Across the spectrum of acute and chronic effects, nearly every organ system can be affected. Trauma is often associated with cocaine use. Even the absence of cocaine, after a cocaine binge, may precipitate an ED visit due to withdrawal symptoms.
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Crack is lipid soluble and therefore rapidly absorbed in the pulmonary capillaries. The term crack describes the crackling sound heard when cocaine freebase is smoked. Crack may be smoked in a pipe bowl containing 50-100 mg or in a cigarette with as much as 300 mg. Smoking crack bypasses the vasoconstriction that results when cocaine is snorted; therefore, the effects are similar to taking cocaine intravenously. Crack smokers may aggressively inhale against a small pipe and then perform a Valsalva maneuver before exhaling against pursed lips or forcefully blow the drug into a partner's mouth. These techniques are reputed to enhance the euphoria of cocaine.
Combining cocaine and heroin into a "speedball" causes frequent complications, as evidenced by the high-profile cases of actors John Belushi, River Phoenix, and Chris Farley in the 1980s and 1990s. Speedballing accounts for 12-15% of cocaine-related episodes in patients presenting to EDs in the United States. In speedballing, heroin is injected or snorted, followed immediately by smoking of cocaine. Cocaine is harder to purchase during the summer months than at other times, thus heroin users may speedball with crack in the summer. The effects of heroin last longer than do those of crack, and it modulates symptoms secondary to withdrawal from crack. In both cases, the second drug is used to supplement, rather than substitute, the primary drug.
Various agents can heighten the effects of cocaine and contribute to complications. Organophosphates may be taken to inhibit pseudocholinesterase, prolonging the effects of cocaine. However, because it produces organophosphate toxicity, the risk of fatality is increased. Cholinesterase inhibitors, such as carbamates, have a similar effect. Another practice involves coabusing crack cocaine and phenytoin to enhance the intoxication. In this practice, unbound phenytoin causes persons with hypoalbuminemia to become symptomatic at lowered drug levels; if death occurs, it usually is the result of respiratory and subsequent circulatory collapse.
Cocaine causes a direct negative inotropic effect on cardiac muscle, resulting in transient toxic cardiomyopathy. In one small series, 8 of 10 subjects who used cocaine long term had chest pain without MI but left ventricular ejection fractions less than 50%. In a case report, Jouriles describes a 35-year-old woman with hypotension, seizures, and hypoxemia who had an ejection fraction of 10% after smoking crack cocaine. [14]
The principal effect of cocaine, like ethanol, on mortality may be its association with homicide, suicide, and motor vehicle collisions. [27] In a study of 14,843 persons who were fatally injured in New York City over 3 years, fatal injury after cocaine use exceeded all deaths associated with other causes in persons aged 15-24 years. Although approximately one third of deaths associated with cocaine use were the result of its direct pharmacologic effects, two thirds were the result of traumatic injuries.
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The potential mechanical impact of different rotary systems used for root canal preparation has been a matter of debate for long. The aim of this study was to explore the incidence of dentinal cracks after root canal instrumentation with various rotary systems, in vitro. One hundred and eighty intact lower central incisors were selected and randomly divided into fourteen treatment groups (n = 12/group) and a control group (n = 12). After decoronation, the root canals were instrumented with fourteen different rotary systems (E3, E3 azure, NT2, Hyflex CM, Hyflex EDM, 2Shape, OneCurve, ProTaper Next, ProTaper Gold, WaveOne Gold, Mtwo, Reciproc Blue, TF adaptive, K3XF). All roots were horizontally sectioned at 3, 6, and 9 mm from the apex with a low-speed saw under water-cooling. The slices were then examined under stereomicroscope for dentinal cracks. No cracks were found in the control group. Cracks were found in all treatment groups, predominantly in the 3 mm slices. There was no statistically significant difference in the number of cracks when comparing the different systems to each other at any section level. At 3 mm, however, five of the studied systems, namely K3XF (p = 0.004), Protaper Next (p = 0.001), Reciproc Blue (p
While a considerable number of studies have investigated the ability of various endodontic instrumentation systems to create cracks, no study has thus far undertaken a comprehensive cross-system analysis in this respect. Therefore, this in vitro study was designed to investigate the formation of dentinal microcracks after root canal preparation with multiple NiTi systems applying a sectioning approach with microscopic analysis. The null hypotheses were that there is no quantitative difference in the formation of dentinal microcracks (1) between the tested groups (including control) at the same section levels, and (2) between different section levels within the same rotary system.
All roots were horizontally sectioned at 3, 6, and 9 mm from the apex with a low-speed saw (Isomet 1000; Buehler, Lake Bluff, IL) under copious water cooling. The slices were then inspected both with a dental operating microscope (Carl Zeiss Omni Pico, Oberkochen, Germany) and the stereomicroscope under illumination. Dentin sections were illuminated with a technique described by Coelho et al [25]. Light-emitting diode (LED) transillumination was performed with the aid of a probe (TransCure-T; Kinetic Instruments Corporation, Bethel, CT) and within 1 mm of the external surface of the root. Samples containing cracks were photographed with a reflex camera (Nikon D90; Nikon Tokyo, Japan) attached to the dental operating microscope.
There is a multitude of NiTi systems on the market, and dentists face difficulty when trying to find studies comparing most of them in a clinically relevant way. This in vitro study tried to address this problem by comparing the microcrack formation by multiple NiTi instrumentation systems in extracted teeth. We included instruments with different kinematics and, for the first time, both multiple-file and single-file systems were included in the analysis. Mandibular incisors were used because they are highly susceptible to fracture due to their narrow mesiodistal dimension [27].
When comparing the number of cracks at different root levels, there was no significant difference between the different systems at 9 or 6 mm from the apex. This is in accordance with the findings of Karataş et al. [18], but not with the findings of Pedulla et al. where the number of cracks differed significantly across single-file systems at 6 mm and 9 mm [19]. Also, the number of cracks present at 6 mm and 9 mm did not differ statistically from the control group at the same level. It seems from our findings that irrespective of the motion of the file system (rotational or reciprocating), the design of the file, or the presence or absence of pre-flaring, dentinal crack formation due to instrumentation cannot be deemed a significant issue in the coronal or middle part of the canal.
Although the number of cracks increased apically (see Fig 3), the difference was not significant within the same rotary system between the 3 mm and 6 mm levels. Also, the within-system comparisons indicated no significant difference between the 3 mm and the 9 mm levels, except for K3XF (p = 0.004) and Reciproc Blue (p = 0.004). In these systems, we found significantly more cracks at the 3 mm (apical) section than at 9 mm. The reason for this is probably that the apical part is the narrowest part of the canal, therefore any instrument contacts with the greatest canal surface in this part. Interestingly, this difference was not so pronounced in case of the other systems. Within the K3XF system multiple files with mainly 6% conicity are used in a crown-down technique with a rotational movement. Contrary to the mentioned system, Reciproc Blue is a single-file system working with a reciprocating motion. Despite being manufactured from a blue superelastic alloy which provides significant flexibility, Reciproc Blue has been documented to produce dentinal cracks during instrumentation [28].
Regarding the kinematics of file systems, reciprocating movement is safer both with respect to cyclic fatigue and torsion fracture [32]. As a result, the life span of the instruments used with this motion is longer [33]. According to a meta-analysis, reciprocating files generate significantly fewer cracks than conventional multiple-file rotary systems with pure rotational movement (e.g. Protaper, Mtwo, etc.) [34]. Our findings suggest that this claim may need to be refined, since this in our study differed according to the level of sectioning (apical, middle or coronal). Furthermore, neither Reciproc Blue, nor WaveOne Gold (both performing reciprocating movement) differed significantly in the number of cracks when compared to the other tested systems. Thus, kinematics does not appear to be the sole factor to influence crack formation. Previous studies found that TF adaptive produced significantly fewer cracks than fully reciprocating systems (Reciproc and WaveOne) [29, 18]. In contrast, we found that TF adaptive did not differ significantly from either Reciproc Blue or WaveOne Gold in such terms.
Within the limitations of this in vitro study, root canal preparation in straight root canals with an apical preparation size of 25 does influence dentinal crack formation inside the root canal. Certain rotary systems seem to be more aggressive in terms dentinal crack development compared to others. Dentinal crack development cannot be traced back to a single factor (e.g.: kinematics of the file, number of files in the sequence, presence or absence of pre-flaring)., it is probably multi-factorial instead. 2ff7e9595c
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