Antimicrobial Photodynamic Therapy in the Non-Surgical Treatment of Aggressive Periodontitis: Cytokine Profile in Gingival Crevicular Fluid, Preliminary Results

Background: Aggressive periodontitis is a specific form of periodontal disease that is characterized by rapid attachment loss and bone destruction. Cytokine profiles are of considerable value when studying disease course during treatment. The aim of this trial was to investigate cytokine levels in the gingival crevicular fluid (GCF) of patients with aggressive periodontitis, after treatment with photodynamic therapy (PDT) or scaling and root planing (SRP), in a split-mouth design on -7, 0, +1, +7, +30, and +90 days. Methods: Ten patients were randomly treated with PDT using a laser source associated with a photosensitizer or SRP with hand instruments. GCF samples were collected, and the concentrations of tumor necrosis factor-alpha (TNF-alpha) and receptor activator of nuclear factor-kappa B ligand (RANKL) were determined by enzyme-linked immunosorbent assays. The data were analyzed using generalized estimating equations to test the associations among treatments, evaluated parameters, and experimental times (alpha = 0.05). Results: Non-surgical periodontal treatment with PDT or SRP led to statistically significant reductions in TNF-alpha level 30 days following treatment. There were similar levels of TNF-alpha and RANKL at the different time points in both groups, with no statistically significant differences. Conclusion: SRP and PDT had similar effects on crevicular TNF-alpha and RANKL levels in patients with aggressive periodontitis. J Periodontol 2009;80:98-105.

Comparison between two surgical techniques for root coverage with an acellular dermal matrix graft

Aim: The aim of this randomized, controlled, clinical study was to compare two surgical techniques with the acellular dermal matrix graft (ADMG) to evaluate which technique could provide better root coverage. Material and Methods: Fifteen patients with bilateral Miller Class I gingival recession areas were selected. In each patient, one recession area was randomly assigned to the control group, while the contra-lateral recession area was assigned to the test group. The ADMG was used in both groups. The control group was treated with a broader flap and vertical-releasing incisions, and the test group was treated with the proposed surgical technique, without releasing incisions. The clinical parameters evaluated before the surgeries and after 12 months were: gingival recession height, probing depth, relative clinical attachment level and the width and thickness of keratinized tissue. Results: There were no statistically significant differences between the groups for all parameters at baseline. After 12 months, there was a statistically significant reduction in recession height in both groups, and there was no statistically significant difference between the techniques with regard to root coverage. Conclusions: Both surgical techniques provided significant reduction in gingival recession height after 12 months, and similar results in relation to root coverage.

Flap vs. ""flapless"" surgical approach at immediate implants: a histomorphometric study in dogs

Aim To compare the remodeling of the alveolar process at implants installed immediately into extraction sockets by applying a flap or a ""flapless"" surgical approach in a dog model. Material and methods Implants were installed immediately into the distal alveoli of the second mandibular premolars of six Labrador dogs. In one side of the mandible, a full-thickness mucoperiosteal flap was elevated (control site), while contra-laterally, the mucosa was gently dislocated, but not elevated (test site) to disclose the alveolar crest. After 4 months of healing, the animals were sacrificed, ground sections were obtained and a histomorphometric analysis was performed. Results After 4 months of healing, all implants were integrated (n=6). Both at the test and at the control sites, bone resorption occurred with similar outcomes. The buccal bony crest resorption was 1.7 and 1.5 mm at the control and the test sites, respectively. Conclusions ""Flapless"" implant placement into extraction sockets did not result in the prevention of alveolar bone resorption and did not affect the dimensional changes of the alveolar process following tooth extraction when compared with the usual placement of implants raising mucoperiosteal flaps. To cite this article:Caneva M, Botticelli D, Salata LA, Souza SLS, Bressan E, Lang NP. Flap vs. ""flapless"" surgical approach at immediate implants: a histomorphometric study in dogs.Clin. Oral Impl. Res. 21, 2010; 1314-1319.doi: 10.1111/j.1600-0501.2009.01959.x.

Optimization in multi-implant placement for immediate loading in edentulous arches using a modified surgical template and prototyping: A case report

Immediate loading of dental implants shortens the treatment time and makes it possible to give the patient an esthetic appearance throughout the treatment period. Placement of dental implants requires precise planning that accounts for anatomic limitations and restorative goals. Diagnosis can be made with the assistance of computerized tomographic scanning, but transfer of planning to the surgical field is limited. Recently, novel CAD/CAM techniques such as stereolithographic rapid prototyping have been developed to build surgical guides in an attempt to improve precision of implant placement. The aim of this case report was to show a modified surgical template used throughout implant placement as an alternative to a conventional surgical guide.

Immediate reconstruction following breast-conserving surgery: Management of the positive surgical margins and influence on secondary reconstruction

The efficacy of breast-conserving Surgery for the local control of early breast cancer has been repeatedly evidenced. Although immediate reconstruction following breast-conserving Surgery has been described, little information is available regarding surgical management in reoperative settings due to positive margins. We studied the influence of intraoperatively assessed and postoperatively controlled Surgical margin status on the type of breast-conserving Surgery and report our results regarding complications in a reoperative breast reconstruction scenario. All patients were seen by a multidisciplinary team who recommended breast-conserving surgery. According to the breast volume, ptosis and tumor size/location, the patients were also evaluated by a plastic Surgeon, who recommended reconstruction with the appropriate technique. Intraoperative assessment Of Surgical margins was determined by histological examination of frozen sections. The mean follow-up time was 48 months. Two hundred and eighteen patients (88.5%) underwent breast-conserving Surgery and immediate reconstruction. Twelve (5.5%) patients had a positive tumor margin after review of the permanent section. All patients underwent re-exploration. In 1.3%, a second reconstructive technique was indicated and in 2.2% a skin-sparing mastectomy with total reconstruction was performed. Our findings support the important role of the intraoperative assessment of surgical margins and its interference in the selection of reconstruction techniques and negative margins: however, it will not guarantee complete excision of the tumor. Success depends on coordinated planning with the oncologic Surgeon and careful intraoperative management, (C) 2008 Elsevier Ltd. All rights reserved.

Efficacy of high intensity diode laser as an adjunct to non-surgical periodontal treatment: a randomized controlled trial

The high intensity diode laser has been studied in periodontics for the reduction of subgingival bacteria in non-surgical treatment. Our study evaluated the bacterial effect as well as changes in periodontal clinical parameters promoted by root scaling and planing associated with this wavelength. Twenty-seven patients randomly assigned in two groups underwent root scaling and planing on the tested sites, and only the experimental group received the diode laser irradiation. Among the clinical parameters studied, the clinical probing depth (CPD) and the clinical attachment level (CAL) resulted in significant enhancement in the control group when compared with the experimental group (P = 0.014 and P = 0.039, respectively). The results were similar for both groups regarding the plaque index (PI) and bleeding on probing (BP). No significant difference in the microbiological parameters was observed between the control and experimental groups. It was possible to conclude that the high power diode laser adjunct to the non-surgical periodontal treatment did not promote additional effects to the conventional periodontal treatment.

Energy-dispersive X-ray fluorescence analysis of a pre-Columbian funerary gold mask from the Museum of Sican, Peru

A funerary gold mask from the Museum of Sican, Ferranafe, Peru was analyzed in 30 different areas using a portable equipment using energy-dispersive X-ray fluorescence. It was deduced from the measurements that the main sheet of the mask and the majority of the pendants have a similar composition and are made of tumbaga, which means a poor gold alloy enriched at the surface by depletion gilding, and have a similar `equivalent` gilding thickness of about 5 mu m. The nose, also on tumbaga, has different composition and a thickness of about 8 mu m. The clamps are on gilded or on silvered copper. The red pigment dispersed on the surface of the mask is cinnabar. Copyright (C) 2009 John Wiley & Sons, Ltd.

Existential issues in surgical care : Nurses’ experiences and attitudes in caring for patients with cancer

The overall aim of this thesis was to explore surgical nurses’ experiences of being confronted with patients’ existential issues when caring for patients with cancer, and to examine whether an educational intervention may support nurses in addressing existential needs when caring for patients with cancer. Previously recorded discussions from supervision sessions with eight healthcare professionals were analysed (I), written descriptions of critical incidents were collected from 10 nurses, and interviews with open questions were conducted (II). An educational intervention on existential issues was pilot tested and is presented in Studies III and IV. The intervention was the basis of a pilot study with the purpose of testing whether the whole design of the educational intervention, including measurements instruments, is appropriate. In Study III and IV interviews with 11 nurses were conducted and 42 nurses were included in the quantitative measurements of four questionnaires, which were distributed and collected. Data was analysed using qualitative secondary analysis (I), hermeneutical analysis (II), and mixed methods using qualitative content analysis and statistical analyses (III-IV). Results in all studies show that existential issues are part of caring at surgical wards. However, although the nurses were aware of them, they found it difficult to acknowledge these issues owing to for example insecurity (I-III), a strict medical focus (II) and/or lacking strategies (I-III) for communicating on these issues. Modest results from the pilot study are reported and suggest beneficial influences of a support in communication on existential issues (III). The results indicate that the educational intervention may enhance nurses’ understanding for the patient’s situation (IV), help them deal with own insecurity and powerlessness in communication (III), and increase the value of caring for severely ill and dying patients (III) in addition to reducing work-related stress (IV). An outcome of all the studies in this thesis was that surgical nurses consider it crucial to have time and opportunity to reflect on caring situations together with colleagues. In addition, descriptions in Studies III and IV show the value of relating reflection to a theory or philosophy in order for attitudes to be brought to awareness and for new strategies to be developed.

Hemodynamic team decision making in the cardiac surgical intensive care context

Purpose
The purpose of this study was to explore the extent and sources of variability of critical care nurses’ hemodynamic decision making as a function of contextual factors in the immediate 2-hour period after cardiac surgery.

Methods
A qualitative exploratory design with observation and interview was used. Eight critical care nurses were observed on different occasions in clinical practice for a 2-hour period. A brief interview immediately followed each observation to clarify observation data.

Findings
Analysis of the data revealed that patient management decisions were made both by individual nurses and by a team of nurses and health professionals. Team decision making (TDM) is described in this study as integrated or non-integrated and refers to an intra-professional nursing team. During displays of integrated TDM, the primary nurse, who was assigned to care for the patient, made most hemodynamic decisions and nurses who assisted the primary nurse deferred decisions. During displays of non-integrated TDM, nurses assisting the primary nurse assumed responsibilities for most patient-related decisions. Non-integrated TDM occurred more frequently when inexperienced cardiac surgical intensive care nurses were in the role of primary nurse, whereas integrated TDM was more common among experienced cardiac surgical intensive care nurses.

Conclusions
This observed variability can occur in multiple ways and in hemodynamic decision making has implications for patient outcomes as behaviors of non-integrated TDM led to nurses sensing a loss of control of patient management.

The haemodynamic status of cardiac surgical patients in the initial 2-h recovery period

Background
Critical care nurses caring for cardiac patients in the immediate postoperative period continually make decisions about the implications and treatment of their patients' haemodynamic status.

Aim
The aim of this study was to describe the haemodynamic status of patients on admission to critical care and over the 2-h period following cardiac surgery.

Methods
A quantitative, descriptive design was used. Data were collected using non-participant observation and an observation tool. The sample consisted of 38 patients.

Results
Analysis of data revealed the dynamic nature of the haemodynamic status of postoperative cardiac patients. On admission, 60% of patients (n = 23) were haemodynamically unstable. The instability in these patients (n = 23) was due to hypotension (34%), bleeding (21%) and hypoxaemia (18%). During the 2-h recovery period, 55% of patients were hypotensive, 16% of patients had low cardiac output syndrome and 16% of patients had low systemic vascular resistance (SVR) syndrome. Twenty-one percent of patients experienced bleeding complications. Shivering was a clinically significant problem in terms of occurrence (23%) and duration (X = 45, S.D. = 30 min). Twenty-nine percent of patients (n = 11) had a profound deterioration in haemodynamic status, necessitating urgent interventions.

Conclusion
Haemodynamic parameters indicate that 95% of patients in this study were haemodynamically unstable at some time during the initial 2-h recovery period. These findings inform resourcing decisions by organisations and have implications for nurses' assessment and interventional haemodynamic decision making.

Surgical accountability in the 1880s: the death of Susan Nixon

Susan Nixon died in 1881 following a surgical error. Her surgeon, Dr W. E. Warren, excised a normal 7-month gravid uterus under the misapprehension that he was removing a tubular pregnancy. It is believed that Mrs Nixon was the first woman in Australia to have an abdominal hysterectomy and the second to have a live Caesarean section. The surgical misadventure that resulted in Mrs Nixon's death became a public scandal, which gained currency through both parliamentary debate and the popular press.

The purpose of referring to this case is to explore the mechanisms of accountability that surgeons faced in the 1880s − a decade of rapid change in the practice of surgery. The response of late nineteenth century society to surgical error and the resultant reaction of the medical profession have resonances that are relevant to surgeons practising today.

Determining clinical pharmacy workload by patient disease classification in medical and surgical patients

Aim: To determine the time needed to provide clinical pharmacy services to individual patient episodes for medical and surgical patients and the effect of patient presentation and complexity on the clinical pharmacy workload. Method: During a 5-month period in 2006 at two general hospitals, pharmacists recorded a defined range of activities that they provided for patients, including the actual times required for these tasks. A customised database linked to the two hospitals' patient administration systems stored the data according to the specific patient episode number. The influence of patient presentation and complexity on the clinical pharmacy activities provided was also examined. Results: The average time required by pharmacists to undertake a medication history interview and medication reconciliation was 9.6 (SD 4.9) minutes. Interventions required 5.7 (SD 4.6) minutes, clinical review of the medical record 5.5 (SD 4.0) minutes and medication order review 3.5 (SD 2.0) minutes. For all of these activities, the time required for medical patients was greater than for surgical patients and greater for 'complicated' patients. The average time required to perform all clinical pharmacy activities for 1071 completed patient episodes was 14.4 (SD 10.9) minutes and was greater for medical and 'complicated' patients. Conclusion: The time needed to provide clinical pharmacy services was affected by whether the patients were medical or surgical. The existence of comorbidities or complications affected these times. The times required to perform clinical pharmacy activities may not be consistent with recently proposed staff ratios for the provision of a basic clinical pharmacy service.

Skin temperature as a noninvasive marker of haemodynamic and perfusion status in adult cardiac surgical patients : an observational study

Objective
Foot temperature has long been advocated as a reliable noninvasive measure of cardiac output despite equivocal evidence. The aim of this pilot study was to investigate the relationship between noninvasively measured skin temperature and the more invasive core-peripheral temperature gradients (CPTGs), against cardiac output, systemic vascular resistance, serum lactate, and base deficit.

Research methodology
The study was of a prospective, observational and correlational design. Seventy-six measurements were recorded on 10 adults postcardiac surgery. Haemodynamic assessments were made via bolus thermodilution. Skin temperature was measured objectively via adhesive probes, and subjectively using a three-point scale.

Setting
The study was conducted within a tertiary level intensive care unit.

Results
Cardiac output was a significant predictor for objectively measured skin temperature and CPTG (p = .001 and p = .004, respectively). Subjective assessment of skin temperature was significantly related to cardiac output, systemic vascular resistance, and serum lactate (p < .001, respectively).

Conclusions
These results support the utilisation of skin temperature as a noninvasive marker of cardiac output and perfusion. The use of CPTG was shown to be unnecessary, given the parallels in results with the less invasive skin temperature parameters. A larger study is however required to validate these findings.