OBJECTIVE:To evaluate the effects of eliminating the routine use of oral opioids for postcesarean delivery analgesia on postcesarean opioid consumption.
METHODS:At a tertiary care center, we ...implemented a quality improvement intervention among faculty practice patients undergoing cesarean delivery, which consisted of 1) eliminating routine ordering of oral opioids after cesarean delivery, 2) implementing guidelines for ordering a short course of opioids when deemed necessary, and 3) coupling opioid prescribing at discharge to patterns of opioid use in-hospital combined with shared decision-making. All patients, both before and after the intervention, were administered neuraxial opioids and scheduled acetaminophen and nonsteroidal antiinflammatory medications in the absence of contraindications. The primary outcome was the percentage of women who used any opioids postoperatively in-hospital. Secondary outcomes included the percentage of women discharged with a prescription for opioids, the quantity of opioids used in-hospital, pain scores, satisfaction, opioid-related side effects, and opioid prescriptions ordered in the 6 weeks after delivery. The effects of this intervention were assessed based on a chart review of patient data and a survey of patients in the 12 weeks before and 12 weeks after the intervention.
RESULTS:We evaluated the records of 191 postcesarean delivery patients before and 181 after the intervention. Less than half of women used oral opioids in-hospital after the intervention, 82 (45%) compared with 130 (68%) before (P<.001). However, there was no change in pain scores or overall satisfaction with pain relief. Postintervention, only 40% of patients were discharged with prescriptions for opioids compared with 91% of patients before the intervention (P<.001).
CONCLUSION:Eliminating routine ordering of oral opioids after cesarean delivery is associated with a significant decrease in opioid consumption while maintaining the same levels of pain control and patient satisfaction. Oral opioids are not needed by a large proportion of women after cesarean delivery.
Aim
To investigate (1) the cytotoxic potential of the brown precipitate (BP) formed with sodium hypochlorite (NaOCl) and chlorhexidine gluconate (CHX), using both a small animal model of ...Caenorhabditis elegans (C. elegans) and cultured human gingival fibroblasts; and (2) the chemical composition of BP using Time‐of‐Flight Secondary Ion Mass Spectrometry (ToF‐SIMS).
Methodology
Brown precipitate was obtained by mixing equal volumes of 6% NaOCl and 2% CHX and separating the BP from clear supernatant by centrifugation. The brown precipitate was weighed and solubilized in dimethyl sulfoxide for cytotoxicity experiments. The cytotoxic effect of BP was assessed using C. elegans larvae and primary immortalized human gingival fibroblasts‐hTERT (hTERT‐hNOF) cells. Various dilutions of BP (25 ng/µL–150 ng/µL), supernatant (0.15% v/v), NaOCl (1:100–1:1000 dilutions of 6% NaOCl) or CHX (1:500–1:1000 dilutions of 2% CHX) along with vehicle control (0.5% v/v ethanol and 0.15% v/v DMSO) or untreated control (growth medium) were tested on C. elegans larvae and hTERT‐hNOF cells. Viability was assessed in C. elegans larvae using stereomicroscopy and in hTERT‐hNOF cells using dehydrogenase‐based colorimetric assay. ToF‐SIMS was used to assess the chemical composition of BP in comparison with CHX and para‐chloroaniline (PCA). The C. elegans and cell line data were analysed using Log‐Rank test and Student's t‐test, respectively (p < .05).
Results
BP‐75 ng/µL and BP‐150 ng/µL were significantly more toxic to C. elegans larvae than the untreated, vehicle, supernatant or CHX treatment groups (p < .0001). Similarly, in hTERT‐hNOF cells, BP‐50 ng/µL, BP‐75 ng/µL and BP‐150 ng/µL induced significant cytotoxicity within 2 h compared with untreated, vehicle, supernatant and CHX treatments (p < .05). ToF‐SIMS analysis of BP revealed ion composition characteristic of both CHX and the carcinogen PCA.
Conclusions
Brown precipitate was toxic in both C. elegans larvae and hTERT‐hNOF cells. The ToF‐SIMS analysis of BP revealed ions characteristic of CHX and PCA that could account for the toxicities observed in C. elegans larvae and human gingival fibroblasts. Because of the insoluble and toxic nature of BP, consecutive use of CHX and NaOCl irrigants should be avoided in root canal treatment.
Zoster sine herpete 16 Ramsay Hunt syndrome 7 Trauma 4 Tumour 4 Otitis media or cholesteatoma 3 Neonatal conditions 6 Rare and unusual conditions 4 Recent developments Bell's palsy is probably caused ...by herpes viruses, mainly herpes simplex virus type 1 and herpes zoster virus Facial palsy improves after treatment with combined oral aciclovir and prednisone Treatment of partial Bell's palsy is controversial; a few patients don't recover if left untreated Treatment is probably more effective before 72 hours and less effective after seven days A fifth of cases of acute facial palsy have an alternative cause that should be managed appropriately Increasing evidence implies that the main cause of Bell's palsy is latent herpes viruses (herpes simplex virus type 1 and herpes zoster virus), which are reactivated from cranial nerve ganglia. ...decompression surgery for Bell's palsy is not routinely offered in the United Kingdom.
Purpose
To evaluate course directors’ feedback on the assessment methods used during the coronavirus disease 2019 (COVID‐19) pandemic and identify effective approaches for future assessments in ...dental education.
Methods
Course directors at the US dental schools were surveyed for changes in assessments implemented during the early stages of the pandemic (March–July 2020) using the Qualtrics platform. The survey questions addressed assessment methods utilized in didactic, preclinical, and clinical arenas pre‐COVID‐19 (before March 2020) and during the early phase of the pandemic (between March and July 2020) and identified any sustained changes in assessments post‐COVID‐19. Of the 295 responses for the type of courses directed, 48%, 22%, and 30% responses were for didactic, pre‐clinical, and clinical assessments, respectively. Chi‐square tests and 95% confidence intervals were used to assess quantitative differences.
Results
Computer‐based un‐proctored and remote– proctored assessments increased whereas paper‐based in‐person proctored assessments decreased during an early pandemic. For pre‐clinical and clinical courses, objective‐structured clinical exams and case‐based assessments increased whereas, for didactic courses, the number of presentations, short‐answer, and multiple‐choice questions‐based assessments increased. Specimen‐based assessments and patient‐based encounters decreased significantly in didactic and clinical courses, respectively. Manikin‐based exams increased in clinical but not in pre‐clinical courses. Survey respondents disagreed that alternative assessments helped students learn better, resulted in better course evaluations, or were an equivalent replacement for pre‐COVID‐19 assessments. Interestingly, 49% of respondents indicated a likelihood of continuing alternative assessments whereas 36% were unlikely and 15% were neutral.
Conclusions
A combination of effective pre‐pandemic and innovative alternative assessments developed during the pandemic may be the new normal in the dental education curriculum.
Purpose
To evaluate student perception of integrating biomedical and clinical sciences based on survey of dental students on the concurrent teaching of a didactic systems‐based course and a ...case‐based course.
Methods
First‐year to fourth‐year students (DS1–DS4) students were surveyed for their experiences in concurrent teaching. Student response rate for the survey was 55% (229/420). Pearson's Chi‐squared tests and Kruskal‐Wallis rank sum tests were used to assess statistical significance (p < 0.05).
Results
Of the students surveyed, 83% strongly agreed or agreed that concurrent teaching of the didactic and case‐based courses helped them better understand the biomedical science background and the clinical ramifications (p < 0.001). On average, 75% percent strongly agreed or agreed that concurrent teaching kept them engaged, motivated, think critically, apply the course content and prepare for clinical practice (p < 0.001). Of the students surveyed, 69% support expanding concurrent teaching to all four years (p < 0.001). Mean responses from DS1 and DS4 students differed for questions relating to understanding of biomedical sciences, critical thinking and application to clinic (p < 0.01). Qualitative data showed that students enjoyed the reinforcement of concepts and application to clinical scenarios.
Conclusions
Concurrent teaching of didactic and case‐based learning courses, thus showing clinical relevance of biomedical sciences in the first year of dental curriculum, is perceived by students as an effective method of educating dental students. Such integrative learning process with horizontal and vertical integration and concurrent curriculum is even more relevant with the implementation of the integrated national board dental examination.
Both temporomandibular disorders (TMDs) and sleep bruxism (SB) are known to be destructive to the masticatory system. However, the association between the 2 conditions is poorly understood. The aim ...of our study was to assess the relationship between TMD and SB through the signs and symptoms in 2 patient groups: TMD only and TMD with SB.
A retrospective chart review was conducted from November 1, 2015, to April 1, 2018, on patients with completed International Network for Orofacial Pain and Related Disorders Methodology history questionnaires and Diagnostic Criteria for Temporomandibular Disorder clinical examinations. Fifty-two patients, including 12 with TMD only and 40 with TMD with SB, met the study criteria. Subjective descriptions and objective measurements of patient symptoms were investigated. The χ2 test and Fisher's exact test were used for statistical analysis.
The TMD with SB group exhibited increased oral behaviors compared with the TMD-only group (P = .0004). The TMD with SB group also experienced more headaches compared with the TMD-only group (P = .045).
Our results revealed that patients with jaw pain who self-report increased oral behaviors and/or exhibit temporal headaches should be evaluated for sleep bruxism.
Objectives
To evaluate intermediate treatments between sodium hypochlorite and chlorhexidine gluconate irrigations for the prevention of a toxic brown precipitate in root canal therapy.
Materials and ...Methods
Thirty‐nine premolars were irrigated with 6% sodium hypochlorite and divided into either: No intermediate treatment; Dry paper points; three different irrigations with 17% ethylenediaminetetraacetic acid, deionized water, or 5% sodium thiosulfate. 2% chlorhexidine gluconate was the final irrigant in all groups. Sectioned teeth were analyzed for brown precipitate intensity and area using stereomicroscopy and components related to para‐chloroaniline using Time‐of‐Flight Secondary Ion Mass Spectrometry (ToF‐SIMS).
Results
Stereomicroscopy showed that 5% STS significantly reduced brown precipitate intensity and area as compared with no intermediate irrigation (p < .05, Chi‐square, generalized linear model, and Tukey's multiple comparison tests). Utilizing ToF‐SIMS, 5% sodium thiosulfate was most effective in reducing the components representing para‐chloroaniline and chlorhexidine gluconate.
Conclusion
The 5% sodium thiosulfate was most effective among other intermediate treatments, assessed by stereomicroscopy and ToF‐SIMS.
To assess the importance of 2 variables, transducer tip diameter and resection of the round window (RW) niche, affecting the optimization of the mechanical stimulation of the RW membrane with an ...active middle ear implant (AMEI).
Ten temporal bones were prepared with combined atticotomy and facial recess approach to expose the RW. An AMEI stimulated the RW with 2 ball tip diameters (0.5 and 1.0 mm) before and after the resection of the bony rim of the RW niche. The RW drive performance, assessed by stapes velocities using laser Doppler velocimetry, was analyzed in 3 frequency ranges: low (0.25-1 kHz), medium (1-3 kHz) and high (3-8 kHz).
Driving the RW produced mean peak stapes velocities (H(EV)) of 0.305 and 0.255 mm/s/V at 3.03 kHz, respectively, for the 1- and 0.5-mm tips, with the RW niche intact. Niche drilling increased the H(EV) to 0.73 and 0.832 mm/s/V for the 1- and 0.5-mm tips, respectively. The tip diameter produced no difference in output at low and medium frequencies; however, the 0.5-mm tip was 5 and 6 dB better than the 1-mm tip at high frequencies before and after niche drilling, respectively. Drilling the niche significantly improved the output by 4 dB at high frequencies for the 1-mm tip, and by 6 and 10 dB in the medium- and high-frequency ranges for the 0.5-mm tip.
The AMEI was able to successfully drive the RW membrane in cadaveric temporal bones using a classical facial recess approach. Stimulation of the RW membrane with an AMEI without drilling the niche is sufficient for successful hearing outputs. However, the resection of the bony rim of the RW niche significantly improved the RW stimulation at medium and higher frequencies. Drilling the niche enhances the exposure of the RW membrane and facilitates positioning the implant tip.
Hyperbaric oxygen therapy for Bell's palsy Holland, N Julian; Bernstein, Jonathan M; Hamilton, John W ...
Cochrane database of systematic reviews,
02/2012, Volume:
2016, Issue:
7
Journal Article
Peer reviewed
Open access
Background
Bell's palsy is an idiopathic, acute unilateral facial weakness that evolves rapidly and is maximal within two days. Moderate ear discomfort, sensitivity to sound and reduced tearing may ...occur.
Objectives
To assess the effects of hyperbaric oxygen therapy on recovery of facial function in adults with moderate to severe Bell's palsy.
Search methods
We searched the Cochrane Neuromuscular Disease Group Specialized Register (January 2012), CENTRAL (2011, Issue 4), MEDLINE (January 1966 to January 2012), EMBASE (January 1980 to January 2012), CINAHL (1937 to January 2012), AMED (1985 to January 2012), LILACS (January 1982 to January 2012). In addition we made a systematic search for relevant controlled trials in specific hyperbaric literature sources.
Selection criteria
Randomised controlled trials or quasi‐randomised controlled trials of adults (over 16 years of age) undergoing hyperbaric oxygen therapy for moderate to severe Bell's palsy. We considered studies to be of sufficient quality for inclusion in the review only if there was blinding in the assessment of the facial palsy grade. We planned to include studies of HBOT used as adjuvant therapy, or in addition to routine medical therapy (including corticosteroids or antivirals, or both). Both treatment and control groups were to receive the same baseline therapy. HBOT had to be delivered at concentrations greater than or equal to 1.2 ATA in a hyperbaric oxygen chamber as a series of dives of 30 to 120 minutes.
Data collection and analysis
Two reviewers independently assessed eligibility and study quality and extracted data. We contacted study authors for additional information.
Main results
Our searches found no randomised controlled trials or quasi‐randomised controlled trials that met the eligibility criteria for this review.
There is very low quality evidence from one randomised trial involving 79 participants with acute Bell's palsy, but this study was excluded as the outcome assessor was not blinded to treatment allocation and thus did not meet pre‐defined eligibility criteria. The trial compared 42 people who received hyperbaric oxygen therapy (2.8 atmospheres for 60 minutes twice daily, five days per week until the facial palsy resolved; maximum 30 'dives') and placebo tablets with 37 people who received placebo hyperbaric oxygen therapy (achieving only a normal partial pressure of oxygen) and prednisone (40 mg twice daily, reducing over eight days). Facial function recovered in more participants treated with hyperbaric oxygen therapy than with prednisone (hyperbaric oxygen therapy, 40/42 (95%); prednisone, 28/37 (76%); risk ratio 1.26, 95% CI 1.04 to 1.53). There were no reported major complications and all participants completed the trial.
Authors' conclusions
Very low quality evidence from one trial suggests that hyperbaric oxygen therapy may be an effective treatment for moderate to severe Bell's palsy, but this study was excluded as the outcome assessor was not blinded to treatment allocation. Further randomised controlled trials are needed.
Mechanical stimulation of the round window (RW) with an active middle ear prosthesis (AMEP) has shown functional benefit in clinical reports in patients with mixed hearing loss (MHL). Further ...objective physiological data on the efficacy of RW stimulation is needed, however, to demonstrate that RW stimulation with an AMEP can generate input to the inner ear comparable to acoustic input.
Cochlear microphonic (CM) and mechanical (stapes velocity) responses to sinusoidal stimuli were measured by electrode and laser Doppler vibrometry in eight chinchillas in response to normal acoustic stimulation via sealed calibrated insert earphones and to AMEP stimulation (Otologics MET, Boulder, CO, USA) of the RW with and without lateral ossicular chain disarticulation.
CM thresholds for acoustic stimulation were frequency dependent and ranged from 16 to 50dB SPL. CM thresholds measured with RW stimulation ranged from −14 to 35dBmV with an intact middle ear chain and from −7 to 36dBmV after lateral ossicular chain disarticulation. Acoustically, stapes velocity maxima was observed at ∼700Hz and minima at ∼2.65kHz. With application of the AMEP to the RW, peak stapes velocity was observed at 2–3kHz. The equivalent ear canal sound pressure level (LEmaxdB SPL) evoked by RW stimulation with the AMEP was 60–105dB SPL for the intact middle ear and 70–100dB SPL after ossicular chain disarticulation.
Stimulating the inner ear through the RW with an AMEP produces evoked responses (CM) comparable to normal acoustic input. When adjusted for threshold (due to unit differences, dB SPL or dB mV), the sensitivity of the CM (slope) for acoustic was comparable to sensitivities obtained by AMEP stimulation of the RW. Mechanical stimulation of the RW with an AMEP produces cochlear responses (CMs) and stapes velocities that are functionally equivalent to acoustic stimulation.
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