David W. Todd

Office Accreditation Experiences With 3 Accrediting Agencies and Suggestions for Changes in Private Oral and Maxillofacial Surgery Facility Evaluations

Historically, oral and maxillofacial surgeons have had considerable autonomy in operating their offices. Oral and maxillofacial surgeons have had a singular history of safety, training, and success in outpatient anesthesia in their offices. However, preventable patient morbidity and mortality in private office-based surgical facilities of a variety of professions have brought increased scrutiny to the office environment. The present report describes the experiences of 3 oral and maxillofacial surgeons with 3 accrediting agencies in obtaining office accreditation and offers recommendations to be considered for the future of our specialty in terms of private office certification.

A Review of the Class III Antiarrhythmic Agents and Their Uses and Implications for Patient Management

The purpose of this article is to review the current view of antiarrhythmic agents and in particular the use of amiodarone and sotalol for treatment of arrhythmias. These antiarrhythmic agents have unique properties and toxicities. Although once reserved for life-threatening arrhythmias, amiodarone and sotalol are now being used for the treatment of recurrent paroxysmal and chronic atrial fibrillation. The oral and maxillofacial surgeon (OMS) should be familiar with the properties and uses of these agents and potential drug interactions. The Vaughn-Williams classification is useful for discussion of antiarrhythmic agents (Table 1). The treatment of arrhythmias has undergone considerable flux over the past 10 years.1,2 As a result of the CAST study in which Class 1c agents showed increased mortality compared with placebo, the approach to arrhythmias management has changed. It is recognized that the antiarrhythmic agents can be proarrhythmic (especially the Class 1c agents) and may not improve survival. As a result, arrhythmias “need” treatment only when they are symptomatically significant or when the prophylactic power of the drug outweighs the risk.3 In terms of Class I agents, quinidine is still a versatile antiarrhythmic agent and popular worldwide, but its popularity has decreased over the past 10 years. Quinidine can be proarrhythmic and has common side effects of diarrhea (33%), nausea (18%), headache (13%), and dizziness (8%).3 Procainamide has limited usefulness because of the risk of lupus (one third of patients over 6 months).3 Of the Class Ic agents, flecainide has regained some usefulness for supraventricular and ventricular arrhythmias if coronary artery disease can be ruled out. Propafenone is a relatively new antiarrhythmic Class Ic agent, but it also has mild -antagonist effect and is approved by the Food and Drug Administration (FDA) for lifethreatening ventricular arrhythmias and suppression of supraventricular arrhythmias including atrial flutter and especially atrial fibrillation.4,5 Propafenone, however, has proarrhythmic effects because of its depressant effect on conduction and is characterized by marked individual variations in metabolism, making dosaging difficult.3 The Class II agents are the -blockers and are used to treat a variety of arrhythmias. The common denominator for these arrhythmias is increased sympathetic adrenergic activity. They are indicated for treatment of inappropriate sinus tachycardia, excercised induced ventricular tachycardia or tachycardia secondary to pheochromocytoma or thyrotoxicosis. They cannot be used for the treatment of atrial flutter or prevention of recurrent atrial fibrillation but can be used for rate control in these arrhythmias. The Class IV agents include the calcium channel blockers verapamil, diltiazem, and adenosine. Although licensed in the United States in intravenous form for treatment of supraventricular tachyarrhythmias, they are not approved in oral form for these indications. Like the -blockers, these agents can be used orally for rate control of chronic atrial fibrillation. As a result of the difficulty with Class I agents, the Class III agents have become more popular. The Class III agents include amiodarone and sotalol. Amiodarone is a structural analog of thyroid hormone and has properties of all 4 classes of antiarrhythmic agents. Although amiodarone has chiefly Class III properties of prolonging action potential duration, it also blocks sodium channels (Class I), noncompetitively blocks and -receptors (Class II), and exhibits Class IV effects of calcium channel antagonism. Unlike other antiarrhythmic agents, which are generally negative inotropes and can exacerbate congestive heart failure (CHF), amiodarone improves ejection fraction. It is an extremely lipophilic agent requiring large loading doses and months for steady state. This complicates management by not knowing if amiodarone effects *Private Practice, Lakewood, NY. Address correspondence and reprint requests to Dr Todd: 120 Southwestern Dr, Lakewood, NY 14750.