HIV Neuropathy-a Review of Mechanisms, Diagnosis, and Treatment of Pain.

PURPOSE OF REVIEW: This article is a systematic review of data from 2018 to 2020 regarding information from publications on epidemiologic, diagnostic, and therapeutic advancements in human immunodeficiency virus-associated peripheral neuropathy. RECENT FINDINGS: The epidemiology/pathology of HIV neuropathy is discussed. Diagnostics includes skin wrinkling-eutectic mixture of local anesthetic test and neurologic examinations. Therapeutic interventions include pharmacologic and nonpharmacologic management as well as self-management strategies. Peripheral neuropathy continues to affect the lives of persons living with HIV. First-line treatment with pregabalin or gabapentin for HIV neuropathic pain has limited data on adequate response. Exercise and self-management strategies may provide benefit in pain reduction. Continuing research on risk factors and biomarkers for HIV-related peripheral neuropathy will be critical for future diagnostic and therapeutic agents.

Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation.

Structural variations of the thoracic outlet create a unique risk for neurogenic thoracic outlet syndrome (nTOS) that is difficult to diagnose clinically. Common anatomical variations in brachial plexus (BP) branching were recently discovered in which portions of the proximal plexus pierce the anterior scalene. This results in possible impingement of BP nerves within the muscle belly and, therefore, predisposition for nTOS. We hypothesized that some cases of disputed nTOS result from these BP branching variants. We tested the association between BP piercing and nTOS symptoms, and evaluated the capability of ultrasonographic identification of patients with clinically relevant variations. Eighty-two cadaveric necks were first dissected to assess BP variation frequency. In 62.1%, C5, superior trunk, or superior + middle trunks pierced the anterior scalene. Subsequently, 22 student subjects underwent screening with detailed questionnaires, provocative tests, and BP ultrasonography. Twenty-one percent demonstrated atypical BP branching anatomy on ultrasound; of these, 50% reported symptoms consistent with nTOS, significantly higher than subjects with classic BP anatomy (14%). This group, categorized as a typical TOS, would be missed by provocative testing alone. The addition of ultrasonography to nTOS diagnosis, especially for patients with BP branching variation, would allow clinicians to visualize and identify atypical patient anatomy.

Anatomical variations in the brachial plexus roots: implications for diagnosis of neurogenic thoracic outlet syndrome.

Neurogenic thoracic outlet syndrome (NTOS) is the most common type of TOS. Typically it results from impingement of the neurovasculature as it passes between the anterior and middle scalene muscles; this classic anatomical relationship being the foundation of clinical diagnosis. Positional testing relies on vascular compromise occurring when the subclavian artery is compressed in this space. This study describes several anatomical variations observed in this relationship. Sixty-five cadavers (35m/30f) were assessed to determine the frequency and extent of brachial plexus branching variants. A total of thirty-one variations from "classic" anatomy were observed (47.7%). In two specimens (3.1%), the entire superior trunk coursed completely anterior to the anterior scalene in a position of relative vulnerability. In 27 instances, a portion of or the entire superior trunk pierced the anterior scalene muscle, and in two, the middle trunk also pierced the muscle belly. Interestingly, while two bilateral branching variations were observed, the majority occurred unilaterally, and almost exclusively on the left side. There were no sex differences in frequency. The high frequency of these variations and their potential to predispose patients to neurogenic TOS suggest that current diagnostic methods may be insufficient in clinical diagnosis. Due to lack of vascular compromise, patients with the piercing variant would not display positive signs on the traditional positional tests. The use of ultrasound to determine the route of the brachial plexus could determine whether this variation is present in patients who suffer from TOS symptoms but lack a diagnosis based on traditional positional testing.

Lateral alveolar ridge augmentation using tenting screws, acellular dermal matrix, and freeze-dried bone allograft alone or with particulate autogenous bone.

This randomized prospective study evaluated the clinical benefits of using a corticocancellous mixture of freeze-dried bone allograft alone or in combination (1:1) with particulated autogenous bone for horizontal ridge augmentation and subsequent implant placement. Twenty-four patients with atrophic ridges received lateral ridge augmentations with particulate grafts placed around tenting screws and covered with a fixed acellular dermal matrix membrane. Thirty-three standard-diameter implants were successfully placed in 21 patients after a 24-week graft healing period. Three patients experienced early postoperative infections following the grafting procedure (12.5% of sites). At reentry, the allograft alone group showed similar average horizontal ridge width gains (3.33 ± 0.83 mm) to the combination group (3.09 ± 0.63 mm; P = .44). The mean graft resorption between baseline and reentry averaged 13.89%.