Conversational artificial intelligence: the interface with the patient concerns inventory.

The patient concerns inventory (PCI) allows patients to highlight the issues they would like to discuss at their outpatient consultation. It improves patient-clinician communication and has proven benefits. While the PCI is effective, patient experiences could be improved with better access to it and the ability to more easily and frequently express their concerns. This, of course, is in the context of ever-increasing healthcare challenges and limited resources. Use of conversational artificial intelligence (CAI) represents an opportunity to improve information flow between patients and professionals remote from the consultation. This paper highlights the potential for CAI to provide an 'always-on' platform, using natural language interface technology and based on the PCI, which patients can access via their mobile devices. We also discuss potential pitfalls and concerns, along with outlining a current clinical trial assessing, in the first instance, usability of this technology.

A 31-year review of composite radial forearm free flaps for head and neck reconstruction.

The aim of this study was to report the patient characteristics and radial fracture rates in a consecutive series of composite radial forearm free flap (CRFFF) for head and neck reconstruction over a 31-year period. The patients were identified from between 1990 to 2020 inclusive from theatre records and records from previous analyses at the Unit on free flap outcomes. Electronic case notes were accessed where available, to gather information on the operation, histopathology, and radiographs. Patients were categorised into three groups for analysis: (1) new oral cancers with a composite radial being the first choice of flap, (2) new oral cancers with a composite radial being the choice of flap following compromise of another bony flap, (3) osteoradionecrosis (ORN) cases. There were 103 CRFFF cases, median (IQR) age 69 (59-80) years, comprising 78 (Group 1), 5 (Group 2) and 20 (Group 3). The CRFFF failure rate was 6% (6/103) and the radius fracture rate was also 6% (6/103), both with 95% confidence interval 2.2-12.2%. Of the 6 radius fractures, 1 underwent surgical management (rush nailing), 1 died in hospital and the others managed with cast immobilisation. Two-year overall survival after surgery for the103 patients was 54% (SE 5%), while 5-year survival was 40% (SE 5%). In conclusion, in spite of the familiarity with other bone flaps such as fibular free flap, DCIA, scapula, and the limited bone stock and potential fracture related morbidity associated with the CRFFF, this flap still has a place in the surgical reconstructive armamentarium.

Prognostic indicators and outcomes following surgical management of metastatic cutaneous squamous cell carcinoma of the head and neck.

Metastatic cutaneous SCC carries a poor prognosis with five-year survival of 25%-57%. The aim of this study is to examine the outcomes following surgery with adjuvant therapy for management of metastatic cSCC in a UK-based population. This is a retrospective review of patients with metastatic cSCC of the head and neck who underwent primary surgery at a regional center during a six-year period. Overall and disease specific survival were calculated using Kaplan-Meier and log-rank tests. Results were reported as hazard ratios (HR) with 95% confidence intervals. Forty-five patients met the inclusion criteria. The mean time to discovery of metastases was 9.3 months (range, 0-40 months). Only two patients (4%) had discovery of metastases after two years, with none after 3.3 years. The overall five5-year survival was 31% (95% CI 15%to 48%) with two-year survival at 48% (95% CI 31%to 63%). The median OS survival was 722 days (95% CI 607to 1359). Patients aged >80 years had a decreased OS. This is the largest UK based study documenting the overall and disease specific survival associated with metastatic cutaneous SCC of the head and neck. Our overall survival is comparable to similar studies, but remains poor. Total number of involved nodes, and lymph node ratio were not statistically significant.

Outcomes of microvascular composite reconstruction for mandibular osteoradionecrosis.

The aim of this retrospective study was to compare outcomes and reconstruction-related complications in patients receiving a composite free flap reconstruction of the mandible for ORN with those reconstructed for other indications. The records of all patients who underwent composite reconstruction of a mandibular defect at Aintree University Hospital, Liverpool, were reviewed and analysed. Based on radiotherapy exposure and ORN history, the study cohort was divided into three separate case-matched groups. Local wound healing issues were markedly more common in the ORN setting, as was infection and subsequent osteosynthesis plate(s) removal. Free flap survival was similar among all three case-matched groups. Advanced mandibular ORN may be safely and predictably reconstructed with composite free flaps, and that while the rate of local complications is greater than non-irradiated, and non-ORN case-matched controls, the free flap survival rate compares favourably.

Management of an aggressive giant cell granuloma of the mandible with denosumab: a case report.

The management of giant cell granulomas is challenging, and aggressive lesions have a high tendency to recur after enucleation alone. Based on assumptions regarding cell type and receptors, multiple pharmacological adjuncts have been used to manage them. We describe the use of denosumab, which was successfully used as a single method of treatment, suggesting that it may be a viable alternative or adjunct to operation on giant cell granulomas of the jaws.

Orthognathic surgery in Melnick-Needles syndrome: a review of the literature and report of two siblings.

Melnick-Needles syndrome (MNS) is a rare congenital X-linked dominant skeletal dysplasia, characterized by exophthalmos, a prominent forehead, and mandibular hypoplasia and retrognathism. Dental features may include anodontia, hypodontia, or oligodontia. Increased collagen content, unpredictable collagen synthesis, and abnormal bony architecture have raised concerns regarding bone splitting intraoperatively and bone healing postoperatively. This report describes the cases of two sisters with MNS, who successfully underwent orthognathic surgery consisting of bilateral mandibular ramus osteotomies combined with advancement genioplasty and iliac crest bone grafting, to correct the classical MNS facial deformity of mandibular retrognathia.

Buccal mucosa urethroplasty: a 10-year retrospective review of maxillofacial and urological outcomes.

BACKGROUND: Reconstruction of a urethral stricture poses a difficult surgical problem. Anastomotic repair remains the gold standard. Strictures longer than 2 cm may require substitution urethroplasty. This is a retrospective review of all patients who underwent urethral reconstruction with an autologous free buccal mucosa graft at a Regional hospital between 1998 and 2009. METHODS: Variables recorded included; demographics: patient gender/age; follow-up period. Urology: pre-operative diagnosis/aetiology; presenting complaint; previous urological surgery, pre-operative retrograde urethrogram, stricture length, graft size, operative time/blood loss, morbidity, complications. Maxillofacial: pre-/post-operative inter-incisal opening, patency of Stenson's parotid duct, ipsilateral parotid swelling, sensory nerve deficit. RESULTS: A total of eight male patients were included. Mean age was 33 years. Two patients had one-stage dorsal onlay urethroplasty, and the remaining six had a two-stage BMG urethroplasty. All patients underwent a urethrogram 20 days post-operatively, which demonstrated no leak, and a good caliber grafted urethra in all cases. A flexible cystoscopy scope was accommodated in all patients 8 weeks post-operatively. Mean follow-up was 42 months. At long-term follow-up, there was no evidence of stricture formation, and all patients were voiding well. There were no long-term intra-oral complications. CONCLUSION: This study suggests that anterior urethral strictures up to 6 cm in length may be predictably and safely managed with buccal mucosal urethroplasty. The buccal mucosa is easy to harvest, and can be used successfully in one- and two-stage grafting procedures. The rate of complications, from both a urological and maxillofacial perspective, in the group of patients studied was low.

Candoxatril, an orally active neutral endopeptidase inhibitor, raises plasma atrial natriuretic factor and is natriuretic in essential hypertension.

OBJECTIVE: Candoxatril (UK79,300) is an orally available inhibitor of the neutral endopeptidase (E.C.3.4.24.11) which degrades atrial natriuretic factor (ANF). This study was designed to establish initial safety and efficacy data in essential hypertension for this novel class of drug. DESIGN: A prospective, double-blind, placebo-controlled, single-dose comparison of candoxatril with placebo in a crossover manner. Three doses of candoxatril (10, 50 and 200 mg) were used, with four subjects at each dose level. SETTING: The Medical Research Council Blood Pressure Unit, Western Infirmary, Glasgow, UK (a hospital clinical research unit). PATIENTS: Twelve patients with untreated essential hypertension. Diastolic blood pressure was greater than 95 mmHg on three separate occasions before entry to the study. INTERVENTION: Candoxatril or matching placebo was administered orally in the fasting state. Serial measurements of urinary volume and electrolyte excretion were taken (on each hour, urine volume was replaced with an equivalent volume of water by mouth). Blood pressure and heart rate were recorded for 12 h after drug administration and serial blood samples were taken for measurement of plasma ANF and neurohormone concentrations. MAIN OUTCOME MEASURES: Urine volume and electrolyte concentration; blood pressure; heart rate; plasma atrial natriuretic factor. RESULTS: Plasma ANF concentrations rose significantly in all patients within 2 h of candoxatril administration compared with placebo although peak and integrated ANF levels were similar at all three doses. A significant natriuresis was only seen after 200 mg candoxatril, with a greater cumulative urine sodium excretion over 12 h compared with placebo; this was associated with a greater diuresis over 12 h compared with placebo. After a single oral dose of candoxatril, blood pressure and heart rate remained unchanged. CONCLUSIONS: Candoxatril in a single dose caused no adverse effects in essential hypertension. The drug caused a rise in basal ANF levels at all doses, but natriuresis was only seen with the highest dose used. No change in blood pressure was recorded after acute dosing, and the results of chronic studies with this compound are awaited. Oral inhibitors of ANF degradation may have therapeutic potential in cardiovascular disorders.

The Comorbidity Symptom Scale: a combined disease inventory and assessment of symptom severity.

OBJECTIVES: To develop and evaluate a scale to quantify the presence and severity of symptoms arising from comorbid diseases in older people. DESIGN: A validation cohort study of hospital inpatients and outpatients aged 65 years and older. SETTING: A Hospital and community in Northeast England. PARTICIPANTS: Development of the Comorbidity Symptom Scale-Convenience sample of 50 hospital inpatients and outpatients aged 65 years and older. Evaluation of the Comorbidity Symptom Scale- Convenience sample of 183 patients aged 65 years and older either awaiting cataract surgery or attending a geriatric day hospital. MEASUREMENTS: For development of the Comorbidity Symptom Scale, 22 comorbid conditions were identified and incorporated into a questionnaire (the CmSS). Evaluation of the Comorbidity Symptom Scale-Assessments included the CmSS, activities of daily living, perceived health status, and anxiety and depression. RESULTS: A 23-item scale was developed. Reliability of the CmSS was demonstrated by a test-retest correlation coefficient for the total instrument score of r = 0. 87 (P < .001). The CmSS scores correlated with assessments of activities of daily living, perceived health status, and anxiety and depression. CONCLUSIONS: The CmSS is a simple interviewer-administered tool for use in older people and provides an objective measure of the presence of comorbid disease and the patient's perception of severity of associated symptoms.

Measuring visual symptoms in British cataract patients: the cataract symptom scale.

AIMS: To develop and validate a scale for the measurement of visual symptoms and functional disability due to cataract in older UK residents. METHODS: In depth semistructured interviews were undertaken with 44 consecutive patients awaiting cataract surgery. Patients were asked to describe visual symptoms and problems with social functioning which were then incorporated into a questionnaire, the cataract symptom scale (CSS). The CSS was further examined in a cohort of 118 consecutive cataract patients awaiting surgery. Further assessments in these patients included visual acuity, visual function using an existing scale (the VF-14), activities of daily living, perceived health status, anxiety and depression, and a global assessment of how much patients felt their visual symptoms affected their daily life. RESULTS: A 15 item scale was derived which was simple to administer to older patients and had a high internal consistency. The test-retest correlation coefficient for the total instrument score was r = 0.91 (p<0.0001). The CSS correlated well with the VF-14 and to a lesser extent with visual acuity in the better eye, activities of daily living, perceived health status, anxiety and depression, and the patients' global assessment of visual symptoms. CONCLUSION: The CSS provides information regarding the symptomatic and functional status of older cataract patients resident in the UK which cannot be obtained by measurement of visual acuity alone.

Treatment of post-stroke hypertension. A practical guide.

Cerebrovascular disease is a common cause of morbidity and mortality, especially in the elderly. Treatment of hypertension is effective in the primary prevention of stroke. Hypertension is seen in 80% of acute stroke patients but, by the tenth day after admission to hospital, only one-third are still hypertensive. The clinical significance of post-stroke hypertension is uncertain and its management is a contentious issue. In this article we review current evidence regarding the risks and benefits of the treatment of post-stroke hypertension. The pathophysiology of post-stroke hypertension is described in relation to autoregulation of cerebral blood flow after cerebral infarction or haemorrhage. In the absence of clinical trial data, recommendations for early treatment of post-stroke hypertension are based on a review of expert opinion that immediate, controlled lowering of blood pressure after acute stroke is required only in defined situations such as hypertensive encephalopathy or aortic dissection. There are no reliable data regarding the comparative effects of different hypotensive agents after acute stroke; short-acting vasodilator drugs are recommended if treatment is essential. The benefits of hypotensive therapy in secondary prevention of recurrent stroke are uncertain but the results of large clinical trials in progress should provide helpful guidelines for clinical practice.

Mechanism for the ethanol-dependent heat-induced dissociation of casein micelles.

An explanation as to how casein micelles dissociate when heated in the presence of ethanol is presented. Dissociation of casein micelles in milk-ethanol mixtures was studied using (1)H NMR, and the effects of addition of CaCl(2), NaCl, or EDTA or alteration of milk pH on this dissociation were studied. It is proposed that at low temperatures, ethanol reduces the solvent quality of milk serum, but above a critical temperature (approximately 30 degrees C in a 35% ethanol solution), ethanol enhances solvent quality and dissociates the casein micelles. Ethanol reduced protein hydrophobicity and increased the pK(a) value of phosphoserine, effects that are likely to be significant in the dissociating effect of ethanol at elevated temperatures.

Ethanol-dependent heat-induced dissociation of casein micelles.

The dissociation of casein micelles when heated to approximately 65 degrees C in the presence of ethanol [1:1 mixture (v/v) of milk and 65% (w/w) aqueous ethanol] was investigated using L* values and transmission measurements. Mixtures of milk and ethanol became transparent on heating, which suggests dissociation of casein micelles. Results of experiments using confocal laser scanning microscopy, light scattering (static and dynamic), and dialysis to examine the changes of milk during heating in the presence of ethanol supported the assertion that such treatments result in dissociation of casein micelles, as did studies of model beta-casein micellar systems.

Association behavior of beta-casein.

The association behavior of beta-casein, a protein with a distinct amphipathic character, was studied. beta-Casein exhibits markedly temperature-dependent association behavior; at low temperatures (<10-15 degrees C), monomers predominate, but as the temperature is increased, monomers associate, via hydrophobic bonding, into micelles. beta-Casein micelles have a hydrodynamic radius of approximately 12 nm, a radius of gyration of approximately 8.3 nm, and an interaction radius of approximately 15 nm. These data are fully consistent with a previous fluffy particle. The association behavior of beta-casein is also strongly affected by concentration and solvent quality. At low concentrations beta-casein exhibits a critical micelle concentration (CMC) of approximately 0.05%, w/v, at 40 degrees C. In the presence of 6 M urea the temperature dependence of beta-casein's association behavior is eliminated, leaving monomers predominantly. Temperature-dependent transformations in micelle morphology can be explained by changes in solvent quality, i.e., the temperature-protein hydrophobicity and temperature-voluminosity profiles of beta-casein. The results obtained are consistent with the shell model as developed by Kegeles, in which a distribution of micelle sizes is formed. They contrast with the traditional description of the micellization of beta-casein by a two-state model or by the closed-association model, i.e., monomers if micelles.

Lateral sinus thrombosis: a problem still with us.

Lateral sinus thrombosis is now a rare complication of ear disease in the developed world, since the advent of the widespread use of antibiotics. The classic picture is often modified by previous antibiotic treatment making diagnosis and management difficult. Lack of familiarity with this condition amongst present day otologists may lead to late diagnosis and treatment. We review three cases that we have managed recently and compare their clinical courses with the classic description of the disease.

Eyelid gold weights in the management of facial palsy.

We reviewed our experiences with 20 patients with established facial palsy who had a total of 24 gold weights inserted. All patients had corneal symptoms: ulceration, exposure keratitis or discomfort abolished. Functional improvement i.e. reduction of lagophthalamos and restoration of the blink reflex was good in our opinion and that of the patients in all cases. Dissatisfaction with the cosmetic result was expressed by two patients due to the prominence of the weight under the thin eyelid skin. Three patients had to have the weight replaced because it was too light. Two patients had their weights removed because of recurrent eyelid infections. In two patients the weights were removed as they had migrated over the tarsal rim. In one of these patients the weight was replaced immediately in the appropriate position, in the other it was not replaced as dissatisfaction had been expressed due to the bulky appearance of the weight under the eyelid skin.

Congenital subglottic fibromatosis.

Benign tracheal tumours are uncommon in adults and rare in children. According to several extensive reviews, fibromas are the second most common benign tumour to occur in the trachea. (Gilbert et al., 1949, 1953). In our review of the literature, 197 adult cases of fibromas have been reported and 23 in children. However only one previous report of a congenital subglottic fibroma exists. (Tsui and Lore 1975). No previous case with a late onset vocal cord palsy has been reported.

Paradoxical vocal cord motion: an unusual cause of stridor.

Stridor due to obstructive causes is relatively common. Functional airway obstruction with paradoxical vocal cord motion is uncommon. Only 12 cases have been reported in the literature in the past 15 years. The majority were young female patients. We have recently encountered two cases. Lack of awareness of this condition caused several problems in management.

The role of surgery in tuberculous mastoiditis: appropriate chemotherapy is not always enough.

We present a case of tuberculous otitis media in which a facial palsy occurred after the start of appropriate chemotherapy. To our knowledge this circumstance has not been described previously. It has been argued that radical surgery is completely unnecessary if chemotherapy is commenced early in the disease. We would suggest that this is not always the case, and would advocate a more measured approach.