Juan R. Lacalle

Clinical assessment of gingival size among patients treated with diltiazem

Gingival overgrowth induced by nifedipine has been extensively reported. This finding, however, does not apply to gingival size changes caused by other calcium antagonists such as diltiazem. We studied the gingiva of 13 subjects with ischemic cardiopathy who had been treated with diltiazem and established two control groups: (1) a healthy group of 12 patients and (2) a group of 10 patients with ischemic cardiopathy and concomitant treatment similar to that applied to the diltiazem group except that they had not been administered any type of calcium antagonists. The size of the gingiva around the six anterior teeth was measured on plaster models of the upper and lower jaws. Significantly higher scores of the size of the gingiva were found when patients treated with diltiazem were compared with the patients in the other two groups (p < 0.05) gingiva were found when patients treated with diltiazem were compared with the patients in the other two groups (p < 0.05) and also when interproximal (p < 0.05) and vestibular (p < 0.05) sites were considered. We did not observe any significant difference in the plaque index of each group (p < 0.05); only bleeding after probing was found statistically different between the diltiazem and the nondiltiazem groups.

Validity of Newly Developed Appropriateness Criteria for Cataract Surgery

OBJECTIVE The introduction of phacoemulsification in the early 1990s significantly changed the treatment of cataract. It is possible that appropriateness criteria for cataract extraction developed before the widespread adoption of phacoemulsification no longer is as accurate or valid as possible. The objective of this study was to validate newly developed explicit appropriateness criteria. DESIGN Prospective, observational cohort study. PARTICIPANTS Consecutive patients with a diagnosis of cataract who were on waiting lists to undergo cataract extraction by phacoemulsification were recruited. METHODS Newly developed explicit appropriateness criteria for cataract extraction, following Research and Development methodology, were applied in this study conducted in 17 public teaching hospitals. Data necessary to classify the appropriateness of the intervention, including demographic and clinical data and that related to the surgery and complications, were recorded by previously trained ophthalmologists in all centers before the intervention and at the 6-week visit afterward. MAIN OUTCOME MEASURES Subjects completed 2 questionnaires that measure health-related quality of life--the Short Form 36 and the Visual Function Index 14 (VF-14)--before the procedure and 3 months afterward. Also, visual acuity was recorded by ophthalmologists previous to the intervention and at 6 weeks after. RESULTS Five thousand two hundred fifty-seven cases were included in the study. At 3 months after cataract extraction, 4335 (82.5%) patients had responded to the questionnaires. Patients whose procedures were classified as necessary or appropriate by the new appropriateness criteria had greater improvements in visual acuity and VF-14 scores than those undergoing procedures classified as inappropriate. These differences seemed to be clinically relevant by measures such as the minimal clinically important difference and minimal detectable change. Complications rates were similar among all appropriateness categories, except for complications occurring in the peri-intervention period. CONCLUSIONS These results suggest a direct relationship between the newly developed explicit appropriateness criteria for cataract extraction and outcomes, as measured by clinical evaluation and health-related quality-of-life instruments. The results support the use of these criteria for clinical evaluation or the development of clinical guidelines.

Clinical indicators of periodontal disease in patients with coronary heart disease: a 10 years longitudinal study.

Objectives: There is evidence about a possible relationship existing between periodontal diseases and coronary heart disease. The aim of the present longitudinal study was to investigate the changes in periodontal evolution after etiological periodontal treatment, comparing a healthy control group with another having coronary heart disease. Study Design: The study included initially 55 patients of which 44 finished it. They were placed into two groups: Healthy Control Group (HCG) n =9, and Coronary Heart Disease Group (CHDG) n=35. The gingival level (GL), probing depth (PD), clinical attachment level (CAL), plaque index (PI) and bleeding on probing (BOP) were measured to compare the periodontal status in both groups. The patients were examined and etiological periodontal treatment was performed and they were then examined at the end of 1 and 10 years. Statistical method: A one way-ANOVA and a MR-ANOVA were established; significance p<0.05. Results: No significant differences between both groups were detected on the first visit (p>0.5). However, at the second visit the CHDG presented a significantly higher PD (p<0.05) and PI (p<0.01). CHDG patients gradually increase PD through time and in comparison to the control group (p<0.041). CHDG patients present a significantly higher CAL loss (p<0.0385) and a significant increase in PI (p<0.0041) at the end of one year, while on the third visit no significant differences were detected in any of these indices. Likewise, a similar fact can be observed on evaluating BOP at the end of ten years causal treatment, a smaller decrease in the cardiac group was observed in regards to the initial values (p<0.001). Conclusion: Patients with coronary heart disease showed a worse evolution of periodontal indices than healthy ones, when referring to probing depth, plaque index and bleeding on probing index. Key words:Attachment loss, coronary heart disease, periodontal disease, risk factors.

Efectividad de la implantaciÓn de una guía clínica sobre la angina inestable mediante una estrategia multifactorial. Ensayo clînico aleatorizado en grupos

Introduccion y objetivos La practica clinica en la angina inestable (AI) no esta siempre basada en la major evidencia disponible. Las guias clinicas tienen el potencial de mejorar la calidad de la asistencia. Hasta el momento no hay ningun ensayo clinico aleatorizado para evaluar diversas estrategias de implantacion de guias en el sistema sanitario publico espanol. El objetivo de este articulo es comparar la efectividad de una estrategia multifactorial de implantacion de una guia clinica (sesiones formativas interactivas, procesos de consenso local) en la AI frente a una estrategia de diseminacion pasiva. Pacientes y metodo El estudio se realizo en 10 unidades de 3 hospitales universitarios de Sevilla. Participaron 153 especialistas (cardiologos, internistas) y sus pacientes admitidos por AI. La intervencion se realizo de enero a abril de 1998. La recogida retrospectiva de datos se hizo en julio de 1999, tanto para los episodios preintervencion como postintervencion atendidos desde enero a octubre de 1997 y de septiembre 1998 a junio de 1999, respectivamente. En cuanto al diseno, fue un ensayo clinico aleatorizado por grupos, antes-despues, pragmatico. Los desenlaces fueron: cumplimiento de las recomendaciones de una guia sobre la utilizacion de la angiografia coronaria, pruebas de estres y valoracion de fraccion de eyeccion. Resultados La estrategia multifactorial comparada con la pasiva se asocio con una mejoria absoluta en la adecuacion de uso de angiografia coronaria y de pruebas de estres del 11% (intervalo de confianza [IC] del 95%, 0,85-21,1; p = 0,03). Para la valoracion de la fraccion de eyeccion no se encontro asociacion: mejoria absoluta del 1,1% (IC del 95%, −15,9 a 18,1; p = 0,88). Conclusiones Nuestros resultados muestran que una intervencion combinada de sesiones formativas interactivas con procesos de consenso de local administrada a unidades asistenciales de facultativos puede mejorar la adecuacion de uso de la angiografia coronaria y de las pruebas de estres.

Effectiveness of a Multifactorial Strategy for Implementing Clinical Guidelines on Unstable Angina: Cluster Randomized Trial

UNLABELLED INTRODUCTION AND OBJECTIVES. Clinical practice in unstable angina is not always based on best evidence. Guidelines have the potential to improve quality of health care. There are no randomised trials assessing implementation strategies in the public healthcare system of Spain yet. OBJECTIVE to compare the effectiveness of a multifaceted strategy (interactive educational meetings, local consensus process) for guideline implementation in unstable angina, with a passive dissemination strategy. Patients and method. SETTING 10 wards from 3 university hospitals in Sevilla. PARTICIPANTS 153 specialists (cardiologists, internists) and their patients admitted for an unstable angina episode. DESIGN a pragmatic, before and after cluster randomized controlled trial. Intervention was delivered from January to April 1998. Retrospective data collection took place in July 1999, of those pre and post-intervention episodes attended from January to October 1997 and from September 1998 to June 1999, respectively. OUTCOMES compliance with the guideline recommendations for coronary angiography and stress testing, and ejection fraction assessment. RESULTS The multifaceted strategy compared with the passive one, was associated with an absolute improvement in the appropriateness of use of coronary angiography and stress testing of 11% (95% CI, 0.85-21.1), P=.03. There was no association for the assessment of the ejection fraction: absolute improvement of 1.1% (95% CI, --15.9 to 18.1), P=.88. CONCLUSIONS Our results show that a combination of interactive educational meetings and local consensus process delivered to wards of physicians may improve the appropriateness of use of coronary angiography and stress testing.