High-resolution ultrasound in the diagnosis of failed carpal tunnel decompression: a study of 35 cases.

We used high-resolution ultrasound to examine 35 median nerves (35 patients) with failed carpal tunnel decompression to identify the cause of failure. The carpal tunnel was examined before revision surgery, and the results were correlated with surgical findings. The cross-sectional area was measured, and nerve morphology was analysed at the sites of compression. We found persistent median nerve compression in 30 out of 35 patients. In 20 patients, the compression was caused by a residual transverse carpal ligament, in four by perineural fibrosis, in five by both of these causes and in one by tenosynovitis. In four patients, evidence of median nerve injury with an epineural/fascicular lesion was detected; and in one, no abnormalities were found. Surgical findings were consistent with the ultrasound findings except in one patient where tenosynovitis was associated with a giant cell tumour, which was missed by ultrasound. High-resolution ultrasound can provide helpful information in preoperative diagnosis of failed carpal tunnel decompression with good correlation between the ultrasound and surgical findings.Level of evidence: IV.

Actinomyces and MRONJ: A retrospective study and a literature review.

The AAOMS in 2014 changed from BRONJ to the term Medication-Related Osteonecrosis of the Jaw (MRONJ), because of the growing number of osteonecrosis cases associated with other antiresorptive and antiangiogenic therapies. Even if the drugs involved are different, the histopathological findings are the same. Colonies of Actinomyces are encountered in most cases. The aim of the present study is to report on Actinomyces prevalence among the cases of MRONJ, taking into consideration also antiresorptive and antiangiogenic therapies in the literature and in our sample between 2005 and 2020. The review was performed using the database Medline the linkage between Actinomyces infection and MRONJ. The retrospective study was conducted on patients between with clinical and radiological manifestations of MRONJ May 2005 and February 2020. A total of 42 articles were found, 30 publications have been taken into consideration for the review. A total of 114 patients have been examined at the Padua Hospital. A total of 101 oncological patients presented the histological confirmation of MRONJ. 83 specimens revealed the presence of Actinomyces infection (82.18%). Actinomyces-associated lesions are frequent and present a wide spectrum of clinical manifestation.

Sustained response to subcutaneous immunoglobulins in chronic ataxic neuropathy with anti-disialosyl IgM antibodies (CANDA): report of two cases and review of the literature.

INTRODUCTION: Chronic ataxic neuropathy with anti-disialosyl IgM antibodies (CANDA) is a rare disorder for which the pathological, neurophysiological, and therapeutic evidence remains anecdotal and controversial. METHODS: This report on CANDA focuses on the neurophysiological patterns and treatment responses shared by two cases. One patient underwent nerve ultrasound follow-up. A comprehensive review of the literature highlighted the diverse experiences with different treatment options. RESULTS: Response to different therapies was similar in both patients: intravenous immunoglobulins achieved a favorable response albeit with significant wearing-off fluctuations; treatment with subcutaneous immunoglobulins (SCIg) was an effective alternative leading to a clinical response for at least 2 years. Rituximab, which was trialed in both patients, was not continued long enough to determine its efficacy in modifying the disease course and/or modulating responsiveness to immunoglobulins. Steroids caused clinical worsening in both patients. CONCLUSIONS: Immunoglobulin therapy appeared as the most effective in the treatment of these two patients. SCIg provided an effective treatment option for the long-term management of CANDA.

Modified Dental Anxiety Scale: validation of the Italian version.

AIM: Anxiety is a relevant problem in dental practice. The Modified Dental Anxiety Scale (MDAS) is a brief, simple questionnaire consisting of five questions with a total score ranging from 5 to 25, the Italian version of which is not available yet. The aim of the study was to provide an Italian version of the MDAS and check its reliability in oral surgery, which is a major cause of dental anxiety due to the expected perception of pain and suffering. METHODS: The Italian version of the test was administered to 230 patients (98 male and 132 female patients, ages 14-88 years) undergoing oral surgery. Further recorded data were: American Society of Anaesthesiologists physical status classification (ASA-PS), frequency of visiting the dentist and any previous distressing experiences in dental or medical setting. RESULTS: The internal consistency of the test was high, with a Cronbach's alpha=0.92. The MDAS score was significantly higher in females (P<0.0001) and in patients with previous distressing experiences in medical and/or dental settings (P<0.0001); the correlation with age (P=0.01) and frequency on visiting the dentist (P=0.02) were also significant. CONCLUSIONS: The patients' selection (oral surgery only) may be a limit of the study, which might not provide an estimation of anxiety prevalence in the general dental population; however our result agree with those of studies performed in other Countries in the generic population, suggesting the absence of major differences with respect to the surgical setting and show the reliability and manageability of the Italian version of MDAS.

Modified dental anxiety scale: validation of the italian version.

AIM: Anxiety is a relevant problem in dental practice. The Modified Dental Anxiety Scale (MDAS) is a brief, simple questionnaire consisting of five questions with a total score ranging from 5 to 25, the Italian version of which is not available yet. The aim of the study was to provide an Italian version of the MDAS and check its reliability in oral surgery, which is a major cause of dental anxiety due to the expected perception of pain and suffering. METHODS: The Italian version of the test was administered to 230 patients (98 male and 132 female patients, ages 14-88 years) undergoing oral surgery. Further recorded data were: American Society of Anaesthesiologists physical status classification (ASA-PS), frequency of visiting the dentist and any previous distressing experiences in dental or medical setting. RESULTS: The internal consistency of the test was high, with a Cronbach's alpha=0.92. The MDAS score was significantly higher in females (p<0.0001) and in patients with previous distressing experiences in medical and/or dental settings (p<0.0001); the correlation with age (p=0.01) and frequency on visiting the dentist (p=0.02) were also significant. CONCLUSIONS: The patients' selection (oral surgery only) may be a limit of the study, which might not provide an estimation of anxiety prevalence in the general dental population; however our result agree with those of studies performed in other Countries in the generic population, suggesting the absence of major differences with respect to the surgical setting and show the reliability and manageability of the Italian version of MDAS.

Rhinorrhea triggered by obturator prosthesis after surgical intervention of partial maxillary resection: a clinical report.

This clinical report describes a case of rhinorrhea that arose after surgical intervention of partial maxillary resection and obturator prosthesis positioning. Ultimately, the diagnosis was that rhinorrhea was induced by mechanical irritation of the nasal mucosa determined by the nasal part of the obturator prosthesis. The differential diagnosis of nasal irritation, vasomotor rhinitis, gustatory rhinorrhea are presented and discussed, as well as the technical notes and measures taken to reach the final diagnosis and a satisfactory functional and aesthetic result for the patient.

Conscious sedation with diazepam and midazolam for dental patient: priority to diazepam.

AIM: The aim of this paper was to determine whether the use of midazolam is a better technique than the use of diazepam, in relation with the definition of conscious sedation in dentistry. METHODS: Eighty-eight patients undergoing oral surgery were divided into 2 groups in which the sedation was randomly achieved with equipotent cumulative doses of diazepam and midazolam, up to a maximum dose of 8 and 4 mg respectively. Patient's tranquillity was assessed after every dose, using a visual analogue score to ten points and the sedation was evaluated as mild, moderate or deep. Blood pressure, heart rate and SpO2 were also recorded. Psychomotor conditions, by Newman test, and the incidence of amnesia and the patient's satisfaction, by telephone interview, were both evaluated. RESULTS: The number of patients who reached maximum subjective tranquillity was greater already after the third dose of diazepam. The average scores of tranquillity were higher after diazepam. Patients treated with diazepam experienced a higher incidence of mild sedation, patients treated with midazolam a higher incidence of moderate and deep sedation. In patients treated with midazolam blood pressure, heart rate and SpO2 were lower. Postoperative recovery was similar in the 2 groups. After midazolam patients experienced greater amnesia for local anesthesia and drowsiness. Satisfaction was high with both treatments. CONCLUSION: The study shows that sedation with diazepam is more in line with the definition of conscious sedation in dentistry. Diazepam guarantees the persistence of consciousness and maximum subjective tranquillity levels. The recovery and satisfaction were comparable in the 2 groups.

Hypnosis as sole anaesthesia for skin tumour removal in a patient with multiple chemical sensitivity.

A female patient with multiple chemical sensitivity and previous anaphylactoid reactions to local anaesthetics was admitted for removal of a thigh skin tumour under hypnosis as sole anaesthesia. The hypnotic protocol included hypnotic focused analgesia and a pre-operative pain threshold test. After inducing hypnosis, a wide excision was performed, preserving the deep fascia, and the tumour was removed; the patient's heart rate and blood pressure did not increase during the procedure. When the patient was de-hypnotised, she reported no pain and was discharged immediately. Our case confirms the efficacy of hypnosis and demonstrates that it may be valuable as a sole anaesthetic method in selected cases. Hypnosis can prevent pain perception and surgical stress as a whole, comparing well with anaesthetic drugs.

Validation of visual analogue scale for anxiety (VAS-A) in preanesthesia evaluation.

BACKGROUND: Anxiety is a relevant but still underscored perioperative problem. The Visual Analogue Scale for Anxiety (VAS-A) seems to be effective, fast and manageable, but has not been fully validated yet. The aim of this study is to validate VAS-A comparing it to, Corah's Dental Anxiety Scale (CDAS) Spielberger's State Trait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI). METHODS: One hundred consecutive patients (38 males and 62 females, median age 49 years) submitted to oral surgery filled out the VAS-A, CDAS, STAI forms Y1 and Y2, and BDI at preoperative examination; the order of administration of tests was randomized. RESULTS: VAS-A score was significantly correlated to CDAS (P<0.0001), STAI-Y1 (P<0.0001), STAI-Y2 (P<0.002) but not to BDI (P=0.18). ROC curve analysis suggested VAS-A equal to 46 mm as threshold for anxiety when using STAI Y1 equal to 40 as reference cutoff. CONCLUSION: Our study confirms that VAS-A is a reliable indicator of preoperative anxiety and may detect patients with depressive symptoms also. Values of VAS-A around 50 mm are a reliable threshold for a clinically meaningful level of preoperative anxiety.

Acupuncture versus valproic acid in the prophylaxis of migraine without aura: a prospective controlled study.

BACKGROUND: The pharmacologic treatment of migraine still remains below the expectations. The aim of this study is to compare the effectiveness of traditional acupuncture and valproic acid in migraine prophylaxis. METHODS: A prospective, controlled study was performed in 100 patients affected by migraine without aura lasting for over one year. The patients were stratified for sex and randomly divided into two groups of 50 patients each. Patients belonging to Group A (acupuncture) were submitted to 20 sessions of acupuncture, while patients belonging to Group V valproate) were administered Valproic acid (Depakin Chrono®) at a dose of 600 mg/day; 10 mg Rizatriptan wafers were allowed as needed to treat the attacks. The Midas Index (MI) and pain intensity (PI, by VAS) were recorded before treatment (T0), at three (T1) and six (T2) months; a six-point scale Pain Relief score (PRS), the Rizatriptan intake and adverse events were recorded at T1 and T2. RESULTS: Eighty-two out of 100 patients completed the study (9 dropouts in each group). In both groups the MI improved at T1 and T2 (P<0.0001). Pain intensity was better at T1 in group V (P<0.0001), but PI and PRS (P=0.02) as well as rizatriptan intake (P=0.001) were better in group A at T2. The rate of adverse events was 47.8% in group V and 0% in group A. CONCLUSION: Our data show a lower pain intensity and lower Rizatriptan intake at six-months follow-up with no adverse events in acupuncture patients compared to those treated with valproic acid.

Comparison by means of bispectral index score, between anxiolysis induced by diazepam and sedation induced by midazolam.

AIM: Bispectral Index Score (BIS) is an objective tool to assess sedation depth. Benzodiazepines have different pharmacological profiles and diazepam may be safer than midazolam in this setting. The aim of this study was to compare BIS values observed during anxiolysis after diazepam versus sedation after midazolam. METHODS: Thirty-six patients were randomly assigned to 3 groups: group 1 was treated with i.v. diazepam, groups 2 and 3 with iv midazolam 1 and 3 mg, respectively. Sedation was monitored clinically and by means of BIS. BIS values were evaluated as area under the curve (AUC) and compared by variance analysis. The statistical comparison of other data was performed by variance analysis or, alternatively, the χ2 according to Yates. The statistical significance was indicated by P values <0.05. RESULTS: AUC values were significantly lower after midazolam when compared to AUC values registered in diazepam treated patients; 22.6% of the group 3 patients showed BIS values <80, versus 0.4% of group 1 patients. CONCLUSION: Diazepam has a safer profile, with BIS values and clinical conditions according to the definition of minimal and/or moderate sedation. Diazepam represents the safer drug for anxiety management in dentistry, because regularly produces a state of sedation during which verbal contact with the patient is maintained and carry a margin of safety wide enough to render loss of consciousness unlikely.

Toward the validation of visual analogue scale for anxiety.

Anxiety is a relevant problem in dental practice. The Visual Analogue Scale for Anxiety (VAS-A), introduced in dentistry in 1988, has not yet been validated in large series. The aim of this study is to check VAS-A effectiveness in more than 1000 patients submitted to implantology. The VAS-A and the Dental Anxiety Scale (DAS) were administered preoperatively to 1114 patients (459 males and 655 females, age 54.7 ± 13.1 years). Statistical analysis was conducted with Pearson correlation coefficient, the receiver operating characteristic (ROC) curve, and McNemar tests. A close correlation between DAS and VAS-A was found (r  =  0.57, P < .0001); the VAS-A thresholds of dental anxiety and phobia were 5.1 and 7.0 cm, respectively. Despite a significant concordance of tests in 800 cases (72%), disagreement was found in the remaining 314 cases (28%), and low DAS was associated with high VAS-A (230 cases) or vice versa (84 cases). Our study confirms that VAS-A is a simple, sensitive, fast, and reliable tool in dental anxiety assessment. The rate of disagreement between VAS-A and DAS is probably due to different test sensitivities to different components of dental anxiety. VAS-A can be used effectively in the assessment of dental patients, using the values of 5.1 cm and 7.0 cm as cutoff values for anxiety and phobia, respectively.

Comparison between two regional anaesthesia techniques performed by inexperienced operators: the Gow-Gates block versus the Kenneth Reed block.

AIM: The aim was to compare the efficacy of Kenneth Reed and Gow-Gates inferior alveolar nerve blocks when performed by an inexperienced operator. METHODS: A group of 60 patients was randomised into two groups. One group had the Kenneth Reed technique used to administer an inferior alveolar nerve block whilst the other received the Gow-Gates technique. The efficacy of nerve block produced was evaluated both clinically and by electric pulp tester. MRI examination was undertaken to determine the spread of local anaesthetic. RESULTS: There were no significant differences in success rate of anaesthesia between groups. The failure rate for the Gow-Gates technique was 16.6%, whilst the failure rate for the Kenneth Reed technique was 23.3%. Time to onset was less with the Kenneth Reed technique. MRI examination showed the solution was more widely distributed after the Kenneth Reed block had been used. CONCLUSIONS: Our research has demonstrated that the Kenneth Reed technique is equally effective at producing anaesthesia of the inferior alveolar nerve. Compared with conventional techniques there is a lower incidence of positive aspiration and potential for lower morbidity as the local anaesthetic is deposited further from the neurovascular bundle than when deposited near the mandibular foramen as in most conventional Inferior Alveolar Nerve Block techniques.

Patients appreciation for information on anesthesia and anxiolysis in dentistry.

AIM: The research regards information on anesthesia to patients undergoing oral surgery. Every patient evaluated the information received at the end of the preoperative visit and in the postoperative period. METHODS: One hundred-fifty dental patients were asked about the most appreciated information received in the preoperative visit on the anxiolytic technique, local anesthesia and treatment of the perioperative pain. Afterwards the patients had to report on their reaction to the content of the preoperative visit and information quality. On a phone interview they had to evaluate their appreciation of the anxiolytic technique, their perception during loco-regional anesthesia and incidence of pain and edema. RESULTS: The most appreciated details were those on the intervention, pharmacologic treatment, postoperative complicances, postoperative pain and operative competence; less appreciated were those on loco-regional anesthesia, duration of the intervention, anxiolytic techniques, hospital reception and permanence in the hospital. Ninety-eight percent of the patients considered to have been adequately informed on a context judged to be extraordinary (99.3%), 96.6% indicated the information as necessary, 98.6% appreciated the treatment of the intraoperative and postoperative (99.3%) pain and 99.3% the anxiolytic treatment. On the telephone interview, 100% of patients expressed satisfaction for the experienced intraoperative tranquillity, 91.3% complained for not having received in the past a similar preoperative visit, 99.3% wished a diffused application of the information. The loco-regional anesthesia was associated to psychological detachment in 84% of the cases and the incidence of postoperative pain was of 36%. CONCLUSION: The information on the anxiolytic techniques, loco-regional anesthesia, treatment of perioperative pain and postoperative distress was enthusiastically accepted and albeit initially induced feelings of astonishment resulted to be appreciated and preferred in the whole of the patients.

Isolated atrial fibrillation (IAF) after local anaesthesia with epinephrine in an anxious dental patient.

Cardiac arrhythmias are not uncommon in dental practice, depending on many factors, including patient features, dental treatment and drugs administered. We describe a case of isolated atrial fibrillation (IAF) developed, in a young patient, soon after a supraperiosteal injection. The patient was admitted to hospital and recovered spontaneously. Since stress is a possible cause of IAF, this may has been triggered by endogenous and/or exogenous epinephrine. We highlight the need for careful preoperative evaluation, including anxiety assessment and treatment in all dental patients.

Pain and motor function in carpal tunnel syndrome: a clinical, neurophysiological and psychophysical study.

OBJECTIVE: Patients with carpal tunnel syndrome (CTS) complain of motor symptoms. The study is aimed to understand which features are associated with the presence of motor symptoms in CTS. METHODS: We recruited 282 consecutive CTS patients. After selection, 129 patients (203 hands) were included. Patients were asked about the presence and severity of hand weakness (HW) and hand clumsiness (HC). They underwent a self-administered questionnaire on symptoms, clinical evaluation and neurographic study. Quantitative sensory testing (QST) was performed on the patients with unilateral right CTS. RESULTS: HW and HC may be found in 56 % and 48 % of CTS hands, respectively. HW was related to the severity of sensory symptoms (pain, numbness and tingling) but not to clinical-neurographic measures of median nerve involvement. HC was related to the severity of sensory symptoms and to the clinical-neurographic signs of motor but not sensory nerve damage. Motor symptoms were significantly more frequent in right hands. QST showed a relationship between the presence and severity of HW and HC and the warm threshold. CONCLUSIONS: Motor symptoms may be found in approximately half of CTS hands. Clinical and neurographic signs of median nerve motor damage appear to be poorly correlated to motor symptoms. The factor that can help reconcile the discrepancy between motor symptoms and motor signs is pain. Pain modulation on motor function may take place at various anatomical levels in CTS. Nociceptive C-fibers may be involved in pain-motor interactions finally leading to motor symptoms.

Motor cortical disinhibition during early and late recovery after stroke.

BACKGROUND: Functional neuroimaging studies show adaptive changes in areas adjacent and distant from the stroke. This longitudinal study assessed whether changes in cortical excitability in affected and unaffected motor areas after acute stroke correlates with functional and motor recovery. METHODS: We studied 13 patients with moderate to severe hemiparesis 5 to 7 days (T1), 30 days (T2), and 90 days (T3) after acute unilateral stroke, as well as 10 healthy controls. We used paired-pulse transcranial magnetic stimulation to study intracortical inhibition and facilitation, recording from the bilateral thenar eminences. F waves were also recorded. RESULTS: At T1, all patients showed significantly reduced intracortical inhibition in the unaffected hemisphere. At T2, in patients whose motor function recovered, intracortical inhibition in the unaffected hemisphere returned to normal. In patients with poor clinical motor recovery, abnormal disinhibition persisted in both hemispheres. At T3, in patients whose motor function progressively recovered, the abnormal disinhibition in the unaffected hemisphere decreased further, whereas in patients whose motor function remained poor, abnormal inhibition in the unaffected hemisphere persisted. No modification of F-wave latency and amplitude were found in patients and controls. CONCLUSIONS: During early days after stroke, motor cortical disinhibition involves both cerebral hemispheres. Longitudinal changes in motor disinhibition of the unaffected hemisphere may reflect the degree of clinical motor recovery.