Dental hypersensitivity: recent advances in diagnosis and treatment

Perirenal extravasation of urine with an intact renal parenchyma and with dye visualized in the ureter was seen on an excretory urogram (IVP) and computed tomographic (CT) scan in two patients (bilateral in one) with multiple injuries following blunt trauma. Expectant management with no invasive procedures resulted in disappearance of the extravasation within 3 to 5 days. Traumatic rupture of a calyceal fornix is thought to be the cause of the extravasation similar to the perirenal extravasation seen with renal colic from a ureteral calculus.     

Diagnosis and management of ischemic heart disease in the patient scheduled to undergo electroconvulsive therapy

The cardiovascular risk of electroconvulsive therapy (ECT) is a product of the stress of ECT itself and the severity and stability of coronary artery disease (CAD), as well as other cardiovascular factors. ECT itself represents a relatively low-risk procedure. Patient-specific risk can be defined by a combination of clinical evaluation and noninvasive testing, much of which is aimed at detecting the presence and staging the severity and stability of CAD. Patients at high risk of a cardiac complication include those with severe or unstable symptoms of CAD, and they should undergo extensive cardiac evaluation before ECT Patients at low risk likely need no further evaluation and can undergo ECT. Patients at intermediate risk should have careful clinical evaluation, and most likely noninvasive evaluation, which should include some form of stress testing. Medical therapy should be continued and/or maximized in all patients with CAD. It is expected that with careful screening, patients with established CAD can undergo ECT safely.     

A successful treatment of drug-resistant depression with electroconvulsive therapy

A woman aged 56 had been treated at the age of 23 for a psychotic depression with vital characteristics in the context of a bipolar disorder. The treatment included electroconvulsive therapy (ECT). From the age of 47, she suffered relapses; drug treatment proved inadequate. For the last 3 years, ECT was administered, which resulted in a good condition. ECT is an effective treatment in patients with depression resistant to medication. However, in spite of continuation pharmacotherapy, the proportion of patients relapsing within 6 months after successful ECT is large. For these patients, continuation ECT may be an efficacious method.     

Cytokines in the treatment of leishmaniasis: from studies of immunopathology to patient therapy

The genus Leishmania, an obligate intramacrophage parasite, causes a wide spectrum of clinical diseases. It is worldwide in distribution and causes 20 million new cases annually with an at risk population of approximately 1.5 billion persons. The most severe forms are associated with high morbidity, mortality and relapses with conventional therapy. The therapeutic issues and responses to standard and alternative therapies are reviewed. Recent developments in molecular biology and immunology methods employed in the study of leishmaniasis have defined an intricate interaction of the parasite with host immune system. Perturbation of the host immune responses may be part of the survival mechanisms of Leishmania. In murine model, the finding of T helper cells that differ by their panel of cytokines has allowed a more precise definition of immunopathogenesis of leishmaniasis. Preliminary data from leishmaniasis patients lend support to this concept of altered immunomodulation. Furthermore, the data from leishmaniasis patients lend support to this concept of altered enhancement of therapeutic response by interferon-gamma has provided a new approach for treatment of patients using recombinant cytokines and for the study of the disease. Current research for early diagnosis, alternative therapies and need for vaccines are reviewed in the context of the immunopathology of leishmaniasis.     

Cervical screening adjuncts: recent advances

In an effort to reduce the false-negative rate of cervical cytologic findings, several new technologies have recently evolved. Automated cytologic testing (PapNet, AutoPap 300 QC) proposes to rescreen negative conventional cytologic findings to identify smears likely to be false negative. Fluid-based monolayers (ThinPrep, CytoRich) propose to reduce the false-negative rates by optimizing the collection and preparation of cells. Human papillomavirus deoxyribonucleic acid testing by Hybrid Capture has been proposed for a variety of screening and triage roles. Visual screening after application of acetic acid is done by cervicography by use of a photographic technique, whereas in speculoscopy the screening is done by direct visualization of the cervix by the primary care provider. Polarprobe uses biophysical parameters and a computer algorithm to give an instantaneous prediction of the likelihood of cervical disease. Each of these techniques, as well as the clinical experience with them, is reviewed. Current and possible future uses are discussed with regard to both clinical usefulness and cost-effectiveness.     

Propofol and electroconvulsive therapy in a patient at risk from acute intermittent porphyria

Evidence for the involvement of the cranial arterial system in migraine is plentiful, but it is unclear whether the cranial venous system may be involved in the mechanism of migraine pain. Venules are the preferentially involved vessels in the neurogenic inflammation animal model of migraine. The cranial and cerebral veins and sinuses are pain sensitive and receive sensory innervation from the trigeminal nerve. If the veins are involved in migraine pathogenesis, a venous dilatation would presumably be painful. The effect of a short lasting cranial venous dilatation, induced by applying pressure on the internal jugular veins (Queckenstedt's manoeuvre), was therefore compared with a placebo procedure, consisting of an equal pressure applied on to the lateral aspect of the neck. In each procedure pressure was applied for 10 seconds. The study used a single blind, randomised, cross over design, and 20 patients with an acute attack of migraine without aura participated. After each procedure, headache intensity was rated on a standardised five point scale. After Queckenstedt's manoeuvre 40% of the patients reported no change in headache intensity, 25% a worsening, and 35% an improvement of their headache. No significant difference between the headache intensity ratings during Queckenstedt's manoeuvre and the placebo manoeuvre was found (p=0.22). The findings make it unlikely that the cephalic venous system is of major importance in migraine pain mechanisms and, therefore, also less likely that neurogenic inflammation plays a significant part in humans during attacks of migraine without aura.     

From genes to gene medicines: recent advances in nonviral gene delivery

Over the last decade, research in somatic gene therapy has focused on selected approaches to deliver therapeutic genes to cells both ex vivo and in vivo. While most current gene therapy clinical trials are based on cell- and viral-mediated approaches, nonviral gene medicines are emerging as potentially safe and effective in the treatment of a wide variety of genetic and acquired diseases. Nonviral technologies consist of plasmid-based expression systems containing a gene encoding a therapeutic protein and synthetic gene delivery systems. In addition to the therapeutic gene, plasmid-based expression systems contain other genetic sequences to control the in vivo production and secretion of a protein. They may include elements that prolong extrachromosomal gene expression, cell-specific promoters and, optionally, gene switches for enabling drug-regulated gene therapy. Unique gene delivery systems will be required depending upon the biology and (patho)physiology of the target tissue. This review provides a critical view of gene therapy with a major focus on advanced nonviral technologies to control the in vivo location and function of administered genes.     

Preconditioning the human myocardium: recent advances and aspirations for the development of a new means of cardioprotection in clinical practice

Ischemic preconditioning has been shown to be one of the most powerful means of protecting the myocardium from ischemic injury in experimental animal models, although the mechanism is incompletely understood. In this review we discuss the evidence for preconditioning occurring in ischemic syndromes in humans, whether the human myocardium can be preconditioned, and whether preconditioning would have a place as a therapeutic tool in clinical practice. Some studies evaluating patients after acute myocardial infarction have shown a better outcome in patients reporting angina before the onset of the infarction, but this is not a universal finding, and it is difficult to exclude other confounding factors, such as collateral flow, from influencing the results. More controlled prospective studies have evaluated patients undergoing percutaneous transluminal coronary angioplasty and have found less ST-segment change and less reported angina during the second balloon inflation when compared with the first. Again, it is impossible to completely exclude other causes for this effect, but the dependence on mechanisms that are known to be important for preconditioning in animal models does suggest the phenomena are the same. Further experiments using isolated human atrial muscle have shown that human myocardium can be preconditioned and that the mechanisms involved are similar to those elucidated in animal models (adenosine, protein kinase C, and ATP-dependent potassium channels). In clinical medicine preconditioning is most likely to benefit patients when it is used to protect against the ischemia induced by cardiac surgery. In this respect, a study has shown that in patients undergoing coronary artery bypass grafts, the reduction in ATP occurring during the first ischemic period is attenuated in those given an ischemic preconditioning protocol beforehand. Despite these advances, it is likely that the full potential of preconditioning in clinical practice will not be realized until the whole mechanism of protection is understood and a safe pharmacological "preconditioning" agent becomes available.     

Relationship of seizure duration to antidepressant efficacy in electroconvulsive therapy

BACKGROUND: Aprotinin and epsilon-aminocaproic acid are routinely used to reduce bleeding during cardiac surgery. The marked difference in average wholesale cost between these two drug therapies (aprotinin, $1,080 vs. epsilon-aminocaproic acid, $11) has generated significant controversy regarding their relative efficacies and costs. METHODS: In a multicenter, randomized, prospective, blinded trial, patients having repeated cardiac surgery received either a high-dose regimen of aprotinin (total dose, 6 x 10(6) kallikrein inactivator units) or epsilon-aminocaproic acid (total dose, 270 mg/kg). RESULTS: Two hundred four patients were studied. Overall (data are median [25th-75th percentiles]), aprotinin-treated patients had less postoperative thoracic drainage (511 ml [383-805 ml] vs. 655 ml [464-1,045 ml]; P = 0.016) and received fewer platelet transfusions (0 [range, 0-1] vs. 1 [range, 0-2]; P = 0.036). The surgical field was more likely to be considered free of bleeding in aprotinin-treated patients (44% vs. 26%; P = 0.012). No differences, however, were seen in allogeneic erythrocyte transfusions or in the time required for chest closure. Overall, direct and indirect bleeding-related costs were greater in aprotinin- than in epsilon-aminocaproic acid-treated patients ($1,813 [$1,476-2,605] vs. $1,088 [range, $511-2,057]; P = 0.0001). This difference in cost per case varied in magnitude among sites but not in direction. CONCLUSIONS: Aprotinin was more effective than epsilon-aminocaproic acid at decreasing bleeding and platelet transfusions. Epsilon-aminocaproic acid, however, was the more cost-effective therapy over a broad range of estimates for bleeding-related costs in patients undergoing repeated cardiac surgery. A cost-benefit analysis using the lower cost of half-dose aprotinin ($540) still resulted in a significant cost advantage using epsilon-aminocaproic therapy (P = 0.022).     

Dexmedetomidine failed to block the acute hyperdynamic response to electroconvulsive therapy

BACKGROUND: Orally administered clonidine (0.2-0.3 mg) has been reported to decrease the acute hypertensive response to electroconvulsive therapy (ECT) without prolonging early recovery. This preliminary study was designed to evaluate the acute hemodynamic effects of the investigational alpha2-adrenergic agonist, dexmedetomidine, in patients undergoing a series of ECT treatments. METHODS: Six patients undergoing a series of three to six consecutive ECT treatments were studied according to a randomized, double-blind, placebo-controlled protocol All patients received either saline or dexmedetomidine, 0.5 or 1.0 microg/kg intravenously, 10-30 min before induction of anesthesia for ECT using a standardized anesthesia protocol. In addition to assessing the cardiovascular variables, the duration of seizure activity, degree of sedation, and time to discharge from the Phase I recovery unit were assessed. RESULTS: Although dexmedetomidine produced dose-related increases in the level of sedation before the ECT procedure, it failed to decrease the peak blood pressure and heart rate responses after the ECT treatment. The 0.5 and 1.0 microg/kg doses of dexmedetomidine prolonged the times to orientation and to discharge from the Phase I unit. CONCLUSIONS: The results of this pilot study suggest that dexmedetomidine (0.5-1.0 microg/kg given intravenously) is not beneficial in controlling the acute hyperdynamic response after ECT.     

Use of EEG in electroconvulsive therapy

BACKGROUND: From the point of view of time we can divide the use of EEG in the electroconvulsive therapy into 1) screening before starting the treatment, 2) the EEG correlates of the ECT: recording of the paroxysm, immediate postparoxysmal recording, interparoxysmal recording during a series of ECT, and persistent changes after finishing the series of ECT. METHODS AND RESULTS: EEG screening has shown that the patients with abnormal EEG do not respond well to ECT. In the recording of the paroxysm EEG correlates with therapeutic effect of ECT are looked for--particularly the length of the paroxysm on the EEG, intensity and pattern of the paroxysmal activity, and the suppression of the EEG curve in the terminal part of the paroxysm. The suppression models are in the focus of interest also in the immediate postparoxysmal recording. In the interparoxysmal recordings during a series of ECT the associations of the generalised slowing in the range of the theta and delta activity with the therapeutic effect were looked for, particularly in the past. Persistent changes after finishing the ECT are usually examined especially to look if ECT does not cause persistent abnormalities of the EEG recording which would be an evidence for brain damage or for epileptic kindling. The results in this direction have been negative so far.     

Molecular biology of opioid receptors: recent advances

Endogenous opioid peptides and opiates like morphine produce their pharmacological effects through the membrane bound opioid receptors. These receptors belong to a superfamily of G-protein-coupled receptors, all of which possess seven membrane-spanning regions. Structure-activity relationship studies of opioids opened up new avenues for the pharmacological characterization of the opioid receptors. As a further advancement in this direction, molecular cloning has led to the identification of three different types of opioid receptors -- OP1 (delta), OP2 (kappa) and OP3 (mu) -- thereby supporting the results of earlier pharmacological studies which postulated their existence. The three opioid receptors are highly homologous. Consequent to the development of highly specific and selective agonists and antagonists, it was proposed that the three types of opioid receptors could be further categorized into different subtypes. However, the molecular biology data generated so far do not support the presence of the various subtypes of the three well-characterized opioid receptors. Recent strides towards the advancement of our knowledge relating to the molecular biology of these receptors have been reviewed in this article.     

Obsessive-compulsive disorder responsive to electroconvulsive therapy in an elderly woman

An elderly woman with a long history of obsessive-compulsive disorder (OCD) was treated with electroconvulsive therapy (ECT) after intractable depression developed. OCD had been well established for many years before onset of the depressive symptoms. After ECT, there was resolution of both OCD and depression. The patient eventually had relapse and was treated with maintenance ECT.     

Impact of advances in diabetes care on dental treatment of the diabetic patient

In medicine and dentistry, studies are published periodically that have a potentially wide-ranging impact on patient health and management. One such study is the Diabetes Control and Complications Trial (DCCT), which offers new hope for millions of individuals with diabetes and has begun to significantly alter medical management of these patients. Advances in the medical treatment of diabetes require a heightened awareness by dental practitioners of the various treatment regimens of their patients with diabetes, especially because of potential complications associated with diabetes care. Intensive medical treatment with oral agents and exogenous insulin injection promises to decrease the long-term risks of major complications of diabetes, but these treatments increase the risk of medical emergencies, especially hypoglycemia. This article reviews the findings of the DCCT, diabetes treatment regimens that might be encountered in a dental practice, and potential alterations to dental treatment protocols.