Dosis de carga de Dexdor® y nivel óptimo de sedación durante procedimientos de cirugía oral y maxilofacial en régimen ambulatorio: un estudio observacional / Loading dose of Dexdor® and optimal sedation during oral and maxillofacial ambulatory surgery procedures: an observational study

Introducción. El objetivo de este estudio fue evaluar el efecto de diferentes dosis de carga de dexmedetomidina (formulación Dexdor®) en el tiempo para lograr y mantener un nivel óptimo de sedación, y su repercusión hemodinámica. Material y métodos. Estudio observacional aprobado por el CEIC-Navarra en pacientes programados para cirugía oral y maxilofacial ambulatoria con dexmedetomidina en la Clínica Universidad de Navarra entre febrero de 2013 y noviembre de 2014. En función de la dosis de carga los pacientes fueron agrupados en 3 categorías:<0,5; 0,5; y>0,5μg/kg. El nivel óptimo de sedación se definió como un índice biespectral<85. Los datos se analizaron utilizando técnicas de análisis de supervivencia. Los requerimientos de fármacos vasoactivos fueron evaluados mediante regresión logística exacta. Resultados. Ochenta y un pacientes fueron evaluados. La hazard ratio de alcanzar un índice biespectral<85 para los pacientes de los grupos de 0,5 y>0,5μg/kg fue de 1,5 (IC 95% 0,9; 2,6) y 1,8 (IC 95% 0,8; 3,9), respectivamente, en comparación con el grupo inferior. Cinco pacientes (6,2%) precisaron de atropina. Los pacientes en el grupo de>0,5μg/kg mostraron mayor riesgo de requerir atropina respecto al grupo de<0,5μg/kg (odds ratio 2,2; IC 95% 0,03; 183). Conclusión. Una dosis de carga de Dexdor®>0,5μg/kg parece reducir el tiempo necesario para alcanzar y mantener un nivel óptimo de sedación durante los primeros 60min de procedimiento. La posible relación entre la dosis de carga y los requerimientos de atropina precisa una investigación más exhaustiva (AU)

Introduction. Dexdor® do not include the possibility of loading dose, which could increase time to achieve adequate sedation for ambulatory procedures. The objective of this study was to evaluate the effect of several loading dose of dexmedetomidine in the time to achieve and maintain an optimal level of sedation and its clinical hemodynamic repercussion. Material and methods. The IRB approved this observational study for patients that underwent oral and maxillofacial ambulatory surgery under dexmedetomidine at the University of Navarra Clinic from February 2013 to November 2014. According to the loading dose the patients were grouped into 3 categories:<0.5, 0.5, and>0.5μg/kg. Optimal level of sedation was defined as bispectral index<85. Data were analyzed using survival analysis techniques. Vasoactive drugs requirements was evaluated using exact logistic regression. Results. Eighty-one patients were evaluated. Hazard ratios for patients in 0.5 and >0.5μg/kg loading dose categories for achieving a bispectral index<85 were 1.5 (95% CI 0.9, 2.6) and 1.8 (95% CI 0.8, 3.9), respectively, compared with the lowest category. Five patients (6.2%) required atropine for bradycardia. Patients in the group>0.5μg/kg showed greater risk of requiring atropine compared with the group<0.5μg/kg (odds ratio 2.2; 95% CI 0.03, 183). Conclusion. Loading dose of dexmedetomidine>0.5μg/kg appears minimize the time to achieve and maintain an optimal level of sedation during the first 60min of procedure. Further investigation to elucidate the association between loading dose of dexmedetomidine and subsequent atropine requirements may be warranted (AU)

Multidrug-resistant tuberculosis patients' views of interventions to reduce treatment loss to follow-up.

SETTING: Patients who initiated treatment for multidrug-resistant tuberculosis (MDR-TB) at 15 Programmatic Management of Drug-resistant Tuberculosis (PMDT) health facilities in the Philippines between July and December 2012. OBJECTIVES: To describe patients' views of current interventions, and suggest changes likely to reduce MDR-TB loss to follow-up. METHODS: In-depth interviews were conducted between April and July 2014 with MDR-TB patients who were undergoing treatment, had finished treatment at the time of the interview (controls), or had been lost to follow-up (LTFU). Responses were thematically analyzed. RESULTS: Interviews were conducted with 182 patients who were undergoing or had completed treatment and 91 LTFU patients. Views and suggestions could be thematically categorized as approaches to facilitate adherence or address barriers to adherence. The top themes were the need for transportation assistance or improvements to the current transportation assistance program, food assistance, and difficulties patients encountered related to their medications. These themes were addressed by respectively 63%, 60%, and 32% of the participants. CONCLUSIONS: A more patient-centered approach is needed to improve MDR-TB treatment adherence. Programs should strive to provide assistance that considers patient preferences, is adequate to cover actual costs or needs, and is delivered in a timely, uninterrupted manner.

Loading dose of Dexdor® and optimal sedation during oral and maxillofacial ambulatory surgery procedures: An observational study. / Dosis de carga de Dexdor® y nivel óptimo de sedación durante procedimientos de cirugía oral y maxilofacial en régimen ambulatorio: un estudio observacional.

INTRODUCTION: Dexdor® do not include the possibility of loading dose, which could increase time to achieve adequate sedation for ambulatory procedures. The objective of this study was to evaluate the effect of several loading dose of dexmedetomidine in the time to achieve and maintain an optimal level of sedation and its clinical hemodynamic repercussion. MATERIAL AND METHODS: The IRB approved this observational study for patients that underwent oral and maxillofacial ambulatory surgery under dexmedetomidine at the University of Navarra Clinic from February 2013 to November 2014. According to the loading dose the patients were grouped into 3 categories:<0.5, 0.5, and>0.5µg/kg. Optimal level of sedation was defined as bispectral index<85. Data were analyzed using survival analysis techniques. Vasoactive drugs requirements was evaluated using exact logistic regression. RESULTS: Eighty-one patients were evaluated. Hazard ratios for patients in 0.5 and >0.5µg/kg loading dose categories for achieving a bispectral index<85 were 1.5 (95% CI 0.9, 2.6) and 1.8 (95% CI 0.8, 3.9), respectively, compared with the lowest category. Five patients (6.2%) required atropine for bradycardia. Patients in the group>0.5µg/kg showed greater risk of requiring atropine compared with the group<0.5µg/kg (odds ratio 2.2; 95% CI 0.03, 183). CONCLUSION: Loading dose of dexmedetomidine>0.5µg/kg appears minimize the time to achieve and maintain an optimal level of sedation during the first 60min of procedure. Further investigation to elucidate the association between loading dose of dexmedetomidine and subsequent atropine requirements may be warranted.

Multidrug-resistant tuberculosis patients lost to follow-up: self-reported readiness to restart treatment.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) patients lost to follow-up (LTFU) from Programmatic Management of Drug-resistant Tuberculosis facilities in the Philippines. OBJECTIVES: To gain insight into patients' readiness to return to treatment. METHODS: MDR-TB patients who initiated treatment and were categorized as LTFU were identified using TB registers, contacted, and asked to consent to an interview and medical record review. At the conclusion of the interview, patients' readiness to restart treatment was assessed and examined in relation to demographic, clinical, and interview data. Odds ratios were calculated. RESULTS: When asked if they would consider restarting MDR-TB treatment, 3% of the 89 participating patients reported that they had already restarted, 34% indicated that they wanted to restart, 33% had not considered restarting, 28% were undecided, and 2% had decided against restarting. Patients who wanted to restart treatment were more likely to report having borrowed money for TB-related expenses (OR 5.97, 95%CI 1.27-28.18), and were less likely to report being self-employed (OR 0.08, 95%CI 0.01-0.67), or perceive themselves at low or no risk for TB relapse (OR 0.30, 95%CI 0.08-0.96) than patients who did not indicate an interest in restarting treatment. CONCLUSIONS: Efforts to re-engage LTFU patients in care should consider financial barriers, knowledge gaps, and personal adherence challenges in patients.

Autotransfusión sanguínea en cirugía ortognática: necesario / Autologous blood transfusions in orthognathic surgery: a necessity

El ahorro de sangre es un asunto que puede simplificar la asistencia médica diaria y mejorar su calidad tanto desde el punto de vista de morbilidad, seguridad y coste económico y social para los pacientes, profesionales de la salud como anestesistas, cirujanos, banco de sangre yde los equipos de dirección de hospitales públicos y privados. Inicialmente el interés por evitar los efectos adversos secundarios a la transfusión alogénica (TAL) (transmisión de enfermedades infecciosas, reaccionestransfusionales, como el Distress Respiratorio Agudo asociado a transfusión, costes, sensibilizaciones…) y posteriormente el ahorro de recursos limitados hacen que múltiples grupos de trabajo desarrollen nuevas estrategias frente a un problema común: la reposición o el ahorro de la sangre perdida durante las interven-ciones quirúrgicas y el postoperatorio inmediato.Asistimos en los últimos años a un menor uso durante las cirugías de cualquier tipo de sangre, especialmente la alogénica, gracias a la mejora de las técnicas quirúrgicas y anestésicas. Entre ellas la utilización de sangre del propio paciente (autóloga o autotransfusión) (AUT) en sus distintas modalidades. Llevamos a cabo una revisión de las distintas modalidades de AUT mostrando la experiencia de nuestro Servicio en el que se lleva practicando desde finales de los años 80

Daily medical care can be simplified by saving blood, andthe quality of care improved from the point of view of morbidity and safety. The economic and social cost can be reduced for patients and for health professionals such as anesthetists, surgeons, and for the blood banks and teams directing private and public hospitals. Initially the interest in avoiding the adverse secondary effects of allogenic transfusion (ALT) (infectious disease transmission, transfusion reactions, such as Acute Respiratory Distress associated with transfusion, cost, sensitivity...) followed by the desire to save limited resources, has led to multiple work groups developing new strategies for dealing with a common problem: replacing or saving blood lost during surgical interventions and the immediate postoperative period.Over recent years we have seen a reduction in the use of all blood types during surgery, especially allogenic, as a result of improvements in surgical and anesthesia techniques. Among these is the use of the patient’s own blood (autologous transfusion or autotransfusion)(AUT) in its different modalities.We have carried out a revision of the different modalities of AUT and the experience of our Service, which has been practicing this since the end of the 80s, is shown

Primary malignant schwannoma of the cervical plexus with melanocytic differentiation.

Primary malignant schwannomas are rare neoplasms of nerve sheath origin, especially in the location of the head and neck where few cases are described in the literature. These tumours may pose a diagnostic dilemma in the work-up of a neck mass. The case presented here is of a malignant schwannoma that originated in the cervical plexus with the rare histological feature of melanocytic differentiation. Histopathological examination with immunostaining techniques is essential for the diagnosis of these tumours. The management of these neoplasms is still controversial, although the treatment of choice is radical surgical excision of the lesion. The role of postoperative radiotherapy or chemotherapy is not clear, although some authors recommend its use to prevent local recurrence, for unresectable recurrent tumours or in cases of distant metastases.

Abordaje diagnóstico y terapéutico de la osteorradionecrosis mandibular / Diagnostic and therapeutic approach of the mandibular osteoradionecrosis

Objetivo: El propósito del estudio ha sido evaluar el abordja diagnóstico y terapéutico de la osteorradionecrosis (ORN) mandibular. La osteorradionecrosis mandibular es una de las complicaciones más serias de la radioterapia en el tratamiento del cáncer de cabeza y cuello. Los refinamientos técnicos que se emplean actualmente y la especial atención en los factores predisponentes han conseguido disminuir la incidencia pero el riesgo no ha podido ser totalmente eliminado. Material y método: Entre el año 1997 y 2000, ocho pacientes, siete hombres y una mujer, con una edad media de 50 años han sido tratados en nuestra institución por presentar ORN mandibular. Todos han tenido un seguimiento mínimo de dos años. Resultados: Cuatro pacientes respondieron al tratamiento conservador consistente en secuestromías limitadas y tratamiento antibiótico. Cuatro pacientes sufrieron una mandibulectomía segmentaria por progresión de la enfermedad. Conclusión: Es necesario centrar todos los esfuerzos en la prevención. Ante el primer signo de la enfermedad como necrosis de la mucosa o hueso expuesto se debe realizar tratamiento intensivo local con irrigaciones frecuentes con antisépticos y terapia con antibióticos. Una vez establecidas amplias áreas de necrosis de tejidos blandos, secuestros óseos extensos o fractura patológica es necesario un tratamiento quirúrgico radical. (AU)

Intraoral mandibular distraction osteogenesis: special attention to treatment planning.

PURPOSE: To demonstrate our experience using internal devices for unidirectional distraction osteogenesis in treating different mandibular hypoplasias (with or without maxillary deformities). An algorithmic table for diagnosis, and treatment planning is presented. PATIENTS AND METHODS: Twenty internal distraction devices were used in 16 patients with mandibular hypoplasia. Deficiency in length of the mandible was calculated on three-dimensional computed tomography scans. The device was activated by a transcutaneous pin on the fifth postoperative day. Distraction was achieved at rates of 0.5 mm/12 h. After a variable period of consolidation the devices were removed. Mean follow-up was 18 months. RESULTS: Successful distraction osteogenesis was achieved in all patients. No premature consolidation or pseudoarthrosis was observed. Improvement of facial aesthetics was produced in all cases. Final occlusion was excellent in those cases where no simultaneous maxillary deformity was present. Orthodontic treatment was applied in all cases. Results remained stable one year postoperatively. CONCLUSIONS: The occlusal results obtained in this series show that we can plan distraction as a definitive treatment in cases with isolated mandibular hypoplasia. When an additional maxillary deformity is present, mandibular distraction must be performed first if indicated, but a maxillary procedure will be necessary later.

Tumor odontogénico adenomatoide: presentación de tres nuevos casos y revisión de la literatura / Adenomatoid odintogenic tumor: presentation of three new cases and literature review

Presentamos tres nuevos casos de tumor odontogénico adenomatoide (TOA), entidad con una baja frecuencia de aparición y comportamiento benigno. De origen incierto, el TOA supone menos del 10 por ciento de todos los tumores odontogénicos, su curso clínico y el bajo índice de recidivas hace que la exéresis de la lexión sea el tratamiento de elección. En ese artículo presentamos dos casos de especiales características; el primero de ellos es una forma asociada a un quiste dentígero de localización periférica, forma que está recogida en contadas ocasiones en la literatura. El segundo de ellos es una variante extrafolicular asociado a un tratamiento previo de ortodoncia, peculiar asociación de la que no existen muchas referencias bibliográficas. Para finalizar se presenta un caso típico de TOA, que ofrece las características peculiares de aparición de esta lesión. Se revisan las principales características de la enfermedad, frecuencia de aparición, diagnóstico, diagnóstico diferencial, así como las formas de presentación y el tratamiento (AU)

Adenoma pleomorfo metastatizante de glándulas salivales: caso clínico y revisión de literartura / Metastazing pleomorphic adenoma of salivary glands: a case report and literature review

El adenoma pleomorfo es el tumor benigno más frecuente en las glándulas salivales. Se localiza habitualmente en las glándulas salivales mayores (sobre todo en las glándulas parótidas), pero puede afectar también a las menores. Es considerado una neoplasia de comportamiento benigno, aunque con tendencia a la recurrencia. El adenoma pleomorfo metastatizante es extremadamente raro, con sólo un puñado de casos descritos. Presentamos el caso de un paciente diagnosticado de adenoma pleomorfo metastizante de glándula submaxilar a ganglios linfáticos cervicales, tres años después de una submaxilectonomía. Realizamos una revisión bibliográfica de las características de este tipo de tumores así como de los tratamientos recomendados. El adenoma pleomorfo es el tumor benigno más frecuente en las glándulas salivales. Se localiza habitualmente en las glándulas salivales mayores (sobre todo en las glándulas parótidas), pero puede afectar también a las menores. Es considerado una neoplasia de comportamiento benigno, aunque con tendencia a la recurrencia. El adenoma pleomorfo metastatizante es extremadamente raro, con sólo un puñado de casos descritos. Presentamos el caso de un paciente diagnosticado de adenoma pleomorfo metastizante de glándula submaxilar a ganglios linfáticos cervicales, tres años después de una submaxilectonomía. Realizamos una revisión bibliográfica de las características de este tipo de tumores así como de los tratamientos recomendados (AU)

A new transfacial approach for lesions of the clivus and parapharyngeal space: the partial segmented Le Fort I osteotomy.

Tumors of the clival and parapharyngeal areas are a challenge because of their location. They used to be considered inaccessible because the aggressive approaches employed caused elevated levels of morbidity. This fact led to more conservative approaches that attempted to preserve the exposure of the lesion. These approaches were a combination of cranial and facial procedures, thus utilizing a combined effort between neurosurgeons and maxillofacial surgeons. We described our experience with a partial segmented Le Fort I osteotomy added to a transmandibular approach to expose a chordoma of the clivus and left parapharyngeal space. A three-dimensional imaging was used as a diagnostic tool and to plan the optimal surgical approach. The operative technique was described in this case study. Some important technical details of the approach are described. The global outcome was favorable.

Squamous cell carcinoma of the oral cavity in patients younger than 40 years.

Squamous cell carcinoma of the head and neck has been regarded as a disease affecting the elderly. Several etiologic factors have been demonstrated, such as tobacco and alcohol use and premalignant lesions, whereas others have been suspected, such as genetic or immunodeficiency disorders. Recently, some reports have addressed a tendency toward an increase in the incidence of squamous cell carcinoma in young patients. In recent years we have observed an increase in the number of squamous cell carcinomas in patients younger than 40 years. Therefore we retrospectively reviewed our clinical experience of cancer in those patients younger than 40 years. After screening 505 clinical charts, 294 patients met the criteria to enter our study. Twenty-four (8.2%) patients were aged 40 years or younger. Data collected included the history of premalignant lesions, etiologic factors, TNM stages, treatment modalities, and histopathologic issues. Statistical analysis with Kaplan-Meier survival rates and log-rank tests between various variables were applied. A significant association in survival was observed between patterns of recurrence (p = 0.031) and presence of neoplastic cells 5 mm or closer to the specimen margin. On the other hand, a lack of association was assessed in carcinogenic-related habits and in premalignant lesions. Likewise, although men showed a slightly worse prognosis than women, statistically no significant differences were found (p = 0.27).

Quintuple cancers: report of a case with triple cancers in the head and neck.

The incidence of multiple primary cancers is increasing. We report a case of quintuple cancers, two located in the genitourinary tract and three arising on the upper aerodigestive tract, two synchronous squamous cell carcinomas of the oral mucosa and another on the larynx. We also present a brief review of the literature.

Epithelioid hemangiomas of the maxillofacial area. A report of three cases and a review of the literature.

Epithelioid hemangioma, also named angiolymphoid hyperplasia with eosinophilia, is a very rare tumor that arises from vascular structures. The relative incidence in the skin of the head and neck area is rather high as compared to other parts of the body. Three cases are reported in an atypical location and the differential diagnosis with other similar vascular lesions and their pathologic features is presented.

Use of buccal fat pad to repair intraoral defects: review of 30 cases.

The buccal fat pad has been frequently used for the closure of oro-antral and oro-nasal communications. There are a few studies in the literature reporting its use in defects secondary to tumoral resections. In this paper we consider both the anatomical basis and the surgical technique. We also review 30 cases, used for the repair of 15 defects due to tumoral resections, 8 to maxillary cysts, 6 to communications and 1 secondary to a postraumatic defect. It has been successful in 28 of the 29 patients, with a complete epithelization of the flap, even in 4 cases with partial necrosis of the pad. It is an acceptable type of reconstruction, versatile and of a simple surgical technique. However, its use is limited to small or medium defects, being sometimes scarce.

Tongue flaps for reconstruction of the oral cavity.

Pedicled tongue flaps (anterior, posterior, double) have proved to be an effective method of repairing defects due to tissue loss in the oral cavity. Their central position, mobility, and excellent blood supply make the use of these flaps feasible in a variety of sites.

Sarcomas of the head and neck.

Fourteen cases of sarcomas involving the head and neck over a period of 15 years were reviewed. The male to female ratio was 3.5:1. Mean age of occurrence was 33.4 years, with a range of 5-84 years. Soft tissue was the site of origin in three cases, maxilla in four and mandible in seven patients. Radical surgery with resection of adequate disease-free margins was the most effective mode of treatment. Radiotherapy and chemotherapy was used in selected cases. Recurrence occurred in 42.9% of patients, and was the main cause of death. Three patients (21.4%) developed distant metastases. The actuarial 2-year and 5-year survivals of the 14 patients assessed were 64% and 56% respectively.

[Pilomatrix carcinoma. A new case]. / Carcinome pilomatrix. Un nouveau cas.

We present a new case of Pilomatrix Carcinoma after having review the 22 cases previously published. The tumor arisen in a 74 years old male, in the left preauricular region. The lesion was excised with wide margins. A year after there is not any evidence of recurrence or metastases.

[Cranio-orbital neurofibrosarcoma]. / Neurofibrosarcome cranio-orbitaire.

We present a type 1 neurofibromatosis case with sarcomatous degeneration of a cranio-orbital neurofibroma, its surgical evolution and the cytogenetics and cellular proliferative potential features (CMF, Ki-67 antibody).