Osteonecrosis of jaws related to intravenous bisphosphonates: the experience of a Jordanian teaching hospital.

INTRODUCTION: We describe our experience with oncology patients on a frequent dosing schedule of intravenous (i.v.) bisphosphonates at the Jordan University Hospital (JUH). PATIENTS AND METHODS: Patients treated by i.v. bisphosphonates in the medical oncology unit at the JUH were examined for bisphosphonate-related osteonecrosis of the jaws (BRONJ). Diagnosis was made according to the guidelines of the American Association of Oral and Maxillofacial Surgeons (AAOMS) original position paper. RESULTS: Of the 41 patients, four developed BRONJ, two in maxilla, one in mandible and one bimaxillary. Patients with BRONJ were older; mean age was 69.3 +/- 3.1 years compared to 62.8 +/- 12.5 years (P = 0.022). Dental co-morbidities were more commonly present in patients with the disease (P = 0.038). Patients who developed BRONJ were on treatment for a longer duration of time; the mean duration of treatment was 23.5 +/- 8.4 months compared to 11.9 +/- 13.4 months (P = 0.10). CONCLUSIONS: The results of this case series demonstrated that age and poor oral health status are significant risk factors of BRONJ for oncology patients on long-term frequent dosing schedule of i.v. bisphosphonates.

Breast reconstruction in conserving breast cancer surgery.

Breast conserving treatment (BCT) combined with radiotherapy have proved the test of time as a sound oncological operation regarding survival and local recurrence. Successful BCT is a balance between adequate surgery and maintaining the breast's appearance. Unsatisfactory outcome reaches 20-30% in standard techniques of BCT. Concepts described to widen the spectrum of BCT, have made an improvement of cosmetic outcome, and facilitated a liberal safety margin. Volume displacement techniques, such as glandular flap, mammoplasty, donut mastopexy, and batwing mastopexy proved useful in large breasts and volume replacement, such as latissimus dorsi flap and local flaps are of great advantage to replace defects in small and medium sized breasts. Some of these techniques are simple, but comprehensive knowledge and training are required for sophisticated ones. The objectives of this article are to shed light on different techniques adopted by surgeons to perform BCT in conjunction with various oncoplastic techniques and to discuss the factors that influence their applications to achieve best oncological and aesthetic outcome.

Breast reconstruction by local flaps after conserving surgery for breast cancer: an added asset to oncoplastic techniques.

This study describes and evaluates the results of a proposed simple technique of volume replacement by local flaps to reconstruct the breast after conserving surgery for breast cancer. Twenty-five patients with breast cancer were enrolled in the study between 1998 and 2004. All patients were surgically treated by wide local excision and axillary dissection of level I & II. The primary closure was not feasible because of resulting large defect in proportion to the breast size. The defect was constructed by local flap raised from adjacent skin and subcutaneous tissue with or without glandular breast tissue. Data analyzed includes: age, tumor location, tumor size, histopathology results, operative techniques, complications, long-term oncological events, and cosmetic outcome. The mean follow-up was 48 months. The mean age was 45.3 years. The mean tumor size was 3.1 cm. All tumors had upper outer or upper central location. Fourteen tumors were in left breast. Histopathological analysis had revealed 84% infiltrating ductal carcinoma of no otherwise specified type, 12% medullary type, and 4% tubulo-lobular carcinoma. Additional ductal carcinoma in situ was found in three patients. One patient had focally positive deep margin. One hematoma and one fat necrosis during radiotherapy were documented. During follow-up, one patient developed local recurrence after 4 years and required mastectomy, another patient developed concomitant local recurrence and distant metastasis in the lung and brain after 18 months of the primary treatment and died 1 year later. In this study, 84% of women were satisfied with their cosmetic outcome. This study demonstrated the value of local flaps to reconstruct breast defects after wide local excision of tumors in upper outer or upper central location as simple alternative to latissimus dorsi flap and other volume displacement techniques.

Mammary duct fistulae: classification and management.

BACKGROUND: The aim of the present study was to review the management of mammary duct fistulae and propose a classification that could be useful in planning the management of mammary duct fistulae. METHODS: Sixteen women presented with a mammary duct fistula, two of whom had two fistulae. The data analysed included age, smoking habit, previous abscesses, nipple abnormalities, imaging, culture, operative technique and histopathological findings. RESULTS: The average follow up was 28 months, the mean age was 36.5 years and two women were heavy smokers. Nipple abnormalities were found in five (32%) patients, the average number of abscesses before the presentation was 1.8 and Staphylococcus coagulase negative predominated the culture. Eleven (69%) patients underwent total excision of the ductal system and fistulous tract using a technique modified by the author. Five patients were offered conservative treatment; however, one of the patients refused surgical treatment, but was still followed up in the present study. Histopathological results revealed periductal mastitis in 10 patients, idiopathic granulomatous mastitis in five patients and tuberculous mastitis in one patient. CONCLUSION: Deep mammary duct fistulae are directly related to a diseased ductal system and should be differentiated from superficial fistulae, which result from the infection of the subepidermal mammary glands. Deep fistulae that result from periductal mastitis should be treated by total excision of the ductal system in conjunction with the fistulous tract under antibiotics to ensure the lowest rate of recurrence. The technique used in the present study resulted in negligible morbidity and good cosmetic appearance. A trial of conservative treatment should be recommended for fistulae resulting from idiopathic granulomatous mastitis; however, further studies are required to establish the best treatment.

Determination of tramadol in hair using solid phase extraction and GC-MS.

Tramadol is a centrally acting synthetic analgesic with mu-opioid receptor agonist activity, it is a widely prescribed analgesic used in the treatment of moderate to severe pain and as an alternative to opiates. Tramadol causes less respiratory depression than morphine at recommended doses. Its efficacy and low incidence of side effects lead to its unnecessary prescribing in patients with mild pain. Tramadol was classified as a "controlled drug" long after its approval for use in Jordan. Analysis of drugs of abuse in hair has been used in routine forensic toxicology as an alternative to blood in studying addiction history of drug abusers. A method for the determination of tramadol in hair using solid phase extraction and gas chromatography-mass spectrometry (GC-MS) is presented, the method offers excellent precision (3.5-9.8%, (M)=6.77%), accuracy (6.9-12%, M=9.4%) and limit of detection 0.5 ng/mg. The recovery was in the range of 87-94.3% with an average of 90.75%. The calibration curve was linear over the concentration range 0.5-5.0 ng/mg hair with correlation coefficient of 0.998. The developed method was tested on 11 hair samples taken from patients using tramadol as prescribed by their physician along with other different drugs in treating chronic illnesses. Tramadol was detected in all hair samples at a concentration of 0.176-16.3 ng/mg with mean concentration of 4.41 ng/mg. The developed method has the potential of being applied in forensic drug hair testing. In Jordan, hair drug testing started to draw the attention of legal authorities which stimulated forensic toxicologists in recent years to develop methods of analysis of drugs known or have the potential to be abused.