKGROUND: The aim of this study was to investigate cardiac autonomic control in patients with hypertrophic obstructive cardiomyopathy (HOCM) and to assess the indexes of heart rate variability (HRV) in relation to the clinical and echocardiographic features. METHODS AND RESULTS: Twenty-three patients (17 male, six female: mean age 43+/-11) with HOCM and 18 healthy volunteers were included. M-mode and two-dimensional echocardiography, pulsed and continuous-wave Doppler studies were obtained. All patients and volunteers underwent continuous 24-h ambulatory ECG monitoring. Time domain variables considered in this study were standard deviation of mean R-R intervals (SDNN), root mean-squared successive difference (RMSSD) and percentage of cycles differing from the preceding one by more than 50 ms (PNN 50%). Patients were compared to detect associations between indices of heart rate variability, left ventricular outflow tract obstruction and clinical status. Heart rate variability parameters were also correlated with the echocardiographic and clinical characteristics of the patients. Both New York Heart Association (NYHA) functional class I-II patients (group I) and NYHA III-IV patients (group II) had lower values of SDNN, RMSSD and PNN 50% when compared with the control group (P<0.001, P<0.05 and P<0.01, respectively, for group I and P<0.001, P<0.001 and P<0.001, respectively, for group II). Time domain heart rate variability parameters were found to be significantly correlated with the subaortic dynamic obstruction. CONCLUSION: Heart rate variability is reduced in HOCM and well correlated with the degree of subaortic obstruction. Heart rate variability indices are also sensitive markers of the functional status.

Left sided inferior vena cava with sinus venosus type atrial septal defect.

A patient with left sided inferior vena cava and sinus venosus type atrial septal defect is presented. The patient was situs solitus, had abnormal pulmonary venous drainage and the left sided inferior caval vein returned to its usual route after the renal vein junction.

Lengthening of intraatrial conduction time in atrial fibrillation and its relation with early recurrence of atrial fibrillation.

Intraatrial conduction delay in atrial fibrillation (AF) that is considered a component of atrial electrical remodeling has been demonstrated previously in experimental models and it is considered an important factor for the induction or stabilization of AF. However, it is not known if this phenomenon exists in human AF. The present study aimed to compare intraatrial conduction time (IACT) in patients with chronic atrial fibrillation who were converted to sinus rhythm and a matched control group, and to investigate its relation with early AF recurrence. Seventeen patients with chronic AF (mean duration of 20.71+/-16.35 months) were enrolled in the study (7 males, 10 females, 63+/-8 years). An age and sex matched control group (n=12) consisted of patients with sinus rhythm who underwent electrophysiological study (EPS). None of the patients were on any antiarrhythmic treatment during the procedures. Cardioversion was performed via external DC cardioversion. Eight patients in the control group were delivered a DC shock because of induced ventricular tachycardia during EPS. IACT was defined as the interval between the onset of P wave surface ECG and the beginning of A wave at high right atrium (IACT 1) and low right atrium (IACT 2). Additionally, the interval between A wave at high right atrium and low right atrium was measured (IACT 3). Patient characteristics such as age, sex and echocardiographic variables were not different between the AF group and the control group. Heart rate after cardioversion was found to be similar between the two groups. Total delivered energy was significantly higher in the AF group than in the control group (464.47+/-165.82 joules vs. 315.00+/-27.77 joules, p<0.001). IACT 1 (15.30+/-7.61 msec vs 8.50+/-5.29 msec, p<0.02 ), IACT 2 (45.25+/-836 msec vs 26.44+/-10.45 msec, p<0.001) and IACT 3 (26.9+/-8.26 msec vs. 18.67+/-10.05, p<0.05) significantly lengthened in the AF group after maintenance of sinus rhythm compared to the control group. There were 6 early AF recurrences during the 1 week follow-up period. Multivariate analysis, revealed IACT 2 and IACT 3 were significantly different between the control group, the patient with recurred AF and the patients with maintained sinus rhythm. Post-hoc analysis revealed that IACT 2 and IACT 3 significantly lengthened in the patients with recurred AF compared to both the control group and patients with maintained sinus rhythm. On the other hand, only IACT 2 patients with maintained sinus rhythm were found to be higher than those of the control group. The present study indicated that intraatrial conduction was disturbed in patients with AF, a finding which is consistent with those of previous experimental studies. Additionally, such a phenomenon may be a risk factor for the early recurrence of AF after cardioversion to sinus rhythm.

QT interval dispersion: non-invasive marker of ischemic injury in patients with unstable angina pectoris?

Prognostic assessment of unstable angina pectoris is a common clinical problem for physicians. Markers of myocardial cell injury, serial electrocardiographic findings and ST segment monitoring are mainly studied for prognosis. We investigated the relation between myocardial injury and the value of cardiac troponin T and QT interval dispersion in hospitalized unstable angina patients. This is a prospective study that includes adult patients admitted to an emergency department with Braunwald class IIIB unstable angina pectoris. Eighty-six patients were enrolled in the study (mean age of 57 +/- 12 years, 63 males and 23 females). Cardiac troponin T was assayed and QT dispersion calculated from surface ECG. Fifty-eight patients with troponin T < 0.1 ng/ml and 28 patients with troponin T levels > or = 0.1 formed group 1 and group 2, respectively. There were no significant differences in sex, age, history of coronary revascularization or ECG findings such as ST depression and T inversions between the two groups. The QT dispersion was significantly greater in patients with elevated cardiac troponin T levels (77 +/- 18 msec vs 38 +/- 13 mse; p < 0.014). Because QT interval dispersion exhibited an association with cardiac troponin T levels, it may be used as a non-invasive marker of ischemic injury in patients with unstable angina.