Accurate cost of breast reconstruction with DIEP flap and implants in a public hospital in the spanish healthcare system

La reconstrucción mamaria postmastectomía puede suponer un importante consumo de recursos humanos y económicos para cualquier sistema sanitario. El propósito de este estudio es saber si el peso económico asignado por el Sistema Nacional de Salud Español según codificación mediante Grupos Relacionados con el Diagnóstico a los dos procedimientos principales de reconstrucción mamaria, se ajusta al gasto inferido según el consumo de recursos real de las pacientes. Realizamos un estudio retrospectivo de cohortes para evaluar el coste económico de 134 pacientes intervenidas de reconstrucción mamaria unilateral diferida mediante los procedimientos expansor-prótesis (E-P) y colgajo de perforantes de la arteria epigástrica inferior profunda (DIEP), durante el periodo comprendido entre 2005 y 2013. Los datos analizados e inferidos de las pacientes fueron los costes directos intrahospitalarios y extrahospitalarios tanto de la cirugía inicial de reconstrucción como de los procedimientos secundarios. Las pacientes reconstruidas con E-P precisaron un mayor número de cirugías para completar su reconstrucción, y presentaron mayor porcentaje de complicaciones relacionadas con la cirugía. El porcentaje de cirugías de retoque estético fue superior en la reconstrucción DIEP. No encontramos diferencias significativas en el coste total inferido de las pacientes entre ambas cohortes (18.857,77 € DIEP frente a 20.502,08 € E-P, p=0,89). El coste total de la reconstrucción mamaria según Grupos Relacionados con el Diagnóstico fue inferior al coste total inferido de las pacientes para ambas cohortes (11.596,43 € frente a 18.857,77 €, p<0,001 DIEP; 13.565,82 € frente a 20.502,08 € E-P, p<0,001). El coste de la reconstrucción mamaria está inadecuadamente tarifado por los gestores sanitarios; el coste según Grupos Relacionados con el Diagnóstico es inferior al coste inferido de las pacientes para cualquiera de los dos procedimientos. Consideramos que la reconstrucción con colgajo DIEP es más costeefectiva que la reconstrucción con E-P, pues requiere menos procedimientos quirúrgicos, presenta menor porcentaje de complicaciones y permanece más estable a lo largo del tiempo.Mastectomy breast reconstruction can be a significant consumption of human and financial resources for any health system. The purpose of this study is whether the economic weight assigned by the Spanish National Health System as encoding by Healthcare Resource Groups to two major breast reconstruction procedures fits true estimate of patients. A retrospective cohort study has been performed to evaluate the economic cost of 134 patients operated on for unilateral breast reconstruction delayed by the expander-prosthesis (E-P) and deep inferior epigastric artery perforator flap (DIEP) procedures during the period between 2005 and 2013. The data analyzed and economic cost estimated of the patients were in-hospital and out-patient direct costs of both the initial reconstruction surgery as secondary procedures. Patients undergoing E-P reconstruction required a higher number of surgery sessions to complete the reconstruction procedure and showed higher rates of surgery-related complications. The percentage of surgery required for aesthetic retouch was higher in patients reconstituted with DIEP flap. No statistically significant differences were found regarding total cost between the two cohorts (18.857,77 € DIEP vs 20.502,08 € E-P, p = 0,89). Total cost of breast reconstruction according Healthcare Resource Groups was lower than total estimated cost of patients for both cohorts (11.596,43 € vs € 18.857,77 €, p < 0.001 DIEP; 13,565.82 vs 20,502.08 €, p < 0.001 E-P). The cost of breast reconstruction is inadequately tariffed by health managers; the cost using Healthcare Resource Groups is less than the estimated cost of the patients to either procedures. We consider that DIEP flap reconstruction is more cost- effective than E-P reconstruction, as it requires less surgical procedures, presents lower complication rate and remains more stable over time

Treatment of temporomandibular myofascial pain with deep dry needling

Objectives: The present study was designed to evaluate the usefulness of deep dry needling in the treatment of temporomandibular myofascial pain. Study D esign: We selected 36 patients with myofascial pain located in the external pterygoid muscle (30 women/6 men, mean age=27 years with SD±6,5). We studied differences in pain with a visual analog scale and range of mandibular movements before and after intervention. Results: We found a statistically significant relationship (p<0,01) between therapeutic intervention and the improvement of pain and jaw movements, which continued up to 6 months after treatment. Pain reduction was greater the higher was the intensity of pain at baseline. Conclusions: Although further studies are needed, our findings suggest that deep dry needling in the trigger point in the external pterygoid muscle can be effective in the management of patients with myofascial pain located in that muscle

Cuándo, cómo y por qué del tratamiento antibiótico en las enfermedades periodontales y perimplantarias

En este trabajo, se revisan los criterios para el uso del tratamiento antibiótico en las enfermedades periodontales y periimplantarias, y la correlación existente entre los mecanismos etiopatogénicos de ambas. La elección racional para el tratamiento profiláctico y terapéutico se fundamenta en diversos factores y premisas que engloban, desde un punto de vista crítico y práctico, los aspectos más relevantes involucrados en la controversia actual referente al tratamiento antibiótico de las enfermedades periodontales y periimplantarias. Se propone el uso sistemático de un grupo determinado de antibiótico s, y se expone un protocolo específico de actuación terapéutica antimicrobiana

Ameloblastoma mandibular: revisión de la literatura y presentación de seis casos

El ameloblastoma es un tumor odontogénico benigno de origen epitelial sin inducción en el tejido conectivo. En el tratamiento del mismo se debe valorar el tipo clínico (sólido y multiquístico, uniquístico, periférico), la localización y el tamaño del tumor, así como la edad del paciente. Recientemente se han publicado algunos artículos con el fin de actualizar los conocimientos y actitudes terapéuticas frente al ameloblastoma. Se presentan seis casos de pacientes afectos de ameloblastomas localizados en la mandíbula, tratados en los últimos siete años. Se aportan datos acerca de su aparición clínica, sus características histológicas, el manejo terapéutico realizado que consistió en la extirpación de la lesión, fresado perilesional del hueso o resección en bloque, según el tipo de ameloblastoma. Finalmente analizamos el seguimiento y la aparición de recidivas en los pacientes presentados. El objetivo de este artículo es revisar los conceptos respecto al ameloblastoma que se han publicado recientemente y valorar su influencia en la actitud del clínico a la hora de actuar frente a esta patología, tomando como punto de partida para ilustrar está discusión la presentación de nuestra experiencia respecto al ameloblastoma.Ameloblastoma is a benign odontogenic tumour of epithelial origin without induction in the connective tissue. In treating this type of tumour, it is important to assess the clinical type (solid, multicystic, unicystic, peripheral), localisation, and size of the tumour as well as age of the patient. Articles have recently been published with the purpose of providing updated knowledge and therapeutic approaches to ameloblastoma. We present six cases of patients with localised mandibular ameloblastoma who were treated during the last seven years. We present data on clinical appearance, histological characteristics, and therapeutic approach that was used, which included excision of the lesion, perilesional drilling of the bone, or block resection, according to the type of ameloblastoma. Lastly, we analysed follow-up measures and the rate of recurrence in these patients. The aim of this paper is to review the concepts relating to ameloblastoma that have been published recently and to assess their influence on the clinical attitude taken when facing this pathology, using our experience with ameloblastoma as a starting point to illustrate this discussion

Ludwig's angina and ketoacidosis as a first manifestation of diabetes mellitus

Ludwig?s angina is a serious and rapidly progressive infectious process that spreads through the floor of the mouth and neck. In this paper we present an infrequent case of a patient who suffered an odontogenic infection with poor response to the previous treatment, which evolved towards a Ludwig?s angina combined with ketoacidosis in the context of a diabetes mellitus not known before. According to the literature reviewed, this case report represents the first contribution of a Ludwig?s angina and ketoacidosis as an initial manifestation of a diabetes mellitus. The airway management, the antibiotic prescription and the surgical drainage allowed the healing of the patient without medical complications. Factors of co-morbidity like the diabetes mellitus together with focus tooth of infection may eventually turn into serious medical complications as the diabetic ketoacidosis and develop potentially lethal cervical infections

Mandibular ameloblastoma. A review of the literature and presentation of six cases

El ameloblastoma es un tumor odontogénico benigno de origen epitelial sin inducción en el tejido conectivo. En el tratamiento del mismo se debe valorar el tipo clínico (sólido y multiquístico, uniquístico, periférico), la localización y el tamaño del tumor, así como la edad del paciente. Recientemente se han publicado algunos artículos con el fin de actualizar los conocimientos y actitudes terapéuticas frente al ameloblastoma. Se presentan seis casos de pacientes afectos de ameloblastomas localizados en la mandíbula, tratados en los últimos siete años. Se aportan datos acerca de su aparición clínica, sus características histológicas, el manejo terapéutico realizado que consistió en la extirpación de la lesión, fresado perilesional del hueso o resección en bloque, según el tipo de ameloblastoma. Finalmente analizamos el seguimiento y la aparición de recidivas en los pacientes presentados. El objetivo de este artículo es revisar los conceptos respecto al ameloblastoma que se han publicado recientemente y valorar su influencia en la actitud del clínico a la hora de actuar frente a esta patología, tomando como punto de partida para ilustrar está discusión la presentación de nuestra experiencia respectoal ameloblastoma.Ameloblastoma is a benign odontogenic tumour of epithelial origin without induction in the connective tissue. In treating this type of tumour, it is important to assess the clinical type (solid, multicystic, unicystic, peripheral), localisation, and size of the tumour as well as age of the patient. Articles have recently been published with the purpose of providing updated knowledge and therapeutic approaches to ameloblastoma. We present six cases of patients with localised mandibular ameloblastoma who were treated during the last seven years. We present data on clinical appearance, histological characteristics, and therapeutic approach that was used, which included excision of the lesion, perilesional drilling of the bone, or block resection, according to the type of ameloblastoma. Lastly, we analysed follow-up measures and the rate of recurrence in these patients. The aim of this paper is to review the concepts relating to ameloblastoma that have been published recently and to assess their influence on the clinical attitude taken when facing this pathology, using our experience with ameloblastoma as a starting point to illu strate this discussion

Facial disability index (FDI): adaptation to Spanish, reliability and validity

Objectives: To adapt to Spanish the facial disability index (FDI) described by VanSwearingen and Brach in 1995 and to assess its reliability and validity in patients with facial nerve paresis after parotidectomy. Study Design: The present study was conducted in two different stages: a) cross-cultural adaptation of the questionnaire and b) cross-sectional study of a control group of 79 Spanish-speaking patients who suffered facial paresis after superficial parotidectomy with facial nerve preservation. The cross-cultural adaptation process comprised the following stages: (I) initial translation, (II) synthesis of the translated document, (III) retro-translation, (IV) review by a board of experts, (V) pilot study of the pre-final draft and (VI) analysis of the pilot study and final draft. Results: The reliability and internal consistency of every one of the rating scales included in the FDI (Cronbach's alpha coefficient) was 0.83 for the complete scale and 0.77 and 0.82 for the physical and the social well-being subscales. The analysis of the factorial validity of the main components of the adapted FDI yielded similar results to the original questionnaire. Bivariate correlations between FDI and House-Brackmann scale were positive. The variance percentage was calculated for all FDI components. Conclusions: The FDI questionnaire is a specific instrument for assessing facial neuromuscular dysfunction which becomes a useful tool in order to determine quality of life in patients with facial nerve paralysis. Spanish adapted FDI is equivalent to the original questionnaire and shows similar reliability and validity. The proven reproducibi- lity, reliability and validity of this questionnaire make it a useful additional tool for evaluating the impact of facial nerve paralysis in Spanish-speaking patients

Transmigration of impacted lower canine : Case report and review of literature

Retention, that is, a permanent tooth which is unerupted more than a year after the normal age of eruption, is a relatively rare event, except in the case of the third molars and the upper canines. Transmigration is defined as the phenomenon of more than half an unerupted impacted tooth crossing the midline. We report the clinical case of a twenty-year-old patient presenting transmigration of the lower left canine, with a type 4 transmigration pattern (Mupparapu). Likewise, we carried out a review of the literature of the cases that have been published on transmigration, updating the main aspects of this pathology

Synchronous occurrence of IgG4-related sialadenitis and ductal carcinoma of the parotid gland a case report

Immunoglobulin G4-related disease (IgG4-RD) is a rare chronic systemic inflammatory pathology that poses a diagnostic challenge since it can simulate malignancy when it affects a salivary gland as a mass-like lesion. Here, the authors report an unusual clinical case of a 42-year-old man who presented with a painless, slow-growing swelling located in the right parotid gland with a 12-month evolution. Based on imaging tests and open biopsy, a diagnosis of chronic parotitis was presumed and oral methylprednisolone was prescribed. Due to poor response to medication, a total parotidectomy preserving the facial nerve was performed. The final pathology described a unilateral IgG4-related sialadenitis (IgG4-RS) in the parotid gland in combination with a poorly differentiated multifocal ductal carcinoma. The postoperative course was uneventful except for a temporary facial paresis (grade III according to the House-Brackmann classification system) that resolved completely within 5 months. There were no systemic manifestations on the whole-body 18F-FDG PET/CT. Adjuvant radiotherapy was administered without complications. Twenty-four months follow-up after surgery showed no recurrence or evidence of systemic involvement. This clinical report highlights the importance of considering the synchronous occurrence of a carcinoma underlying an isolated parotid gland mass in the context of IgG4-RS, especially if there is no response to prior steroid medication