Analgesic efficacy of Pericapsular Nerve Group (PENG) block compared with Fascia Iliaca Block (FIB) in the elderly patient with fracture of the proximal femur in the emergency room. A randomised controlled trial

INTRODUCTION AND OBJECTIVES

Data on the efficacy of PENG (Pericapsular Nerve Group) block in hip trauma pain are scarce. We hypothesized that PENG block was more effective than infra-inguinal ultrasound-guided FIB (Fascia Iliaca block) for pain control in patients aged 65 years or older presenting in the emergency room (ER) with traumatic proximal femoral fracture.

MATERIALS AND METHODS

We conducted an exploratory, double-blind, randomized controlled trial. One anaesthesiologist performed the block and another assessed outcomes. Patients were randomly allocated to the PENG group (20 ml ropivacaine 0.375%) or the infrainguinal FIB group (40 ml ropivacaine 0.2%). Standard hypothesis tests (t test or χ2 test) were performed to analyse baseline characteristics and outcome parameters. The primary end-point of the study was analgesic success, defined as "NRS pain score ≤ 4" 30 min after blockade, with PENG vs to FIB. Secondary outcomes were pain at rest ("pain at rest NRS score ≤ 4" 30 min after blockade), duration of analgesia (time to first request for analgesia), need for rescue medication in case of block failure, and complications during blockade.

RESULTS

After obtaining ethical committee approval and written informed consent, 60 patients were included. The primary endpoint was achieved in 16 out of 30 patients (53.3%) in the PENG group and in 15 out of 28 patients (53.6%) in the FIB group. Comparison between groups did not show superiority of the PENG vs FIB (P-value .98).

CONCLUSIONS

PENG block does not provide better pain than FIB in proximal femoral fracture in elderly patients treated in the ER.

Tuning the catalytic acidity in Al2O3 nanofibers with mordenite nanocrystals for dehydration reactions

The chemical and structural properties of Al2O3 are tuned for dehydration reactions. The synergy between the structured Al2O3 shaped as nanofiber and the acid site nature of the zeolite mordenite in the nanofiber improves the dehydration reaction.

Comparison of Histogram-based Textural Features between Cancerous and Normal Prostatic Tissue in Multiparametric Magnetic Resonance Images

In the last decade, multiparametric magnetic resonance imaging (mpMRI) has been expanding its role in prostate cancer detection and characterization. In this work, 19 patients with clinically significant peripheral zone (PZ) tumours were studied. Tumour masks annotated on the whole-mount histology sections were mapped on T2-weighted (T2w) and diffusion-weighted (DW) sequences. Gray-level histograms of tumoral and normal tissue were compared using six first-order texture features. Multivariate analysis of variance (MANOVA) was used to compare group means. Mean intensity signal of ADC showed the highest showed the highest area under the receiver operator characteristics curve (AUC) equal to 0.85. MANOVA analysis revealed that ADC features allows a better separation between normal and cancerous tissue with respect to T2w features (ADC: P = 0.0003, AUC = 0.86; T2w: P = 0.03, AUC = 0.74). MANOVA proved that the combination of T2-weighted and apparent diffusion coefficient (ADC) map features increased the AUC to 0.88. Histogram-based features extracted from invivo mpMRI can help discriminating significant PZ PCa.

Seismic Assessment of Steel MRFs by Cyclic Pushover Analysis

Background:

Structural members subjected to strong earthquakes undergo stiffness and strength degradation. To predict accurately the seismic behaviour of structures, nonlinear static methods of analysis have been developed in scientific literature. Generally, nonlinear static methods perform the pushover analysis by applying a monotonic lateral load. However, every earthquake input is characterized by several repeated loads with reverse in signs and the strength and deformation capacities of structures are generally related to the cumulative damage. This aspect is neglected by the conventional monotonic approaches, which tend to overestimate the strength and stiffness of structural members.

Objective:

This paper aims to investigate the possibility that the Cyclic Pushover Analysis (CPA) may be used as a tool to assess the seismic behaviour of structures. During the CPA, the structure is subjected to a distribution of horizontal forces that is reversed in sign when predefined peak displacements of the reference node are attained. This process repeats in cycles previously determined in a loading protocol.

Methods:

To investigate the effectiveness of the CPA in predicting the structural response, a steel moment resisting frame is designed as a case study building. A numerical model of this frame is developed in OpenSees. To examine the influence of the loading protocols on the seismic response, the CPA is run following the ATC-24 and the SAC protocols. Additionally, the seismic demand of the case study frame is determined by a Monotonic Pushover Analysis (MPA) and by Incremental nonlinear Dynamic Analysis (IDA).

Results and Conclusions:

The following results are obtained:

• Despite the differences between the SAC and the ATC-24 loading protocols, the CPA applied according to those two protocols led to almost the same structural response of the case study frame.

• The CPA showed the capability of catching the stiffness and strength degradation, which is otherwise neglected by the MPA. In fact, given a base shear or peak ground acceleration, the CPA leads to the estimation of larger displacement demands compared to the MPA.

• During long (or medium) duration earthquakes, the CPA was necessary to estimate accurately the response of the structure. In fact, at a PGA equal to 1 g, the CPA estimated the top displacement demand with an error lower than 10%, while the MPA underestimated it by 18%.

• The importance of considering the cyclic deterioration is shown at local level by the damage indexes of the frame. In the case of long earthquakes, given a top displacement of 600 mm (corresponding to a PGA equal to 1 g), the CPA estimated the damage indexes with an error equal to 12%.

Law on advance health care directives: a medical perspective

The paper's authors aim to elaborate on law 22 dicembre 2017, n. 219 , designed to regulate informed consent practices and advance health care directives", which has sparked a passionate debate centered on the substantial innovation achieved over the past decades in bio-medical science and at the same time, the noteworthy accomplishments made in enforcing human and personal rights. Within the paper, article three is delved into, which covers the creation of the so-called DAT ("Disposizioni anticipate di trattamento", advance health care directives), by which patients, in light of possible future incapacity to choose, can express their convictions and decisions on how to be treated and their consent or dissent to undergo treatments and procedures, including artificial nutrition and hydration. The authors peruse the new law's provisions through a medical perspective, and observe how they are heavily tilted towards patient choice, thus making doctors little more than mere tools of such decisions.

Nephrotic Syndrome and Plasmapheresis

We studied 15 patients suffering from nephrotic syndrome (NS) in bioptically-accertained primary and secondary glomerulopathies responding poorly to the common pharmacological treatment. They were monitored for one year by assessing their immunological and kidney functionality parameters, especially proteinuria. The patients underwent 3 apheretic sittings using the cascade double-filtration technique. After the third apheretic sitting the patients received metilprednisolone 300 mg/m2. This therapy was repeated every month for 6 months.

At the end of the apheretic cycle it was shown that all patients had responded well to the therapy with a dramatic decrease in proteinuria, maintenance and/or recuperation of kidney functionality and improvement of lipidic asset; these data remained unchanged over time. Considering our preliminary results, we believe that therapeutic apheresis has a precise function in refractory nephrotic syndrome and, in particular, we propose the use of the cascade double-filtration technique. (Int J Artif Organs 2000; 23: 111–3)

Evaluation of masseter muscle in different vertical skeletal patterns in growing patients

AIM

The present study aimed to evaluate the relationship between masseter size, maxillary intermolar width and craniofacial vertical skeletal pattern.

STUDY DESIGN

The study followed a prospective longitudinal design and enrolled 61 subjects (30 males and 31 females), 9-14 years of age (mean age 11.5) at 2-3 CVM stage. The participants were divided into three groups based on their vertical skeletal pattern which was estimated using the Frankfurt-mandibular plane angle: low-angle group (L-A), normal-angle group (N-A), high-angle group (H-A). An additional gender-based distinction was made. Maxillary intermolar width was measured on the maxillary cast of each patient by means of an electronic caliper; masseter volume was estimated by using magnetic resonance (MR) and masseter thickness was measured by means of ultrasonography (US). The US registrations were performed during the relaxation state (RS) and the maximum voluntary contraction (MVC) of the muscle. The indipendent samples T- test was used for sex comparisons; the analysis of variance test (ANOVA) was used to evaluate the differences between the three groups in males and females, and the Pearson r correlation coefficient was employed to assess the correlation between maxillary intermolar width and masseter volume.

RESULTS AND CONCLUSION

Maxillary intermolar width, masseter volume and thickness showed significant gender differences; all the tested variables decreased significantly according to the facial vertical pattern, with greater values in females, especially in low- and normal-angle subjects; maxillary intermolar width and masseter volume showed significant correlations, higher in females.

Effect of repeated firings on flexural strength of veneered zirconia

OBJECTIVE

Chipping and/or delamination represent a clinical failure of porcelain fused to zirconia (PFZ) prostheses. Causes and solutions have not been completely clarified. The present study was aimed at evaluating the effects of number of firings on the flexural strength of PFZ specimen.

METHODS

Forty-five zirconia specimens in shape of bars were cut, sintered and divided in 3 groups (n=15). Group 1: veneering ceramic was layered "in bulk" and fired. Group 2: veneering ceramic was layered in three layers, individually fired. Group 3: veneering ceramic was layered in five layers, individually fired. Each layer thickness was controlled by the use of calibrated molds. The total veneering ceramic thickness for all the specimens was 1.2mm, and the total thickness of the specimen of 2.0mm. Three-point bending test was performed. Fracture load was recorded in Newton and MPa value was calculated taking into account the bi-layered nature of the specimen. Data were statistically analyzed.

RESULTS

Specimens obtained with on single firing cycle obtained a statistically significant (p<0.001) lower flexural strength (54.61±8.98MPa) than specimens veneered with 3 or 5 firing cycles. The last two obtained very similar results (77.63±13.17MPa and 73.62±12.38MPa respectively) and the differences was not statistically significant.

SIGNIFICANCE

In bi-layered PFZ specimen, three to five layers and firings determine higher flexural resistance when compared to a single firing. Thus, a 3-layers veneering procedure is recommended to increase flexural resistance. If a 5-layer procedure is necessary to improve esthetics, it does not decrease flexural resistance.

Soft tissue depression at the iliac crest prominence: a new landmark for identifying the L4-L5 interspace

BACKGROUND

One of the most common approaches to identifying the L4-L5 interspace is using the iliac crest as a landmark. We propose a new landmark to identify the L4-L5 interspace based on the soft tissue depression palpable at the iliac crest prominence. The aim of this study was to assess the reliability and time saving when using this new landmark compared to using the iliac crest to perform a lumbar plexus block.

METHODS

Fifty-four patients scheduled for lower limb surgery were randomly allocated to have a lumbar plexus block performed using the iliac crest (Chayen's approach) or the soft tissue depression (Borghi's approach). The landmarks for both approaches were drawn on each patient prior to randomization (N.=27 per group). All the blocks were performed by an anesthesiologist familiar with both techniques using a nerve stimulator and 30 mL of 0.5% levobupivacaine. The time to achieve successful needle placement and the number of needle re-directions, as well as the onset time for the sensory and motor blockade, were recorded.

RESULTS

All the blocks using Borghi's approach were performed successfully. With the Chayen's approach, there were 5 needle placement failures. The mean times to onset of a successful block after injection of the local anesthetic did not differ between the two groups: 17.8±3.9 min for the Chayen vs. 15.9±2.4 min for the Borghi's approach (P=0.14). However, the mean time to achieve correct needle placement was 7.6±3.2 min with the Chayen's approach compared to 5.1 (±2.6 SD) min with the Borghi's approach (P<0.01). The Chayen's approach also required a significantly higher median number of needle redirections (2 [inter-quartile range (IQR): 0-4] vs. 0 [IQR: 0-4], P<0.01). In obese patients (BMI ≥30 kg/m(2)), the mean placement time was 10.5±1.7 min vs. 4.8±2.1 min (P<0.01), and median number of needle re-directions was 2.5 (IQR: 2-3) vs. 0.5 (IQR: 0-3) (P=0.04), with the Chayen and Borghi's approach, respectively.

CONCLUSION

Use of the palpable soft tissue depression at the iliac crest prominence for performing a lumbar plexus block offered several potential advantages over the standard inter-iliac crest approach.

Diagnosis of deep-seated lymphomas by endoscopic ultrasound-guided fine needle aspiration combined with flow cytometry

OBJECTIVE

Although endoscopic ultrasound combined with fine needle aspiration (EUS-FNA) is rapidly becoming the preferred diagnostic approach for the sampling and diagnosis of gastrointestinal and mediastinal malignancies, there are limited data as to its use in the diagnosis of lymphoproliferative disorders. Therefore, we carried out a retrospective evaluation of the performance of EUS-guided FNA combined with flow cytometry (FC) as a tool to improve overall sensitivity and specificity in the diagnosis of lymphoma.

METHODS

Of 1560 patients having EUS-guided FNA during the period of the study, a total of 56 patients were evaluated by cytology with FC after EUS-FNA. There was adequate material to perform FC analysis for all but one case.

RESULTS

EUS-FNA-FC gave a diagnosis of lymphoma in 11 cases and of reactive lymphadenopathy in 20. A specific histological type was defined by FC alone in eight cases. The remaining cases were diagnosed later by cytology and cell block sections: 13 carcinomas, nine granulomatous lymphadenopathies and one mediastinal extramedullary haematopoiesis. One case was considered only suspicious for lymphoma on cytology and FC but was not confirmed on molecular analysis and one had insufficient material for FC.

CONCLUSIONS

Our results show that a combination of EUS-FNA-FC is a feasible and highly accurate method, which may be used for the diagnosis and subtyping of deep-seated lymphoma, providing a significant improvement to cytomorphology alone both for diagnosis and treatment planning, as long as immunocytochemistry is available for non-lymphoma cases.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

[Chronic renal failure after hematopoietic stem cell transplantation]

Hematopoietic stem cell transplantation, autologous or allogeneic, is a well established hematology procedure. There can be a number of renal complications in this setting, which may occur in every phase but all strongly influence prognosis. Among the late complications, there is the well-known possibility of progressive chronic renal failure, appearing together with hypertension and modest alterations of the urinary sediment, and characterized by pathological findings of thrombotic microangiopathy, often without the corresponding clinical aspects. This clinical picture must be distinguished from other forms of clinically more severe thrombotic microangiopathy, such as those occurring in the early post-transplant period, and from other causes of renal disease in the hematopoietic stem cell transplantation setting. Total body irradiation, chemotherapeutic drugs, calcineurin inhibitors and opportunistic infections have all been considered as causal factors. The nosological classification is still poorly defined, as are the real prognosis and the best treatment. Kidney biopsy is a necessary tool to make a correct diagnosis, assess the frequency of the condition, make a prognostic judgment, and set up rational treatment.

Resolution of phenol, and its di-hydroxyderivative mixtures by excitation-emission fluorescence using MCR-ALS Application to the quantitative monitoring of phenol photodegradation

The photodegradation of phenol using TiO(2) as catalyst was studied and monitored by fluorescence excitation-emission matrix (EEM). Hydroquinone, catechol and resorcinol were the dihydroxyderivative intermediates although in lower concentrations than phenol. The data were analyzed using a three-way multivariate curve resolution alternating least squares method (MCR-ALS) and augmented matrices. The procedure was assessed using synthetic samples prepared with a {4,3} Simplex-lattice design that considered a representative range of analyte concentrations. The results were analyzed in terms of overall RMSEP for the overall data set. A detailed study was made of how the analytes behaved at each concentration level and how the concentration of the other species affected the process. The method was used to quantify phenol in photodegradation samples with an overall prediction error of 5.37%. The conversion values were fitted to pseudo first-order kinetics and the apparent rate constant was calculated to be -4.9x10(-4)+/-5.2x10(-5)min(-1).

Otologic symptoms in temporomandibular disorders patients: is there evidence of an association-relationship?

Several studies in the literature investigated the association between temporomandibular disorders (TMD) and otogenous symptoms, like vertigo, tinnitus, otalgia and muffling, although the question of the existence of a cause-effect relationship is still controversial. Epidemiological findings showed that the prevalence of ear symptomatology in the general population is variable from 10% to 31%, and increases up to 85% in TMD patients. Based on these data, many attempts have been performed to describe the physiopathological interactions between aural symptoms and TMD, as a strict anatomical link exists between the structures of the ear and those of the stomatognathic system. Unfortunately, methodological weaknesses of most studies are evident so that the comparison of results is often difficult. Considering these premises, the present study critically reviewed the literature on this debated issue, discussing the main etiopathogenetic hypotheses, the features of ear symptomatology in TMD patients and its relationship with TMD treatment in order to present current suggestions about the relationship between aural and TMD symptoms. Suggestions for future researches have been also presented, since a full understanding of this plausible interaction will be an important factor in diagnosis making and treatment planning for both pathologies.

[Complications of the Lichtenstein inguinal hernioplasty]

The Lichtenstein inguinal hernioplasty in the original version or with small variations currently allows good results both from the surgical point of view and in terms of reduction of the sanitary expenses. "Tension free" repair and diffusion of local anesthesia allow a drastic reduction of the hospital stay, a early time of the working activity and the diffusion of the admission to the Day Hospital. The authors introduce the own casuistic that comprise 1116 inguinal hernioplasty in 1,034 patients and on the base of two studies, a retrospective one and another prospective, they conclude that a greater attention in the behavior of the intervention and a more accurate preparation of the patients represent fundamental moments to obtain even more satisfactory results.

[Leiomyosarcoma of brachiocephalic vein: case report]

Primary leiomyosarcoma of venous origin is a rare but frequently lethal disease. Clinical symptoms can be different, often not much evident or absolutely absent. Preoperative diagnosis is difficult also with modern imaging and only pathological examination can identify this malignant tumor. Successful therapy requires early surgery but the long-term survival is poor. A case of leiomyosarcoma arising from veins has been presented.

Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis I diagnoses in an Italian patient population

The aim of this work was twofold: to evaluate the prevalence of different Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) diagnosis in an Italian population of subjects seeking TMD treatment in a tertiary clinic; and to compare data with those from similar studies in the literature. Participants in this study were 433 consecutive patients seeking TMD treatment at the Section of Prosthetic Dentistry, Department of Neuroscience, University of Pisa, Italy; mean age of patients was 38.8 years, with a female:male ratio of 2.6:1 (276 females, 73.2%; 101 males, 26.8%). RDC/TMD guidelines for examination were adopted to assign axis I diagnosis. The prevalence of RDC/TMD diagnoses was 38.2% (144/377) for group I disorders (muscle disorders), 52.3% (197/377) for group II disorders (disc displacements), and 52.6% (198/377) for group III disorders (arthralgia, osteoarthritis, osteoarthrosis). The present investigation provided findings that, compared and integrated with literature data, can be useful to create a world-wide database, in accordance with the nature of the RDC/TMD classification system.

Efficacy of physical therapy in the treatment of masticatory myofascial pain: a literature review

The term temporomandibular disorders (TMD) is used to indicate a heterogeneous group of painful conditions involving masticatory apparatus and its related structures whose complicated etiology involves a number of diagnostic and taxonomical matters. The prevalence of TDM has remarkably increased in the last years, such that, at present, these clinical conditions represent the most frequent cause of orofacial pain in the general population: in particular, among these disorders, pathologies affecting masticatory muscles have a considerable clinical and epidemiological relevance. Due to the high prevalence of masticatory myofascial pain, as well as the taxonomical issue that emerges from literature data, the wide range of treatment modalities proposed for this condition seems to be justifiable. Among the various therapeutic solutions employed in the management of masticatory myofascial pain, it is interesting to focus on the efficacy of the different kinds of physical therapy. In fact, due to the difficulties related with the attempt to isolate a sole etiological factor, at the beginning should be carried out reversible and noninvasive interventions: in these terms, the use of physical therapy seems to be reasonable. The aim of the present paper is to provide a critical review of the literature about the use of physical therapy approaches in relieving pain symptoms that often accompany masticatory muscles disorders. This study seems to suggest that the employ of physical therapy could be useful in the treatment of myogenous TDM, even though further studies are needed to assess the efficacy of this tool.

[The clinical significance of lymph node micrometastases and of concept of sentinel lymph node]

Micrometastases, (metastases smaller than 2 mm), had benn subject of several studies. In literature is documented a prognostic worsening due to their presence. Research of micrometastases in sentinel lymph node is of great interest and can allow a clinical application with profitable cost efficacy ratio. The Authors discuss about clinical, prognostical and therapeutical implicationes in case of micrometastases into sentinel lympho nodes.

Anxiety symptoms in clinically diagnosed bruxers

The present work was an attempt to investigate for the existence of an association between anxiety psychopathology and bruxism. The presence of bruxism was investigated according to validated clinical criteria in 98 subjects, who also filled out a self-report questionnaire (PAS-SR) for the assessment of panic-agoraphobic spectrum. 34.7% (n = 34) of participants were diagnosed as bruxers. The prevalence of anxiety psychopathology was similar between bruxers and non-bruxers, but Mann-Whitney U-test revealed significant differences in total PAS-SR (P = 0.026) score, indicating that subclinical symptoms of the anxiety spectrum might differentiate bruxers from controls. In particular, significant differences emerged in scores of domains evaluating panic (P = 0.039), stress sensitivity (P = 0.006) and reassurance sensitivity symptoms (P = 0.005) of panic-agoraphobic spectrum. Support to the existence of an association between bruxism and certain psychopathological symptoms has been provided.

Magnetic resonance of the temporomandibular joint: experience at an Italian university center

AIM

The aim of this investigation was to suggest criteria in order to evaluate magnetic resonance imaging (MRI) of the temporomandibular joint (TMJ). Such criteria have been discussed on the basis of our experience at the Section of Prosthetic Dentistry, Department of Neurosciences, University of Pisa.

METHODS

The study sample was constituted by 135 patients. All subjects underwent bilateral MRI of the TMJs to evaluate disc structure and position, bony structure abnormalities, joint effusion localization and entity.

RESULTS

MRI allowed depiction of the articular disc in 98.9% of the TMJs, showing a normal disc structure in 91.1% of the cases and abnormal in 7.7%. The disc-condyle relationship was normal in 46.6% TMJs, while a disc displacement with reduction was revealed in 35.5% cases, a disc displacement without reduction in 16.7% and a posterior disc displacement in 1.5% joints. In the coronal images, the disc was positioned lateral to the condyle in 8.9% of the TMJs and medial in 6.7%. Osseous abnormalities have been found in 177 joints (65.5%), with cases of bony flattening (condyle and/or tuberculum), erosions, subchondral cysts, osteophytosis and sclerosis. T2 sequences showed effusion in 26.7% of the TMJs.

CONCLUSIONS

These findings suggest that standardized methodology application and well-defined criteria can facilitate MR imaging observations and interpretation as well as the diagnosis of intra-articular pathologies.

Coronoid hyperplasia. A case report

Coronoid hyperplasia is a rare condition which is macroscopically characterized by an increase in the dimensions of the coronoid process resulting from an abnormal bony elongation of histologically normal bone. Unilateral cases are more frequent than bilateral ones and can recognize a number of etiological factors, such as exostoses, osteochondroma, traumatic events, inflammatory reactions, neoplasia and manifestations secondary to other pathologies. Etiopathogenesis of bilateral forms has not yet been clarified: in the literature hints to both developmental and endocrine abnormalities are present, and a familiar pattern of inheritance has been evidenced. The poor specificity of signs and symptoms associated with coronoid hyperplasia, which are similar to those of other more frequent forms of temporomandibular disorders, present some problems of differential diagnosis. An accurate assessment must be based on a clinical and anamnestical approach aiming at the identification of pathognomonic clinical symptoms. Considering its limits (such as the possible presence of artefacts and image distortions), orthopantomography has a poor diagnostic usefulness. In this case, magnetic resonance (MR) allowed to evaluate disk-condyle relationship, but it could be also useful to evaluate post-operative complications. In the case of coronoid hyperplasia, the computed tomography (CT) is fundamental for a correct differential diagnosis. CT also allows surgical planning due to its accuracy to detect coronoid process volume and morphology. The present case report is an example of the need for a correct differential diagnosis between the different types of temporomandibular disorders, and it also lends support to the importance of requesting modern imaging techniques during the diagnostic process of the rare or complex cases.

Comparison of ultrasonography and magnetic resonance imaging in the evaluation of temporomandibular joint disc displacement

The aim of this work was to evaluate the accuracy and reliability of ultrasonography in the diagnosis of temporomandibular joint (TMJ) disc position abnormalities compared with magnetic resonance imaging (MRI). Participants in this study were 41 consecutive patients with signs and symptoms of temporomandibular disorders. All 82 TMJs were evaluated to detect disc position abnormalities by means of ultrasonography and MRI, performed by blinded operators. The accuracy of ultrasonography was evaluated with respect to MRI. Ultrasonography demonstrated good accuracy in the evaluation of disc position, showing a sensitivity of 65.8% and a specificity of 80.4%, resulting in a positive likelihood ratio of 3.35, a negative likelihood ratio of 0.42, and a diagnostic odds ratio of 7.97. The predictive positive and negatives values were respectively 77.1% and 70.2% and the overall agreement between the two radiological techniques was 73.1%. Ultrasonography proved to be accurate in detecting normal disc position and the presence of abnormalities in disc-condyle relationship but not so useful for the distinction between disc displacement with and without reduction.

Comparison of ultrasonography and magnetic resonance imaging in the evaluation of temporomandibular joint disc displacement

The aim of this work was to evaluate the accuracy and reliability of ultrasonography in the diagnosis of temporomandibular joint (TMJ) disc position abnormalities compared with magnetic resonance imaging (MRI). Participants in this study were 41 consecutive patients with signs and symptoms of temporomandibular disorders. All 82 TMJs were evaluated to detect disc position abnormalities by means of ultrasonography and MRI, performed by blinded operators. The accuracy of ultrasonography was evaluated with respect to MRI. Ultrasonography demonstrated good accuracy in the evaluation of disc position, showing a sensitivity of 65.8% and a specificity of 80.4%, resulting in a positive likelihood ratio of 3.35, a negative likelihood ratio of 0.42, and a diagnostic odds ratio of 7.97. The predictive positive and negatives values were respectively 77.1% and 70.2% and the overall agreement between the two radiological techniques was 73.1%. Ultrasonography proved to be accurate in detecting normal disc position and the presence of abnormalities in disc-condyle relationship but not so useful for the distinction between disc displacement with and without reduction.

17-beta-estradiol and progesterone serum levels in temporomandibular disorder patients

AIM

Considering the hypothesis that some temporomandibular joint (TMJ) tissues could be a potential target for sexual hormones, the aim of the study was to evaluate estrogen (17-beta-estradiol) and progesterone serum levels in a young adult population affected by articular forms of temporomandibular disorders (TMD) versus a control group of healthy subjects.

METHODS

A total of 35 patients with Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I Group II diagnosis of disk displacement and/or Group III diagnosis of arthralgia, osteoarthritis or osteoarthrosis, were recruited at the Section of Prosthetic Dentistry, Department of Neurosciences, University of Pisa, Italy, along with a sex- and age-matched group of 24 healthy controls. In all patients, 17-beta-estradiol, progesterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH) serum levels were determined using a radioimmunoassay. A T-test was performed to compare mean 17-beta-estradiol and progesterone serum levels in the TMD groups with mean serum levels of their respective control groups. Significance was set at p<0.05.

RESULTS

Significant differences between patients affected by TMJ disorders and healthy controls were found for serum concentration of 17-beta-estradiol, both in males (p<001) and in the luteal phase of the menstrual cycle in females (p<0.05). No difference was found for progesterone serum levels in the different experimental samples.

CONCLUSIONS

The results of this study suggest that high serum estrogens levels might be implicated in the physiopathology of temporomandibular joint disorders, since subjects with these pathologies showed significantly higher serum levels with respect to a group of healthy controls.

Comparison of masticatory dysfunction in temporomandibular disorders and fibromyalgia

AIM

Many theories have been proposed as to the relationship between fibromyalgia (FM) and temporomandibular disorders (TMD). The aim of this study was to investigate the clinical features of the involvement of the stomatognathic system in patients with fibromyalgia, and to compare signs and symptoms of masticatory dysfunction between TMD and FM patients.

METHODS

The study sample consisted of 30 subjects with fibromyalgia recruited at the Rheumatology Disease Department, University of Pisa, Italy, and of 30 with temporomandibular disorders at the Section of Prosthetic Dentistry, Department of Neurosciences, University of Pisa, Italy. Masticatory dysfunction has been compared between the 2 groups by means of a clinical assessment conducted according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Patients of the TMD group underwent a rheumatologic examination to investigate for the presence of previously undiagnosed fibromyalgia.

RESULTS

As regards specific clinical variables and RDC/TMD diagnoses, differences between the 2 groups appear to be not relevant, with the exception of the values of mouth opening, both voluntary and passive, and the presence of trigger points. FM patients showed a decrease in both maximum voluntary and passive mouth opening which was about 2 mm worse than that recorded in TMD patients. FM patients also showed a significantly higher number of trigger points, even though muscle palpation evoked tenderness in the same number of sites in the 2 groups.

CONCLUSIONS

This study showed that most patients with fibromyalgia (86.7%) report signs and symptoms localized at the stomatognathic system; by contrast, only a minority of patients with temporomandibular disorders (10%) are actually affected by fibromyalgia.

Mood and anxiety psychopathology and temporomandibular disorder: a spectrum approach

Psychological factors play an important role in the aetiopathogenesis of temporomandibular disorders (TMD), as demonstrated by an increase in stress, anxiety, depression and somatization in TMD patients. The aim of this work was to investigate the presence of mood and panic-agoraphobic symptoms in different groups of TMD patients by means of a spectrum approach to psychopathology. A total of 131 subjects were included in this study and TMD signs and symptoms were investigated by means of a standardized clinical examination. Two self-report questionnaires were used to evaluate mood (MOODS-SR) and panic-agoraphobic (PAS-SR) spectrum. anova and Bonferroni's post hoc test for multiple comparisons were used to compare mean scores of all TMD groups for MOODS-SR, PAS-SR and all their domains. Results revealed a significantly higher prevalence of both mood (P < 0.001) and panic-agoraphobic (P < 0.01) symptoms in myofascial pain patients than in all other diagnostic groups (TMD-free, disc displacement and joint disorders). With regard to mood spectrum, strong differences emerged for all domains evaluating depressive symptoms. As for the panic-agoraphobic spectrum, myofascial pain patients differed from the other groups for the presence of stress sensitivity, panic, separation anxiety, hypochondriac and agoraphobic symptoms. It was concluded that myofascial pain patients differed from those with disc displacement, joint disorders and no TMD in relation to some psychopathological symptoms, while the last three groups presented very similar profiles.

Psychic and occlusal factors in bruxers

BACKGROUND

The aim of this study was to investigate the existence of associations between bruxism and psychic and occlusal factors.

METHODS

Participants in this study (n=85) were recruited from the Section of Odontostomatology, Deparent of Neuroscience, University of Pisa, Italy. They were split into two groups, bruxers (n=34) and non-bruxers (n=51), on the basis of the presence of both clinical and anamnestical indicators of bruxim. All participants were administered two self-reported validated questionnaires to evaluate (MOODS-SR) and panic-agoraphobic (PAS-SR) spetra. A number of occlusal variables (deep-bite: cross-bite, open-bite, mediotrusive and laterotrusive interferences, slide RCP-ICP, laterotrutsive guides, canine and molar classes) were also recorded.

RESULTS

With regards to occlusal factors, the only association was revealed between bruxism mediotrusive interferences (p < 0.05). As for psychiatric investigation, significant differences between bruxers and controls emerged for the presence of both depressive (p < 0.01) and manic symptoms (p < 0.01) in MOODS-SR, and for stress sensitivity (p < 0.01), anxious expectation (p < 0.05), and reassurance sensitivity symptoms (p < 0.05) in PAS-SR. In particular, both mood (p < 0.01) and panic-agoraphobic (p < 0.05) spectra symptoms seem to differentiate bruxers from controls in males, while in females strong differences emerged for stress sensitivity symptoms (p < 0.05).

CONCLUSIONS

It can be confirmed that certain psychic traits are present in bruxers, while occlusal factors are not useful parameters to discern bruxers from non-bruxers.

Is clinical assessment valid for the diagnosis of temporomandibular joint disk displacement?

AIM

The aim of this work was to evaluate the predictive value of clinical examination for magnetic resonance imaging (MRI) findings of temporomandibular joint (TMJ) disk position abnormalities.

METHODS

Participants in this study were 51 consecutive patients with signs and symptoms of temporomandibular disorders (TMD). All 102 temporomandibular joints (TMJ) were evaluated to detect disk position abnormalities by means of a standardized clinical assessement according to Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and MRI performed by a blinded radiologist at the Section of Prosthetic Dentistry, University of Pisa, Italy. The accuracy of clinical assessment was evaluated with respect to MRI.

RESULTS

Clinical assessment showed a good predictive value (PV) for the diagnosis of normal disk position (86.2%) and an acceptable PV for the diagnosis of disk displacement with reduction (70.3%), while it seems less accurate in predicting MRI diagnosis of disk displacement without reduction. The overall agreement between clinical RDC/TMD examination and MRI for the evaluation of disk position was 77.3%.

CONCLUSION

Clinical RDC/TMD examination proved to be accurate in detecting normal disk position and disk displacement with reduction but not reliable in predicting MRI diagnosis of disk displacement without reduction in the temporomandibular joint.

Diagnosis of temporomandibular disorders according to RDC/TMD axis I findings, a multicenter Italian study

AIM

The aim of the present study was to evaluate the prevalence of the different Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I types of temporomandibular disorders (TMD) in a population of subjects seeking for TMD treatment at 2 University Departments in Italy and to compare it with data from similar studies in the literature, in order to assess the usefulness of the RDC/TMD classification system as a tool for epidemiological data gathering and multicenter and cross-cultural comparison.

METHODS

A total of 210 consecutive patients seeking for TMD treatment at the Section of Prosthetic Dentistry, Department of Neuroscience, University of Pisa, Italy, and 109 consecutive patients seeking treatment at the Section of Prosthetic Dentistry and Temporo-mandibular Disorders, University of Pavia, Italy, were assessed using RDC/TMD.

RESULTS

Only 181 of the patients referring to the University of Pisa and 104 of those referring to the University of Pavia satisfied the criteria for inclusion. Findings from the 2 study populations were very similar. Mean age of the patients was 40 years, with a female:male ratio of 3.5:1 (222 females, 77.9%; 63 males, 22.1%). The prevalence of RDC/TMD Axis I diagnoses was 50.2% (143/285) for Group I disorders (muscle disorders), 38.6% (110/285) for Group II disorders (disc displacement), and 50.2% (143/285) for Group III disorders (arthralgia, osteoarthritis, osteoarthrosis).

CONCLUSION

Results from the present investigation have confirmed the usefulness of the RDC/TMD classification system for research purposes and for data gathering in cross-cultural and multicenter comparisons.

Muscle relaxants in the treatment of myofascial face pain. A literature review

Among the different pharmacological approaches that could be adopted in the treatment of myofascial pain of masticatory muscles, attention has to be paid to muscle relaxants drugs, since very few studies evaluated their efficacy, despite most authors suggest their use. The present paper is a critical review of the literature on the use of the most common drugs with muscle relaxant effects (benzodiazepines, tricyclic antidepressants) and of a muscle relaxant drug (tizanidine hydrochloride) in the treatment of such condition. From literature data it emerged that these drugs had phases of alternate enthusiasm, characterized by a not constant clinical use and a fair interest in research. Nevertheless, within all the limitations that have been discussed in this paper, the use of muscle relaxants in patients with myofascial pain of masticatory muscles seems to be justifiable, even though further research is needed to verify their usefulness in terms of risk-benefit ratio.

Occlusal features are not a reliable predictor of bruxism

AIM

The aim of this investigation was to estimate the contribution of occlusion to differentiate bruxers from non-bruxers.

METHODS

Participants in the study were 160 patients consecutively selected among 20-30 year old patients attending the Section of Prosthetic Dentistry for conservative care. The presence of bruxism was clinically and anamnestically investigated. In each patient the following occlusal features were recorded: retruded contact position-intercuspal position slide length, vertical overlap, horizontal overlap, unilateral posterior crossbite, incisor dental midline discrepancy, mediotrusive interferences, laterotrusive interferences. A stepwise logistic regression model was used to identify the significant associations between occlusal features and bruxism.

RESULTS

Diagnosis of bruxism was made in 67/160 subjects (41.8%). Differences between sex were not significant (p=0.814). Among the 8 occlusal variables included in the logistic regression analysis, those remaining in the final model were laterotrusive interferences (OR 2.47) and anterior open-bite (OR 0.88). This model showed good specificity (87%) but an unacceptable sensitivity (26.9%) to predict bruxism (accuracy=61.6%). Therefore, multivariate analysis did not lead to an improvement in bruxism predictability with respect to univariate analysis, which revealed that the presence of bruxism was significantly associated with laterotrusive interferences alone (p=0.040), and not with unilateral cross-bite (p=0.208), anterior open-bite (p=0.202), deep-bite (p=0.572), large horizontal overlap (p=0.261), dental midline discrepancy (p=0.519), mediotrusive interferences (p=0.119), slide >or=2 mm (p=0.857).

CONCLUSION

According to our findings the contribution of occlusion to differentiate bruxers from non-bruxers is very poor. Infact, only laterotrusive interferences seem to be significantly associated with bruxism.

Efficacy of tizanidine hydrochloride in the treatment of myofascial face pain

AIM

The aim of the present investigation was to evaluate the usefulness of tizanidine hydrochloride in the treatment of myofascial pain of the masticatory muscles.

METHODS

This work is a preliminary report of clinical experience with the use of tizanidine hydrochloride at the Section of Prosthetic Dentistry, Department of Neuroscience, University of Pisa, Pisa, Italy. During the period from January 2000 to March 2003, 145 patients were given Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) axis I group I diagnosis of myofascial pain in the absence of any painful temporomandibular joint condition. Seventy-eight subjects agreed to suspend any kind of treatment they had undergone and to start assuming tizanidine hydrochloride (SIRDALUD) 4 mg/die per os (2 2- mg tablets a day, 1 in the morning and 1 after dinner) for 2 weeks. All underwent a clinical assessment according to RDC/TMD guidelines at baseline time and were re-evaluated at the end of the treatment period.

RESULTS

At the end of the treatment period all patients had improved; 42/78 patients (53.8%) showed absence of clinical symptoms; 18/78 (23.1%) showed a good improvement, still presenting a low number of painful sites, but not satisfying RDC/TMD parameters for diagnosis of myofascial pain; 18/78 (23.1%) showed only a slight improvement, still presenting a high number of painful sites and satisfying RDC/TMD parameters for diagnosis of myofascial pain.

CONCLUSION

Given the absence of papers on the use of tizanidine hydrochloride in the treatment of myofascial pain of the masticatory muscles, the present investigation could provide some preliminary data about its possible efficacy. Randomized and controlled clinical trials are needed to confirm these results.

Ultrasound assessment of increased capsular width as a predictor of temporomandibular joint effusion

OBJECTIVES

The aim of this study was to evaluate whether an increased capsular width evidenced by ultrasound (US) could be an indirect marker of temporomandibular joint (TMJ) effusion.

METHODS

138 TMJs were evaluated by US and magnetic resonance imaging (MRI) by two blinded calibrated investigators. US measures of capsular width (in mm) and MRI diagnosis of TMJ effusion (presence/absence) were used to perform a receiver operating characteristic (ROC) curve analysis in order to assess the most accurate cut-off value of capsular width that was able to discriminate between joints with and without MRI effusion.

RESULTS

Diagnostic accuracy of US to detect MRI-depicted TMJ effusion was good (area under the ROC curve=0.817). US sensitivity was high for values below the cut-off value of 1.950 mm (true positive rate (TPR)=83.9%; false positive rate (FPR)=26.3%), while specificity was high for values above the cut-off value of 2.150 mm (TPR=71.0%; FPR=11.8%).

CONCLUSIONS

Analysis of ROC curve appears to reveal that the critical area is around the 2 mm value for TMJ capsular width. These findings need to be refined by further studies assessing the smallest detectable difference in capsular width, with attention to reliability of interobserver observations.