A systematic review of procedural modalities in the treatment of notalgia paresthetica.

BACKGROUND: Notalgia paresthetica (NP) is a rare condition characterized by localized pain and pruritus of the upper back, associated with a distinct area of hyperpigmentation. Given the lack of standardized treatment and the uncertain efficacy of available options, applying procedural methods is of growing interest in treating NP. AIMS: We sought to comprehensively evaluate the role of procedural treatments for NP. METHODS: We systematically searched PubMed/Medline, Ovid Embase, and Web of Science until November 14th, 2023. We also performed a citation search to detect all relevant studies. Original clinical studies published in the English language were included. RESULTS: Out of 243 articles, sixteen studies have reported various procedural modalities, with or without pharmacological components, in treating NP. Pharmacological procedures, including injections of botulinum toxin, lidocaine, and corticosteroids, led to a level of improvement in case reports and case series. However, botulinum toxin did not show acceptable results in a clinical trial. Moreover, non-pharmacological procedures were as follows: physical therapy, exercise therapy, kinesiotherapy, acupuncture and dry needling, electrical muscle stimulation, surgical decompression, and phototherapy. These treatments result in significant symptom control in refractory cases. Physical therapy can be considered a first-line choice or an alternative in refractory cases. CONCLUSION: Procedural modalities are critical in the multidisciplinary approach to NP, especially for patients who are refractory to topical and oral treatments. Procedural modalities include a spectrum of options that can be applied based on the disease's symptoms and severity.

Nitrous Oxide-induced Myeloneuropathy Due to Recreational Abuse.

BACKGROUND: The recreational use of nitrous oxide (N2O) has increased in recent years with a noticeable surge in the incidence of nitrous oxide-related myeloneuropathy. OBJECTIVES: To raise awareness of increasing myeloneuropathy due to recreational nitrous oxide misuse in Israel. METHODS: We conducted a case series documenting the clinical and investigative features of eight patients presenting with nitrous oxide-induced myeloneuropathy who were admitted to our departments. RESULTS: Paresthesia was the chief complaint in all patients, with sensory gait ataxia being a common feature, which was often accompanied by Romberg's sign and mild lower limb weakness. Vitamin B12 levels were below the normal range in seven patients, accompanied by elevated homocysteine and methylmalonic acid levels. Magnetic resonance imaging scans revealed hyperintense signals in the dorsal columns of the cervical spine. All patients improved following vitamin B12 injections. CONCLUSIONS: Enhancing awareness, prompting the use of appropriate investigations, and advocating for timely treatment are needed to overcome the risks associated with nitrous oxide misuse.

Vitamin B12 deficiency and neuropsychiatric symptoms in Lebanon: A cross-sectional study of vegans, vegetarians, and omnivores.

BACKGROUND: Vitamin B12 deficiency is responsible for a variety of complications, particularly neurological/neuropsychiatric complications, including depression, irritability, paresthesia and insomnia. Since vitamin B12 is found in animal-derived products, vegans/vegetarians are at a greater risk for developing vitamin B12 deficiency. AIMS: This study aims to investigate the occurrence of vitamin B12 deficiency among a sample of adult Lebanese population, with a particular emphasis on assessing the severity of its neurological/neuropsychiatric signs and symptoms, especially among vegans/vegetarians. METHODOLOGY: A cross-sectional study was conducted among a sample of 483 Lebanese adults. Data was collected through a standardized questionnaire that included socio-demographic characteristics, the Patient Health Questionnaire-9 (PHQ-9), Generalized anxiety disorders-7 (GAD-7), and the Insomnia Severity Index (ISI) scales. RESULTS: Among the participants, 11.4% were in the vegan/vegetarian group, and about 43.1% had vitamin B12 deficiency. After analyzing the PHQ-9, GAD-7 and ISI total scores, higher scores were reported in participants with vitamin B12 deficiency, compared to individuals with normal vitamin B12 serum levels (p < 0.001). Regarding the diet type, vegans/vegetarians were more susceptible to developing depression compared to omnivores (mean scores of 11.92 vs 8.02 on the PHQ-9 scale, respectively, with p < 0.001). Of the patients with vitamin B12 deficiency, 81.1% reported having paresthesia compared to 43.7% of individuals with no vitamin B12 deficiency (p < 0.001). CONCLUSION: Vitamin B12 deficiency in Lebanon is notably high and is linked to an increased risk of developing depression, generalized anxiety disorder, insomnia, and paresthesia. Vegans/vegetarians exhibit a higher susceptibility to developing depression compared to omnivores, whereas the risk of developing insomnia, generalized anxiety disorder and paresthesia was statistically insignificant when comparing vegans/vegetarians to omnivores.

Perioral Paresthesia, Generalize Muscle Cramps, and Rhabdomyolysis After a Socotra Island Blue Baboon Tarantula (Monocentropus Balfouri) Bite.

BACKGROUND: Literature on systemic envenomation caused by tarantula bites, particularly from the Theraphosidae family, is relatively scarce. This case report provides a formal description of the first known instance of systemic envenomation caused by the Socotra Island Blue Baboon Tarantula (Monocentropus balfouri). CASE REPORT: In this case, a 23-year-old employee of an exotic pet shop suffered from perioral paresthesia, generalized muscle cramps, and rhabdomyolysis because of a Monocentropus balfouri bite. His symptoms were successfully relieved with oral benzodiazepines. EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the potential for serious complications resulting from the bite of Monocentropus balfouri, a species gaining popularity among global exotic pet collectors.

Adjunctive Effect of Photobiomodulation Therapy with Nd:YAG Laser in the Treatment of Inferior Alveolar Nerve Paresthesia.

Background: Disruption of peripheral branches of the trigeminal nerve in the field of maxillofacial surgery is a known risk due to the close connection of these branches with the bony structures of the maxilla and mandible. As a result, injuries of the lingual nerve and inferior alveolar nerve take place within routine maxillofacial surgery procedures, including local anesthetic injection, wisdom tooth surgery, and dental implant placement, resulting in paresthesia and dysesthesia. During the last three decades, low-level lasers (LLL) have been frequently used in various medical fields. Lately, this application has increased in several sectors. Methods and materials: This experiment was designed to explore the effect of low-level laser therapy (LLLT) with Nd:YAG on the paresthesia and dysesthesia of the lower lip. This ethics committee of Tbzmed, Tabriz, Iran, proved the present experiment with ethical code: IR.TBZMED.REC.1401.839. Results: After completing 10 sessions of laser therapy for the case group consisting of 25 patients with lower lip anesthesia, the visual analog scale index results revealed that following six sessions of laser therapy, a significant difference appeared in contrast to the control group. Also, according to the two-point tests, significant difference among the experimental and the control group appeared after ninth session of the laser therapy. Conclusions: Altogether, these data suggested LLLT with Nd:YAG as an effective treatment option for decreasing the anesthesia of the lower lip.

Lazertinib as a frontline treatment in patients with EGFR-mutated advanced non-small cell lung cancer: Long-term follow-up results from LASER201.

OBJECTIVE: This analysis of the first-line cohort of LASER201 study evaluated the efficacy and safety of lazertinib 240 mg as a frontline therapy for epidermal growth factor receptor (EGFR)-mutated locally advanced or metastatic non-small cell lung cancer (NSCLC). METHODS: A total of 43 patients, with EGFR mutation-positive (Exon19Del, n = 24; L858R, n = 18; G719X, n = 1) locally advanced or metastatic NSCLC who had not previously received EGFR tyrosine kinase inhibitor (EGFR TKI) therapy, received once-daily lazertinib 240 mg. EGFR mutation status was confirmed by local or central testing. The primary endpoint was objective response rate (ORR) assessed by blinded independent central review. Secondary efficacy endpoints included duration of response (DoR), disease control rate (DCR), progression-free survival (PFS), tumor shrinkage, and overall survival (OS). RESULTS: At the primary data cut-off (DCO; January 8, 2021), the ORR was 70 % (95 % confidence interval [CI]: 56.0-83.5), DCR was 86 % (95 % CI: 75.7-96.4) and the median DoR was 23.5 (95 % CI: 12.5-not reached) months. The median PFS was 24.6 (95 % CI: 12.2-30.2) months. At the final DCO (March 30, 2023), the median OS was not estimable and the median follow-up duration for OS was 55.2 [95 % CI: 22.8-55.7] months. OS rates at 36 months and 54 months were 66 % (95 % CI: 47.5-79.3 %) and 55 % (95 % CI: 36.6-70.7 %), respectively. The most commonly reported TEAEs were rash (54 %), diarrhea (47 %), pruritus (35 %), and paresthesia (35 %). No drug-related rash or pruritus TEAEs of grade 3 or higher were reported. Diarrhea and paresthesia of grade 3 or higher were reported in 3 (7 %) and 1 (2 %) patients, respectively. CONCLUSION: This analysis demonstrated long-term clinical benefit with lazertinib 240 mg in patients with EGFR-mutated NSCLC who had not previously received EGFR TKIs. The safety profile for lazertinib was tolerable and consistent with that previously reported.

Coronectomy of impacted mandibular third molars: a clinical and radiological retrospective case series study with 2-9 years of follow-up / Coronectomía de terceros molares mandibulares impactados: un estudio de serie de casos retrospectivo clínico y radiológico con 2-9 años de seguimiento

Background: Impacted mandibular third molars occasionally are in intimate relation to the inferior alveolar nerve (IAN). Coronectomy has been proposed as a good alternative to prevent injury of the IAN. The present study evaluates the clinical and radiological outcomes of impacted mandibular third molars presenting radiographic signs associated with a high risk of IAN injury, and which were treated with the coronectomy technique. Material and Methods: A retrospective case series evaluated the outcomes of coronectomies of impacted mandibular third molars. The inclusion criteria were: available preoperative, immediate postoperative and two-year panoramic radiographs, preoperative cone-beam computed tomography (CBCT), and a complete case history. The clinical evaluation comprised intraoperative complications (mobilized fragments of root and damage to adjacent structures), short-term complications (sensory alterations and postoperative infection), and long-term complications (infection or oral exposure). The IAN position with respect to the roots, root shape, eruption status, third molar position, radicular-complex migration and bone above roots were radiographically evaluated as well. Results: Approximately a total of 2000 mandibular third molars were removed from 2011 to 2022. Of these, 39 molars in 34 patients were partially extracted using the coronectomy technique. The mean age was 36 years (range 22-77), and the mean follow-up was 28 months (range 24-84). There were two short-term postoperative infections. One of them was resolved through reintervention to remove the roots after antibiotic treatment, while the other required hospital admission and removal of the roots. One case of short-term transient lingual paresthesia was also recorded. Two long-term oral exposures were detected, and the root fragments had to be extracted. There were no permanent sensory alterations...(AU)

Preservation of the inferior alveolar vasculonervous bundle in mandibular resective therapies: systematic review and report of two cases

Background: Segmental surgical resection is a frequently indicated procedure to treat aggressive mandibular tumors. One of the most important complications derived from this technique is permanent paresthesia of the inferior alveolar nerve (IAN), which significantly affects the quality of life of patients who experience it. This could be avoided through maneuvers that preserve the IAN. The objective of this paper is to review the main techniques for IAN preservation and to present 2 cases with the technique used by the author. Material and Methods: A systematic review was performed according to the PRISMA guidelines, apropos of two clinical cases reported in this study. The MEDLINE/PubMed and Scopus databases were searched. Several variables were considered and are presented in detail in the form of tables and figures. In addition, 2 case reports with NAI preservation techniques are presented. Results: 13 articles were finally obtained for analysis. 127 patients were evaluated, reporting mandibular resections associated with various pathologies. Various surgical techniques were used, all with the same goal of maintaining the IAN. In most of the patients, the maintenance of sensitivity was achieved, which was verified with different methods. Conclusions: Preservation of the IAN in maxillofacial surgical procedures where surgical resection of the mandibular bone has been performed is an alternative that has demonstrated successful results in terms of reducing postoperative sequelae and is currently positioned as a necessary and feasible procedure. (AU)

Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis.

BACKGROUND: Female sex has been associated with worse outcomes after groin hernia repair (GHR), including a higher rate of chronic pain and recurrence. Most of the studies in GHR are performed in males, and the recommendations for females extrapolate from these studies, even though females have anatomy intricacies. The round ligament of the uterus (RLU) is associated with pelvic stabilization and plays a role in sensory function. Transection of the RLU during GHR is controversial as it can allow easier mesh placement but can favor genitourinary complications and chronic pain. As no previous meta-analysis compared preserving versus transecting the RLU during minimally invasive (MIS) GHR, we aim to perform a systematic review and meta-analysis evaluating surgical outcomes comparing the approaches. METHODS: Cochrane Central, Embase, and PubMed databases were systematically searched for studies comparing transection versus preservation of the RLU in MIS groin hernia surgeries. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, chronic pain, paresthesia, recurrence rates, and genital prolapse rates. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics. A review protocol for this meta-analysis was registered at PROSPERO (CRD 42023467146). RESULTS: 1738 studies were screened. A total of six studies, comprising 1131 women, were included, of whom 652 (57.6%) had preservation of the RLU during MIS groin hernia repair. We found no statistical difference regarding chronic pain, paresthesia, recurrence rates, and postoperative complications. We found a longer operative time for the preservation group (MD 6.84 min; 95% CI 3.0-10.68; P = 0.0005; I2 = 74%). CONCLUSION: Transecting the RLU reduces the operative time during MIS GHR with no difference regarding postoperative complication rates. Although transection appears safe, further prospective randomized studies with long-term follow-up and patient-reported outcomes are necessary to define the optimal management of RLU during MIS GHR.

Oral dysaesthesia: a special focus on aetiopathogenesis, clinical diagnostics and treatment modalities.

Oral dysaesthesia is a condition characterised by persistent alteration to oral sensation, perceived by the patient to be abnormal and/or unpleasant, in the absence of any mucosal pathology. The condition can be difficult to detect and diagnose. A possible peripheral or central neuropathic aetiology has been proposed. Burning mouth syndrome (BMS) is the most common idiopathic oral dysesthesia in which long-term suffering is often reported by patients. Recent efforts from professional organisations and study groups have provided a consensus on BMS disease definition and diagnostic criteria. Large-scale epidemiological studies are required to provide an accurate estimate for prevalence and incidence of the condition. Meticulous diagnostic investigations which may require interdisciplinary teamwork are often warranted to reach an accurate diagnosis. A combination of interventional modalities, with a holistic approach, is key for successful management and improvement in patients' quality of life.

Burning mouth in oncology care: a systematic review.

Burning mouth, also referred to as oral dysesthesia, is an underreported condition among cancer patients that may represent an early symptom of cancer or an adverse effect of treatment. This review sought to characterize this symptom in oncology care where burning symptoms may occur. A systematic review of the literature was performed based on the PRISMA statement, and the protocol was registered at PROSPERO database. A structured search was done using eight databases. The process of study selection was conducted in two distinct phases. The JBI Critical Appraisal Tools were utilized to evaluate the risk of bias in the studies included. Of the total number of studies assessed, sixteen met the eligibility criteria. Of these studies included, 7 were case reports, 7 cross-sectional studies, and 2 non-randomized clinical trials. Most studies presented low risk of bias (n = 9), while the remaining studies were evaluated and scored as moderate (n = 5) or high (n = 2) risk of bias. Burning mouth was reported as a first symptom of cancer in three studies, and as an adverse event of radiotherapy (n = 2), chemoradiotherapy (n = 2), and chemotherapy (n = 9). Burning mouth was a first symptom in 0.62% of oral squamous cell carcinoma (OSCC), and 3.3% of patients with pain as chief complaint. Oral dysesthesia prevalence was 13.6% in patients experiencing chemotherapy-induced oral adverse events. The symptom of burning mouth should be examined in oncology care, as it may be underreported and therefore undertreated. New therapies may be related to a higher risk of oral burning and studies assessing approach to management are needed. Current management borrows from the current management of burning mouth in the non-cancer setting.

Sun pain and solar dysesthesia: A new challenge in clinical practice.

BACKGROUND: A few patients report intense pain and other unpleasant sensations, such as burning, dysesthesia and hyperalgesia, after even brief exposure to the sun and in the absence of any skin lesion. Sometimes they also develop systemic symptoms, such as mild fever, fatigue, faintness and fainting. As a result, these patients carefully avoid even short-term sun exposure with a consequent severe negative impact on their lives. METHODS: We have reviewed the clinical findings and the results of photobiological investigations of 10 patients who presented this clinical picture. Six of these patients were previously described by our group with the diagnosis of sun pain. We have reviewed the similarities with other previously described disorders such as solar dysesthesia and PUVA pain and have evaluated possible pathogenetic mechanisms. RESULTS: During phototesting our patients experienced intense pain in the exposed area and in the surrounding skin, without any visible lesion, even with very low sub-erythemal doses. At follow-up, five patients were diagnosed with fibromyalgia, three with a major depressive disorder, one with bipolar syndrome and one with a conversion disorder. The pathogenesis remains unclear, but the use of a psychopharmacological treatment with antidepressants improved both the neuropsychiatric symptoms and sensitivity to the sun in most subjects. CONCLUSION: For patients with pain and other severe symptoms in the absence of skin lesions and clinical and laboratory manifestations of known photodermatoses, a neuropsychiatric evaluation should be suggested.

Does high-frequency stimulation of sensory axons break the causal link between pain relief and paresthesia?

Neurostimulation produces unnatural cutaneous sensations with potent analgesic effects in pain syndromes. In this issue of Neuron, Sagalajev et al.1 demonstrate that these sensations are an epiphenomenon and explain how high-frequency stimulation can provide analgesia without these unnecessary sensations.

Weekly hair washing: The recommended solution for women with afro-textured hair to alleviate dandruff and scalp discomfort.

Dandruff and scalp discomfort are common concerns for women and men in Africa. Moreover, women with afro-textured hair are prone to scalp discomfort owing to irregular hair washing, frequent use of oil-based products on their scalp, and harsh chemical treatments. Current literature does not, however, provide data on the pathophysiological mechanisms of these conditions in this population. In this study, we investigated the mechanisms behind scalp discomfort and dandruff in women of African descent before and after hair washing. We conducted the in Durban, South Africa, over a 3-week period with 60 women of African descent aged 20-40 years. The respondents were equally divided into a "dandruff" and a "no dandruff" group, based on clinical grading of adherent dandruff by a dermatologist. Malassezia spp. and bacterial loads were quantified by quantitative polymerase chain reaction. Evaluations of scalp condition and sample collection were performed at five time points during the 3 weeks. Data on discomfort symptoms were collected via a self-assessment questionnaire. We observed that the dandruff severity peaked at the end of the first week after hair washing and plateaued from thereon in both groups. Dandruff was associated with higher Malassezia and bacterial load counts and there was a direct correlation between the Malassezia spp. load and dandruff score. Via self-assessment questionnaire responses submitted by participants, we observed that itching was the most pronounced scalp discomfort, compared with the sensation of tingling and burning at baseline, while an improvement of the scalp symptoms of dandruff and itch was observed in both groups after one hair wash. The study also showed that higher colonization with Malassezia spp. and bacteria is associated with dandruff independently of the time point, confirming a scalp microbiome contribution to the dandruff pathophysiology in the study population. The benefits of washing were, however, not sustained after 1 week and we thus recommend weekly hair washing for long-term management of dandruff and scalp itchiness in this population.

Investigation of the efficacy of two different laser types in the treatment of lower lip paresthesia after sagittal split ramus osteotomy.

Orthognathic surgery involves invasive and major surgical procedures commonly used to correct maxillofacial deformities. Bilateral sagittal split ramus osteotomy (BSSO) is often used to treat dentofacial anomalies related to the mandible, but it can result in various complications, the most common of which is inferior alveolar nerve damage. Nerve damage-induced paresthesia of the lower lip significantly affects patient comfort. Medical treatments such as steroids and vitamin B, low-level laser therapy (LLLT), and platelet-rich fibrin (PRF) can be used as supportive therapies for nerve regeneration after damage. This study aimed to investigate the effectiveness of two different types of lasers in treating lower lip paresthesia after BSSO. This clinical trial was a controlled, single-center, prospective, single-blind, randomized study. Thirty patients were included in the study and randomly assigned to three groups: Group I (laser GRR, n = 10) received transcutaneous and transmucosal GRR laser treatment, Group II (Epic10 laser, n = 10) received transmucosal and transcutaneous Epic10 laser treatment, and Group III (vitamin B, n = 10) received B-complex vitamin tablets orally once a day. Two-point and brush tests were performed six times at specific intervals, and a visual analog scale was used to evaluate pain and sensitivity. Both vitamin B and laser therapies accelerated nerve regeneration. The contribution of the laser groups to the healing rate was better than that of the vitamin B group. Although there was no statistically significant difference between the two laser groups, clinical observations indicated better results in the GRR laser group.

A Case Report on an Unusual Presentation of Pernicious Anemia.

Pernicious anemia is an autoimmune disease leading to impaired absorption of dietary cobalamin. Patients with pernicious anemia can present with multiple hematological, neurological and gastrointestinal complaints. Herein, we have a case of pernicious anemia presenting with alternating bowel habit. This was challenging and unique as the patient didn't have any usual condition responsible for alternating bowel habit and it is not reported in cases of pernicious anemia either. The case is a 46-year-old male who was admitted with alternating bowel habit, paresthesia and fever for the last 6 months. Patient was found to be severely anemic. After full workup, he was diagnosed with pernicious anemia. The patient was treated with IM Injections of Vitamin B12. After 3 months of discharge, the patient was free of all the symptoms. This case emphasizes the importance of investigating anemic patients with alternating bowel habit for pernicious anemia and also the need to exclude other causes of this symptom before labeling it as pernicious anemia only.

Home-based high tone therapy may alleviate chemotherapy-induced neuropathic symptoms in patients with colorectal cancer: A randomized double-blind placebo-controlled pilot evaluation.

BACKGROUND: Most oncologic patients receiving chemotherapy suffer from neuropathy, which not only severely affects quality of life but also may lead to chemotherapy dose reductions or even discontinuation of cancer therapy. Still, it is difficult to sufficiently control these symptoms with the currently available pharmacological treatments. High tone therapy was reported to be an effective option for neuropathies due to different etiologies. However, to date, there are no studies on high tone therapy in patients with chemotherapy-induced peripheral neuropathy. METHODS: This randomized, double-blind, and placebo-controlled two-center study was conducted at the Departments of Physical and Rehabilitation Medicine at the Clinics Donaustadt and Ottakring, Vienna, Austria. Patients with histologically verified colorectal carcinoma treated with a platin derivate and neuropathic symptoms were invited to participate. High tone therapy took place in a home-based setting using the HiToP 191 PNP ® or placebo device for three weeks. Neuropathic symptoms and quality of life were assessed via questionnaires. After the follow-up examination, an opt-in was offered to the patients in the placebo group in terms of an open-label treatment with a verum HiToP PNP ® device. In addition, patients with chemotherapy-induced peripheral neuropathy due to various malignant diseases were treated in an open-label setting reflecting a clinical application observation. These patients are reported as a separate group. RESULTS: In the verum group, there was a significant reduction of paresthesias and mental stress due to paresthesias from baseline until end of therapy, compared to placebo. These findings were observed in the opt-in subgroup, as well. In the open-label clinical application observation group, intensity and mental stress due to paresthesia, pain, cramps, and intensity of tightness/pressure were significantly lower at the end of therapy, compared to baseline. CONCLUSIONS: Home-based high tone therapy brought about a significant alleviation in paresthesias and mental stress due to paresthesias in the verum but not the placebo group. In the clinical application observation, a significant alleviation in several further neuropathic symptoms was seen. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov (NCT06048471, 03/02/2020).

Not a Laughing Matter: When Nitrous Oxide Causes Functional Vitamin B12 Deficiency.

Subacute combined degeneration (SCD) is an acquired neurologic complication from prolonged vitamin B12 deficiency. As a result of dorsal and lateral spinal cord column degeneration, patients present with a range of neurological symptoms, including paresthesias, ataxia, and muscle weakness. Without prompt treatment, irreversible nerve damage occurs. Here we present a young man who developed progressive ascending paresthesias and lower extremity weakness after escalated nitrous oxide use. This case highlights the importance of considering SCD from nitrous oxide toxicity when patients present with progressive ataxia, paresthesia, and lower extremity weakness.