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To compare the clinical and economic outcomes of EVICEL (Ethicon, Inc., Somerville, NJ) and TISSEEL (Baxter Healthcare Corporation, Westlake Village, CA) use in patients undergoing primary coronary artery bypass graft (CABG) surgery.Retrospective database analysis.Premier prospective hospital database (June 2009 through March 2014) covering approximately 20% of hospital discharges in the United States.Adults undergoing primary CABG surgery who received either EVICEL or TISSEEL on the day of surgery (index date).Two intervention groups were formed, EVICEL and TISSEEL. Clinical outcomes compared included postoperative bleeding complications (International Classification of Diseases, Ninth Revision, Clinical Modification code: 998.1) and number of blood transfusions received on the index day. Economic outcomes compared included hospital length of stay, hospital costs, and 30-day readmission rates. Propensity-score matching was used to control for patient and hospital characteristics.A total of 129,014 primary CABG surgery patients were identified; 986 patients (mean age: 64 years, 73% male) received EVICEL and 6,340 patients (mean age: 65 years, 75% male) received TISSEEL on the index day. After propensity-score matching, patients who received EVICEL compared with TISSEEL had significantly fewer postoperative bleeding complications (3.0% v 5.0%, p = 0.0197), index-day blood transfusion rates (19% v 34%, p0.0001), readmission rates (18% v 32%, p0.0001), and costs ($40,736 [standard deviation $19,465] v $46,005 [standard deviation $24,049], p0.0001). Results from a sensitivity analysis using a generalized linear model to control for other hemostatic agent use also favored EVICEL over TISSEEL.Results from this real-world retrospective database analysis showed fewer bleeding complications and lower costs in patients undergoing primary CABG surgery who received EVICEL compared with TISSEEL.

L-selectin (CD62L) is a type-I transmembrane glycoprotein and cell adhesion molecule that is expressed on most circulating leukocytes. Since its identification in 1983, L-selectin has been extensively characterized as a tethering/rolling receptor. There is now mounting evidence in the literature to suggest that L-selectin plays a role in regulating monocyte protrusion during transendothelial migration (TEM). The N-terminal calcium-dependent (C-type) lectin domain of L-selectin interacts with numerous glycans, including sialyl Lewis X (sLex) for tethering/rolling and proteoglycans for TEM. Although the signals downstream of L-selectin-dependent adhesion are poorly understood, they will invariably involve the short 17 amino acid cytoplasmic tail. In this review we will detail the expression of L-selectin in different immune cell subsets, and its influence on cell behavior. We will list some of the diverse glycans known to support L-selectin-dependent adhesion, within luminal and abluminal regions of the vessel wall. We will describe how each domain within L-selectin contributes to adhesion, migration and signal transduction. A significant focus on the L-selectin cytoplasmic tail and its proposed contribution to signaling via the ezrin-radixin-moesin (ERM) family of proteins will be outlined. Finally, we will discuss how ectodomain shedding of L-selectin during monocyte TEM is essential for the establishment of front-back cell polarity, bestowing emigrated cells the capacity to chemotax toward sites of damage.

In surgery, rapid hemostasis can be required in various settings and bleeding intensities to minimize complications related to blood loss. While effective hemostats are available for mild-to-moderate surgical bleeding, few are effective against challenging severe hemorrhage. We report the effectiveness and safety of the fibrin pad (FP), a novel combination hemostat (device/human biologic), in controlling severe soft-tissue bleeding as compared to the standard of care (SoC).This randomized, controlled, superiority study enrolled subjects ≥18 years, requiring elective abdominal, retroperitoneal, pelvic, or thoracic (non-cardiac) surgery. A severe target bleeding site (TBS) was identified intra-operatively following which, subjects were randomized to the FP or the SoC group. Hemostatic status was observed at 4 min (primary endpoint) and 10 min post-randomization. Safety variables included TBS-related bleeding and thrombotic events.At 4 min post-randomization, 50/59 (84.7 %) subjects in the FP group and 10/32 (31.3%) [Corrected] subjects in the SoC group achieved hemostasis without needing re-treatment (P0.0001). Compared to the SoC group, the FP group showed better hemostasis at 10 min post-randomization [58/59 (98.3 %) vs. 28/32 (87.5 %); P = 0.01], lower mean time to hemostasis (6.1 ± 13.5 vs. 17.8 ± 32.0 min), and a less frequent need for re-treatment (5.1 vs. 53.1 %). The triangular test for binary response demonstrated the FP to be superior to SoC (95 % CI 1.474-3.290; P0.0001). Safety profiles in both groups were similar to those typically observed after long-duration surgery.The FP is safe and superior to SoC for controlling challenging severe soft-tissue bleeding encountered during intra-abdominal and thoracic surgical procedures.

Recent trends suggest that young people in Britain are refraining from engaging in formal political processes. At the same time, they are increasingly expressing support for, and turning toward, a new and diverse range of non-institutionalized forms of political action in order to actualize their interests. Using Inglehart's ideas on postmaterialism, we consider whether this apparent rejection of mainstream politics in favour of less conventional - and sometimes radical - forms of political action is changing over time in Britain, reflecting fluctuating economic conditions witnessed over the last two decades. We do this by comparing results from surveys of British 18 year olds conducted in 2002 during an era of relative global prosperity, and then in 2011 at the height of the current global crisis. The findings suggest that British young postmaterialists are considerably more likely than materialists to participate in and support both institutionalized and non-institutionalized forms of political action.

IntroductionHaemostasis after liver resection may be difficult to achieve as a result of the presence of challenging bleeding, the anatomic landscape of the liver and the quality of tissue making up the hepatic parenchyma. The fibrin pad (FP) is a topical absorbable haemostat designed to be effective in a variety of tissues and across multiple bleeding intensities. This is the first clinical trial to evaluate the hemostat's safety and effectiveness in controlling bleeding during elective hepatic resection.MethodsThis prospective, randomized, controlled superiority trial enrolled 104 subjects undergoing elective hepatectomy in 5 countries. After parenchymal transection, subjects with an appropriately defined target bleeding site (TBS) were stratified according to the type of hepatic parenchyma and immediately randomized 1:1: FP versus Standard of Care (SoC). SoC comprised manual compression with the use of an approved topical absorbable haemostat. The primary endpoint was haemostasis at 4 min from identification of the TBS, with no re‐bleeding requiring re‐treatment prior to abdominal closure. Results were stratified for both normal and abnormal (steatosis or cirrhosis) hepatic parenchyma. All subjects were followed for 60 days post‐operatively.ResultsThe intent‐to‐treat (ITT) analysis showed an overall treatment difference of 53.0% (P < 0.001), 82.5% (33/40 FP) versus 29.5% (13/44 SoC) in achieving haemostasis at 4 min with no re‐bleeding requiring treatment up to wound closure. The per protocol analysis showed an overall treatment difference of 65.7% (P < 0.001), with 33/35 successes (94.3%) in the FP group and 12/42 in the SoC group (28.6%). The stratification results showed treatment differences between the normal parenchyma group, 63.6% (95.8% FP versus 32.3% SoC P < 0.001) and a larger difference of 72.7% in the abnormal parenchyma group (90.9% FP versus 18.2% SoC P = 0.0003). Post‐operative intra‐abdominal fluid collections were less frequent in the FP group (3.4% FP versus 13.3% SoC P = 0.059). There was no difference in the safety profile between the FP or SoC groups.ConclusionsThe FP is safe and effective when used as an adjunct to achieve haemostasis during hepatic surgery. The success rate of achieving haemostasis with a FP remained high compared with the SOC group, especially in steatotic or cirrhotic liver tissue where the control success rates diminish. In addition, FP treatment of hepatic parenchymal surfaces may reduce the risk of post‐operative biliary and fluid collections.

Introduction: Little data exists to help urgent care (UC) clinicians predict morbidity and mortality risk. Age, systolic blood pressure (SBP), and heart rate (HR) are easily obtainable and have been used in other settings to predict short-term risk of deterioration. We hypothesized that there is a relationship between advancing age, SBP, HR, and short-term health outcomes in the UC setting. Methods: We collected retrospective data from 28 UC clinics and 22 hospitals in the Intermountain Healthcare system between years 2008-2013. Adult patients (≥18 years) were included if they had a unique UC visit and HR or SBP data. Three endpoints following UC visit were assessed: emergency department (ED) visit within three days, hospitalization within three days, and death within seven days. We analyzed associations between age, SBP, HR and endpoints using local regression with a binomial likelihood. Five age groups were chosen from previously published national surveys. Vital sign (VS) distributions were determined for each age group, and the central tendency was compared against previously published norms (90-120mmHg for SBP and 60-100bpm for HR.) Results: A total of 1,720,207 encounters (714,339 unique patients) met the inclusion criteria; 51,446 encounters (2.99%) had ED visit within three days; 12,397 (0.72%) experienced hospitalization within three days; 302 (0.02%) died within seven days of UC visit. Heart rate and SBP combined with advanced age predicted the probability of ED visit (p

Previous studies have reported VTE rates during surgical stays in hospitals or by diagnoses over extended periods without being linked to specific surgical events. The purpose of this project was to assess the potential rate of venous thromboembolism in patients with cancer after a surgical procedure within the immediate posthospital admission period of 30 days, with special emphasis in increased sensitivity of detection. Patients with cancer who had a major surgery were identified in a large commercial (non-Medicare) database containing data from more than 22 million patients in the United States. Those with a new diagnosis of VTE within 30 days postadmission for surgery were identified. Additional drug-based criteria were used to vary the VTE definition in a sensitivity analysis. VTE rates are reported for each of the surgical procedure group and overall. The overall 30-day VTE rate was 3.5% with a diagnosis based definition, with rates ranging by procedure from 1.8 to 13.2%. Esophageal resection patients have a VTE rate of 13.2% (95% confidence interval (CI), 8.8–18.9%), whereas prostatectomy patients have a VTE rate of 1.8% (95% CI, 1.5–2.1%). Of the 3.5% of patients with a VTE diagnosis on or before postoperative day 30, 73% of those have the VTE diagnosis by day 14. Another 1.15% is added to the overall VTE rate as the definition sensitivity is increased with outpatient pharmacy claims data. Using administrative data from large populations provides valuable insight into the potential VTE rates that occur within the 30-day post period after various cancer-related surgeries. The information can be used by surgeons as one component of the benefit-risk decision regarding postoperative VTE prophylaxis in surgical patients.

To compare the effectiveness of plasma-derived human thrombin and bovine thrombin for achieving hemostasis during surgery.Adults (N = 305) withor = 1 mild or moderate bleeding site not manageable by conventional modalities during elective cardiovascular, neurologic, or general surgical procedures at multiple study centers were randomized to human (n = 153) or bovine (n = 152) thrombin, applied topically with an absorbable gelatin sponge. Bleeding was assessed 3, 6, and 10 min post-application. Other evaluations included laboratory assessments, vital signs, blood loss, blood transfusions, time in specialty-care units, procedure duration, and length of hospital stay. Blood samples for antibody assessment were collected at baseline and postoperative week 5.The proportion of patients achieving hemostasis within 10 min (primary outcome) was equivalent for human and bovine thrombin (97.4 vs. 97.4%, respectively; ratio, 1.00; 95% CI, 0.96-1.05). The proportions of patients achieving hemostasis at 6 min (94.8 vs. 92.8%) and 3 min (73.2 vs. 72.4%) were also equivalent. No clinically meaningful differences were noted for other variables. The products had similar adverse event profiles. More patients (12.7%) who received bovine thrombin demonstrated seroconversion foror = 1 of the 4 antibodies assayed than patients who received human thrombin (3.3%). No patients in the human thrombin group developed seroconversion for anti-human thrombin or anti-human factor V/Va antibodies. Limitations of this study include the lack of a placebo-control group, the potential for inter-surgeon variability, and the fact that antibody assessment was not evaluable in all patients.Plasma-derived human thrombin and bovine thrombin were equivalent in achieving hemostasis within 10, 6, and 3 min and had comparable safety profiles. None of the patients receiving human thrombin developed seroconversion for antibodies to any of the human antigens.

Synchronized nasal intermittent positive pressure ventilation (SNIPPV) is non-invasive respiratory support that delivers ventilator breaths via the nasal prongs. We hypothesized that SNIPPV is more effective than nasal continuous positive airway pressure (NCPAP) in premature neonates due to decreased work of breathing (WOB). Fifteen infants (BW: 1,367 +/- 325 g, GA: 29.5 +/- 2.4 weeks) were studied on (a) NCPAP at 5 cmH(2)O (NCPAP5) and (b) three increasing SNIPPV settings achieved by NCPAP5 with additional delivered peak inspiratory pressures (PIP) of 10, 12, and 14 cmH(2)O. Tidal volumes and transpulmonary pressures were estimated via calibrated respiratory inductance plethysmography (RIP) and esophageal pressures, respectively. Inspiratory (WOB(insp)), resistive (RWOB), and elastic (WOB(E)) components of WOB were calculated using standard methods. Compared to NCPAP5, (a) WOB(insp) and RWOB were significantly lower with SNIPPV12, and were similarly lower with SNIPPV14 and (b) WOB(E) was significantly lower only with SNIPPV14. WOB components did not differ significantly for the three SNIPPV settings. Tidal volume, respiratory rate (RR), minute ventilation, compliance, and phase angle were similar for all four measurements. In conclusion, compared to NCPAP, the addition of ventilator-delivered PIP during SNIPPV decreases WOB in premature infants.

Background This study examined whether a state surveillance system for work-related carpal tunnel syndrome (WR-CTS) based on workers' compensation claims (Sentinel Event Notification System for Occupational Risks, SENSOR) and the Annual Survey of Occupational Injuries and Illnesses (SOII) identified the same industries, occupations, sources of injury, and populations for intervention. Methods Trends in counts, rates, and female/male ratios of WR-CTS during 1994–1997, and age distributions were compared across three data sources: SENSOR, Massachusetts SOII, and National SOII. SENSOR and National SOII data on WR-CTS were compared by industry, occupation, and injury source. Findings Due to small sample size and subsequent gaps in available information, state SOII data on WR-CTS were of little use in identifying specific industries and occupations for intervention. SENSOR and National SOII data on the frequency of WR-CTS cases identified many similar occupations and industries, and both surveillance systems pointed to computer use as a risk factor for WR-CTS. Some high rate industries identified by SENSOR were not identified using National SOII rates even when national findings were restricted to take into account the distribution of the Massachusetts workforce. Conclusions Use of national SOII data on rates of WR-CTS for identifying state industry priorities for WR-CTS prevention should be undertaken with caution. Options for improving state SOII data and use of other state data systems should be pursued. Am. J. Ind. Med. 46:284–296, 2004. © 2004 Wiley-Liss, Inc.

This study evaluated the hemostatic effectiveness and safety of Fibrin Pad (Omrix Biopharmaceuticals Ltd.) vs absorbable hemostat in patients undergoing nonemergent surgery. Fibrin Pad is a topical absorbable hemostat designed to be effective in a variety of soft tissues and across multiple bleeding intensities.Patients 18 years and older, requiring abdominal, retroperitoneal, pelvic, or thoracic (noncardiac) surgery and with an appropriate soft-tissue target bleeding site (TBS), were randomized to receive Fibrin Pad or absorbable hemostat (NCT00658723). Patients were stratified by bleeding severity at the TBS. Assessments included percentage of patients achieving hemostasis at 4 minutes after randomization with no rebleeding requiring treatment during the subsequent 6 minutes (primary endpoint), proportion of patients achieving hemostasis at 10 minutes, and incidence of treatment failure.On the primary endpoint, 98.3% of patients with Fibrin Pad and 53.3% with absorbable hemostat achieved hemostasis at 4 minutes (p0.0001). The treatment differential was magnified (efficacy was maintained with Fibrin Pad but decreased with absorbable hemostat) with increasing bleeding intensity: in patients with mild bleeding, 100.0% vs 80.0% achieved hemostasis with Fibrin Pad and absorbable hemostat (p = 0.03), respectively; rates were 96.6% vs 26.7%, respectively (p0.0001) with moderate bleeding. Percentages of patients who achieved hemostasis at 10 minutes were: Fibrin Pad, 98.3% and absorbable hemostat, 73.3% (p0.0001). Incidences of adverse events were comparable between groups.Fibrin Pad is superior to absorbable hemostat (SURGICEL Original Absorbable Hemostat [Ethicon]) in soft-tissue bleeding control and is safe and effective as an adjunct for rapidly and reliably achieving hemostasis for soft-tissue bleeding during surgery.

Background Bleeding severity, anatomic location, tissue characteristics, and visibility are common challenges encountered while managing intraoperative bleeding, and conventional hemostatic measures (suture, ligature, and cautery) may sometimes be ineffective or impractical. While topical absorbable hemostats (TAH) are useful hemostatic adjuvants, each TAH has associated disadvantages. Methods We evaluated the safety and hemostatic efficacy of a new advanced biologic combination product―fibrin pad―to potentially address some gaps associated with TAHs. Fibrin pad was assessed as adjunctive hemostat in open partial nephrectomy in single-center, open-label, Phase I study (N = 10), and as primary hemostat in multicenter, single-blind, randomized, standard-of-care (SOC)-controlled Phase I/II study (N = 7) in Israel. It was used to control mild-to-moderate bleeding in Phase I and also spurting arterial bleeding in Phase I/II study. Phase I study assessed safety and Phase I/II study, proportion of successes at 10 min following randomization, analyzed by Fisher exact tests at 5% significance level. Results Phase I (N = 10): All patients completed the study. Hemostasis was achieved within 3–4 min (average = 3.1 min) of a single application in all patients. Fibrin pad was found to be safe for human use, with no product-related adverse events reported. Phase I/II (N = 7): Hemostatic success at 10 min (primary endpoint) was achieved in 3/4 patients treated with fibrin pad versus 0/3 patients treated with SOC. No clinically significant change in laboratory or coagulation parameters was recorded, except a case of post-procedural hemorrhage with fibrin pad, which was considered serious and related to the fibrin pad treatment, and required re-operation. Although Data Safety Monitoring Board authorized trial continuation, the sponsor decided against proceeding toward an indication for primary treatment of severe arterial hemorrhage as a replacement for sutures. The study was suspended after 7/30 planned subjects were enrolled. Conclusions The first-in-man trial of fibrin pad demonstrated its safety and efficacy as an adjunctive hemostatic technique for mild-to-moderate bleeding in partial nephrectomy. The study also suggested that the product should not replace sutures or meticulous surgical techniques for the treatment of severe arterial hemorrhage. Trial registration Phase I/II trial, NCT00598130

Background: This study evaluated the safety and hemostatic effectiveness of a tranexamic acid- and aprotinin-free fibrin sealant versus an absorbable hemostat in soft tissue during elective retroperitoneal or intra-abdominal surgery. Materials and Methods: This randomized, active-controlled, multicenter study enrolled patients who were undergoing elective retroperitoneal or intra-abdominal surgery and required adjunctive hemostatic measures at the target bleeding site (TBS). Patients were randomized (time = 0 minutes) to receive fibrin sealant or absorbable hemostat. The primary endpoint was the absence of bleeding at the TBS at 10 minutes. Secondary endpoints included the absence of bleeding at 4 and 7 minutes and the incidence of treatment failure (bleeding at 10 minutes or brisk bleeding requiring additional hemostatic measures), and the incidence of complications potentially related to bleeding. Adverse events were assessed. Results: Patients (N = 124) were randomized to receive fibrin sealant (n = 62) or absorbable hemostat (n = 62). A higher percentage of patients who received fibrin sealant versus absorbable hemostat achieved hemostasis within 10 minutes (95.2% vs 82.3%; 95% CI, 1.02-1.35) and also at 4 (74.2% vs 54.8%; 95% CI, 1.04-1.80) and 7 (90.3% vs 77.4%; 95% CI, 1.00-1.39) minutes. A lower incidence of treatment failure was observed for patients receiving fibrin sealant. Similar incidences of adverse events and complications potentially related to bleeding were observed. Conclusions: This tranexamic acid- and aprotinin-free fibrin sealant is safe and effective for achieving hemostasis in soft tissue during elective retroperitoneal or intra-abdominal surgery.

Surgical site infection (SSI) is an important cause of morbidity and occasionally death after coronary artery bypass graft (CABG) surgery. These infections also are associated with higher costs and poorer surgical outcomes. We used a retrospective observational database to examine and quantify the effects of the topical skin adhesive 2-octyl cyanoacrylate, used as the final layer of site closure in patients undergoing CABG surgery, on the incidence of post-operative SSI.All patients in the Premier Perspective™ Comparative Database of inpatient hospitalizations who underwent CABG surgery in 2005 and 2006 were identified. Qualifying patients were classified into four groups according to the method of surgical site closure on the basis of detailed hospital billing charges: Sutures only; sutures and 2-octyl cyanoacrylate; sutures and staples; and sutures, 2-octyl cyanoacrylate, and staples. Site infections were identified by a combination of International Classification of Diseases (ICD-9-CM) diagnosis codes, patterns of post-operative use of antibiotics, and All Patient Refined Diagnostic Related Group (APR-DRG) and Diagnostic Related Group (DRG) codes indicating post-operative infections at hospital re-admission.A total of 59,006 patients qualified for the study: 38,799 who had sutures only; 10,262 having sutures and 2-octyl cyanoacrylate; 8,180 having sutures and staples; and 1,765 having sutures, 2-octyl cyanoacrylate, and staples. The lowest unadjusted rate of post-CABG SSI was found in the sutures and 2-octyl cyanoacrylate group (4.3%; 95% confidence interval [CI] 3.9-4.7), followed by sutures only (5.3%; 95% CI 5.1-5.5); sutures and staples (6.2%; 95% CI 5.7-6.8); and sutures, staples, and 2-octyl cyanoacrylate (7.1%; 95% CI 6.0%-8.4%). A logistic regression model that controlled for selected baseline patient, hospital, and surgical characteristics showed significantly lower rates of post-CABG SSI (odds ratio 0.76; 95% CI 0.68-0.85) in patients closed with sutures and 2-octyl cyanoacrylate relative to patients who had only sutures.The observed rates of post-CABG SSI were consistent with the rates observed in the literature. The SSI rate for patients who had sutures and 2-octyl cyanoacrylate used as the final layer of site closure was significantly lower than the rates for patients having other types of closure.

When a lateral pterygoid muscle is more tender to palpation than the other muscles of mastication, and a stress test is positive, an occlusal cause should be suspected. Patients with lateral pterygoid tenderness are divided into three categories according to two criteria: the position of the condyles in their glenoid fossae and the degree of dysfunction in the articulation. Only patients in category 1, those with a centered condylar position and without dysfunction, are discussed in this article. Occlusal adjustment is executed on the basis of information gathered from radiographs of the temporomandibular joint, diagnostic casts, and leaf gauge measurements of unequal bilateral occlusal contact. The amount of tooth structure requiring removal can be determined by using leaf gauges of differing thicknesses. Occlusal adjustments are performed without mandibular manipulation until the tenderness of the lateral pterygoid muscle is relieved.

To determine whether inferior vena cava oxygen saturation (UvO2) or lower-body fractional oxygen extraction (FOE) could detect poor cardiac output in newborns.UvO2 and arterial oxygen saturation (SaO2) were measured simultaneously with echocardiographic determination of superior vena cava blood flow (SVC flow) at12, 12-24 and24 h. Haemoglobin concentration ([Hb]), haemoglobin oxygen affinity (HOA) and lactate were measured and FOE calculated.56 studies in 17 infants, gestational age (median (range)) 26 wk 4 d (23 wk 2 d-42 wk 3 d): UvO2 (mean (SD)) was 84.9% (5.0), 77.6% (9.2) and 81.7% (12.9) at12, 12-24 and24 h, respectively; SVC flow (mean (SD)) increased from 71.7 (33) to 85 (66) and 123 (88) ml/kg/min at12, 12-24 and24 h, respectively. Despite a fall in mean [Hb], mean upper-body oxygen delivery increased due to increases in both SVC flow and arteriovenous content difference. There was a negative correlation between [Hb] and FOE. Infants with high HOA had significantly lower FOE.Measurement of UvO2 is feasible in newborns. Changes to SVC flow and arteriovenous content difference lead to improvements in oxygen delivery. The interaction of HOA warrants further study.

Summary The resurgence of dengue in Singapore since 1986 had been associated with an adult predominance and a very low incidence in children. No study had been carried out to investigate this finding. Here we report a serological study of 1068 children aged 0 to 15 years. There is a significant rise in seroconversion in children aged 6 years and older coinciding with the start of formal schooling. This suggests that there may be a change in the location where dengue is acquired.

A new device is described that may be used (1) diagnostically to determine the relationship of the occlusion to tenderness in the lateral pterygoid and other muscles of mastication; (2) to relieve ischemic muscle tenderness; (3) to assist in the reduction of articular clicks; and (4) as a positioning device for the registration of physiologic interocclusal relations. The rationale for the causal relationship between the occlusion and lateral pterygoid muscle tenderness is explained.

Two diagnostic tests, positive tenderness to palpation of the inferior bellies of the lateral pterygoid muscles and a positive stress test, are helpful in determining whether the dental occlusion is a principal etiologic factor in ischemic pain in the muscles of mastication. To avoid a noxious occlusal contact, the muscles of mastication, and particularly the lateral pterygoid muscles, must increase their activity. The ability of the patient to supply the oxygen for this activity is variable. When it is inadequate, to relieve ischemic pain the muscular activity must be decreased or the oxygen supply increased. The dentist has the option of using four modalities for the treatment of these painful muscles: physiotherapy, drug therapy, psychotherapy, and occlusal therapy. When the lateral pterygoid muscles are not tender to palpation and the stress test is negative, occlusal therapy is not indicated.

This article describes a device that is intended to prevent the clenching of the teeth. The principle involved is that to clench the teeth for an extended period, an intraoral vacuum must be formed and maintained. A tube or drinking straw held between the lips extending out of the mouth will prevent a vacuum. The article explains and illustrates how such a device can be made that will exploit this principle. Disadvantages and advantages are discussed. (J Prosthet Dent 1998;79:353-4.)

A device called a leaf gauge consists of a number of leaves of plastic and can be used to locate the mandible in centric relation. The leaf gauge, when placed between the anterior teeth, aids the patient in retruding the mandible. The biting force tends to move the condyles against their menisci. Since the patient is applying all pressures, the position of the mandible is not likely to exceed physiologic limits.

An intraoral technique for locating the terminal hinge axis has been described. The key to the success of this technique lies in the accurate location of centric relation at 2 different degrees of jaw separation. Centric relation can be located by many techniques but there is some variability in the results obtained by any of them. Therefore, each dentist should have a means of comparing his registrations so that an intelligent selection can be made. The Buhnergraph and the technique described here provide a means of locating centric relation and determining and/or verifying the location of the terminal hinge axis.