Enantiomer-selective pharmacokinetics and metabolism of ketorolac in children.

OBJECTIVE: To compare the pharmacokinetics and metabolism of R(+)- and S(-)- ketorolac in children. METHODS: Children from 3 to 18 years old received 0.6 mg/kg racemic ketorolac intravenously. Serial blood samples were obtained for 12 hours, and urine was collected for 12 to 24 hours. Racemic ketorolac was measured in plasma, and racemic ketorolac, para-hydroxyketorolac, and ketorolac glucuronide were measured in urine by HPLC. S(-)- and R(+)-ketorolac were measured in plasma; S(-)- and R(+)-ketorolac and ketorolac glucuronide were measured in urine by chiral HPLC separation. Plasma pharmacokinetic parameters for racemic drug and both enantiomers were determined for each patient. RESULTS: Clearance of racemic ketorolac in children was approximately 2 times the clearance reported in adults. Clearance of the S(-) enantiomer was 4 times that of the R(+) enantiomer. Terminal half-life of S(-)-ketorolac was 40% that of the R(+) enantiomer, and the apparent volume of distribution of the S(-) enantiomer was greater than that of the R(+) form. Recovery of S(-)-ketorolac glucuronide was 2.3 times that of the R(+) enantiomer. CONCLUSION: The higher clearance in children suggests that the weight-adjusted dose of ketorolac may have to be greater for children to achieve plasma concentrations comparable to those of adults. Because of the greater clearance and shorter half-life of S(-)-ketorolac, pharmacokinetic predictions based on racemic assays may overestimate the duration of pharmacologic effect. Enantiomeric pharmacokinetic differences are best explained by stereoselective plasma protein binding. Selective glucuronidation of the S(-) enantiomer suggests that stereoselective metabolism may also be a contributing factor.

Syndrome of inappropriate antidiuretic hormone secretion in children following spinal fusion.

OBJECTIVES: a) To determine if antidiuretic hormone (ADH) is elevated in patients undergoing spinal fusion, especially in those who have clinical evidence of syndrome of inappropriate antidiuretic hormone (SIADH); b) to evaluate the relationship between ADH secretion and the secretion of atrial natriuretic peptide (ANP). SETTING: Tertiary care pediatric intensive care unit (ICU) in a university hospital. DESIGN: A prospective cross-sectional, observational study with factorial design. PATIENTS: Thirty patients > or = 10 yrs of age undergoing spinal fusion admitted to the ICU for postoperative care. INTERVENTIONS: Patients underwent anterior, posterior, or both anterior/posterior spinal fusion. Blood was collected for serial measurements of ADH, ANP and serum electrolyte levels. Heart rate, blood pressure and central venous pressure were measured. MEASUREMENTS AND MAIN RESULTS: Thirty children were studied. Nineteen had idiopathic scoliosis, nine had neuromuscular scoliosis, one had Marfan's disease, and one had congenital scoliosis. Ten (33%) children met clinical criteria of SIADH. There was no difference in duration of surgery, blood loss, volume of iv fluid administration pre- and intraoperatively, or type of scoliosis between those who developed SIADH and those who did not. Hemodynamic variables were similar in both groups. ADH levels increased in both groups immediately postoperatively and at 6 hrs after surgery, but were much more elevated in those patients with SIADH. Patients with SIADH also had significantly higher ADH levels preoperatively. In relation to serum osmolality, ADH was considerably higher in those with SIADH compared with those who did not. Although ANP values tended to be higher in the group with SIADH, this did not reach statistical significance. CONCLUSION: SIADH occurs in a subset of children who undergo spinal fusion. The diagnosis of SIADH can be made easily using clinical parameters which are well-defined. In the face of SIADH, continued volume expansion may be harmful, and should therefore be avoided.

A randomized comparison of ketorolac tromethamine and morphine for postoperative analgesia in critically ill children.

OBJECTIVES: To evaluate the efficacy of a single dose of ketorolac compared with morphine for the relief of pain in children, and to determine the safety of ketorolac. SETTING: Tertiary pediatric intensive care unit in a university-affiliated hospital. DESIGN: Prospective, randomized, double-blind, parallel, single-dose, positive control study. PATIENTS: Children admitted to the intensive care unit with postoperative pain. INTERVENTIONS: Patients received a single dose of either morphine or ketorolac as the first postoperative analgesic when the pain score indicated significant pain. Blood pressure, heart rate, and urine output were recorded, as well as blood urea nitrogen, creatinine, bleeding time, hematuria or proteinuria, and aspartate aminotransferase. Side effects such as nausea and vomiting were noted. Morphine was used for rescue treatment if the patient continued to have significant pain > or =30 mins after study drug administration. MEASUREMENTS AND MAIN RESULTS: Of the 102 children studied, 48 received morphine and 54 received ketorolac. The percentage of patients reporting pain relief in the first and second hours after drug administration was not different between groups. Likewise, the proportion of patients who met the criteria for pain relief during the entire evaluation period was not different between groups. There was a trend toward fewer patients who received ketorolac requiring remedication in the first 4 hrs compared with those who received morphine, but this trend did not reach statistical significance. More patients in the morphine group failed to achieve pain relief at any time after the dose compared with those who received ketorolac. There were no differences between the two groups in physiologic or laboratory variables. Vomiting was more common in patients who received ketorolac. CONCLUSION: Ketorolac is comparable to morphine in relief of postoperative pain in children. A single dose of ketorolac does not result in abnormal postoperative bleeding or alter renal function. However, ketorolac may cause nausea and vomiting in some patients.

Effectivity of the Electronic Dental Anesthesia in controlling pain caused by local anesthetic injections.

This study was designed to determine if an electrical signal can effectively control the pain caused by injection of local anesthesia for mildly and moderately apprehensive patients. Five techniques were used in this study: the Mandibular Block injection, Long Buccal nerve injection, Maxillary Infiltration injection, Incisive Papilla injection, and the Great Palatine nerve injection. Two injections, using the Electronic Dental Anesthesia (EDA/EA) as the adjunct, and the other using a topical anesthetic ointment of Xylocaine 5%, were performed on 30 patients who passed the criteria we have set including the indications for use of the EDA. The volunteers were asked on the spot to report the level of pain they felt during the penetration of the needle in the mucosa, and during the deposition of the local anesthetic solution. A pool of 47 patients were gathered for this experiment. Of this number, 11 failed to pass for reasons of high-anxiety level and 2 were contraindicated for use of the EDA. Of the 34 who successfully passed the screening, only 30 patients were chosen. A total of 6 patients each, 3 males and 3 females, were used for the five techniques. The results of this study show that in all five injection techniques, the EDA is effective in blocking pain transmission. The EDA is proven to be an effective adjunct to local anesthetic injections.

A preliminary clinical study on the oral lesions among the Dumagats.

The objectives of the preliminary study is to gather baseline data on oral lesions among Dumagat samples living in the vicinity of Angat Dam, San Jose Del Monte, Bulacan. Scores for CPITN (Community Periodontal Index for Treatment Needs), Loss of Attachment, DMFT (Decayed, Missing and Filled Teeth) and clinical oral lesions were determined from 41 Dumagat samples. Results of the study showed 61% had oral lesions of some type (37.8% females and 62.5% males). Lesions clinically detected were; betal nut chewer's mucosa (44%), leukoedema (6%), melanin pigmentation (8%), geographic tongue (16%), Fordyce's spots (8%), leukoplakia (6%) and Fibroepithelial papilloma (8%).

Comparative study of dimensional accuracy of different impression techniques using addition silicone impression material.

This study compared dimensional accuracy of the single, double with spacer, double with cut-out and double mix impression technique using addition silicone impression material. A typhodont containing Ivorine teeth model with six (6) full-crown tooth preparations were used as the positive control. Two stone replication models for each impression technique were made as test materials. Accuracy of the techniques were assessed by measuring four dimensions on the stone dies poured from the impression of the Ivorine teeth model. Results indicated that most of the measurements for the height, width and diameter slightly decreased and a few increased compared with the Ivorine teeth model. The double with cut-out and double mix technique presents the least difference from the master model as compared to the two latter impression techniques.

138 cases of mandibular fractures in four government hospitals from July 1995 to July 1996.

A descriptive type of study was utilized in the presentation of this paper. The main sources of information were the different government hospitals namely, East Avenue Medical Center, Jose R. Reyes Memorial Hospital, Philippine Orthopedic Hospital, and V. Luna Memorial Hospital. This paper was based on information gathered from actual cases and medical records of the patients treated in the above mentioned government hospitals from July 1995 to July 1996. The results of the study sample shows that 117 (84.8%) males were affected. The major cause of mandibular fracture was alleged assaults or mauling comprising 60 (43.5%) cases of the entire study. The symphysis was the part of the mandible most susceptible to fracture having 75 (54%) cases of the study.

Clinical study of comparative plaque removal performance of two manual toothbrushes.

A clinical study was performed to evaluate and compare plaque removal performance of the two commercially available products; the Colgate Precision Full Head Soft toothbrush and Reach Full Head soft toothbrush. Twenty high school students, male and female subjects participated, each refraining from toothbrushing for 24 hours. Plaque was scored according to the Personal Hygiene Performance (PHP) Index of Podshadley and Haley, as modified by Martens and Meskin. Following screening, the subjects were divided into two balanced groups on the basis of initial plaque scores. At Visit 1, each group having refrained from toothbrushing for 24 hours, was evaluated for plaque before brushing for 60 seconds with the assigned toothbrush, after which plaque was again scored. At Visit 2, one week later, the same procedure was followed. Subjects were instructed to resume their normal routine and return to the clinical site for Visit 2. On completion of the study, the data collected were subjected to statistical analysis which indicated that the Colgate Precision Full Head soft toothbrush removed significantly more plaque than Reach Full Head soft toothbrush.

The prevalence and distribution of gingival recession among U.E. dental students with a high standard of oral hygiene.

The aims of this study were to evaluate the prevalence and the distribution of the attachment loss and gingival recession at facial tooth surfaces in a population sample with a high standard of oral hygiene, at the same time, to determine the occurrence of gingival recession. An additional aim was to study the relationship between attachment loss and gingival recession and its relation to its etiologic factors. The subject sample comprised of 100 male and female dental students in the University of the East between the ages of 18 and 26 with a minimum of 25 natural teeth, no advance periodontitis or history of periodontal surgery were examined, gingival recession was scored as present whenever the free gingival margin was apical to the c.e.i. and root surface was exposed. The clinical examination involved assessment of gingivitis, probing depth, probing attachment and gingival recessions. The results of the combined cross-sectional and longitudinal analysis performed in the study demonstrated among 100 U.E. dental students with a high standard of oral hygiene showed that: 1) Facial gingival recessions was a frequent finding due to the compensatory and remodelling process caused by loss of approximal periodontal attachment; 2) Prevalence and distribution of gingival recessions is independent with the presence of attachment loss; 3) Facial gingival recessions can exist with or without attachment loss and teeth without gingival recessions may or may not present attachment loss; 4) And presence of gingival recessions in patients with a high standard of oral hygiene can either be attributed to orthodontic treatment or wrong toothbrushing technique, too much strength exerted in brushing, overbrushing, and usage of hard toothbrush bristles.

Electronic dental anesthesia versus topical anesthesia for the control of pain caused by nasopalatine block injections.

Topical anesthetics are routinely used to reduce the pain and discomfort that patients may experience during dental injections. Just recently, however, an anesthesia (Electronic Dental Anesthesia or EDA) which works by transcutaneous electrical nerve stimulation (TENS) was introduced to the dental profession. The purpose of this study was to determine whether an electrical signal as provided by an EDA is more effective than topical anesthesia in reducing pain and discomfort caused by local anesthetic injections. Two nasopalatine block injections, one using and EDA as the adjunct, and the other using a topical anesthetic ointment of Xylocaine 5% were performed on thirty-four patients. The volunteers were asked on the spot to report the level of the pain they felt during the penetration of the needle to the mucosa, during the deposition of local anesthetic solution, and their overall evaluation of the injections. The results of this investigation showed that the EDA is the more effective adjunct for local anesthetic injections compared to the traditional topical anesthetics.

A bacterial sensitivity test to determine the effectiveness of minocycline HCI (Minocin), erythromycin (Erythrocin) and ampicillin (Ampicin) on the predominant microorganisms present in a diseased periodontium.

The purpose of this study was to determine the effectiveness of the three antimicrobials--Minocycline HCI, Erythromycin and Ampicillin based on the percentage reduction of bacteria present in subgingival microflora and in vitro assessment of antibiotic susceptibility of cultured strains of predominant microorganisms present in a diseased periodontium. Twelve volunteers 18 to 65 years of age, with moderate to severe periodontal disease, were randomly divided into Group A and Group B of 6 members each. Oral lavage procedure was performed to Group A and Group B received systemic administration of antibiotic for five days. Patients 1 & 2, 3 & 4 and 5 & 6 received minocycline HCI, Erythromycin and Ampicillin respectively. Microbiologic samples in the subgingival crevicular area in selected tooth exhibiting clinical periodontal breakdown were obtained from all the subjects prior to and after the oral lavage procedure and systemic drug administration. Streptococcus viridans is the most predominant aerobic microorganism obtained from 83% of samples. However no anaerobic microorganism has been isolated. Bacterial sensitivity testing showed 60% of samples with positive growth of microorganisms (S. viridans) were also equally sensitive to Minocycline HCI, Erythromycin and Ampicillin. Oral lavage proved to be ineffective in reducing the number of bacteria. However, systemic drug administration revealed that there was a reduction in bacterial count after taking such antibiotics for five days which is more favorable to Minocycline HCI.

A comparative study: classical, Akinosi, and Gow-Gates techniques of mandibular nerve block.

This study was conducted to compare the effectiveness and the degree of patient acceptability of the three techniques of mandibular nerve block, namely the classical, the Akinosi and the Gow-Gates. Forty five patients with mandibular posterior tooth/teeth indicated for extraction were chosen and divided equally into three groups to represent the three techniques of mandibular nerve block. Following the administration of the local anesthetic, the patients were evaluated using the evaluation sheet prepared for the study. Tabulation and analysis of the collected data followed. Results show that the Gow-Gates technique was the most effective in inducing anesthesia while the Akinosi technique appeared to be the most acceptable among the patients.

Histopathologic studies on wound healing caused by scalpel incision, cryosurgery and electrocautery on hamsters.

Scalpel incision, cryosurgery as demonstrated by the use of dry ice, and electrocautery have different effects both clinically and histologically. Twelve hamsters of equal weight were divided into four study groups to compare which of the three methods of incision initiates a faster healing capacity. Surgical incisions were made of equal depths and were observed after 2, 5, 10 and 12 days. Results showed a marked cellular infiltration in electrocautery as compared with the scalpel incision method and the dry ice incision.

Histopathological studies on the effects of experimental trauma and N-methyl-N-nitrosourea on the developing molar in rats.

Physical trauma to the developing first molar after initial dentin formation (5-day-old rat) and apposition stage (10-day-old rat) caused disturbance in amelogenesis, dentinogenesis, root formation which lead to aberrant odontogenesis. On the other hand, a combination of trauma and injection of carcinogenic substance (NMU) produced a more pronounced disturbance in odontogenesis and higher incidence of unerupted tooth. The transformation of the retained reduced enamel epithelium to squamous type cells was an interesting finding and has not been reported elsewhere. The presence of large proliferating type of odontogenic cell rests was observed.

Histopathologic study of squamous cell carcinoma of the gingiva in edentulous and dentulous jaws of hamsters treated with N-methylnitrosourea.

Unilateral maxillary or mandibular molars were extracted from twenty-four, 25-day-old male syrian golden hamsters; 25 days after extraction, 20 received MNU intragastrically twice a week for 3 months. All animals were killed 1 month later. High degrees and incidence of invasion of gingival SCC were observed in dentulous jaws without functional occlusion, followed by dentulous jaws with functional occlusion and edentulous jaws. Invasion of carcinomas with extensive bone destruction was observed commonly in the gingiva of dentulous maxillary jaws without functional occlusion, but was scarcely observed in the gingiva of edentulous jaws. By analogy, disuse atrophy of the periodontium due to loss of functional occlusion may result in early deeper invasion, while loss of periodontal ligament due to tooth extraction and disappearance of so-called inner gingival epithelium may result in less invasive carcinomas.