Lavez et aseptisez la plaie et les points. Partie 2 sur Vous devez voir nettement chacun des points de suture pour faire du bon travail. Soulevez le premier point. Coupez le point. Sinon, vous risqueriez de le sentir passer et de faire saigner! Designed to withstand high pressures. Available for either two or three flask. Sirve indistintamente para una o dos muflas. This useful clamp can save a great deal of time.
It is put into the press with the flask inside. They are removed after pressing and lateral nut approach. It can be used for one or two flasks.
This clamp for presses is made of special hardened and treated aluminum for greater consistency and recovery, and longer life than iron clamps.
The use of stainless steel screws, nuts and washers makes the assembly rust-proof and reduces its weight by half. Elle peut servir pour un seul moufle ou pour deux. Double safety valve. Air intake valve with backflow preventer. Hose with automatic closing. Tuyau avec fermeture automatique. Cuba de aluminio anodizado con triple sistema de seguridad en la apertura y cierre de la tapa.
Its automatic computerized control makes possible a switch on controlling time, temperature rises and controlled temperatures.
When working cycle finishes, there is a manual discharge and automatical disconnection. Sencilla de mantener y manejar. A compact high-performance table-top induction melter that is easy to operate. Despite being equipped with a sophisticated electronic control system, its operation has been simplified so it is as easy to use as a conventional centrifuge. In general, it can melt any dental alloy with the exception of titanium and its alloys.
The main advantages of Vestacast can be summarised as follows: 1 Excellent energy performance: high melting capacity with low energy consumption. Considerable reduction in the finishing needed in work done with the Vestacast.
Easy to maintain and operate. Sa puissance est de W. The control panel is synoptic, allowing easy handling. Three control buttons and a potentiometer to regulate melting are sufficient to carry out casting. The state of the process is visualised by four pilot lights. The components used are topquality and are assembled to form independent modules.
This design greatly simplifies maintenance tasks: just remove the damaged module and replace it with a new one. This operation can be carried out by any Technical Service at a reasonable cost.
Available as an accessory, there is a practical stainless steel stand for the device to take up a minimal room and to achieve an optimal operation height. It is strongly recommended to cool the device through a direct connection to the water source. But in the case the device is installed in a room with no access to a water source, there is a closed cooling circuit available. The circuit, compact and small, is monitored automatically by the machine itself.
The electronic control uses a microprocessor to regulate starting motor torque and casting time simply and accurately. The main features of the arm are its extraordinary lightness, its automatic return system to prevent losses on unexpected start-ups and its ability to handle casting rings of up to mm in diameter. The bodywork is completely made in stainless steel. Light arm that reduces starting inertia and operating vibrations.
Completely made of high resistant steel with nickel coat. Casting ring support allows mounting up to mm casting rings. By a simple height regulating system an optimum line-up between crucible muzzle and dish is obtained. When the machine is working, cabin door is blocked by a safety closing that avoids possible accidents. Completely made in stainless steel with three 20 cm separated shelves.
This facilitates the casting of highly-melted materials by adding rotary speed to initial speed. The counterweight can be displaced gradually according to the weight and size of the cylinder.
Se adaptan indistintamente todos los cilindros de las medidas expuestas anteriormente. Made of rubber. Can be fitted in any above mentioned cylinder. Made of plastic. R Conos con bebedero en tubo de acero inoxidable: 10 unidades. Injected polythethylene cones for the duplication tecnique in removable chrome cobalt prostheses. Waste-free calcination. They make possible a significant coating saving in castings. Silicone adapts perfectly to the expansion undergone by coating while forging.
Stainless steel manufactured, it makes possible to easily adapt oval casting blocks to casting machine casting ring-holder. Essential for the elimination of micropores produced in casting rings linings by bubbles not eliminated even by vacuum mixers. Thanks to the strong pressure atmospheres exerted on the lining, air bubbles are eliminated and the lining is compacted. This favours casting, particularly of hard metals such as Cr-Ni.
Se maneja con una sola mano por su escaso peso. Made of special aluminium. Light enough to hold in one hand. Rectangular refractory ceramic plate. R y mm. Dimensions: mm. R et de mm.
El crisol en Paking de 10 u. Crucible in 10 unit packs reduced price. Creuset en pack de 10 u. L x W x H 85 mm 40 1, kg aprox. L x W x H 85 mm 1, kg aprox. R 44 - - N. These model formers are designed in broad dimensions to allow a later trimming work and adjust it to standard formats. These are recommended for colleges and training centres. Con los zocaladores se logra un asiento firme en el articulador, sin tener que recortar ni serruchar Made of rubber. For quick clean construction of models.
With these base formers a firm seating is achieved in the articulator with no cutting or sawing. Of identical shape and construction to the above. Provided with split pyramids for shaping and marking the model and use as guides when replaced. Their connection when the models are assembled or torn down in the articulator is reliable thanks to the splicats and the magnets on both the upper S and lower I models.
Small P and large G. Su acoplamiento en el montaje y desmontaje de los modelos en el articulador es fiable gracias a las Splicats y los imanes tanto en los modelos superiores S como inferiores I. Fit the base former with the metal plate. Empty the impression as usually. Insulate the model and fit the magnet on the metal plate. Then separate the model carefully from the counterform which can be reused for another model.
Fabrication en caoutchouc. Fabricado en goma. Same support diameter. Different support diameters. Made of hardened stainless steel. Made in one piece with polished finish.
M-2 - Table type, telescopic, with disc for clamping on table. Reduced height for easier use. In order to use the container, place it upon the lame nozzle.
Pour utiliser la coupelle, emboitez-la sur le bec du bunsen. Desmontar los brazos laterales negros , que sujetan el modelo. Nota: Es muy importante la limpieza del polvo, restos de escayola, etc. Hacer el vaciado sobre vibrador. Posicionamos al modelo su antagonista, sujeto con unas gotas de cera y procedemos a ponerlo en el articulador con escayola blanca, como es habitual.
Dismount the black side arms holding the model. Remove the model from the bowl and place it on the white expulsion base. Press on it, and once the model is extracted individulize the stumps required. Note: It is very important to clean dust, residues of plaster, etc. Set the opposite half against the model and attach it with a few drops of wax. Designed for use as an individualiser. The method used is very simple, intuitive and very well known. Its low cost is another attractive point of this technique.
There are three high-quality brushes available: Marta Kolinsky hair round-tipped, Toray Oro fibre round-tipped and the flat-tipped Toray Oro fibre brush. Quality enamelled-wood handle, with a nickel brass collar. Numbers 0, 1, 2, 4, 6, 8 and 10 are included of each type, so there are 21 paintbrushes altogether. This set is supplied in a practical imitation-leather case.
Le set comprend les numeros 0, 1, 2, 4, 6, 8, et 10 de chaque type, soit un total de 21 pinceaux. Cada pincel dispone de una capucha protectora que mantiene la humedad y lo preserva de la suciedad.
A selection of six high quality paintbrushes made in Marta Kolinsky hair. Each paintbrush has a cap that protects it against dirt and damp.
This set is supplied in a practical case. Rounded edged 6 mm. It has 4 transparent silicone legs to avoid sliding, and a transversal slot that is very useful to deposit water or mixed solvents. Ideal para mezclas. Dispone de 5 cavidades rectangulares 30 x 45 mm. It is equipped with 5 rectangular cavities 30 x 45 mm and 5 other circular ones 25 mm. Rounded edged 8 mm thick resistant Glass Abaculus. Disponibles con 12 y con 6 cavidades. Con textura porosa para guardar la humedad. Cada paleta cuenta con tres cavidades recubiertas de porcelana.
Se suministran en cajas de ocho soportes con cuatro formas diferentes dos de cada tipo. Available with 12 and 6 cavities. Porous texture to keep in humidity. Each try has three porcelain-covered cavities. Supplied in a carton with a plastic cover. Their shapes are designed carefully to hold efficiently porcelain works while in the furnace. In order to avoid accidental burns, these pegs change colour when they get hot. Indicado para evitar contaminaciones en el horno cuando se trabaja con cierto tipo de metales.
Suministrado con 10 pines. Suministrado con 20 pines. R Con color que cambia al calentarse, evitando quemaduras por accidente. Se suministra con 20 pines. Cada herramienta incluye una punta de moldeo y otra flexible situadas en cada extremo. R With a carbon piece, used to avoid contamination in the furnace when working with certain types of metals.
R Round with conical pins. Supplied with 10 pins. R Round with cylindrical pins. Supplied with 20 pins. R The colour changes as it warms up, avoiding accidental burns.
R Rond avec des tiges coniques. Fourni avec 10 tiges. R Rond avec des tiges cylindriques. Fourni avec 20 tiges. Each tool includes both a moulding and a flexible tip located on each end. This set is delivered in a practical case. Set of trays to put works in the ceramic furnace.
Their numerous orifices make easier adaptation of support pins to the geometry of any work. Et 15 pins. Flexibles y con 3 perfiles diferentes. These flexible ceramic moulding instruments have 3 different outlines and screwed ending for fixing them to the instrument. Ahorra consumible y evita la suciedad. Stainless steel instrument designed for an accurate dosage of the materials used in ceramic works. It saves consumable and avoids dirt. Available in two sizes: big and small.
Con estuche de vinilo. Se compone de 19 instrumentos: Very complete. Vinyl case. Se compone de 18 instrumentos: Very complete. Para facilitar el manejo, al dejarse sobre la mesa el mango siempre permanece elevado. Made of polyamide resistant to high temperatures. Innovative design including an easy to handle and safe lock. For an easier handling, when you leave it on the table, the handle remains raised. Ideal accessory for teeth cleaning with steam machine or washing machine.
Made of clear injected plastic. Prevents losses of precious metal powder. Prevents eye accidents due to flying particles, and considerably reduces inhalation of harmful dust. Evite les projections de particules sur les yeux. Como accesorio se encuentra disponible un KIT formado por un engrasador y un manorregulador con filtro; y un pedal de accionamiento.
Essential tool for a quick cleaning off of models. It has air flow regulation; ergonomic shape; made in corrosion-free materials; small dimensions. It has been designed to reduce to the maximum vibrations and sound level. Three chisel heads with different sizes and shapes are included. The air connection hose is 6 mm. Pince concentrique pour tiges de 2 mm. Concentric clamp for 2 mm rods. Useful tool to get jelly ready in a few seconds so that it can be put directly inside the Jelly Mixer.
Made in stainless steel with plastic handle. Do not use this tool to cut jelly inside the Jelly Mixer. Fabrique en acier inoxydable avec manche en plastique. Dispone de 16 formas diferentes. Partiendo de un modelado inicial realizado por el usuario de manera tosca, se selecciona la plantilla adecuada al tipo de muela.
Allows highly accurate modelling of the occlusal side of molars mastication surface in ceramic, acrylic and wax. Sixteen different shapes. Starting from an initially rough modelling by the user, the right template for the type of molar is selected.
By pressing the template against the molar the instant modelling of the exact shape of the piece is obtained, thus saving a considerable amount of time. Supplied in a kit consisting of 16 different templates, an instrument to hold the templates in place and a case to keep all the components. Economie de temps garantie. High-quality, high-resistance plastic.
These are essential for proper laboratory task organisation. Their x x 40 mm dimensions make them ideal for this application. Disponibles en 5 colores: amarillo, azul, rojo, verde, blanco. Se suministran en cajas de 10 unidades un color. As above larger. Useful when organizing Dental Lab production. Diclofenac and metabolite pharmacokinetics in children. Perioperative pharmacokinetics of ibuprofen enantiomers after rectal administration.
Paediatr Anaesth. Cerebrospinal fluid distribution of ibuprofen after intravenous administration in children. Intravenous ketoprofen as an adjunct to patient-controlled analgesia morphine in adolescents with thoracic surgery : a placebo controlled double-blinded study. Comparison of perioperative ketoprofen 2. Pharmacokinetics of intravenous and rectal ketoprofen in young children.
The effect of ketoprofen on recovery after tonsillectomy in children : a 3-week follow-up study. Int J Pediatr Otorhinolaryngol. The analgesic efficacy of acetaminophen, ketoprofen or their combination for pediatric surgical patients having soft tissue or rthopaedic procedures.
A randomized, single-blind, parallel, multicentre trial. Peroperative treatment with i. An evaluation of the safety and efficacy of administering rofecoxib for postoperative pain management. Anesth Analg ; niveau 2. Post-tonsillectomy pain management in children : can we do better? Otolaryngol Head Neck Surg. Comparative study of acetaminophen-morphine versus rofecoxib-morphine for post-tonsillectomy pain control.
J Otolaryngol. Double-blind, placebo-controlled analgesic study of ibuprofen or rofecoxib in combination with paracetamol for tonsillectomy in children. Br J Anaesth ;88 niveau 1. The safety of acetaminophen and ibuprofen among children younger than two years old. The safety of ibuprofen suspension in children. A teenager with severe asthma exacerbation following ibuprofen. Asthma morbidity after the short-term use of ibuprofen in children. Pediatrics ; niveau 1 Ulinski T, Bensman A.
Short-term niflumic-acid-induced acute renal failure in children. Renal function after short-term ibuprofen use in infants and children. Safety profile of ibuprofen suspension in young children.
Inflammopharmacology ;7 3 Litalien C. Jacqz-Aigrain E. Ibuprofen use in children :a benefit or a risk? Ibuprofen and skin and soft tissue surinfections in children with varicella. A case-control study of necrotizing fasciitis during primary varicella. Invasive group A streptococcal infection and nonsteroidal anti-inflammatory drug use among children with primary varicella.
An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema : risk factors and microbiological associations. Efficacy of rectal ibuprofen in controlling postoperative pain in children. Can J Anaesth. Perioperative intravenous ketoprofen neither prolongs operation time nor delays discharge after adenoidectomy in children. Rectally administered diclofenac Voltaren reduces vomiting compared with opioid morphine after strabismus surgery in children.
Analgesic efficacy of paracetamol and diclofenac in children receiving PCA morphine. Oral naproxen but not oral paracetamol reduces the need for rescue analgesic after adenoidectomy in children. Acta Anaesthesiol Scand.
A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Comparative effect of paracetamol, NSAIDs or their combination in postoperative pain management : a qualitative review.
Postoperative analgesia with preoperative oral ibuprofen or acetaminophen undergoing myringotomy. A comparison of rectal and intramusculare codeine phosphate in children following neurosurgery.
Codeine phosphate in paediatric medicine. Codeine intoxication in the neonate. Impact of environmental and genetic factors on codeine analgesia. Pharmacogenetics of codeine metabolism in an urban population of children and its implications for analgesic reliability.
Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Pharmacokinetics of nalbuphine in infants, young healthy volunteers, and elderly patients. Analgesic and respiratory effect of nalbuphine and pethidine for adenotonsillectomy in children with obstructive sleep disorder. Pharmacokinetics of intrarectal nalbuphine in children undergoing general anaesthesia.
Pharmacokinetics of oral tramadol drops for postoperative pain relief in children aged 4 to 7 years--a pilot study. Tramadol for pain relief in children undergoing tonsillectomy: a comparison with morphine. Pharmacokinetics of rectal tramadol in postoperative paediatric patients. Relief of posttonsillectomy pain with low-dose tramadol given at induction of anesthesia in children. Double-blind randomized study of tramadol vs. Recovery following tonsillectomy a comparison between tramadol and morphine for analgesia.
Analgesia for adenotonsillectomy in children and young adults: a comparison of tramadol, pethidine and nalbuphine. Analgesic efficacy of tramadol 2 mg kg-1 for paediatric day-case adenoidectomy. Preemptive analgesia with tramadol and fentanyl in pediatric neurosurgery.
Tramadol disposition in the very young : an attempt to assess in vivo cytochrome P 2D6 activity. Intraoperative administration of tramadol for postoperative nurse-controlled analgesia resulted in earlier awakening and less sedation than morphine in children after cardiac surgery. Comparison of morphine and tramadol by patientcontrolled analgesia for postoperative analgesia after tonsillectomy in children.
An evaluation of the efficacy and tolerability of oral tramadol hydrochloride tablets for the treatment of postsurgical pain in children. Oral tramadol: analgesic efficacy in children following multiple dental extractions. Eur J Anaesthesiol. Tramadol versus diclofenac for post-tonsillectomy analgesia. Paediatric ventilatory effects of morphine and buprenorphine revisited. Comparison of the ventilatory effects of morphine and buprenorphine in children.
Recommended use of morphine in neonates, infants and children based on a literature review: part 1: pharmacokinetics. Clearance of morphine in postoperative infants during intravenous infusion: the influence of age and surgery.
Developmental pharmacokinetics of morphine and its metabolites in neonates, infants, and young children. Does neonatal surgery lead to increased pain sensitivity in later childhood?
Anesth Analg ; niveau 4. Patient—controlled analgesia with low dose background infusions after lower abdominal surgery in children. Comparison of patient-controlled analgesia with and without a background infusion after lower abdominal surgery in children. Comparison of patient-controlled analgesia with and without nighttime morphine infusion following lower extremity surgery in children.
Patient controlled analgesia in children and adolescents: a randomized controlled trial. Efficacy of continuous versus intermittent morphine administration after major surgery in 0—3-year-old infants; a double-blind randomized controlled trial. Age and therapy-related effects on morphine requirements and plasma concentrations of morphine and its metabolites in postoperatives infants.
Ventilatory arrest after a fluid challenge in a neonate receiving s. Sublingual morphine may be a suitable alternative for pain control in children in the postoperative period. Intravesical morphine analgesia after bladder surgery. Intravesical morphine analgesia is not effective after bladder surgery in children: results of a randomised doubleblind study. Efficacy and complications of morphine infusions in postoperative paediatric patients. The effects of a small dose naloxone infusion on opioid-induced side effects and analgesia in children and adolescents treated with intravenous patient-controlled analgesia : a double-blind, prospective, randomised, controlled study.
Intravenous nalbuphine 50 microg x kg -1 is ineffective for opioid-induced pruritus in pediatrics. The addition of antiemetics to the morphine solution in patient controlled analgesia syringes by children after an appendectomy does not reduce the incidence of postoperative nausea and vomiting. Extrapyramidal side-effects from droperidol mixed with morphine for patient-controlled analgesia in two children. Intravenous morphine in postoperative infants:intermittent bolus dosing versus targeted continuous infusions.
Reccurent hypoxemia in young children with obstructive sleep apnea is associated with reduced opioid. Ketamine as adjuvant analgesic to opioids: a quantitative and qualitative systematic review. Ketamine reduces swallowingevoked pain after paediatric tonsillectomy.
Does ketamine or magnesium affect posttonsillectomy pain in children? Effecy of an intravenous single dose of ketamine on postoperative pain on tonsillectomy patients.
A prospective randomized controlled study of the efficacy of ketamine for postoperative pain relief in children after adenotonsillectomy. Comparison of ketamine and morphine for analgesia after tonsillectomy in children. Double-blind randomizer placebo-controlled trial of the effect of ketamine on postoperative morphine consumption in children following appendicectomy. Intraoperative lowdose ketamine S-Ketamine has no preventive effects on postoperative pain and morphine consumption after major urological surgery in children.
Pain intensity after laseruvulopalatoplasty and tonsillectomy. Post-tonsillectomy pain: the difference between younger and older patients. Children's pain at home following adeno tonsillectomy. A randomized clinical trial of the effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in children following tonsillectomy.
Rectal and parenteral paracetamol, and paracetamol in combination with NSAIDs, for postoperative analgesia. Propacetamol and diclofenac alone and in combination for analgesia after elective tonsillectomy. Examination of acetaminophen for outpatient management of postoperative pain in children. Recovery and complications after tonsillectomy in children: a comparison of ketorolac and morphine. A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: analgesia and bleeding.
Ketoprofen, diclofenac or ketorolac for pain after tonsillectomy in adults? A comparison of intramuscular tenoxicam with intramuscular morphine for pain relief following tonsillectomy in children. The effect of ketoprofen on recovery after tonsillectomy in children: a 3-week follow-up study. Comparison of pre- and postoperative administration of ketoprofen for analgesia after tonsillectomy in children.
Use of nonsteroidal anti-inflammatory drugs in infants. Nonsteroidal antiinflammatory drugs and the risk of operative site bleeding after tonsillectomy: a quantitative systematic review. Postoperative hemorrhage with nonsteroidal anti-inflammatory drug use after tonsillectomy: a meta-analysis. Effects of postoperative, nonsteroidal, antiinflammatory drugs on bleeding risk after tonsillectomy: meta-analysis of randomized, controlled trials.
Nonsteroidal antiinflammatory drugs and hemorrhage following tonsillectomy : do we have the data? Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy.
Rofecoxib administration to paediatric patients undergoing adenotonsillectomy. Cost-efficacy of rofecoxib versus acetaminophen for preventing pain after ambulatory surgery. Comparison of morphine sulphate and codeine phosphate in children undergoing adenotonsillectomy.
Preoperative oral dextromethorphan does not reduce pain or analgesic consumption in children after adenotonsillectomy. An appraisal of codeine as an analgesic: single-dose analysis. Controlled comparison of nalbuphine and morphine for post-tonsillectomy pain. Ketoprofen and tramadol for analgesia during early recovery after tonsillectomy in children. Singapore Med J. Comaprison of morphine and tramadol by patient-controlled analgesia for postoperative analgesia after tonsillectomy in children.
Tramadol versus diclofenac for posttonsillectomy analgesia. The dose-effect relationship for morphine and vomiting after day-stay tonsillectomy in children. Urgent adenotonsillectomy: an analysis of risk factors associated with postoperative respiratory morbidity.
Can assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications? Anesthesiology ; Analgesia for adenotonsillectomy in children: a comparison of morphine, ketamine and tramadol. Adenotonsillectomy in children: a comparison of morphine and fentanyl for peri-operative analgesia. Pain prevention with intra-operative ketamine in outpatient children undergoing tonsillectomy or tonsillectomy or adenotomy.
Pain relief for children after adenotonsillectomy. Ketamine does not decrease postoperative pain after remifentanil-based anaesthesia for tonsillectomy in adults. Dexamethasone in adenotonsillectomy. The effect of intravenous dexamethasone in pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg. Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy. The effect of preoperative dexamethasone on the immediate and delayed postoperative morbidity in children undergoing adenotonsillectomy.
The effect of preoperative dexamethasone on early oral intake, vomiting and pain after tonsillectomy. The effects of dexamethasone, bupivacaine and topical lidocaine spray on pain after tonsillectomy. A meta-analysis of dexamethasone use with tonsillectomy. Steroids for improving recovery following tonsillectomy in children. There is no dose-escalation response to dexamethasone 0. Dexamethasone and risk of nausea and vomiting and postoperative bleeding after tonsillectomy in children: a randomized trial.
JAMA 10; Local bupivacaine-epinephrine infiltration combined with general anesthesia for adult tonsillectomy. Efficacy of bupivacaine for posttonsillectomy pain: a study with the intra-individual design. Effect of pre-emptive analgesia on self-reported and biological measures of pain after tonsillectomy.
Peritonsillar infiltration with bupivacaine for paediatric tonsillectomy. The efficacy of peritonsillar lidocaine infiltration for postoperative pain relief in the immediate postoperative period after pediatric adenotonsillectomy. Pre-incisional infiltration for pediatric tonsillectomy: a randomized double-blind clinical trial. Comparison of bupivacaine and ropivacaine on postoperative pain after tonsillectomy in paediatric patients.
Pre-emptive effects of ibuprofen syrup and lidocaine infiltration on post-operative analgesia in children undergoing adenotonsillectomy. Effect of perioperative administration of ropivacaine with epinephrine on postoperative pediatric adenotonsillectomy recovery. Vocal cord paralysis as a consequence of peritonsillar infiltration with bupivacaine. Glossopharyngeal nerve block for pain relief after pediatric tonsillectomy: retrospective analysis and two cases of life-threatening upper airway obstruction from an interrupted trial.
Brain stem stroke associated with bupivacaine injection for adenotonsillectomy. Life-threatening deep cervical abscess after infiltration of the tonsillar bed for tonsillectomy.
Single-blind evaluation of post-tonsillectomy pain treatment with an eutectic mixture of local anesthetics. Effect on postoperative pain after local application of bupivacaine in the tonsillar fossa; a prospective single blind controlled trial.
Does topical ropivacaine reduce the post-tonsillectomy morbidity in pediatric patients? Hydrogen peroxide mouth rinse: an analgesic post-tonsillectomy. Ketamine in post-tonsillectomy pain. The efficacy of intravenous or peritonsillar infiltration of ketamine for postoperative pain relief in children following adenotonsillectomy. Tonsillar fossa steroid injection for reduction of the post-tonsillectomy pain. Topical lidocaine and oral acetaminophen provide similar analgesia for myringotomy and tube placement in children.
Can J Anaesth ; niveau 1. Intraoperative local anaesthesia for paediatric postoperative oral surgery pain- a randomized controlled trial. Bilateral intre-oral, infra-orbital nerve block for postoperative analgesia following cleft lip repair in paediatric patients : comparison of bupivacaine vs bupivacaine-pethidine combination. A comparison of bilateral infraorbital nerve block with intravenous fentanyl for analgesia following cleft lip repair in children.
Diclofenac and flurbiprofen with or without clonidine for postoperative analgesia in children undergoing elective ophtalmological surgery. Ketoprofen for add-on pain treatment to paracetamol after strabismus surgery in children. Other imaging modalities — As discussed above, we suggest upper GI series with small bowel follow-through as the primary imaging technique to assess for small bowel disease in a patient with suspected IBD.
This test may not be necessary if another imaging modality such as CT, MRI, or video-capsule endoscopy has already provided an adequate examination of the small bowel. No imaging modality is a substitute for thorough endoscopic examination and histopathologic diagnosis.
MRI and CT — Other imaging modalities, including computerized axial tomography CT , magnetic resonance imaging MRI , and nuclear medicine studies are sometimes valuable in assessing for complications of IBD, but their role in the initial evaluation of a patient and the differentiation between CD and UC has not been established [9,13].
At this time, the upper GI series with small bowel follow-through remains the customary test for the initial evaluation of the small bowel inaccessible by endoscopy. Like barium contrast studies, MRI can detect small bowel disease in areas of the small intestine that are inaccessible to endoscopy.
In studies of children with suspected Crohn's disease, MRI detected erosive ileitis with sensitivity of 84 to 96 percent, and specificity of 92 to percent as compared to histopathologic diagnosis [30,31]. However, expertise with and access to MRI imaging of the small bowel is not widely available.
The relative merits of fistulography, CT, MRI, and ultrasonography in evaluating anal fistulas are discussed separately. Scintigraphy — Scintigraphy with the 99mTc hexamethyl, propylene amine oxime HMPAO labeled leukocyte scan 99mTc WBC scans may provide a useful noninvasive diagnostic test to determine the extent and distribution of inflammation in children with IBD .
In one pediatric study, the findings on 99mTc WBC scan correlated with histologic examinations on recent colonoscopic and endoscopic biopsies in of the children . Seven falsenegative and two false-positive 99mTc WBC scan studies were noted, with a sensitivity of 90 percent, specificity of 97 percent, a positive predictive value of 97 percent, and negative predictive value of 93 percent with a prevalence of disease 53 percent .
Thus, scintigraphy may help identify which areas of the bowel are inflamed, and substantial inflammation of the small bowel is suggestive of Crohn's disease. However, because it does not provide information about type or degree of inflammation, it is not a substitute for thorough endoscopic evaluation. For UC, the disease involvement should be categorized as proctitis rectal involvement limited to 15 cm or less , left-sided colitis, or pancolitis extending past the splenic flexure.
For CD, localizing disease means identifying whether the mouth, esophagus, stomach, small bowel, colon, or anus are involved. By defining the affected areas of the gastrointestinal tract, the clinician will be able to better target medical management appropriately. These may involve the skin, joints, liver, eye, and rarely respiratory system show table 4.
These disorders appear idiosyncratically in some patients and not others, but are more often associated with colonic disease; they do not consistently correlate with the degree of intestinal inflammation. The differential diagnosis of conditions causing E. Pyoderma gangrenosum, a severe ulcerating rash that responds to immunosuppression, is rare in children and is seen more often in patients with long-standing UC than in patients with CD.
Granulomatous inflammation of other areas, including the lymph nodes, genitalia, and lungs  also may be seen in individuals with CD. Eye — Episcleritis and uveitis are the most frequent eye manifestations of IBD in adults.
Affected patients may be asymptomatic or complain of burning and itching. Injection of the ciliary vessels and inflammation of the episcleral tissues are the prominent features on physical examination. Uveitis is less common than episcleritis, occurring in 0. However, its consequences often are more severe. The uveitis is frequently bilateral, posterior to the lens, insidious in onset, chronic in duration, and is more common in females than males .
Joints — Arthritis in CD typically is nonerosive and asymmetric, affects large joints, including the hips, knees, and wrists, and parallels the activity of the intestinal involvement [39,40] ; this occurs in 10 to 20 percent of patients [41,42]. In contrast, axial skeletal involvement, in the form of ankylosing spondylitis and sacroiliac joint arthritis, may follow an independent course . Chronic recurrent multifocal osteomyelitis is a rare complication of both CD and UC .
Liver — Nonspecific mild elevations of serum aminotransferases AST, ALT are common and often are caused by medications or hepatic steatosis .
Individuals with CD have an increased risk for cholelithiasis, but this is uncommon in UC [45,46]. Autoimmune hepatitis also may occur . The most serious liver disease associated with IBD is primary sclerosing cholangitis PSC , a condition causing inflammation and scarring of the bile ducts, which may lead to hepatic cirrhosis.
PSC occurs in 2 to 4 percent of patients with UC, and a slightly smaller proportion of patients with Crohn's colitis . Patients with PSC may present with fatigue, pruritus, and intermittent jaundice; colitis symptoms may be mild. Biochemical tests demonstrate an elevation of gamma-glutamyl transpeptidase, alkaline phosphatase, and a less pronounced elevation of aminotransferases. Diagnosis is made by a combination of radiographic imaging ultrasound, magnetic resonance cholangiopancreatography , endoscopic retrograde cholangiopancreatography ERCP , and liver biopsy.
Although no therapy has been definitively shown to alter the natural history of the disease, treatment with ursodeoxycholic acid results in improvement of laboratory markers of hepatic inflammation and cholestasis . Other — Other complications of inflammatory bowel disease include micronutrient deficiencies especially vitamin B12 deficiency in ileal CD , renal stones, and osteopenia.
Rarely, granulomatous infiltration of the lungs and fibrosis may occur. Clinical features supportive of the diagnosis include abdominal tenderness, oral ulcers, or perianal disease. If diarrhea or loose stools are present, stool cultures should be performed to identify enteric pathogens. If stools are formed, other causes of rectal bleeding should be explored, including Meckel's diverticulum and anal fissures.
These studies usually are sufficient to confirm the diagnosis of IBD show table 1. Significant perianal disease also strongly supports the diagnosis of CD. This information often supports the classification of the disease into CD or UC subtypes, and is often important in choosing types of therapy.
If poor nutrition suspected: serum iron, calcium, magnesium, folate, vitamins A, E, B12, zinc. Clinical manifestations of pediatric inflammatory bowel disease. Since the approval of infliximab for the treatment of Crohn's disease in , CD has been viewed as an excellent proving ground for antiinflammatory biologics.
Despite increasing available therapies, the approved therapies have limited efficacy, and there continues to be concerns related to their safety.
Thus, a large unmet need exists for the treatment of CD. Mesalamine, though used widely in Crohn's disease, has a minor role with little data supportive of a significant benefit, if any, for the treatment of CD. Corticosteroids, while clinically useful, do not completely control the disease in many patients and have no role for maintenance. While some patients respond to the available anti-TNF agent, many fail to respond or lose response over time. Thus, newer approaches are being evaluated.
The dramatic advances in mucosal immunology have revealed a broad set of new targets to resolve the inflammation and symptoms of the disease. The prevailing understanding of CD suggests that the intestinal inflammation is initiated by an aberrant innate immune response, which eventuates in a T-cell driven process, characterized by a T-helper cell 1 type cytokine profile.
Many new treatments focus on inhibiting, suppressing or altering T-cell differentiation. With the identification of a T cell subset, Th17, which may be responsible for much of the inflammatory process and production of inflammatory cytokines, a new set of therapeutic antibodies are in early phase of testing. The importance of Treg a T cell subset that regulates other T cells has also opened other potential avenues for influencing activated T cells.
In addition to efforts to manipulate T cells, T cell products, or inflammatory pathways, other therapeutics are being investigated that take very different theoretical approaches.
Examples include the administration or cytokines to stimulate innate immunity, the use of helminths to restore T cell regulation or the use of prebiotics, complex carbohydrates to alter the gut flora. This topic review will discuss experimental treatments for Crohn's disease. None of the treatments that will be discussed is currently approved for routine clinical application.
Furthermore, because many of these agents are in early stages of development, information regarding their efficacy and safety is derived largely from unpublished sources of data. Conventional treatments for Crohn's disease such as 6-mercaptopurine, azathioprine and infliximab and an overview of the medical management of Crohn's disease are discussed in separate topic reviews. Because IBD represents a state of dysregulated inflammation, drugs that can augment the antiinflammatory response have the potential to downregulate inflammation and thereby improve the disease.
While the demarcation of Th1 and Th2 types of disease in humans is less clear than in murine models, Crohn's disease continues to be viewed as a Th1 disease, with interferon and IL as dominant cytokines. Anti-TNF therapy — Infliximab, a monoclonal antibody with high specificity for and affinity to tumor necrosis factor TNF -alpha, is highly effective in the treatment of patients with moderately to severely active Crohn's disease and patients with fistulizing Crohn's disease, who have had an inadequate response to conventional therapy.
Adalimumab has been approved by the FDA for use in Crohn's disease. Other anti-TNF agents have been investigated. Except for issues of antigenicity, which will vary with each agent, these anti-TNF drugs will likely all share similar safety concerns as has been seen with infliximab, including the risk of infection, reactivation of tuberculosis, and lymphoma, among other adverse events.
Initial studies have shown mixed results . This compound is not currently in active trials and further development is unlikely. It is currently used to treat rheumatoid arthritis. In a pilot study, the drug was associated with a reduction in disease activity in 6 of 10 patients with active Crohn's disease .
However, no benefit was observed in a subsequent placebo-controlled four-week trial . Onercept — Onercept is a recombinant form of the natural human soluble p55 TNF receptor. A clinical benefit was suggested in a pilot study involving 12 patients with active Crohn's disease .
However, a subsequent placebo controlled trial found no significant benefit for clinical response or induction of remission . Anti-interleukin 12 antibodies — Interleukin 12 has a central role in driving the inflammatory response mediated by type 1 helper cells.
Patients were randomly assigned to a seven week course of subcutaneous injections 1 or 3 mg per kg or placebo. Seven weeks of uninterrupted treatment with the 3 mg dose was associated with a significantly higher rate of response than placebo 75 versus 25 percent.
The differences were no longer significant at 18 weeks of follow-up. Adverse events were similar to placebo except for a higher rate of local reactions at the injection site in the active intervention arms.
Il shares a common subunit, p40, with Il, a cytokine important in the activation of a T cell subset. While Il is important in Th1 differentiation, Il is central for the development of Th17 cells. Antibodies directed against Il also bind to this shared subunit of Il, consequently inhibiting two important targets in T cell differentiation. Another antibody directed against this shared subunit, CNTO , was evaluated in a dosefinding study involving patients .
A significant response was demonstrated among those who had previously responded to infliximab. Further studies of antibodies directed against Il and Il are anticipated in the near future. Anti-interferon gamma antibodies — Interferon gamma is an important cytokine involved in cellmediated immunity. A study evaluated the efficacy and safety of fontolizumab Huzaf , a humanized anti-interferon gamma antibody in patients with moderate or severe Crohn's disease .
The drug appeared to be well tolerated. Additional studies are ongoing. Anti-interleukin 6 receptor monoclonal antibody tocilizumab — As noted above, IL-6 is a proinflammatory cytokine. Thus, blockage of IL-6 activity has the potential to downregulate inflammation [12,13]. A humanized monoclonal antibody directed against the IL-6 receptor tocilizumab, atlizumab, MRA is in early clinical trials.
An initial pilot study in patients with active Crohn's disease showed promising results with 80 percent 8 out of 10 responding at the full dose compared to 31 percent 4 out of 13 in the placebo group, although only two patients achieved remission .
Anti-interleukin 18 antibodies — Interleukin 18 is involved in the TH1 immune response. Antibodies against interleukin 18 reduced the severity of colitis in animal models . Clinical trials of a human anti IL antibody or IL binding protein are anticipated .
Interleukin — Interleukin IL is a cytokine that has antiinflammatory and immunosuppressant properties. Endogenous expression of IL is increased in inflamed mucosa from patients with inflammatory bowel disease . The efficacy of recombinant IL in Crohn's disease was first demonstrated in a pilot study in which 46 patients with active, steroid-resistant Crohn's disease were randomized to varying doses of IL or placebo administered once daily intravenously for seven consecutive days .
Following treatment, the average score on the Crohn's disease activity index was lower among patients receiving active treatment versus , although results were not statistically significant. No significant differences in the induction of remission were observed between the groups.
Treatment was well tolerated; a dose-dependent and fully reversible decrease in hemoglobin and platelet counts was observed. Remission was defined as a score on the Crohn's disease activity index of less than , with a decrease in baseline of at least points, plus improvement or resolution on endoscopic appearance.
A strain of recombinant bacteria that secrete IL and are capable of colonizing the intestinal tract have been developed. The bacteria suppressed colitis in animal models . A pilot study in humans suggested a potential clinical benefit . A dose ranging study involving 76 humans with active Crohn's disease suggested that short-term treatment three weeks significantly improved clinical response compared to placebo . A subsequent preliminary report from the same authors that included patients with active Crohn's disease found that treated patients were significantly more likely to be in remission by six weeks compared to placebo 37 versus 16 percent .
By contrast, interleukin was inferior to prednisolone in achieving induction of remission in a randomized controlled trial involving 51 patients . Miscellaneous agents Fish oil — A variety of proinflammatory cytokines are synthesized from n-6 fatty acids.
An approach to reducing cytokine activity is the administration of fish oil using n-3 fatty acids. A meta-analysis of four studies of fish oil with a total of patients found a non-statistically significant benefit for maintaining remission RR 0.
Subgroup analysis revealed a statistically significant benefit for enteric-coated capsules. However, two subsequent high-quality placebo controlled trials EPIC-1 and EPIC-2 involving a total of patients with quiescent Crohn's disease found no benefit for prevention of relapse .
Thus, a benefit of fish oil in maintenance of remission of Crohn's disease appears to have been disproven. It was banned after its use in pregnancy for hyperemesis was found to cause severe birth defects.
However, the antiinflammatory effects of thalidomide have generated renewed interest in its use in a variety of conditions. Its safety and efficacy in Crohn's disease were evaluated in two open label pilot trials [30,31]. The first enrolled 12 adult patients with Crohn's disease that was refractory to prednisone or who were intolerant of 6- mercaptopurine or azathioprine .
Patients were treated with thalidomide 50 or mg for 12 weeks. At the end of treatment, clinical response was observed in 70 percent of patients, with clinical remission in 20 percent. Steroids could be discontinued in 44 percent of patients. Toxicity included drowsiness, peripheral neuropathy, edema, and dermatitis. In the second study, 22 patients with refractory Crohn's disease were treated with thalidomide or mg orally QHS . Fourteen patients completed 12 weeks of treatment, all of whom achieved a clinical response, including nine who achieved clinical remission.
Five of six patients with fistulas had complete closure of all fistulas after 12 weeks of therapy. Six patients withdrew from the study within the first four weeks two requiring surgery for refractory or worsening symptoms, and four others because of side effects or lack of perceived improvement. It is structurally unrelated to other known immunomodulatory drugs. Clinical improvement was noted in 8 of 12 patients who were intolerant of azathioprine or 6-MP suggesting that further study in controlled trials is warranted .
Alequel — Alequel is an extract of autologous colonic proteins from patients with Crohn's disease. The rationale for its use is based upon observations in animal models of IBD in which feeding autologous proteins prevented colitis.
A pilot controlled trial in humans suggested possible clinical benefits, but none of the endpoints reached statistical significance on an intention-to-treat analysis . Blockage of leukocyte migration has been proposed as a means of downregulating inflammation. Antisense therapy is under investigation for a number of diseases including inflammatory bowel disease.
Intercellular adhesion molecule-1 — Intercellular adhesion molecule-1 ICAM-1 is a transmembrane glycoprotein that has multiple functions involving propagation of inflammatory processes, and is upregulated in inflammatory bowel disease . Initial results in human pilot studies using antisense therapy against ICAM-1 were equivocal [36,37]. Results of two subsequent placebo-controlled trials were negative . Anti-integrin antibodies — Alpha-4 integrins are involved in leukocyte migration across vascular endothelium .
MLN — MLN is a recombinant humanized, anti-alpha4beta7 integrin monoclonal antibody, an integrin relatively specific to the gastrointestinal tract. This agent was effective in a study of ulcerative colitis. An initial controlled trial in Crohn's disease suggested a higher remission rate, although the results did not achieve statistical significance .
Further studies are anticipated for UC but development in Crohn's has not been planned at this point. GROWTH HORMONE — A number or regulatory peptides such as growth hormone, and insulinlike growth factor I are involved in the control of intestinal permeability providing a rationale for clinical trials in Crohn's disease, which is associated with increased intestinal permeability. One study included 37 patients with moderately to severely active Crohn's disease who were randomly assigned to receive growth hormone 5 mg per day subcutaneously for one week followed by a maintenance dose of 1.
All patients were also instructed to increase their dietary protein intake to at least 2 g per kilogram of body weight per day since protein enhances the synthesis of endogenous intestinal protein. After four months, the mean Crohn's Disease Activity Index decreased significantly more in patients receiving growth hormone a decrease of versus 19 points. Side effects included edema observed in 10 patients and headache observed in five patients , which resolved within one month in most patients.
These observations provided the rationale for clinical trials of human granulocyte colony stimulating factor GCSF and human granulocytemacrophage colony stimulating factor GM-CSF in patients with Crohn's disease .
Antibiotics and aminosalicylates were allowed while immunosuppressants and glucocorticoids were prohibited. There was no significant difference in the rate of clinical response at the primary endpoint defined by a decline of 70 points in the CDAI score. After cessation of medication, the response continued for a mean of 10 weeks. A study involving G-CSF included 20 patients with mucosal or fistulizing Crohn's disease who were treated with daily subcutaneous injections for 12 weeks .
Fifteen patients completed 8 weeks while 13 completed 12 weeks of therapy. At week 12, 11 patients 55 percent had a decrease in the Crohn's Disease Activity Index by at least 70 points, while 25 percent achieved a sustained remission.
Three of four patients with fistulae had a positive response. One patient required hospitalization with a viral-like syndrome of unclear relationship to treatment.
It has been known for nearly a century that Crohn's disease resembles tuberculous gastroenteritis and is histopathologically similar to Johne's disease, an enteritis of ruminants caused by M. According to Le Parisien , "a gothico-melancholic muddle fills some vaporous songs of the album".
The newspaper blamed it for the lack of novelty and the "disappointing duet" with Moby , but also said that this one "shows itself finally effective when it accelerates the rhythm, takes up the sound, let itself overcame by the electro heart-beat". It also stated that with this new album, "Farmer does not envisage a revolution or even a revelation", and that it has "a methodical faithfulness" to her previous works. It also reproached the "naivety of certain texts" and their "tendency for abstraction".
Very critical, 20 Minutes stated the album "does not play either in the sobriety or in the sharpness. According to Le Matin , this disc "tries to reconcile all the publics of [the singer]". In it, "she combines all that which makes her strength: techno lightings, evident melodies, easy to remember, ballads touching straight to the heart, ambiguous texts". It also said that the last two songs are the best ones of the album. With 5, downloads on four days, the album went straight to number-one on the French digital albums chart, on 23 August,  which is one of the records of the year.
With , sales, the album was directly number one on the SNEP Albums Chart on 30 August,  which was to date the third weekly best-selling debut for an album in in France.
Overall, it spent 64 weeks on the chart, 34 weeks in the top 50 and 48 weeks in the top In Russia, Europa Plus radio aired the album for the first time on 23 August. It was available two days later and was certified Platinum on a single day for over 20, units sold.
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