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Background: Preoperative anxiety is common in paediatric patients and is associated with negative postoperative outcomes. Sedative premedication may alleviate some of this anxiety. A new sedation protocol using midazolam and ketamine in combination was instituted at our tertiary hospital. We aimed to evaluate the efficacy and the side effect profile of this regimen. Methods: We conducted a retrospective review of paediatric surgical patients who received oral midazolam (0.25 mg/kg) together with ketamine (3 mg/kg) as premedication, prior to induction of anaesthesia for elective surgery. The Watcha scale was used to assess preoperative and postoperative behaviour. Premedication efficacy was assessed using the Wilson sedation scale together with the 4-point anxiety scale. We further compared the incidence of significant preoperative anxiety with the incidence from a previous study. Results: We included 146 patients in our study. There was optimal sedation (Wilson sedation score = 1/2) in 47.9% of the patients (CI 39.9–56.1) with failed sedation (Wilson sedation score = 0) in 34.9% (CI 27.6–43.1) and over-sedation (Wilson sedation score = 3/4) in 17.1% (CI 11.8–24.2) of the patients. Optimal anxiolysis (4-point anxiety scale = 1) was achieved in 76.0% of the patients (CI 68.4–82.3). Failed anxiolysis (4-point anxiety scale = 2/3/4) occurred in 23.3% of the patients (CI 17.7–31.6). The majority of patients had no side effects (79.5%; CI 72.1–85.3). For those who experienced side effects, the most common was hypersalivation (12.3%; CI 7.9–18.8). The incidence of postoperative delirium was 3.4% (CI 1.4–8.0) and there was significantly less anxiety compared to our previous regimen (5.5%; CI 2.7–10.6 versus 13.5%; p = 0.007). Conclusion: The combination of midazolam and ketamine appears effective in providing safe sedation and reducing preoperative anxiety. Side effects occurred in up to a fifth of patients; predominantly hypersalivation. The combination of midazolam and ketamine for premedication should be considered for ASA I–II patients without contraindications undergoing elective surgery.

The present study was designed to compare the effects of lidocaine and ropivacaine in intravenous regional anaesthesia (IVRA) in dogs. Twelve adult male dogs were used. Under isoflurane anaesthesia, exsanguination was performed in the target forelimb. Then, a blood pressure cuff was encircled around the limb proximal to the elbow joint with a pressure of approximately 150 mmHg above the mean arterial blood pressure. The animals then received one of the two treatments of lidocaine (3 mg/kg) or ropivacaine (1.5 mg/kg) with a final volume of 0.6 mL/kg into the cephalic vein. After 60 min, the anaesthesia was disrupted and the tourniquet was removed using intermittent opening (30 s) and closing (5 min) manner for three times. The results revealed that at 20 and 30 min after the initiation of IVRA, the dogs in ROP showed higher analgesia than LID. A leakage under the tourniquet during IVRA was detected. Tremor and hypersalivation were observed after tourniquet removal in some dogs. It was concluded that ropivacaine might provide a higher quality of anaesthesia than lidocaine in IVRA in dogs. The development of local anaesthetic toxicity is a major concern and should be considered at the time of tourniquet removal., The effects of lidocaine and ropivacaine in intravenous regional anaesthesia (IVRA) in dogs were investigated. The results showed that ropivacaine provided a better quality of analgesia than lidocaine. Leakage under the tourniquet during IVRA was detected. Tremor and hypersalivation were observed after tourniquet removal in some dogs.

CASE DESCRIPTION A 5-month-old domestic shorthair cat was presented for recurrent regurgitation and hypersalivation after eating, which had been evident since adoption 2 months earlier. CLINICAL FINDINGS Physical examination was unremarkable. Plain thoracic radiography, positive contrast esophagography, endoscopy, CT, electromyography, and blood analysis were performed. A caudal cervical esophageal diverticulum, likely congenital, was diagnosed. TREATMENT AND OUTCOME A diverticulectomy was performed with a surgical stapler while an endoscope was in the esophageal lumen. No intra- or postoperative complications were reported. Postoperative and short-term outcomes were excellent, with resolution of clinical signs and no endoscopic esophageal abnormality 3 months after surgery. The cat remained without clinical signs 8 months after surgery. CLINICAL RELEVANCE An esophageal diverticulum in a cat is rare. The cat of this report had a good outcome following surgical management of a cervical esophageal diverticulum. Surgery is worth considering for similarly affected cats, but additional cases are required to confirm the benefit of surgery versus conservative management. (J Am Vet Med Assoc 2021;259:396–400)

This study evaluates acute and subchronic toxicity of a Korean herbal formula HAD-B1 in rat to investigate whether HAD-B1 has potential toxicity to humans. First, the study to assess the acute oral toxicity at dose levels of 0, 500, 1000, and 2000 mg/kg body weight (BW) was performed in male and female SD rats (Crl: CD, specific pathogen-free) (n = 5/group). Based on the result of the acute oral study, 4 weeks’ dose range finding study and 13 weeks’ subchronic study were performed (dose range finding study, DRF; n = 5/group) and 13 weeks (subchronic study; n = 10/group) in male and female SD rats. The control group was administered with distilled water (DW). Clinical signs, body weight, food consumption, ophthalmic examination, urinalysis, hematological/biochemical parameters, gross finding at necropsy, and histopathological examination were investigated and recorded. In the oral acute toxicity study of SD rats, no clinical signs, mortality, body weight changes, and gross findings were observed. Also, there were no treatment-related changes in the 4-week DRF study. Based on these results, a 13-week repeated-dose toxicity study (subchronic) in SD rats was performed. HAD-B1 showed temporal hypersalivation in clinical signs and an increased tendency in body weight at 2000 mg/kg BW. However, there were no treatment-related changes in mortality, food consumption, ophthalmology, urinalysis, hematology, biochemistry, gross finding at necropsy, organ weights, and histopathology in either sex of any group. Based on this toxicological evaluation of HAD-B1, we concluded that no target organ was determined, and the no observed adverse effect level (NOAEL) of HAD-B1 was determined to be > 2000 mg/kg B W. Therefore, we decided that consuming HAD-B1 is relatively nontoxic.

A functional hypersalivation reduces patient's quality of life by the need of repeated changes of cloths, skin damage around the mouth and reduced personal contacts. The indication to treat hypersalivation is justified furthermore when respiratory infections by saliva aspiration occur. Transnasal swallowing endoscopy allows to evaluate sufficiently dysphagia with limited risks. With this method therapy options can be judged for effectiveness. There are other additional radiologic assessments to complete diagnostic. Swallowing therapy should be initiated as first-line approach for hypersalivation and offers several treatment concepts to overcome the syndrome. Glycopyrrolate bromid received approval for children and adolescents as it reduces saliva flow relevantly with limited risk. Other anticholinergic drugs are restricted in use because of their side effects and off-label-use situation. Ultrasound guided injections of botulinum toxine in salivary glands are an established treatment option since decades. Meanwhile, the evidence for this method has improved, so Incobotulinum toxine is an approved therapy for chronic hypersalivation in adults, whereby new injections are needed about every four months. In the light of effective medical options, surgical approaches such as salivary duct relocation are recommended less often today because of invasiveness and failure. Radiotherapy is reserved mainly for neurodegenerative diseases and shows good response, but the cancer induction risks need to be discussed. A close follow-up regime is necessary to establish compliance not only by the patient, but also by his family and caregivers. By this, treatment effects can be optimized and therapies can be adjusted individually.

Purpose Symptoms of oral chronic graft-versus-host-disease (cGVHD) may significantly affect the oral health–related quality of life (OHRQoL). This study aimed to assess the OHRQoL in patients with oral cGVHD and to examine whether oral cGVHD symptoms, mucosal cGVHD, and salivary gland function correlated with OHRQoL. Methods Patients referred to the oral cGVHD outpatient clinic were included. Severity of oral mucosal cGVHD, oral cGVHD symptoms, and OHRQoL was assessed by the NIH OMS, NIH OSS, and OHIP-14, respectively. Unstimulated and stimulated whole salivary flow rates were determined and categorized into “hyposalivation,” “normal salivary flow,” and “hypersalivation.” Results Of 56 included patients, 80% had mild, moderate, or severe oral mucosal cGVHD. Mean total score of OHRQoL was 16.5 (±11.7), negatively affected by functional problems. Patients reported highest scores regarding oral sensitivity and xerostomia. Significant correlations were found between severity of oral pain and OHRQoL and between oral sensitivity and OHRQoL. No correlation was found between oral mucosal cGVHD and OHRQoL. Patients with hyposalivation, normal salivary flow, and hypersalivation reported equal levels of OHRQoL. Conclusion Results demonstrate that the OHRQoL was mostly negatively affected by complaints of oral pain and oral sensitivity and less by the severity of oral mucosal cGVHD assessed by the NIH OMS score. Special attention of (oral) health care professionals for patients with oral cGVHD is mandatory to alleviate their symptoms and improve OHRQoL.

Parathormone is a key polypeptide hormone controlling bone remodeling by influencing calcium, phosphorus, and vitamin D homeostasis in mammalian body. This report describes unusual presentation of osteodystrophy causing facial hyperostosis due to nutritional secondary hyperparathyroidism in a puppy. A female Labrador Retriever dog aged 5 months was presented with progressive bilaterally symmetrical swelling on facial region, hypersalivation, and reduced growth rate. Excessive meat intake in daily ration since weaning was reported. Clinical examination revealed dyspnoea, open mouth breathing, epiphora, excessive nasal secretions, tachycardia, pale mucous membranes, debility, loosely attached teeth, and pigmented oral mucosa of the upper jaw. Microcytic anemia, lymphocytosis, eosinophilia, monocytopenia, hypoproteinemia with hypoglobulinemia, hyperalbuminemia, hypocalcemia, hyperphosphatemia, and decreased Ca:P ratio were evident in the hemato-biochemical study. Lateral radiographic view of the head revealed hyperostosis of the facial bones with irregularly arranged teeth on the upper jaw. Nutritional secondary hyperparathyroidism–induced facial osteodystrophy was diagnosed in the animal based on the history and other supporting clinical evidence. The animal was treated with a protocol extending for 4 weeks using calcium, calcitriol, essential minerals, vitamins, and steroids. The animal showed considerable improvement on day 14 and regained normal facial architecture by day 28 of the therapy.

Pneumomediastinum is defined as the presence of air in the mediastinum. Spontaneous pneumomediastinum is a very rare condition, often encountered in young male patients, and usually heals itself. In the anamnesis of a patient with spontaneous pneumomediastinum, there is chest pain most frequently observed in the substernal region. Besides pain, the reasons for applying to the clinic are difficulty swallowing, globus sensation, hoarseness and hypersalivation. We present 3 patients, who applied with different symptoms and received conservative treatment due to spontaneous pneumomediastinum.

OBJECTIVE Ketamine is commonly used as an anesthetic and analgesic agent for procedural sedation, but there is little evidence on its current use as a prolonged continuous infusion in the PICU. We sought to analyze the use of ketamine as a prolonged infusion in critically ill children, its indications, dosages, efficacy, and safety. METHODS We retrospectively reviewed the clinical charts of patients receiving ketamine for ≥24 hours in the period 2017–2018 in our tertiary care center. Data on concomitant treatments pre and 24 hours post ketamine introduction and adverse events were also collected. RESULTS Of the 60 patients included, 78% received ketamine as an adjuvant of analgosedation, 18% as an adjuvant of bronchospasm therapy, and 4% as an antiepileptic treatment. The median infusion duration was 103 hours (interquartile range [IQR], 58–159; range, 24–287), with median dosages between 15 (IQR, 10–20; range, 5–47) and 30 (IQR, 20–50; range, 10–100) mcg/kg/min. At 24 hours of ketamine infusion, dosages/kg/hr of opioids significantly decreased (p < 0.001), and 81% of patients had no increases in dosages of concomitant analgosedation. For 27% of patients with bronchospasm, the salbutamol infusions were lowered at 24 hours after ketamine introduction. Electroencephalograms of epileptic patients (n = 2) showed resolution of status epilepticus after ketamine administration. Adverse events most likely related to ketamine were hypertension (n = 1), hypersalivation (n = 1), and delirium (n = 1). CONCLUSIONS Ketamine can be considered a worthy strategy for the analgosedation of difficult-to-sedate patients. Its use for prolonged sedation allows the sparing of opioids. Its efficacy in patients with bronchospasm or status epilepticus still needs to be investigated.

Dental sleep medicine traditionally focuses on sleep-related breathing disorders, such as snoring and obstructive sleep apnea. However, everyday practice shows that also other sleep disorders touch on dentistry, including sleep-related orofacial pain, xerostomia, hypersalivation, gastroesophageal reflux disease and bruxism. A new definition, which covers all the diagnostic and treatment aspects of these disorders, has therefore been formulated for dental sleep medicine. This article describes why this development started and sketches the current state of affairs regarding the discipline of dental sleep medicine. The different dental sleep disorders are also described briefly, with special focus on the more remarkable associations between them.

Objective Rapidly and safely managing severe acute behavioural disturbance (ABD) in the prehospital setting is important for the welfare of both patient and prehospital clinician alike. We investigated the safety and effectiveness of ketamine as rescue sedation in patients with severe ABD. Methods This prospective observational study investigated ketamine use by a state ambulance service as rescue sedation for patients with severe ABD who remained agitated following droperidol administration. The primary outcome was the proportion of adverse events (vomiting, hypersalivation, emergence, over-sedation, airway obstruction, laryngospasm, hypoxia, bradypnoea and intubation). Secondary outcomes included time to sedation, requirement for additional sedation and rate of successful sedation. Results There were 105 presentations (males 69/102 [69%]; median age 31 years (16-83 years). The commonest causes of ABD were illicit drug (39%) and alcohol (33%) intoxication. The median total dose of intramuscular ketamine was 200 mg (interquartile range [IQR] 150-200 mg). There were 64 adverse events in 40 (38%) patients. Four had vomiting, two had hypersalivation, two had emergence, 15 were oversedated, four had hypoxia, three had bradypnoea and 16 were intubated. Sedation was achieved in 103 (98%) patients at a median time post-ketamine of 8 min (IQR 5-13 min). Additional sedation was administered to 41 patients (nine prehospital and 37 within 1 h of arriving to hospital). In 44 (42%) patients, ketamine successfully sedated the patient with no adverse effects and no ongoing sedation requirement. Conclusion The use of ketamine as rescue sedation in prehospital patients with severe ABD is effective. Adverse events are common but can be managed supportively.

ObjectiveMorvan syndrome is characterized by central, autonomic, and peripheral hyperexcitability due to contactin-associated protein 2 (CASPR2) antibody. Our objective was to study the clinical spectrum, electrophysiologic, autonomic, polysomnographic, and neuropsychological profile in patients with CASPR2–related Morvan syndrome.MethodsSerum and CSF samples that were CASPR2 antibody positive from 2016 to 2019 were assessed. Among them, patients with Morvan syndrome diagnosed based on clinical and electrophysiologic basis were included.ResultsFourteen (M:F = 10:4) patients with Morvan syndrome were included with age at onset of 37.1 ± 17.5 years. The clinical features were muscle twitching (12), insomnia (12), pain (11), paresthesias (9), hyperhidrosis (7), hypersalivation (6), double incontinence (3), spastic speech (2), dysphagia (2), behavioral disturbances (2), seizures (1), and cold intolerance (1). Neurologic examination revealed myokymia (12), hyperactive tendon reflexes (10), and tremor (6). EMG revealed neuromyotonia (12) and increased spontaneous activity (7). Autonomic function tests conducted in 8 patients revealed definite autonomic dysfunction (4), orthostatic hypotension (2), early dysfunction (1), and postural orthostatic tachycardia syndrome (1). Polysomnography findings in 6 patients revealed insomnia (3), absence of deep sleep (1), high-frequency beta activity (1), REM behavior disorder (1), and periodic leg movements (1). Neuropsychological evaluation showed subtle involvement of the left frontal and temporal lobe. Malignancy workup was negative. All patients were treated with steroids. There was complete neurologic resolution in follow-up with persistent neuropathic pain in 5 patients.ConclusionsThis study has contributed to the growing knowledge on CASPR2-related Morvan syndrome. It is important for an increased awareness and early recognition as it is potentially treatable by immunotherapy.

Hypersalivation is a common, clozapine-related adverse drug reaction with a serious impact on quality of life. Pharmacokinetic correlates of clozapine-related hypersalivation have evaded attention. The purpose of this study was to compare pharmacokinetic parameters between clozapine-treated patients with vs. without hypersalivation from a large therapeutic drug monitoring database. Out of a large therapeutic drug monitoring dataset of clozapine-treated patients, we compared a group of patients with hypersalivation (n = 72) and a control group of patients without any adverse reactions in this regard (n = 323). Comparisons included plasma concentrations and concentrations-by-dose as well as demographic characteristics between groups. Post-hoc analyses were performed separately in smokers and non-smokers. We used the non-parametric Mann–Whitney U test and the chi-square test, while effects of confounders were assessed using a bootstrapping analysis of covariance. Patients with hypersalivation had higher clozapine plasma concentrations and concentrations-by-dose (p

Objectives: To evaluate efficacy and side effects of free opioid anesthesia for laparoscopic cholecystectomy. Methods: A prospective study was performed on 94 patients undergoing laparoscopic cholecystectomy in Military Hospital 103 from May 2018 to February 2019. These patients were randomly allocated into two groups: patients in FOA (free - opioid anesthesia) group were administered lidocaine (2 mg/kg before induction and 1.5 mg/kg/h for maintenance), magnesium (30 mg/kg before induction and 1.5 g infusion for maintenance) combined with Intravenous (IV) injection of ketamine (0.5 mg/kg), and ketorolac (30 mg); while patients in OA group (opioid anesthesia) were provided with IV fentanyl (5 mcg/kg for induction and 1.5 mcg/kg every 30 minutes for maintenance of anesthesia). Both groups received total intravenous anesthesia by propofol. The depth of anesthesia was monitored by the entropy module during surgery. Neuromuscular blockade was reversed by sugammadex 2 mg/kg at the end of surgery. The postoperative analgesia was delivered using IV fentanyl for 48 to 72 hours. Visual Analog Scale (VAS) score was measured 10 mins, 20 mins, 1 hour, 2 hours and 3 hours after surgery. Results: All patients had an excellent quality of anesthesia with RE (Respond Entropy), SE (State Entropy) always under 60 from induction to abdominal closure without intraoperative awareness and postoperative recall of the operation; 100% of the patients were extubated immediately after surgery. In the first three postoperative hours fentanyl consumption in Group FOA was significantly lower than in Group OA (31.91 ± 3.98 mcg versus 34.47 ± 7.17 mcg, p=0,035). In the OA group, the rate of intraoperative hypotension was higher compared to its counterpart. Despite the higher risk of hypersalivation, group FOA had a significantly lower incidence of nausea and vomiting. Conclusion: Free opioid anesthesia provided adequate sedation and amnesia and may be an alternative approach to opioid anesthesia for laparoscopic cholecystectomy. Patients under free opioid anesthesia experienced a lower incidence of intraoperative hypotension, lower rate of nausea, vomiting and lower demand for analgesia in the early postoperative period (0 - 3 h) compared to those receiving opioid anesthesia.

Background Clozapine remains the only medication licensed for treating refractory schizophrenia. However, it remains underutilized in part due to concerns regarding adverse events. Sources of data Published literature. Areas of agreement Common adverse events during clozapine treatment include sedation, hypersalivation, postural hypotension, dysphagia, gastrointestinal hypomotility, weight gain, diabetes mellitus and dyslipidaemia. Rare but serious events include agranulocytosis, cardiomyopathy, myocarditis, pneumonia, paralytic ileus and seizure. Areas of controversy It remains unclear how best to minimize clozapine-induced morbidity/mortality (i) during dose titration, (ii) from hypersalivation and (iii) from gastrointestinal hypomotility. It is also unclear how clozapine pharmacokinetics are affected by (i) gastrointestinal hypomotility, (ii) systemic infection and (iii) passive exposure to cigarette smoke. Whether monthly haematological monitoring needs to continue after 12 months of uninterrupted therapy is also a subject of debate. Growing points There is a need for better management of serious clozapine-related adverse events in addition to agranulocytosis. There is also a need for better education of patients and carers, general practitioners, A&E and ITU staff and others of the problems posed in using clozapine safely. Areas timely for developing research There is a need for more research on assessing clozapine dosage (i) as patients get older, (ii) with respect to exposure to cigarette smoke and (iii) optimizing response if adverse events or other factors limit dosage.

A 10-year-old boy with spastic quadriplegic cerebral palsy (CP) was admitted into the hospital with a lower respiratory tract infection. His parents complained that he had a problem with excessive drooling of saliva; they had tried different treatments but to no avail. There was no formal guidance on the management of drooling in CP in the hospital. This raised the question regarding the effectiveness and safety of different interventions in the management of drooling in children with CP. In a child with CP (patient), which is the treatment with maximum effectiveness and minimum adverse effects (intervention) to reduce sialorrhoea (outcome)? MEDLINE, Embase, PsychINFO, AMED, PubMed, CINAHL, Cochrane Library and Google Scholar were searched from 1 January 1980 to 23 January 2020 and reference lists also scoured. Searches used synonyms of ‘drooling’ (sialorrhoea, hypersalivation, ptyalism, slobbering), ‘cerebral palsy’, ‘children’ and management/intervention/therapy. Two hundred and twenty-one unique records were screened (online supplementary figure 1) and 14 studies with 510 participants were included (table 1). Six studies evaluated the efficacy of botulinum toxin type A (BoNT-A) and one evaluated botulinum toxin type B (BoNT-B). Five trials examined pharmacological interventions: benztropine, glycopyrrolate and hyoscine. Three studies evaluated non-pharmacological non-invasive interventions: kinesio taping, oromotor exercises, functional chewing training and behavioural techniques. One randomised controlled trial (RCT) compared BoNT-A with submandibular duct ligation. No RCTs or controlled clinical trials could be retrieved on acupuncture or intraoral devices. ### Supplementary data [archdischild-2020-319309supp001.pdf] View this table: Table 1 Summary of included studies CP describes a group of permanent …

Niemann-Pick type C (NPC) is a rare autosomal recessive disorder characterized by storage of unesterified glycolipids and cholesterol in lysosome. NPC's clinical presentation is highly heterogeneous, depending on the time of onset. It encompasses visceral, neurological, and/or psychiatric manifestations. As the motor findings are so important and devastating in this disease, there is a lack of description about non-motor symptoms, even though they play important role in quality of life of NPC patients. We described the most common non-motor findings in NPC like cognitive dysfunction, neuroimaging, psychiatric symptoms, sleep disorders, seizures, hearing problems, respiratory and other systemic features, bladder and fecal dysfunction, hypersalivation, and malnutrition. In this review, we highlighted the importance of these undervalued symptoms and their management. Specific measures of all aforementioned clinical features may work as relevant biomarkers in order to evaluate successful therapies in future clinical trials.

Lacosamide, an antiepileptic drug prescribed for children with refractory focal epilepsy, is generally well tolerated, with dose-dependent adverse effects. We describe 4 children who developed a movement disorder in conjunction with the initiation and/or uptitration of lacosamide. Three patients developed dyskinesias involving the face or upper extremity whereas the fourth had substantial worsening of chronic facial tics. The patients all had histories suggestive of opercular dysfunction: 3 had seizure semiologies including hypersalivation, facial and upper extremity clonus while the fourth underwent resection of polymicrogyria involving the opercula. Onset, severity, and resolution of dyskinesias correlated with lacosamide dosing. These cases suggest that pediatric patients with dysfunction of the opercular cortex are at increased risk for developing drug-induced dyskinesias on high-dose lacosamide therapy. Practitioners should be aware of this potential side effect and consider weaning lacosamide or video electroencephalography (EEG) for differential diagnosis, particularly in pediatric patients with underlying opercular dysfunction.

A considerable number of patients arriving in dental offices are being treated with ongoing medication for a variety of chronic diseases. As a result, dentists must be familiar with the potential side effects these therapeutic agents may have on the tissues of the oral cavity, and in particular on the salivary gland. Salivary gland function may be altered by a wide range of medications, leading to effects such as xerostomia, hyposalivation, hypersalivation or even swelling of the glands. These disorders can cause a variety of other health complications. This review will focus on the most common groups of drugs responsible for salivary gland dysfunction, including psychoactive drugs, antidepressants, antipsychotics, antihypertensives, and antihistamines.

Background: Parkinson’s disease (PD) remains a challenge for neurologists, particularly in its advanced stages when non-motor symptoms become a burden for the patient. While motor symptoms may be satisfactorily controlled with levodopa therapy or continuous levodopa/carbidopa intestinal gel (LCIG) administration, autonomic, sleep and mental disorders are hard to treat. During the last years, researchers have shifted their interest more to non-motor symptoms, PD being now considered a complex multiorgan impairment. Objective: The aim of this study was to describe non-motor symptoms in 40 Romanian patients diagnosed with PD, under conventional and LCIG administration treatment. Methods: A cross-sectional observational study was conducted, consisting of two groups of 20 patients each: the first group comprised PD patients who received conventional Levodopa treatment, while the second group was formed of patients receiving LCIG therapy. Various data concerning patient’s age, gender, duration of illness, comorbidities, motor and non-motor symptoms were recorded. The data were processed in SPSS v.20. Results: Subjects under continuous LCIG administration, although showing amelioration of motor symptoms, complained more frequently of constipation, mental, and sleeping disorders (statistically significant). Regarding anosmia, orthostatic hypotension, hypersalivation, urinary incontinence and restless legs syndrome, no statistical significant difference was observed between the two groups (p > 0.05). Conclusion: Nowadays, more research is conducted on non-motor symptoms in PD patients, as therapeutic measures try to limit these burdens, in order to improve patient’s quality of life.

Pharyngeal foreign bodies are medical emergencies that require airway protection. Rapid diagnosis and adequate treatment are needed. However, in elderly patients with dementia, diagnosing foreign body aspiration sometimes seems difficult only from the medical history, so we should maintain a high degree of suspicion when treating patients with unexplained symptoms. We herein present a 95-year-old woman with hypersalivation and sore throat two hours after dinner. Due to her mild dementia, sufficient medical history could not be obtained. She could walk and talk, but could not swallow. Her vital signs were all within normal limits. There were no abnormal findings in the oral cavity. The neck x-ray images revealed the patent airway and foreign body in the hypopharynx. We used Macintosh laryngoscope and Magill forceps to remove the foreign body, which was a sliced lotus root with a diameter of 61 mm. After removal, she could swallow, and her symptoms rapidly improved. We should suspect this if the patient presents unexplained pharyngeal symptoms.

Background Administration of botulinum toxin through intraductal salivary infusion may decrease the risks of percutaneous needle injection and improve delivery to permeate the entire gland parenchyma. Methods The safety of intraductal salivary gland infusion was tested with prospective evaluation of two patients using interviews, clinical examination, and pressure measurement during infusion. Retrospective chart review of two subsequently treated patients assessed treatment of a parotid-cutaneous fistula and sialorrhea. Results No complications were identified in the safety study. Pressure changes during infusion supported the concept of botulinum neurotoxin delivery to permeate the gland. Patient-assessed success was subjectively reported as a reduction in the parotid-cutaneous output "by 95%" and the sialorrhea "by 90%" at 2-week follow-up. Conclusions The intraductal route of botulinum toxin delivery to salivary glands was without complication and was effective in two patients treated therapeutically. Pressure measurements during infusion may be helpful to direct treatment. Level of evidence 4.

The objective of this study is to discover whether incobotulinumtoxinA (inco) can reduce relative hypersalivation in patients with amyotrophic lateral sclerosis (ALS). 14 patients with ALS (8 males and 6 females, age 55.4 ± 16.3 years) received ultrasound-guided injection of inco 100 MU in both parotid glands and inco 50 MU in both submandibular glands. Saliva production was gravimetrically measured with three cotton rolls placed in the mouth. Weight increase after 5 min was measured on an electronic scale. Subjective saliva production was registered with drooling frequency scale (DFS) and drooling severity scale (DSS). Saliva production was gravimetrically reduced at week 4 (p = 0.04), week 8 (p = 0.01) but not after week 12 after BT application. DFS was reduced at week 4 (p = 0.04), week 8 (p = 0.02), but not after week 12. DSS was reduced at week 4 (p = 0.03), week 8 (p = 0.04) and week 12 (p = 0.04). Patients in our study did not experience changes in their swallowing patterns or any other safety-relevant events. Inco is effective and well tolerated for saliva reduction in patients with ALS for 8-12 weeks.

A 17-year-old male green tree python (Morelia viridis) was presented with anorexia, intermittent hypersalivation and open-mouth breathing since 2 months. Besides irresponsiveness to antimicrobial and supportive treatment, the presence of a focal coelomic distention was noted at the ventral aspect of the cardiac region 1 month after initial presentation. Ultrasonography revealed a well-defined mass located at the base of the heart and excluded a cardiogenic origin. Nuclear 99mTc-pertechnetate (99mTcO4−Na+) scintigraphy was performed to confirm or exclude a thyroid gland disorder. Explorative coeliotomy revealed the presence of an ulcerated mass originating from the mucosal surface of the esophagus. Caudal to the intraluminal mass, an esophageal perforation showing healthy margins was observed and successfully surgically restored. Based on histological and microbiological examination, the esophageal mass proved to be a bacterial granuloma associated with an esophageal perforation. The current case highlights the need for a multidirectional approach toward establishing a definitive antemortem diagnosis of granulomatous esophagitis and esophageal perforation in snakes. This is the first report of a surgically managed esophageal perforation in a snake.

OBJECTIVE: To compare the efficacy of hydromorphone and dexmedetomidine at inducing emesis in cats. DESIGN: Prospective, blinded, randomized crossover study. SETTING: Veterinary university teaching hospital. ANIMALS: 12 healthy purpose‐bred cats. INTERVENTIONS: Cats were randomly assigned to receive hydromorphone (0.1 mg/kg, subcutaneously) or dexmedetomidine (7 μg/kg, IM). Following administration, the incidences of emesis, number of emetic events, signs of nausea (hypersalivation, lip licking), temperature, heart rate, respiratory rate, and sedation score were recorded for 6 hours. MEASUREMENTS AND MAIN RESULTS: Emesis was successful in 9 of 12 (75%) cats when treated with hydromorphone and in 7 of 12 (58%) cats when treated with dexmedetomidine (P = 0.67). Dexmedetomidine was more likely to cause sedation than hydromorphone (P < 0.001). Heart rate in cats was significantly decreased at 1 and 2 hours post‐hydromorphone (P = 0.003, 0.014, respectively) and at 1, 2, 3, 5, 6 hours post‐dexmedetomidine (P = 0.001, 0.003, 0.038, 0.013, 0.001, respectively). Cats were more likely to develop an increase in body temperature with hydromorphone administration although this was not clinically significant. CONCLUSIONS: Results of the present study indicate that hydromorphone is an effective alternative to dexmedetomidine for the induction of emesis in cats. Hydromorphone appears to cause less sedation and less decrease in heart rate. Further investigation into the most adequate dose of hydromorphone for optimizing emesis is warranted.

ZusammenfassungHypersalivation bezeichnet einen übermäßigen Speichelfluss, der durch insuffiziente orofaziale Fähigkeiten, verminderte zentralnervöse Kontrolle und Koordination oder gestörte Schluckabläufe entstehen kann. Die Aktualisierung der S2k-Leitlinie soll den neuen diagnostischen und therapeutischen Kenntnisstand berücksichtigen.Die Diagnostik- und Therapiemaßnahmen sollten multidisziplinär erfolgen. Schwerpunkte sind die Abklärung von Schluckstörungen mit Speichelaspiration. Hier sind klinische Screeninguntersuchungen und die fiberendoskopische Schluckuntersuchung (FEES) hervorzuheben.Bei fast allen Ursachen sind die schlucktherapeutischen Übungsmaßnahmen zur Aktivierung und zum Erlernen von Kompensationsmechanismen unverzichtbar. Insbesondere bei Kindern mit hypotoner orofazialer Muskulatur sind myofunktionelle Therapiekonzepte indiziert, allerdings ist die Kompetenz zur Mitarbeit entscheidend. Zusätzlich können orale Stimulationsplatten durch die Veränderung der Zungenpositionierung zu einer Symptomreduktion führen. Sinnvolle medikamentöse Therapien sind insbesondere die verschiedenen Applikationsformen von Glycopyrrolat, von denen Sialanar® (Glycopyrronium) als Saft eine Genehmigung zur Behandlung bei Kindern ab 3 Jahren und Jugendlichen erhalten hat. Die Injektion von Botulinumtoxin in die Kopfspeicheldrüsen hat sich als effektive und sichere Behandlungsform mit einer langanhaltenden Speichelreduktion erwiesen. Für Incobotulinumtoxin A ist die Phase III-Studie bei Erwachsenen aktuell abgeschlossen und führte in den USA bereits zur Zulassungserweiterung bei Hypersalivation. Chirurgische Eingriffe der Speicheldrüsen bleiben Einzelfällen vorbehalten. Die Bestrahlung der Speicheldrüsen ist, insbesondere wenn sie in moderner 3-D-konformaler Technik zur Gewebeschonung durchgeführt wird, eine sichere und effektive Therapie. In einer regelhaften Nachsorge sind Therapieeffekte und mögliche Nebenwirkungen zu erfassen; insbesondere bei neurodegenerativen Erkrankungen ist die individuelle Dynamik der Symptomverschlechterung zu berücksichtigen.

Objectives: Tooth wear is a common finding in adult patients with dental sleep disorders. The aim of this paper was to review the literature on the possible associations between tooth wear and the following dental sleep disorders: sleep‐related oro‐facial pain, oral moistening disorders, gastroesophageal reflux disease (GERD), obstructive sleep apnoea syndrome (OSAS) and sleep bruxism.Methods: A PubMed search was performed on 1 June 2018 using MeSH terms in the following query: Tooth Wear AND (Facial Pain OR Temporomandibular Joint Disorders OR Xerostomia OR Sialorrhea OR Gastroesophageal Reflux OR Sleep Apnea Syndrome OR Sleep Bruxism).Results: The query yielded 706 reports on tooth wear and the mentioned dental sleep disorders. Several associations between tooth wear and the dental sleep disorders were suggested in the literature. It could be concluded that: (a) tooth wear is associated with dental pain and/or hypersensitivity; (b) oral dryness is associated with tooth wear, oro‐facial pain and sleep bruxism; (c) GERD is associated with tooth wear, oro‐facial pain, oral dryness, OSAS and sleep bruxism; (d) OSAS is associated with oral dryness, GERD and sleep bruxism; and (e) sleep bruxism is associated with tooth wear.Conclusions: Tooth wear is associated with the dental sleep disorders oro‐facial pain, oral dryness, GERD and sleep bruxism. The dental sleep disorders are interlinked with each other, which leads to indirect associations as well, and makes the consequences of each single condition difficult to disentangle. Knowledge of these associations is clinically relevant, but more research is needed to confirm their validity.

The management of head and neck cancers (HNC) and esophageal cancer (EC) is complex and often involves multiple modalities of treatment, including chemotherapy, radiation therapy, and surgery. The side effects associated with these therapies and disease processes are extensive. A literature review was performed to evaluate the use of botulinum toxin as an intervention for side-effect management in patients with HNC and EC. Specific adverse events reviewed included salivary function (hypersalivation, fistula, hyposalivation) and gastrointestinal motility (esophageal stricture, delayed gastric emptying after esophagectomy). Published results demonstrate an improvement in hypersalivation and, when botulinum toxin was used as an adjunct to treatment, a reduction in symptoms associated with salivary fistula, or an inappropriate communication between the salivary gland and the skin that causes the leakage of saliva through the skin. Positive effects were also demonstrated in regard to esophageal stricture and equivalent effects in the management of gastric emptying to prevent complications after esophagectomy when compared to currently available interventions. However, the potential for increased symptoms associated with botulinum toxin injection related to its use in the management of gastric secretions was noted in one of the studies reviewed.

Hypersalivation is a well-known ictal semiology of benign Rolandic epilepsy and other childhood epilepsy syndromes. There are also occasional reports of adults with temporal, parietal, or frontal lobe epilepsy in which hypersalivation is a prominent seizure manifestation. Notably lacking are reports linking salivary gland enlargement to ictal hypersalivation. A 33-year-old man with frontal lobe epilepsy due to a ruptured aneurysm presented with focal seizures and facial swelling. The only seizures he had in the past were generalized tonic-clonic seizures. Eight days prior to admission, he started having focal seizures characterized by pronounced hypersalivation, speech arrest, impaired awareness, and left upper extremity posturing or automatism. Seizure frequency increased from five to 30 per day. Four days prior to admission, his face started to swell up, and his family thought he had mumps. Computed tomography (CT) of the head showed encephalomalacia in the inferomedial cortex of the right frontal lobe, the same lesion seen in his old CT images. Maxillofacial CT revealed enlargement of the parotid and submandibular glands. Although electroencephalography (EEG) showed seizure onset in the right frontal region, the initial ictal discharge on the scalp may represent seizure propagation from a focus near the zone of encephalomalacia. After seizure freedom was achieved with antiepileptic drugs, the patient's salivary glands decreased in size and returned to normal.

Background There is little knowledge about factors which may affect oral health among older adults. The objective of this study was to determine the relationship between Streptococcus mutans (MS) and Lactobacilli (LB) counts and caries among older adults. Methods In this community-based observation study, 141 participants aged 60 years and above were recruited from the west district of Singapore. Alongside the clinical examination, saliva samples were collected to determine Streptococcus mutans (MS) and Lactobacilli (LB) counts, as well as to record salivary flow rate and buffering capacity of saliva. Results Of the 141 participants, 63.8% were female and 94.3% were of Chinese ethnicity. The mean DMFT was 11.08 (s.d. 8.27). 9.9% of participants had at least one decayed tooth, 52.5% had minimum one missing tooth and 86.5% had at least one filled tooth. 67.4% had MS counts of ≥ 105 while LB counts were ≥ 105 for 48.2%. 83.7% had normal salivary flow or hypersalivation (> = 1 mL/min), the buffering capacity of the saliva was alkaline in 61% of the participants. Multivariate analysis showed that participants who had high MS counts were less likely to have a DMFT Conclusion Our study showed a positive correlation between MS and LB counts and caries experience in older adults. The mean DMFT was on the low side in our sample despite having a relatively high MS count. This suggests that there are many other factors which vary according to host environment, physiological and biological conditions that may affect MS and LB counts in the oral cavity. Clinical relevance Our study supports the knowledge that the aetiology of dental caries among older adults is a complex process and it would be wrong to consider caries as a same problem with the same solution for all age groups.

Salivary glands pathology is various and very often related to a significant impairment of the patient’s oral quality of life. Drug-induced salivary complications are very common, especially in polymedicated and long-course treated elderly patients. Medication may result in increased or decreased salivary secretion and altered taste. Most often, hyposialia are drug induced.

Background: Parkinson’s disease is the second most common neurodegenerative disorder which affectsaround four million people globally.Many of the signs of Parkinson’s disease are found in the head andneck. The typical “masklike” facial appearance with infrequent blinking and lack of expression is causedby bradykinesis.. Abnormalities in oral behaviour, such as purposeless chewing, grinding, and suckingmovements, are also well recognized in patients with Parkinson’s disease.Aim and Objectives: The aim of this study is to assess the overall oral health status of the patients withParkinson’s disease and to analyze the impact of Parkinson’s disease on the oral cavity of the individualssurviving with the disease.Materials and Methods: The study sample included 50 Parkinson’s disease patients. The patients of all agegroups and both genders were included.Results: Out of fifty patients. majority of the patient s were above 60 yrs. 6% of the patients reported withPositive family history of Parkinson’s diseases.14% of the patients had gross facial asymmetry, 68% of thepatients showed dryness of mouth.8% of the patients suffered loss of taste.14% of the patients showed hypersalivation. 54% of the patients showed gingivitis. And 76% of the patients were found having periodontitis.Conclusion: Treatment for oral and dental problems of Parkinson’s disease affected patients is mandatory.Treatment can be done by supplementing artificial saliva for dryness of mouth, dental fillings for dentalcaries, periodic scaling for periodontal problems, oral rehabilitation measures and regular dental check up

Organophosphate pesticide (OP) poisoning is quite common and can cause cardiovascular complications and even direct myocardial injury. However, no guideline has included an acute poisoning as a potential cause for a type 2 myocardial infarction (MI) so far. Here we present a case of a 61-year-old woman brought by ambulance to emergency department one hour after accidental ingestion of an unknown quantity of a solution she used against flea infestation. The patient presented with dizziness, myosis, excessive sweating, hypersalivation, sphincteric incontinence, muscle fasciculation, tremor of the extremities, pale skin, alcoholic and pesticide breath odour. Even though we had no guidelines to fall back on, we successfully treated the patient with low-molecular-weight heparin, antiplatelets, statin, diltiazem, antidote therapy, and supportive care. Physicians should be aware that OP poisoning can induce type 2 MI as a complication within a few hours since exposure, and emergency management should always include close cardiac monitoring., Otrovanje organofosfatnim pesticidima prilično je često i može dovesti do komplikacija sa srcem i krvožiljem, a ponekad i izravno oštetiti srčani mišić. Do sada, međutim, nije zabilježen slučaj infarkta miokarda tipa 2. U ovom je radu prikazan slučaj otrovanja 61-godišnjakinje koja je primljena u odjel hitne pomoći jedan sat nakon slučajnoga gutanja nepoznate količine otopine koju je upotrebljavala za suzbijanje biljnih uši. Bolesnica je primljena sa znakovima i simptomima ošamućenosti, mioze, prekomjernoga znojenja, hipersalivacije, urinarne inkontinencije, mišićne fascikulacije, drhtavice u udovima, bljedilom te dahom koji je mirisao na alkohol i pesticide. Premda nije bilo smjernica za liječenje u takvom slučaju, primjena heparina niske molekulske mase, antitrombotika, statina, diltiazema, antidota i potpornoga liječenja dovela je do povoljnog ishoda. Svrha je ovoga prikaza ukazati liječnicima da otrovanje organofosfatima može uzrokovati infarkt miokarda tipa 2, koji se javlja kao komplikacija unutar nekoliko sati od otrovanja, tako da obrada u odjelu hitne pomoći svakako treba obuhvatiti i strogi nadzor srčane funkcije.

Objectives: The present study describes clinical, biochemical, molecular genetic data, current treatment strategies and follow-up in nine patients with tetrahydrobiopterin (BH4) deficiency due to various inherited genetic defects. Methods: We analyzed clinical, biochemical, and molecular data of nine patients with suspected BH4 deficiency. All patients were diagnosed at Ege University Faculty of Medicine in Izmir, Turkey and comprised data collected from 2006 to 2019. The diagnostic laboratory examinations included blood phenylalanine and urinary or plasma pterins, dihydropteridine reductase (DHPR) enzyme activity measurement in dried blood spots, folic acid and monoamine neurotransmitter metabolites in cerebrospinal fluid, as well as DNA sequencing. Results: Among the nine patients, we identified one with autosomal recessive GTP cyclohydrolase I (ar GTPCH) deficiency, two with 6-pyruvoyl-tetrahydropterin synthase (PTPS) deficiency, three with sepiapterin reductase (SR) deficiency, and three with DHPR deficiency. Similar to previous observations, the most common clinical symptoms are developmental delay, intellectual disability, and movement disorders. All patients received treatment with l-dopa and 5-hydroxytryptophan, while only the ar GTPCH, the PTPS, and one DHPR deficient patients were supplemented in addition with BH4. The recommended dose range varies among patients and depends on the type of disease. The consequences of BH4 deficiencies are quite variable; however, early diagnosis and treatment will improve outcomes. Conclusions: As BH4 deficiencies are rare group of treatable neurometabolic disorders, it is essential to diagnose the underlying (genetic) defect in newborns with hyperphenylalaninemia. Irreversible brain damage and progressive neurological deterioration may occur in untreated or late diagnosed patients. Prognosis could be satisfying in the cases with early diagnose and treatment. © 2021 The Authors. JIMD Reports published by John Wiley & Sons Ltd on behalf of SSIEM.

INTRODUCTION Sialorrhea, also known as hypersalivation, ptyalis, or drooling, results in physical and psychosocial complications that may have a significant negative impact on quality of life for both the patient and their caregiver. The goal of pharmacological treatment is to reduce excessive salivary flow, while maintaining a moist and healthy oral cavity; until recently, however, few of the agents used to treat chronic sialorrhea have been approved in pediatric patients. AREAS COVERED This article summarizes early evidence for the use of botulinum neurotoxin A formulations in the treatment of children/adolescents with chronic sialorrhea, and findings of the recently completed phase III trial of incobotulinumtoxinA in this indication. Alternative therapies are also briefly discussed. EXPERT OPINION IncobotulinumtoxinA is the first botulinum neurotoxin A to be approved for the treatment of chronic sialorrhea in children and adults, following the results of phase III trials that demonstrate the efficacy and safety of the drug in these patients. The authors expect that the positive findings will result in updates to clinical guidelines for the treatment of children with chronic sialorrhea. ABBREVIATIONS AE, adverse event; AESI, adverse event of special interest; BoNT/A, botulinum neurotoxin A; CI, confidence interval; CP, cerebral palsy; DIS, drooling impact scale; DQ, drooling quotient; DSFS, Drooling Severity and Frequency Scale; GICS, Global Impression of Change Scale; LS, least squares; mTDS, modified Teacher's drooling scale; NR, not reported; PD, Parkinson's disease; SAE, serious adverse event; SE, standard error; SIAXI, Sialorrhea in Adults Xeomin Investigation; SIPEXI, Sialorrhea Pediatric Xeomin Investigation; SNAP-25, synaptosomal associated protein-25; TBI, traumatic brain injury; TDS, Teacher Drooling Scale; USA, United States of America; uSFR, unstimulated Salivary Flow Rate; VAS, visual analog scale.

Introduction: Saliva is the most important biological factor to protect against dental caries. When saliva flow is reduced, oral health problems such as dental caries and oral infections can develop. It was suggested that the effect of low salivary pH is more in plaque close to the area of susceptible tooth surface. The presence of saliva in pre-school age children is a significant indicator in oral health assessment oral health. There has been an association between salivary cortisol and socioeconomic variable. Descriptions above have encouraged us to examine the salivary pH, feature, and volume of pre-school-aged community. Thus, this study was aimed to describe the differences in salivary pH, feature, and volume of the children in the three pre-school with different location and socioeconomics aspect. Methods: Descriptive survey, with a population of preschool students in 3 different kindergartens with different socioeconomic environment. Inclusion criteria were the pre-school-aged community and got permission from parents. Exclusion criteria were a pre-school-aged community under medication treatment causes hyposalivation or hypersalivation and children who did not want to be involved in the study, with total sampling as the sampling technique, resulted in as much a 101 respondents as the study sample. The saliva was collected with unstimulated technique. Data analysis was performed using relative frequency distribution. Results: The salivary pH was slightly higher in male children than female by 0.1. The average pH value was 7.25. The salivary feature was mostly frothy bubbly, followed by thin and watery, and the sticky bubbly feature was found the least. The salivary volume of the pre-school-aged community was mostly in the very less category, followed by the less category, with no normal category was found. the p-values of salivary pH and salivary features were below 0.05 There are no significant differences between the salivary pH and salivary feature of children from the three studied kindergartens. However, there is a significant difference in the salivary volume found in children from kindergartens located in high socioeconomic standard and middle socioeconomic standard areas, which have a higher salivary volume than the children from kindergartens situated in areas with lower socioeconomic standard. Conclusion: since the reduced salivary volume was associated to children with lower socioeconomic standard, this association can justify the higher risk for caries described in the literature. KEYWORDS Salivary pH; Salivary feature; Salivary volume; Pre-school-aged children.

Arizona's rugged desert landscape harbors many venomous animals, including a small nocturnal scorpion, Centruroides sculpturatus, whose venom can cause severe neuromotor disturbance. An effective antivenom is available at selected health care facilities in the state.We analyzed 4398 calls of scorpion stings to the Arizona Poison and Drug Information Center (APDIC) in Tucson over a period of 3 years, from January 2017 to December 2019.We followed 1952 (44.4%) of the victims to resolution. We excluded 2253 callers with minimal effects of the sting and 193 victims with possible toxic effects who were lost to follow-up. The most common complaints among callers were pain at the sting site in 88.9% and local numbness in 62.2%. Detailed clinical information was obtained from 593 calls from a health care facility. Neuromotor signs consistent with C. sculpuratus envenomation included nystagmus in 163 (27.5%), hypersalivation in 91 (15.3%), and fasciculations in 88 (14.8%). Antivenom (Anascorp; Rare Disease Therapeutics, Inc., Franklin, Tenn) was administered to 145 patients. Most were children5 years old (n = 76, or 54.4%); 27 (18.6%) were 5-9 years old and 42 (30.0%) were ≥10 years of age. About half, 79 of 145 (54.5%) victims who received antivenom, met the APDIC recommended use criteria.Patients treated with antivenom exhibited a rapid resolution of symptoms without immediate or delayed hypersensitivity reactions. We recommend broadened availability of antivenom at sites where it is most needed.

Rapidly progressing descending areflexic quadriplegia with autonomic dysfunction in the form of hypertension, tachycardia, hypersalivation, sweating and lacrimation in the absence of proper history from attendants poses a challenge in emergency area. Neuroparalytic snake envenomation by elapid species has been known to produce autonomic symptoms and even locked-in states. Here we present a case of young male with rapidly progressing areflexic quadriplegia with autonomic dysfunction; with no documented history of snake bite who improved after antisnake venom and ventilatory support.

Objectives To determine the frequency, severity and duration of adverse events including myoclonus, pain on injection, hypersalivation, regurgitation and apnoea after administration of midazolam or saline followed by etomidate in hydromorphone premedicated dogs. Materials and methods Dogs undergoing elective dental prophylaxis or soft tissue surgeries were enrolled in this randomised trial. Dogs were premedicated with hydromorphone 0.1 mg/kg IV. Sixty seconds later, midazolam 0.3 mg/kg or saline at an equivalent volume was administered IV. Sixty seconds after that, etomidate 1.5 mg/kg IV was administered over 60 seconds. Additional doses of 0.5 mg/kg etomidate were administered until endotracheal intubation was successful. Observers were blinded to the treatment. Frequency, duration and a severity score of 0 to 3 were recorded for myoclonus, pain on injection, hypersalivation and regurgitation. Duration of apnoea and frequency of any additional complications was recorded. Results Forty variable breed healthy dogs were enrolled in the study. Myoclonus, pain on injection, regurgitation, hypersalivation, gagging, tachypnoea and pigmenturia occurred, respectively, in 10%, 40%, 0%, 15%, 35%, 25% and 5% of dogs in the saline group and 0%, 65%, 0%, 10%, 45%, 15% and 5% of dogs in the midazolam group. Apnoea occurred for 115 seconds (range 0 to 660 seconds) and 160 seconds (range 0 to 600 seconds) in the saline and midazolam groups, respectively. Two dogs developed pigmenturia. The trial was stopped early due to the occurrence of pigmenturia. Clinical significance Due to early stopping of the trial, the predefined sample size was not reached. Further investigation is needed to determine if midazolam reduced the incidence of adverse events or improved the induction quality when combined with hydromorphone and etomidate.

A three-month-old male suckler calf presented with a history of acute recumbency, anorexia, hypersalivation and subsequent central blindness. The calf was in a group at grass near an old quarry, so concerns were raised regarding primary lead toxicity and supportive treatment implemented. Unfortunately, this treatment proved unsuccessful and the calf passed away. A damaged lead-acid car battery was later found in the field and postmortem testing of kidney tissue yielded lead levels of 22 mg/kg, with

Case summary A 3-year-old entire female Burmese cat was presented for investigation of intermittent lethargy during gestation followed by persistent hypersalivation and ataxia postpartum. The cat had queened three litters in total, with clinical signs worsening during the most recent lactation period. Mild anaemia (26%), hypoglycaemia (2.4 mmol/l; reference interval [RI] 3.9–8.3 mmol/l) and increased postprandial serum bile acids (74 µmol/l; RI Relevance and novel information Mesentericorenocaval portosystemic shunt morphology has not been previously reported in the cat and should be considered as a differential diagnosis for cats presenting with peripartum onset of malaise, ptyalism or ataxia.

Oral mucositis is a common side effect of chemo and radiotherapy causing painful ulcers in the oral mucosa. One of the preventive treatments recommended in international guidelines is oral cryotherapy (OC). Randomized clinical trials on OC have used ice and ice-chips to cool the mouth, but this cooling method can be difficult for the patients to tolerate. Studies have shown that OC with ice for a period of 60 min reduces the oral temperature by 12.9 degrees C. The aim of this pilot study was to evaluate the temperature reduction and tolerability of OC using an intra-oral air-cooling (IOAC) device in healthy volunteers. Twelve healthy volunteers, mean age 35.4 years, were included in the study. They were treated with OC using the IOAC device for 60 min. Measurements of temperature were obtained at baseline, 5 and 60 min using a FLIR (R) C2 camera. After the OC session, tolerability and adverse events were documented using a questionnaire. All participants were able to use the device for 60 min. The overall temperature reduction after 5 min of OC was 10.7 degrees C (p < 0.01) and after 60 min 14.5 degrees C (p < 0.01). The most common adverse events were bad fit of the mouthpiece (n = 6), hypersalivation (n = 6), and difficulties swallowing (n = 5). The oral device reduced the temperature of the oral mucosa as much as treatment with ice with tolerable adverse events. The mouthpiece will be remodeled to improve tolerability before further studies are conducted. A Correction to this article was published on 29 January 2021.Correction in: MEDICAL ONCOLOGY, Volume:38, Issue:2, Article Number:16, DOI:10.1007/s12032-020-01453-y

The purpose of this study was to develop the Glasgow Antipsychotic Side effects Scale for Clozapine Japanese version (GASS-C-J) and examine its reliability to assess clozapine-related side effects. We developed the GASS-C-J using forward and backward translation. Semantic equivalence of the GASS-C-J to the GASS-C was confirmed by the original author. We then administered the GASS-C-J twice to 109 patients on clozapine treatment at two psychiatric hospitals in Japan. We assessed the internal consistency and test-retest reliability of the GASS-C-J using Cronbach's alpha and weighted kappa coefficient, respectively. We also examined if discrepancies in each GASS-C-J item score between the first and second rating were correlated with items of the Brief Evaluation of Psychosis Symptom Domains (BE-PSD). The Cronbach's alpha coefficient of the GASS-C-J at the first and second rating was 0.78 (95% CI: 0.72 to 0.84) and 0.82 (95% CI: 0.76 to 0.88), respectively. The weighted kappa coefficient of individual and total GASS-C-J item scores ranged from 0.45 to 0.88. Some symptom domains were correlated with discrepancies in specific items of the GASS-C-J: psychotic symptoms and nausea/vomiting (rs = 0.27), thirst (rs = 0.31), and appetite/weight gain (rs = 0.27); disorganized thinking and urinary incontinence (rs = 0.26); depression/anxiety and myoclonus (rs = 0.25), hypersalivation (rs = -0.27), and blurred vision (rs = -0.22). These findings demonstrate that the GASS-C-J can be used in clinical and research settings as a reliable scale to assess clozapine-related side effects.

BACKGROUND: Anaphylaxis is a systemic hypersensitivity reaction marked by life-threatening, rapid onset of the airway, breathing, and circulation problems. Despite its rare incidence, without proper treatment, it may cause fatality. CASE REPORT: In this report, we present a 19-year-old female with an infected ovarian cyst, who was scheduled for gynecologic laparotomy. In pre-operative assessment, she was classified as an American Society of Anesthesiologist (ASA) one patient without any history of drug or food allergy. Hemodynamic changes occurred on anesthesia induction after the administration ofatracurium, a muscle relaxant agent. Marked clinical signs were wheezed-bronchospasm, dyspnea, hypersalivation, desaturation, tachycardia, hypotension, and systemic erythema. She was diagnosed with anaphylactic shock. We provided 100% oxygenation, fluid resuscitation, epinephrine, and supportive therapy by anaphylaxis guidelines. Respiratory and cardiovascular functions stabilized 2 h post-resuscitation. The surgery was canceled, and she was observed in ICU for 24 h. CONCLUSION: Timely diagnosis and early resuscitation are key factors determining the outcome of an anaphylactic reaction.

Attenuating emesis elicited by both disease and medical treatments of disease remains a critical public health challenge. Although cannabinergic medications have been used in certain treatment-resistant populations, Food and Drug Administration–approved cannabinoid antiemetics are associated with undesirable side effects, including cognitive disruption, that limit their prescription. Previous studies have shown that a metabolically stable analog of the endocannabinoid anandamide, methanandamide (mAEA), may produce lesser cognitive disruption than that associated with the primary psychoactive constituent in cannabis, Δ(9)-tetrahydrocannabinol (Δ(9)-THC), raising the possibility that endocannabinoids may offer a therapeutic advantage over currently used medications. The present studies were conducted to evaluate this possibility by comparing the antiemetic effects of Δ(9)-THC (0.032–0.1 mg/kg) and mAEA (3.2–10.0 mg/kg) against nicotine- and lithium chloride (LiCl)-induced emesis and prodromal hypersalivation in squirrel monkeys. Pretreatment with 0.1 mg/kg Δ(9)-THC blocked nicotine-induced emesis and reduced hypersalivation in all subjects and blocked LiCl-induced emesis and reduced hypersalivation in three of four subjects. Pretreatment with 10 mg/kg mAEA blocked nicotine-induced emesis in three of four subjects and LiCl-induced emesis in one of four subjects and reduced both nicotine- and LiCl-induced hypersalivation. Antiemetic effects of Δ(9)-THC and mAEA were reversed by rimonabant pretreatment, providing verification of cannabinoid receptor type 1 mediation. These studies systematically demonstrate for the first time the antiemetic effects of cannabinoid agonists in nonhuman primates. Importantly, although Δ(9)-THC produced superior antiemetic effects, the milder cognitive effects of mAEA demonstrated in previous studies suggest that it may provide a favorable treatment option under clinical circumstances in which antiemetic efficacy must be balanced against side effect liability. SIGNIFICANCE STATEMENT: Emesis has significant evolutionary value as a defense mechanism against ingested toxins; however, it is also one of the most common adverse symptoms associated with both disease and medical treatments of disease. The development of improved antiemetic pharmacotherapies has been impeded by a paucity of animal models. The present studies systematically demonstrate for the first time the antiemetic effects of the phytocannabinoid Δ(9)-tetrahydrocannabinol and endocannabinoid analog methanandamide in nonhuman primates.

Background : Poisoning by Xanthium spp. plants are important causes of deaths of cattle in the state of Rio Grande do Sul. This plant has as toxic principle a triterpenoide glycoside that acts inhibiting the transport of adenosine diphosphate and adenosine triphosphate across the mitochondrial membrane, responsible for causing acute liver failure. Clinical signs occur within hours of ingesting the plant. However, the knowledge of the metabolic disorders that these animals suffer are poorly described, so the objective of the reports is to describe an outbreak of spontaneous intoxication by Xanthium cavanillesii and demonstrate the clinical, metabolic and anatomopathological changes of a poisoned bovine. Case : An 8-month-old male bovine, Aberdeen Angus breed, was sent to the Veterinary Hospital of Clinics of Federal University of Pelotas (HCV-UFPel). The animal came from a property located in the southern region of Rio Grande do Sul, belonged to a herd of 506 animals, of which 258 were nulliparous cows and 248 calves, in total 92 died, being 20 cows and 62 calves in a period of 3 days. The clinical course ranged from 3 to 72 h and was characterized by neurological signs (pedaling movements, opisthotonus and motor incoordination), sternal decubitus, muscle tremors, apathy, anorexia, hypersalivation, dehydration, tenesmus and death. In the field where the animals were, there was the present of Xanthium cavanillesii in the dicotyledonouns sprouting phase, with signs of ingestion. During the clinical examination of the animal sent to the hospital, sternal decubitus, muscle tremor, motor incoordination, apathy, anorexia, hypersalivation and opisthotone were observed, heart rate of 60 beats per minute, respiratory rate of 15 movements per minute, 2 ruminal movements incomplete at every 2 minutes, moderate dehydration and temperature of 37.9o C. For laboratory exams, blood samples were collected in vacuum tubes with 10% EDTA, to perform blood count with hemoparasite research, and without anticoagulant, to perform serum biochemistry tests, liver and kidney function. Highlighting the increase in liver enzymes (aspartate aminotransferase, gamma glutamyltranferase and alkaline phosphatase), hypoglycemia, elevation of total bilirubin and direct bilirubin, hypoalbuminemia, increase in triglycerides with leukocytosis by neutrophilia with regenerative left shift. Due to advanced clinical condition of the animal, was realized euthanasia for post-mortem examination. At necropsy, the main diagnostic macroscopic lesions were an accentuation of the lobular pattern of the organ parenchyma with the appearance of “nutmeg” and centrilobular coagulative necrosis accompanied by congestion and hemorrhages, characterizing a picture of acute liver failure. In addition, X. cavanillesii fruits were detected in the rumen content. Discussion : The diagnosis was based on epidemiological, clinical-anatomopathological, laboratory data and experimental reproduction of the disease in cattle and sheep. Regarding the epidemiological findings, the presence of the plant with signs of ingestion stands out in addition to the absence of other plants capable of producing similar cases on the farm. The metabolic changes described, if analyzed in isolation, do not confirm the diagnosis, but combined with other parameters, it contributes to the assessment and prognosis of the patient, becoming of great importance in elucidating and conducting the clinical condition.

Background: Idiopathic trigeminal neuropathy is a peripheral neuropathy whose clinical signs include inability to close the mouth. A neurological examination reveals mainly flaccid paralysis of the masticatory muscles, which may be accompanied by atony/hypotonia of the masseter and temporalis muscles. Altered sensitivity may also be present in very rare cases. This article reports a case of idiopathic trigeminal neuropathy with involvement of the motor and sensory nerve fibers in a dog, describing the clinical symptoms, neurological findings, exclusion of other diseases, and evolution of the condition.Case: A 5-year-old bitch showing signs of difficulty in picking up food, swallowing water, and hypersalivation was taken to a veterinary clinic. According to her owner, these signs had started spontaneously 2 days earlier. A physical examination of the animal revealed only a persistently open mouth, although the mouth opening and closing movements could be performed manually by manipulating the jaw. The patient showed swallowing ability, and her tongue movements were intact. The neurological examination revealed that the animal also presented bilateral absence of nasal sensitivity and absence of palpebral reflex. The animal’s blood test results showed changes only in the CK and AST levels, which were 1,182.60 U/L (reference: 1.5 to 28.4 U/L) and 87.1 IU/L (reference: 6.2 to 13 IU/L), respectively. The animal tested negative for distemper, leishmaniasis, toxoplasmosis and neosporosis. Abdominal ultrasound and thoracic radiography were performed to investigate neoplasia, as well as radiography of the temporomandibular joints, and none of these imaging tests revealed any alterations. A cerebrospinal fluid (CSF) analysis was also within the normal range of reference parameters. In view of the possibility of idiopathic trigeminal neuropathy, prednisolone (Prediderm® 10 mg) was prescribed, to be administered orally in a dose of 0.5 mg/kg at 12 h intervals for 2 days. In addition, the owner was told to provide supportive care by feeding the animal a pasty diet placed directly in the back of its mouth, using a syringe if necessary. An examination of the animal in a follow-up visit to the veterinary clinic 14 days later found that she had recovered completely from her initial condition.Discussion: Among the most common causes of neurogenic flaccid paralysis of the masticatory muscles is idiopathic trigeminal neuropathy, although trigeminal neuropathy secondary to neoplasms and infectious or parasitic diseases may also occur. Because its etiology is of unknown origin, it is essential to exclude other causes of peripheral neuropathies. Moreover, this disorder is characterized by its self-limiting evolution, with spontaneous cure of the clinical condition within two weeks, as was observed in the case reported here. The absence of nasal sensitivity is not usually found in dogs diagnosed with idiopathic trigeminal nerve paralysis. In this case, however, there was involvement of the motor and sensory fibers, since, in addition to flaccid paralysis of the masticatory muscles, nasal sensitivity was also found to be affected. The condition can be treated with corticosteroids when it first appears, simply in order to hasten the animal’s recovery from the disorder. In addition, given the animal’s inability to close its mouth, it is essential to provide supportive care by feeding it with pasty foods and water by hand to ensure it receives adequate nutrition during the course of the disorder.