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In his latest Clinical Update, Gary Culliton looks at severe presentations of asthma, which in some cases may be life-threatening, as well as international guidance on methods of prevention, testing and treatment. Patients with asthma have impairments in their quality of life, especially when they experience a flare-up of the symptoms.
For patients well enough for discharge after treatment, the common approach would involve systemic corticosteroids, combined with an ICS agent to avoid relapse after discharge. Population-based data illustrate that one patient with asthma in Alberta presents to an ED every 16 minutes. While asthma ED visits are declining in adults, they remain stable and high in children across Canada. As is the case in many countries, the Canadian Association of Emergency Physicians and the Canadian Thoracic Society have a clinical practice guideline, including a severity assessment scale. Patients who are severe, who are unchanged following treatment or who deteriorate, tend to be admitted to hospital.
Following SARS and H1N1 pandemic influenza outbreaks, Canada has moved from being a country that largely nebulised SABA and SAAC agents, to one that uses spacer and MDI delivery. Where patients are severe, Prof Carlos Camargo’s systematic review in the Cochrane suggests that perhaps continuous nebulisation or continuous infusion of SABA would be appropriate.
The evidence to support non-invasive ventilation (NIV) treatment for severe asthma is weak. Guidelines recommend that patients should be seen within a week by a primary care physician and efforts to enhance this follow-up and protect patients until that event occurs appear warranted. Treating patients with systemic corticosteroids compared to placebo after ED discharge has been studied in only 374 patients. A randomised, controlled trial published in JAMA in 1999 by Alberta Professor Brian Rowe’s group examined the role of ICS agents added to systemic corticosteroids after discharge.
At discharge, patients were randomised to receive short-acting beta agonists and prednisone for seven days. Prof Rowe’s group published a study in Academic Emergency Medicine in 2008, which examined factors associated with relapse. In summary, for asthma patients seen in the ED, SABA, SAAC and systemic corticosteroids should be administered to most patients. Do you agree that private hospitals should be paid via the NTPF to cut public hospital waiting lists? AbstractThe discipline of orthodontics is directed towards alteration of the occlusion of the teeth and the relationships of the jaws.
Unfortunately, there is no evidence that achieving this 'optimal' occlusion has any influence upon long-term stability, masticatory function or the alleged association between orthodontic treatment and temporomandibular disorders.
The goals of orthodontic treatment for the PatientThe prime reason for a patient to seek orthodontic treatment is to gain an improvement in appearance.
The need for a full examinationOcclusal examinationIt is important to emphasise that it is necessary to carry out a full occlusal examination for all orthodontic patients. Treatment considerationsOrthodontic treatment methods can be divided into two depending on the goals of treatment,3 these are camouflage and modification.
To provide treatment directed at camouflaging the problem and not changing the skeletal pattern. Orthodontics and temporomandibular disorders (TMD)This link, as always, courts considerable controversy.
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The man responsible for bringing films like Jason And The Argonauts and The Clash Of The Titans to life with his special effects has died.Ray Harryhausen, a special effects master whose sword-fighting skeletons, a giant octopus, Cyclops and other fantastical creations were adored by film lovers and admired by industry heavyweights, has died. Dalton said it was too soon to tell the exact cause of death, but described Harryhausen's passing as 'very gentle and very quiet.' Harryhausen's films included The Beast From 20,000 Fathoms, Valley Of The Gwangi and The 7th Voyage of Sinbad. Though his name was little-known by the general public, many directors borrowed Harryhausen's special effects techniques.
HOW KING KONG INSPIRED THE SPECIAL EFFECTS MASTER The great-grandson of African explorer David Livingstone, Harryhausen was born in Los Angeles on June 19, 1920. These exacerbations lead to significant time lost from work, school and other leisure activities.


While death is rare, it can occur among young people in pre-hospital settings, University of Alberta Professor Brian Rowe told a recent conference in Dublin. In some patients, long-acting beta agonists (LBAB) might also be added to the treatment regimen. The province has 3.4 million people, and this represents a major burden on the healthcare system. Rural communities in Alberta have much higher rates of ED presentations than some urban centres. Admission proportions have been stable: in Canada, 10 per cent of ED asthma results in admission, compared to 20 per cent reported in some US studies. Prof Rowe said evidence from the Cochrane Collaboration’s Airways Review Group has been employed in asthma guidelines to reduce admissions and complications. A Cochrane review looked at seven high-quality, randomised, controlled trials with nearly 2,200 patients. The Canadian national study on asthma showed that 96 per cent of patients in Canadian EDs received SABA agents, 85 per cent received SAAC and 80 per cent received systemic corticosteroids. We would suggest it is an option to consider if patients are severely unwell,” said Prof Rowe. The Canadian guidelines make limited comment about NIV and this treatment is not recommended by the British Thoracic Society (BTS). After discharge, patients appear to benefit from administration of systemic corticosteroids and inhaled corticosteroids.
Cochrane reviews indicate that early systemic corticosteroids, the addition of inhaled corticosteroids (ICS) and some non-pharmacological approaches – action plans and regular follow-up – are all effective. The review is based on studies of a single intramuscular dose or oral agents for seven-to-10 days, versus standard of care. No statistically significant difference was found between the groups at 21 days with respect to relapse. Rates of relapse were much higher among females, those who have had an ED visit in the last two years, patients who had ever been admitted to hospital for asthma, those who were already on combination agents — for example, Advair (seretide) and Symbicort — and those who were already on systemic corticosteroids. It is therefore somewhat surprising to find that there is little scientific evidence to support any of the concepts that suggest occlusal goals for orthodontic treatment. 1b), and secondly, the pre-adjusted edgewise appliance designed to achieve them was a quantum leap for orthodontists. Arguably, we should primarily aim to treat the patient's needs rather than pursue a dogmatic adherence to the six keys of occlusion. This is because if at least keys 2—5 have been achieved, the patient will have perfectly aligned upper and lower front teeth, irrespective of the relationship between the jaws. It is essential to record not only the patient's habitual bite (centric occlusion CO or intercuspation position ICP) but also to record the patient's ideal jaw relationship (centric relation = CR or retruded contact position = RCP). To introduce this concept we must first consider the aetiology of a malocclusion, which includes skeletal, dento-alveolar and soft tissue components, the first two components being particularly relevant. This may be achieved by 'growth modification' which comprises the use of functional appliances in the growing child pattern (Fig. As discussed there is a tendency to be critical of tooth extraction as part of orthodontic treatment. For It Came From Beneath The Sea (1955), he employed an octopus with six tentacles instead of eight.
There is potential for serious sequelae such as emergency department (ED) visits and hospitalisations. Prof Rowe, a Clinical Emergency Physician at the University of Alberta Hospital in Edmonton, Alberta, spoke about life-threatening asthma. Connecting patients to their primary care providers is a key factor in improving health outcomes. More boys have the condition than girls; at puberty, the prevalence changes and girls more commonly have this disorder, at least in the ED setting. Patients with asthma must be differentiated from chronic obstructive pulmonary diseases (COPD); most asthmatic patients are younger, they don’t generally have a causal smoking history, sputum production is infrequent, they often have allergies and their disease course is relatively stable. The comparison involved single or multiple doses of ipratropium bromide treatment added to SABA alone. A Cochrane review of 12 randomised, controlled trials compared systemic corticosteroids to standard of care or placebo. Most of the current concepts of orthodontic treatment are based upon personal opinion and retrospective studies.
If we examine the early orthodontic literature, we will find that the founder of contemporary orthodontics, Edward Angle, attempted to treat his patients' occlusion with reference to the occlusion of a skull displayed on a shelf in his surgery. These aims were modified by the concepts of Andrews who introduced the 'six keys of occlusion' (see Fig.
An example of the dento-alveolar component is crowding as a result of an adverse tooth-alveolar tissue ratio.
Some clinicians may say they can accurately predict facial changes, but this claim is totally unfounded. Implicit in this is the feeling that orthodontic extractions adversely affect the occlusion and furthermore this then leads to a temporomandibular disorder. For example, patients on welfare or who have designated aboriginal status have much higher presentation rates than do people who are employed and who pay their own health insurance.


In between exacerbations, their spirometry normalises; their symptoms would be considered intermittent.
Patients often do not demonstrate a decrease in their oxygen saturations until they are very severe. The initial studies of budesonide — an ICS compound — in croup, showed short-term effects and efficacy. This study did demonstrate a benefit for NIV; a reduction in hospitalisation, increased per cent predicted FEV1 and decreased heart rate. Guidelines recommend rapid follow-up; however, patients visited their family doctors a median of 19 days after the ED visit. This study indicated that ICS and prednisone could be safely prescribed to those patients who were not on ICS at ED presentation; relapse would be expected in approximately 5 per cent over the next three weeks.
Nevertheless, an attempt is made here to provide a guide to the relationship of orthodontics and the occlusion that is evidence based. In Figure 3, the patient does not have an optimal buccal interdigitation (keys 1 and 2 missing), yet there is very little perceptible difference in the aesthetics of the dentition. The jaw and facial examination will record the pattern of the skeletal bases and the facial symmetry, the condition of the TMJs and mandibular muscles, and the soft tissue characteristics. 9).How does the orthodontist decide on attempting camouflage or growth modification therapy?If there is a possibility of changing the jaw relationship, the clinician should examine the patient's jaw relationship before and after treatmentThere is currently a debate in orthodontics concerned with the detrimental effect of camouflage on the facial profile. First premolar extractions are considered by some to be an aetiological factor in TMD, it is suggested that these extractions permit the posterior teeth to move forward resulting in a decrease in the vertical dimension of occlusion.8Another theory is that first premolar extractions lead to over-retraction of the anterior teeth, particularly the maxillary incisors.
He sculpted characters from 3 to 15 inches tall and photographed them one frame at a time in continuous poses, thus creating the illusion of motion.
Moreover, patients with severe or near-fatal asthma have limited or no response to inhaled beta agonists. Over the six hours of the ED stay, there appeared to be an important improvement if this treatment is given earlier, said Prof Rowe.
Most of the data in a systematic review of seven trials involving 600 patients, by Marcia Edmonds, based in London, Ontario, came from inhaled corticosteroids versus placebo comparisons. At 21 days, the reduction amounted to 50 per cent — even though the drug would have been stopped many days before the relapse event or the end of the study.
The study suggested that there were some patients who were failing to maintain control on regular ICS monotherapy. Secondly does the anterior guidance on the front teeth occur with an absence of posterior interferences?Without doing this the dentist or orthodontist cannot fully assess a malocclusion or avoid a potential mistake in treatment planning.This is illustrated in Figure 4. The dental and occlusal examination will record the position of the teeth and their occlusal contacts. He had three live actors dueling seven skeletons and it took four months to produce a few minutes on the screen.
Many patients with poorly-controlled asthma, however, have a ratio below 0.7 and have been identified in the course of research performed by Prof Rowe’s group. A thorough history will identify patients who have a high need for beta agonists; they may require beta agonists up to 24 times per day. In summary, SABA (for example, salbutamol) plus SAAC would be the appropriate approach in moderate-to-severe asthma exacerbations, in Prof Rowe’s view. As the chronic asthma guidelines suggest, these patients should receive a more aggressive treatment, Prof Rowe said.
In centric occlusion this patient has an overjet of 5 mm and appears to represent a relatively straight forward orthodontic problem.
Again, it is hypothesised that this may lead to a TMD.9 These theories may superficially appear plausible. Harryhausen's last film, The Clash Of The Titans (1981), was the only one with a big budget and major cast that included Laurence Olivier, Maggie Smith, Burgess Meredith, Harry Hamlin and Claire Bloom. In locations or countries where compliance is low, intramuscular corticosteroids have been shown to be effective. However, when she is placed into centric relation, the mandible is considerably more posteriorly placed and she has an overjet of 10 mm, which is far more difficult to treat. When, however, they are subjected to scientific scrutiny they do not satisfy even the most basic criteria of scientific investigation. Hamlin as Perseus struggled to tame a white-winged Pegasus and to battle the snake-haired Medusa. This is an example of a 'postured bite' and is a relatively common problem in Class II Div i malocclusions.
This is because the presence of large discrepancies between CO and CR are a positive indication for orthodontic treatment.
In 1992, Harryhausen received a special award from the Academy of Motion Picture Arts and Sciences. As a result, this aspect of an examination is essential if misdiagnosis and incorrect treatment planning is to be minimised. Unfortunately, the myth still persists and the orthodontists who suggest this type of conventional treatment are frequently described as 'narrow minded' and those who 'do not know any better'.If a thorough appraisal of the scientific literature is undertaken no evidence of the deleterious effect of extractions can be found.



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