Uso do laser cirúrgico de alta potência em lesões bucais: considerações clínicas e histopatológicas

TCC (graduação) - Universidade Federal de Santa Catarina. Centro de Ciências da Saúde. Odontologia.Desde as primeiras aplicações do LASER na Odontologia, em 1964, até os dias atuais, ocorreram muitos avanços tecnológicos que nos permitem utilizar a laserterapia com mais segurança. As indicações do uso desta tecnologia têm aumentado muito em Odontologia. O laser de baixa intensidade tem sido muito estudado em Odontologia e já estão comprovadas suas indicações e vantagens como um instrumento para tratamento de dor, redução de edema e inflamação de lesões da mucosa bucal. No entanto, a utilização do laser de alta intensidade em Odontologia ainda exige maior número de pesquisas. Os estudos publicados indicam muitas vantagens na sua utilização em situações cirúrgicas de pacientes com baixa capacidade hemostática; contrapondo-se a isto, apenas seus efeitos térmicos gerando possíveis efeitos adversos sobre os tecidos adjacentes às áreas operadas. Este trabalho objetivou avaliar a ação do laser de alta potência em lesões de tecidos moles bucais removidas cirurgicamente bem como analisar o efeito térmico sobre as margens nas lesões de tecidos moles biopsiadas afim de verificar se o comprometimento das margens interfere no diagnósitico histopatológico. A pesquisa foi realizada com 21 lesões bucais removidas de pacientes do Núcleo de Odontologia Hospitalar do Hospital Universitário/UFSC com o laser cirúrgico de alta potência do tipo diodo, no período entre janeiro de 2015 e março de 2017, incluindo pacientes de ambos os sexos e sem preferência por faixa etária ou diagnóstico clínico da lesão. Nenhuma das lesões biopsiadas a laser foi excluída da amostra. Após a localização das fichas de biópsia do Laboratório de Patologia Bucal/UFSC, foi feita a busca pelas lâminas histopatológicas geradas a partir das peças biopsiadas. Todos os cortes histológicos obtidos, seriados ou não, foram analisados através de microscópio óptico em aumentos de 50, 100 e 400x. Os danos causados pelo laser na região de cortes foram avaliados por consenso, entre autora e orientadora, tendo sido classificados em pequeno, médio e grande, de acordo com o padrão do dano predominante. A amostra foi composta por 21 pacientes, 8 do sexo masculino e 13 do sexo feminino. Do total das lesões, 57% foram classificadas hiperplasia fibrosa inflamatória, seguido de granuloma piogênico (9%), hiperplasia fibrosa focal (9%), sialoadenite (5%), neuroma encapsulado em paliçada (5%), linfangioma (5%), processo inflamatório crônico inespecífico com áreas de abscedação (5%) e fragmento de mucosa com degeneração generalizada de tecido conjuntivo (5%). Os resultados mostraram que os danos predominantes foram os classificados como “médio”, no entanto, em nenhum dos casos analisados o corte a laser inviabilizou o diagnóstico histopatológico da lesão. Houve variações de acordo com o tecido biopsiado ser mais ou menos fibroso, provavelmente devido aos ajustes necessários na potência do laser no momento da realização do procedimento, bem como da experiência do operador em realizar tal procedimento. Os dados foram organizados em planilhas do programa Microsoft Excel e a análise descritiva foi realizada. Deve-se, portanto, considerar as indicações e vantagens clínicas da utilização desta tecnologia na tomada de decisão sobre seu uso, uma vez que, se usado corretamente, tende a trazer muitos benefícios tanto ao paciente quanto ao operador. Desta forma, mais estudos clínico-histopatológicos, randomizados, são necessários para melhor avaliar os danos térmicos que ocorrem com os tecidos bucais seccionados com laser de alta potência.Since the first applications of LASER in Dentistry in 1964 to the present day, many technological advances have occurred that allow us to use laser therapy safety. The clinical indications of this technology are increasing in Dentistry. The low level laser therapy (LLLT) has been studied in dentistry and its indications and advantages are already proven as an instrument for pain control, reduction of swelling and inflammation of lesions in the oral cavity. However, the use of high level laser therapy in dentistry still requires more research.Many studies indicate the advantages of high level laser therapy in surgical procedures, especially in patients with low hemostatic capacity. Thermal damage on adjacent tissues is the greatest contraindication of this technique. This study aims to evaluate the action of high level laser therapy on oral lesions removed under this technique, as well as analyze the thermal effects of laser in the soft tissue lesions removed. The research was performed with 21 oral lesions removed from patients from Dental Service of the University Hospital of Santa Catarina Federal University with the diode surgical laser, from January 2015 to March 2017. Are included patients of both sexes and with no preference for age or clinical diagnosis of the lesion. None of the biopsied laser lesions were excluded from the sample. After the pursuit of the biopsy files from Laboratório de Patologia Bucal/UFSC, the search for the histopathological slides generated from the biopsied specimens was made. All histological sections obtained, serial or non-serial, were analyzed under optical microscopy with increments of 50, 100 and 400 times. The laser thermal damage on the histopathological slides was evaluated by consensus, between author and supervisor, and was classified as “small, medium and large damage” according to the pattern of predominant damage. The results showed that the predominant thermal damage was "medium damage". However, in none of the cases analyzed, the laser surgical incision made the histopathological diagnosis of the lesion impossible. There were variations according to whether the biopsied tissue was more or less fibrous, probably due to the necessary adjustments in laser power at the time of the procedure, as well as the operator's experience in performing such a procedure. No statistical analysis was performed, only description analysis. Therefore, it is necessary to consider the indications and clinical advantages of the use of this technology in the decision making about its use, since if used correctly; it tends to bring many benefits to both the patient and the operator. Thus, more randomized clinical and histopathological studies are needed to better understand all the histological processes that occur with buccal tissues sectioned with high level laser therapy. Therefore, it is necessary to consider the indications and clinical advantages of the use of this technology in the decision making about its use, since if used correctly, it tends to bring many benefits to both the patient and the operator

Reserva ovariana e crescimento folicular em mulheres com endometriose e infertilidade

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Reduced Cancer Incidence in Huntington's Disease: Analysis in the Registry Study

Background: People with Huntington's disease (HD) have been observed to have lower rates of cancers. Objective: To investigate the relationship between age of onset of HD, CAG repeat length, and cancer diagnosis. Methods: Data were obtained from the European Huntington's disease network REGISTRY study for 6540 subjects. Population cancer incidence was ascertained from the GLOBOCAN database to obtain standardised incidence ratios of cancers in the REGISTRY subjects. Results: 173/6528 HD REGISTRY subjects had had a cancer diagnosis. The age-standardised incidence rate of all cancers in the REGISTRY HD population was 0.26 (CI 0.22-0.30). Individual cancers showed a lower age-standardised incidence rate compared with the control population with prostate and colorectal cancers showing the lowest rates. There was no effect of CAG length on the likelihood of cancer, but a cancer diagnosis within the last year was associated with a greatly increased rate of HD onset (Hazard Ratio 18.94, p < 0.001). Conclusions: Cancer is less common than expected in the HD population, confirming previous reports. However, this does not appear to be related to CAG length in HTT. A recent diagnosis of cancer increases the risk of HD onset at any age, likely due to increased investigation following a cancer diagnosis

Clinical and genetic characteristics of late-onset Huntington's disease

Background: The frequency of late-onset Huntington's disease (&gt;59 years) is assumed to be low and the clinical course milder. However, previous literature on late-onset disease is scarce and inconclusive. Objective: Our aim is to study clinical characteristics of late-onset compared to common-onset HD patients in a large cohort of HD patients from the Registry database. Methods: Participants with late- and common-onset (30–50 years)were compared for first clinical symptoms, disease progression, CAG repeat size and family history. Participants with a missing CAG repeat size, a repeat size of ≤35 or a UHDRS motor score of ≤5 were excluded. Results: Of 6007 eligible participants, 687 had late-onset (11.4%) and 3216 (53.5%) common-onset HD. Late-onset (n = 577) had significantly more gait and balance problems as first symptom compared to common-onset (n = 2408) (P &lt;.001). Overall motor and cognitive performance (P &lt;.001) were worse, however only disease motor progression was slower (coefficient, −0.58; SE 0.16; P &lt;.001) compared to the common-onset group. Repeat size was significantly lower in the late-onset (n = 40.8; SD 1.6) compared to common-onset (n = 44.4; SD 2.8) (P &lt;.001). Fewer late-onset patients (n = 451) had a positive family history compared to common-onset (n = 2940) (P &lt;.001). Conclusions: Late-onset patients present more frequently with gait and balance problems as first symptom, and disease progression is not milder compared to common-onset HD patients apart from motor progression. The family history is likely to be negative, which might make diagnosing HD more difficult in this population. However, the balance and gait problems might be helpful in diagnosing HD in elderly patients

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research