Comparación del injerto gingival libre y el injerto submucoso de tejido conectivo para el cubrimiento de recesiones marginales gingivales / Comparison of the free gingival graft and the connective tissue submucous graft for the coverage of marginal gingival recessions

Este estudio clínico aleatorizado pretende determinar la efectividad de dos procedimientos utilizados para cubrir las recesiones marginales gingivales, el injerto gingival libre (IGL) y el injerto submucoso de tejido conjuntivo (ISTC). Se realizaron 18 cirugías: nueve de IGL y nueve de ISTC, en cinco pacientes con recesiones bilaterales, con un promedio de edad de 34,5 años , en buena condición de salud bucal. Se evaluó el porcentaje de cubrimiento radicular, el nivel clínico de unión, la estética periodontal, el uso de la tetraciclina (HCL) y la molestia postoperatoria. Adicionalmente, se diseñó un índice de estética periodontal. Ninguno de los procedimientos mostró diferencias estadísticamente significativas en el porcentaje de cubrimiento radicular, con una P=0.0719. El IGL cubrió un 52.3 por ciento y el ISTC un 67.9 por ciento. Se ganó inserción clínica favorable, siendo significativa la diferencia con un valor P=0.00. Al comparar la estética periodontal, se presentaron diferencias con un valor P=0.0117, mostrando un comportamiento excelente y bueno de 88,9 por ciento para el ISTC y bueno en un 22.2 por ciento para el IGL. Este estudio comprobó que el sitio más molesto es el paladar, el IGL es una cirugía más dolorosa, el ISTC presenta un mejor comportamiento clínico que el IGL, y la tetraciclina no representa beneficios adicionales

Aspirin effects on endometrial cancer cell growth.

OBJECTIVE: To find whether aspirin (acetylsalicylic acid, ASA) inhibits the growth of endometrial cancer cells in vitro in a way similar to that in colorectal cancer cells and to investigate the mechanisms by which aspirin might lead to growth inhibition. METHODS: Ishikawa human endometrial tumor cells were grown in the presence of ASA (1-5 mM) for 96 hours. Controls were treated with vehicle (absolute ethanol). Cell proliferation was assessed by 3-(4,5-dimethylthiazol-2-yl) -2,5-diphenyltetrazolium bromide assay. Apoptosis was determined by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay. Analysis of cell-cycle distribution and bcl-2 expression was assessed by flow cytometry. RESULTS: Acetylsalicylic acid induced a dose-dependent inhibition of Ishikawa cells in vitro. The percentage of growth inhibition was 21-88% at concentrations of 1-5 mM. It also induced apoptosis and reduced bcl-2 expression in Ishikawa cells in a dose-dependent manner. Control cells and cells treated with the lowest concentration of ASA exhibited 2% apoptosis and more than 60% of the population expressed bcl-2. Apoptosis levels increased as levels of ASA increased from 2 to 5 mM (7-58%) with a concommitant decrease in bcl-2 expression from 46% at 2 mM to 2% at 5 mM. Acetylsalicylic acid concentrations of 3 mM or greater induced a shift from the resting phase (G0/G1) to S phase of the cell cycle. CONCLUSION: Acetylsalicylic acid inhibited Ishikawa cell growth in vitro in a dose-dependent manner. Apoptosis is one of the mechanisms involved in the response, which can be mediated in part by downregulation of bcl-2.

Accuracy of lymph node palpation to determine need for lymphadenectomy in gynecologic malignancies.

OBJECTIVE: To assess the accuracy of intraoperative lymph node palpation for identifying lymph node metastasis in gynecologic malignancies. METHODS: We prospectively evaluated 126 women who had lymphadenectomies for staging of various gynecologic malignancies from August 1995 to June 1997. Surgeries were done by obstetrician-gynecologists with subspecialty certification in gynecologic oncology from the American Board of Obstetrics and Gynecology, who had practiced gynecologic oncology for at least 5 years. Data were collected on gynecologic oncologists' opinions of lymph node status by palpation. Nodes believed to be positive were sent separately. We recorded operating time for lymphadenectomies, and intraoperative and postoperative complications. RESULTS: Mean (range) patient age was 55 (18-83) years. Mean (range) operating time was 188 (85-435) minutes. The mean (range) lymphadenectomy time was 46 (5-150) minutes. The total number of lymph nodes dissected was 2138. One hundred seven of 2138 (5%) nodes were positive for malignancy. Thirty-eight of 107 (36%) positive lymph nodes were missed by palpation. Fifty-six of 2031 (3%) negative lymph nodes were selected as positive. Sixty-nine of 107 (64%) positive lymph nodes were identified correctly. Sensitivity and specificity of palpation were 72% and 81%, respectively. The positive and negative predictive values of lymph node palpation were 56% and 89%, respectively. CONCLUSION: Intraoperative lymph node palpation has low sensitivity and positive predictive value even when done by experienced board-certified gynecologic oncologists.

Lateral microscopic extension of squamous cell carcinoma of the vulva.

PURPOSE: The aim of this study was to measure the radial occult microscopic spread of tumor in patients with invasive squamous cell carcinoma of the vulva. MATERIALS AND METHODS: In the operating room the gross tumor border was marked. The pathologist took a radial section in each quadrant and measured the distance of occult lateral spread of the tumor. RESULTS: From 7/01/93 to 6/30/96, 24 tumors from 21 patients were studied. The mean maximum tumor diameter was 3. 2 cm (0.5-7.0) and the mean depth of invasion was 9.1 mm (1.1-28.0). The gross and microscopic extent correlated in 20 tumors. Maximum lateral microscopic extent of the other 4 tumors was 3.5, 5 (to the margin), 10, and 16 mm. These 4 tumors were ulcerative and infiltrative and arose from or involved mucosa. CONCLUSION: The gross and microscopic periphery of most invasive squamous vulvar cancers are approximately the same. Ulcerative tumors with an infiltrative pattern of invasion which involve mucosal epithelium may be more likely to extend beyond what is grossly apparent. Measurement of the tumor-free margin should be included in future studies.

Does ligation of the hypogastric artery at the time of radical hysterectomy and lymphadenectomy decrease blood loss? Results of a prospective randomized trial.

A prospective, randomized study of patients undergoing radical hysterectomy for gynecologic malignancies was undertaken from 10/95 to 11/96 to determine if ligation of the hypogastric arteries at the time of radical hysterectomy decreases blood loss. Patients were randomized to either ligation of the hypogastric artery (Group 1) or no ligation (Group 2) prior to a standard Piver type III radical hysterectomy. Surgeries were performed by Board certified gynecologic oncologists with gynecologic oncology fellows and/or OB/GYN residents. Patients were analyzed for demographic characteristics and intraoperative and postoperative parameters. Statistical analysis was performed with independent samples t-test, Mann-Whitney rank sum test, Chi square and Fisher exact test. Twenty-one patients were randomized to group 1 and 22 to group 2. Groups were similar with respect to demographics and preoperative parameters except for age. There were no differences among the groups with respect to intraoperative and postoperative parameters. The mean estimated blood loss for group 1 was 600 ml and 550 ml for group 2 (P = NS). Hypogastric artery ligation (HAL) at the time of radical hysterectomy for gynecologic malignancy does not reduce blood loss.

Anterior enterocele following cystectomy for intractable interstitial cystitis.

PURPOSE: We clinically define the development of an anterior vaginal wall hernia following cystectomy for the management of intractable interstitial cystitis and establish surgical technique for its correction. MATERIALS AND METHODS: Of 27 women who underwent simple cystectomy and urethrectomy for intractable interstitial cystitis an anterior vaginal wall hernia developed in 3 (71, 56 and 61 years old) at 8, 14 and 16 months, respectively, postoperatively. Clinical appearance was similar to a midline cystocele but it contained bowel contents in the form of an anterior enterocele. Anterior enterocele was associated with vaginal vault prolapse in 1 patient who was treated with transvaginal sacro-spinous colpopexy. Patients with isolated anterior enterocele required a transabdominal approach with mobilization of the intestinal hernia contents and obliteration of the intervaginal abdominal wall space. RESULTS: At 12, 19 and 33 months following reconstruction prolapse has not recurred, and sexual function was restored in 1 patient. CONCLUSIONS: These cases suggest that an extended simple cystectomy performed on women with intractable interstitial cystitis may result in a weakening of the anterior vaginal wall with resultant anterior enterocele formation. When it is associated with vaginal vault prolapse a transvaginal technique may be considered but we prefer a transabdominal approach for an isolated anterior enterocele. Prevention of this entity may be warranted at the time of cystectomy.

A pilot study utilizing intraoperative lymphoscintigraphy for identification of the sentinel lymph nodes in vulvar cancer.

OBJECTIVE: To identify sentinel lymph nodes using intraoperative lymphoscintigraphy. METHODS: Technetium-99-labeled sulfur colloid was injected at the site of primary vulvar carcinoma. An intraoperative gamma counter was used to identify one or more sentinel lymph nodes. RESULTS: Ten patients underwent bilateral inguinal and femoral lymphadenectomy. The clinical stages are as follows: T1 in 6, T2 in 2, and T3 in 2. A total of four groins (3 patients) were positive for metastases. In one patient only the sentinel node was positive for disease. In a second patient, two unilateral nodes were positive for disease and both were identified with the gamma counter as sentinel nodes. In the third patient, a single sentinel node was positive for malignancy in each groin. Multiple nonsentinel lymph nodes were positive in each groin in this patient. In no case was the sentinel node negative when other nonsentinel nodes were positive. CONCLUSION: Intraoperative lymphoscintigraphy quantitatively identifies one or more sentinel lymph nodes. Since sentinel lymph nodes can be localized transcutaneously, this technique may be useful for selective lymphadenectomy. Larger patient accrual is necessary to verify this technique.

The failed anti-incontinence mechanism: a flap valve or cecal wrap for surgical reconstruction.

PURPOSE: On a long-term basis patients with continent urinary diversions may have an acceptable number of complications, such as urinary incontinence. We report on a new surgical technique for treatment of the incompetent anti-incontinence segment. MATERIALS AND METHODS: Seven patients presented with a large capacity, low pressure reservoir and an incompetent anti-incontinence mechanism. The original anti-incontinence mechanism consisted of an intussuscepted reimplanted appendix (Mitrofanoff) in 2 patients, tapered ileum and reinforced ileocecal valve in 3, and tapered and reimplanted ileal segment in 2. Surgical reconstruction involved 2 stages: stage 1 - lengthening and tubularizing the cecum with the anti-incontinence segment and stage 2 - creation of the flap valve mechanism. Stage 2 required intraoperative modification when abundant peri-reservoir fibrosis, a thin-walled reservoir (cecal wrap) or an excessive thickened mesentery was encountered. RESULTS: After a mean followup of 7 months 6 of 7 patients performed catheterization every 4 hours and were continent. Several patients required a concomitant procedure with the incontinence revision. CONCLUSIONS: We describe a 2-stage technique for correction of a variety of untoward anatomical conditions related to a failed anti-incontinence segment with continent urinary reservoirs. Concomitant repair of other coexisting structural abnormalities related to the continent reservoir may also be necessary.

Transvestibular retropubic bladder neck suspension. A pilot study.

A pilot study was conducted assessing the operative feasibility, complications and results of a retropubic bladder neck suspension performed through a transvestibular approach. This study extended from July 1, 1990, to June 30, 1991, and included patients who planned to undergo primary surgical correction of stress urinary incontinence. Through a transvestibular incision, a bladder neck suspension was performed by suturing the adjacent area of the vagina to the back of the pubic symphysis or the puborectalis muscle near the pubic bone. Ten women were entered into the study. There was one notable complication, a hematoma in the space of Retzius. One patient described worsening of her incontinence and underwent a Marshall-Marchetti-Krantz procedure three months postoperatively. The mean follow-up for the remaining nine patients was 27 months (range, 13-31). At this writing, 6 patients were completely continent, 1 was improved, and 2 had some degree of bladder instability with associated incontinence. Overall, the transvestibular procedure was thought to be technically difficult. Based on very limited data, the results of the study have discouraged our continued use of this procedure. The transvestibular approach may be applicable occasionally on selected patients.

Management of chemotherapy in a pregnancy complicated by a large neuroblastoma.

BACKGROUND: The English literature contains infrequent reports of neuroendocrine carcinoma during pregnancy. The chemotherapy for this type of malignancy can cause severe nausea and neutropenia. We used recently developed modalities to ameliorate these side effects. CASE: A 22-year-old woman, gravida 4, para 2-0-1-2, presented at 24 weeks' gestation with a complaint of massive lower-extremity edema. Computed tomography scan delineated a large retroperitoneal mass. Biopsy of a small neck mass revealed a poorly differentiated neuroblastoma. A multidisciplinary approach to therapy was undertaken. The patient received cisplatin and etoposide chemotherapy. Complications of the first course included severe neutropenia and nausea with vomiting. Filgrastim and ondansetron were used to treat these complications. She delivered an 1825-g healthy male by cesarean for fetal distress at 35 weeks. No anomalies were noted at birth. Neonatal hematologic indices were normal CONCLUSION: A multidisciplinary approach to rare malignancies is warranted in pregnancy. Filgrastim and ondansetron are effective agents in the treatment of chemotherapy-associated complications. Their use in pregnancy warrants further investigations.

Reaching unserved poor communities. The MEXFAM Community Doctors Programme.

PIP: MEXFAM established the Community Doctors Program in 1986 to deliver, at modest cost, health and family planning services to low-income populations in areas not served by government or other agencies. An initial cohort of 49 doctors opened modest doctor's offices from which they provided services at fees affordable by the community with the goal of eventually becoming self-sufficient as a micro-enterprise in an economically deprived area. MEXFAM has collected data to evaluate the project since its beginning in 1986. Women were the main users of the centers and most of them visited for reasons related to their children. Of very low educational and income level, most of the women rated the services as satisfactory or highly satisfactory. Women doctors seemed to be better accepted. The program expanded over the years to enable the association to successfully work with 250 doctors in 1993. Lessons learned over the years have been incorporated to form the current program model. The author also notes that the rate of program expansion has slowed since 1992 and only twelve doctors will join the program in 1994. Furthermore, departing from previous practice, new community doctors do not purchase their equipment and furniture at the end of two years and become independent. The doctors instead rent their equipment after the initial subsidies are terminated. They are then supervised and continue to receive training from MEXFAM. The physicians remain eligible to buy contraceptives and other items from MEXFAM at a price which allows the organization to recover costs.^ieng

Responding to the real needs of women.

PIP: INPPARES, the International Planned Parenthood Federation affiliate in Peru, has provided family planning and other services to the Peruvian population since 1976. The organization concentrates upon interventions targeted to women of low socioeconomic status. One of the group's most important strategies has been to distribute contraceptives at the community level in rural and peri-urban areas of the country through a network of centers managed by promoters. These promoters are virtually all female. The organization in 1993 supplied 812 distribution centers. Promoters and their supervisors have received training in contraception, basic data recording, community work, and related topics. INPPARES, however, suspected that the quality of the project would be improved if promoters and supervisors were trained about the role of women in the community and their rights and identity as women. The personnel would then be able to better understand the role of contraception and reproductive health in women's lives. To that end, INPPARES in 1992-93 developed a project in coordination with the Manuela Ramos Association, a Peruvian women's organization. A questionnaire was given to forty promoters on issues related to women's roles, values, attitudes, the place of women in society and the family, family planning, sexual relations, and decision making. Their responses pointed to a real need to provide promoters and supervisors with more information through workshops on women in Peruvian society, women's identity and roles, women's sexual rights, and the quality of care in service provision. Four pamphlets were drafted from a seminar of fifty supervisors from both organizations to be used in a series of twelve workshops for 256 promoters. Post-intervention evaluation of the original forty participants confirm the significant effectiveness of both subjects covered and materials used in achieving desired project goals. Four workshops were subsequently held in which project results were presented to 261 promoters. Promoters and supervisors are now using flipcharts and pamphlets in their training activities.^ieng

Human fetal response to vibroacoustic stimulation as a function of stimulus duration.

The effect of stimulus duration on the initial fetal heart rate (FHR) acceleration response was evaluated by assessing its amplitude and span following a single vibroacoustic stimulation with durations of 0 (sham), 1, 3, or 5 seconds. Statistically significant differences were observed in the mean amplitude and duration of acceleration in groups 3 and 5 when compared with groups 0 and 1 (P less than .05). In addition, groups 3 and 5 demonstrated significantly greater fetal reactivity than group 0 and a decrease in testing time over groups 0 and 1 (P less than .05). Our results suggest that the magnitude of the FHR acceleration response is dependent on the duration of the stimulus. Furthermore, a 3-second sound stimulus appears to be adequate for a shift to the fetal behavioral "awake" state.