Systematic mapping review of interventions to prevent blood loss, infection and relapse in orthognathic surgery

BACKGROUND

This systematic mapping review aims to identify, describe, and organize the currently available evidence in systematic reviews (SR) and primary studies regarding orthognathic surgery (OS) co-interventions and surgical modalities, focusing on the outcomes blood loss, infection and relapse.

MATERIAL AND METHODS

A comprehensive search strategy was performed to identify all SRs, randomized controlled trials and observational studies that evaluate surgical modalities and perioperative co-interventions in OS that evaluate the outcomes blood loss, infection and relapse, regardless of language or publication date. Searches were conducted in MEDLINE, EMBASE, Epistemonikos, Lilacs, Web of Science, and CENTRAL. In addition, grey literature was screened.

RESULTS

27 SRs and 150 primary studies fulfilled the inclusion criteria, 91 from SRs, and 59 from our search strategy. Overall, the quality of the SRs was graded as "Critically low," and only two SRs were rated as "High" quality. 11 PICO questions were extracted from SRs and 31 from primary studies, which focused on osteosynthesis methods, surgical cutting devices, use of antibiotics, and induced hypotension. In addition, evidence bubble maps for each outcome were created to analyze in a visual manner the existing evidence.

CONCLUSIONS

Future primary and secondary high-quality research should be addressed focused on the eight knowledge gaps identified in this mapping review. We concluded that the evidence mapping approach is a practical methodology for organizing the current evidence and identifying knowledge gaps in OS, helping to reduce research waste and canalize future efforts in developing studies for unsolved questions.

Effect of antibiotic prophylaxis for preventing infectious complications following impacted mandibular third molar surgery. A randomized controlled trial

Background

The objective of this study was to determine the effect of antibiotic prophylaxis in preventing postoperative infections after extraction of impacted mandibular third molars.

Material and Methods

A Parallel-group, randomized, blind, placebo-controlled trial was performed. 154 patients were randomly allocated to 2 groups; experimental (n=77) receiving 2g amoxicillin 1 hour prior to surgery and control (n=77) receiving placebo. Primary outcome was postoperative infections and secondary outcome was the need for rescue analgesia.

Results

4.5% of patients developed postoperative infections, five patients of the control group (4 alveolar osteitis, 1 surgical site infection) and two of the experimental group (1 alveolar osteitis, 1 surgical site infection). Difference between groups was not statistically significant, RR=0.4 (95%CI 0.08-1.99, 𝘱=0.41) NNTB=26. Rescue analgesia intake was significantly higher in the control group (41 vs 18 patients of experimental group) RR=0.49 (95%CI 0.32-0.75, 𝘱<0.05) NNTB=3.

Conclusions

The use of 2g amoxicillin 1 hour before surgery was not effective in significantly reducing the risk of postoperative infections from impacted mandibular third molars extraction, when compared to placebo. Nevertheless, antibiotic prophylaxis was associated with a reduced need for rescue analgesia.

Key words:Antibiotic prophylaxis, third molar, tooth extraction, impacted tooth, dry socket, surgical wound infection, oral surgery.

Clinical characteristics and outcomes of 1,331 patients with COVID-19: HM Spanish Cohort

OBJECTIVE

Spain is one of the European countries most affected by the COVID-19 pandemic. Epidemiologic studies are warranted to improve the disease understanding, evaluate the care procedure and prepare for futures waves. The aim of the study was to describe epidemiologic characteristics associated with hospitalized patients with COVID-19.

METHODS

This real-world, observational, multicenter and retrospective study screened all consecutive patients admitted to 8 Spanish private hospitals. Inclusion criteria: hospitalized adults (age≥18 years old) with clinically and radiologically findings compatible with COVID-19 disease from March 1st to April 5th, 2020. Exclusion criteria: patients presenting negative PCR for SARS-CoV-2 during the first 7 days from hospital admission, transfer to a hospital not belonging to the HM consortium, lack of data and discharge against medical advice in emergency departments.

RESULTS

One thousand and three hundred thirty-one COVID-19 patients (medium age 66.9 years old; males n= 841, medium length of hospital stayed 8 days, non-survivors n=233) were analyzed. One hundred and fifteen were admitted to intensive care unit (medium length of stay 16 days, invasive mechanical ventilation n= 95, septic shock n= 37 and renal replacement therapy n= 17). Age, male gender, leukocytes, platelets, oxygen saturation, chronic therapy with steroids and treatment with hydroxychloroquine/azithromycin were independent factors associated with mortality. The proportion of patients that survive and received tocilizumab and steroids were lesser and higher respectively than those that die, but their association was not significant.

CONCLUSIONS

Overall crude mortality rate was 17.5%, rising up to 36.5% in the subgroup of patients that were admitted to the intensive care unit. Seven factors impact in hospital mortality. No immunomodulatory intervention were associated with in-hospital mortality.

Thyroid and Parathyroid Neoplasms with Lipomatous Stroma: Report of Three Cases and Review of the Literature

Introduction/Objective

Tumors with mixed adipose tissue and epithelial components are rare in thyroid and parathyroid glands. Most of them are benign and referred to as adenolipoma (or lipoadenoma). A handful of malignant tumors of thyroid follicular cell origin have been reported with abundant adipose tissue known as thyroid carcinoma with lipomatous stroma (TCLS). Adenolipomas of thyroid or TCLS are usually manifested as large thyroid nodules and evaluated by fine needle aspiration biopsy (FNAB) which frequently yield low-cellularity samples due to abundant adipose tissue. On FNAB, the adipose tissue usually interpreted as contamination of subcutaneous or perithyroid origin. Similarly, adenolipomas of the parathyroid are not frequently identified because of presence of adipose tissue which is a feature associated with normal parathyroid glands. Therefore, these tumors are not often correctly diagnosed preoperatively. For that reason, pathologist should report additional cases about this rare entity to increase our understanding and to decrease preoperative diagnostic error.

Methods

We report three cases of thyroid and parathyroid tumors with abundant adipose tissue with sonographic, cytologic and histologic features along with literature review.

Results

Among the reported cases in the literature and our cases; 10 out of 17 cases of thyroid carcinoma with lipomatous stroma are papillary thyroid carcinomas (58.8%), 3 out of 17 cases are papillary microcarcinomas (17.6%), 2 out of 17 cases are noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) (11.7%), and 2 out of 17 cases are minimally invasive follicular carcinomas (11.7%). No cases of poorly differentiated or anaplastic thyroid carcinomas have been reported.

Conclusion

Lipomatous stroma in thyroid carcinoma appears to be associated with differentiated carcinomas since no reported cases of poorly differentiated or anaplastic thyroid carcinomas are present to our knowledge. Although the presence of fatty tissue does not appear to alter the prognosis of these lesions, the question of the histogenesis of the adipose component is intriguing. Awareness of this unusual feature and increased utilization of multimodal approaches in the evaluation of this entity may increase preoperative detection and the understanding of the histogenesis and its possible significance.

Poorly Differentiated Chordoma with Rhabdoid Features

Casestudy: Chordoma is an uncommon primary malignant tumor of the bone showing notochordal differentiation. The current World Health Organization classifies chordoma into three subtypes: conventional, chondroid, and dedifferentiated.

Poorly differentiated chordoma (PDC) is a newly described variant of chordoma, with its own distinct features in terms of age distribution (common in pediatric and young adults), histopathology (lack of physaliphorous cells and chondromyxoid matrix), immunohistochemical and molecular characteristics (loss of SMARCB1/INI1 expression) and clinical outcome (poor prognosis with rapid onset of local recurrence and metastasis).

Herein, we report the case of a 43 year old man with history of fall and injury of tailbone 2 years prior, who presented with pain and swelling at the sacrcoccygeal region and intermittent numbness in the legs. MRI of the pelvis showed a 9.8 cm lobulated mass centered on the sacrum with osseous destruction of S5 through coccyx, with intralesional hemorrhage, and mild heterogeneous enhancement. Biopsy of the sacrococcygeal mass demonstrated a malignant neoplasm composed of lobules of epithelioid cells with abundant eosinophilic cytoplasm showing focal vacuolization, and mild to moderate nuclear pleomorphism with an average 3 mitoses per high power field (400x). Immunohistochemically, the neoplastic cells were positive for pancytokeratin, CAM 5.2, vimentin and brachyury. They had loss of SMARCB1 (INI1) and were negative for S100, CK7, CK20, desmin and actin. The location, imaging studies, morphologic features and immunohistochemical profile were consistent with poorly differentiated chordoma with rhabdoid features. With its specific clinical, morphologic, immunophenotypical, and molecular features, PDC may be recognized as a chordoma subtype in a future WHO classification. According to current knowledge, the diagnosis of PDC should be restricted to cases with brachyury expression (specific for notochord tumors) and INI1 protein loss, especially in tumors of pediatric and young patients, regardless of cellular characteristics.

Development of a predictive model for hospital mortality and re-admission in a cohort of infected patients that require hospitalization

Introducción

Los objetivos del estudio fueron: identificar variables asociadas a mortalidad intrahospitalaria y reingreso hospitalario a 3 meses; identificar el impacto de la demora en el inicio de la antibioticoterapia en la mortalidad y reportar la tasa de antibioticoterapia inapropiada.

Material y métodos

Estudio observacional de cohortes retrospectivo realizado en el Hospital Universitario HM Sanchinarro en Madrid. Los criterios de inclusión fueron: edad> 18 años de edad, hospitalización desde urgencias durante el periodo 1 de septiembre 2012 al 31 de marzo del 2013 con diagnóstico de infección bacteriana. Los criterios de exclusión fueron: sospecha de infección viral y cultivos bacteriológicos negativos, expectativa de vida inferior a 6 meses, falta de información clínica, asistencia exclusivamente por el servicio de urgencias traumatológicas. Se realizaron dos modelos logísticos (mortalidad y reingreso hospitalarios).

Resultados

Se incluyeron 517 pacientes. Variables asociadas a mortalidad (30 fallecidos): frecuencia respiratoria (OR 1,12; IC95% 1,02; 1,22), saturación de oxígeno (OR 0,92; IC95% 0,87; 0,98), creatinina (OR 2,33; IC95% 1,62; 3,36), EPOC (OR 3,02; IC95% 1,06; 8,21), cáncer OR 3,34; IC95% 1,07; 9,98) y quimioterapia en los últimos 3 meses (OR 4,83; IC95% 1,54; 16,41). Variables asociadas a reingreso hospitalario (28 fallecidos): hepatopatía, GPT, antecedente de ictus e hipertensión arterial. Ambos modelos se destacan por su elevada especificidad y capacidad discriminativa pero baja sensibilidad. La demora en el inicio de la antibioticoterapia no influyo en la mortalidad ni reingreso. En 56 pacientes se identificó el microorganismo causal y el tratamiento antibiótico fue inapropiado en 11.

Conclusiones

Se registro un 5,8% de mortalidad hospitalaria y un 5,7% de reingresos. Las variables asociadas a la mortalidad intrahospitalaria difieren de las asociadas al reingreso. La demora en el inicio de la antibioticoterapia no se asoció a un efecto deletéreo. La antibioticoterapia inadecuada fue de casi el 20%.

Infectious postoperative complications in oral surgery. An observational study

Background

The main objective of this investigation was to determine the incidence of infectious postoperative complications in oral surgery.

Material and Methods

A observational and descriptive study was developed, with the use of prospective registry of the patients admitted for oral surgery at the San Borja Arriarán Hospital Complex during twelve months observation period (April 2017 to March 2018).

Results

The sample consisted of 532 patients undergoing surgical procedures of oral surgery and 19 cases of infectious postoperative complications. The incidence of complications reached 3,57% and it was observed predominantly in exodontic type interventions. The most commonly observed complication was dry socket, reaching 2,5% of third molar surgeries and 3,7% of extractions of other teeth. Other postoperative complication were 7 cases of facial spaces abscesses, also observed predominantly in exodontic type interventions.

Conclusions

The results were similar to those reported in the literature both in their frequency and in the type of complication.

Key words:Oral surgery, incidence, postoperative complications, dry socket, third molar.

Antiplatelet therapy in patients undergoing oral surgery: A systematic review and meta-analysis

Background

The number of patients under antiplatelet therapy (APT) continues to raise as current recommendations foster this practice. Although some recommendations to manage this treatment during oral surgery procedures exist, these have methodological shortcomings that preclude them from being conclusive.

Material and Methods

A systematic review and meta-analysis of the best current evidence was carried out; The Cochrane Library, EMBASE and MEDLINE databases were searched for Randomized Controlled Trials (RCT) concerning patients undergoing oral surgery with APT, other relevant sources were searched manually.

Results

5 RCTs met the Inclusion criteria. No clear tendency was observed (RR= 0.97 CI 95%: 0,41–2,34; p=0,09; I2= 51%), moreover, they weren’t clinically significant.

Conclusions

According to these findings and as bleeding is a manageable complication it seems unreasonable to undermine the APT, putting the patient in danger of a thrombotic event and its high inherent morbidity, which isn’t comparable in severity and manageability to the former.”

Key words:Antiplatelet therapy, aspirin, oral surgery, platelet aggregation inhibitors, oral surgical procedures, systematic reviews.