Aportaciones de la cirugía guiada por ordenador y navegación en oncología de cabeza y cuello: una revisión bibliográfica sistemática y actualización

Introducción: El objetivo de este trabajo es hacer una revisión y actualización de la literatura sobre la aportación de la planificación quirúrgica y de la navegación en el manejo de la enfermedad oncológica de cabeza y cuello, para valorar y determinar sus aplicaciones actuales. Material y métodos: Se realiza una búsqueda electrónica empleando los términos craniomaxillofacial tumors, head and neck cancer, navigation system, computer-assisted surgery y oral cancer. Resultados: El número de artículos encontrados en la revisión de la literatura ha sido de 16, publicados entre los años 1991 y 2014. Entre ellos no hay ninguna revisión sistemática, hay 5 artículos de revisión, 6 series de casos y 5 casos clínicos. Solo 10 artículos aportan información completa en relación con la enfermedad oncológica manejada con tecnología de navegación quirúrgica. Actualmente las aplicaciones de la navegación en oncología de cabeza y cuello pueden enumerarse en las siguientes áreas: biopsia guiada, resección y reconstrucción de tumores, monitorización del volumen del tumor, control de márgenes de resección quirúrgica basados en TC, RMN o PET y sistema de comunicación interdisciplinar. Conclusiones: Actualmente hay un número escaso de publicaciones sobre las aplicaciones de la navegación quirúrgica en el novedoso ámbito de la oncología de cabeza y cuello. A pesar de la ausencia de revisiones sistemáticas, parece tener un futuro prometedor por la valiosa aportación que hace para el manejo de tumores de cabeza y cuello, como proporcionar precisión anatómica, precisión diagnóstica y seguridad quirúrgica, siendo de gran utilidad en el tratamiento oncológico multidisciplinar.

Desenvolvimento e avaliação de um sistema de cálculo de dose independente para controle de qualidade de IMRT do tipo jaws-only

Dissertação (mestrado)—Universidade de Brasília, Faculdade Gama, Programa de Pós-Graduação em Engenharia Biomédica, 2015.

Laryngeal amyloidosis: An uncommon cause of dysphonia

Introduction: Amyloidosis is used to describe a range of disorders deined by extracellular deposition of abnormal protein ibrils. The larynx is the most common site of localized amyloidosis in the head and neck region and constitutes less than 1% of benign laryngeal lesions. Hoarseness is the most common symptom. Objective: Prospective clinical evaluation of patients with localized laryngeal amyloidosis. Clinical cases: Presented are 4 cases of patients with localized laryngeal amyloidosis who were treated at the Otolaryngology and Head and Neck Surgery Department at the “Dr. José Eleuterio González” University Hospital in Monterrey, Mexico. Three patients underwent phonomicrosurgery by direct microlaryngoscopy with the removal of the amyloid implantation using a cold knife excision with great results. In each patient the major site of involvement was the supraglottis with a small focus on the false vocal cord. A medical work-up, including a complete blood count (CBC), a basic metabolic panel, urinalysis, liver function test, chest X-ray and physical examination were performed to rule out the presence of systemic disease; no amyloidosis or signs of systemic disease were found. Congo red staining conirms the diagnosis of amyloidosis in all surgical specimens. Conclusions: In laryngeal amyloidosis, the treatment should be directed toward the improvement of the voice and the maintenance of the airway.

Avaliação do nível de conhecimento geral e grau de alerta sobre cancro oral numa população do nordeste transmontano

O cancro é um dos principais causadores de milhões de mortes em todo o mundo e sendo o cancro oral, especificamente, a sexta neoplasia mais frequente a nível mundial. Todos os anos são diagnosticados mais de 500 mil novos casos, sendo que as altas taxas de mortalidade e mortalidade não se têm alterado ao longo dos anos. A maior incidência de cancro oral encontra-se na Ásia e na Europa do Sul. Em Portugal, mais precisamente em 2012, foram diagnosticados cerca de 1924 novos casos de cancro oral, dos quais 967 ocorreram em homens. O carcinoma espinocelular é o tipo histológico mais comum, sendo que 90% dos casos de cancro oral são deste tipo. Sabe-se também que esta variante é mais frequente no sexo masculino entre a 5ª e 6 ª década de vida apesar de, a incidência no sexo feminino, ter vindo a aumentar, devido à contínua exposição ao tabaco, álcool e a outros factores de risco. Como foi dito anteriormente, o cancro oral tem uma alta taxa de mortalidade e de morbilidade e, apesar dos avanços no diagnóstico, no tratamento e no conhecimento de quais os factores de risco desta patologia, a taxa de sobrevivência ainda é inferior a 50% o que revela que, o grande problema, passa pelo diagnóstico do cancro em estádios avançados. Assume-se então que, grande parte dos casos de cancro oral, poderiam ter sido evitados se houvesse maior conhecimento e grau de alerta sobre a doença o que tendencialmente, levaria a diagnósticos mais precoces. Neste sentido, este estudo tem como propósito a avaliação do nível de conhecimento geral e do grau de alerta de uma população do interior do país, mais precisamente do Nordeste Transmontano, bem como, efectuar o registo da percepção dos inquiridos relativamente a esta patologia, passando pelo reconhecimento da doença, pelo conhecimento epidemiológico e etiológico, e pela melhor percepção a nível de sinais e sintomas clínicos próprios desta patologia.

Caracterización de trastornos musculo esqueléticos en trabajadores de dos empresas de servicios en Bogotá D.C 2015

Objetivo: El objetivo de este estudio fue determinar la prevalencia de los trastornos músculoesqueléticos y la asociación con factores sociodemográficos y hábitos de vida en trabajadores de las áreas administrativa y operativa de dos empresas de servicio de la ciudad de Bogotá 2015. Materiales y Métodos: Se realizó un estudio de corte transversal, con información secundaria, procedente de bases de datos suministrada por las dos empresas con 696 registros de trabajadores de servicios generales, y 943 registros de trabajadores del área administrativa, para un total de 1639 registros, en los cuales se evaluó la presencia de síntomas osteomusculares clasificados por segmento. Adicionalmente se contaba con información de características sociodemográficas y estilos de vida de estos trabajadores. Se obtuvieron las distribuciones de frecuencias absolutas y relativas para las variables cualitativas, y las medidas de tendencia central y de dispersión para las variables cuantitativas. Para establecer la asociación entre factores sociodemográficos con las variables dependientes se utilizó la prueba chi2 de asociación. Resultados: La prevalencia de molestia o dolor en los diferentes segmentos corporales fue de 21.5 % (n = 203) en cuello para la población administrativa y de 17.5% (n = 148) en mano y muñeca derecha para la población de servicios generales. Vale la pena aclarar que el diagnóstico médico más frecuente referido por la población en estudio fue traumas en musculo, bursa tendón y/o ligamento con 10.5% en la población administrativa y con el 12.4% en la población de servicios generales. De las asociaciones significativas entre diagnósticos presentes y hábitos de vida y sueño se encontró que sueño no reparador se asoció significativamente con enfermedad general de músculos y huesos (p = 0.001), enfermedad o trauma activo de tejidos blandos (p = 0,000) y antecedente o enfermedad actual de columna vertebral (p = 0,000). De manera similar, el consumo de medicamentos para conciliar el sueño se asoció con enfermedad de tejidos blandos (p = 0,000) y enfermedad actual de columna vertebral (p = 0,000). El consumo de café (p = 0.001) y el sedentarismo (p = 0.031) están asociados con la enfermedad general de músculos y huesos. Conclusiones: Los TME son un factor de alta prevalencia en la población trabajadora de Colombia, y como se demostró en este estudio, afectan a la población de las empresas de servicio. Se evidencia cada vez más que los segmentos corporales más afectados en la población administrativa, son cabeza y cuello, debido a las posturas mantenidas por largos periodos de tiempo, y en la población de servicios se encontró molestia y dolor en muñecas y manos debido a los movimientos repetitivos que deben de realizar durante la jornada laboral. Se hace necesario profundizar más en la asociación significativa de los trastornos del sueño y la presencia de los TME, ya que se encontró una relación importante entre estos dos.

Tratamiento quirúrgico del síndrome de apnea hipopnea obstructiva del sueño en la Clínica Rivas, Bogotá – Colombia

Introducción: El Síndrome de Apnea Hipopnea Obstructiva del Sueño es un trastorno respiratorio del sueño mayor ampliamente conocido, con importantes implicaciones para los pacientes y cuya incidencia ha venido en aumento durante los últimos años; comprende diversas manifestaciones clínicas que varían desde el ronquido hasta consecuencias cardiovasculares importantes. Objetivo: Describir la experiencia de los procedimientos quirúrgicos más utilizados para el tratamiento de pacientes con Trastornos Respiratorios del Sueño en la Clínica Rivas. Diseño: Estudio observacional descriptivo. Métodos: Revisión de 366 historias clínicas de pacientes con diagnóstico clínico y Polisomnográfico de SAHOS intervenidos quirúrgicamente debido al Trastorno Respiratorio del Sueño por rechazo de terapia de presión positiva en 3 años de observación. Resultados: Se evaluaron diferencias en medianas de los cambios del IAH, índice de Saturación de oxigeno basal y mínima, y el índice de microdespertares nocturnos tanto prequirúrgica como postquirúrgicamente. Como medida de evaluación secundaria se evaluaron las complicaciones quirúrgicas. Conclusión: En nuestra institución, como centro de referencia en apnea del sueño, la cirugía ha demostrado que disminuye de forma significativa gravedad del SAHOS y disminuye el riesgo de los pacientes con trastornos respiratorios del sueño que han rechazado el dispositivo de presión positiva.

Head repositioning accuracy in patients with neck pain and asymptomatic subjects: concurrent validity, influence of motion speed, motion direction and target distance

Background: Cervicocephalic kinesthetic deficiencies have been demonstrated in patients with chronic neck pain (NP). On the other hand, authors emphasized the use of different motion speeds for assessing functional impairment of the cervical spine. Purpose: The objectives of this study were (1) to investigate the head repositioning accuracy in NP patients and control subjects and (2) to assess the influence of target distance, motion speed, motion direction and pain. Materials and methods: Seventy-one subjects (36 healthy subjects and 35 NP patients; age 30–55 years) performed the head repositioning test (HRT) at two different speeds for horizontal and vertical movements and at two different distances. For each condition, six consecutive trials were sampled. Results: The study showed the validity and reproducibility of the HRT, confirming a dysfunctional threshold of 4.5°. Normative values of head repositioning error up to 3.6° and 7.1° were identified for healthy and NP subjects, respectively. A distance of 180 cm from the target and a natural motion speed increased HRT accuracy. Repositioning after extension movement showed a significantly larger error in both groups. Intensity, duration of pain as well as pain level did not significantly alter head repositioning error. Conclusions: The assessment of proprioceptive performance in healthy and NP subjects allowed the validation of the HRT. The HRT is a simple, not expensive and fast test, easily implementable in daily practice to assess and monitor treatment and evolution of proprioceptive cervical deficits.

A description of neck motor performance, neck pain, fatigue, and mental effort while driving in a sample with chronic whiplash-associated disorders

Objective: Individuals with chronic whiplash-associated disorders (WADs) often note driving as a difficult task. This study’s aims were to (1) compare, while driving, neck motor performance, mental effort, and fatigue in individuals with chronic WAD against healthy controls and (2) investigate the relationships of these variables and neck pain to self-reported driving difficulty in the WAD group. Design: This study involved 14 participants in each group (WAD and control). Measures included self-reported driving difficulty and measures of neck pain intensity, overall fatigue, mental effort, and neck motor performance (head rotation and upper trapezius activity) while driving a simulator. Results: The WAD group had greater absolute path of head rotation in a simulated city area and used greater mental effort (P = 0.04), but there were no differences in other measures while driving compared with the controls (all P Q 0.05). Self-reported driving difficulty correlated moderately with neck pain intensity, fatigue level, and maximum velocity of head rotation while driving in the WAD group (all P G 0.05). Conclusions: Individuals with chronic WAD do not seem to have impaired neck motor performance while driving yet use greater mental effort. Neck pain, fatigue, and maximum head rotation velocity could be potential contributors to self-reported driving difficulty in this group.

Does flexibility of the cervical and thoracic spine influence forward head posture in healthy individuals?

Background: Forward head posture (FHP) is a commonly reported deviation from a neutral neck posture, usually implying a protracted head position in the sagittal plane. Habitual FHP has been associated with a higher incidence of painful neck disorders, changes in joint mobility and muscle behaviour within the cervicothoracic regions. One factor that has received attention in the literature with regards to FHP is flexibility of the neck. A number of previous studies have previously investigated the relationship between neck flexibility and neck posture under different conditions, but at present this relationship is unclear.

Cancer risk and use of protease inhibitor or nonnucleoside reverse transcriptase inhibitor-based combination antiretroviral therapy: the d: a: d study.

BACKGROUND The association between combination antiretroviral therapy (cART) and cancer risk, especially regimens containing protease inhibitors (PIs) or nonnucleoside reverse transcriptase inhibitors (NNRTIs), is unclear. METHODS Participants were followed from the latest of D:A:D study entry or January 1, 2004, until the earliest of a first cancer diagnosis, February 1, 2012, death, or 6 months after the last visit. Multivariable Poisson regression models assessed associations between cumulative (per year) use of either any cART or PI/NNRTI, and the incidence of any cancer, non-AIDS-defining cancers (NADC), AIDS-defining cancers (ADC), and the most frequently occurring ADC (Kaposi sarcoma, non-Hodgkin lymphoma) and NADC (lung, invasive anal, head/neck cancers, and Hodgkin lymphoma). RESULTS A total of 41,762 persons contributed 241,556 person-years (PY). A total of 1832 cancers were diagnosed [incidence rate: 0.76/100 PY (95% confidence interval: 0.72 to 0.79)], 718 ADC [0.30/100 PY (0.28-0.32)], and 1114 NADC [0.46/100 PY (0.43-0.49)]. Longer exposure to cART was associated with a lower ADC risk [adjusted rate ratio: 0.88/year (0.85-0.92)] but a higher NADC risk [1.02/year (1.00-1.03)]. Both PI and NNRTI use were associated with a lower ADC risk [PI: 0.96/year (0.92-1.00); NNRTI: 0.86/year (0.81-0.91)]. PI use was associated with a higher NADC risk [1.03/year (1.01-1.05)]. Although this was largely driven by an association with anal cancer [1.08/year (1.04-1.13)], the association remained after excluding anal cancers from the end point [1.02/year (1.01-1.04)]. No association was seen between NNRTI use and NADC [1.00/year (0.98-1.02)]. CONCLUSIONS Cumulative use of PIs may be associated with a higher risk of anal cancer and possibly other NADC. Further investigation of biological mechanisms is warranted.

A comparison of neck bending and flexion measurement methods for assessment of ergonomic risk

International audience

Sensitivity of proximal femoral stiffness and areal bone mineral density to changes in bone geometry and density

Areal bone mineral density (aBMD) is the most common surrogate measurement for assessing the bone strength of the proximal femur associated with osteoporosis. Additional factors, however, contribute to the overall strength of the proximal femur, primarily the anatomical geometry. Finite element analysis (FEA) is an effective and widely used computerbased simulation technique for modeling mechanical loading of various engineering structures, providing predictions of displacement and induced stress distribution due to the applied load. FEA is therefore inherently dependent upon both density and anatomical geometry. FEA may be performed on both three-dimensional and two-dimensional models of the proximal femur derived from radiographic images, from which the mechanical stiffness may be redicted. It is examined whether the outcome measures of two-dimensional FEA, two-dimensional, finite element analysis of X-ray images (FEXI), and three-dimensional FEA computed stiffness of the proximal femur were more sensitive than aBMD to changes in trabecular bone density and femur geometry. It is assumed that if an outcome measure follows known trends with changes in density and geometric parameters, then an increased sensitivity will be indicative of an improved prediction of bone strength. All three outcome measures increased non-linearly with trabecular bone density, increased linearly with cortical shell thickness and neck width, decreased linearly with neck length, and were relatively insensitive to neck-shaft angle. For femoral head radius, aBMD was relatively insensitive, with two-dimensional FEXI and threedimensional FEA demonstrating a non-linear increase and decrease in sensitivity, respectively. For neck anteversion, aBMD decreased non-linearly, whereas both two-dimensional FEXI and three dimensional FEA demonstrated a parabolic-type relationship, with maximum stiffness achieved at an angle of approximately 15o. Multi-parameter analysis showed that all three outcome measures demonstrated their highest sensitivity to a change in cortical thickness. When changes in all input parameters were considered simultaneously, three and twodimensional FEA had statistically equal sensitivities (0.41±0.20 and 0.42±0.16 respectively, p = ns) that were significantly higher than the sensitivity of aBMD (0.24±0.07; p = 0.014 and 0.002 for three-dimensional and two-dimensional FEA respectively). This simulation study suggests that since mechanical integrity and FEA are inherently dependent upon anatomical geometry, FEXI stiffness, being derived from conventional two-dimensional radiographic images, may provide an improvement in the prediction of bone strength of the proximal femur than currently provided by aBMD.

Quantitative sensory measures distinguish office workers with varying levels of neck pain and disability

This study was undertaken to investigate any relationship between sensory features and neck pain in female office workers using quantitative sensory measures to better understand neck pain in this group. Office workers who used a visual display monitor for more than four hours per day with varying levels of neck pain and disability were eligible for inclusion. There were 85 participants categorized according to their scores on the neck disability index (NDI): 33 with no pain (NDI < 8); 38 with mild levels of pain and disability (NDI 9–29); 14 with moderate levels of pain (NDI ⩾ 30). A fourth group of women without neck pain (n = 22) who did not work formed the control group. Measures included: thermal pain thresholds over the posterior cervical spine; pressure pain thresholds over the posterior neck, trapezius, levator scapulae and tibialis anterior muscles, and the median nerve trunk; sensitivity to vibrotactile stimulus over areas of the hand innervated by the median, ulnar and radial nerves; sympathetic vasoconstrictor response. All tests were conducted bilaterally. ANCOVA models were used to determine group differences between the means for each sensory measure. Office workers with greater self-reported neck pain demonstrated hyperalgesia to thermal stimuli over the neck, hyperalgesia to pressure stimulation over several sites tested; hypoaesthesia to vibration stimulation but no changes in the sympathetic vasoconstrictor response. There is evidence of multiple peripheral nerve dysfunction with widespread sensitivity most likely due to altered central nociceptive processing initiated and sustained by nociceptive input from the periphery.

Incidence trends of keratinocytic skin cancers and melanoma in Israel 2006-2011

BACKGROUND The incidence of skin cancer, both melanoma and keratinocyte cancers (KC) is rising throughout the world, specifically squamous cell carcinomas(SCC) and basal cell carcinoma(BCC), being the most common of all cancers. OBJECTIVE To determine trends in incidence of Melanoma, BCC and SCC among 1.7 million members of Maccabi Healthcare Services from 2006 to 2011. METHODS Data on newly diagnosed Melanoma, SCC and BCC cases was collected from the MHS Cancer Registry and based on histology reports from the centralized pathology lab. Age-specific and overall age-adjusted European standardized rates were computed. Trends were estimated by calculating Average Annual Percentage Change(AAPC). RESULTS During the six year study period, a total of 16,079 subjects were diagnosed with at least one BCC, 4,767 with SCC and 1,264 with invasive melanoma. Age-standardized incidence rates were 188, 58 and 17 per 100,000 person years for BCC, SCC and melanoma, respectively. All lesions were more common among males and primarily affected the elderly. BCC rates were stable throughout the study period(AAPC -0.7%, 95%CI -4.5% to 3.2%) while SCC incidence increased significantly(AAPC 15.5%, 95%CI: 2.6% to 30.0%). In contrast, melanoma rates continuously decreased with a significant AAPC of -3.0%, 95%CI (-4.5 to -0.1). CONCLUSIONS Previously unreported, the incidence of KC in Israel is high. The disparities in incidence trends between SCC, BCC and melanoma allude to their different etiologies. These findings underscore the importance of continuous monitoring, education and prevention programs in a growing high risk population.

Evaluation of Vestibular Function with Visual Feedback Posturography and Motorized Head Impulse Test.

Objectives: To evaluate the applicability of visual feedback posturography (VFP) for quantification of postural control, and to characterize the horizontal angular vestibulo-ocular reflex (AVOR) by use of a novel motorized head impulse test (MHIT). Methods: In VFP, subjects standing on a platform were instructed to move their center of gravity to symmetrically placed peripheral targets as fast and accurately as possible. The active postural control movements were measured in healthy subjects (n = 23), and in patients with vestibular schwannoma (VS) before surgery (n = 49), one month (n = 17), and three months (n = 36) after surgery. In MHIT we recorded head and eye position during motorized head impulses (mean velocity of 170º/s and acceleration of 1 550º/s²) in healthy subjects (n = 22), in patients with VS before surgery (n = 38) and about four months afterwards (n = 27). The gain, asymmetry and latency in MHIT were calculated. Results: The intraclass correlation coefficient for VFP parameters during repeated tests was significant (r = 0.78-0.96; p < 0.01), although two of four VFP parameters improved slightly during five test sessions in controls. At least one VFP parameter was abnormal pre- and postoperatively in almost half the patients, and these abnormal preoperative VFP results correlated significantly with abnormal postoperative results. The mean accuracy in postural control in patients was reduced pre- and postoperatively. A significant side difference with VFP was evident in 10% of patients. In the MHIT, the normal gain was close to unity, the asymmetry in gain was within 10%, and the latency was a mean ± standard deviation 3.4 ± 6.3 milliseconds. Ipsilateral gain or asymmetry in gain was preoperatively abnormal in 71% of patients, whereas it was abnormal in every patient after surgery. Preoperative gain (mean ± 95% confidence interval) was significantly lowered to 0.83 ± 0.08 on the ipsilateral side compared to 0.98 ± 0.06 on the contralateral side. The ipsilateral postoperative mean gain of 0.53 ± 0.05 was significantly different from preoperative gain. Conclusion: The VFP is a repeatable, quantitative method to assess active postural control within individual subjects. The mean postural control in patients with VS was disturbed before and after surgery, although not severely. Side difference in postural control in the VFP was rare. The horizontal AVOR results in healthy subjects and in patients with VS, measured with MHIT, were in agreement with published data achieved using other techniques with head impulse stimuli. The MHIT is a non-invasive method which allows reliable clinical assessment of the horizontal AVOR.