Percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease: The experience of a single stroke centre.

BACKGROUND: Percutaneous transluminal angioplasty and stenting in acute stroke due to severe basilar artery stenosis or basilar artery occlusion remain a matter of debate. The higher risk of stroke recurrence in patients with vertebrobasilar stenosis compared to anterior circulation atherosclerotic disease creates high expectations concerning endovascular approaches. This study aims to review our experience with percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease. METHODS: Our prospective database from June 2014 until December 2020 was screened and patients with acutely symptomatic severe (>80%) basilar artery stenosis or acute basilar artery occlusion who underwent percutaneous transluminal angioplasty and stenting were analysed. RESULTS: Twenty-five patients included: 72% men (mean age 68.6 years), all with prior modified Rankin Scale <2. Twelve presented with acute basilar artery occlusion and were submitted to mechanical thrombectomy before percutaneous transluminal angioplasty and stenting, while the remaining had severe basilar artery stenosis. Successful stent placement was achieved in 22 (88%). Procedure-related complications included new small ischemic lesions (16%), basilar artery dissection (8%), vertebral artery dissection (12%) and death (12%). At 3 months post-percutaneous transluminal angioplasty and stenting, 10 out of 23 patients (43.5%) were independent (mRS ≤ 2) and six died. Fourteen patients underwent transcranial Doppler ultrasound 3 months post-percutaneous transluminal angioplasty and stenting: 12 showed residual stenosis, one significant stent restenosis and one presented stent occlusion. CONCLUSIONS: Percutaneous transluminal angioplasty and stenting showed to be a technically feasible and reasonably safe procedure in selected patients. However, good clinical outcomes may be difficult to achieve as only 43.5% of the patients remained independent at 3 months. Randomized studies are needed to confirm the efficacy and safety outcomes of percutaneous transluminal angioplasty and stenting in acute stroke caused by basilar artery steno-occlusive disease.

Herramientas y criterios para la de prescripción de medicación inapropiada en adultos mayores: una revisión de la literatura con implicaciones para la atención al paciente y la práctica clínica / Assessment tools and criteria for deprescribing inappropriate medication in older adults: A literature review with implications for patient care and clinical practice

Objetivo: Identificar las herramientas y los criterios para deprescribir medicación potencialmente inapropiada en adultos mayores. Métodos: Se realizó una búsqueda de literatura en MEDLINE (vía PubMed), EMBASE, LILACS, SCIELO, para recopilar las herramientas y criterios de evaluación para deprescribir medicamentos inapropiados en adultos mayores. Se incluyeron herramientas, algoritmos y enfoques, hasta marzo de 2020. Los términos se ajustaron para cada una de las bases de datos. Resultados: La estrategia de búsqueda produjo 3326 publicaciones potencialmente relevantes. Se evaluaron un total de 258 artículos y se incluyeron 69 en el análisis descriptivo. Estos se organizaron en dos categorías: criterios específicos (n =55) y algoritmos o enfoques para evaluar la medicación inapropiada (n =14). La mayoría de las herramientas y criterios fueron desarrollados basados en la evidencia. Conclusiones: Esta revisión proporciona una compilación de herramientas disponibles para identificar medicación potencialmente inapropiada en adultos mayores. Las herramientas y los criterios de evaluación sirven de apoyo a los profesionales de la salud para la toma decisiones en torno a los medicamentos usados en esta población. Además, estos resultados ilustran la complejidad de la farmacoterapia actual en los adultos mayores debido al número y tipo de medicamentos incluidos en las herramientas, como una alerta frente a su posible uso inapropiado. Los AINE y las benzodiazepinas son los fármacos más comunes en los criterios explícitos.(AU)

Objective: To identify tools and criteria for evaluating potentially inappropriate medication in older adults with implications in patient care and clinical practice. Methods: A literature search was conducted in MEDLINE (via PubMed), EMBASE, LILACS, SCIELO, to gather relevant data regarding assessment tools and criteria for deprescribing inappropriate medication in older adults. Assessment tools, algorithms, and approaches to identify potentially inappropriate medication were included from inception to March 2020. The terms were adjusted for each of the databases. Results: The search strategy produced 3326 potentially relevant publications. A total of 258 were evaluated. A total of 69 articles were included in the descriptive analysis. These were organized into two categories: specific criteria (n =55) and algorithm or frameworks for assessing medication (n =14). Most tools and criteria were developed using an evidence-based approach. Conclusions: This review provides a compile of available tools to identify potentially inappropriate medication in older people. Tools support health care professionals to make decisions around older adults and frail elderly medication. These results show the complexity of current pharmacotherapy in older people due to the number and type of drugs classes included in all of tools which is an alert of inappropriate use. NSAIDs and benzodiazepines are the most common drugs in the explicit criteria.(AU)

Neurologists' Diagnostic Accuracy and Interspecialties' Diagnostic Concordance of Acute Vertigo: Observational Study at the Emergency Department in a Tertiary Center.

BACKGROUND: Acute vertigo (AV) is often a challenging condition. Because of its multiple causes, patients are frequently observed by neurologists and physicians from other areas of specialites, particularly Ear, Nose, and Throat (ENT). We aimed to assess the diagnostic accuracy of AV in patients observed by Neurology and other medical specialties. MATERIALS AND METHODS: Retrospective cross-sectional study with the selection of all patients with AV observed by Neurology at the Emergency Department (ED) of a tertiary center in 2019, regarding demographic data, imaging studies, diagnosis by Neurology and ENT at the ED, and diagnosis after ED discharge by different medical specialties. RESULTS: In all, 54 patients were selected, 28 (52%) of them were women. The mean age was 59.96±14.88 years; 48% had a history of AV and 89% underwent imaging studies (computed tomography scan and/or magnetic resonance imaging scan). The most frequent diagnosis established by Neurology was benign paroxysmal positional vertigo, followed by vestibular neuronitis; 28 patients were also observed by ENT with an overall concordance rate of diagnosis of 39%. After ED discharge, most patients were observed at the Balance Disorders Outpatient Clinic. Diagnosis by Neurology at the ED was not significantly different from observation by other medical specialties after ED discharge regarding the distinction between peripheral and central causes of AV (κ=0.840, 95% confidence interval: 0.740 to 0.941, P<0.005). CONCLUSIONS: Neurologists can effectively differentiate central and peripheral causes of AV at the ED. Patients with AV should be primarily evaluated by Neurology at the ED, avoiding redundant observations and allowing faster patient management.

Functional Outcome After Mechanical Thrombectomy with or without Previous Thrombolysis.

INTRODUCTION: Combined intravenous therapy (IVT) and mechanical thrombectomy (MT) is the standard treatment for acute ischemic stroke (AIS) with large vessel occlusion (LVO). However, the use of  IVT before MT is recently being questioned. OBJECTIVES: To compare patients treated with IVT before MT with those treated with MT alone, in a real-world scenario. METHODS: Retrospective analysis of AIS patients with LVO of the anterior circulation who underwent MT, with or without previous IVT, between 2016 and 2018. RESULTS: A total of 524 patients were included (347 submitted to IVT+MT; 177 to MT alone). No differences between groups were found except for a higher time from stroke onset to CT and to groin puncture in the MT group (297.5 min vs 115.0 min and 394.0 min vs 250.0 min respectively, p < 0.001). Multivariable analysis showed that age<75 years (OR 2.65, 95% CI 1.71-4.07, p < 0.001), not using antiplatelet therapy (OR 1.93, 95% CI 1.21-3.08, p = 0.006), low prestroke mRS (OR 4.33, 95% CI 1.89-9.89, p < 0.001), initial NIHSS (OR 0.89, 95% CI 0.86-0.93, p < 0.001), absent cerebral edema (OR 7.83, 95% CI 3.31-18.51, p < 0.001), and mTICI 2b/3 (OR 4.56, 95% CI 2.17-9.59, p < 0.001) were independently associated with good outcome (mRS 0-2). CONCLUSIONS: Our findings support the idea that IVT before MT does not influence prognosis, in a real-world setting.

Evaluación de los procesos de organización, representación y almacenamiento de la información / Evaluation of the information organization, representation and storage processes

INTRODUCCIÓN: el Centro de Estudios, Documentación e Información de Medicamentos se ha propuesto el desarrollo e implementación de un sistema de gestión de la calidad total, que le permita la evaluación y certificación de la calidad de sus servicios. Se hace entonces imperativo para esta organización el diagnóstico de su desempeño, identificar fortalezas y debilidades, así como implementar acciones en aquellos procesos susceptibles a mejoras. OBJETIVO: evaluar los procesos de organización, representación y almacenamiento de la información en el Centro de Estudio, Documentación e Información de Medicamentos (CEDIMED). MÉTODOS: se analizó la variable organización, representación y almacenamiento de la información, incluida en el Modelo Integral para Auditar Organizaciones de Información en Cuba; para lo cual se evaluó el comportamiento de ocho indicadores. RESULTADOS: dos indicadores fueron evaluados de excelente, uno de regular y cinco recibieron evaluación de mal. Estos últimos fueron: normalización de la descripción bibliográfica, sistemas de lenguajes para la descripción de contenidos, tiempo para el procesamiento de los documentos, utilización de software para la ejecución de los procesos técnicos y representación de la información a través de catálogos. En general, la variable estudiada fue evaluada de mal. CONCLUCIONES: la falta de capacitación de los recursos humanos de la organización en las actividades propias de la representación y organización de la información, resulta ser el factor determinante en los resultados alcanzados por el CEDIMED en esta variable(AU)

INTRODUCTION: the Center for Study, Documentation and Information of Drugs has set out to develop and implement an overall quality management system that allows the evaluation and certification of the quality of its services. It was then imperative for this organization to make a diagnosis of its performance, to identify strengths and weaknesses and to carry out actions in those processes that may be upgraded. OBJECTIVE: to evaluate the processes of information organization, representation and storage in the Center of Study, Documentation and Information of Drugs (CEDIMED). METHODS: the variable called information organization, representation and storage included in the Integrated Model for Auditing Information Organizations in Cuba was analyzed on the basis of the behavior of eight indicators. RESULTS: two indicators were rated as excellent, one as regular and five as unsatisfactory. The latter were standardization of bibliographic description, language systems for content descriptions, time elapsed for document processing, use of software for technical processes and representation of information through the catalogues. The general evaluation of this variable was unsatisfactory. CONCLUSIONS: the lack of training of human resources in the center in terms of information representation and organization activities was the key factor for the results achieved in this specific variable by CEDIMED(AU)

Evaluación de los procesos de organización, representación y almacenamiento de la información / Evaluation of the information organization, representation and storage processes

Introducción: el Centro de Estudios, Documentación e Información de Medicamentos se ha propuesto el desarrollo e implementación de un sistema de gestión de la calidad total, que le permita la evaluación y certificación de la calidad de sus servicios. Se hace entonces imperativo para esta organización el diagnóstico de su desempeño, identificar fortalezas y debilidades, así como implementar acciones en aquellos procesos susceptibles a mejoras. Objetivo: evaluar los procesos de organización, representación y almacenamiento de la información en el Centro de Estudio, Documentación e Información de Medicamentos (CEDIMED). Métodos: se analizó la variable organización, representación y almacenamiento de la información, incluida en el Modelo Integral para Auditar Organizaciones de Información en Cuba; para lo cual se evaluó el comportamiento de ocho indicadores. Resultados: dos indicadores fueron evaluados de excelente, uno de regular y cinco recibieron evaluación de mal. Estos últimos fueron: normalización de la descripción bibliográfica, sistemas de lenguajes para la descripción de contenidos, tiempo para el procesamiento de los documentos, utilización de software para la ejecución de los procesos técnicos y representación de la información a través de catálogos. En general, la variable estudiada fue evaluada de mal. Concluciones: la falta de capacitación de los recursos humanos de la organización en las actividades propias de la representación y organización de la información, resulta ser el factor determinante en los resultados alcanzados por el CEDIMED en esta variable(AU)

Introduction: the Center for Study, Documentation and Information of Drugs has set out to develop and implement an overall quality management system that allows the evaluation and certification of the quality of its services. It was then imperative for this organization to make a diagnosis of its performance, to identify strengths and weaknesses and to carry out actions in those processes that may be upgraded. Objective: to evaluate the processes of information organization, representation and storage in the Center of Study, Documentation and Information of Drugs (CEDIMED). Methods: the variable called information organization, representation and storage included in the Integrated Model for Auditing Information Organizations in Cuba was analyzed on the basis of the behavior of eight indicators. Results: two indicators were rated as excellent, one as regular and five as unsatisfactory. The latter were standardization of bibliographic description, language systems for content descriptions, time elapsed for document processing, use of software for technical processes and representation of information through the catalogues. The general evaluation of this variable was unsatisfactory. Conclusions: the lack of training of human resources in the center in terms of information representation and organization activities was the key factor for the results achieved in this specific variable by CEDIMED(AU)

Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies.

BACKGROUND: Pharmaceuticals are important interventions that could improve people's health. Pharmaceutical pricing and purchasing policies are used as cost-containment measures to determine or affect the prices that are paid for drugs. Internal reference pricing establishes a benchmark or reference price within a country which is the maximum level of reimbursement for a group of drugs. Other policies include price controls, maximum prices, index pricing, price negotiations and volume-based pricing. OBJECTIVES: To determine the effects of pharmaceutical pricing and purchasing policies on health outcomes, healthcare utilisation, drug expenditures and drug use. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library (including the Effective Practice and Organisation of Care Group Register) (searched 22/10/2012); MEDLINE In-Process & Other Non-Indexed Citations and MEDLINE, Ovid (searched 22/10/2012); EconLit, ProQuest (searched 22/10/2012); PAIS International, ProQuest (searched 22/10/2012); World Wide Political Science Abstracts, ProQuest (searched 22/10/2012); INRUD Bibliography (searched 22/10/2012); Embase, Ovid (searched 14/12/2010); NHSEED, part of The Cochrane Library (searched 08/12/2010); LILACS, VHL (searched 14/12/2010); International Political Science Abstracts (IPSA), Ebsco (searched (17/12/2010); OpenSIGLE (searched 21/12/10); WHOLIS, WHO (searched 17/12/2010); World Bank (Documents and Reports) (searched 21/12/2010); Jolis (searched 09/10/2011); Global Jolis (searched 09/10/2011) ; OECD (searched 30/08/2005); OECD iLibrary (searched 30/08/2005); World Bank eLibrary (searched 21/12/2010); WHO - The Essential Drugs and Medicines web site (browsed 21/12/2010). SELECTION CRITERIA: Policies in this review were defined as laws; rules; financial and administrative orders made by governments, non-government organisations or private insurers. To be included a study had to include an objective measure of at least one of the following outcomes: drug use, healthcare utilisation and health outcomes or costs (expenditures); the study had to be a randomised trial, non-randomised trial, interrupted time series (ITS), repeated measures (RM) study or a controlled before-after study of a pharmaceutical pricing or purchasing policy for a large jurisdiction or system of care. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed the risk of bias. Results were summarised in tables. There were too few comparisons with similar outcomes across studies to allow for meta-analysis or meaningful exploration of heterogeneity. MAIN RESULTS: We included 18 studies (seven identified in the update): 17 of reference pricing, one of which also assessed maximum prices, and one of index pricing. None of the studies were trials. All included studies used ITS or RM analyses. The quality of the evidence was low or very low for all outcomes. Three reference pricing studies reported cumulative drug expenditures at one year after the transition period. Two studies reported the median relative insurer's cumulative expenditures, on both reference drugs and cost share drugs, of -18%, ranging from -36% to 3%. The third study reported relative insurer's cumulative expenditures on total market of -1.5%. Four reference pricing studies reported median relative insurer's expenditures on both reference drugs and cost share drugs of -10%, ranging from -53% to 4% at one year after the transition period. Four reference pricing studies reported a median relative change of 15% in reference drugs prescriptions at one year (range -14% to 166%). Three reference pricing studies reported a median relative change of -39% in cost share drugs prescriptions at one year (range -87% to -17%). One study of index pricing reported a relative change of 55% (95% CI 11% to 98%) in the use of generic drugs and -43% relative change (95% CI -67% to -18%) in brand drugs at six months after the transition period. The same study reported a price change of -5.3% and -1.1% for generic and brand drugs respectively six months after the start of the policy. One study of maximum prices reported a relative change in monthly sales volume of all statins of 21% (95% CI 19% to 24%) after one year of the introduction of this policy. Four studies reported effects on mortality and healthcare utilisation, however they were excluded because of study design limitations. AUTHORS' CONCLUSIONS: The majority of the studies of pricing and purchasing policies that met our inclusion criteria evaluated reference pricing. We found that internal reference pricing may reduce expenditures in the short term by shifting drug use from cost share drugs to reference drugs. Reference pricing may reduce related expenditures with effects on reference drugs but the effect on expenditures of cost share drugs is uncertain. Reference pricing may increase the use of reference drugs and may reduce the use of cost share drugs. The analysis and reporting of the effects on patients' drug expenditures were limited in the included studies and administration costs were not reported. Reference pricing effects on health are uncertain due to lack of evidence. The effects of other purchasing and pricing policies are until now uncertain due to sparse evidence. However, index pricing may reduce the use of brand drugs, increase the use of generic drugs, and may also slightly reduce the price of the generic drug when compared with no intervention.

Detecção de simulação com o uso do wisconsin card sorting test e do trail making test / Detection of malingering using the wisconsin card sorting test and the trail making test

Neste trabalho, tentamos identificar índices de simulação na avaliação neuropsicológica forense, através da avaliação dos padrões de resposta em provas neuropsicológicas. A amostra foi constituída por 56 sujeitos com traumatismo crânioencefálico. Todos se encontravam numa situação de possível recompensa monetária por incapacidade. Utilizamos os instrumentos Wisconsin Card Sorting Test (WCST), Trail Making Test (TMT), Inventário de Sintomas Psicopatológicos (BSI), e a grelha de análise dos autos do processo. Cerca de 30% da amostra enquadrou-se no grupo de prováveis simuladores. Essa porcentagem é congruente com a literatura. Verificou-se uma grande homogeneidade entre os indivíduos com e sem indicadores de simulação, a nível sintomatológico e características sócio-demográficas, o que reforça a necessidade de desenvolvimento de métodos eficazes na detecção da simulação.

The objective of this study was to identify indicators of malingering in forensic neuropsychological assessment by identifying response patterns in neuropsychological tests. The sample was composed by 56 subjects diagnosed with a cranioencephalic trauma. All subjects were in a situation of monetary reward if incapacity was proven. The instruments used were the Wisconsin Card Sorting Test (WCST), the Trail Making Test (TMT), the Brief Symptom Inventory (BSI), and a legal process data file. Approximately 30% of the studied sample was identified as probable malingerers. This percentage is consistent with the literature. We identified a high level of homogeneity of psychological symptoms and socio-demographic features in the group of subjects with indicators of malingering and in the group without such indicators. These results reinforce the necessity to develop efficient methods to detect malingering.

Detecção de simulação com o uso do wisconsin card sorting test e do trail making test / Detection of malingering using the wisconsin card sorting test and the trail making test

Neste trabalho, tentamos identificar índices de simulação na avaliação neuropsicológica forense, através da avaliação dos padrões de resposta em provas neuropsicológicas. A amostra foi constituída por 56 sujeitos com traumatismo crânioencefálico. Todos se encontravam numa situação de possível recompensa monetária por incapacidade. Utilizamos os instrumentos Wisconsin Card Sorting Test (WCST), Trail Making Test (TMT), Inventário de Sintomas Psicopatológicos (BSI), e a grelha de análise dos autos do processo. Cerca de 30% da amostra enquadrou-se no grupo de prováveis simuladores. Essa porcentagem é congruente com a literatura. Verificou-se uma grande homogeneidade entre os indivíduos com e sem indicadores de simulação, a nível sintomatológico e características sócio-demográficas, o que reforça a necessidade de desenvolvimento de métodos eficazes na detecção da simulação.(AU)

The objective of this study was to identify indicators of malingering in forensic neuropsychological assessment by identifying response patterns in neuropsychological tests. The sample was composed by 56 subjects diagnosed with a cranioencephalic trauma. All subjects were in a situation of monetary reward if incapacity was proven. The instruments used were the Wisconsin Card Sorting Test (WCST), the Trail Making Test (TMT), the Brief Symptom Inventory (BSI), and a legal process data file. Approximately 30% of the studied sample was identified as probable malingerers. This percentage is consistent with the literature. We identified a high level of homogeneity of psychological symptoms and socio-demographic features in the group of subjects with indicators of malingering and in the group without such indicators. These results reinforce the necessity to develop efficient methods to detect malingering.(AU)

Análise do tempo de trabalho da instrumentação recíproca com lima única: waveOne e reciproc / Analysis of working time of the reciprocating single file instrumentation: WaveOne and Reciproc

O objetivo deste estudo foi analisar o tempo de trabalho necessário para a instrumentação do conduto radicular utilizando-se da instrumentação reciproca alternada com lima única: WaveOne e Reciproc, Vinte canais simulados curvos foram utilizados, onde 10 amostras foram instrumentadas pelo sistema WaveOne e 10 amostras foram instrumentadas pelo sistema Reciproc, O tempo de trabalho com e sem a adição do tempo utilizado para irrigação e exploração do conduto foi cronometrado. Os diferentes terços também foram considerados separadamente, Os dados obtidos foram analisados utilizando teste de Mann-Whitney, Kuskal-Wallis e Student- Newman-Kels (p=0,05), Os resultados apresentaram diferença significante entre os grupos em ambas as situações (com e sem tempo adicional), onde o Reciproc obteve menor tempo nos terços médio e apical do que o WaveOne, Pode-se concluir que ambos os sistemas apresentaram ser bem rápidos na instrumentação do canal radicular, contudo o sistema Reciproc foi mais rápido que o WaveOne.

The aim ofthis study was to analyze the working time for endodontic instrumentation using the reciprocating single file system: WaveOne and Heciproc. Twenty curved simulated resin root canais were used, where 10 samples were shaped using WaveOne system and 10 samples using Reciproc, The working time with and without irrigation and exploration time was recorded, The thirds were also individually consídered, The data were analyzed by Mann-Whitney, Kuskal- Wallis and Student-Newman-Kels tests (p=0,05), The results showed signifficant difference between the groups on both situations (with and without irrigation and exploration time), where time needed for instrumentation of medium and apical thirds was shorter for Reciproc group than for WaveOne qroup, It can conclude that both systems are fast on the endodontic instrumentation, but the Reciproc system is faster than the WaveOne svstem.

Reparación quirúrgica de la inestabilidad medial crónica del tobillo. caso clínico / Surgical repair of the media un certainty chronic ankle: clinical case

Paciente masculino de 23 años de edad, quien posterior a accidente de tránsito presentó fractura del maleolo peroneal y rotura del ligamento deltoideo del tobillo izquierdo, por lo que es intervenido quirúrgicamente realizándose reducción cruenta y osteosíntesis de fractura del peroné con exploración medial y reparación del ligamento deltoideo. Evolucionando tórpidamente por lo que es intervenido con el diagnóstico de "Inestabilidad Medial Crónica del Tobillo" realizándose reconstrucción del ligamento deltoideo con una transposición de hemitendón del tibial posterior, con resultados satisfactorios. Se hace a su vez revisón bibliográfica de las técnicas recomendadas para la reparación quirúrgica de la inestabilidad lateral medial del tobillo

Conducta ante las fracturas supracondileas en niños: revisión de 10 años en el Hospital Pérez de León / Behavior before fractures supracondylar in children: review for ten years in the Pérez of León Hospital

Se realizó un estudio retrospectivo de 56 niños con fracturas supracondíleas de húmero en el Hospital Pérez de León, encontrándose que los tratamientos más utilizados fueron la reducción incruenta más osteosíntesis con alambres de Kirschner percutáneos cruzados y la reducción cruenta más osteosíntesis con alambres de Kirschner cruzados, ambos con resultados satisfactorios similares

Colocación de clavos bloqueados femorales sin fluroscopia / Situation of interlokings mails femorals out fluroscopy

Se realizó una revisión de todos los casos de femúr que fueron tratados con clavos bloqueados cielo abierto sin intensificador de imagen desde Abril de 1992 hasta Marzo de 1995 en los hospitales Ricardo baquero G.(periférico de catia) y Peréz de León de Petare. Se incluyeron en este estudio de 69 fracturas diaficiarias de fémur y 3 pseudoartrosis en 70 pacientes. Todos los pacientes se trataron con reducción abierta,bloqueo proximal convencional y bloqueo distal empleando una de estas dos técnicas: 1 Osteotomía en Ventana, 2 Uso de punzón iniciador, obteniendose 91,66 por ciento de resultados satisfactorios