Charcot-Marie-Tooth disease (CMTD) is a hereditary peripheral neuropathy and is characterized by progressive muscle atrophy and motor-sensory disorders in all 4 limbs. Most reports have indicated that major challenges with general anesthetic administration in CMTD patients are the appropriate use of nondepolarizing muscle relaxants and preparation for malignant hyperthermia in neuromuscular disease. Moderate sedation may be associated with the same complications as those of general anesthesia, as well as dysfunction of the autonomic nervous system, reduced perioperative respiratory function, difficulty in positioning, and sensitivity to intravenous anesthetic agents. We decided to use intravenous sedation in a CMTD patient and administered midazolam initially and propofol continuously, with total doses of 1.5 mg and 300 mg, respectively. Anesthesia was completed in 3 hours and 30 minutes without adverse events. We suggest that dental anesthetic treatment with propofol and midazolam may be effective for patients with CMTD.
We studied the effects of electrical stimulation of the inferior alveolar nerve (IAN) on cardiovascular responses in cats. There was statistical correlation between cardiovascular response and prestimulus mean arterial blood pressure (MABP) and heart rate (HR). A trigeminal depressor response (TDR) was induced when the prestimulus MABP and HR were above 95 mm Hg and 140 beats/min, respectively. We investigated further to identify the vasomotor regulating center and neural transmitters involved in TDR. In the medulla, electrical stimulation of the dorsomedial medulla, the infratrigeminal nucleus (IFT), and the rostral ventrolateral medulla (RVLM) induced a vasopressor response. We confirmed that neurons in the RVLM were retrogradely labeled by wheat germ agglutinin-conjugated horseradish peroxidase injection into the nucleus intermediolateralis of the spinal cord. The vasopressor response induced by IFT stimulation was similar to that induced by IAN stimulation. Vasodepressor responses were induced when the caudal ventrolateral medulla, the nucleus tractus solitarius, the lateral tegmental field, the trigeminal nucleus interpolaris, the trigeminal spinal tract, and the paramedian reticular nucleus were stimulated. These responses, however, were not similar to the vasodepressor response induced by IAN stimulation but were similar to the cardiovascular response induced by vagal afferent stimulation. After spinalization or lesion of the RVLM, MABP and HR decreased and TDR completely disappeared. Inhibitory synaptic ligands and receptors were localized using immunohistochemical techniques. Neurons immunopositive for adrenaline, noradrenaline, and gamma-aminobutyric acid (GABA), and adrenaline alpha(2A), GABA(A), GABA(B), and glycine receptors were distributed along the sympatho-reflexive route including the RVLM and IFT. These results suggest that TDR could be induced as negative feedback to sympathetic hyperactivity whenever MABP and HR are high, because of the inhibitory control of the RVLM.
We describe the case of a 37-year-old woman who had been diagnosed with EhlersDanlos syndrome (EDS) 4 years earlier and was scheduled to undergo removal of synovial chondromatosis in the temporomandibular joint. EDS is a heritable connective tissue disorder and has 6 types. In this case, the patient was classified into EDS hypermobility type. The major clinical feature of this type is joint hypermobility. The patient had sprain or subluxation of the elbows and ankles and dislocation of the knees. Anticipated problems during general anesthesia would be affected by the disease type. For this patient, extra attention was directed to positional injury-induced neuropathy and articular luxation, cutaneous injuries, injuries related to intubation and ventilation, and postoperative pain. Anesthesia was induced with propofol, remifentanil, and rocuronium and maintained with oxygenair-desflurane, propofol, remifentanil, fentanyl, and rocuronium. In this case, the patient was safely managed without adverse events.Key Words: Ehlers-Danlos syndrome; Hypermobility type; Joint hypermobility and dislocation. E hlers-Danlos syndrome (EDS) is a heritable connective tissue disorder classified into 6 types: classic, hypermobility, vascular, kyphoscoliosis, arthrochalasis, and dermatosparaxis.1 This case is classified into EDS hypermobility type (EDS-HT), and the chief manifestation was joint hypermobility and dislocation. In the branch of dentistry, temporomandibular joint (TMJ) disorder may be one of the complaints. 2 We report the case of a patient with EDS-HT who underwent removal of synovial chondromatosis in the TMJ under general anesthesia. CASE REPORTA 37-year-old woman (173 cm [68 in], 100 kg, body mass index ¼ 33) with EDS-HT was scheduled for removal of synovial chondromatosis in the TMJ space under general anesthesia.The patient was a native-born American and had been living in Japan for about 20 years. Her thumb showed joint hypermobility, and her elbow showed hyperextension. Her thumb in conjunction with flexion and extension of her wrist could touch her forearm ( Figure A and B). Her skin was not hyperextensible but smooth and velvety. She had suffered sprain or subluxation of the elbows and ankles many times. She had also undergone operations for dislocation of the knees. At present, she had pain into the TMJ, both knees, thumb of the hand, and the iliotibial band. Her medical history included gastroesophageal reflux without current medication use. Thinning hair was being treated with cepharanthine, carpronium chloride hydrate, and deprodone propionate. Electrocardiography revealed sinus arrhythmia with irregular R-R interval and inverted T waves in leads III and V1. Screening echocardiography revealed normal systolic and diastolic function.
The aim of this study was to assess knowledge, attitude, behavior, and compliance concerning infection control among dental practitioners in a dental university hospital in Japan. A 12‐item questionnaire about infection control during radiographic procedures was distributed to 686 dental personnel working at Osaka Dental University. The questionnaire collected information on occupation and the use of gloves, holders, door handles, control panels, dental chairs, protectors, tube head, tube arms, tube cones, and keyboards for personal computers. To identify misunderstandings about, and thus noncompliance with, current infection control practices, the percentage of correct answers (PCA) was calculated. Understanding and compliance with the current practices was considered low when <75% and high when ≥75%. In addition, contaminated objects in the clinical setting were examined using black light. PCA was low for one question on using gloves in film positioning and high for three questions on using protective film barriers, regardless of the respondents' occupation. PCA was generally high for three questions on practicing hand hygiene before putting on gloves, methods to protect film holders, and methods to protect radiographic equipment, but was low among some subjects. PCA was generally low for four questions on using film protective barriers, developing images from unprotected films, practicing hand hygiene after removing gloves, and awareness of a procedures manual for taking intraoral x‐rays, but was high among some subjects. Saliva contamination of radiographic equipment was confirmed by direct visualization using black light. Awareness was low of infection control measures to be used during intraoral projection. This study indicates the need for additional education and training to improve infection control practices, through, for example, using a standard procedures manual for all dental practitioners and visual evidence (visualization) of contamination.
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