Anesthetic management with remimazolam for a pediatric patient with Duchenne muscular dystrophy.

RATIONALE: With Duchenne muscular dystrophy (DMD) being the most common and most severe type of muscular dystrophy, DMD patients are at risk for complications from general anesthesia due to impaired cardiac and respiratory functions as the pathological condition progresses. In recent years, advances in multidisciplinary treatment have improved the prognosis of DMD patients, and the number of patients requiring surgery has increased. Remimazolam is a benzodiazepine derivative similar to midazolam. Its circulatory stability and the fact that it has an antagonist make it superior to propofol.There are no reports of pediatric patients with DMD undergoing total intravenous anesthesia with remimazolam. PATIENT CONCERNS: A 4-year boy was scheduled for single-incision laparoscopic percutaneous extraperitoneal closure for inguinal hernia under general anesthesia, but the surgery was postponed because his serum creatine phosphokinase level was extremely high. DIAGNOSIS: He was diagnosed with DMD. According to the results of the genetic test, exon deletion of the DMD gene was detected using multiplex ligation-dependent probe amplification, although he had no symptoms of DMD except for elevated serum levels of creatine phosphokinase, etc. INTERVENTION: He was admitted for the same surgical purpose. Anesthesia was induced with 3 mg of intravenously administered remimazolam. He lost the ability to respond to verbal commands. After the intravenous administration of 100 µg of fentanyl, a continuous infusion of remifentanil (1.0 µg/kg/min) and remimazolam (15 mg/h) was started, and the endotracheal tube was inserted smoothly after the administration of 10 mg of rocuronium with which the muscle twitches disappeared in train-of-four monitoring. At the end of the surgery, 15 mg of flurbiprofen was administered intravenously. After surgery, we injected 40 mg of sugammadex to confirm a train-of-four count of 100%. OUTCOMES: Although the dose of remimazolam was reduced to 5 mg/h 30 minutes before the end of the surgery, it took 20 minutes after the discontinuation of remimazolam for the patient to open his eyes upon verbal command. On postoperative Day 2, he was discharged from the hospital without any complications. LESSONS: Remimazolam was shown to be safe to use for general anesthesia in a pediatric patient with DMD.

Effect of advanced periodontal self-care in patients with early-stage periodontal diseases on endothelial function: An open-label, randomized controlled trial.

Although a significant association between periodontal disease and atherosclerotic cardiovascular disease has been reported, their cause-to-effect relationship remains controversial. This randomized controlled clinical trial aimed to investigate the effect of advanced self-care on atherosclerotic cardiovascular disease-related vascular function markers flow-mediated brachial artery dilatation (FMD) and serum asymmetric dimethylarginine (ADMA) level in patients with early-stage periodontal disease. The study was designed as a parallel group, 3-month follow-up, open-label, randomized controlled trial. The control group received standard care for periodontal diseases, whereas the test group additionally applied disinfectant using a custom-fabricated prescription tray for advanced self-care twice a day. Overall, 110 patients provided data for FMD and serum ADMA level. No significant improvements in FMD were observed in the control (mean increase, -0.1%; 95% confidence interval [CI], -1.0-0.8; P = 0.805) or test (mean increase, -0.3%; 95% CI, -1.1-0.4; P = 0.398) group. No significant changes in serum ADMA levels were observed (mean reduction, 0.01 µmol/L; 95% CI, -0.00-0.02; P = 0.366 and mean reduction, 0.00 µmol/L; 95% CI, -0.01-0.01; P = 0.349, respectively). No significant between-group differences were found in FMD (mean difference, -0.2%; 95% CI, -1.4-0.9; p = 0.708) or serum ADMA levels (mean difference, 0.01 nmol/L; 95% CI, -0.00-0.03; p = 0.122). Significant improvements in the average probing pocket depth were observed in the control and test groups. The bleeding on probing score in the test group was significantly reduced, while that in the control group was reduced, although not significantly. Periodontal care for a 3-month duration did not provide better endothelial function although improvements of periodontal status in patients with early-stage periodontal diseases. This trial is registered in UMIN Clinical Trials Registry (www.umin.ac.jp/ctr/; ID: UMIN000023395).

Diagnosis and management of temporomandibular joint dysfunction before surgery: a case report.

We present a case of colorectal cancer with temporomandibular joint dysfunction and discuss the management of the case. Type IIIb temporomandibular disorder involves anterior dislocation of the articular disk, trismus and difficult intubation. A 68-year-old woman was scheduled for colectomy. The day before surgery, the patient had temporomandibular pain. On examination, the mouth opening was 13 mm. We diagnosed type IIIb temporomandibular disorder. A simple splint was fabricated with gauze and she bit it. The mouth opening was 55 mm on the day of surgery. The pain disappeared, and intubation was uneventful. Temporomandibular disorders are generally treated by dentists. It is beneficial for general hospitals without a dentistry department to employ a dental anaesthesiologist to assist in potentially difficult intubations in patients with temporomandibular disorders.

Differences in the degree of infiltration of local anesthesia according to the site of injection in rats.

This study was conducted for morphological and quantitative evaluation of the diffusional pattern of infiltration anesthesia according to the site of injection. The maxillary first molar of rats was anesthetized by local infiltration of 100 microL of 2% lidocaine containing trypan blue at a distance of 2 mm from the palatal mucogingival junction or mucobuccal fold over the root apex of the maxillary first molar. The frozen sections were prepared in order to measure the volume of the anesthetics using volume-calculating software. On the palatal side, the anesthetic infiltrated the submucosal layer at an infiltration volume of 0.51 +/- 0.78 mm(3). On the buccal side, the solution entered the space formed by the masseter muscles, the arcus zygomaticus, and the lacrimal gland, at an infiltration volume of 23.80 +/- 13.16 mm(3). The results indicate the infiltration volume depends on the injection site and that insufficient anesthesia or unnecessary numbness is expected.