Comparing Outcomes in Orthognathic Surgery Using Clear Aligners Versus Conventional Fixed Appliances.

PURPOSE: Orthognathic surgery for dentofacial deformities is typically preceded and followed by orthodontic treatment. Traditionally, orthodontic hardware is secured to the dentition to allow dental movement and stabilization. Clear-aligner therapy (eg, Invisalign) provides an aesthetic alternative, consisting of a series of transparent trays. Its use has not been described in complex triple-jaw orthognathic surgery. The purpose of this study is to evaluate perioperative outcomes and 3-dimensionally quantify postoperative edema in Invisalign patients undergoing triple-jaw orthognathic procedures, comparing this to patients treated with conventional fixed appliances. The surgical approach to patients with clear-aligners is also outlined. METHODS: The authors conducted a retrospective chart review and 3-dimensional morphometric study of Invisalign patients undergoing triple-jaw surgery (LeFort I osteotomy, bilateral sagittal split osteotomy, and genioplasty). An identical assessment of demographically matched patients treated with conventional fixed appliances was performed and compared with the Invisalign group. RESULTS: Thirty-three patients, with a mean age of 19.99 years, were included: 13 with Invisalign and 20 with conventional fixed appliances. No significant difference was observed in operating time, concurrent extraction of teeth, fat grafting, duration of hospital stay, diet advancement, and use of narcotic analgesics between the 2 groups. Nine patients had sufficient 3-dimensional images for volumetric analysis (4 with Invisalign and 5 with conventional fixed appliances). Postoperative edema was not significantly different (P = 0.712) when comparing conventional fixed appliances (44.29 ±â€Š23.16 cm) to Invisalign (37.36 ±â€Š31.19 cm). CONCLUSION: The present study demonstrates that complex multiple-jaw orthognathic procedures can be successfully performed in Invisalign patients. Perioperative and short-term clinical outcomes are not compromised.

A Summation Analysis of Compliance and Complications of Compression Hosiery for Patients with Chronic Venous Disease or Post-thrombotic Syndrome.

OBJECTIVES: Compression stockings are commonly prescribed for patients with a range of venous disorders, but are difficult to don and uncomfortable to wear. This study aimed to investigate compliance and complications of compression stockings in patients with chronic venous disease (CVD) and post-thrombotic syndrome (PTS). METHODS: A literature search of the following databases was carried out: MEDLINE (via PubMed), EMBASE (via OvidSP, 1974 to present), and CINAHL (via EBSCOhost). Studies evaluating the use of compression stockings in patients with CVD (CEAP C2-C5) or for the prevention or treatment of PTS were included. After scrutinising full text articles, compliance with compression and associated complications were assessed. Compliance rates were compared based on study type and degree of compression. Good compliance was defined as patients wearing compression stockings for >50% of the time. RESULTS: From an initial search result of 4303 articles, 58 clinical studies (37 randomised trials and 21 prospective studies) were selected. A total of 10,245 limbs were included, with compression ranging from 15 to 40 mmHg (not stated in 12 studies) and a median follow-up of 12 months (range 1-60 months). In 19 cohorts, compliance was not assessed and in a further nine, compliance was poorly specified. Overall, good compliance with compression was reported for 5371 out of 8104 (66.2%) patients. The mean compliance, weighted by study size, appeared to be greater for compression ≤25 mmHg (77%) versus > 25 mmHg (65%) and greater in the randomised studies (74%) than in prospective observational studies (64%). Complications of stockings were not mentioned in 43 out of 62 cohorts reviewed. Where complications were considered, skin irritation was a common event. CONCLUSIONS: In published trials, good compliance with compression is reported in around two thirds of patients, with inferior compliance in those given higher degrees of compression. Further studies are required to identify predictors of non-compliance, to help inform the clinical management of these patients. Complications of compression are not documented in many studies and should be given more consideration in the future.

Self-inflicted Burns: The Experience of a UK Regional Burns Center.

Self-inflicted burns (SIBs) are preventable injuries that often occur due to suicidal intent or deliberate self-harm. The incidence of SIB and demographics vary across different countries. This study highlights our regional experience of SIB over almost 2 decades, assessing characteristics and outcomes. A retrospective chart review of all patients assessed at a UK regional burns center, presenting with SIB, from 2003 to 2021, was performed. Subgroup analyses based on gender, the presence or absence of pre-existing psychiatric disorders, and in-hospital patient mortality were undertaken. The relationship between annual mental health funding and the incidence of SIB was assessed. Over the study period, a total of 285 SIB cases, with a median age of 42.84 years, were presented to our center. The majority of patients were male (63.2%) and had a pre-existing psychiatric disorder (74.7%). Flame burns were the most frequent type of injury (82.1%) and the median total BSA (TBSA) was 10.25%. The average length of hospital stay was 10 days and the inpatient mortality rate was 20.7%, significantly greater than the mortality of the rest of the cohort (3.7%, P < .01). SIB survivors were younger and had less severe burns, relative to non-survivors. There was no statistically significant correlation between the incidence of SIBs and mental health funding. SIBs account for a minority of referrals to our regional burns center. Adequately funded regional and national measures should be implemented to reduce the incidence and impact of these injuries, alongside appropriate mental health support.

Epidemiology of adult hand injuries presenting to a tertiary hand surgery unit: a review of 4216 cases.

This study investigates the pattern of hand injuries presenting to a UK regional tertiary centre. All referrals to our Hand Surgery Unit in 2019 were reviewed. Subgroup analyses of sex, deprivation, occupational injuries and assault cases were carried out. Over the study period, 4216 cases were referred. Most were male (70%), with a median age of 36 years and from a deprived area (75.2%). Soft tissue injury was documented in 53.6% and bone injury (fracture/dislocation) in 52.4%. Surgical management was required in 2214 (52.5%) cases. Work-related injuries accounted for 16.7% of cases and were more likely to require surgery. Assault-related injuries accounted for 8% of cases, with a male preponderance. Our findings can help facilitate service provision and guide regional and national prevention policies.Level of evidence: III.

Protocol for clinical diagnosis and empiric treatment of pulmonary tuberculosis in severely burned patients: observations and literature review.

Introduction: Reactivation of pulmonary tuberculosis is a prevalent concomitant infection and cause for mortality in burns patients in Sub-Saharan Africa. First line laboratory diagnostic studies for pulmonary tuberculosis are often negative in these patients and if relied on, result in high mortality. The purpose of this report is to share our experience with a novel protocol of empiric treatment of clinically suspected pulmonary tuberculosis in severely burned patients with negative GeneXpert tests in a tertiary burns centre and to present a brief literature review on the topic. Methods: A retrospective chart review of all patients, who sustained thermal injury with an inhalation component, with negative GeneXpert tests who were treated empirically for pulmonary tuberculosis over a five-year period (2015-2020) was performed. Additionally, a literature search was performed on Medline (PubMed), Cochrane and Google Scholar databases. Results: Over the five-year period, 20 patients with suspected pulmonary tuberculosis and severe burns requiring ventilation were managed according to the protocol and all survived to discharge. The literature search identified six factors that explain the consequence of pulmonary tuberculosis in severely burned patients and provide a hypothesis for the negative laboratory studies encountered. Conclusion: There was an improved outcome for patients with the clinical diagnosis of reactivation of pulmonary tuberculosis when they were started on empirical pulmonary tuberculosis treatment. There are several potential mechanisms that can contribute to reactivation of pulmonary tuberculosis in susceptible severely burned patients. The GeneXpert test should not be relied upon in these patients for a diagnosis, but rather all other clinical evidence should inform management. Lay Summary: From the current literature evidence most patients who have severe burns complicated by a secondary infection known as pulmonary (lung) tuberculosis, die as a result. The purpose of this report is to share our experience with treatment of pulmonary tuberculosis during a five-year period, from 2015 to 2020, in a specialized adult tertiary burn center. Severely burned patients who were suspected of having pulmonary tuberculosis and received treatment despite having negative laboratory tests for pulmonary tuberculosis, had a better survival rate than expected. A brief literature review on the topic of pulmonary tuberculosis and severe burns was done to investigate causes for reactivation of pulmonary tuberculosis and negative laboratory studies in these patients.The literature search identified the following factors that can potentially affect the reactivation of pulmonary tuberculosis in severely burned patients: decreased immune system; secondary infections; low blood albumin(protein) levels; decreased clearance of bacteria from the airways, the development of pulmonary tuberculosis biofilms (capsules that protect the bacteria from chemicals and antibiotics) and the role of a fat molecule called phosphatidylinositol mannoside in pulmonary tuberculosis.In conclusion, the pulmonary tuberculosis test should not be relied upon in these patients, but rather all the clinical evidence such X-ray changes in association with difficulty to wean the patient off the ventilator should be used to inform treatment choice.

The Use of Laser Doppler Imaging in Nitric Acid Burns: A Case Report and Literature Review.

Laser Doppler imaging (LDI) technology has been validated to assess thermal burn depth by predicting wound healing potential. However, there is no clear evidence for its use in chemical burns. We present a case of an 8% total burn surface area (TBSA) nitric acid burn following an industrial accident, in an otherwise healthy 36-year-old man. LDI assessment was suggestive of poor healing potential of >21 days, warranting surgical management. However, conservative management was opted for based on clinical assessment as the wound eschar appeared thin and more consistent with epithelial staining. Patient follow-up confirmed a total burn healing time of two months, suggesting that the LDI assessment was accurate. A comprehensive literature review was performed using the MEDLINE (PubMed) database to identify animal or clinical studies evaluating the efficacy of LDI in chemical burns. A qualitative synthesis of our findings is presented. We identified two experimental studies in porcine models with sulfur mustard burns, each confirming the accuracy of LDI assessment when compared to the histopathology findings. Limited experimental animal studies on the use of LDI suggest similar validity in chemical burns, and this correlates with the clinical outcome in this case. However, this alone is insufficient to prove its validity and define its role in the assessment of chemical burns. Clinical trials are required to further assess and define the parameters of LDI use and efficacy in this context.

Patient or Prisoner?: Acute Burn Injuries in Prisoners-The Birmingham Burns Centre Experience.

Increased risk of violence and self-harm means prisoners are a vulnerable population with complex health needs. They account for a small proportion of patients with burn injuries; however, present a unique set of challenges. This study investigates the incidence, pattern and outcomes of burn injuries in prison population. Prisoners referred from 2010 to 2021 were identified using the International Burn Injury Database (iBID). Patient demographics, burn injury characteristics and outcomes were collected. Patients were then stratified based on mechanism of injury, treatment modality (surgery/conservative), hospital admission (inpatient/outpatient), and compliance with outpatient follow-up, for subgroup analyses. Sixty-eight prisoners sustained burns during the study period, with a median age of 28.5 years and TBSA of 3%. The majority were male (98.5%) and required hospital admission (75%). Scalds were the most common injury type (77.9%) and assault the most frequent cause of burns (63.2%). Eighteen patients (26.5%) underwent a surgical procedure and there were two mortalities. Of patients for whom follow-up was planned, 22% attended no appointments, with a further 49% of prisoners missing at least one appointment. Relative to patients managed nonoperatively, prisoners undergoing surgery had a longer stay and all attended outpatient follow-up appointments. Prisoners represent a unique population with exceptional challenges. Attention should be given to protecting vulnerable patients at risk of assault, education of prison staff around burn prevention and first aid, and ensuring that prisoners are able to access burns follow-up to minimize long-term sequelae. Opportunities exist to aid this such as the adoption of telemedicine.

Unusual Clinical Presentation of a Benign Peripheral Nerve Sheath Tumor of the Radial Nerve.

Diagnosis of simple benign peripheral nerve tumors (PNT) is usually based on imaging studies and in most cases, surgical excision leads to no significant functional deficit. The clinical presentation is often asymptomatic with incidental imaging findings. We present an unusual clinical presentation of a benign peripheral nerve sheath tumor of the radial nerve.

Outcomes Following Surgery for Common Peroneal Nerve Intraneural Ganglion Cysts: A Case Series and Systematic Review.

Background: Intraneural ganglia are a rare cause of common peroneal nerve palsy. Although several treatment modalities exist, surgical intervention is recommended, especially in the setting of neurological dysfunction. We present a case series and systematic review on the clinical outcomes following surgical excision of common peroneal nerve intraneural ganglia. Methods: We performed a retrospective chart review of all patients who had undergone surgery for common peroneal nerve intraneural ganglia at Queen Elizabeth Hospital in Birmingham, UK, from 2012 to 2022. Demographic and pre- and postoperative findings were collected. A comprehensive literature search of MEDLINE and EMBASE databases was also performed to identify similar studies. Data were subsequently extracted from included studies and qualitatively analyzed. Results: Five patients at our center underwent procedures to excise intraneural ganglia. There was a male preponderance. Pain, foot drop, and local swelling were the common presenting features. Postoperatively, all patients who completed follow-up demonstrated improved motor function with no documented cyst recurrence. The systematic review identified 6 studies involving 128 patients with intraneural ganglia treated with surgery. Similar findings were reported, with objective and subjective measures of foot and ankle function and symptoms improving after surgical intervention. The recurrence rate varied from 0% to 25%, although most recurrences were extraneural. Conclusions: Excision of intraneural ganglia is associated with symptomatic relief and functional improvement. Recurrence rates are relatively low and are rarely intraneural.

A Histological and Clinical Study of MatriDerm® Use in Burn Reconstruction.

Dermal substitutes are well established in the reconstructive ladder. MatriDerm® (Dr. Otto Suwelack Skin & Health Care AG, Billerbeck, Germany) is a single-layer dermal substitute composed of a bovine collagen (type I, III, and V) and elastin hydrolysate, that allows for immediate split-thickness skin grafting (SSG). The aim of this study was to histologically characterize the integration of MatriDerm® when used during burns surgery reconstruction. Eight subjects with nine burn scars and one acute burn wound underwent reconstruction with MatriDerm® and an immediate SSG. MatriDerm® integration and skin graft take were assessed with serial biopsies performed at weeks 1, 2, 3, and 4 and months 2, 3, 6, 9, and 12. Biopsies were assessed with standard special stains and immunohistochemistry, and representative slides were imaged with a transmission electron microscope. Patient satisfaction and clinical scar outcome were assessed with the Vancouver Scar Scale and a patient questionnaire. Histological analysis showed similar stages of wound healing as shown in other dermal templates but on a different timescale. There is early evidence of vascularization and an inflammatory infiltrate in the first 2 weeks. MatriDerm® is resorbed earlier than other dermal substitutes, with evidence of resorption at week 3, to be completely replaced by a neodermis at 2 months. The use of MatriDerm® in reconstruction with immediate skin grafting is supported histologically with early evidence of vascularization to support an epidermal autograft. Future histological studies may help further characterize the ideal dermal substitute.

A systematic review of anterior cruciate ligament primary repair rehabilitation.

BACKGROUND: Rehabilitation after surgery of the injured anterior cruciate ligament (ACL) is crucial for satisfactory outcomes. Many trials have investigated this process after ACL reconstruction. The treatment of acute ACL ruptures with a repair technique has recently regained interest, although very little information is available about appropriate rehabilitation for such patients. The objective of this review was to evaluate studies on rehabilitation following ACL repair. METHODS: A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for patients undergoing a rehabilitation programme after ACL repair. The review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO, Registration number: CRD42020173450). Elements of rehabilitation care we included in our strategy are postoperative bracing, home-based rehabilitation, strengthening exercises, proprioception and neuromuscular training. We searched PubMed, CINAHL, EMBASE, and the Cochrane Library for randomised trials of any form investigating rehabilitation protocols after repair of the injured ACL. Two reviewers independently assessed eligibility of trials. RESULTS: No trials were included. Available literature of lower evidence was included for discussion. CONCLUSIONS: No information is available from randomised trials to indicate whether there is any difference between rehabilitation protocols for patients who have undergone primary ACL repair.

Breast cancer: presentation, investigation and management.

Breast cancer is the most common global malignancy and the leading cause of cancer deaths. Despite this, undergraduate and postgraduate exposure to breast cancer is limited, impacting on the ability of clinicians to accurately recognise, assess and refer appropriate patients. This article provides a comprehensive review of the pathology, epidemiology, clinical presentation, referral pathways and management of breast cancer in the UK. It also describes how to conduct a thorough clinical breast examination.

Acute burn injuries associated with long-term mortality: a systematic review and meta-analysis.

BACKGROUND: Emerging evidence suggests that the pathophysiological impact of acute burn injuries may have chronic health consequences. We conducted a systematic review and meta-analysis to investigate the association between burn injuries and long-term mortality in patients surviving to initial discharge from hospital. METHODS: Medline and Embase databases were searched on 22 October 2021. Studies were eligible for inclusion if they compared long-term mortality amongst burn survivors to non-injured controls from the general population. When the same output metrics related to mortality were reported, meta-analyses were undertaken using a random effects model. Risk of bias was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool. RESULTS: Following an extensive literature search, six studies (seven articles) were identified for inclusion. They were predominantly based in high-income countries, with each comparing burns' survivors to matched non-injured controls from the general population. The four studies included in the meta-analysis had a combined unadjusted odds ratio of 2.65 (1.84 - 3.81; 95 % confidence interval) and adjusted mortality rate ratio of 1.59 (1.31 - 1.93; 95 % confidence interval). Thus, burn survivors demonstrated greater mortality rates when compared to their non-injured counterparts. Similar findings were illustrated in the remaining studies not included in the meta-analysis, with the exception of one study which found no significant difference between the two groups. CONCLUSIONS: Our review suggests that acute burn injuries may be associated with greater long-term mortality rates (unadjusted and adjusted). The underlying mechanism is unclear and further work is required to establish the role of certain factors such as biological ageing processes, to improve outcomes for burn patients.

Skull Base Osteomyelitis: A Diagnostic Dilemma.

Skull base osteomyelitis is a rare but potentially fatal condition. It is often characterised by a series of non-specific clinical and radiological signs, making it difficult to distinguish from a malignant lesion. We present the case of an immunocompetent elderly gentleman with multiple cranial nerve palsies and an unremarkable initial ear examination, diagnosed and treated for skull base osteomyelitis, masquerading as malignancy. This initially regressed without antibiotic therapy. This case emphasises the importance of clinicians having a high degree of diagnostic suspicion in order to initiate prompt treatment, thereby improving patient prognosis.

Thermal Preconditioning for Surgery: A Systematic Review.

BACKGROUND: Optimising patients pre-operatively reduces the chance of complications. This may be achieved by preconditioning. Thermal preconditioning refers to the supraphysiological heating of organisms or specific organs prior to an environmental insult. This review explores the current application and efficacy of thermal preconditioning for surgery. METHODS: A comprehensive search of Medline (via PubMed), Embase and the Cochrane library was performed. Only articles evaluating the use of supraphysiological heating prior to a surgical intervention were included. Qualitative syntheses of data were undertaken due to the heterogeneity of the studies. The quality of each article was appraised using risk of bias tools (Cochrane and SYRCLE). RESULTS: The primary literature search returned 3175 articles. After screening and reviewing reference lists, 28 papers met the inclusion criteria. The majority of studies were performed in animals, with only three clinical trials. Although there was broad coverage of different surgical techniques, flap transfer was the most commonly performed procedure. Most studies demonstrated a beneficial effect of thermal preconditioning, ranging from increased joint mobility to improved flap or organ transplant survival rates. The quality of evidence was variable, with experimental animal studies limited by a lack of methodological detail. CONCLUSIONS: Thermal preconditioning for surgery has been primarily investigated using animal models. A beneficial effect has been demonstrated in most cases, across specialties ranging from plastic to general surgery. Future studies should aim to assess the clinical significance through large multicentre randomised controlled trials.

COVID-19 antibody tests: statistical implications.

The coronavirus disease 2019 (COVID-19) pandemic has had significant implications for society, with the introduction of restrictive social measures. Antibody tests provide a way of identifying patients who have been previously exposed to the virus and thus may have a degree of immunity. This is important in the development of public health policy, as local and national bodies seek to relax social restrictions in an attempt to mitigate the socioeconomic impact of the pandemic. This article explores the essential statistical concepts used to interpret the findings of diagnostic investigations, with examples illustrated using COVID-19 antibody tests.

Achieving margin clearance following oncoplastic breast surgery in comparison with simple wide local excision: a three-dimensional specimen assessment.

BACKGROUND: Pre-operative breast tumour radial dimensions often determine the choice between simple wide local excision (WLE) and oncoplastic breast surgery (OBS). We reviewed the three-dimensional interplay between tumour and surgical specimen dimensions in the two cohorts. METHODS: Demographic, tumour and treatment data were collected for all patients undergoing OBS by a single surgeon and compared with a randomly selected cohort of WLE patients treated. The relationship between tumour and specimen medio-lateral, supero-inferior and antero-posterior dimensions were explored in both groups. Subgroup analyses were performed in the OBS cohort (parenchymal displacement versus replacement). RESULTS: We identified 60 OBS patients (63 breasts), comparing them with 60 WLE patients. Pre-operative tumour estimated size was significantly larger in the OBS cohort and concordant with macroscopic tumour radial dimensions and final microscopic tumour size. Surgical specimen weight was more than 3.5 times higher in the OBS group and its radial dimensions were almost double. No significant difference was observed for the antero-posterior dimensions. The rate of margin re-excisions and completion mastectomies were lower in the OBS cohort. WLE patients with positive margins had a lower tumour-to-specimen ratio, whereas, the requirement for further surgery in the OBS cohort was associated with larger tumour dimensions. CONCLUSION: Despite larger tumour dimensions, OBS is not inferior to WLE in providing clear surgical margins. Our analysis of the three-dimensional spatial relationship between cancer and surgical specimen, although not completely conclusive, can be helpful in the selection of the most appropriate surgical approach for every patient.

Urinary catheterization 2: technique and managing failure.

Urinary catheterization is an important procedure that is regularly performed in hospital. All clinicians should have a good working knowledge of urinary catheters and the competence to manage them effectively. This topic is discussed over two articles: the first article focused on indications, and this second discusses techniques and managing failure. Good technique is essential to prevent complications and if problems do occur, these must be managed efficiently to prevent long-term consequences. In some situations, this may require referral to the urology team for more specialized intervention. This article discusses this in more detail to help guide clinicians involved in urethral catheterization.

Urinary catheterization 1: indications.

Urinary catheterization is an important procedure that is regularly performed in hospital. All clinicians should have a good working knowledge of urinary catheters and the competence to manage them effectively. This topic will be discussed over two articles: this first article will focus on indications, and the second on techniques and managing failure. There are multiple indications for urethral catheter insertion and a range of catheter types and sizes. The choice of catheter is dependent on the patient and indication. This article discusses this in more detail to help guide clinicians involved in urethral catheterization.

A rare reaction to synthetic mono-filament sutures: a report of two cases.

Due to their clinical advantages, synthetic mono-filament sutures are dominantly used for postoperative wound closures. We present two patients who suffered rare skin reactions to either poliglecaprone 25 or glyconate sutures, following breast cancer lumpectomy. This report aims to make perioperative practitioners and clinicians aware of reactions to sutures and possible management options.