Pilomatrixoma: A Comprehensive Review of the Literature.

INTRODUCTION: Pilomatrixoma, also known as calcifying epithelioma of Malherbe, is a superficial benign skin tumor that arises from hair follicle matrix cells. Although pilomatrixomas are well-recognized lesions, clinically they are frequently misdiagnosed as other skin conditions. By reviewing all the literature over the past 10 years, the aims of this article are to analyze the cause, clinical presentation, management, and outcome of pilomatrixoma among children and adults to gain a more complete understanding of this lesion in today's clinical context. METHODS: A MEDLINE and EMBASE search was conducted from January 2005 to February 2015 using a combination of the terms: "child," "childhood," "adult," and keywords: "pilomatrixoma," "pilomatricoma," and "calcifying epithelioma of Malherbe." A total of 150 articles were reviewed. RESULTS: The lesions occurred most commonly in the first and second decades (mean age 16 years and 7 months). The commonest presentation was of an asymptomatic, firm, slowly growing, mobile nodule. Only 16% were accurately diagnosed on clinical examination. Imaging in the form of ultrasound, computed tomography, and magnetic resonance imaging has been reported. Pathological diagnosis was achieved through incision, punch, and shave biopsies. Pathological findings are discussed and summarized in this review. CONCLUSION: Pilomatrixomas are thought to arise from mutation in the Wnt pathway and has been linked to several genetic conditions. It is commonly misdiagnosed preoperatively; however, with better awareness of the lesion, it can be appropriately treated while avoiding unnecessary diagnostic tests. Complete surgical excision with clear margins is almost always curative.

Death from Ingestion of E-Liquid.

BACKGROUND: The use of e-liquids is becoming more prevalent. There is a risk that such liquids may be ingested by mouth rather than being vaped/ inhaled. Due to the high concentration of drugs such as nicotine in these liquids, there may be toxic, and possibly fatal consequences. CASE REPORT: We report the death of a 32-year-old male who ingested nicotine-containing e-liquid while under the influence of alcohol. A serum sample taken 24 h after collapse contained nicotine at a concentration of 1600 ng/mL of nicotine. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Death secondary to e-liquid ingestion is still very rare, but has the potential for causing deaths due to the easy access of such liquids to the general public. Such toxicity should be considered in individuals who present in the early phases with symptoms of stimulant toxicity, but also in the latter phase where there may be autonomic depressive effects.

Estimation of postmortem interval using vitreous potassium levels in cases of fatal road traffic collision

AIM OF THE STUDY: To produce a formula that can accurately predict postmortem interval (PMI) based on vitreous potassium levels using road traffic collision fatalities. MATERIAL AND METHODS: Vitreous humour samples were taken from 78 individuals who had died following road traffic collisions between 2010 and 2015. Samples were obtained from both eyes and were sent for on-site analysis. Measurement of potassium was by an indirect ion-specific electrode Siemens diagnostics ADVIA 2400 chemistry system. Exact time of death was known from police reports, the time of postmortem was recorded and the postmortem interval was calculated. Linear regression was then used to analyse the relationship between the two. The impact of age was also assessed. RESULTS: PMI was between 6 and 162 hours. As vitreous potassium increases, the PMI also increases; exhibiting a linear relationship. This is illustrated by a regression equation of PMI = 6.42[K+] - 40.94, R = 0.67 (p < 0.001). This produced a formula closely comparable with three other studies proposed in previous literature and produces estimates that may exceed one calendar day. When both age and medical intervention are accounted for there is an insignificant improvement in prediction. CONCLUSIONS: Validated methods have been used to produce a formula for prediction of PMI using vitreous potassium. Although this is specific to road traffic collisions, the methods are transferable and can be seen to be comparable with other recently published methods. Nonetheless, if greater levels of accuracy are required it is suggested that biomarkers delivering a higher level of precision should still be sought.

Presenting life with cystic fibrosis: a Q-methodological approach to developing balanced, experience-based prenatal screening information.

BACKGROUND: Cystic fibrosis (CF) is one of the most common life-threatening genetically inherited conditions and prenatal screening for CF is available in many countries. Genetic counsellors and other health professionals are expected to provide information about the condition in a way that facilitates personal decision making. Knowing what information to deliver about complex genetic conditions to support informed screening decisions can be challenging for health professionals. OBJECTIVE: To solicit views from those with personal experience with CF on which aspects of the condition they consider most important to include in prenatal screening materials. METHODS: Q-methodology; an approach to systematically explore variations in viewpoint that combines factor analytic techniques with qualitative approaches to pattern interpretation. SETTING AND PARTICIPANTS: Twelve adults with CF and 18 parents of affected children were recruited from a regional centre in the UK. RESULTS: Five distinct viewpoints on the items most and least important to include in screening information were identified: Factor 1 the normality of life with CF and increasing life expectancy; Factor 2 the hardships and reduced lifespan. Factor 3 medical interventions and the importance of societal support. Factor 4 longer-term consequences of CF. Factor 5 the ability to adjust to the condition. DISCUSSION: The identification of five different views on what represented the most and least important information to include about CF highlights the challenge of portraying a complex genetic condition in a balanced and accurate manner. Novel ways in which Q-methodology findings can be used to meet this challenge are presented.

Maternal use of methadone and risk of sudden neonatal death.

AIM: To identify and describe infant deaths presenting suddenly and unexpectedly in whom there was a history of maternal methadone consumption or misuse of drugs during pregnancy. METHODS: Retrospective review of neonatal postmortem examinations between 2004 and 2011. RESULTS: A total of 138 autopsies were performed in infants up to 28 days. Thirty-two cases (23%) presented suddenly and unexpectedly. In 12 of 32 (37.5%), in whom the cause of death remained unexplained after a thorough postmortem, there was a history of methadone use and/or other drugs of abuse during pregnancy. Their mean age at death was 11 days (range 1-28 days). Multiple risk factors for sudden infant death syndrome were present in these 12 cases: smoking (10), prematurity (7), and inappropriate sleeping place (8). Five mothers were positive for hepatitis C. The history was inconsistent with the findings in only one case. CONCLUSION: An unexpectedly high proportion of infants dying suddenly and unexpectedly in the first month had a history of maternal substance misuse. All had multiple risk factors, for sudden infant death syndrome many avoidable. We would stress the need to emphasise the 'Safe Sleep' message with these families at every contact with health professionals.

Delivering an Optimised Behavioural Intervention (OBI) to people with low back pain with high psychological risk; results and lessons learnt from a feasibility randomised controlled trial of Contextual Cognitive Behavioural Therapy (CCBT) vs. Physiotherapy.

BACKGROUND: Low Back Pain (LBP) remains a common and costly problem. Psychological obstacles to recovery have been identified, but psychological and behavioural interventions have produced only moderate improvements. Reviews of trials have suggested that the interventions lack clear theoretical basis, are often compromised by low dose, lack of fidelity, and delivery by non-experts. In addition, interventions do not directly target known risk mechanisms. We identified a theory driven intervention (Contexual Cognitive Behavioural Therapy, CCBT) that directly targets an evidence-based risk mechanism (avoidance and ensured dose and delivery were optimised. This feasibility study was designed to test the credibility and acceptability of optimised CCBT against physiotherapy for avoidant LBP patients, and to test recruitment, delivery of the intervention and response rates prior to moving to a full definitive trial. METHODS: A randomised controlled feasibility trial with patients randomised to receive CCBT or physiotherapy. CCBT was delivered by trained supervised psychologists on a one to one basis and comprised up to 8 one-hour sessions. Physiotherapy comprised back to fitness group exercises with at least 60 % of content exercise-based. Patients were eligible to take part if they had back pain for more than 3 months, and scored above a threshold indicating fear avoidance, catastrophic beliefs and distress. RESULTS: 89 patients were recruited. Uptake rates were above those predicted. Scores for credibility and acceptability of the interventions met the set criteria. Response rates at three and six months fell short of the 75 % target. Problems associated with poor response rates were identified and successfully resolved, rates increased to 77 % at 3 months, and 68 % at 6 months. Independent ratings of treatment sessions indicated that CCBT was delivered to fidelity. Numbers were too small for formal analysis. Although average scores for acceptance were higher in the CCBT group than in the group attending physiotherapy (increase of 7.9 versus 5.1) and change in disability and pain from baseline to 6 months were greater in the CCBT group than in the physiotherapy group, these findings should be interpreted with caution. CONCLUSIONS: CCBT is a credible and acceptable intervention for LBP patients who exhibit psychological obstacles to recovery. TRIAL REGISTRATION: ISRCTN43733490 , registered 15/12/2010.

Psychological therapies for the management of chronic and recurrent pain in children and adolescents.

BACKGROUND: This is an update of the original Cochrane review first published in Issue 1, 2003, and previously updated in 2009 and 2012. Chronic pain affects many children, who report severe pain, disability, and distressed mood. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update focuses specifically on psychological therapies delivered face-to-face, adds new randomised controlled trials (RCTs), and additional data from previously included trials. OBJECTIVES: There were three objectives to this review. First, to determine the effectiveness on clinical outcomes of pain severity, disability, depression, and anxiety of psychological therapy delivered face-to-face for chronic and recurrent pain in children and adolescents compared with active treatment, waiting-list, or standard medical care. Second, to evaluate the impact of psychological therapies on depression and anxiety, which were previously combined as 'mood'. Third, we assessed the risk of bias of the included studies and the quality of outcomes using the GRADE criteria. SEARCH METHODS: Searches were undertaken of CENTRAL, MEDLINE, EMBASE, and PsycINFO. We searched for further RCTs in the references of all identified studies, meta-analyses, and reviews. Trial registry databases were also searched. The date of most recent search was January 2014. SELECTION CRITERIA: RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment, standard medical care, or waiting-list control for children or adolescents with episodic, recurrent or persistent pain were eligible for inclusion. Only trials conducted in person (face-to-face) were considered. Studies that delivered treatment remotely were excluded from this update. DATA COLLECTION AND ANALYSIS: All included studies were analysed and the quality of outcomes were assessed. All treatments were combined into one class, psychological treatments. Pain conditions were split into headache and non-headache. Both conditions were assessed on four outcomes: pain, disability, depression, and anxiety. Data were extracted at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (between three and 12 months post-treatment). MAIN RESULTS: Seven papers were identified in the updated search. Of these papers, five presented new trials and two presented follow-up data for previously included trials. Five studies that were previously included in this review were excluded as therapy was delivered remotely. The review thus included a total of 37 studies. The total number of participants completing treatments was 2111. Twenty studies addressed treatments for headache (including migraine); nine for abdominal pain; two for mixed pain conditions including headache pain, two for fibromyalgia, two for recurrent abdominal pain or irritable bowel syndrome, and two for pain associated with sickle cell disease.Analyses revealed psychological therapies to be beneficial for children with chronic pain on seven outcomes. For headache pain, psychological therapies reduced pain post-treatment and at follow-up respectively (risk ratio (RR) 2.47, 95% confidence interval (CI) 1.97 to 3.09, z = 7.87, p < 0.01, number needed to treat to benefit (NNTB) = 2.94; RR 2.89, 95% CI 1.03 to 8.07, z = 2.02, p < 0.05, NNTB = 3.67). Psychological therapies also had a small beneficial effect at reducing disability in headache conditions post-treatment and at follow-up respectively (standardised mean difference (SMD) -0.49, 95% CI -0.74 to -0.24, z = 3.90, p < 0.01; SMD -0.46, 95% CI -0.78 to -0.13, z = 2.72, p < 0.01). No beneficial effect was found on depression post-treatment (SMD -0.18, 95% CI -0.49 to 0.14, z = 1.11, p > 0.05). At follow-up, only one study was eligible, therefore no analysis was possible and no conclusions can be drawn. Analyses revealed a small beneficial effect for anxiety post-treatment (SMD -0.33, 95% CI -0.61 to -0.04, z = 2.25, p < 0.05). However, this was not maintained at follow-up (SMD -0.28, 95% CI -1.00 to 0.45; z = 0.75, p > 0.05).Analyses revealed two beneficial effects of psychological treatment for children with non-headache pain. Pain was found to improve post-treatment (SMD -0.57, 95% CI -0.86 to -0.27, z = 3.74, p < 0.01), but not at follow-up (SMD -0.11, 95% CI -0.41 to 0.19, z = 0.73, p > 0.05). Psychological therapies also had a beneficial effect for disability post-treatment (SMD -0.45, 95% CI -0.71 to -0.19, z = 3.40, p < 0.01), but this was not maintained at follow-up (SMD -0.35, 95% CI -0.71 to 0.02, z = 1.87, p > 0.05). No effect was found for depression or anxiety post-treatment (SMD -0.07, 95% CI -0.30 to 0.17, z = 0.54, p > 0.05; SMD -0.15, 95% CI -0.36 to 0.07, z = 1.33, p > 0.05) or at follow-up (SMD 0.06, 95% CI -0.16 to 0.28, z = 0.53, p > 0.05; SMD 0.05, 95% CI -0.24 to 0.33, z = 0.32, p > 0.05). AUTHORS' CONCLUSIONS: Psychological treatments delivered face-to-face are effective in reducing pain intensity and disability for children and adolescents (<18 years) with headache, and therapeutic gains appear to be maintained, although this should be treated with caution for the disability outcome as only two studies could be included in the follow-up analysis. Psychological therapies are also beneficial at reducing anxiety post-treatment for headache. For non-headache conditions, psychological treatments were found to be beneficial for pain and disability post-treatment but these effects were not maintained at follow-up. There is limited evidence available to estimate the effects of psychological therapies on depression and anxiety for children and adolescents with headache and non-headache pain. The conclusions of this update replicate and add to those of the previous review which found that psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up for children with headache conditions.

Segmental masseteric flap for dynamic reanimation of facial palsy.

The masseter muscle is one of the major chewing muscles and contributes to define facial contour. It is an important landmark for aesthetic and functional surgery and has been used for facial palsy reanimation or as source of donor motor nerve. We present an anatomic study to evaluate the possibility of using a muscle subunit for dynamic eye reanimation. Sixteen head halves were dissected under magnification to study the neurovascular distribution and determine safe muscle subunits; areas of safe/dangerous dissection were investigated. Once isolated, the arc of rotation of the muscular subunit was measured on fresh body to verify the reach to the lateral canthus. The patterns of neurovascular distribution and areas of safe dissection were identified; the anterior third of the muscle represents an ideal subunit with constant nerve and artery distribution. The muscle is too short to reach the lateral canthus; a fascia graft extension is needed. The information provided identified the main neurovascular branches and confirms the feasibility of a dynamic segmental flap. The need of efficient motor units for facial reanimation demands for different surgical options. A detailed anatomic description of the neurovascular bundle is mandatory to safely raise a functional motor subunit.

Broad evidence of xylazine in the UK illicit drug market beyond heroin supplies: Triangulating from toxicology, drug-testing and law enforcement.

BACKGROUND AND AIMS: Xylazine is a non-opioid sedative which has spread rapidly throughout the US illicit drug supply. This study aimed to describe the spread of xylazine throughout the UK illicit drug supply. METHODS: Xylazine detections in human biological samples were collated from toxicology laboratories operating in the United Kingdom with the date, location, case type, xylazine concentration and co-detected drugs (with quantifications where performed) detailed, where permitted, by the corresponding coroner. Drug-testing cases positive for xylazine were collated from the Welsh Emerging Drugs and Identification of Novel Substances (WEDINOS) drug-testing postal service with the date, location, purchase intent and co-detected drugs detailed. Drug seizures made by UK law enforcement were communicated by the Office for Health Improvement and Disparities with the date and location detailed. RESULTS: By the end of August 2023, xylazine was detected in 35 cases from throughout toxicology, drug-testing and drug seizure sources covering England, Scotland and Wales. There were no cases reported from Northern Ireland. Xylazine was detected in biological samples from 16 people. In most cases where full toxicology results were provided, xylazine was detected with heroin and/or a strong opioid (n = nine of 11), but this polydrug use pattern was not evident in all cases (n = two of 11), suggesting a wider circulation of xylazine in the UK illicit drug market beyond heroin supplies. Evidence from WEDINOS supports this claim, as all 14 drug samples (100%) submitted from across the UK contained xylazine; however, in none of these cases was heroin the purchase intent but rather counterfeit prescription medication tablets (n = 11 of 14), tetrahydrocannabinol (THC) vapes (n = two of 14) or white powder (n = one of 14). Additional evidence for the spread of illicit xylazine comes from five drug seizures made by law enforcement. CONCLUSIONS: Xylazine has penetrated the UK illicit drug market and is not limited to heroin supplies.

The functional intraoral Glasgow scale in floor of mouth carcinoma: longitudinal assessment of 62 consecutive patients.

The functional integrity of the floor of the mouth (FOM) is essential in maintaining tongue mobility, deglutition, and control and disposal of saliva. The present study focused on reporting oral function using functional intraoral Glasgow scale (FIGS) in patients who had surgical ablation and reconstruction of FOM carcinoma with or without chemo-radiotherapy. The study included patients who had surgical treatment of floor of mouth cancer in two regional head and neck units in Glasgow, UK between January 2006 and August 2007. Patients were assessed using FIGS before surgery, 2 months, 6 months and 1 year after surgery. It is a five-point scale self-questionnaire to allow patients to self-assess speech, chewing and swallowing. The maximum total score is 15 points. The influence of socio-demographic parameters, tumour characteristics and surgical parameters was addressed in the study. A total of 62 consecutive patients were included in the study; 41 (66.1 %) were males and 21 (33.9 %) were females. The patients' mean age at the time of diagnosis was 60.6 years. Fifty (80.6 %) patients had unilateral origin of FOM tumours and 10 (19.4 %) had bilateral origin. Peroral approach was the most common approach used in 35 (56.4 %) patients. The mean preoperative FIGS score was 14. Two months after surgery, it droped to 9.4 then started to increase gradually thereafter and recorded 10.1 at 6 months and 11 at 1 year. Unilateral FOM resection recorded better score than bilateral and lateral FOM tumours than anterior at 1 year postoperatively. Furthermore, direct closure showed better functional outcome than loco-regional and free flaps. The FIGS is a simple and comprehensive way of assessing a patient's functional impairment following surgery in the FOM. Tumour site and size, surgical access, surgical resection and method of reconstruction showed significant influence on oral function following surgical resection. A well-designed rehabilitation programme is required to improve oral function after surgical resection of oral cancer.

'Are dynamic procedures superior to static in treating the paralytic eyelid in facial paralysis?'

BACKGROUND: Facial nerve weakness can cause deficient eye closure with reduced corneal protection. Surgical remedies can be static to oppose the levator muscle (lid loading) or dynamic procedures, which act to increase the strength of closure. This retrospective cohort study compares these groups. The hypothesis is that dynamic reconstruction has advantages over static techniques in terms of eye closure, symptomatic improvement, blink restoration, and complication rate. METHODS: Two cohorts were compared: those treated with a gold weight insertion into the upper eyelid and those who had received dynamic reconstruction. These included temporalis transfer; cross face nerve grafting alone (CFNG) and CFNG followed by free tissue transfer. Assessments included standard photography and video; measurement of eyelid excursion including residual gap and if full eye closure was possible. The presence of the blink reflex and symptoms of dry eye was assessed. RESULTS: Overall improvement in eye closure was similar with the gold weight compared to dynamic procedures (5.1 mm vs 5.3 mm). Dynamic procedures however gave improved results in terms of symptom relief and restoration of blink. They also had fewer complications and revision rates overall. CONCLUSION: The study confirms the hypothesis that dynamic reconstructions of the paralysed eyelid confer advantages compared to simple lid loading techniques. Improvements in lid excursion are similar, but symptom improvement and blink restoration are significantly better. A decision regarding eyelid reanimation should be made early in the patient's journey of facial reanimation to allow for accurate planning and placement of nerve grafts at an early stage.

Psychological therapies for the management of chronic pain (excluding headache) in adults.

BACKGROUND: Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review. OBJECTIVES: To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking. SEARCH METHODS: We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators. SELECTION CRITERIA: Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20. DATA COLLECTION AND ANALYSIS: Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25. MAIN RESULTS: Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not. AUTHORS' CONCLUSIONS: Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why.

Psychological therapies for the management of chronic and recurrent pain in children and adolescents.

BACKGROUND: Chronic pain affects many children, who report severe pain, distressed mood, and disability. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update adds recently published randomised controlled trials (RCTs) to the review published in 2009. OBJECTIVES: To assess the effectiveness of psychological therapies, principally cognitive behavioural therapy and behavioural therapy, for reducing pain, disability, and improving mood in children and adolescents with recurrent, episodic, or persistent pain. We also assessed the risk of bias and methodological quality of the included studies. SEARCH METHODS: Searches were undertaken of MEDLINE, EMBASE, and PsycLIT. We searched for RCTs in references of all identified studies, meta-analyses and reviews. Date of most recent search: March 2012. SELECTION CRITERIA: RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment were eligible for inclusion (waiting list or standard medical care) for children or adolescents with episodic, recurrent or persistent pain. DATA COLLECTION AND ANALYSIS: All included studies were analysed and the quality of the studies recorded. All treatments were combined into one class: psychological treatments; headache and non-headache outcomes were separately analysed on three outcomes: pain, disability, and mood. Data were extracted at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (at least three months after the post-treatment assessment point, but not more than 12 months). MAIN RESULTS: Eight studies were added in this update of the review, giving a total of 37 studies. The total number of participants completing treatments was 1938. Twenty-one studies addressed treatments for headache (including migraine); seven for abdominal pain; four included mixed pain conditions including headache pain, two for fibromyalgia, two for pain associated with sickle cell disease, and one for juvenile idiopathic arthritis. Analyses revealed five significant effects. Pain was found to improve for headache and non-headache groups at post-treatment, and for the headache group at follow-up. Mood significantly improved for the headache group at follow-up, although, this should be interpreted with caution as there were only two small studies entered into the analysis. Finally, disability significantly improved in the non-headache group at post-treatment. There were no other significant effects. AUTHORS' CONCLUSIONS: Psychological treatments are effective in reducing pain intensity for children and adolescents (<18 years) with headache and benefits from therapy appear to be maintained. Psychological treatments also improve pain and disability for children with non-headache pain. There is limited evidence available to estimate the effects of psychological therapies on mood for children and adolescents with headache and non-headache pain. There is also limited evidence to estimate the effects on disability in children with headache. These conclusions replicate and add to those of the previous review which found psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up.

Drug- and alcohol-related deaths at a pediatric institution in the United kingdom.

AIM: The study aimed to identify the incidence, clinical presentation, and demographic features of drug- and alcohol-related deaths diagnosed at a pediatric pathology department between 2004 and 2010. MATERIAL AND METHODS: Databases of the histopathology and toxicology departments were searched. Three groups were defined as follows: (1) cause of death is toxicologically related; (2) drugs present are consistent with therapeutic range use; and (3) a drug was detected, but the contribution of this drug to the mechanism of death was not clear. RESULTS: Fifty-five cases (36 males, 19 females; mean, 4.8 years; range, 2 hours to 17 years) were identified. This corresponded to 3.3% (55/1669) of all postmortems. Ten cases were group 1, 42 cases were group 2, and 3 cases were group 3. The results in group 1 were methadone (n = 2); methadone, alcohol, and dothiepin (n = 1); diazepam (n = 1); dothiepin (n = 1); carbon monoxide (n = 2); tramadol (n = 1); codeine and paracetamol (n = 1); and dihydrocodeine, citalopram, amitriptyline, and paracetamol (n = 1). The types of death were considered accidental (n = 2), suicide (n = 2), and undetermined (n = 6). CONCLUSIONS: The presence of a toxin in lethal concentration was found in 10 (0.6%) of 1669 of any kind of postmortem examinations. This increased to 2.2% when the analysis was restricted to "sudden deaths." These results demonstrate the need to conduct toxicological screening in all postmortems of this sort.

Fat Grafting in Facial Palsy: A Secondary Revision Technique to Improve the Facial Aesthetics.

We report our experience of using autologous fat grafting (AFG) as an adjunct to dynamic and static facial reanimation surgical techniques in patients with facial palsy. A consecutive series of patients with facial palsy (congenital or acquired) treated by AFG between September 2007 and October 2017 were reviewed. Multiple strategies for initial dynamic facial reanimation have been utilized. Indications for AFG included asymmetry, volume deficiency, and visible muscle tethering. Standard AFG technique was used with fat harvested from the lower abdomen or thigh and injected into multiple affected areas. Fat grafting was repeated as necessary. Two-dimensional analysis was performed using standardized pre- and postoperative photographs to assess facial symmetry. Patient, surgeon, and independent evaluator satisfaction was recorded using a five-point Likert scale (0-4). Thirty-two patients with a mean age of 43 ± 15.5 years were treated with AFG following facial reanimation. A mean of 1.7 ± 1.4 secondary procedures were performed following initial dynamic reanimation before fat grafting. The average number of AFG episodes was 2.2 ± 1.4 with a mean volume of 12.9 ± 6.0 ml. Minimal complications were seen in either the donor or the recipient sites. There was significant improvement (P ≤ 0.001) of postoperative quantitative facial symmetry following fat grafting. At one-year follow-up, surgeon, patient, and independent evaluator were mostly satisfied (3.06 ± 0.62, 3.31 ± 0.59, and 3.16 ± 0.57, respectively). We report a positive experience of correction of facial asymmetry, contour abnormality and visible muscle pull with fat transplantation following dynamic facial reanimation. The procedure has been shown to be quick and simple, with few complications.

Can cannabis kill? Characteristics of deaths following cannabis use in England (1998-2020).

BACKGROUND: Cannabis is the most widely used illegal drug but is rarely considered a causal factor in death. AIMS: This study aimed to understand trends in deaths in England where cannabinoids were detected at post-mortem, and to evaluate the clinical utility of post-mortem cannabinoid concentrations in coronial investigations. METHODS: Deaths with cannabinoid detections reported to the National Programme on Substance Abuse Deaths (NPSAD) were extracted and analysed. RESULTS: From 1998 to 2011, on average 7% of all cases reported to NPSAD had a cannabinoid detected (n = 110 deaths per year), rising to 18% in 2020 (n = 350). Death following cannabis use alone was rare (4% of cases, n = 136/3455). Traumatic injury was the prevalent underlying cause in these cases (62%, n = 84/136), with cannabis toxicity cited in a single case. Polydrug use was evident in most cases (96%, n = 3319/3455), with acute drug toxicity the prevalent underlying cause (74%, n = 2458/3319). Cardiac complications were the most cited physiological underlying cause of death (4%, n = 144/3455). The median average Δ9-tetrahydrocannabinol post-mortem blood concentrations were several magnitudes lower than previously reported median blood concentrations in living users (cannabis alone: 4.3 µg/L; cannabis in combination with other drugs: 3.5 µg/L). CONCLUSIONS: Risk of death due to cannabis toxicity is negligible. However, cannabis can prove fatal in circumstances with risk of traumatic physical injury, or in individuals with cardiac pathophysiologies. These indirect harms need careful consideration and further study to better elucidate the role cannabis plays in drug-related mortality. Furthermore, the relevance of cannabinoid quantifications in determining cause of death in coronial investigations is limited.

Albumin level and patient age predict outcomes in patients referred for gastrostomy insertion: internal and external validation of a gastrostomy score and comparison with artificial neural networks.

BACKGROUND: Significant mortality after gastrostomy insertion remains and some risk factors have been identified, but no predictive scoring system exists. OBJECTIVE: To identify risk factors for mortality, formulate a predictive scoring system, and validate the score. Comparison to an artificial neural network (ANN). DESIGN: Endoscopic database analysis. SETTING: Six hospitals (2 teaching hospitals) in the South Yorkshire region, United Kingdom. PATIENTS: This study involved all patients referred for gastrostomy insertion. INTERVENTION: Generation of clinical scores to predict 30-day mortality in patients undergoing gastrostomy insertion. MAIN OUTCOME MEASUREMENTS: Risk factors for 30-day mortality. Internal and external validation of the score. Comparison with an ANN. RESULTS: Univariate analysis showed that 30-day mortality was associated with age, albumin levels, and cardiac and neurological comorbidities. Multivariate analysis showed that only age and albumin levels were independent. Modeling provided scores of 0, 1, 2, and 3 corresponding to 30-day mortalities of 0% (0-2.1), 7% (2.9-13.9), 21.3% (13.5-30.9), and 37.3% (24.1-51.9), respectively. Application of the scoring system at the other teaching hospital and the 4 district general hospitals gave 30-day mortality rates that were not significantly different from those predicted. Receiver operating characteristic curves for the score and the ANN were comparable. LIMITATIONS: Nonrandomized study. Score not used as a decision-making tool. CONCLUSION: The gastrostomy score provides an estimate of 30-day mortality for patients (and their relatives) when gastrostomy insertion is being discussed. This score requires evaluation as a decision-making tool in clinical practice. ANN analysis results were similar to the outcomes from the clinical score.

Combining an end to side nerve to masseter transfer with cross face nerve graft for functional upgrade in partial facial paralysis-an observational cohort study.

BACKGROUND: Results of a single stage technique combining cross facial nerve graft(s) (CFNG) with an ipsilateral end to side nerve to masseter transfer (NTM) in incomplete facial paralysis are assessed in a retrospective cohort study. The hypothesis is that the technique can safely improve the quality of smile in these patients. End to side coaptations for the recipient facial nerve minimise the risk of iatrogenic function loss, contrasting with the end to end neurorrhaphies used in conventional babysitting procedures. METHODS: A series of 27 patients was studied through case note review and standardised assessments. Surgical technique involves extensive exposure of the facial nerve and the NTM on the affected side and access is by bilateral preauricular incisions. End to end coaptations are made to the facial nerve on the donor side and on the recipient a standard CFNG is combined with an end to side NTM coaptation. Follow up was a minimum of 9 months from surgery. RESULTS: Overall improvement in the Sunnybrook scale averaged 33, from a pre-operative score of 40 (p < 0.05). Average upgrade of 4.7 mm of increased movement at the modiolus was achieved (p < 0.05), 43% improvement compared to the normal side. An improved resting symmetry of 3.8 mm was achieved in relevant cases. Where eye closure was strengthened the average improvement was 5 mm of increased lid closure. The smile achieved was spontaneous in 22 of 27 cases. CONCLUSION: The study confirms the hypothesis that CFNG with NTM transfer offers a physiological upgrade of facial movement in partial facial paralysis, applicable in both early and longstanding cases.

Quantitation of Synthetic Cannabinoid Receptor Agonists in Postmortem Blood Using a Single Point Calibration.

Synthetic cannabinoid receptor agonists (SCRA) share minimal structural similarities to tetrahydrocannabinol or themselves. Due to their heterogeneous structures and the rapid appearance and disappearance of new SCRA on the drug scene, the quantitation of SCRA has not been attempted extensively. We present a wide series of SCRA concentrations based on a single-point calibration using peak height ratios for the extracted ion chromatogram of the protonated precursor ion against that of the internal standard. These concentrations are viewed as indicative only given the use of a single concentration "calibrator" based on the response of a deuterated analogue of a structurally related compound. What is of note, is that, despite the potential differences in potency the majority of SCRA seem to have relatively similar concentrations in postmortem cases.

Quantification of Flualprazolam in Blood by LC-MS-MS: A Case Series of Nine Deaths.

The emergence of novel designer benzodiazepines continues to be a public health concern. Flualprazolam is one of these drugs. It was initially identified in 2017. User forums suggest it is slightly more potent than alprazolam and has longer-lasting central nervous system depressant effects. Here we report a simple, sensitive liquid chromatography-tandem mass spectrometry method for flualprazolam and report a series of nine cases in which flualprazolam was quantified. As is typical of forensic toxicology in the twenty-first century, all the cases had more than one drug present. None of the deaths could be directly attributed to flualprazolam alone, but all were likely due to a combination of sedative drugs. However, this paper still adds to the data available to allow interpretation of postmortem flualprazolam concentrations.