Comparison of sustained-release and rapid-release ß-alanine formulations on changes in skeletal muscle carnosine and histidine content and isometric performance following a muscle-damaging protocol.

ß-alanine supplementation increases muscle carnosine content and improves anaerobic exercise performance by enhancing intracellular buffering capacity. ß-alanine ingestion in its traditional rapid-release formulation (RR) is associated with the symptoms of paresthesia. A sustained-release formulation (SR) of ß-alanine has been shown to circumvent paresthesia and extend the period of supply to muscle for carnosine synthesis. The purpose of this investigation was to compare 28 days of SR and RR formulations of ß-alanine (6 g day-1) on changes in carnosine content of the vastus lateralis and muscle fatigue. Thirty-nine recreationally active men and women were assigned to one of the three groups: SR, RR, or placebo (PLA). Participants supplementing with SR and RR formulations increased muscle carnosine content by 50.1% (3.87 mmol kg-1ww) and 37.9% (2.62 mmol kg-1ww), respectively. The change in muscle carnosine content in participants consuming SR was significantly different (p = 0.010) from those consuming PLA, but no significant difference was noted between RR and PLA (p = 0.077). Although participants ingesting SR experienced a 16.4% greater increase in muscle carnosine than RR, fatigue during maximal voluntary isometric contractions was significantly attenuated in both SR and RR compared to PLA (p = 0.002 and 0.024, respectively). Symptoms of paresthesia were significantly more frequent in RR compared to SR, the latter of which did not differ from PLA. Results of this study demonstrated that only participants consuming the SR formulation experienced a significant increase in muscle carnosine. Differences in the muscle carnosine response between these formulations may have practical significance for athletic populations in which small changes may have important implications on performance.

Intradiscal Expandable Balloon Distraction During Transforaminal Decompression for Lumbar Foraminal and Lateral Recess Stenosis.

Advanced videoendoscopic equipment (such as motorized drills, chisels, and rongeurs) facilitates the use of modern decompression tools through the inner working channel of the spinal endoscope using the transforaminal approach. Postoperative dysesthetic leg pain, however, is common because of irritation of the dorsal root ganglion. This article presents a novel surgical technique employing an expandable balloon placed into the hollow intervertebral space in patients without any functional disc tissue to distract the stenotic motion segment. This approach improves visualization, facilitates removal of bone during the decompression, and minimizes intraoperative manipulation of the exiting and traversing nerve roots. In a study of 52 targeted patients with symptomatic spinal stenosis at 60 levels (L2/3-1, L3/4-9, L4/5-28, and L5/S1-22) due to advanced degenerative changes of the intervertebral disc and facet joint complex contributing to both foraminal and lateral recess stenosis, only 2 of the 52 patients complained of postoperative dysesthetic leg pain (3.85%) after undergoing this novel procedure. At the final 2-year follow-up, 80.9% of patients showed Excellent and Good outcomes according to modified Macnab criteria.

Digital Relief of the Mental Foramen for a CAD/CAM-Fabricated Mandibular Denture.

Relief of the intaglio surface of a denture base is conventionally performed using thin wax and soft metal foil attached to the master cast. The following report highlights a new relief procedure for the mental foramen using a CT double scan technique on the CAD/CAM dentures fabricated for the patient with paresthesia of the left lower lip and chin during mastication.

Is 2 mm a safe distance from the inferior alveolar canal to avoid neurosensory complications in implant surgery?

AIM: The aim of the present study was to compare the neurosensory complications related to implants inserted closer than 2 mm to the inferior alveolar canal (IAC) with those inserted further than 2 mm. MATERIALS AND METHODS: A total of 474 implants in 314 patients placed posterior to mental foramen area were evaluated retrospectively on panoramic radiographs. Patients were divided into two groups regarding implant proximity to the IAC (Group 1, distance ≤2 mm, Group 2, distance >2 mm). Postoperative neurosensory complications (pain and paresthesia) were recorded. Chi-square test was used for statistical comparison and P ≤ 0.05 was considered significant. RESULTS: One hundred and fifty-three implants (32.2%) were inserted closer than 2 mm to the IAC whereas 321 implants (67.8%) were inserted further than 2 mm. Three implants which had a distance of 0 mm to the IAC (0.63%) caused paresthesia after surgery. Implant distance to IAC did not show a significant difference regarding pain and paresthesia (P = 0.06 and P = 0.08, respectively). CONCLUSION: When 2 mm is considered as a safety distance, the distance of the implants to the IAC did not yield any statistical difference regarding postoperative neurosensory complications.

[EXPERIENCE OF TOTALLY TRANSCUTANEOUS ENDOPROSTHESIS OF THE INFRARENAL AORTA АNEURYSM].

Endovascular endoprosthesis infrarenal aorta constitutes a miniinvasive highly technological method of treatment of a life-thretening pathology. Experience of transcutaneous endoprosthesis of infrarenal aorta in 6 patients was presented. Possibility of a common femoral artery (CFA) suturing, using Prostar XL apparatus, was estimated on a stage of the endoprosthesis dimensions calculation in accordance to a CT and duplex US scanning data and recommendations of manufacturer. In transcutaneous CFA suturing the complications were absent. Absence of a sectional access to CFA have permitted to avoid such complications, as neuralgia, paresthesia, seroma, suppuration of operative wound. In bilateral suturing of CFA a duration of the patients stationary state have reduced.

Can pregabalin prevent paclitaxel-associated neuropathy?--An ACCRU pilot trial.

PURPOSE: Paclitaxel can cause an acute pain syndrome (P-APS), considered to be an acute form of neuropathy and chronic chemotherapy-induced peripheral neuropathy (CIPN). Anecdotal reports suggested that gabapentin may be helpful in the prevention of these toxicities. The purpose of this pilot study was to obtain data to support or refute the utility of pregabalin for the prevention of P-APS and CIPN. METHODS: Patients scheduled to receive weekly paclitaxel (80 mg/m(2)/dose) were randomized 1:1 to receive pregabalin 75 mg or a placebo, twice daily, during the 12 weeks of chemotherapy. Patients completed the European Organization of Research and Treatment of Cancer Quality of Life (EORTC QLQ) CIPN20 questionnaire at baseline, prior to each dose of paclitaxel and monthly for 6 months post-treatment. Patients completed a post-paclitaxel questionnaire for 6 days after each dose of paclitaxel and an acute pain syndrome symptom questionnaire on day 8. The primary end point was to determine the effect of pregabalin on the maximum of the worst acute pain scores for the week following paclitaxel administration for cycle 1. RESULTS: Forty-six patients were randomly assigned to the treatment or placebo arm. There was no suggestion of a difference between the two study arms with regard to P-APS measures. While there was a suggestion that pregabalin decreased numbness, there was no suggestion that it decreased tingling, pain, or the EORTC QLQ-CIPN20 subscale scores. There were no evident toxicity differences between the two study arms. CONCLUSIONS: The results of this pilot trial do not support that pregabalin is helpful for preventing P-APS or paclitaxel-associated CIPN.

Transverse small skin incision for carotid endarterectomy.

BACKGROUND: The purpose of this report is to determine the feasibility of short transverse skin incision (STI < 4 cm) for eversion (EEA) and patch (PEA) endarterectomy with or without shunt by comparing it with the outcomes after long transverse skin incision (LTI 4-8 cm). METHODS: Of 164 elective consecutive patients (71 ± 2.73% symptomatic) operated at one institution over 24 months, 81 were treated with STI, while 83 patients received LTI. The LTI and STI groups did not differ in terms of age, symptoms, or risk factors. EEA or PEA under locoregional (LRA) or general (GA) anesthesia were performed. RESULTS: STI was associated with shorter operation times (75.19 ± 15.33 vs. 94.87 ± 41 and 99.4 ± 27.36 vs. 132.66 ± 51.32, respectively, P < 0.01) and similar clamping times (26.05 ± 5.71 vs. 26.07 ± 7.14 and 34.04 ± 9.49 vs. 42.5 ± 20.8, respectively) in the EEA and PEA groups that did not receive shunts compared with the corresponding LTI groups, and the operating room stays of the STI patients operated on GA were shorter than that of the corresponding LTI patients (181.11 ± 39.16 vs. 212.5 ± 64, P < 0.001). Nonsignificant differences were found between the corresponding STI and LTI shunt groups. No perioperative deaths occurred. STI was associated with less perioperative complications than LTI. Macroscopically nondistinguishable scar was present in 85% in the STI and 52% in the LTI groups (P < 0.001). Postoperative local irritation and paresthesia occurred similarly in the STI (11%) and LTI (14%) groups. CONCLUSIONS: STIs are feasible for PEA and EEA. STIs produce significantly better cosmetic outcomes and shorter operation times than LTI and have similar rates of complication and similar incidences of local discomfort. Although no neurological consequences of using STIs for PEAs with shunts were revealed, STI should be applied with caution until sufficient patch length and long-term patency of this procedure are demonstrated.

Embryonic NOTES thoracic sympathectomy for palmar hyperhidrosis: results of a novel technique and comparison with the conventional VATS procedure.

BACKGROUND: To avoid the disadvantages of chronic pain and chest wall paresthesia associated with video-assisted thoracic surgery (VATS) procedures, we developed a novel surgical technique for performing sympathectomy by embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) with a flexible endoscope. In this study, we compared the outcomes of E-NOTES with conventional VATS thoracic sympathectomy on palmar hyperhidrosis. METHODS: From January 2010 to April 2011, a total of 66 patients with severe palmar hyperhidrosis were treated with thoracic sympathectomy in our department. Thirty-four transumbilical thoracic sympathectomies were performed via a 5-mm umbilicus incision with ultrathin gastroscope, then compared with 32 conventional needlescopic thoracic sympathectomies. Retrospective statistical analysis of a prospectively collected group of patients was performed. RESULTS: There was no significant difference with regard to gender, mean age, body mass index, and length of hospital stay between the two groups. The operative time for E-NOTES thoracic sympathectomy was longer than that of VATS thoracic sympathectomy (56.4 ± 10.8 vs. 40.3 ± 6.5 min, p < 0.01). No mortality, diaphragmatic hernia, or Horner syndrome was observed in either group. Postoperative questionnaires were returned by all treated patients with a mean time from operation to follow-up of 1.4 ± 0.3 years. All 66 patients receiving sympathectomy reported successful treatment of their palmar hyperhidrosis. Compensatory hyperhidrosis was noticed in 7 (20.1 %) and 6 (18.8 %) patients in the E-NOTES and VATS groups, respectively (p > 0.05). Postoperative pain and paresthesia were significantly reduced in the E-NOTES group at each time interval, and the aesthetic effect of the incision was superior in the E-NOTES group. CONCLUSIONS: Transumbilical-diaphragmatic thoracic sympathectomy is a safe and efficacious alternative to the conventional approach. This novel procedure can further reduce postoperative pain and chest wall paresthesia as well as afford maximum cosmetic benefits by hiding the surgical incision in the umbilicus.

Chloroprocaine 40 mg produces shorter spinal block than articaine 40 mg in day-case knee arthroscopy patients.

BACKGROUND: Articaine and chloroprocaine have recently gained interest as short-acting spinal anaesthetics. Based on previous work comparing articaine 60 mg with chloroprocaine 40 mg, we hypothesised that articaine 40 mg and chloroprocaine 40 mg would produce similar spinal anaesthesa regarding block onset, maximal spread, and recovery. METHODS: In this randomised, double-blind study, adult patients (18-70 years, American Society of Anaesthesiologists physical status I-III, BMI < 36 kg/m(2) ) scheduled for day-case knee arthroscopy received either articaine 40 mg (20 mg/ml) (group A40, n = 16) or chloroprocaine 40 mg (20 mg/ml) (group C40, n = 18) intrathecally. Telephone interviews were performed on the first and seventh postoperative day to disclose possible side effects, e.g. transient neurological symptoms (TNS). RESULTS: The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. Surgery could be performed successfully under spinal anaesthesia except once in A40 (insufficient block) and once in C40 (prolonged surgery). Complete recovery was significantly slower in A40 vs. C40 for both motor block (105 (94/120) vs. 75 (71/90) min) [P < 0.001, Mann-Whitney U-test (MW-U)] and sensory block [135 (109/176) vs. 105 min (90/124)] (P < 0.02, MW-U), respectively [data are median (25th/75th percentiles)]. One patient from A40 showed mild TNS. CONCLUSION: Both A40 and C40 provided mainly adequate spinal anaesthesia for day-case knee arthroscopy. While onset and maximal spread were comparable, the recovery from motor block was clearly faster with chloroprocaine after equivalent doses of spinal articaine and chloroprocaine.

Effect of infrared laser in the prevention and treatment of paresthesia in orthognathic surgery.

Orthognathic surgery is the surgical procedure that makes correcting deformities of the bones in the region of the maxilla and mandible a reality in the Brazilian dentistry. However, this type of surgery usually involves paresthesia in the postoperative period, concerning the surgeons who perform them and generating discomfort to patients. This study aimed at evaluating the effect of infrared laser (830 nm) in the prevention and treatment of paresthesias after orthognathic surgery. Six patients underwent orthognathic surgery: the experimental group composed of 4 patients and the control group that did not receive laser therapy composed of 2 patients. The experimental group received laser applications during the transoperative and 12 postoperative sessions. Tests for mechanical (deep and shallow) and thermal (cold) sensitivity were performed in the preoperative and postoperative period (during 12 sessions) in the lip and chin areas by the same operator. The paresthesia was classified into 1, strong; 2, moderate; 3, mild; and 4, absent, through the patient's response to stimuli. The results showed that all patients had no disturbance of sensitivity in the preoperative period, but paresthesia was presented at various levels in the postoperative period. Both groups showed recovery of deep mechanical sensitivity within a shorter time interval compared with the superficial mechanical and thermal sensitivity. However, at the 12th assessment, patients who underwent the laser therapy showed better reduction in the level of paresthesia or even complete regression of this. The laser, therefore, brought benefits to the treatment of paresthesia, accelerating the return of neurosensorial sensitivity.

Peripheral blood stem cell collection in allogeneic donors: impact of venous access.

BACKGROUND: Peripheral blood stem cell (PBSC) collection is accepted as a routine procedure in related and unrelated healthy donors worldwide. Venous access can be accomplished by peripheral veins or a central venous catheter (CVC). STUDY DESING AND METHODS: We compared efficacy and tolerability of 40 PBSC collections via CVC with 6267 PBSC collections via peripheral veins in healthy allogeneic donors. Results of the leukapheresis procedures and side effects in the donors were evaluated. RESULTS: The median CD34+ cell counts on Day 5 and the results of the stem cell collection were not significantly different between the two groups of allogeneic donors. Pain or problems at the site of puncture or catheter insertion occurred in 58.6% of the donors with a CVC versus 37.8% of the donors with peripheral venous access (p = 0.03). The incidence and severity of paresthesia during the leukapheresis was not significantly different in both groups of donors (p = 0.09). During follow-up no major adverse events related to CVC were reported. CONCLUSION: Central femoral lines proved to be safe and tolerable in healthy allogeneic donors but peripheral venous access should be preferred, whenever possible.

Common nerve decompressions of the upper extremity: reliable exposure using shorter incisions.

UNLABELLED: Considering that several different specialties perform nerve decompressions in the upper extremity, universal technical standards do not exist. Many of these procedures are performed via incisions that are made unnecessarily long to achieve adequate exposure of the nerves and their known anatomical compression points. The purpose of this article is to introduce reproducible techniques that reliably allow the necessary anatomical exposure while minimizing the length of required skin incisions. METHODS: The senior author's surgical approach to the most common nerve compression syndromes of the upper extremity is presented in detail. Typical incision lengths and surgical exposure are demonstrated photographically. The safety of using this technique is examined by review of the medical records of all patients undergoing this procedure from 2003 to 2011, looking for technical complications such as unintentional damage to nerves or adjacent structures. RESULTS: Three hundred twenty consecutive cases were identified in which the described techniques were used to release known anatomical compression points of the upper extremity nerves, including 161 decompressions of the ulnar nerve at the elbow, 37 decompressions of the anterior interosseous nerve and 45 of the posterior interosseous nerve in the proximal forearm, and 77 decompressions of the radial sensory nerve in the distal forearm. Typical incision lengths we used for these procedures were 5 cm for the ulnar nerve, 4.5 cm for the anterior interosseous nerve, 4 cm for the posterior interosseous nerve, and 3 cm for the radial sensory nerve. Review of medical records revealed no incidences of unintentional injury to nerves or adjacent important structures. Functional and neurological recovery outcomes were not assessed, as those would be the subject of subsequent studies. CONCLUSIONS: Known anatomical compression points can be reliably accessed and decompressed for the treatment of all common upper extremity nerve compression syndromes using minimized skin incisions and the techniques presented in this article. With appropriate knowledge of anatomy, this can be performed without expensive equipment or any additional risk of injury to the patient, making classically described longer incisions unnecessarily morbid.

Prospective study of outcome of foramen magnum decompressions in patients with syrinx and non-syrinx associated Chiari malformations.

OBJECTIVE: To assess the outcome in patients with syrinx and non-syrinx associated Chiari malformations undergoing Foramen Magnum Decompression (FMD). METHODS: Sixty-one patients undergoing FMD for Chiari malformations were prospectively studied with disease specific, generic (SF 36) and subjective (patient reported) outcomes. Of these, 34 patients had objective outcome data including SF36, visual analogue pain scores, Neck and Myelopathy disability indices and the Hospital anxiety and depression score. SF 36 scores were compared to normative data. Data were collected pre-operatively, at 3 months and during long-term follow up (12-60 months). RESULTS: Patient reported improvements in headache and neck pain post-operatively was reported in both syrinx and non-syrinx associated patients. Visual Analogue scores showed improvements in arm pain, paresthesia and hand tingling at 3 months in the syrinx group only. Non-syrinx patients showed significant improvements post-operatively in the Neck disability index and the SF-36 domains for physical function, role physical and bodily pain. Comparison with SF-36 normative data indicates that patients still have significantly impaired quality of life 12 months post-operatively. CONCLUSION: FMD is able to relieve symptoms and improve quality of life in patients with both syrinx and non-syrinx associated Chiari malformations. In syrinx patients we observed symptomatic improvement in limb symptoms as well as radiological resolution of the syrinx. The use of SF-36 allows the health gain associated with FMD to be quantified. SF 36 is not adequate as a stand alone measure of outcome in this complex disorder and we advocate the concurrent use of disease specific measures and post-operative imaging of the syrinx.

Use of temporalis fascia as an interpositional arthroplasty in temporomandibular joint ankylosis: analysis of 8 cases.

PURPOSE: Different interpositional materials have been used to prevent recurrence after gap arthroplasty in temporomandibular joint ankylosis. In this study, the versatility of the temporalis fascia as an interpositional arthroplasty was evaluated. MATERIALS AND METHODS: Eight cases of unilateral temporomandibular joint ankylosis were evaluated, with a follow-up of 11 months to 6 years. RESULTS: Patients had a preoperative maximal interincisal opening of 1 to 9 mm (mean, 2.75 mm). During the last follow-up observation after surgery, patients had a maximum interincisal opening of 32 to 40 mm (mean, 36.5 mm). Deviation to the affected side was observed in all cases. Paresthesia or anesthesia of the temporal branch of facial nerve was absent in all cases. Periodic panoramic radiographs showed that the intra-articular space was well maintained because of interposed tissue, without signs of relapse. There were no signs of reankylosis in any patient. CONCLUSION: The findings of this study show that the temporalis fascia is a good alternative for interpositional arthroplasty.

Prevention of development of postoperative dysesthesia in transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation: floating retraction technique.

BACKGROUND: Transforaminal percutaneous endoscopic lumbar discectomy (PELD) has become a routine surgical procedure because it is minimally invasive. Perioperative complications such as dural injury, infection, nerve root irritation and recurrence can occur not only with PELD, but also with conventional open microsurgery. In contrast, post-operative dysesthesia (POD) due to existing dorsal root ganglion (DRG) injury is a unique complication of PELD. When POD occurs, even if the traversing root has been successfully decompressed, it hinders swift recovery and delays the return to daily routines. Thus, prevention of POD is the key to successful and widespread use of PELD. MATERIAL AND METHODS: From January 2006 to December 2008, 154 patients underwent percutaneous endoscopic discectomy by floating retraction technique at 160 disc levels under local anesthesia. This approach towards the superomedial border of the lower pedicle and the cannula can be placed by gentle retraction of the root with perineural fat instead of direct compression of dorsal root ganglion. The clinical outcomes were assessed using the Visual Analogue Scale (VAS, 0-10 point) for radicular pain and low back pain, and using the Oswestry Disability Index (ODI) for functional status. Perioperative complications and recurrence were reviewed. RESULTS: The mean age was 45 years, the mean operative time was 36 min and the mean follow-up period was 3.4 years. The mean hospital stay for endoscopic discectomy was 1.8 days. No patient underwent repeated PELD or convert microsurgery by incomplete removal of the ruptured particle. All patients experienced early relief of symptoms, as determined by VAS and ODI. No patient developed POD. 1 patient experienced dural injury. There was 1 case of discitis. The recurrence rate was 1.95% (3 patients). CONCLUSION: Transforaminal percutaneous endoscopic lumbar discectomy for intracanalicular lumbar disc herniation is a safe and effective procedure. The floating retraction technique is recommended to avoid development of POD.

Assessment of the risk of perforation of the mandibular canal by implant drill using density and thickness parameters.

OBJECTIVE: The objective of this study was to investigate whether the resistance of the bone surrounding the mandibular canal had sufficient density and thickness to avoid perforation by drills when preparing the bed of the implant. BACKGROUND: Damage to the inferior alveolar nerve (IAN) is more common than expected. This injury may lead to serious complications ranging from mild paresthesia to total anaesthesia of the lower jaw. MATERIALS AND METHODS: The CT images of 99 patients, whose ages ranged between 20 and 79years, and who applied for an implant application to the posterior aspect of the mandible were included in this study. RESULTS: The overall average bone thickness in the premolar and molar regions was 0.8717±0.1818 and 0.8556±0.1756mm, respectively, whereas the bone density in the premolar and molar regions was 649.18±241.42 and 584.44±222.73 Hounsfield Units (HU), respectively (p<0.001). CONCLUSION: It was determined that the average density and thickness of the bone that surrounds the mandibular canal was not sufficient to resist the implant drill. It can be concluded that the risk of injury to the IAN may be minimised by accurately determining the bone mass on the canal prior to the implant procedure, and avoiding excessive force when approaching the canal.

A trial to assess the efficacy of glutamic acid in prevention of vincristine-induced neurotoxicity in pediatric malignancies: a pilot study.

Vincristine is considered as a backbone of therapy in the induction and consolidation phases of pediatric malignancies. Neurotoxicity is a principal side effect of its use. This study is a randomized single-blinded placebo-controlled clinical trial to evaluate the role of glutamic acid in ameliorating neurotoxicity in pediatric patients with hematologic and solid tumors receiving vincristine during induction course. Fifty-four patients in the glutamic acid group received glutamic acid 1.5 grams daily orally in 3 divided doses during the 4-week induction with vincristine in a dose of 1.5 mg/m² IV weekly. Placebo group (40 patients) received oral placebo 3 times daily in the same way as the glutamic acid group. The onset of neurotoxicity was significantly earlier in placebo group than in glutamic acid group regarding tendon Achilles reflex, Patellar reflex, parasthesia, and increased frequency of constipation. This was statistically significant mostly in third and fourth visits, no severe cases of strength and mental alteration side effects in both groups. Glutamic acid was well tolerated with no gastrointestinal side effects in patients. This study suggests that the coadministration of oral glutamic acid with repetitive intravenous bolus injections of vincristine resulted in a reduction of its neurotoxicity.

Sensory disturbances associated with serotonin reuptake inhibitors: brief review.

Serotonin reuptake inhibitors (SRIs) are occasionally associated with sensory symptoms, which are one of the less recognized adverse effects. A PUBMED search supplemented with manual search was made to review the relevant literature. Anesthesia, paresthesia, and mastalgia have been reported to occur with this group of medications. The possible pathophysiology and management strategies are discussed.

A novel surgical approach to impacted mandibular third molars to reduce the risk of paresthesia: a case series.

PURPOSE: Extraction of impacted mandibular third molars (M3s) may cause temporary or permanent neurosensorial disturbances of the inferior alveolar nerve (IAN). Although the incidence of this complication is low, a great range of variability has been reported in the literature. Several methods to reduce or eliminate this complication have been proposed, such as orthodontic-assisted extraction, extraction of the second molar, or intentional odontoectomy. The purpose of this series of cases is to present a novel approach for a riskless extraction of impacted mandibular M3s in contact with the IAN. MATERIALS AND METHODS: Nine consecutive patients (4 male and 5 female; mean age 24.9 years, range 18-43 years) required the extraction of 10 horizontally or mesioangular impacted mandibular M3s. In all cases the M3 was in contact with the IAN with a high risk of nerve injury. A staged approached was proposed and accepted by the patients. This approach consisted in the surgical removal of the mesial portion of the anatomic crown to create adequate space for mesial M3 migration. After the migration of the M3 had taken place, the extraction could then be accomplished in a second surgical session minimizing neurological risks. RESULTS: All M3s moved mesially within 6 months (mean 174.1 days, range 92-354 days) and could be successfully removed without any neurological consequences. CONCLUSION: This technique may be considered as an alternative approach to the extraction of horizontally or mesioangular impacted M3s in proximity to the IAN.

The use of cod liver oil by patients receiving pegylated liposomal doxorubicin is associated with a lack of severe palmar-plantar erythrodysesthesia.

Pegylated liposomal doxorubicin (PLD) is an effective and tolerable agent in the treatment of recurrent and refractory ovarian carcinoma. One of the most common dose-limiting toxicities of PLD is palmar-plantar erythrodysesthesia (PPE). We report a retrospective review of patients who took cod liver oil (CLO) while being treated with PLD at Roswell Park Cancer Institute. None of the patients required dose reduction, treatment interruption or discontinuation secondary to skin toxicity. No patient experienced grade 2 or greater PPE. The mechanism for the development of PLD-induced PPE is unknown. CLO may possibly mitigate it via decreased extravasation of PLD and/or by a blunting of the local inflammatory response. The effects of CLO should be further evaluated in a prospective, randomized trial, and attempts to elucidate the mechanism by which CLO may exert its effects should be pursued.