[Pregnancy and lactation period: Which antibiotic and rinsing solutions?]

The aim of this paper is to show aspects of dental treatment in pregnancy. The reader should gain security in the election of the proper drugs for antibiotic therapy and rinsing solutions. Antibiotics as penicillins are the first choice in case of dental infections in pregnancy. In allergic patients, macrolides may be an alternative. Wound and mouth rinsing solutions containing chlorhexidine should be preferred in pregnancy. Ledermix(®) in endodontic treatment should be avoided in the pregnant woman. Solcoseryl(®) can be used for wound healing. Elective dental procedures should be postponed after delivery and after lactation period.

[Pregnancy and lactation period: Which antibiotic and rinsing solutions?]

The aim of this paper is to show aspects of dental treatment in pregnancy. The reader should gain security in the election of the proper drugs for antibiotic therapy and rinsing solutions. Antibiotics as penicillins are the first choice in case of dental infections in pregnancy. In allergic patients, macrolides may be an alternative. Wound and mouth rinsing solutions containing chlorhexidine should be preferred in pregnancy. Ledermix(®) in endodontic treatment should be avoided in the pregnant woman. Solcoseryl(®) can be used for wound healing. Elective dental procedures should be postponed after delivery and after lactation period.

Evidence for the use of demeclocycline in the treatment of hyponatraemia secondary to SIADH: a systematic review

AIMS

Hyponatraemia (HN) is the most common electrolyte balance disorder in clinical practice. Since the 1970s, demeclocycline has been used in some countries to treat chronic HN secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH). The precise mechanism of action of demeclocycline is unclear, but has been linked to the induction of nephrogenic diabetes insipidus. Furthermore, the safety profile of demeclocycline is variable with an inconsistent time to onset, and a potential for complications. There has been no systematic evaluation of the use of demeclocycline for the treatment of HN secondary to SIADH to date. A systematic literature review was performed to obtain an insight into the clinical safety and efficacy of demeclocycline for this condition.

METHODS

Embase(™) , MEDLINE(®) , MEDLINE(®) In-Process, and The Cochrane Library were searched on two occasions using MeSH terms combined with free-text terms. References were screened by two independent reviewers. Relevant publications were then extracted by two independent reviewers, with a third reviewer collating and finalising extractions.

RESULTS

The searches returned a total of 705 hits. 632 abstracts were screened after the removal of duplicates. Following screening, 35 full-length publications were reviewed. Of these, 17 were excluded, resulting in 18 studies deemed relevant for data extraction. Two were randomised controlled trials (RCTs), 16 were non-RCTs, and 10 were case reports.

DISCUSSION

Although most reports suggest that demeclocycline can address serum sodium levels in specific patients with HN, efficacy is variable, and may depend upon the underlying aetiology. Demeclocycline dose adjustments can be complex, and as its use in clinical practice is not well defined, it can differ between healthcare professionals.

CONCLUSION

There is a lack of clinical and economic evidence supporting the use of demeclocycline for HN secondary to SIADH. Patients receiving demeclocycline for HN secondary to SIADH must be closely monitored.

Management of euvolemic hyponatremia attributed to SIADH in the hospital setting

Hyponatremia is the most frequent electrolyte disorder in hospitalized patients. Acute and severe hyponatremia can be a life-threatening condition, but recent evidence indicates that also mild and chronic hyponatremia is associated with neurological and extra-neurological signs, such as gait disturbances, attention deficits, falls and fracture occurrence, and bone loss. The syndrome of inappropriate ADH secretion (SIADH) is the most frequent cause of hyponatremia. Hyponatremia secondary to SIADH may result for instance from ectopic release of ADH in lung cancer, from diseases affecting the central nervous system, from pneumonia or other pneumopathies or as a side-effect of various drugs In SIADH, hyponatremia results from a pure disorder of water handling by the kidney, whereas external sodium balance is usually well regulated. Despite increased total body water, only minor changes of urine output and modest oedema are usually seen. Neurological impairment may range from subclinical to life-threatening, depending on the degree and mostly on the rate of serum sodium reduction. The management of hyponatremia secondary to SIADH is largely dependent on the symptomatology of the patient. This review briefly summarizes the main aspects related to hyponatremia and then discusses the available treatment options for the management of SIADH, including vaptans, which are vasopressin receptor antagonists targeted for the correction of euvolemic hyponatremia, such as that observed in SIADH.

Managing hyponatremia in patients with syndrome of inappropriate antidiuretic hormone secretion

Disorders of sodium [Na+] and water metabolism are commonly encountered in the hospital setting due to the wide range of disease states that can disrupt the balanced control of water and solute intake and output. In particular, the prompt identification and appropriate management of abnormally low serum [Na+] is critical if we are to reduce the increased morbidity and mortality that accompany hyponatremia in hospitalized patients. Use of an algorithm that is based primarily on the symptomatology of hyponatremic patients, rather than the serum [Na+] or the chronicity of the hyponatremia, will help to choose the correct initial therapy in hospitalized hyponatremic patients. However, careful monitoring of serum [Na+] responses is required in all cases to adjust therapy appropriately in response to changing clinical conditions. Although this approach will enable efficacious and safe treatment of hyponatremic patients with syndrome of inappropriate antidiuretic hormone secretion (SIADH) at the present time, evolving knowledge of the consequences of chronic hyponatremia will likely alter treatment indications and guidelines in the future.

The effects of Ledermix paste on discolouration of immature teeth

AIM

The aims of this study were to: (i) investigate the effects of Ledermix paste as an intracanal medicament on discolouration of immature teeth, (ii) examine whether the discolouring effects were related to the method of application, (iii) examine the effects of sunlight upon discolouration of immature teeth and (iv) compare the degree of discolouration between mature and immature teeth.

METHODOLOGY

The root canals of 45 immature extracted human teeth were prepared and filled with either Ledermix paste, calcium hydroxide [Ca(OH)2], or saline. In group 1, Ledermix paste was only placed apical to the cemento-enamel junction (CEJ) whilst in groups 2 and 3, the paste filled the entire pulp chamber and the root canals. In group 4, Ca(OH)2 paste and in group 5, saline (control) were allowed to fill the pulp chamber and the root canals. Group 3 teeth were kept in the dark and the other groups were exposed to daylight for 12 weeks.

RESULTS

After 12 weeks, sunlight exposure had caused dark grey-brown staining in the Ledermix groups but this did not occur when the teeth were kept in the dark. More severe staining was noted when Ledermix paste filled the pulp chamber than when the paste was restricted to below the CEJ and when teeth were exposed to sunlight. When compared to the results of a similar study using mature teeth, the results were similar but the immature teeth were more severely stained than the mature teeth. The Ca(OH)2 paste caused an increase in lightness and yellowness in immature teeth.

CONCLUSION

It was concluded that Ledermix paste may cause discolouration of immature teeth. Such effects can be minimized if placement of the paste is restricted to below the gingival margin. Clinicians should ensure that Ledermix paste is not left on the walls of access cavities, especially in immature teeth.

The effects of Ledermix paste on discolouration of mature teeth

AIM

The aims of this study were to: (i) investigate the effects of Ledermix paste as an intracanal medicament on discolouration of mature teeth, (ii) examine whether the discolouring effects were related to the method of application, and (iii) examine the effects of sunlight upon discolouration of mature teeth.

METHODOLOGY

The root canals of 45 mature extracted human teeth were prepared and filled with either Ledermix paste, calcium hydroxide [Ca(OH)2], or saline. In group 1, Ledermix paste was placed apical to the cemento-enamel junction (CEJ), whilst in groups 2 and 3 the paste filled the entire pulp chamber and root canals. In group 4, a Ca(OH)2 and methyl cellulose paste and, in group 5, saline (control) were allowed to fill the pulp chamber and the root canals. Group 3 teeth were kept in the dark and the other groups were exposed to indirect sunlight for 12 weeks.

RESULTS

After 12 weeks, sunlight exposure had caused dark grey-brown staining of the teeth in the Ledermix groups, but this did not occur when the teeth were kept in the dark. More severe staining was noted when Ledermix paste filled the pulp chamber than when the paste was restricted to below the CEJ.

CONCLUSIONS

It was concluded that Ledermix paste may cause discolouration of teeth. Such effects can be minimized if placement of the paste is restricted to below the gingival margin. Clinicians should ensure that Ledermix paste is not left on the walls of access cavities.

Fatal massive liver steatosis--a clinicopathological case report

Hepatic fatty change is a common lesion. Two forms are recognized: micro- and macrovesicular steatosis, the former being much less frequent and more serious than the latter. The case of an alcoholic woman under anticonvulsivant therapy and with medications for a syndrome of inappropriate secretion of antidiuretic hormone (SIADH) who presented with rapidly progressive cholestasis and hepatocellular failure is reported. Massive macro- and micro-vesicular hepatic steatosis was diagnosed at autopsy. The authors review the clinico-pathological features associated with this condition, and causal factors possibly implicated in this case are discussed in regard with currently considered pathophysiological mechanisms.

Nephrogenic diabetes insipidus: causes revealed

In congenital NDI, the failure of the renal tubules to respond to antidiuretic hormone is caused by mutation of the arginine vasopressin receptor gene. Two dozen different mutations have been identified to date--all with the same clinical consequences. Several causes of acquired NDI, of which lithium is the most common, are also discussed.

Demeclocycline-induced phosphate diabetes in a patient with inappropriate ADH secretion and systemic sarcoidosis

We report a case of phosphate diabetes in a patient with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) associated with sarcoidosis. Our patient was affected by systemic sarcoidosis and he fits the criteria of Schwartz for the diagnosis of SIADH. He presented with phosphate diabetes which appeared during demeclocycline (DMC) therapy and persisted for about 1 month from the end of DMC. It constitutes the fourth case of phosphate diabetes induced by tetracycline described in the literature and it is the third case of SIADH associated with sarcoidosis.

Relationship of intracanal medicaments to endodontic flare-ups

The purpose of the study was to compare the effect of three intracanal medicaments on the incidence of post-instrumentation flare-ups. All teeth were instrumented to a predetermined minimum size using a 0.5% solution of sodium hypochlorite as the irrigant. Formocresol, Ledermix, and calcium hydroxide were placed in strict sequence irrespective of the presence or absence of symptoms or radiographic signs of apical periodontitis. The patients were given written post-operative instructions and a prescription for 600 mg ibuprofen to be taken if mild to moderate pain developed. If severe pain and/or swelling developed the patient was instructed to call the office immediately and was considered to have had a flare-up. Twelve flare-ups occurred in teeth with radiographic signs of apical periodontitis; none in teeth without periapical radiolucencies. Six of the twelve flare-ups occurred in retreatment cases and the other six occurred in teeth without previous endodontic treatment. No significant difference was found in the flare-up rate among the three intracanal medicaments.

A clinical comparison of pivmecillinam plus pivampicillin (Miraxid) and a triple tetracycline combination (Deteclo) in respiratory infections treated in general practice

Seven-day courses of either pivmecillinam 200 mg plus pivampicillin 250 mg (Miraxid) or a combination of tetracycline hydrochloride, chlortetracycline hydrochloride and demeclocycline hydrochloride (Deteclo) 300 mg, both given twice daily, were compared in a multicentre general practice study in 408 patients with symptoms of upper or lower respiratory tract infection. Patients were stratified into four diagnostic groups: sinusitis, otitis media, throat infections, and acute bronchitis and randomly allocated to treatment within these groups. Assessment at 7 days showed no difference in clinical efficacy between the two treatments where 193 of the 208 infections receiving Miraxid (93%) were rated as either cured or improved compared with 181 of the 201 infections treated with Deteclo (90%). At 7 days, the percentage of patients completely free of symptoms was the same for both groups (66%). The mean time for symptoms to clear was 3.9 days in the Miraxid group and 4.0 days in the Deteclo group. Side-effects were reported by significantly fewer patients in the Miraxid group (9.3%) than the Deteclo group (17.5%) (p less than 0.05) and six patients in the latter group failed to complete the course of treatment. Miraxid given twice daily for respiratory tract infections is as effective as Deteclo but causes significantly fewer side-effects.

Effect of demeclocycline on renal function and urinary prostaglandin E2 and kallikrein in hyponatremic cirrhotics

8 cirrhotics with hyponatremia were given demeclocycline (DMC) 900 mg/day to investigate its effect on renal function, plasma renin activity, aldosterone and urinary excretion of prostaglandin E2 and kallikrein. In 7 patients DMC induced an increase of free water clearance (from -0.36 +/- 0.06 to 0.13 +/- 0.06 ml/min) and serum sodium concentration (from 125.4 +/- 0.09 to 131.1 +/- 1.0 mEq/l, mmol/l). In 5 of these patients DMC also induced a marked reduction of glomerular filtration rate (from 72.2 +/- 6.2 to 31,2 +/- 4.7 ml/min) and renal plasma flow (from 468 +/- 98 to 195 +/- 55 ml/min) which could not be explained on the basis of hypovolemia. In each case this renal impairment was not associated with changes in urinary concentration of beta 2-microglobulin, urinary casts excretion, fresh urine sediment or urine protein content and disappeared after discontinuation of the drug. DMC induced a marked increase in the urinary excretion of prostaglandin E2 (from 0.82 +/- 0.27 to 6.16 +/- 1.91 ng/min) in 6 out of the 7 patients who responded to DMC and a marked reduction in urinary kallikrein (from 16.1 +/- 4.4 to 4.2 +/- 1.6 pkat/min) in the 5 patients who developed renal insufficiency. The serum DMC concentration was greater than 5 micrograms/ml in all patients who responded to DMC, greater than 8 micrograms/ml in all cases who developed renal insufficiency and of 3 micrograms/ml in the case not responding to DMC. (ABSTRACT TRUNCATED AT 250 WORDS)

Pathophysiology of renal concentrating defects

A number of advances which took place during the last decade have increased our understanding of the physiology and pathophysiology of urinary concentrating defects. The development of a highly sensitive radioimmunoassay for plasma vasopressin concentration has shed new light on vasopressin control mechanisms. The cellular action of vasopressin in biological membranes has been studied by various techniques. The role of adenylate cyclase, cyclic adenosine monophosphate (cAMP), microtubules, and microfilaments, in the response of vasopressin-sensitive membranes is now partially understood. New models of countercurrent multiplication systems, in which urea plays a prominent role, offer a better explanation of certain experimental facts. Such advances had permitted a better understanding of clinical conditions characterized by concentrating defects, including hyperkalemia, hypercalcemia, parenchymal renal disease, obstructive renal disease, and polyuria induced by certain drugs.

Serious hyponatremia in patients with cancer: management with demeclocycline

Seventeen patients with cancer or aplastic anemia received demeclocycline as treatment for hyponatremia. Prior to demeclocycline therapy no patients showed clinical signs of fluid overload or saline depletion. In all patients inappropriately concentrated urine (mean urine osmolality = 548 mOSM/kg H2O) or increased urine content of sodium (mean urine sodium = 91 mEq/L) were documented prior to demeclocycline therapy. No patient had developed hyponatremia in association with antineoplastic drug therapy. The average serum sodium (NaS) at the time of initiation of therapy was 121 mEq/L. NaS increased in all patients despite the simultaneous administration of generous volumes of fluid. NaS exceeded 130 mEq/L and average of 3.5 days following institution of demeclocycline. Patients lost an average of 2.3 kg during demeclocycline. The toxicity noted following demeclocycline was azotemia and increased serum creatinine. Eight patients developed serum urea nitrogen (SUN) in excess of 25 mg/dl; average maximum creatinine in these eight patients was 1.9 mg/dl. Average peak creatinine in eight patients who did not develop azotemia was 0.87 mg/dl. Azotemia seemed to be correlated with simultaneous administration of other nephrotoxic agents and with administration of higher doses (1200 mg/day) of demeclocycline.

Phototoxic reactions to photoactive drugs in patients treated with PUVA

To determine the potentially adverse effects of photoactive medications taken in conjunction with oral methoxsalen photochemotherapy (PUVA) for psoriasis, we studied the incidence of phototoxic reactions in 1,125 patients treated with PUVA at 15 centers. During the initial (clearing) phase of PUVA therapy, patients using photoactive medications were no more likely to have diffuse delayed erythema than patients who did not use such medications. After clearing, patients 45 years of age or older who used photoactive drugs were 2.3 times as likely to discontinue PUVA therapy for at least one month owing to problems related to UV-induced burns than were those who did not use such drugs. Only 6% of patients older than 45 years who took photoactive medications had problems with phototoxicity sufficiently severe to contribute to permanent discontinuation of PUVA therapy.

Plasma demeclocycline levels and nephrotoxicity. Correlation in hyponatremic cirrhotic patients

In five hyponatremic, cirrhotic patients, demeclocycline hydrochloride was used to inhibit the hydroosmotic effect of vasopressin. In four, renal impairment developed during the 7 to 20 days of demeclocycline hydrochloride (900 to 1,200 mg/day) administration. In these four patients, creatinine clearance fell (72 to 20 mL/min, P less than .01) as BUN (12 to 47 mg/dl, P less than .02) and serum creatinine (0.9 to 4.2 mg/dl, P less than .01) levels rose. The azotemic effect of the drug could not be accounted for consistently by volume depletion secondary to its natriuretic effect. However, a close correlation between plasma demeclocycline levels and its azotemic effect was observed. We conclude that a nephrotoxic effect of demeclocycline severly limits its usefulness in treating hyponatremia in the cirrhotic patient.

Demeclocycline in the treatment of the syndrome of inappropriate secretion of antidiuretic hormone

Fourteen patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) have been treated with demethylchlortetracycline (demeclocycline) 1200 mg daily. In 12 patients the underlying lesion was malignant. The serum sodium returned to normal (greater than 135 mmol/l) in all patients after a mean of 8.6 days (SD +/- 5.3 days). Blood urea rose significantly from the pretreatment level of 4.2 +/- 2.3 mmol/l to 10.1 +/- 5.1 mmol/l at ten days (P less than 0.001). The average maximum blood urea was 13.4 +/- 6.8 mmol/l. In four patients the urea rose above 20 mmol/l, and in two of these demecyocycline was discontinued because of thie rise. The azotaemia could be attributed to a combination of increased urea producation and a mild specific drug-induced nephrotoxicity. Discontinuation of demeclocycline in six patients led to a fall in serum sodium, in one case precipitously, and return of the urea towards normal levels. Demeclocycline appears therefore to be an effective maintenance treatment of SIADH, and the azotaemia that occurs is reversible and probably dose dependent.

Clinicopathological conference. Two cases of drug-induced disease. Demonstration at the Royal College of Physicians of London

Images

Renal function during treatment of inappropriate secretion of antidiuretic hormone with demeclocycline

Two patients with the syndrome of inappropriate secretion of antidiuretic hormone were studied in a metabolic ward during treatment with 1.2 g demeclocycline daily. In both patients, demeclocycline treatment led to increased renal water excretion with consequent correction of hyponatremia and hypo-osmolality. Three episodes of reversible deterioration in glomerular filtration rate developed in these patients. Each episode was accompanied by clinical evidence of extracellular fluid volume contraction, and on each occasion there was an inappropriate natriuresis with daily urinary sodium excretion remaining above 50 mEq. Although demeclocycline effectively reverses the electrolyte abnormalities of this syndrome, the potentially dangerous side effects that may develop exclude the routine usage of the drug.

Nephrogenic diabetes insipidus due to demethylchlortetracycline hydrochloride in a child

Nephrogenic diabetes insipidus occurred in a 7-year-old child who had received a high dose of demethylchlortetracycline hydrochloride (DMC). The patient had a relatively elevated urinary sodium concentration in addition to isosthenuria. The nephrogenic diabetes insipidus was completely reversible within one month after cessation of DMC administration.

Renal failure associated with demeclocycline in cirrhosis

Three patients with cirrhosis, ascites, and dilutional hyponatremia were treated with demeclocycline in an attempt to correct the abnormal water retention. Demeclocycline administration (600 to 900 mg/day for 8 to 9 days) resulted in [a] increased blood urea nitrogen and plasma creatinine concentrations; [b] reduction of the inulin clearance by between 63% to 78% and of paraaminophippurate clearance by 36% to 77%; and [c] an impairment of the renal concentrating ability. Urine osmolality decreased to hypotonic levels, but polyuria did not appear, probably because it was prevented by the reduction of the glomerular filtration rate. Renal failure was reversible on withdrawal of demeclocycline. No other causes than demeclocycline administration could be found to explain the reduction of the glomerular filtration rate and the estimated renal plasma flow.

Pathophysiologic and pharmacologic alterations in the release and action of ADH

The physiologic factors involved in vaseopressin (ADH) release and action are reviewed with emphasis on the interaction between osmotic and volume stimuli to the discharge of ADH. Abnormalities in reception of stimuli to ADH release, and in the impaired synthesis and release of ADH, are reviewed in relation to the causes of diabetes insipidus, and information on the biochemical changes which have been described in patients with nephrogenic diabetes insipidus is also discussed. We summarize the pathologic lesions and associated diseases found in 54 of our patients with diabetes insipidus. Criteria for establishing the diagnosis of diabetes insipdus are reviewed with emphasis on the dehydration test, including the importance of measuring plasma osmolality at the conclusion of water deprivation. Treatment of diabetes insipidus is briefly discussed with emphasis on the use of DDAVP and oral agents. The syndrome of inappropriate ADH secretion (SIADH) is reviewed including our experience with 39 patients. The differential diagnosis of SIADH, including the value of water loading and the measurement of ADH levels, is discussed. We comment on treatment of these patients including the use of investigational drugs. Lastly, we review the pharmacologic features and clinical relevance of some drugs which alter the release and action of ADH.

Demeclocycline treatment in the syndrome of inappropriate antidiuretic hormone secretion

We have studied the effects of demeclocycline on the water metabolism of a patient with the syndrome of inappropriate antidiuretic hormone (ADH) secretion who presented with a serum sodium concentration of 110 meq/litre. Free water clearance was studied before, during, and after treatment with demeclocycline. This study shows that demeclocycline (900 mg/day) can at least partially inhibit the action of ADH in the setting of tumor-induced ADH secretion, with the production of a reversible, partial nephrogenic diabetes insipidus, and with few or no side effects. Demeclocycline may be useful in the treatment of chronic inappropriate ADH secretion.