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Abstract This study aimed to compare parental satisfaction between two pediatric dental anesthesia techniques, computerized intraosseous anesthesia (CIA) and inferior alveolar nerve block (IANB). This study was designed as a split-mouth randomized controlled clinical trial. A total of 52 parents of children undergoing dental treatment were enrolled in the study. Each participant received both CIA and IANB anesthesia, with the order of administration randomized. Parental satisfaction was evaluated using the parental satisfaction of dental local anesthetic techniques scale (PSLAS). Statistical analysis revealed that parental satisfaction regarding CIA was higher than that for IANB with a significant difference (P ˂ 0.05). However, there was no difference regarding the age, gender or the education level of the parents. (P > 0.05). This study provides insights into parental satisfaction with pediatric dental anesthesia techniques and highlights the influence of socioeconomic factors on anesthesia decision-making. Within the limitations of this trial, it was concluded that CIA was significantly superior to IANB in overall parental satisfaction. However, parental satisfaction values were lower in CIA group regarding costs and concern from complications. In addition, it was concluded that there was no difference in satisfaction levels regarding the gender, age and education level of the parents.

Purpose: The aim of the study is to determine the pain during intraosseous anesthesia (IA) with the Quicksleeper and the post-operative state of the perforation site. Materials and methods: The subjects of the study were 58 patients who underwent successful intraosseous analgesia, indicated with treatment of caries or irreversible pulpitis of mandibular first and second molars. The Visual Analogue Scale was used to assess the pain during the perforation of the compact bone and during the infiltration of anesthetic solution into the cancellous bone. All 58 patients were followed up at the 24th hour and on the 7th day after the manipulation, and the following parameters were evaluated: condition of the perforation site and presence of palpation pain. Results: Only 10 patients registered mild pain during perforation of compact bone and 8 – during anaesthetic infiltration. At 24 hours after IA, 12 patients registered mild pain, 6 patients registered moderate pain at the perforation site. On the 7th day, we established mild pain in 4 patients. After IA a reactive inflammatory process was registered in 27% of the cases at 24 hours, while on the 7th day, the inflammatory reaction was registered in only 6% of the cases. Conclusion: The intraosseous system Quicksleeper allows painless perforation of the compact bone and infiltration of the anesthetic solution into the cancellous bone due without risk of serious post-operative complications at the site of anesthesia.

Computer-controlled local anesthetic delivery systems (CDS) represent one of the resources that have progressed the most in recent years, but their efficacy and applicability in pediatric dentistry is still the subject of certain controversies. This randomized, controlled, split-mouth clinical trial assessed two CDS in children (n = 100) with deep caries in the temporary dentition that required invasive therapeutic procedures, using inferior alveolar nerve block as the gold standard. Half of the patients (n = 50) underwent the intraligamentary technique (Wand STA®) on one side of the mouth and conventional inferior alveolar nerve block on the contralateral side, while the other half (n = 50) underwent the intraosseous technique (QuickSleeper®) on one side of the mouth and conventional inferior alveolar nerve block on the contralateral side. The following were considered covariates: age, sex, type of dental procedure and the applied local anesthesia system. The outcome variables were the pain caused by the anesthesia injection, the physical reaction during the anesthesia injection, the need for anesthetic reinforcement, pain during the therapeutic procedure, the overall behavior during the visit, the postoperative morbidity and, lastly, the patient's preference. In conclusion, we confirmed the efficacy of intraligamentary and intraosseous techniques administered using a CDS for conducting invasive dental treatments in children, their advantages compared with inferior alveolar nerve block in terms of less pain generated by the anesthesia injection and less postoperative morbidity, as well as the pediatric patients' preference for CDS versus conventional techniques. [ABSTRACT FROM AUTHOR]

Competing Interests: DECLARATION OF INTERESTS: The authors declare no conflicts of interest regarding the publication of this letter.

Background: Effective pain management is crucial for the successful completion of dental procedures in children. Research has examined whether computerized intraosseous anesthesia (CIOA) could serve as a safe and viable substitute for the conventional inferior alveolar nerve block (IANB) technique in pediatric patients. This study investigates the efficacy of CIOA, aiming to determine its effectiveness as an alternative anesthesia method., Aim: This study compared the efficacy of local intraosseous anesthesia using a computerized device (QuickSleeper 5) to conventional IANB anesthesia on cooperation and pain perception in children, using a randomized controlled trial design., Design: The study included 88 healthy children, aged between 6 and 9 years, who required pulpotomy for their mandibular second primary molars. The study was approved by the local research ethics committee and registered at clinicaltrials.gov (NCT05193487). The heart rate and Venham behavior rating scale were recorded and analyzed. Categorical data were analyzed using Fisher's exact test. Age and heart rate were compared using an independent t-test for intergroup comparison. The intragroup comparison was carried out using repeated measures ANOVA, followed by the Bonferroni post hoc test. The Mann-Whitney U-test was used to analyze the Venham scale scores. The significance level was set at p < .05 RESULTS: The mean Venham score was slightly higher in the IANB group than in the CIOA group, but was not statistically significant (p = .852). One minute after anesthesia administration, the heart rate (beats per minute [BPM]) was significantly higher in the IANB group (92.30 ± 13.45) than in the CIOA group (83.20 ± 10.40) (p < .001). Additionally, there was a significant difference in heart rate values measured at different intervals within the IANB group., Conclusion: The QuickSleeper 5 device was found to be a feasible alternative for IANB in children over 6 years old., (© 2024 BSPD, IAPD and John Wiley & Sons Ltd.)

Objective: The aim of the study was to investigate the effectiveness of primary intraosseous anesthesia (IO) in the endodontic treatment of lower molars with irreversible pulpitis. Material and method: The subject of the study was 30 clinically healthy patients diagnosed with irreversible pulpitis of mandibular first or second molars. All of endodontic treatments were performed in a single visit. IO was performed with computer assisted system Quicksleeper. Our goal was to investigate the presence of pain during various parts of endodontic treatment with Visual Analog Scale. The pain level was registered at the end of the following parts of the endodontic treatment: 1-st part - after preparation of the endodontic access; 2-nd part - after determining the working length for all root canals; 3-rd part - after root canal preparation. Results: No pain was registered either in preparation of endodontic access or in determining the working length for all root canals. Only four patients (14.3%) registered mild pain during root canal preparation, which did not interfere of the endodontic treatment. In the 3-rd part of endodontic treatment it was registered moderate and severe pain respectively from 3.5% and 7.2% of patients, requiring a supplemental anesthesia. Conclusion: The IO can be use as primary method of analgesia that provides reliable pulpal anesthesia for routine endodontic treatment.

Given the proven in a series of recent scientific papers leading vascular component of the mechanism of spongy injections, traditional classification techniques of dental local anesthesia needs to be transformed. We offer its modification, which is to split all ways on diffuse and vascular diffuse. Diffuse anesthesia includes application, infiltration and conduction. Vascular diffuse include intraosseous, intraligamentary, intraseptal and intrapulpal. For the last 4 methods, you can use the term spongy (intraosseous) anesthesia.

Computer-controlled local anesthetic delivery systems (CDS) represent one of the resources that have progressed the most in recent years, but their efficacy and applicability in pediatric dentistry is still the subject of certain controversies. This randomized, controlled, split-mouth clinical trial assessed two CDS in children (n = 100) with deep caries in the temporary dentition that required invasive therapeutic procedures, using inferior alveolar nerve block as the gold standard. Half of the patients (n = 50) underwent the intraligamentary technique (Wand STA®) on one side of the mouth and conventional inferior alveolar nerve block on the contralateral side, while the other half (n = 50) underwent the intraosseous technique (QuickSleeper®) on one side of the mouth and conventional inferior alveolar nerve block on the contralateral side. The following were considered covariates: age, sex, type of dental procedure and the applied local anesthesia system. The outcome variables were the pain caused by the anesthesia injection, the physical reaction during the anesthesia injection, the need for anesthetic reinforcement, pain during the therapeutic procedure, the overall behavior during the visit, the postoperative morbidity and, lastly, the patient’s preference. In conclusion, we confirmed the efficacy of intraligamentary and intraosseous techniques administered using a CDS for conducting invasive dental treatments in children, their advantages compared with inferior alveolar nerve block in terms of less pain generated by the anesthesia injection and less postoperative morbidity, as well as the pediatric patients’ preference for CDS versus conventional techniques.

Objective of this critical literature review was to analyze, systematize and summarize the literature reference on the anesthetic effectiveness, heart rate changes and the pain during and after application of Stabident, X-tip and Quicksleeper systems of intraosseous anesthesia of the mandibular molars. This bibliographic search was carried out in PubMed and Scopus databases, using the following search keywords "Stabident System", "X-tip System", Quicksleeper System", "success rate of intraosseous anesthesia", "increase of heart rate after intraosseous anesthesia", "pain during and after intraosseous anesthesia". Original research publications were included. Data were grouped and rearranged in tables in Microsoft Word 7 for Windows and descriptively presented. [ABSTRACT FROM AUTHOR]

This study presents a novel method to deliver intraosseous anesthesia using dynamic navigation technology. The study aimed to evaluate its safety and 3-dimensional (3D) accuracy in comparison to traditional freehand injection of intraosseous anesthesia. Six identical sets of 3D-printed surgical jaw models (TrueJaw; DELendo, Santa Barbara, CA) comprising simulated alveolar and dental anatomy with 54 interradicular sites were used in this study. The injection sites were equally distributed based on the range of the inter-radicular distance (ie, 1.5–2.5 mm, 2.5–3.5 mm, and 3.5–4.5 mm). A board-certified endodontist randomly completed intraosseous drilling at inter-radicular sites of varying distance using freehand technique and the Navident dynamic navigation system (ClaroNav, Toronto, Ontario, Canada) with the X-Tip system (Dentsply Sirona, York, PA). The rate of root perforation associated with inter-radicular distance was compared between the 2 groups using the Fisher exact test. Two-dimensional (2D) and 3D horizontal, vertical, and angulation discrepancies between the planned and dynamically navigated guide sleeves were digitally measured using superimposed cone-beam computed tomographic scans. Analysis of variance models were used to determine if the interdental distance was associated with the accuracy measures from the dynamic navigation system. The significance level was set at 0.05. The rate of root perforation was significantly higher for the freehand group than the dynamic navigation (22% vs 0%, P <.05). For dynamic navigation, the 2D entry deviation was 0.71 mm (95% confidence interval [CI], 0.56–0.87). The mean 2D horizontal deviation was 0.96 mm (95% CI, 0.79–1.14), and the mean 2D vertical deviation was 0.70 mm (95% CI, 0.55–0.84). The 3D deviation at the tip was on an average 1.23 mm (95% CI, 1.05–1.42). The overall 3D angular deviation was on average 1.36° (95% CI, 1.15–1.56). The inter-radicular distance was not significantly associated with any 2D or 3D discrepancies. Successful and accurate drilling of dynamically navigated intraosseous delivery occurred in 100% of injection sites irrespective of the inter-radicular distance. It was significantly safer in comparison to freehand intraosseous drilling to prevent injury of the roots of the adjacent teeth in close proximity. [ABSTRACT FROM AUTHOR]

Distraction osteogenesis (DO) is the latest addition to the variety of alveolar ridge augmentation procedures used to increase the volume of bone prior to implant placement. Thirty DO procedures were performed in 30 patients using 17 intraosseous and 13 extraosseous devices to augment deficient alveolar ridges. Fifty-five implants placed in the distracted bone were followed for a period of 34 to 60 months after loading. Five implants failed, for a 90.9% success rate. Vertical augmentation ranged from 3.5 to 13.0 mm (average, 7.8 mm). At least one complication was encountered, requiring additional hard or soft tissue surgery, in each of the 30 reported cases. This paper reviews complications encountered in the DO-treated patients, suggesting solutions and measures to prevent these problems. [ABSTRACT FROM AUTHOR]

Pain and dysfunction in the temporomandibular joint (TMJ) region represent a diagnostic challenge. Temporomandibular disorders (TMD) are usually diagnosed by means of a thorough patient history and comprehensive clinical examination. However, additional diagnostic tests, such as imaging of the TMJ area, are necessary in cases where the signs do not explain the symptoms. Neoplasms and pseudotumors of the TMJ are quite uncommon, but their early recognition is necessary in order prevent the delay of correct treatment. This report describes 3 cases of different intraosseous lesions of the mandibular condyle in which the patient was erroneously first treated for a TMD. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to determine the effect of intraosseous (IO) anesthesia with 4% articaine and 1:100,000 epinephrine on pulpal blood flow (PBF) and pulpal anesthesia of mandibular first molars and canines in human subjects.Materials and methods: Ten healthy volunteers with intact mandibular first molar and canine were given an osteocentral technique of IO injection using the Quick Sleeper 5 system and 4% articaine with 1:100,000 epinephrine at distal site of mandibular first molar. The PBF was monitored by a laser Doppler flowmeter (LDF). Pulpal anesthesia was assessed with an electric pulp tester (EPT).Results: IO injection caused a decrease in PBF in molars from 6.31 ± 3.85 perfusion units (P.U.) before injection to 2.51 ± 2.53 P.U. 1 min after injection (P < 0.001). The percentage reduction in PBF was 60% after 1 min and PBF returned back to the baseline after 45 min. No significant reduction in PBF was observed in the canines (P = 0.212). For pulpal anesthesia in the molars, the mean onset was 2.40 ± 0.84 min and the mean duration was 38 ± 16.19 min. In the canines, there was a decrease in the sensitivity to EPT but complete pulpal anesthesia was not achieved.Conclusions: IO injection distal to mandibular first molar caused a decrease in PBF and successful pulpal anesthesia in first molar, but not in canine. Both PBF and EPT readings returned to normal, suggesting that pulpal ischemia may not occur.Clinical relevance: IO anesthesia is safe to use as a primary technique in teeth with normal pulp. [ABSTRACT FROM AUTHOR]

To comprehensively review about the intraosseous (IO) anesthesia in dentistry. Effective local anesthesia is arguably the single most important pillar on which modern dentistry stands. The traditional aspirating syringe is the most common method by which local anesthetics are administered, newer technologies have been developed that can assist the dentist in providing enhanced pain relief with reduced injection pain and fewer adverse effects like IO systems for local anesthetic injection. The IO injection allows placement of a local anesthetic solution directly into the cancellous bone adjacent to the tooth to be anesthetized. Because infiltration injections with lidocaine solutions are not effective for anesthesia of the mandibular molar teeth due to the thickness of the cortical plate. The IO injection overcomes this problem by allowing direct access to the cancellous bone. The review is to know more about the uses, techniques, advantage, and disadvantage of IO anesthesia. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed at analyzing the effect of the temporary removal of trigeminal dental afferents on electrogustometric thresholds (EGMt).Material and methods: EGMt were measured in 300 healthy subjects randomized in three groups, in nine loci on the right and left side (RS, LS) of the tongue surface before and after anesthesia. Group IAN (n = 56 RS, n = 44 LS) received intraosseous local anesthesia of the inferior alveolar nerve (IAN). Group MdN received mandibular nerve (MdN) block targeting IAN before its entrance into the mandibular foramen (n = 60, RS, and n = 40, LS); group MxN receiving maxillary nerve (MxN) anesthesia (n = 56 RS and n = 44 LS) was the control group. Differences between mean EGMt were analyzed with the Wilcoxon test; correlation between type of anesthesia and EGMt was performed with Spearman’s rho, all with a level of significance set at p ≤ 0.05.Results: Significant EGMt (μA) differences before and after anesthesia were found in all loci with MdN and IAN on the ipsilateral side (p < 0.05), but not with MxN. Anesthesia of the MdN was positively correlated with the increase in EGMt (p < 0.001). Selective anesthesia of IAN was positively correlated only with the increase in EGMt measured at posterior and dorsal loci of the tongue surface (p < 0.01).Conclusion: The increase in EGMt following IAN anesthesia suggests a participation of dental afferents in taste perception.Clinical relevance: Extraction of teeth may impair food intake not only due to impaired masticatory ability but also to alteration of neurological trigemino-gustatory interactions.Trial registration number: PACTR201602001452260 [ABSTRACT FROM AUTHOR]

This in vitro study investigated intraos seous heat production during insertion, with and without pre-drilling, of a self-drilling orthodontic mini-implant. To measure temperature changes and drilling times in pig ribs, a special testing apparatus was used to examine new and worn pre-drills at different speeds. Temperatures were measured during mini-implant placement with and without pre-drilling. The average intraosseous temperature increase during manual mini-implant insertion was similar with and without pre-drilling (11.8 ± 2.1°C vs. 11.3 ± 2.4°C, respectively; P = 0.707). During pre-drilling the mean temperature increase for new drills was 2.1°C at 100 rpm, 2.3°C at 200 rpm, and 7.6°C at 1,200 rpm. Temperature increases were significantly higher for worn drills at the same speeds (2.98°C, 3.0°C, and 12.3°C, respectively), while bone temperatures at 100 and 200 rpm were similar for new and worn drills (P = 0.345 and 0.736, respectively). Baseline bone temperature was approximated within 30 s after drilling in most specimens. Drilling time at 100 rpm was 2.1 ± 0.9 s, but was significantly shorter at 200 rpm (1.1 ± 0.2 s) and 1,200 rpm (0.1 ± 0.03 s). Pre-drilling did not decrease intraosseous temperatures. In patients for whom pre-drilling is indicated, speeds of 100 or 200 rpm are recommended, at least 30 s after pilot drilling. [ABSTRACT FROM AUTHOR]

Background: The intraosseous (IO) access is an alternative route for vascular access when peripheral intravascular catheterization cannot be obtained. In Denmark the IO access is reported as infrequently trained and used. The aim of this pilot study was to investigate if medical students can obtain competencies in IO access when taught by a modified Walker and Peyton's four-step approach. Methods: Nineteen students attended a human cadaver course in emergency procedures. A lecture was followed by a workshop. Fifteen students were presented with a case where IO access was indicated and their performance was evaluated by an objective structured clinical examination (OSCE) and rated using a weighted checklist. To evaluate the validity of the checklist, three raters rated performance and Cohen's kappa was performed to assess inter-rater reliability (IRR). To examine the strength of the overall IRR, Randolph's free-marginal multi rater kappa was used. Results: A maximum score of 15 points was obtained by nine (60%) of the participants and two participants (13%) scored 13 points with all three raters. Only one participant failed more than one item on the checklist. The expert rater rated lower with a mean score of 14.2 versus the non-expert raters with mean 14.6 and 14.3. The overall IRR calculated with Randolph's free-marginal multi rater kappa was 0.71. Conclusion: The essentials of the IO access procedure can be taught to medical students using a modified version of the Walker and Peyton's four-step approach and the checklist used was found reliable. [ABSTRACT FROM AUTHOR]

Objective The purpose of the current study is to assess the thickness of the maxillary sinus lateral wall in dentate and edentulous patients using cone beam computed tomography (CBCT). This study also provides information about the diameter, prevalence, and course of the posterior superior alveolar artery (PSAA), and its relation to the maxillary sinus floor. Materials and Methods Four hundred and thirty CBCT scans of the maxillofacial complex (860 maxillary sinuses) were reviewed. Measurements of the lateral wall of the maxillary sinus and PSAA were performed on the CBCT images. Results Statistical analysis showed that dental status (edentulous, non-edentulous) of the patients had no significant effect on the lateral wall thickness. The mean thickness of the lateral wall of the maxillary sinus was 1.21 ± 1.07 mm at the second molar (M2), 1.98 ± 1.87 mm at the first molar (M1), 2.02 ± 1.53 mm at the second premolar (P2) and 2.16 ± 1.25 mm at the first premolar (P1). There was statistically significant difference between the left and right sides of the maxillary sinus only at P2 ( p =.043). Detection rate of the PSAA on CBCT was reported as 60.58%. The mean diameter of the artery was 1.17 mm (range 0.4-2.8 mm). There was no significant correlation between age and the size of the PSAA. The most frequent path of the PSAA was intraosseous (69.6%), followed by intrasinusal (24.3%) and superficial (6.1%). The overall mean distance of the PSAA from the floor of the maxillary sinus is 8.16 mm. Conclusions The results from this study suggest that using CBCT prior to the surgery provides valuable diagnostic information. However, undetected intraosseous canal in CBCT does not exclude its existence. Alteration in the lateral window design and the use of piezoelectric instruments are recommended if intraoperative complications are expected. [ABSTRACT FROM AUTHOR]

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Inflammation, including microglial activation in the CNS, is an important hallmark in many neurodegenerative diseases. Microglial stimuli not only impact the brain microenvironment by production and release of cytokines and chemokines, but also influence the activity of bone marrow derived cells and blood born macrophage populations. In many diseases including brain disorders and spinal cord injury, researchers have tried to harbor the neuroprotective and repair properties of these subpopulations. Hematopoietic bone marrow derived cells (BMDCs) are of great interest, especially during gene therapy because certain hematopoietic cell subpopulations traffic to the sites of injury and inflammation. The aim of this study was to develop a method of labeling endogenous bone marrow derived cells through intraosseous impregnation of recombinant adeno-associated virus (rAAV) or lentivirus. We utilized rAAV serotype 9 (rAAV-9) or lentivirus for gene delivery of green florescence protein (GFP) to the mouse bone marrow cells. Flow cytometry showed that both viruses were able to efficiently transduce mouse bone marrow cells in vivo. However, the rAAV9-GFP viral construct transduced BMDCs more efficiently than the lentivirus (11.2% vs. 6.8%), as indicated by cellular GFP expression. We also demonstrate that GFP labeled cells correspond to bone marrow cells of myeloid origin using CD11b as a marker. Additionally, we characterized the ability of bone marrow derived, GFP labeled cells to extravasate into the brain parenchyma upon acute and subchronic neuroinflammatory stimuli in the mouse CNS. Viral mediated over expression of chemokine (C–C motif) ligand 2 (CCL2) or intracranial injection of lipopolysaccharide (LPS) recruited GFP labeled BMDCs from the periphery into the brain parenchyma compared to vehicle treated mice. Altogether our findings demonstrate a useful method of labeling endogenous BMDCs via viral transduction and the ability to track subpopulations throughout the body following insult or injury. Alternatively, this method might find utility in delivering therapeutic genes for neuroinflammatory conditions. [ABSTRACT FROM AUTHOR]

Objective: To assess the importance of using the new system Quick Sleeper for local anesthesia, to highlight benefits of quick and comfortable anesthesia. Material and Methods. The examination of effectiveness, convenience of this kind of anesthesia has been carried out. Results. All patients, taking part in this examination, confirmed more comfortable condition after this anesthesia than conductor and infiltration methods of anesthesia. The effect of anesthesia is better than after conductor anesthesia. Conclusion. This technology guarantees equal introduction and spread of anesthetic, independently of tissue density, eliminating the risk of carpule breakage.

Neurofibroma (NF) is a benign neoplasm derived from peripheral nerve cells. NF may extend either as a solitary lesion or as part of a generalized syndrome of neurofibromatosis. Intraorally, the intraosseous variant of neurofibroma is a very rare tumor. The literature provides only few cases of solitary intraosseous neurofibroma of the mandible. We report a case of 28-year-old female who was diagnosed with a solitary intraosseous neurofibroma involving the lower left quadrant of the mandible. The present case is rare in regard to its dimensions and its location. [ABSTRACT FROM AUTHOR]

Aim: To assess retrospectively the efficacy of computer-assisted intraosseous anaesthesia (CAIO) in children using an anaesthetic solution with a lower concentration of epinephrine (1:400,000). Methods: In a retrospective study, CAIO was evaluated in healthy children and adolescents for restorative and endodontic treatments, uncomplicated tooth extractions or scalings using articaine 4 % plus epinephrine 1:400,000. Anaesthesia was performed in children who showed enough compliance (score of 0-3 according to modified behaviour Venham scale). Efficacy, amount of anaesthetic solution as well as need of a complementary injection was assessed. Results: A total of 421 consecutive sessions were performed on 278 patients aged 7.1 ± 2.9 years with 518 teeth involved in the anaesthetic process and analysed process. When teeth to be anaesthetised were considered, the overall success rate was 97.2 %. In most of the cases, only 0.9 mL was needed to achieve anaesthesia. Permanent teeth needed significantly more anaesthetics than primary teeth. Sensitivity of the teeth anaesthetized reappeared in 5.7 % of cases after 30-60 min of treatment. Conclusions: These results suggest that CAIO with 4 % articaine and epinephrine diluted 1:400,000 can be an alternative to usual infiltration techniques or IO with epinephrine at a higher concentration for most of treatments in primary and permanent teeth. Further studies are needed to evaluate its efficacy in permanent teeth in case of endodontic treatment or extraction. [ABSTRACT FROM AUTHOR]

Intraosseous vascular access is a time-tested procedure that is reemerging in popularity. This is primarily a result of the emphasis on intraosseous access in the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Advanced Cardiac Life Support. Modern intraosseous insertion devices are easy to learn and use, suggesting the possibility of use beyond the resuscitation setting. We present a case series of recent intraosseous insertions for a variety of indications by anesthesiologists at our institution to demonstrate the potential utility of this alternative access technique. [ABSTRACT FROM AUTHOR]

Primary intraosseous arteriovenous malformations (AVMs) are rare and have only been occasionally reported. We herein report a histologically proven case of primary intraosseous AVM in the tibia, which mimicked a fibrous tumour on radiography. This presentation carries a risk of triggering acute large haemorrhage through unnecessary biopsy. In intraosseous AVM, the magnetic resonance (MR) imaging features typical of a soft tissue AVM are absent, making diagnosis difficult. In this report, peculiar MR features in the presence of a connecting vessel between the normal deep venous system of the lower extremity and the tumour provide a clue for the early diagnosis of primary intraosseous AVM. [ABSTRACT FROM AUTHOR]

An essay is presented on how pain is controlled endodontic therapy. Topics discussed include the definition and cause of pain, pain management and diagnosis, and drugs for pain treatment including nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol, supplemental intra-osseous injections, and corticosteroids.

Introduction: Pain management remains the utmost important qualifying criteria in minimizing patient agony and establishing a strong dentist-patient rapport. Symptomatic irreversible pulpitis is a painful condition necessitating immediate attention and supplemental anesthetic techniques are often resorted to in addition to conventional inferior alveolar nerve block. Aim: The purpose of the study was to evaluate the anesthetic efficacy of X-tip intraosseous injection in patients with symptomatic irreversible pulpitis, in mandibular posterior teeth, using 4% Articaine with 1:100,000 adrenaline as local anesthetic, when the conventional inferior alveolar nerve block proved ineffective. Materials and Methods: X-tip system was used to administer 1.7 ml of 4% articaine with 1:100,000 adrenaline in 30 patients diagnosed with irreversible pulpitis of mandibular posterior teeth with moderate to severe pain on endodontic access after administration of an inferior alveolar nerve block. Results: The results of the study showed that 25 X-tip injections (83.33%) were successful and 5 X-tip injections (16.66%) were unsuccessful. Conclusion: When the inferior alveolar nerve block fails to provide adequate pulpal anesthesia, X-tip system using 4% articaine with 1:100,000 adrenaline was successful in achieving pulpal anesthesia in patients with irreversible pulpitis. [ABSTRACT FROM AUTHOR]

Background: The achievement of successful local anesthesia is a continual challenge in dentistry. Adjunctive local anesthetic techniques and their armamentaria, such as intraosseous injection (the Stabident system and the X-tip system) have been proposed to be advantageous in cases where the conventional local anesthetic techniques have failed. Aim: A clinical study was undertaken using intraosseous injection system by name X-tip to evaluate its effectiveness in cases where inferior alveolar nerve block has failed to provide pulpal anesthesia. Materials and Methods: Sixty adult patients selected were to undergo endodontic treatment for a mandibular molar tooth. Inferior alveolar nerve block was given using 4% articaine with 1:100,000 epinephrine. Twenty-four patients (40%) had pain even after administration of IAN block; intraosseous injection was administered using 4% articaine containing 1:100,000 epinephrine, using the X-tip system. The success of X-tip intraosseous injection was defined as none or mild pain (Heft-Parker visual analog scale ratings = 54 mm) on endodontic access or initial instrumentation. Results: Intraosseous injection technique was successful in 21 out of 24 patients (87.5%), except three patients who had pain even after supplemental X-tip injection. Conclusion: Within the limits of this study, we can conclude that supplemental intraosseous injection using 4% articaine with 1:100,000 epinephrine has a statistically significant influence in achieving pulpal anesthesia in patients with irreversible pulpitis. [ABSTRACT FROM AUTHOR]

Purpose of this study was to compare the use of intramuscular (IM) and intraosseous (IO) xylazine-ketamine combination by monitoring clinical parameters in quails. The experiment was carried out on twenty clinically healthy mature male quails randomly divided into two groups. The first group (n=10) received the combination of 8 mg/kg Xylazine HCl 50 mg/kg and Ketamine HCl IM and second group (n=10) received: the same combination via IO route. Each quail was monitored for heart rate (HR), respiratory rate (RR), cloacal temperature (CT) and electrocardiography (ECG). The induction and duration time of anesthesia in IO group was significantly shorter than that for IM Group (P<0.05). The HR of IO group was significantly decreased on 15th, 20th and 30th min as compared to the IM group (P<0.05). When statistical differences were compared among different groups, the RR of IO group reduced significantly (P<0.05) on the 3th, 5th, 10th and 15th min than that of the IM group. There were no significant differences observed in the CT values between IO and IM group during the anesthesia. Also, reflexes disappeared in both groups throughout the anesthesia. In conclusion, sufficient anesthesia can be obtained by the use of both the IM and the IO xylazine-ketamine administration. Furthermore, it was determined that IO route can be easily used in clinical practice such as IM anesthesia in quails. [ABSTRACT FROM AUTHOR]

Résumé: Objectif: Évaluer les connaissances théoriques et pratiques sur les cathéters intraosseux (CIO) chez l’adulte en France en 2012. Type d’étude: Étude observationnelle descriptive transversale nationale de type enquête d’opinion et de pratique. Matériels et méthodes: Un courriel, avec un lien vers un questionnaire automatisé en ligne, a été adressé aux médecins et internes en poste dans les services d’anesthésie, de réanimation et de médecine d’urgence de France. Les questions posées portaient sur les connaissances théoriques et l’expérience pratique de l’utilisation de dispositifs intraosseux. Résultats: Sur les 1359 réponses obtenues, 396 (29 %) praticiens avaient déjà utilisé un CIO, principalement en cas d’ACR (68 %). L’assurance des opérateurs et la proportion de médecins ayant déjà posé un CIO augmentaient avec les années d’expérience. Les raisons justifiant le non-recours à cette voie étaient principalement l’absence de difficulté à la pose d’une voie veineuse périphérique (77 %) et la méconnaissance du matériel et de la technique (32 %). Plus de la moitié (n =753 [55 %]) des praticiens avaient reçu une formation et 90 % (n =265) des médecins non formés la jugeaient nécessaire. Les systèmes motorisés étaient majoritairement utilisés (71 %). Conclusion: Seulement 29 % des praticiens français interrogés déclaraient avoir déjà mis en place un CIO. Avec l’avènement des dispositifs les plus récents, une formation théorique et pratique s’avère indispensable pour l’essor de la technique. [ABSTRACT FROM AUTHOR]

Background Intraosseous ( IO) access is used in emergency situations to allow rapid initiation of treatment. IO access is also sometimes used for blood sampling, although data on accuracy of such sampling in critical illness are limited. There is also a potential risk that bone marrow fragments in IO samples may damage laboratory equipment. It is ethically questionable to perform a simultaneous comparison between IO and arterial/venous sampling in critically ill humans. We have, thus, studied the analytical performance of IO sampling in a porcine septic shock model using a cartridge-based analyser. Methods Eight pigs with endotoxin-induced septic shock were sampled hourly for 6 h, and analysed for blood gases, acid base status, haemoglobin, glucose and lactate using point of care instruments. Samples were taken from three IO cannulae (tibia bilaterally, one with infusion, and humerus), one arterial and one venous. An interaction test was used to assess changes in agreement between methods over time. Bland-Altman plots were constructed to study bias between methods. Results There were, to a varying extent, differences between IO and arterial/venous levels for all studied variables, but agreement did not change significantly during the experiment. A general finding was a large dispersion of differences between methods. Conclusions IO sample values should be treated with caution in this setting but may add useful information to the clinical picture. The tibia or humerus may be used for sampling. IO infusion decreases agreement, thus sampling during infusion should be avoided. [ABSTRACT FROM AUTHOR]

Study Objective: To describe the success and complication rate of intraosseous (IO) access for delivery of anesthesia with the use of an 18-gauge (G) intravenous (IV) needle. Design: Prospective study. Setting: Children's Welfare Teaching Hospital, Baghdad, Iraq. Patients: 300 critically ill infants and toddlers, age 3 weeks to 16 months, requiring emergency surgery for intra-abdominal or pelvic conditions, in whom peripheral or central access was not obtainable. Patients presented for surgery between 2007 and 2010. Interventions: In 26 patients, the IO catheter was established when peripheral access was not obtained at the outset of surgery' in 4 patients standard peripheral vascular access failed during the surgical procedure and IO access was obtained. An 18-G IV needle was placed into the proximal tibia and attached to an extension set with a 3-way stopcock to deliver anesthesia. Main Results: For 26 critically ill children and 4 other children, IV access failed during delivery of anesthesia' vascular access was successfully obtained within minutes in all 30 infants (100%) using the intraosseous route. Ninety percent (27/30) of patients awoke immediately postoperatively in good condition' 10% (3/30) went to the pediatric intensive care unit (PICU) for further care due to their critical preoperative condition. Complications associated with use of the IO route were considered minor (3/30 pts [10%]) and included extravasation of fluid in two cases and cellulitis in one. [ABSTRACT FROM AUTHOR]

Introduction: The inferior alveolar nerve block (IAN) is the most frequently used mandibular injection technique for achieving local anesthesia in endodontics. Supplemental injections are essential to overcome failure of IAN block in patients with irreversible pulpitis. Aim: To evaluate the anesthetic efficacy of X-tip intraosseous injection (2% lidocaine with 1:80,000 epinephrine) in patients with irreversible pulpitis in mandibular posterior teeth when conventional IAN block failed. Materials and Methods: Thirty emergency patients diagnosed with irreversible pulpitis in a mandibular posterior tooth received an IAN block and experienced moderate to severe pain on endodontic access or initial instrumentation. The X-tip system was used to administer 1.8 ml of 2% lidocaine with 1:80,000 epinephrine. The success of X-tip intraosseous injection was defined as none or mild pain (Heft-Parker visual analogue scale ratings < 54 mm) on endodontic access or initial instrumentation. Results: Ninety-three percent of X-tip injections were successful and 7% were unsuccessful. Discomfort rating for X-tip perforation: 96.66% patients reported none or mild pain, whereas 3.34% reported moderate to severe pain. For discomfort rating during solution deposition, 74.99% patients reported none or mild pain and 24.92% reported moderate to severe pain. Ninety-six percent of the patients had subjective/objective increase in heart rate. Conclusions: Supplemental X-tip intraosseous injection using 2% lignocaine with 1:80,000 epinephrine has a statistically significant influence in achieving pulpal anesthesia in patients with irreversible pulpitis. [ABSTRACT FROM AUTHOR]

Background Confirming the presence of arteries crossing the osteotendinous junctions ( OTJs) of the rotator cuff may explain why rates of avascular necrosis ( AVN) of the humeral head vary between three- and four-part proximal humeral fractures. It is hypothesized that the humeral head remains better vascularized in three-part fractures because one tuberosity with its inserting rotator cuff tendons is still attached to the articular fragment and supplying it with blood. Methods Eighty rotator cuff tendons from 20 shoulder girdles of cadavers aged 68-94 years were studied. In six shoulder girdles, the anterior circumflex humeral artery and posterior circumflex humeral artery ( PCHA) were injected with ink, and the extra- and intraosseous courses of the vasculature were dissected until the OTJs of the rotator cuff. Results The rotator cuff insertions received an arterial supply across their OTJs in 50% of cases (75% in supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor). Supraspinatus and subscapularis insertions were vascularized by the arcuate artery, while the insertions of infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA. This was named 'posterolateral artery'. Conclusion The presence of arteries crossing the OTJs of the rotator cuff, as well as the differences in the frequency arteries crossed the OTJs of individual rotator cuff tendons, may help explain why there is a lower rate of AVN of the humeral head in thee-part, compared with four-part proximal humeral fractures. [ABSTRACT FROM AUTHOR]

Abstract: Background: Intraosseous access is an essential method in emergency medicine when other forms of vascular access are unavailable and there is an urgent need for fluid or drug therapy. A number of publications have discussed the suitability of using intraosseous access for laboratory testing. We aimed to further evaluate this issue and to study the accuracy and precision of intraosseous measurements. Methods: Five healthy, anaesthetised pigs were instrumented with bilateral tibial intraosseous cannulae and an arterial catheter. Samples were collected hourly for 6h and analysed for blood gases, acid base status, haemoglobin and electrolytes using an I-Stat® point of care analyser. Results: There was no clinically relevant difference between results from left and right intraosseous sites. The variability of the intraosseous sample values, measured as the coefficient of variance (CV), was maximally 11%, and smaller than for the arterial sample values for all variables except SO2. For most variables, there seems to be some degree of systematic difference between intraosseous and arterial results. However, the direction of this difference seems to be predictable. Conclusion: Based on our findings in this animal model, cartridge based point of care instruments appear suitable for the analysis of intraosseous samples. The agreement between intraosseous and arterial analysis seems to be good enough for the method to be clinically useful. The precision, quantified in terms of CV, is at least as good for intraosseous as for arterial analysis. There is no clinically important difference between samples from left and right tibia, indicating a good reproducibility. [Copyright &y& Elsevier]

Increase in size of cysts is slowly in intraosseous stage. When the osteoperiosteal barrier is overcome cysts usually become clinically evident and evolution is faster. A clinical case belongs to a 39 years old patient who presented to the doctor for the emergence of large deformation of labial and nasal-genian left region, accompanied by pain and functional disorders. Patient charges serious disturbances in mastication and important esthetic disorders: facial asymmetry, lifting the left wing nose, nasal-gentian delete ditch, deepening ditches left lower eyelid, lifting oral commissure on the affected side. [ABSTRACT FROM AUTHOR]

Abstract: The myofibroma, especially the intraosseous variety is an uncommon benign tumor that occurs primarily in children younger than 3 yrs of age. Since 1966 less than 40 cases of solitary myofibroma of the mandible have been reported in literature. Myofibroblasts and spindle cells are predominantly found in this benign lesion. These cells are also commonly found in many lesions; due to which great difficulty can be encountered in the diagnosis. A rare case of the intraosseous variety of infantile myofibroma of the mandible diagnosed in a 10-month-old boy has been reported. The tumor was completely excised via an intraoral approach and no recurrence has been noted 15 months postoperatively. A brief review of the differential diagnosis of this lesion in terms of its clinicopathologic, histologic and immunohistochemical features is also discussed. [Copyright &y& Elsevier]

Objective: The effectiveness of the intraosseous (IO) route for fluid resuscitation remains uncertain. This study compares IO infusion rates and estimated volume expansion using clinically relevant infusion pressures with lactated Ringer's (LR) and hetastarch (HES). Methods: IO needles were placed in the sternum or tibia for infusion of HES and LR in 8 Yorkshire pigs. Pressures were recorded at variable flow rates and linear regression used to identify flow rates at 100 and 400 mm Hg. Volume expansion was calculated for a 10-minute infusion. Results: Mean LR flow rates (mL ⋅ min-1) were 24/111 (tibia--100/400 mm Hg) and 8/34 (sternum--100/400 mm Hg). The HES flow rates (mL ⋅ min-1) of 10/44 (tibia--100/400 mm Hg) and 6/26 (sternum--100/400 mm Hg) were significantly lower or ~40% (p < 0.01) of the LR flow rates into the tibia and ~70% (p < 0.05) into the sternum. Mean volume expansion (mL) for a 10-min infusion of LR was estimated to be 80/369 (tibia--100/400 mm Hg) and 27/112 (sternum--100/400 mm Hg). In comparison, HES volume expansion was ~20% higher for the tibia (p > 0.05) and 110% to 120% higher for the sternum (p < 0.05). Conclusion: HES flow rates are lower than LR flow rates in the sternum and tibia of swine. Sternal infusion of HES is likely to provide greater estimated intravascular volume expansion than LR despite the lower infusion rates. [ABSTRACT FROM AUTHOR]

Background: Anterior knee pain is one of the most common complaints of patients in orthopedic clinics. The first step in the treatment of this problem is conservative treatment which includes administration of anti-inflammatory drugs, exercise and changes in life style. Many patients respond well to these measures in about six months, but a small number of patients may not respond to the conservative treatment; therefore, surgical procedures such as Maquet osteotomy or lateral retinacular release may be needed in these cases. The aim of this study was to determine the efficacy of intraosseous drilling and decompression of patella in the treatment of chronic anterior knee pain. Methods: This study was performed as a case series on ten patients with chronic anterior knee pain attending the Orthopedic Clinic of Imam Khomeini Hospital, in Tehran, Iran in 2009-2010. Eight of the patients were male and the rest were female. The patients met the inclusion criteria and were followed up for at least 12 months after the surgery. Results: The mean age of the patients was 27.8±4.66 yr and their mean BMI was 22.5±1.71 kg/m². The mean pain severity before the interventions was 8.2±0.78 based on VAS but it decreased to 2.5±1.26 post-surgically. An average reduction of 5.7 scores were noticed in pain severity depicting a significant reduction of pain (P<0.0001). Conclusion: It may be concluded that intraosseous drilling and decompression of patella is a safe and effective method in the treatment of chronic anterior knee pain not responding to conservative treatment. [ABSTRACT FROM AUTHOR]

Abstract: We compared the pharmacokinetics of intraosseous (IO) drug delivery via tibia or sternum, with central venous (CV) drug delivery during cardiopulmonary resuscitation (CPR). Methods: CPR of anesthetized KCl arrest swine was initiated 8min post arrest. Evans blue and indocyanine green, each were simultaneously injected as a bolus with adrenaline through IO sternal and tibial needles, respectively, n =7. In second group (n =6) simultaneous IO sternal and IV central venous (CV) injections were made. Results: Peak arterial blood concentrations were achieved faster for sternal IO vs. tibial IO administration (53±11s vs. 107±27s, p =0.03). Tibial IO dose delivered was 65% of sternal administration (p =0.003). Time to peak blood concentration was similar for sternal IO and CV administration (97±17s vs. 70±12s, respectively; p =0.17) with total dose delivered of sternal being 86% of the dose delivered via CV (p =0.22). Conclusions: IO drug administrations via either the sternum or tibia were effective during CPR in anesthetized swine. However, IO drug administration via the sternum was significantly faster and delivered a larger dose. [Copyright &y& Elsevier]

Multiple intraosseous lipoma (MIOL) is extremely rare bone tumour. Its real incidence is estimated as much more because of most of these tumours is asymptomatic and undiagnosed. We reported 3 MIOL patients involving both upper and lower extremity. Two female patient with 30 and 26 age and one male with 52 years old represented by intraosseous lipomatous lesions involving bilateral wrist and hand bones, distal radius, proximal and distal femur, patella, proximal and distal tibia metaphyses, distal fibula, ankle and foot bones. Painful lesions were curetted and grafted by allograft. A distal radius fracture is treated by closed reduction and percutaneus pining. All the lesions healed that is managed by surgery. The asymptomatic lesions were not treated anyway. MIOL needs surgery in the case of pain, pathologic fracture, pathologic diagnosis confirmation and impending fracture. The malign transformation potential is present even rare. It must be followed in long period and carefully. CT is a good diagnostic imaging allowing negative density measurement in lesions between -60 and -110 HU. [ABSTRACT FROM AUTHOR]

Background: Intraosseous infusion has become established as a fast and safe alternative to conventional vascular access in emergency situations. Originally the use of intraosseous access was limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation but this limitation has now been removed. The aim of this study was to obtain data on mission reality regarding the use of intraosseous access in the prehospital setting against the background of the expanded recommendations on the use of the intraosseous infusion. Methods: An analysis of rescue missions by all rescue helicopters of the ADAC (German Automobile Club) Air Rescue as well as the German Air Rescue Service (58 helicopter emergency medical service bases) over a 4 year period from January 2005 to December 2008 was carried out. Results: A total of 247,454 rescue missions were carried out during the study period and in 525 patients (0.2% of the total study collective) an intraosseous access was established. There was a significant increase in the intraosseous infusion rate from 0.1% to 0.4% (p<0.05). Furthermore, there was a significant increase in its use in elderly patients and in patients with lower National Advisory Committee for Aeronautics (NACA) scores (2005 vs. 2008): 92.4% vs. 42.9% of all intraosseous infusions in patients ≤ 6 years of age (p<0.05) and 74.4% vs. 42.9% of all intraosseous infusions in patients with NACA score VI/VII (p<0.05). The proportion of trauma patients in the total study collective was 33% and there was no significant change in the frequency of trauma cases over the study period but there was a remarkable increase of intraosseous infusions in trauma patients in the last year of the study period compared to the previous years (38% in 2008 vs. 27-30% in 2005-2007). Furthermore, there was an increase in the number of different drug groups used for intraosseous infusion over the study period. Conclusions: The expanded indication recommendations for the use of intraosseous infusion in the prehospital setting enter more and more mission reality in air rescue services in Germany. [ABSTRACT FROM AUTHOR]

Polyglycolic acid and poly-L-lactic acid have become popular choices for bioabsorbable anchor fixation in the hand and wrist. We report a case of osteolysis, synovitis, and chondral erosion secondary to a poly-L-lactic acid suture anchor in the wrist. [Copyright &y& Elsevier]

Objectives: Knowledge and evaluation of the maxillary sinus anatomy before sinus augmentation are essential for avoiding surgical complications. Posterior superior alveolar artery (PSAA) is the branch of maxillary artery that supplies lateral sinus wall and overlying membrane. The aims of this study were to examine the prevalence, diameter, and location of the PSAA and its relationship to the alveolar ridge and to study the prevalence of the sinus pathology and septum using computerized tomography (CT) scans. Materials and methods: One hundred and twenty-one CT scans (242 sinuses) from patients undergoing sinus augmentation procedure and/or implant therapy were included. Lower border of the artery to the alveolar crest, bone height below the sinus floor to the ridge crest, distance of the artery to the medial sinus wall, diameter of the artery, and position of the artery were measured; presence of septa and pathology were recorded from CT sections. Results: Prevalence of sinus septa and sinus pathology was 16.1% and 24.8%, respectively. Artery was seen in 64.5% of all sinuses and was mostly intraosseous (68.2%). Mean diameter of PSAA was found 1.3 ± 0.5 mm. No significant correlation between the diameter of the artery and age was observed. Conclusions: The results from this study suggested that CT scan is a valuable tool in evaluating presence of sinus pathology, septa, and arteries before maxillary sinus surgery. Although variations exist in every patient, the findings from this study suggest limiting the superior border of the lateral window up to 18 mm from the ridge to avoid any potential vascular damage. To cite this article: Güncü GN, Yildirim YD, Wang H-L, Tözüm TF. Location of posterior superior alveolar artery and evaluation of maxillary sinus anatomy with computerized tomography: a clinical study. Clin. Oral Impl. Res. 22, 2011; 1164-1167. doi: 10.1111/j.1600-0501.2010.02071.x [ABSTRACT FROM AUTHOR]

Abstract: Objective: The purpose of this study was to investigate the tissue distribution of lidocaine hydrochloride in mandibular bone marrow after intraosseous anesthesia (IOA) in rabbits. Methods: We used macroautoradiography to examine the tissue distribution of a 14C-labeled 2% lidocaine hydrochloride solution containing 1:80,000 epinephrine (14C-lidocaine). Under general anesthesia, 14C-lidocaine was injected intraosseously or paraperiosteally. After IOA, animals were divided into three groups and observed at 1 (IOA-1), 5 (IOA-5), and 10 minutes (IOA-10) after injection. After infiltration anesthesia (IA), animals were observed at 1 minute after injection. Results: The accumulation of 14C-lidocaine was observed around the injection site in both the IA and the IOA groups. Paraperiosteally injected 14C-lidocaine diffused to the surrounding tissues such as the lip, whereas IOA showed concentrated accumulation around the root apex throughout the experiment. The distribution area was significantly smaller in the IOA-1 group than in the IA group. The distribution area in the IOA-5 group was larger than those in the IOA-1 and IOA-10 groups. Conclusions: The accumulation of 14C-lidocaine injected by IOA in rabbits was concentrated around the root apex. These results may explain the rapid onset time of IOA. [Copyright &y& Elsevier]

The neurilemmoma is a benign neoplasm of Schwann cell origin. One of the histopathologic subtypes of this tumor is ancient schwannoma which is characterized by degenerative alterations including cystic change, calcification, hemorrhage, and hyalinization. Intraosseous schwannomas especially ancient ones are rare tumors. Here we present a case of intraosseous ancient schwannoma in the lower jaw of an 11-year-old girl which caused a non-tender expansion. Radiographic examination showed a well-circumscribed, unilocular radiolucent lesion with thin sclerotic borders in the mandibular body and the ramus. Histopathologic examination of the incisional biopsy showed areas of typical Antoni A with verocay bodies and Antoni B that was strongly suggestive of a schwannoma. Complete excision of the lesion was done under general anesthesia. The histopathologic examination confirmed the primary diagnosis and also degenerative changes such as hyalinization and calcification. Based on these findings, the diagnosis of ancient schwannoma was made. No recurrence was observed in the follow-up examination after 3 months. [ABSTRACT FROM AUTHOR]

Background: Timely establishment of venous access in infants and toddlers during emergency medical care can be a particularly challenging task. Alternative routes for drug and fluid administration, such as endobronchial, intramuscular, central venous or venous cut-down do not offer reliable solutions. Intraosseous infusion (IOI) has become established as an effective alternative intravascular access for rapid and efficient drug delivery. IOI was introduced in our local emergency medical service (EMS) in 1993 and was assigned a high priority in international guidelines for pediatric emergency medical care in 2000 and 2005. The aim of this study was to review the impact of the introduction of IOI on drug administration routes during prehospital emergency treatment of critically ill or severely injured pediatric patients (NACA index V-VII) in our tertiary medical care centre over a period of 20 years. Methods: Pediatric prehospital emergency medical protocols from 1990 to 2009 were analyzed with respect to the administration routes for fluids and medications in severely injured or critically ill children with NACA severity scores V-VII. The frequency and mode of vascular access during prehospital treatment including IOI, endobronchial administration, central venous catheterization (CVC) and intramuscular administration as well as prehospital treatment and transportation without vascular access were analyzed. Two groups were compared: the introduction phase of IOI between 1990 and 1999 and the phase of growing IOI routine after introducing guidelines and regular staff IOI technique training between 2000 and 2009. Demographic data and drug administration routes in the two different time periods were analyzed using the Mann-Whitney-u test and t-test or χ-test, respectively. A p-value <0.05 was regarded as significant. Results: A total of 5,279 pediatric prehospital emergency charts were analyzed and 401 patients (7.6%) were scored as NACA V-VII. At the emergency scene 299 patients (75%) received a peripheral intravenous access, 3 (0.7%) a central venous line access, 77 (19%) an intraosseous needle and in 22 (5.4%) no vascular or intraosseous access was used during the course of prehospital treatment (NACA VII - 13 patients, NACA VI - 2 patients, NACA V - 7 patients). Of the NACA VII patients 3 were transported under continuous cardiopulmonary resuscitation without vascular access. After 2002 all patients with NACA index VII were treated with vascular or intraosseous access. In 48 patients (12%) at least initial medication was given by the endobronchial or alternative route but within the last 3 years endobronchial drug administration was no longer reported. Thus, in 124 critically ill patients (31%) routine peripheral venous access could not be established initially or until the end of treatment (77 times IOI, 22 times no access over the course of treatment, 3 times CVC and 22 times initial endobronchial followed by peripheral venous access). Over the reviewed period the use of IOI increased significantly (p<0.001), while the incidence of lacking vascular access (p<0.05) and alternative drug administration routes (p<0.001) continuously decreased. Conclusion: The IOI technique has not only been assigned a high priority in the guidelines for pediatric emergency care of critically ill children with difficult or failed venous access but has also significantly influenced current prehospital care. The introduction of the IOI technique in our prehospital pediatric emergency system has markedly reduced the number of critically ill or severely injured pediatric patients without vascular access or with less reliable alternative administration routes in the last 20 years. [ABSTRACT FROM AUTHOR]