Virtual Surgical Guidance Improves Quality of Life Following Scapular Free-Flap Reconstruction of Maxillary Defects.

BACKGROUND: The best approach to maxillary reconstruction with negative impact on the patient's quality of life (QOL) remains the subject of debate. PURPOSE: This study was designed to evaluate the QOL outcomes following maxillary reconstruction using a scapular-free flap, with and without the computer-aided design and computer-aided manufacturing (CAD/CAM) technique. STUDY DESIGN, SETTING, SAMPLE: A prospective randomized controlled clinical trial was performed following the CONSORT checklist. To be included, patients suffering from maxillary defects without previous surgery or lymph node involvement were selected. Patients with poor oncological prognosis, deficient performance status, preoperative chemotherapy, or radiotherapy, besides vascular contraindications, were excluded. PREDICTOR VARIABLE: The predictor variable was the reconstruction technique, grouped into two equal categories. Patients were randomly assigned to reconstruction with a scapular-free flap, with the control group not utilizing a guide and the study group utilizing a CAD/CAM-customized guide. MAIN OUTCOME VARIABLE: The primary outcome variable was the various domains of QOL, measured using the University of Washington Quality of Life score, 12 months after reconstruction. COVARIATES: Age; sex; scapular flap side; and maxillary defect tumour type, histopathology, side, length, class, sagittal, and axial differential areas were considered. ANALYSES: Shapiro-Wilk and Kolmogorov-Smirnov tests were performed for normality. For comparisons between the two groups, Student's t-test and Mann-Whitney test were used. The category variables were compared using the χ2 test. P ≤ .05 was considered statistically significant. RESULTS: The sample was composed of twenty-two eligible patients, eleven in each group. The mean age of the control group was (50.09 ± 17.14) years, and 45.45% were male, while in the study group, the mean age was (48.36 ± 14.14) years, with 36.36% male. All the patients were evaluated, showing statistically significant differences between control and study groups in terms of pain, appearance, chewing, swallowing, speech, and shoulder (P ≤ .05), indicating that the scapular-free flap with a CAD/CAM osteotomy guide had improved the patient's QOL. CONCLUSION AND RELEVANCE: The findings of this study indicate that virtual surgical planning with a CAD/CAM customized osteotomy guide using a scapular-free flap can improve QOL in maxillary reconstruction in terms of pain, appearance, chewing and swallowing food, pronouncing words, and shoulder QOL outcomes.

Aesthetic Reconstruction of Onco-surgical Mandibular Defects Using Free Fibular Flap with and without CAD/CAM Customized Osteotomy Guide: A Randomized Controlled Clinical Trial.

BACKGROUND: Reconstruction of mandibular defects following ablative surgery remains a challenge even for experienced surgeons. Virtual planning and guided surgery, including computer-aided design/computer-aided manufacturing (CAD/CAM), afford optimized ways by which to plan complex surgery. This study aimed to evaluate and compare aesthetic outcome and surgical efficiency of free fibular flap (FFF) with and without CAD/CAM customized osteotomy guide (COG) for reconstruction of onco-surgical mandibular defects. METHODS: Twenty-two patients indicated for segmental mandibulectomy were randomly assigned to either CAD/CAM with COG group or that without COG- Model based reconstruction (MB group) at a 1:1 ratio. Aesthetic outcomes were evaluated by means of morphometric assessment and comparison for each differential area (DAr) and angle (DAn) in the affected side to the contralateral side of the mandible using computerized digital imaging analysis (CDIA) based on the post-operative 3D CT-scan. Subjective evaluation was performed using the Visual Analogue Scale (VAS) and Patient's Satisfaction Score (PSS). Surgical efficiency was a secondary outcome and evaluated as total operative time and ischemia time. RESULTS: The mean sagittal DAr was significantly lower in the COG group (277.28 ± 127.05 vs. 398.67 ± 139.10 mm2, P = 0.045). Although there was an improvement in the axial DAr (147.61 ± 55.42 vs. 183.68 ± 72.85 mm2), the difference was not statistically significant (P = 0.206). The mean differences (Δ) in both sagittal and coronal DAn were significantly lower in the COG group than in the MB group (6.11 ± 3.46 and 1.77 ± 1.12° vs. 9.53 ± 4.17 and 3.44 ± 2.34°), respectively. There were no statistically significant differences in the axial DAn between the two groups (P = 0.386). The PSS was significantly higher in the COG group, reflecting better aesthetic satisfaction than in the MB group (P = 0.041). The total operation and ischemia time were significantly shorter in favor of the COG group with a mean of (562.91 ± 51.22, 97.55 ± 16.80 min vs. 663.55 ± 53.43, 172.45 ± 21.87 min), respectively. CONCLUSION: The CAD/CAM with COG is more reliable and highly valuable in enhancing aesthetic outcomes and surgical efficiency of mandibular reconstruction by FFF compared to that without COG (MB reconstruction). TRIAL REGISTRATION: This trial was registered at ClinicalTrials.gov . REGISTRATION NUMBER: NCT03757273. Registration date: 28/11/2018.

Aesthetic reconstruction of onco-surgical maxillary defects using free scapular flap with and without CAD/CAM customized osteotomy guide.

BACKGROUND: Reconstruction of the maxillary defects following tumor ablation remains to be a challenge for surgeons. Virtual surgical planning (VSP), intraoperative cutting guides and stereolithographic models provides the head and neck reconstructive surgeon with powerful tools for complex reconstruction planning. Despite its use in fibular osteocutaneous reconstruction, application to the scapular free flap has not been as widely reported. The aim of this study was to compare aesthetic results and operation time of free scapular flap, with and without computer-aided design and computer-aided manufacturing (CAD/CAM) customized osteotomy guide, for reconstruction of maxillary defects. METHODS: In this prospective randomized controlled clinical trial study, we randomly assigned 22 patients with maxillary defects who were scheduled to undergo maxillary reconstruction with either free scapular flap with CAD/CAM customized osteotomy guide; study group (n = 11) or free scapular flap without CAD/CAM customized osteotomy guide; control group (n = 11). All patients were followed up for 3 months. The aesthetic outcome, operation and ischemic times were evaluated and compared. RESULTS: Aesthetic outcomes were evaluated objectively by means of differential surface area (sagittal and axial) measurement, which showed improved aesthetic outcome (contour symmetry) in the study group with a mean of (241.39 ± 113.74 mm2), compared to patients in control group with a mean of (358.70 ± 143.99 mm2). There were significant differences between the two groups (P < 0.05). Aesthetic outcomes were also evaluated subjectively by means of visual analogue scale (VAS) and patient's satisfaction score (PSS). The postoperative aesthetic appearance was better in the study group with more patients satisfied than that in control group and there were statistically significant differences (P = 0.039). The mean total operative time was 678.81 min and 777.18 min in the study group and control group respectively (P < 0.05) and the mean ischemia time was 133.18 min and 195.72 min for study group and control group respectively (P < 0.05). The ischemia time and total operative time were shorter in the study group compared to those in the control group and there were no flap losses in both groups. CONCLUSION: The use of CAD/CAM prefabricated cutting guides facilitates scapular flap molding and placement, minimizes ischemic time and operating time as well as improves aesthetic outcomes. Trial registration This trial was registered at ClinicalTrials.gov. REGISTRATION NUMBER: NCT03757286. Registration date: 28/11/2018.

The hidden hazardous effects of stevia and sucralose consumption in male and female albino mice in comparison to sucrose.

Replacing sucrose with non-caloric sweeteners is an approach to avoid overweight and diabetes development. Non-caloric sweeteners are classified into either artificial as sucralose or natural as stevia. Both of them have been approved by FDA, but the effects of their chronic consumption are controversial. The present study aimed to evaluate the effects of these two sweeteners, in male and female albino mice, on different blood biochemical parameters, enzymes activities and immunological parameters after 8 and 16 weeks of sweeteners administration. 40.5 mg/ml of sucrose, 5.2 mg/ml of sucralose and 4.2 mg/ml of stevia were dissolved individually in distilled water. Mice were administrated by sweetener's solution for 5 h daily. Male and female mice showed a preference for water consumption with sucralose or stevia. Both of the two sweeteners significantly reduced the hemoglobin level, HCT%, RBCs and WBCs count. After 18 weeks, significant elevations in liver and kidney function enzymes were observed in male and female mice administrated with both non-caloric sweeteners. Histopathological examination in sucralose and stevia administrated groups confirmed the biochemical results; where it revealed a severe damage in liver and kidney sections. While, sucrose administration elevated, only, the levels of ALT, AST and cholesterol in male mice. A vigorous elevation in levels of different immunoglobulin (IgG, IgE and IgA) and pro-inflammatory cytokines (IL-6 and -8), that was accompanied by a significant reduction in level of anti-inflammatory cytokine IL-10, was observed in male and female mice groups administrated with sucralose or stevia. On the other hand, sucrose administration led to an elevation in IgA and reduction in IL-10 levels.

Repair Bond Strength of Aged Silorane-based Composite Using Intermediate Adhesive Systems Based on Different Monomers.

PURPOSE: To investigate the effect of pre-repair aging periods and intermediate adhesive systems based on different monomers on the repair bond strength of silorane-based resin composite. MATERIALS AND METHODS: A total of 32 Filtek P90 (3M ESPE) substrate specimens (4 mm diameter and 4 mm height) were made. Substrate specimens were grouped according to the pre-repair time periods into four groups (n = 8/group): 15 to 30 min, 24 h, 1 month, and 3 months. All substrate specimens were ground flat using a diamond stone and were etched using Scotchbond phosphoric acid etchant (3M ESPE). The specimens of each pre-repair time period were equally distributed among the two repair groups, using either silorane-based (P90 System Adhesive) or acrylamide-based (AdheSE One F, Ivoclar Vivadent) intermediate adhesive systems. Specimens of P90 System adhesive received Filtek P90 as the repair resin composite, and Tetric N-Ceram (Ivoclar Vivadent) was used with AdheSE One F specimens. Additional specimens were made from the repair resin composite materials to study the cohesive strength. Specimens were sliced into sticks (0.6 ± 0.01 mm2) for microtensile bond strength testing (µTBS). Modes of failure were determined. RESULTS: Two-way ANOVA with repeated measures revealed no significant effect for the pre-repair aging periods, intermediate adhesive systems based on different monomers, or their interaction on repair bond strength of silorane-based resin composite. CONCLUSION: Up to 3 months of pre-aging the repaired silorane-based resin composite had no negative effect on its repair bond strength, even when an intermediate adhesive system based on a different monomer (acrylamide) was used.

Transaxillary thoracodorsal artery perforator flap: a versatile new technique for hypopharyngeal reconstruction.

INTRODUCTION: Reconstruction of the hypopharynx and cervical esophagus after tumor resection remains a challenging problem. Different techniques of reconstruction have been described for such defects. Although free flap reconstruction, including jejunum and fasciocutaneous flaps, has gained popularity for this complex defect, regional flaps are still in use worldwide. PATIENTS AND METHODS: We present our experience using the pedicled thoracodorsal artery perforator (TDAP) flap whereby only a small cuff of latissimus dorsi muscle around the perforators is harvested. The remaining muscle with its nerve supply is preserved. The flap is delivered to the neck through the cervicoaxillary tunnel. It was used as a complete tube in six patients and with an additional attached skin island for reconstruction of the neck skin in another four patients. RESULTS: A total of 11 TDAP flaps were used for reconstruction in 10 patients. All flaps survived except in one patient who suffered from a complete flap loss. This was salvaged by another TDAP flap from the contralateral side. Partial sloughing of the outer part of the pedicled TDAP occurred in one other patient. Pharyngeal fistulas developed in another two patients and eventually healed spontaneously. All patients resumed an oral diet within 2 weeks except two with fistulas. All patients resumed their shoulder active range of motion within 3 weeks. CONCLUSION: The transaxillary TDAP flap is an ideal technique for hypopharyngeal reconstruction. It offers the advantages of free fasciocutaneous flaps, has a wide arc of rotation, a relatively larger flap dimension, a reliable vascular pedicle, and acceptable donor site morbidity.

Full Bayesian analysis of double seasonal autoregressive models with real applications.

We present a full Bayesian analysis of multiplicative double seasonal autoregressive (DSAR) models in a unified way, considering identification (best subset selection), estimation, and prediction problems. We assume that the DSAR model errors are normally distributed and introduce latent variables for the model lags, and then we embed the DSAR model in a hierarchical Bayes normal mixture structure. By employing the Bernoulli prior for each latent variable and the mixture normal and inverse gamma priors for the DSAR model coefficients and variance, respectively, we derive the full conditional posterior and predictive distributions in closed form. Using these derived conditional posterior and predictive distributions, we present the full Bayesian analysis of DSAR models by proposing the Gibbs sampling algorithm to approximate the posterior and predictive distributions and provide multi-step-ahead predictions. We evaluate the efficiency of the proposed full Bayesian analysis of DSAR models using an extensive simulation study, and we then apply our work to several real-world hourly electricity load time series datasets in 16 European countries.

Micronuclei detection in oral cytologic smear: does it add diagnostic value?

BACKGROUND: Screening and early diagnosis of oral squamous cell carcinoma (OSCC) are directly associated with increased survival rate and improved prognosis. Noninvasive diagnostic tools have been implemented in the early detection as toluidine blue staining, optical imaging, and oral cytology. This study aimed to assess and compare the presence of micronuclei (MN) in oral exfoliative cytology of healthy controls, subjects exposed to high-risk factors for oral cancer, subjects with oral potentially malignant lesions (OPMLs), and those with malignant oral lesions. SUBJECTS AND METHODS: A total number of 92 subjects were divided into 46 healthy controls with no oral mucosal lesions (23 with no evidence of cancer risk factors and 23 with cancer risk factors), 23 with OPMLs and 23 with oral malignant lesions. All the 92 participants were subjected to cytological sampling for detection of MN. The final diagnosis of the oral lesions was confirmed by the histopathological picture and compared to the cytological results. RESULTS: The results showed that the diagnostic accuracy of MN was higher in OPMLs group (95.2%). The sensitivity of MN test in malignant group was much lower (52.2%); however, all the cytological criteria of malignancy were markedly detected as compared to the OPMLs group. CONCLUSIONS: Conventional oral cytology supported by MN is highly beneficial as adjunctive tool in the screening for early detection of dysplastic oral lesions.

Pectoralis Major in Salvage Total Laryngectomy after Irradiation: Morbidity, Mortality, Functional, and Oncological Results in a Referral Center in Egypt.

BACKGROUND: Nonsurgical organ preservation protocols have seen a large diffusion worldwide in the last decades. Their oncological and functional effectiveness in a real-world setting has been recently questioned because of the high morbidity of salvage procedures. The aim of this study is to review the outcomes of postirradiation salvage total laryngectomy (STL) and reconstruction with pectoralis major flap. METHODS: This retrospective observational study included 37 cases of STL in the period from January 2015 to December 2021. Data for each patient were extracted from the hospital information system and reviewed. RESULTS: The 3-year overall and disease-specific survival are, respectively, 28% and 51%. Only seven recurrences after salvage surgery were recorded and all of them died from the disease. The other 14 deaths derived from comorbidities, with diabetes being the most significant predictive parameter for overall survival. Also, lower postoperative albumin levels were associated with a higher risk of death. CONCLUSIONS: Overall survival after STL and reconstruction with PMMF is low but most deaths are due to comorbidities and not to cancer progression or recurrence.

Endovascular management of early hepatic artery thrombosis after living donor liver transplantation.

To study the feasibility of endovascular management of early hepatic artery thrombosis (HAT) after living-donor liver transplantation (LDLT) and to clarify its role as a less invasive alternative to open surgery. A retrospective review of 360 recipients who underwent LDLT. Early HAT developed in 13 cases (3.6%). Diagnosis was performed using Doppler, CT angiography, and digital subtraction angiography. Intra-arterial thrombolysis (IAT) was performed using streptokinase or tPA. In case of underlying stricture, PTA was attempted. If the artery did not recanalize, continuous infusion was performed and monitored using Doppler US. Initial surgical revascularization was successful in 2/13 cases. IAT was performed in 11/13 cases. The initial success rate was 81.8% (9/11), the failure rate was 18.2% (2/11). Rebound thrombosis developed in 33.3% (3/9). Hemorrhage developed after IAT in 2/11 cases (18.2%). Definite endovascular treatment of HAT was achieved in 6/11 cases (54.5%) and definite treatment (surgical, endovascular or combined) in 9/13 cases (69%). (Follow-up 4 months-4 years). Endovascular management of early HAT after LDLT is a feasible and reliable alternative to open surgery. It plays a role as a less invasive approach with definite endovascular treatment rate of 54.5%.

Management of Adenoid Cystic Carcinoma of the Head and Neck: Experience of the National Cancer Institute, Egypt.

PURPOSE: This study presents the experience of the National Cancer Institute, Cairo University, in diagnosis and management of ACC of the head and neck. METHODS: This is a retrospective review of 57 patients with ACC managed during the period from January 2011 to January 2016. Data about the characteristics and management of the disease were recorded. All patients were followed up to detect the development of local recurrence and distant metastasis and their management. RESULTS: The mean age was 45.5 ± 15.1, with a femaleto-male ratio of 1.5:1. The minor salivary glands were affected in 61.4% of cases. Four patients (7%) were metastatic at presentation. The main presenting symptom was swelling, followed by pain. Surgical resection was performed in 48 patients (84.2%) followed by adjuvant radiotherapy in 36 of them. Four patients received radical radiotherapy. Treatment failed in 3 patients. Recurrences were recorded in 21 out of the 50 cured patients; 9 had locoregional recurrence, 9 had distant metastases, and 3 had both. The overall survival (OS) and disease-free survival (DFS) at three years were 79% and 57.1%, respectively. Surgical resection improved OS (p<0.001). Advanced T-stage, lymph node invasion, solid tumors, close or positive margins worsened OS. Adjuvant radiotherapy was associated with better DFS (p = 0.003), while solid tumors were associated with worse DFS. CONCLUSION: Despite aggressive management with radical surgery and adjuvant radiotherapy, recurrence affects 42% of the patients within three years. Patients with unresectable tumors have a poor prognosis. Adjuvant radiotherapy improves DFS but not OS.

Effect of local application of platelet-rich fibrin scaffold loaded with simvastatin on peri-implant bone changes.

Aim: The purpose of this study was to compare the effects of autologous platelet-rich fibrin (PRF) alone and PRF loaded with SIM on peri-implant bone changes and implant stability in patients undergoing implant rehabilitation. Settings and Design: This was a nonrandomized controlled split-mouth study. Materials and Methods: The study included 8 males between the ages of 45 and 60 years. Each patient received two implants, one on each side of the arch. One side was treated with PRF alone and the other side with PRF loaded with SIM at the time of osteotomy. A cone-beam computed tomography was used to evaluate bone changes around the insertion of implant sites at 3, 6, and 12 months postoperatively. The secondary outcome included measuring implant stability using Osstell device at baseline and 3 months postinsertion. To compare groups at different time periods, data were examined using a two-way analysis of variance. Statistical Analysis Used: The results were compared between the groups using a two-way analysis of variance, followed by a post hoc Bonferroni test. To examine total bone changes and stability comparisons between the two groups at the end of the trial, an unpaired t-test was utilized. Results: The mean crestal bone-level changes in the SIM/PRF group were significantly lower than the PRF group, with a mean shift of 0.9788 ± 0.04853 versus 1.356 ± 0.0434, respectively (P < 0.0001). There was no significant difference between the two groups in implant stability. Conclusion: Peri-implant application of SIM/PRF resulted in less bone changes than PRF alone, which may prove to be beneficial for the long-term success of implants. SIM showed promising results in limiting peri-implant bone resorption providing new clinical application for SIM in dental implant rehabilitation.

Value of diffusion MRI versus [18F]FDG PET/CT in detection of cervical nodal metastases in differentiated thyroid cancer patients.

BACKGROUND: In differentiated thyroid cancer (DTC) patients, cervical nodal metastasis is a negative prognostic factor. Preoperative imaging plays an important role in treatment planning for nodal metastasis and recurrence. The aim of the study is to compare the diagnostic performance of the diffusion-weighted magnetic resonance imaging (DW-MRI) and the F-18 flurodeoxyglucose positron emission computed tomography ([18F]FDG PET/CT) in detection of cervical nodal deposits in DTC patients. MATERAL AND METHODS: The study was conducted on 30 patients, each performed both modalities just before the surgery. The gold standard was the pathological specimens with post-operative clinico-radiological follow-up, to assess the diagnostic performance of each modality. RESULTS: Based on pathological and post-operative clinico-radiological follow up data. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV) and accuracy were 84%, 80%, 50%, 95% and 83% for PET/CT compared to 84%, 60%, 42.8%, 91.3% and 80% for DW-MRI. On comparing the diagnostic performance of combined DW-MRI and PET/CT to each modality alone, the sensitivity and NPV were improved to 96% and 80% respectively. CONCLUSIONS: [18F]FDG PET/CT study is a valuable diagnostic modality for the assessment of cervical nodal deposits in DTC patients, surpassing DW-MRI. Combined PET/CT and DW-MRI techniques seemed to have synergistic performance, mainly in terms of sensitivity and NPV, for detection of nodal metastases.

Learning curve and volume outcome relationship of endoscopic trans-oral versus trans-axillary thyroidectomy; A systematic review and meta-analysis.

BACKGROUND: In the modern era, minimally invasive surgery is rapidly evolving and even replacing conventional open techniques in many surgical fields. Thyroidectomy was not an exception, with the introduction of multiple endoscopic thyroidectomy techniques. Trans-oral endoscopic trans-vestibular thyroidectomy (TOT) is a novel technique with promising outcomes. We conducted this meta-analysis to compare surgical outcomes and learning curves for TOT and other endoscopic thyroidectomy techniques. METHODS: A systematic review in PubMed, MEDLINE, and EMBASE databases was conducted searching for publications on TOT versus trans-axillary thyroidectomy (TAT). The primary endpoint was operative (OR) time. Secondary endpoints were number of harvested lymph nodes (LNs), estimated blood loss (EBL), recurrent laryngeal nerve (RLN) injury, hoarseness, seroma, infection, chyle leak, hypocalcemia, hospital length of stay (LOS), and Cost. We also investigated the learning curve for each technique. Leave-out-out analysis, meta-regression, and subgroup analysis were used. Random effect inverse variance method was utilized. RESULTS: Among 3820 retrieved studies, 15 studies (10 unmatched and 5 matched), with 2173 (TOT: 1024(47.12%) and TAT:1149(52.87%)) patients, met the inclusion criteria. The operative time and harvested L. Ns number were higher in TOT versus TAT (standard mean difference (SMD) = 0.72 [95%CI 0.07; 1.37], P = 0.029 and SMD = 0.32 [95%CI 0.02; 0.62], P = 0.036 respectively) while less EBL in TOT versus TAT (SMD = -0.26 [-0.43; -0.09], P = 0.0018). All other outcomes showed no significant difference between both groups. Weighted mean values for TOT and TAT were 158.03 vs 144.97 min for OR time, 6.33 vs 5.16 for harvested LNs, and $5,919.05 vs $6,253.79 for the cost. Statistical significance in learning curve development was noticed ranging between 6 and 15 annual cases. CONCLUSION: Trans-oral thyroidectomy is a safe and reliable technique with outcomes comparable to other endoscopic techniques. It provides better access to the central compartment with a more feasible LN dissection. Improvement in surgical outcomes is expected with growing learning curve and technique mastery.

Re-engineering pre-employment check-up systems: a model for improving health services.

PURPOSE: The purpose of this paper is to develop a model for improving health services provided by the pre-employment medical fitness check-up system affiliated to Egypt's Health Insurance Organization (HIO). DESIGN/METHODOLOGY/APPROACH: Operations research, notably system re-engineering, is used in six randomly selected centers and findings before and after re-engineering are compared. The re-engineering model follows a systems approach, focusing on three areas: structure, process and outcome. The model is based on six main components: electronic booking, standardized check-up processes, protected medical documents, advanced archiving through an electronic content management (ECM) system, infrastructure development, and capacity building. The model originates mainly from customer needs and expectations. FINDINGS: The centers' monthly customer flow increased significantly after re-engineering. The mean time spent per customer cycle improved after re-engineering--18.3 +/- 5.5 minutes as compared to 48.8 +/- 14.5 minutes before. Appointment delay was also significantly decreased from an average 18 to 6.2 days. Both beneficiaries and service providers were significantly more satisfied with the services after re-engineering. The model proves that re-engineering program costs are exceeded by increased revenue. RESEARCH LIMITATIONS/IMPLICATIONS: Re-engineering in this study involved multiple structure and process elements. The literature review did not reveal similar re-engineering healthcare packages. Therefore, each element was compared separately. PRACTICAL IMPLICATIONS: This model is highly recommended for improving service effectiveness and efficiency. ORIGINALITY/VALUE: This research is the first in Egypt to apply the re-engineering approach to public health systems. Developing user-friendly models for service improvement is an added value.

Tracheostomy During the COVID-19 Pandemic: Comparison of International Perioperative Care Protocols and Practices in 26 Countries.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has led to a global surge in critically ill patients requiring invasive mechanical ventilation, some of whom may benefit from tracheostomy. Decisions on if, when, and how to perform tracheostomy in patients with COVID-19 have major implications for patients, clinicians, and hospitals. We investigated the tracheostomy protocols and practices that institutions around the world have put into place in response to the COVID-19 pandemic. DATA SOURCES: Protocols for tracheostomy in patients with severe acute respiratory syndrome coronavirus 2 infection from individual institutions (n = 59) were obtained from the United States and 25 other countries, including data from several low- and middle-income countries, 23 published or society-endorsed protocols, and 36 institutional protocols. REVIEW METHODS: The comparative document analysis involved cross-sectional review of institutional protocols and practices. Data sources were analyzed for timing of tracheostomy, contraindications, preoperative testing, personal protective equipment (PPE), surgical technique, and postoperative management. CONCLUSIONS: Timing of tracheostomy varied from 3 to >21 days, with over 90% of protocols recommending 14 days of intubation prior to tracheostomy. Most protocols advocate delaying tracheostomy until COVID-19 testing was negative. All protocols involved use of N95 or higher PPE. Both open and percutaneous techniques were reported. Timing of tracheostomy changes ranged from 5 to >30 days postoperatively, sometimes contingent on negative COVID-19 test results. IMPLICATIONS FOR PRACTICE: Wide variation exists in tracheostomy protocols, reflecting geographical variation, different resource constraints, and limited data to drive evidence-based care standards. Findings presented herein may provide reference points and a framework for evolving care standards.

The contralateral based submental island flap for reconstruction of tongue and floor of mouth defects: Reliability and oncological outcome.

BACKGROUND: Submental artery island flap (SIF) is a viable alternative to free flaps for selected oral-cavity defects, however, concerns about its oncologic safety still exists. A novel harvesting technique and its outcome is described in here. METHODS: This is a prospective study for patients with lateralized oral tongue and/or floor of mouth (FOM) cancers who undergone reconstruction using pedicled SIF based on contralateral submental vessels (CSIF) following resection. RESULTS: Forty-one patients were included. Twenty-four patients had T2, 13 had T3, and 4 had T1 tumors. The largest flap skin paddle was 15 × 9 cm. One patient sustained complete and five sustained partial flap loss. Three patients developed tongue tethering. Median follow-up was 13.6 months. Locoregional recurrence occurred in 11 patients (26.8%); 6 oral-cavity recurrences (14.6%), 6 ipsilateral, and 1 contralateral neck recurrences (2.4%). CONCLUSION: CSIF is a reliable flap that addresses the oncologic controversy and overcomes the disadvantages of ipsilateral flap.

The extended latissimus dorsi flap option in autologous breast reconstruction: A report of 14 cases and review of the literature.

BACKGROUND: Autologous breast reconstruction using the extended latissimus dorsi flap has been infrequently reported. In the current study, the authors are reporting their own clinical experience with this method. A review of the literature is also discussed. MATERIALS AND METHODS: Over a three year period, 14 patients underwent breast reconstruction using the extended latissimus dorsi (LD) flap. Patients with small to medium sized breasts were selected. The age of the patients ranged from 29 to 42 years with a follow-up period ranging from six to 18 months. The indications, flap-related complications and donor site morbidity and aesthetic results were evaluated. RESULTS: The main indication to use the flap was dorsal donor site preference by patients. The remaining patients were either not suitable for a flap from the abdomen or wished to get pregnant and were offered the dorsal donor site. Neither total nor partial flap loss was recorded but donor site morbidity was mainly due to seroma, which was treated conservatively in all patients, except for one who required surgery. Another two patients suffered from wound breakdown and distal necrosis of the back flaps. Mild contour deformity was also noted on the back of all patients but caused no major concern. Indeed, the overall patient satisfaction was very high. CONCLUSION: The extended LD flap proved to be a good option for autologous breast reconstruction in selected patients. Patients should be warned of the potential for seroma and mild contour back deformity.

Osteosarcoma of the jaw: Challenges in the diagnosis and treatment.

PURPOSE: Osteosarcomas rarely affect jaw bones. Patients are usually older than those who suffer long bone sarcomas, with a rare incidence of metastasis. This is suggestive of a different pattern of behavior compared with long bone sarcomas. This study aimed to present NCI, Cairo University experience in treating patients diagnosed with osteosarcomas of the jaw, including the diagnostic challenges and treatment outcome. PATIENTS AND METHODS: This is a retrospective case series study of all cases of osteosarcomas of mandible and maxilla that were treated at the NCI, in the period between 2006 and 2013. Patients' data, including demographic data, various clinical presentations, results of investigations, treatment modalities performed and outcomes, were collected from hospital records kept in the Biostatistics Department at NCI. RESULTS: Records showed 21 cases of osteosarcoma of the jaw. The mandible was affected in 15 cases, the maxilla in six. Two cases had sun-ray periosteal reactions. Erroneous biopsy results were found in 4 cases compared with final pathology reports of surgical resections. All cases underwent surgical resections, with 8 cases having positive margins. The median follow-up period was 19.3 months (range 0.3-98.0 months). The cumulative disease-free survival (DFS) was 27.5% and the median DFS was 72 months. The cumulative overall survival at end of the study was 77.4%. CONCLUSIONS: Osteosarcoma of the jaw is challenging both to diagnose and manage. This is due to the high incidence of mistakes in biopsy results, rare specific radiological features and difficulties in proper resection due to proximity to vital structures.