The presence and duration of preoperative pain from the tooth site, lasting at least 3 months, a positive history of previous chronic pain experience or painful treatment in the orofacial region, and female gender were important risk factors associated with persistent pain after successful endodontic treatment.

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A national strategy is needed to reduce costs, standardise teaching and increase pain clinic resources to maximise patient care.

SUMMARY The concentration of the elastase-a 1 proteinase inhibitor complex (E-a I PI) in a meningococcal infection in an index case with severe changes in haemostasis was measured. The concentration of the E-al PI complex was increased throughout the duration of the illness, although concentrations of the blood clotting factors were severely decreased. The release of polymorphonuclear elastase activity may contribute to the depletion in clotting factors.Disseminated intravascular coagulation is often associated with meningococcal infection.1 Recently data have been presented, which suggest that the depletion in blood clotting factors, observed in blood testing, could be the direct result of clotting factor degradation by the action of systemically released polymorphonuclear leucocyte elastase activity.2 With the development of a sensitive immunoassay for the elastase-a 1 proteinase inhibitor complex (E-a 1 PI), its quantitation in plasma provides an indirect but clear indication of elastase release.3 We describe a case of disseminated intravascular coagulation caused by Neisseria meningitidis. Material and methodsClotting factor assays were performed using methods previously described.4 Total white cell count, platelet count, one stage prothrombin times (PT), and partial thromboplastin (kaolin) times (PTTK) were estimated using routine tests available in the department.The estimation of the elastase-c 1 proteinase inhibitor complex (E-al PI) was performed as previously described,3 but with the following changes: standard, test, and control plasmas were diluted 1/1000 in 0 05 M phosphate buffer (pH 7 4) containing 0-05% Tween and 1% chick serum. The second antibody in the assay was conjugated to peroxidase and used at a dilution of 1/800. CASE REPORTA five year old girl was admitted to hospital with an 18 hour history of malaise, fever, and vomiting followed by the abrupt and rapid appearance of an extensive generalised purpuric and ecchymotic rash.Accepted for publication 30 June 1986 Culture of cerebrospinal fluid and blood yielded group B meningococci. The child was immediately treated with intravenous penicillin. Ecchymotic spots continued to develop over the next few hours, and at 15 hours (T15) this was followed by the abrupt and rapid appearance of extensive generalised purpuric and ecchymotic rash. The clotting screen repeated at 30 hours (T30) showed a pronounced deterioration in the clotting factor activity and platelet count. The coagulation screen at 34 hours (T34) showed a considerable improvement. Thereafter she made a slow steady improvement, her toxaemia settling within 48 hours. About five days after admission all coagulation changes had returned to normal. ResultsBacterial analysis identified the organism as Neisseria meningitidis. The results show a time dependent decrease in blood clotting factors (table 1). The concentration of the E-a 1 PI complex showed a sustained increase throughout the duration of the illness. One hundred and twenty hours (T120) after admission all coagulation variabl...