Health-related quality of life, functional outcomes, and complications after sentinel lymph node biopsy and elective neck dissection in early oral cancer: A systematic review.

BACKGROUND: Elective neck dissection improves survival in early oral cancer. Sentinel lymph node biopsy may also do this with less morbidity. This systematic review compared health-related quality of life, functional outcomes, and complications after sentinel lymph node biopsy and elective neck dissection in early oral cancer. METHODS: PRISMA guidelines were followed. Thirteen studies met inclusion criteria. RESULTS: Results favoring sentinel lymph node biopsy were found in complications, scar length and appearance, length of hospital stay, time to drain removal, and objective shoulder measures at timepoints up to 12 months. Where differences in health-related quality of life were found, methodological issues make their clinical significance questionable. CONCLUSIONS: Sentinel lymph node biopsy was associated with fewer complications and statistically better outcomes in a number of physical measures. There is as yet no strong evidence to suggest it is associated with better health-related quality of life outcomes. While a number of health-related quality of life outcome measures show promise, their interpretation is hampered by methodological concerns. Further rigorous research is required to address this.

The use of steroids in cervicofacial infections in UK OMFS departments: a Maxillofacial Surgery Trainees Research Collaborative (MTReC) study.

INTRODUCTION: Defining current inpatient management of cervicofacial infections is key to identifying strategies to optimise care. Steroid use is beneficial in peritonsillar and orbital abscess, but there are few studies of steroid use in odontogenic cervicofacial infections. Our previous research identified widespread variation in practice, necessitating a national audit to define current practice. METHODS: A multicentre, trainee-led snapshot audit was carried out across 25 hospitals in the UK. Information recorded included demographic features, presentation, surgical and medical management, and steroid administration. RESULTS: One thousand two admissions were recorded. Fifty-five percent were male, with mean age 37.3 years (range 0-94 years). Steroids were administered to 357 patients (36%), 159 of whom received steroids on admission, and 254 peri-operatively. Patients who were prescribed steroids had significantly higher white cell count (12.4 vs 11.5), CRP (79.5 vs 57) and heart rate (94 vs 88) on admission. Justifications given for administration included swelling (74), dysphagia (21), and airway compromise (7). Three patients (0.8%) reported steroid-related side effects. CONCLUSIONS: This study uses the largest recorded cohort of cervicofacial infections to define current inpatient steroid administration. Our results suggest that steroids are targeted towards the most compromised 1/3 of patients. The incidence of steroid-related side effects was low. Defining the characteristics of patients currently receiving steroids will aid in determining whether steroid administration is an effective adjunct in treating odontogenic cervicofacial infection.

Dental implants and risk of bleeding in patients on oral anticoagulants: a systematic review and meta-analysis.

BACKGROUND: Dental implant placement is safe and predictable, yet optimal management of anticoagulated patients remains controversial. Whilst cessation of anticoagulation pre-operatively should decrease risks of bleeding, risk of thrombosis increases. We aim to define risk of bleeding in patients on oral anticoagulation who are undergoing dental implant placement, in order to establish best management. METHODS: This systematic review is registered with the National Institute for Health Research (NIHR) PROSPERO database (Registration No: CRD42021233929). We performed a systematic review as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Studies were identified using an agreed search strategy within the OVID Gateway (this included Pubmed, MEDLINE, Cochrane Collaborative). Studies assessing bleeding complications in patients who were undergoing dental implant placement were selected. The primary outcome was bleeding events in anticoagulated patients undergoing dental implant placement. Secondary outcomes included any complication requiring further intervention. RESULTS: We identified 182 studies through screening, and after review of titles and abstracts reduced this to 8 studies. In these studies, 1467 participants received at least 2366 implants. Studies were analysed for quality using the ROBINS-I risk of bias tool. Four studies were retrospective case reviews, and four were prospective reviews, three of which also blinded the operator to anticoagulation status. There was significant heterogeneity between the included studies. Meta-analysis showed an increased risk of bleeding (RR, 2.30; 95% CI, 1.25-4.24 p = 0.37 I = 7%) when implants were placed in the presence of anticoagulation however these were not clinically significant haemorrhagic events. CONCLUSION: The continuation of anticoagulants peri-operatively during dental implant surgery does increase the risk of clinically non-significant peri- and post-operative bleeding. Dental implant surgery encompasses a broad spectrum of procedures ranging from minor to more invasive surgery with simple local haemostatic measures mitigating the risk of bleeding. The decision to discontinue anticoagulants prior to dental implant surgery must consider patient and surgical factors with the clinician undertaking a risk-balance assessment.

Gender differences in patients with severe dental infections presenting to hospital.

Introduction Gender differences have been documented in prevalence and morbidity of caries, gingivitis and oral health, but not previously in cervicofacial infection. Identification and minimisation of gender inequalities is a World Health Organisation priority, and there are physiological, behavioural and cultural reasons to suspect that sex and gender differences may be present.Methods Analysis was carried out of the MTReC National Snapshot audit of cervicofacial infections. This database was created by oral and maxillofacial surgery trainees in 2017 and records over 400 variables in 1,002 individual patients admitted to hospital with severe odontogenic infection.Results Records were available for 1,002 patients with cervicofacial infection (456 females and 546 males). There were significant differences between recorded gender in those presenting with airway compromise (male 7% vs female 2%, p = 0.001), severe inflammatory response syndrome (male 60% vs female 39%, p = 0.007) and requirement for awake fibre-optic intubation on admission (male 4% vs female 1%, p = 0.014).Discussion These results suggest that male patients access healthcare later in their disease than female patients, and with more severe systemic compromise. This may be due to prevalent cultural and behavioural norms. As equality of access is the responsibility of the administrator, we discuss methods which might improve timely presentation in males with cervicofacial infections.

Brain tissue oxygenation in children diagnosed with brain death.

BACKGROUND: Diagnosing brain death in children is challenging. Guidelines recommend using confirmatory testing to provide ancillary information to support the diagnosis. Brain tissue oxygenation (PbtO(2)) is being increasingly used in the adult neurocritical care for continuous monitoring of the adequacy of brain oxygenation; however, data in pediatrics is limited. Evidence from adult studies suggests that persistent PbtO(2) of 0 mmHg is associated with brain death, but this relationship has not yet been demonstrated in children; therefore, we examined our experience with PbtO(2) monitoring and brain death in children with acute neurological pathology. METHODS: We retrospectively reviewed patient records from a prospectively maintained database of 85 children who were ventilated for coma due to acute neurological injury and who received intracerebral monitoring. RESULTS: We identified five children who had suffered brain death while being monitored. PbtO(2) had decreased to 0 mmHg in all five children at the time of brain death diagnosis. In contrast, PbtO(2) in patients, who did not develop brain death, never decreased to 0 mmHg. We review the benefits and drawbacks of using brain tissue oxygenation as ancillary information in diagnosing brain death in children. CONCLUSIONS: Preliminary data from this study suggest that PbtO(2) decreases to 0 mmHg when brain death occurs in children. Further study is needed to determine the limitations, and the sensitivity and specificity of this finding in a larger group of children.

Immediate movement history influences reach-to-grasp action selection in children and adults.

Action selection is subject to many biases. Immediate movement history is one such bias seen in young infants. Is this bias strong enough to affect adult behavior? Adult participants reached and grasped a cylinder positioned to require either pronation or supination of the hand. Successive cylinder positions changed either randomly or systematically between trials. Random positioning led to optimized economy of movement. In contrast, systematic changes in position biased action selection toward previously selected actions at the expense of movement economy. Thus, one switches to a new movement only when the savings outweigh the costs of the switch. Immediate movement history had an even larger influence on children aged 7-15 years. This suggests that switching costs are greater in children, which is consistent with their reduced grasping experience. The presence of this effect in adults suggests that immediate movement history exerts a more widespread and pervasive influence on patterns of action selection than researchers had previously recognized.

Designing for Safety: Implications of a Fifteen Year Review of Swallowed and Aspirated Dentures.

OBJECTIVES: Dentures are worn by around 20% of the population, yet if they become displaced they may enter the gastrointestinal or respiratory system, sometimes with grave consequences. The aim of this study was to review recent published literature in order to identify the epidemiology of patients and characteristics of swallowed and aspirated dental prostheses, and propose strategies to minimise these risks. MATERIAL AND METHODS: A fifteen year retrospective of published case series and case reports was carried out. Photographs, radiographs and descriptions of the dental prostheses were gathered, as well as the patient's presenting complaint, the anatomical site where the denture was caught and the procedure required to remove the denture. RESULTS: Ninety one separate events of swallowed or aspirated dentures were identified from 83 case reports and series from 28 countries. Average age was 55 years, and these were 74% male. Photographs were retrieved for 49 of these dentures. Clasps were present in 25 of the dentures. There was no significant difference between clasped and unclasped dentures for perforation rates, need for open surgery and spontaneously passed dentures. CONCLUSIONS: We discuss the implications of this study regarding denture designs, specifically the importance of using a radiopaque acrylic, using clasps when required even if there is a risk of aspiration, advising patients to return if a denture is loose or damaged, and finally that all patients who wear a denture are at risk of aspiration and swallowing events, and associated morbidity and mortality.

Should we add smells in simulation training? A systematic review of smells in healthcare-related simulation training.

Olfactory stimuli are rarely used in healthcare-related simulation training. Their addition may improve simulator validity, biographical memory formation and coping mechanisms for exposure to strong malodours. Some military simulators already employ smells in simulation training, and the technology and principles may be used to cross over into medical simulation training. We set out to determine if there is evidence to suggest that smell should be routinely incorporated into medical simulation training. We carried out a systematic review of the literature relating to use of olfactory stimuli in medical simulation training, and identified 5 relevant papers. 3 were experimental studies and 2 were observational studies. The results of the experimental studies were mixed, though there were some indications that the use of a clinically relevant smell instead of a congruent background smell may be more effective. We discuss the benefits of the inclusion of smell in simulation training and identify that there are currently few high-quality studies addressing the use of smell in medical simulation training.

Demographics and management of dog bite victims at a level two hospital in KwaZulu-Natal.

INTRODUCTION: Dog bites are a significant cause of morbidity and mortality worldwide, particularly where rabies is endemic. There is also a significant financial burden attached to prophylactic treatment to diminish the risk of rabies infection. KwaZulu-Natal (KZN) has a high incidence of human rabies yet little is known about the demographics of dog bites in the province. OBJECTIVES: To analyse the demographics of dog bites in Northern KZN. METHODS: Records of all dog bites presenting to the main referral hospital in Northern KZN between August 2007 and September 2011 were analysed. RESULTS: We collected data for 821 instances of dog bite. Male children aged 6 - 10 years are most likely to present with dog bites, while women >40 years are more likely to present than men in the same age bracket. Whilst initial vaccine administration is high (98%) with all grades of bite, only 82% of grade 3 bites receive immunoglobulin. CONCLUSION: Our results correlate well with two large studies of the demographics of dog bites, but are the first to show a reverse in male preponderance of presentations above the age of 40 years. Reasons for low rates of immunoglobulin administration in grade 3 bites are discussed. Finally, methods are suggested to improve data collection and the care of patients presenting with dog bites.

A test of motor (not executive) planning in developmental coordination disorder and autism.

Grip selection tasks have been used to test "planning" in both autism and developmental coordination disorder (DCD). We differentiate between motor and executive planning and present a modified motor planning task. Participants grasped a cylinder in 1 of 2 orientations before turning it clockwise or anticlockwise. The rotation resulted in a comfortable final posture at the cost of a harder initial reaching action on 50% of trials. We hypothesized that grip selection would be dominated by motoric developmental status. Adults were always biased towards a comfortable end-state with their dominant hand, but occasionally ended uncomfortably with their nondominant hand. Most 9- to 14-year-olds with and without autism also showed this "end-state comfort" bias but only 50% of 5- to 8-year-olds. In contrast, children with DCD were biased towards selecting the simplest initial movement. Our results are best understood in terms of motor planning, with selection of an easier initial grip resulting from poor reach-to-grasp control rather than an executive planning deficit. The absence of differences between autism and controls may reflect the low demand this particular task places on executive planning.