Evaluation of the sedative effect of intranasal versus intramuscular ketamine in 2-6-year-old uncooperative dental patients

BACKGROUND

Conscious sedation has gained more popularity these days, with different routes of drug administration having various advantages and disadvantages. Among all, ketamine is one of the most commonly used drugs in children.

OBJECTIVES

The aim of the present study was to compare 2 different routes of ketamine administration - intranasal (IN) vs. intramuscular (IM) - in 2-6-year-old uncooperative children needing dental treatment.

MATERIAL AND METHODS

This single-blind, crossover clinical trial was conducted on a group of 26 uncooperative children aged 2-6 years, who required at least 2 similar dental treatment visits. The patients were randomly assigned into 2 groups: group I - IN ketamine at their 1st session and IM ketamine at the 2nd session; and group II - exactly the opposite sequence. The sedative efficacy of the 2 techniques was assessed by 2 independent pediatric dentists based on the Houpt sedation rating scale. The data was analyzed using the Wilcoxon test, the repeated measures analysis of variance (ANOVA) and the least significant difference (LSD) test.

RESULTS

The participants showed reduced crying and movement with improved sleepiness at the 3 time points examined when IM administration was performed as compared to IN sedation (p < 0.05). The overall behavior scores were higher for the IM route as compared to the IN route at all tested time points (p < 0.05). The operating dentist and the parents believed that the IM route was significantly more effective (p < 0.05). The children in the IN session reached equilibrium faster than those in the IM session (p < 0.05). No significant statistical differences were noted between the groups with regard to various physiological parameters investigated at different time intervals.

CONCLUSIONS

Intramuscular ketamine was more satisfactory and effective than the IN route when sedating uncooperative children for dentistry.

THREE-YEAR OUTCOME OF DIODE LASER PULPOTOMY OF PRIMARY MOLARS USING THREE PULP CAPPING AGENTS: A SPLIT-MOUTH RANDOMIZED CLINICAL TRIAL

OBJECTIVES

Pulpotomy is the most commonly performed treatment for asymptomatic primary molars with exposed dental pulp. This study aimed to assess the clinical /radiographic success of diode laser pulpotomy with mineral trioxide aggregate (MTA), calcium hydroxide (CH), and calcium-enriched mixture (CEM) cement as pulp capping agents.

METHODS

This split-mouth randomized clinical trial was conducted initially on 34 children aged 3-8 years but 4 patients left the study before the first follow-up visit and the study was accomplished and analyzed with 30 cases. The patients had at least 3 first/second molars with deep caries that in radiographic evaluation revealed that they required pulpotomy. Following pulpotomy, the pulp stump was irradiated with diode laser (noncontact mode, 632 nm, 30 mW power) as photobiomodulation mode. Pulp tissue was then capped with MTA, CH, or CEM cement (n = 30 in each group). Reinforced zinc oxide eugenol was applied over the capping agent, and the teeth were restored with stainless steel crowns. Teeth were clinically/radiographically assessed at 6, 12, 18, and 36 months, after treatment. Data were analyzed by Cochran and McNemar tests.

RESULTS

All 30 patients showed up for clinical/radiographic follow-ups for up to 36 months. Regarding clinical outcomes, the 6-, 12-, 18-, and 36-month success rates of all experimental groups were nearly similar with no significant difference (p > .05). Regarding radiographic outcomes, the 6-month success rates were similar among the groups (p > .05); however, the 12-, 18-, and 36-month outcomes of CEM and MTA groups were similar but significantly superior to that of CH group (p < .05).

CONCLUSION

Diode laser irradiation and subsequent capping of pulp tissue with MTA or CEM cement can be employed for pulpotomy of primary molars.

POS1546-HPR DISEASE ACTIVITY BURDEN FOR LONG TERM RHEUMATOLOGY FOLLOW-UP PATIENTS

Background

There has been a lot of emphasis for early diagnosis and treatment for immune mediated rheumatology conditions such as Treat to target (T2T) for inflammatory arthritis, Fast track pathway for Giant cell arteritis. However, the data regarding burden of disease activity, nature and proportion of long term rheumatology follow up patients in rheumatology clinics have not been explored. There are conditions which are refractory to treatment or affected by recurrent flare-ups requiring long term follow-ups and constant monitoring. With increasing life expectancy and better treatment of the long term conditions, emphasis on long term disease activity monitoring is under strain. It is important to understand the nature of illnesses and treatment of long term follow-up patients to decide management strategies.

Objectives

The aim of this quality improvement project was to understand profile of disease and management of patient being seen as long term follow-up (defined as >2 years follow-up after their first presentation in specialist clinic).

Methods

This was a single point, retrospective cohort analysis of patients seen in rheumatology clinics in a district general hospital, UK in March 2021. We reviewed consecutive 120 follow-up patients and recruited 80 patients who had >2yrs follow-up. We have a community rheumatology service arm where all patients with stable inflammatory arthritis on non-biologic treatments are reviewed while patients with multisystem complicated illness and biologics are seen in secondary care. The stable patients from community clinics have not been included in this analysis. The data was reviewed using clinic letters, date of first appointment & last appointment. We looked at gender, age, diagnosis, number of follow ups in the first and last year, disease activity scores of the respective diagnosis and treatment given.

Results

Sixty six percent of follow-up patients are long term with complicated illness or treatment. Of these 52 patients (65%) were female with median age 64 years (range 23-94 years). Median duration of follow up for this group of patients was 6 years (range 2-11 years). Inflammatory arthritis was the most common diagnosis in 75% of patients (11 patients were Psoriatic arthritis, 30- Rheumatoid arthritis, 7- undifferentiated inflammatory arthritis and 7- Axial spondyloarthritis), 17.5% connective tissue disease, 11.2% vasculitis and others (Still’s disease) 3.7%. Some patients had more than one diagnoses. The number of follow ups in the first year ranged from 1-13 (median 4). In final year of analysis, patients were seen median of 3 times (range1-8). Amongst them, 25% of patients were seen 4 or more times. The commonly prescribed drugs were methotrexate (41.2%), sulfasalazine(17.5%), hydroxychloroquine(15%), leflunomide (7.5%),biologics (8.7%), mycophenolate mofetil and azathioprine (6.5%).The activity scores such as DAS28, BVAS, PsARC and BASDAI were documented in 46 patients (57.5%).

Conclusion

This study shows that 66.6% of follow-up patients in rheumatology clinics are complicated long term conditions on immunomodulatory treatment. Despite T2T approach, use of combination DMARDs and early use of biologics, majority are inflammatory arthritis. It also shows that even after median follow-up of 6 years, these patients require an average review 3 or more times per year. The reasons for this may be poor disease control, disease complications, comorbidities and medication side effects. Further analysis is ongoing to look into these aspects for better disease control and long term outcome.

Disclosure of Interests

None declared

AB1012 MANAGEMENT OF BREAST CANCER TREATMENT INDUCED BONE LOSS- RE-AUDIT

Background

Breast cancer treatment therapies (aromatase inhibitors (AI)) are associated with early menopause and adverse effect on bone density. Identifying high-risk patients and managing them appropriately will help reduce their fracture risk.

Objectives

We wanted to ascertain whether our management of breast cancer patients on aromatase inhibitors (AI) referred to osteoporosis clinic were as per guidelines. A consensus position statement from a UK expert group regarding breast cancer treatment induced bone loss, published with the support of the National Osteoporosis Society, the National Cancer Research Institute, Breast Cancer Study Group and the International Foundation.

The guideline recommend lifestyle advice for low risk patients; calcium plus vitamin D supplementation and lifestyle advice for medium risk; bisphosphonate, calcium plus vitamin D supplementation and lifestyle advice for high risk.

Methods

This is a re-audit cycle conducted for all patients referred to the osteoporosis clinic who were treated with aromatase inhibitors for breast cancer between 2016-2020. Patients were divided into two algorithms:

Algorithm 1: women who had experienced premature menopause associated with ovarian suppression with or without AI.

Algorithm 2: Postmenopausal women receiving treatment with an AI.

T-scores were used to stratify patients in algorithm 1 into high risk (HR- T score <-2), medium risk (MR-T score -1 to -2) and low risk (LR- T score >-1).

Algorithm 2 into high risk (HR-T score <-1) medium risk (MR -T score >-1).

Results:

Table 1.

Showing the results of Audit 1 and Re-audit

Audit 1Re-auditTotal Patients5472Data collected2014-20162016-2020GenderFemale 100 (%)Female 100 (%)Age in years45-9638-92Median age7768No of Osteoporotic patients3141No of Osteopenic patients2331Algorithm 1:Total patients=23• 18 HR• 5MR• LR nilTotal patients = 20• 19HR • 1 MRAlgorithm 2:Total patients =31• 31 HR • MR-nil • LR nilTotal patients =52• 45HR • 5MR • 2LRDrug therapy4563Bisphosphonates2149Denosumab2314Teriparatide10Declined treatment01Lifestyle/Vit D & Cal96Lifestyle advice only02

Conclusion

Re-audit showed all patients were on AI and treated appropriately. As compare to audit 1, all high risk group patients were treated with drug therapy and bisphosphonate was the first line therapy as per guidelines. It was recommended that patients with risk of osteoporosis should be referred and treated according to their risk stratification. It is a collective responsibility of Breast surgeons, Geriatrician, Frailty team, Oncologist, Rheumatology and General Practitioners).All patients should have repeat bone density scan in 2 years’ time after initial bisphosphonate therapy. The next audit cycle will be conducted in five years’ time.

Disclosure of Interests

None declared

The clinical and radiographic evaluation of Allium sativum oil (garlic oil) in comparison with mineral trioxide aggregate in primary molar pulpotomy

Background

Mineral trioxide aggregate (MTA) is known as a common biomaterial for pulpotomy of primary molars, with limitation including high cost, difficult handling, and long setting time. This study was conducted to compare the clinical and radiographic success rate of Allium sativum oil and MTA in pulpotomy of primary molar teeth.

Materials and Methods

This randomized, controlled, clinical trial was performed on a group of children with at least two symptom-free primary molars requiring pulpotomy. A total of 90 teeth were randomly assigned into two groups: After pulp amputation and hemostasis, Group I received MTA as medication in the pulp chamber and Group II received Allium sativum oil over the pulp stumps. Pulp chamber was then filled with reinforced ZOE paste (zinc oxide eugenol) and teeth were restored using stainless steel crowns. The follow-up scheme of 6, 12, and 18 months was set, and teeth evaluation was conducted by a calibrated pediatric dentist based on the modified criteria proposed by Zurn and Seale. The results were analyzed using the generalized estimating equation analysis with the P = 0.05 as the level of significance.

Results

The clinical success rate was 100% in both groups after all follow-ups. The radiographic success rate was, however, 91.1% after 6.75. 6% after 12 and 18 months in Group II while it was 95.6% after 6, 91.1% after 12 and 18 months in Group I in those follow-up points. The difference between the two groups was not statistically significant.

Conclusion

According to the results, Allium sativum oil has a high clinical and radiographic success rate comparable to those of MTA.

Dental Management of a Patient with Pulmonary Atresia and Ventricular Septal Defect

Pulmonary atresia with ventricular septal defect (PA/VSD) is one of the congenital heart diseases that results in cyanosis, susceptibility to bacterial endocarditis, and increased risk of complications during general anesthesia. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common inherited genetic disorder affecting the red blood cells. We aimed to elaborate the potential dental management for patients with this serious condition. This report presents the single-visit dental treatment of a three-year-old female with PA/VSD, G6PD deficiency and rampant caries. The complexity of dental treatments, high incidence of dental caries, lack of cooperation, and the systemic condition limit treatment options to providing service under general anesthesia and hospitalization. Careful monitoring of oxygen saturation during general anesthesia and antibiotic prophylaxis are essential due to the invasive nature of dental treatments. It appears that single-visit dental management under general anesthesia minimizes the risk of treatment of patients at high risk of bacterial endocarditis.

AB0262 CLINICAL EFFICACY OF SWITCHING FROM ORAL TO SUBCUTANEOUS METHOTREXATE IN MANAGEMENT OF RHEUMATOID ARTHRITIS: EXPERIENCE FROM OUT-PATIENT SETTING OF A DISTRICT GENERAL HOSPITAL IN UK

Background:

Methotrexate (MTX) is an anchor drug in the treatment of Rheumatoid arthritis. The literature review has shown that subcutaneous (SC) methotrexate has shown better efficacy, less adverse side effects and better compliance in inflammatory arthritis. Our department modified Inflammatory arthritis pathway in 2018 where all patient with moderate or severe disease are switched from oral to SC Methotrexate injection for improved management.

Objectives:

The aim of our study is to review whether switching of oral methotrexate (PO MTX) to subcutaneous methotrexate (SC MTX) helps to improve disease activity in patients with rheumatoid arthritis and avoids the need to introduce biologic therapy.

Methods:

We conducted a retrospective audit of patients with rheumatoid arthritis seen between January 2018 to January 2020 recording their age, gender, diagnosis, date of MTX switch and disease activity score 6 months after switching to SC MTX. Significance of change was calculated with test of proportion/chi square test.

Results:

Fifty patients were reviewed, thirty eight (76%) were female and twelve (24%) were male with age ranging between 34 - 86 years (median 61.5 years). Switching to MTX injection was done within 2 yrs of diagnosis in 21 (42%) patients, between 2-5 yrs of diagnosis in 11 (22%) patients and more than 5 yrs after diagnosis in 18 (36%) patients. The main reasons of switching were either maximum MTX dose (25mg) or intolerance to oral MTX at any dose.

After switching methotrexate, review at 6 months showed 26 patients (52%) in remission (compared to 6 at baseline) and 3 (6%) patients avoided the need to go on biologic therapy. Five patient commenced on biologic therapy between 3 and 6 months.

Table 1.

Disease activity compared at Baseline and at 6 months

Disease ActivityBaselineAt 6 monthsRemission <2.6626 (p<0.0001)Mild (26-3.19)1110Mod (3.2 - 5.09)259 (p<0.01)Severe (>5.1)85

Conclusion:

Switching to SC Methotrexate even in patients with long duration of disease results in significant number of patients achieving remission or lower disease activity (P<0.001). This may obviate the need of biologics therapy

Disclosure of Interests:

None declared

Association of salivary physicochemical characteristics and peptide levels with dental caries in children

AIM

The purpose of this investigation was to evaluate the association of physicochemical properties and antimicrobial peptide levels of saliva with caries activity in children.

MATERIALS AND METHODS

The required volume of unstimulated saliva was collected from 41 children aged 3-12 years with no systemic diseases. Caries activity was calculated using DMFS and dmfs records for each participating child. Collected saliva samples were then examined for their flow rate, pH, and buffering capacity. The concentration of three peptides was assessed including LL-37, human neutrophil peptide (HNP) 1-3, and human beta-defensin (HBD)-3 through an enzyme-linked immunosorbent assay. The correlation between caries activity score (CAS) and salivary variables was looked using the linear regression and Spearman's correlation method. The comparison of CAS means between high- and low-value groups of salivary items was performed using independent sample t-test while the association of CAS and salivary parameters in categorical scale was tested by Chi-square test.

RESULTS

No statistically significant differences were found between the CAS means at low and high categories of each salivary physicochemical parameter and those of antimicrobial peptides. There was a negative correlation between HNP1-3 and CAS and also between HBD-3 and CAS, but these results were not statistically meaningful. High HNP1-3 concentration was noted in 67% of the low caries rate group and 29% of the high caries rate group, with a statistically significant difference between the low and high caries rate groups (P = 0.019).

CONCLUSION

Salivary inherent factors are not dominant determinants in caries activity. The current results may suggest that α-defensins (HNP1-3) have a protective role against dental caries.

Comparing the effect of dry and wet brushing on dental plaque removal in children

AIMS

This study was aimed to assess the efficacy of wet and dry brushing on cleaning outcome of tooth surfaces.

METHODS

Forty-three children aged 10-12 years were randomly selected and instructed for this brushing project. Each case served as self-control. Each patient was requested to brush through one of the wet/dry techniques for 1 week and other technique on the 2^nd week. Samples had a washout step using pumice prophylaxis prior to each brushing week. Tooth Cleanliness Index was used to measure the plaque removal level. Two uniform Oral-B toothbrushes were used one for each week through the Modified Stillman technique. Mann-Whitney test was employed along with the Wilcoxon signed-rank test to analyze the data.

RESULTS

The level of brushing efficacy was slightly higher in males with no statistically significant difference between sexes. Remaining plaque measured was higher in wet group with significant difference (7.3 ± 1.7 for dry brushing and 7.6 ± 2.6 for wet brushing) (P < 0.05).

CONCLUSIONS

Dry and wet brushing did not show a significant difference in their capacity to remove plaque indicating that dry brushing could be considered as an acceptable brushing technique.

Clinical and radiographic evaluation of diode laser pulpotomy on human primary teeth

Background and aims

The aim of this investigation was to evaluate clinical and radiographic effects of diode laser pulpotomy on young human primary molars.

Materials and methods

This double-blind, split-mouth randomized clinical trial was conducted on 14 children, aged 3-9 years. In total, 20 pairs of teeth were selected from those with pulpal exposure due to caries. Case selection was conducted based on clinical and radiographic criteria with similar teeth in each patient. One tooth was randomly assigned to diode laser pulpotomy as case and the other tooth was pulp-treated using formocresol as control. Diode laser at a 10-W power was applied on the remaining pulp tissue following coronal pulp amputation in the case group, while a cotton pellet with diluted formocresol was placed over the amputated pulp in the control group. Reinforced zinc oxide-eugenol paste was then placed over the pulp stump and the tooth was restored with stainless steel crown. A 6- and 12-month followed-up was conducted clinically and radiographically in order to assess the success rates. Data were analyzed with Fisher's exact test.

Results

Clinical failure rate was almost zero when the cases were followed and examined clinically (100% success), with 95% and 90% of the cases in the case group (diode laser) being judged as successful in radiographic examination after 6 and 12 months, respectively. Cases in the control group (formocresol) had almost the same clinical success rate (100%) with no failure judged by radiographic evaluation at 6 and 12 months. These results did not show any significant differences when analyzed using Fisher's exact test (P > 0.05).

Conclusion

There was no significant difference between diode laser pulpotomy and formocresol pulpotomy of human primary teeth after 6 and 12 months. Only a fraction of cases (5%) had radiographic problems at their follow-up in the laser group.

Comparison of sedative effects of oral midazolam/chloral hydrate and midazolam/promethazine in pediatric dentistry

Background. The aim of this investigation was to compare the sedative effects of oral midazolam/chloral hydrate and midazolam/promethazine combinations on fearful children needing dental treatment. Methods. This crossover double-blind clinical trial was conducted on 30 children aged 2‒6 years, who had at least two similar teeth needing pulp treatment. Standard vital signs were recorded before and after premedication. Wilson sedation scale was used to judge the level of sedation. Cases were divided into two groups based on the sequence of medication received. This was to overcome the sequence effect. Group I received oral midazolam (0.4 mg/kg/chloral hydrate (50 mg/kg) at the first visit while they received midazolam (0.4 mg/kg)/promethazine (5 mg/kg) in their second visit. Group II received the premedication in the opposite sequence. The operator and child were blinded to the medication administered. Sedative efficacy of the two combinations were assessed and judged by two independent pediatric dentists based on the Wilson scale. Data were analyzed with ANOVA and paired t-test. Results. Only 10% of children who received chloral hydrate with midazolam exhibited high improvement in their behavior while 53% showed reasonable positive changes and 12% had no change or even deterioration of behavior. The difference between the effect of the two combination drugs was statistically significant (P<0.05) in favor of the chloral hydrate group. Conclusion. The results showed a significant difference in the sedation level induced between the two groups. Midazolam/chloral hydrate combination more effectively improved the co-operation for dental treatment.

Oral Melatonin Versus Midazolam as Premedication for Intravenous Sedation in Pediatric Dental Patients

OBJECTIVES

This study aimed to evaluate the effect of oral melatonin and oral midazolam as premedication for intravenous (IV) sedation of pediatric dental patients.

MATERIALS AND METHODS

This crossover, double-blind randomized clinical trial was conducted on 23 uncooperative 2-6-year-olds with definitely negative behaviors according to the Frankl's scale. Each child served as their own control. The children were randomly divided into two groups: group I received 0.5mg/kg of oral melatonin one hour before IV sedation, while group II received 0.5mg/kg of oral midazolam 30 minutes before IV sedation on their first visit. Every child received the other premedication on their second visit. The degree of sedation was judged according to the Houpt scale. Physiologic parameters including blood pressure (PB), heart rate (HR), and blood oxygen saturation (SpO2) and side effects including dizziness, nausea, vomiting, and sleepiness were assessed. The parents' and the operator's satisfaction rates were scored. Data were analyzed using paired t-test and Wilcoxon signed-rank test.

RESULTS

There were significant differences in sedation scores between the two sessions (P<0.05). However, there were no significant differences in alterations of physiologic parameters between the two sessions (P>0.05). Nausea and vomiting were more common during the first two hours in the midazolam group (P=0.002). Tremors were more common in the melatonin group (P=0.013). Dizziness was more evident when melatonin was used (P<0.001). The clinician and the parents were more satisfied with the results of midazolam intake (P<0.05).

CONCLUSIONS

Premedication with oral midazolam in pediatric patients is superior to that with melatonin with a higher parents' and operator's satisfaction.

Intranasal Premedication Effect of Dexmedetomidine Versus Midazolam on the Behavior of 2-6-Year-Old Uncooperative Children in Dental Clinic

OBJECTIVES

The aim of this study was to compare the intranasal premedication effect of newly introduced dexmedetomidine (DEX) versus midazolam on the behavior of uncooperative children in the dental clinic.

MATERIALS AND METHODS

This crossover double-blind clinical trial was conducted on 20 uncooperative children aged 2-6 years who required at least two similar dental treatment visits. The subjects were randomly given 1 μg/kg of DEX and 0.5 mg/kg of midazolam via the intranasal route. For the sedation protocol in the two groups, 0.25 mg/kg of atropine in combination with 0.5 mg/kg of midazolam added to 1-2 mg/kg of ketamine were used 30 minutes after premedication and transferring the patient to the operating room. Dental treatments were carried out by a pediatric dentist blinded to the type of the administered premedication. The sedative efficacy (overall success rate) of the agents was assessed by two independent pediatric dentists based on the Houpt scale. Data analyses were carried out according to Wilcoxon signed-rank test and paired t-test.

RESULTS

There were no significant differences in the premedication efficacy of intranasal DEX and midazolam according to the Houpt scale (P>0.05).

CONCLUSIONS

Intranasal midazolam and DEX are satisfactory and effective premedication regimens for uncooperative children.

Conscious Sedation Efficacy of 0.3 and 0.5 mg/kg Oral Midazolam for Three to Six Year-Old Uncooperative Children Undergoing Dental Treatment: A Clinical Trial

OBJECTIVES

Midazolam with variable dosages has been used to induce sedation in pediatric dentistry. The aim of this study was to compare the efficacy of two dosages of oral midazolam for conscious sedation of children undergoing dental treatment.

MATERIALS AND METHODS

In this randomized crossover double blind clinical trial, 20 healthy children (ASA I) aged three to six years with definitely negative Frankl behavioral rating scale were evaluated. Half of the children received 0.5mg/kg oral midazolam plus 1mg/kg hydroxyzine (A) orally in the first session and 0.3mg/kg oral midazolam plus 1mg/kg hydroxyzine (B) in the next session. The other half received the drugs on a reverse order. Sedation degree by Houpt sedation rating scale, heart rate and level of SpO2 were assessed at the beginning and after 15 and 30 minutes. The data were analyzed using SPSS 19 and Wilcoxon Signed Rank and McNemar's tests.

RESULTS

The results showed that although administration of 0.5mg/kg oral midazolam was slightly superior to 0.3mg/kg oral midazolam in terms of sedation efficacy, the differences were not significant (P>0.05). The difference in treatment success was not significant either (P>0.05). Heart rate, oxygen saturation (SpO2) and respiratory rate were within the normal range and did not show a significant change (P>0.05).

CONCLUSIONS

The overall success rate of the two drug combinations namely 0.5mg/kg oral midazolam plus hydroxyzine and 0.3mg/kg oral midazolam plus hydroxyzine was not significantly different for management of pediatric patients.

Role of Anatomic and Salivary Factors in Dental Calculus Formation in Primary and Mixed Dentition Stages

PURPOSE

Clinical experience shows that formation of calculus is a very rare phenomenon in primary teeth, but it increases as the permanent teeth erupt. The purpose of this study was to assess the relationship between dental calculus, dental anatomy, and salivary factors in primary and mixed dentition stages.

METHODS

A cross-sectional study was carried out to determine the buccolingual dimensions of the most concave and the most convex surfaces of the lingual aspect of mandibular central incisor crowns in a sample group of 120 three- to five-old children and 120 eight- to 10-year old children. Saliva samples were collected from 20 in each group. Data were analyzed using t tests.

RESULTS

Significant differences were found between the ratio of the buccolingual dimensions of the most convex to the most concave areas of the lingual surfaces in primary and permanent incisors (P=0.028). Saliva analysis revealed significant differences in total protein (P=0.002), sodium (P=0.037), bicarbonate (P=0.003), and ammonia (P=0.025) between the two age groups.

CONCLUSIONS

Anatomic and salivary factors may be important reasons for the differences in calculus formation.

Comparison of Oral and Intranasal Midazolam/Ketamine Sedation in 3-6-year-old Uncooperative Dental Patients

Background and aims. There are several known sedative drugs, with midazolam and ketamine being the most commonly used drugs in children. The aim of this study was to compare the effect of intranasal and oral midazolam plus ketamine in children with high levels of dental anxiety.

Materials and methods.A crossover double-blind clinical trial was conducted on 23 uncooperative children aged 3-6 (negative or definitely negative by Frankel scale), who required at least two similar dental treatment visits. Cases were randomly given ketamine (10 mg/kg) and midazolam (0.5 mg/kg) through oral or intranasal routes in each visit. The sedative efficacy of the agents was assessed by an overall success rate judged by two independent pediatric dentists based on Houpt’s scale for sedation. Data analysis was carried out using Wilcoxon test and paired t-test.

Results. Intranasal administration was more effective in reduction of crying and movement during dental procedures compared to oral sedation (P<0.05). Overall behavior control was scored higher in nasal compared to oral routes at the time of LA injection and after 15 minutes (P<0.05). The difference was found to be statistically significant at the start and during treatment. However, the difference was no longer significant after 30 minutes, with the vital signs remaining within physiological limits. Recovery time was longer in the intranasal group (P<0.001) with a more sleepy face (P=0.004).

Conclusion.. Intranasal midazolam/ketamine combination was more satisfactory and effective than the oral route when sedating uncooperative children.

Epidermolysis bullosa, dental and anesthetic management: a case report

Epidermolysis bullosa (EB) is a group of rare inherited skin and mucous membrane disorders in which blister formation may arise spontaneously or following a minor friction. Various patterns of inheritance are explicated for the disease. The disease has a profound effect on oral mucosa and may result in high prevalence of dental caries. General anesthesia is sometimes the only choice for dental treatments in patients with EB. The following case report describes the dental and anesthetic management of an 12.5 -year-old girl with dystrophic type of EB. The patient was followed up every 6 months. New carious lesions were detected one year after the treatment, on the last visit. Presenting a perfect dental care to children with this disorder can be challenging for the in charge specialist, both pediatric dentist and anesthesiologist.

Steam sterilization effect on the accuracy of friction-style mechanical torque limiting devices

AIM

This study was aimed to evaluate the effect of steam sterilization on the accuracy (within 10%) of friction-style mechanical torque limiting devices (F-S MTLDs) to achieve their target torque values.

MATERIALS AND METHODS

Fifteen new F-S MTLDs were selected from Astra Tech (25 Ncm, Hader SA, La Chaux-de-Fonds, Switzerland), BioHorizons (30 Ncm, Dynatorq ITL, Irvine, California, USA), Dr. Idhe (15-60 Ncm, Dr. Idhe Dental, Eching/Munich, Germany). Every peak torque measurement was tested ten times before steam sterilization using Tohnichi torque gauge (6Tohnichi-BTG (-S), Japan). Steam sterilization was performed using a 100 cycle autoclave. Preparation steps were carried out for the devices before each autoclave sterilization cycle. Peak torque measurements were repeated after every sterilization cycle. Mean difference between the measured and the targeted torque values were evaluated before and after aging. Repeated-measures of ANOVA were used to compare the differences of accuracy between subjects. Bonferroni post-hoc test was used for pairwise comparison.

RESULTS

Autoclaving resulted in an increase in the error values (the difference between peak torque and target torque values) in all the three groups studied (P < 0.05), with only Astra Tech devices showing >10% (maximum 12%) difference from their torque values in 5% of the measurements.

CONCLUSION

Steam sterilization effect differs between target torque and measured peak values with an increase trend. The peak torque values showed a significant decrease for BioHorizons, while a significant increase was noted for Astra Tech and no significant change in Dr. Idhe group after sterilization.

CLINICAL IMPLICATION

Within the limitation of this study the torque output of each individual device deviated in varying degrees from target torque values. However, the majority of the new frictional-style devices tested in this study, delivered fairly consistent torque output within 10% of their preset target values after sterilization. Astra Tech devices were the only one showing more than 10% difference from their torque values in 5% of the measurements. Combined effects of sterilization and aging still needs to be determined.

The effect of sterilization and number of use on the accuracy of friction-style mechanical torque limiting devices for dental implants

BACKGROUND

Mechanical torque limiting devices (MTLDs) are necessary tools to control a peak torque and achieving target values of screw component of dental implants. Due to probable effect of autoclaving and number of use on the accuracy of these devices, this study aimed to evaluate the effect of sterilization and number of use on the accuracy of friction-style mechanical torque limiting devices (F-S MTLDs) in achieving their target torque values.

MATERIALS AND METHODS

Peak torque measurements of 15 new F-S MTLDs from three different manufacturers (Astra Tech, BioHorizons, Dr. Idhe) were measured ten times before and after 100 steam sterilization using a digital torque gauge. To simulate the clinical situation of aging (number of use) target torque application process was repeated 10 times after each sterilization cycle and the peak torque values were registered. Comparison of the mean differences with target torque in each cycle was performed using one sample t test. Considering the type of MTLDs as inter subject comparison, One-way repeated measure ANOVA was used to evaluate the absolute values of differences between devices of each manufacturer in each group (α = 0.05).

RESULTS

The results of this study in Dr. Idhe group showed that, mean of difference values significantly differed from the target torque (P = 0.002) until 75 cycles. In Astra Tech group, also mean of difference values with under estimation trend, showed a significant difference with the target torque (P < 0.001). Mean of difference values significantly differed from the target torque with under estimation trend during all the 100 cycles in BioHorizons group (P < 0.05).

CONCLUSION

The torque output of each individual device stayed in 10% difference from target torque values before 100 sterilization cycles, but more than 10% difference from the target torque was seen in varying degrees during these consequent cycles.

Sedative Effect of Oral Midazolam/Hydroxyzine versus Chloral Hydrate/Hydroxyzine on 2-6 Year-Old Uncooperative Dental Patients: A Randomized Clinical Trial

OBJECTIVE

Different drugs are used for conscious sedation in pediatric dentistry either single or in combination. This study assessed the comparative effect of midazolam/hydroxyzine and chloral hydrate/hydroxyzine on 2-6 year-old uncooperative children needing dental treatment.

MATERIALS AND METHODS

A double blind cross-over randomized clinical trial was designed and 16 children aged 2-6 years with ASA1 status who were judged with negative to definitely negative behavior (according to Frankl) were chosen. Cases were divided randomly into two groups. The first group received midazolam/hydroxyzine (MH) at the first visit while the second group received chloral hydrate/hydroxyzine (CHH) as the first medication. Both groups received the other regimen at the second visit. Midazolam 0.5mg/kg and chloral hydrate 50mg/kg with 1mg/kg hydroxyzine were administered. Cases were subsequently assessed for sedation and then dental treatment was performed. Blood oxygen saturation (SpO2) and pulse rate (PR) were measured before and after drug administration, as well as during and after dental treatment. The Houpt scale was also used for the level of sedation before, during and after treatment. Data were analyzed using Wilcox-on signed rank test and the paired t-test.

RESULTS

Sedative success rate was 64.3% in cases of MH and 33.3% in CHH. The difference between groups was significant (P=0.046). The success rate was significantly different between groups at different measurement stages as well (P<0.05). No difference was found on the child's behavior scale based on the type of drugs used first; this indicates no carry-over effect. Comparing the PR and SpO2 values at different readings showed no significant differences.

CONCLUSION

Midazolam/hydroxyzine showed a significantly higher sedative effect than chloral hydrate/hydroxyzine in this study.

Sequential supernumerary teeth development in a non-syndromic patient; report of a rare case

Isolated impacted supernumerary teeth are quite rare, but they can be seen associated with several syndromes such as cleidocranial dysostosis or Gardner's syndrome. This article aims to discuss a case of sequential formation of supernumerary teeth with no other associated disease or syndrome. A 17-year-old Iranian male with 8 impacted supernumerary teeth was referred to the department of pediatric dental clinic at Shahid Beheshti Medical University in Tehran with a history of several impacted unerupted teeth. Repeated and periodical clinical and radiographic examinations revealed newly formed teeth buds in unusual dental ages. All extra teeth were associated with generalized enamel hypoplasia to some degree on their relative permanent adjacent teeth. The patient did not have any record of a systemic disease or any syndromic condition to relate his dental problem to. This rare condition involved repeated and continued formation of extra teeth out of the normal numbers and dental age evident in serial radiographs.

Assessing the sedative effect of oral vs submucosal meperidine in pediatric dental patients

BACKGROUND

THE GOAL OF THIS INVESTIGATION WAS TO COMPARE THE BEHAVIORAL AND PHYSIOLOGICAL EFFECTS OF THREE SEDATIVE DRUG REGIMENS: oral meperidine (OM), submucosal meperidine (SM) and oral midazolam (M) in healthy pediatric patients.

MATERIALS AND METHODS

This study sample consisted of thirty children aged 24-72 months (mean = 41.1) exhibiting definitely negative behavior. Three sedative regimens including: Oral meperidine/hydroxyzine, oral midazolam/hydroxyzine and submucosal meperidine/oral hydroxyzine were administered randomly during three consecutive appointments with a crossover design. Houpt behavioral scale was employed for evaluating the sedation effect of each regimen by a calibrated independent Pediatric dentist. Physiologic parameters were also recorded including blood oxygen saturation and pulse rate. Data was analyzed using Wilcoxon-signed ranked test, Mc-Nemar, GEE Logistic regression, Friedman, Fisher exact and Cochran tests for significance.

RESULTS

Overall success rates were 50%, 46.7% and 26.7% for submucosal meperidine, oral meperidine and oral midazolam, respectively (P = 0.03). The probability of achieving a success in behavior control was more in 48-72 month olds. Child's age and drug type were the two main predictors of altered behavior. Evaluating the differences between the effects of three tested regimens on recorded physiological parameters showed no significant differences.

CONCLUSION

All three regimens were proved safe within the limits of the current study. Meperidine sedation in both routes was considered to be more effective. Although there was less sleep and more head/oral resistance in midazolam group, the difference between groups was not significant.

Remineralization Effect of Topical NovaMin Versus Sodium Fluoride (1.1%) on Caries-Like Lesions in Permanent Teeth

OBJECTIVE

NovaMin, a synthetic mineral composed of calcium, sodium, phosphorous and silica releases deposits of crystalline hydroxyl-carbonate apatite (HCA) structurally similar to tooth mineral composition. The aim of this investigation was to compare the potential remineralization effect of topical NovaMin and Sodium Fluoride gel on caries like lesions in permanent teeth.

MATERIALS AND METHODS

A total of 60 sound human freshly extracted teeth were subjected to a pH-cycling protocol. Specimens were randomly assigned to one of the two treatment groups with NovaMin contained dentifrice applied to group 1, while group 2 received a dentifrice containing 1.1% neutral Sodium Fluoride. Pastes were applied five times after the samples received a demineralization from an earlier cariogenic challenge. Specimens were then evaluated by a Surface Micro Hardness test (SMH, 25G, 5s). Post-treatment SMH measurements were conducted and Mann Whitney test was employed for statistical analysis.

RESULTS

Mean post lesion SMH values were 221.99±26.27 and 224.50±28.64 for the first and second groups, respectively. Post treatment SMH values were 232.52±24.34 for NovaMin and 232.03 ±24.46 for the fluoride group. Two way ANOVA test showed a highly significant difference between the two different treatment protocols (p<0.001).

CONCLUSION

NovaMin dentifrice appears to have a greater effect on remineralization of carious-like lesions when compared to that of fluoride containing dentifrice in permanent teeth.

Comparison of oral Midazolam-Ketamine and Midazolam-Promethazine as sedative agents in pediatric dentistry

BACKGROUND

Investigation was designed to evaluate the behavioral changes in children receiving dental treatment while they have been administered combination of Midazolam/Ketamine or Midazolam/Promethazine.

MATERIALS AND METHODS

This was a randomized double blind clinical trial with cases being selected from those uncooperative children aged 2 to 6 years from those referred for treatment under general anesthesia. Anxiety score of all cases were recorded before any attempt using Frankel's anxiety scoring system with those in negative category being included. Cases with at least a pair of similar size cavities on similar teeth were selected with each tooth being randomly allocated for one sedative regimen group. To avoid sequence effect, half of the patients received one regimen at the first visit while the other half received the other regimen as the first. Each case served as control for him or herself to reduce influencing factors. Child's reaction was recorded before, during, and at the end of dental procedure. SO2 as well as Pulse rate were recorded as the most critical vital signs. Collected data were then analyzed using analysis of variance (ANOVA) and paired t-test.

RESULTS

Patients' mean age was 3.5 years with 43% being male. Only 10% of the Ketamine/Midazolam group showed considerable amount of change in their behavior with a statistical significant difference being presented (P=0.029).

CONCLUSION

Under the current circumstances, Ketamine/Midazolam combination provided sufficient sedative effect in lower doses. However, Midazolam/Promethazine combination did not produce similar results.

Microleakage assessment of pit and fissure sealant with and without the use of pumice prophylaxis

OBJECTIVES

This study evaluated the effect of pumice prophylaxis on the level of microleakage around and between the sealant and enamel.

MATERIALS AND METHODS

A total of 32 freshly extracted sound upper first premolars, assigned as suitable for sealant application, were chosen and divided randomly into two groups: (1) a test group, without prophylaxis; and (2) a control group, with prophylaxis. Sealant was applied to all teeth using the same conventional technique, with prophylaxis being omitted in the test group. The sealed teeth were thermocycled (120 x 30 s, 5 and 55 degrees C cycles) and then immersed in 2% Basic Fuchsin solution for 72 h. Each tooth was sectioned and examined for dye penetration under a stereomicroscope (x 60 magnification).

RESULTS

No dye penetration was seen in 19 (29.6%) of the teeth in the test group and 36 (56.2%) of the teeth in the control group. Dye had penetrated to the base of the fissure in 31 (48.4%) of the teeth in the test group and 23 (35.9%) of the teeth in the control group. Using a chi-square test for trend, the frequency of microleakage was significantly higher in the test group compared to the controls (P < 0.016).

CONCLUSION

Prophylaxis has a role in improving sealant retention. Removing this step may cause an increase in microleakage.

Chemomechanical caries removal in primary teeth in a group of anxious children

Chemomechanical removal of dental caries has considerable potential in the treatment of patients with management problems, especially in paediatric dentistry. The aim of this study was to assess the acceptance and success of the technique in young nervous patients. A group of 20 patients, aged between 4 and 10 years with a high level of dental anxiety was selected. The study achieved a success rate of over 90% in acceptance of cavity preparation by this procedure followed by placement of a restoration. The length of time required for cavity preparation was comparable with conventional methods. The need for local anaesthesia was reduced or eliminated and the children did not complain of any pain during the procedure. It is concluded that chemomechanical caries removal in vivo in primary teeth is an effective alternative to conventional mechanical caries removal and is advantageous in patients who have a phobia to the dental handpiece and/or injections.

The effect of cyclosporine with and without nifedipine on gingival overgrowth in renal transplant patients

PURPOSE

This investigation was performed to evaluate the effect of cyclosporine alone and in combination with nifedipine on gingival overgrowth.

METHODS

One hundred and nineteen patients who had undergone renal transplantation at least 12 months previously were selected for the study. The patients were divided into 2 groups according to whether they had received cyclosporine alone (group 1, n = 98) or cyclosporine with nifedipine (group 2, n = 21). Periodontal and pharmacological characteristics were assessed for all patients.

RESULTS

Marked gingival overgrowth was seen in 11 (52%) of the patients in group 2 but just 6 (6%) of those in group 1. In addition, the gingival overgrowth index was significantly greater for patients who had received both nifedipine and cyclosporine (Mann-Whitney U-test, p < 0.001). However, there were no significant differences between groups with higher and lower gingival overgrowth index in terms of age, sex, cyclosporine dose, nifedipine dose or level of cyclosporine in the serum.

CONCLUSION

The combination of cyclosporine and nifedipine may increase the incidence as well as the severity of gingival overgrowth in renal transplant patients. Among patients who had received both drugs, there was a clear relationship between gingival overgrowth and duration of cyclosporine and nifedipine use.

Role of modified nucleosides of yeast tRNA(Phe) in ribosomal binding

Naturally occurring nucleoside modifications are an intrinsic feature of transfer RNA (tRNA), and have been implicated in the efficiency, as well as accuracy-of codon recognition. The structural and functional contributions of the modified nucleosides in the yeast tRNA(Phe) anticodon domain were examined. Modified nucleosides were site-selectively incorporated, individually and in combinations, into the heptadecamer anticodon stem and loop domain, (ASL(Phe)). The stem modification, 5-methylcytidine, improved RNA thermal stability, but had a deleterious effect on ribosomal binding. In contrast, the loop modification, 1-methylguanosine, enhanced ribosome binding, but dramatically decreased thermal stability. With multiple modifications present, the global ASL stability was mostly the result of the individual contributions to the stem plus that to the loop. The effect of modification on ribosomal binding was not predictable from thermodynamic contributions or location in the stem or loop. With 4/5 modifications in the ASL, ribosomal binding was comparable to that of the unmodified ASL. Therefore, modifications of the yeast tRNA(Phe) anticodon domain may have more to do with accuracy of codon reading than with affinity of this tRNA for the ribosomal P-site. In addition, we have used the approach of site-selective incorporation of specific nucleoside modifications to identify 2'O-methylation of guanosine at wobble position 34 (Gm34) as being responsible for the characteristically enhanced chemical reactivity of C1400 in Escherichia coli 16S rRNA upon ribosomal footprinting of yeast tRNA(Phe). Thus, effective ribosome binding of tRNA(Phe) is a combination of anticodon stem stability and the correct architecture and dynamics of the anticodon loop. Correct tRNA binding to the ribosomal P-site probably includes interaction of Gm34 with 16S rRNA C1400.

Structural and functional roles of the N1- and N3-protons of psi at tRNA's position 39

Pseudouridine at position 39 (Psi(39)) of tRNA's anticodon stem and loop domain (ASL) is highly conserved. To determine the physicochemical contributions of Psi(39)to the ASL and to relate these properties to tRNA function in translation, we synthesized the unmodified yeast tRNA(Phe)ASL and ASLs with various derivatives of U(39)and Psi(39). Psi(39)increased the thermal stability of the ASL (Delta T (m)= 1.3 +/- 0.5 degrees C), but did not significantly affect ribosomal binding ( K (d)= 229 +/- 29 nM) compared to that of the unmodified ASL (K (d)= 197 +/- 58 nM). The ASL-Psi(39)P-site fingerprint on the 30S ribosomal subunit was similar to that of the unmodified ASL. The stability, ribosome binding and fingerprint of the ASL with m(1)Psi(39)were comparable to that of the ASL with Psi(39). Thus, the contribution of Psi(39)to ASL stability is not related to N1-H hydrogen bonding, but probably is due to the nucleoside's ability to improve base stacking compared to U. In contrast, substitutions of m(3)Psi(39), the isosteric m(3)U(39)and m(1)m(3)Psi(39)destabilized the ASL by disrupting the A(31)-U(39)base pair in the stem, as confirmed by NMR. N3-methylations of both U and Psi dramatically decreased ribosomal binding ( K (d)= 1060 +/- 189 to 1283 +/- 258 nM). Thus, canonical base pairing of Psi(39)to A(31)through N3-H is important to structure, stability and ribosome binding, whereas the increased stability and the N1-proton afforded by modification of U(39)to Psi(39)may have biological roles other than tRNA's binding to the ribosomal P-site.

Caries detector dyes--an in vitro assessment of some new compounds

Previous studies have shown that the caries detector dyes, basic fuchsin and acid red, lack specificity. Accordingly, their clinical use can lead to the unnecessary removal of sound tissue. In the present study, the specificity of three further dyes, Carbolan Green, Coomassie Blue and Lissamine Blue was studied. Carious dentine was removed in vitro by means of rotary instruments until the cavities were deemed caries free by conventional clinical criteria. Experimental dyes were applied to the cavity floors, all of which became stained. Stained dentine was removed from half the cavity by means of a burr, the other half remaining as a control. Further stain was then applied and the procedure repeated until no further reduction of the staining of the cavity floor could be achieved. Light microscopy of ground sections of experimental teeth showed that sound tissue had been removed unnecessarily from the experimental half of the cavity due to the lack of specificity of these dyes. This lack of specificity of staining was similar to basic fuchsin and acid red. Only Carbolan Green showed possible differential staining between control and experimental sites, but this was not caries specific. If a clinically useful dye is to be developed, it would need to specifically stain either bacteria in infected dentine and/or the carious degradation products of dentine matrix.

The uridine in "U-turn": contributions to tRNA-ribosomal binding

"U-turns" represent an important class of structural motifs in the RNA world, wherein a uridine is involved in an abrupt change in the direction of the polynucleotide backbone. In the crystal structure of yeast tRNAPhe, the invariant uridine at position 33 (U33), adjacent to the anticodon, stabilizes the exemplar U-turn with three non-Watson-Crick interactions: hydrogen bonding of the 2'-OH to N7 of A35 and the N3-H to A36-phosphate, and stacking between C32 and A35-phosphate. The functional importance of each noncanonical interaction was determined by assaying the ribosomal binding affinities of tRNAPhe anticodon stem and loop domains (ASLs) with substitutions at U33. An unsubstituted ASL bound 30S ribosomal subunits with an affinity (Kd = 140+/-50 nM) comparable to that of native yeast tRNAPhe (Kd = 100+/-20 nM). However, the binding affinities of ASLs with dU-33 (no 2'-OH) and C-33 (no N3-H) were significantly reduced (2,930+/-140 nM and 2,190+/-300 nM, respectively). Surprisingly, the ASL with N3-methyluridine-33 (no N3-H) bound ribosomes with a high affinity (Kd = 220+/-20 nM). In contrast, ASLs constructed with position 33 uridine analogs in nonstacking, nonnative, and constrained conformations, dihydrouridine (C2'-endo), 6-methyluridine (syn) and 2'O-methyluridine (C3'-endo) had almost undetectable binding. The inability of ASLs with 6-methyluridine-33 and 2'O-methyluridine-33 to bind ribosomes was not attributable to any thermal instability of the RNAs. These results demonstrate that proton donations by the N3-H and 2'OH groups of U33 are not absolutely required for ribosomal binding. Rather, the results suggest that the overall uridine conformation, including a dynamic (C3'-endo > C2'-endo) sugar pucker, anti conformation, and ability of uracil to stack between C32 and A35-phosphate, are the contributing factors to a functional U-turn.

Dentinal dysplasia type I: review of the literature and report of a family

A family is reported with dentinal dysplasia type I affecting both dentitions. Presenting features included unusual mobility of the teeth, followed by early exfoliation; normal clinical shape of the crowns of the teeth, but with an amber color without any sign of attrition or abnormal loss of enamel. Radiographic findings showed pulp-chamber and root-canal obliteration, poor root formation, radiolucent linear appearance of the pulp chamber parallel to the cementoenamel junction and frequent periapical radiolucencies. Histological studies have reported large masses of calcified tubular dentin, atypical osteodentin, and also true denticle.

Regional odontodysplasia: report of four cases

Four cases of regional odontodysplasia are described. Clinically erupted teeth appear hypoplastic and are often mobile. The radiographic appearance has given rise to the term 'ghost teeth' and the cases presented demonstrate this with short roots which are less well calcified than normal teeth. Clinical and radiographic findings showed that this condition affects only one side of the jaw, but can be seen in any part of the upper or lower jaws. This article represents cases in different parts of the mouth with varying degrees of involvement.

Front-line management of pulmonary tuberculosis: an analysis of tuberculosis and treatment practices in urban Sindh, Pakistan

SETTING

Karachi and Hyderabad, Pakistan.

OBJECTIVE

To describe the level and quality of tuberculosis (TB) case management by non-TB control program (TCP) physicians in urban Sindh, Pakistan.

DESIGN

We interviewed 152 adults with pulmonary TB confirmed by Karachi's TB control program regarding the initial management of their TB symptoms before entering the TCP. We also surveyed 65 general practitioners (GPs) attending continuing education seminars with a multiple choice test to assess their management of suspected pulmonary TB. We compared both results to guidelines from the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (IUATLD).

RESULTS

Eighty percent (122/152) of patients first sought GPs. Only 14% of GPs performed any sputum test. At most, 17 (40%) of the 42 patients recalling their GP's treatment, received the recommended 4-drug regimen. However, 68% (45/65) of surveyed GPs chose correct treatment from a multiple choice format. But their initial laboratory investigations, follow-up, and treatment cessation criteria (9%, 9-31%, and 11% correct, respectively) demonstrated under-utilization of sputum tests and over-reliance on unhelpful tests.

CONCLUSIONS

GPs first saw most of these TCP patients, but their weak management likely hinders TB control. A partnership between TB control programs and GPs could improve case management and hasten TB control.

Glucose intolerance in pulmonary tuberculosis

The frequency of glucose intolerance was studied in 106 patients with pulmonary tuberculosis attending Nazimabad Chest Clinic. Diagnosis was based on X-ray and a positive sputum smear. An oral glucose tolerance test (OGTT) was performed and evaluated according to the WHO criteria. Glucose intolerance was detected in 52 (49%) patients, 31 Impaired Glucose Tolerance (IGT), 21 Diabetes Mellitus (DM). After adequate antitubercular therapy and sputum conversion, the OGTT was repeated in 23 cases. Of these 13 (56.5%) patients had a normal glucose tolerance indicating that glucose intolerance observed during active pulmonary tuberculosis improves or normalizes after adequate therapy.

The effect of cholecystokinin-octapeptide on the hepatobiliary dysfunction caused by total parenteral nutrition

PURPOSE

Patients on total parenteral nutrition (TPN) commonly have hepatobiliary dysfunction. Interruption of the enterohepatic circulation (EHC) and gallbladder stasis are part of the pathogenesis. Cholecystokinin-octapeptide (CCK-OP), by emptying the gallbladder, stimulates the EHC. This study was performed to determine whether daily CCK-OP infusions can ameliorate the hepatobiliary dysfunction caused by TPN.

METHODS

Rabbits maintained on a standard TPN for 12 days were divided into two groups. One group (n = 6) received daily intravenous doses of CCK-OP, and the other (n = 13) received TPN only. A lab-chow-fed (LCF) group (n = 8) served as controls. The authors studied bile flow and bile acid secretion rates, sulfobromophthalein (BSP) secretion, gallbladder emptying in response to CCK-OP, and liver histology.

RESULTS

The LCF group had a bile flow of 82.3 microL/kg/min; that for the TPN-only group was 45.7 microL/kg/min (P < .001). The daily CCK-OP group did not improve more than the TPN-only group, with a bile flow of 45.8 microL/kg/min (P = NS). Bile acid secretion was 0.64 mumol/kg/min for the LCF group, 0.46 for the TPN-only group (P = NS), and 0.46 for the daily CCK-OP group (P = NS). TPN impaired the ability of the gallbladder to empty, and this was restored with daily CCK-OP. In the LCF group, the mean BSP secretion was 81.7% of a 5-mg/kg bolus within 60 minutes, compared with 72.5% in the daily CCK-OP group (P = NS) and 63.5% in the TPN-only group (P < .01). Histological examination of the liver showed that daily CCK-OP produced less periportal inflammation and fibrosis, although all TPN groups had hepatocyte damage in the centrilobular area.

CONCLUSION

Stimulation of the EHC with daily CCK-OP infusions during TPN decreased periportal inflammation and fibrosis, maintained gallbladder emptying capacity, and improved organic anion (BSP) secretion, although bile flow and bile acid secretion were not improved, and hepatocyte damage persisted.

Traumatic work related fatalities in commercial fishermen in Australia

OBJECTIVES

To describe the types and circumstances of traumatic work related fatalities in Australian commercial fishermen.

METHODS

Work related traumatic fishing fatalities were studied as part of a larger study of all work related traumatic fatalities in Australia from 1982 to 1984. Data on 47 cases were obtained from inspection of coroners' files.

RESULTS

The incidence of fatality of 143/100,000 person-years was 18 times higher than the incidence of fatality for the entire workforce, and considerably higher than that of the mining and agricultural workforces. 68% of decedents drowned and 13% died from physical trauma. Rough weather, non-seaworthy vessels, inadequate use of personal flotation devices, and inexperience were associated with many of the fatal incidents.

DISCUSSION

Improved vessel and equipment maintenance, better training of workers, greater use of personal flotation devices, and development of improved clothing and personal flotation devices are recommended.

Hepatobiliary dysfunction during total parenteral nutrition is caused by infusate, not the route of administration

Cholestatic jaundice is the major complication of total parenteral nutrition (TPN). Both the intravenous (IV) route of nutrition and the enteral fast have been implicated as causes of TPN-associated cholestasis (TPN-AC). The purpose of this study was to determine whether TPN-AC is caused by the TPN solution itself or the IV route of administration and enteral fast. Prepubescent rabbits (n = 24) were divided into four groups: CONTROL, fed standard lab chow; TPN, received a standard hyperalimentation solution of dextrose, Aminosyn, and lipids via the jugular vein; ENT, received the same hyperalimentation solution via a duodenostomy tube; and OSM, received a polymeric formula (Osmolite) via a duodenostomy tube. After 14 days on these diets, we measured bile flow, bile acid excretion, sulfobromophthalein (BSP) excretion, plasma amino acid profile, serum liver enzymes, and liver histology. Statistical analysis was by analysis of variance. Hyperalimentation solution significantly depressed hepatobiliary function, whether it was given IV or by gut. Bile flow in both the TPN (36.4 microL/kg/min) and ENT (46.2) groups was significantly less than CONTROL (84.5) or OSM (62.9). Hepatic secretory function, measured by excretion of the cholephilic dye BSP, was depressed in both TPN and ENT (57% and 55% of IV dose excreted in bile over 60 minutes, respectively) compared with CONTROL (84%) or OSM (71%). Serum liver enzymes were normal in all groups. Histological injury similar to TPN-AC in humans (portal inflammation and hepatocyte degeneration) was seen in both groups receiving the hyperalimentation solution.(ABSTRACT TRUNCATED AT 250 WORDS)