Immediate postoperative care on high dependency unit or ward following microvascular free tissue transfer: lessons learnt from a change in practice imposed during the COVID-19 pandemic.

The COVID-19 pandemic resulted in sudden changes to the established practice of using the high dependency unit (HDU) for the first night of postoperative care following microvascular free tissue transfer. Patients were managed instead on the head and neck ward. This retrospective case-note review aimed to report outcomes in consecutive patients treated before and during the pandemic, and to reflect on the implications of ward-based rather than HDU care. A total of 235 patients had free tissue transfer between 3 January 2019 and 25 February 2021: 125 before (lockdown 23 March 2020), and 110 during the pandemic (52 ward-managed and 58 HDU-managed). There were subtle case-mix differences during the pandemic, with 92% of ward-treated patients having oral cancers compared with 64% of HDU patients, and 73% of ward patients having a tracheostomy compared with 40% of HDU patients. Ward patients were less likely to receive electrolyte replacement (45% HDU vs 0% ward) and inotropes (12% HDU vs 2% ward). There were fewer returns to theatre for evacuation of a haematoma or re-anastomosis during the pandemic than there were before it. Other than fewer haematoma complications during the pandemic, the nature of complications was similar. In conclusion, the dramatic changes imposed by the pandemic have shown that the ward is a safe place for patients to be cared for immediately postoperatively, and it alleviates the bed pressures experienced in HDU. Careful case selection and clear criteria are required to identify patients who need the HDU.

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.

Results of flap reconstruction: categorisation to reflect outcomes and process in the management of head and neck defects.

The reporting of the outcomes of flap reconstruction is often based on numerical success rates. Whilst this remains a useful variable with which to measure success, it is limited in its ability to reflect the complex processes involved. The lack of consistency in the categorisation of outcomes of flap reconstruction in the head and neck could potentially lead us to lose the opportunity to fully capture the implications of its success or failure, or both. We propose a classification that moves away from primarily reporting the results of its binary nature, and focuses more on the process of reconstruction, particularly in the head and neck.

Molecular pathogenesis of proliferative verrucous leukoplakia: a systematic review.

Proliferative verrucous leukoplakia (PVL) is a potentially premalignant lesion that undergoes malignant transformation in over 40% of cases. Its clinical homogeneity suggests that a single or a small number of molecular pathogenic pathways may exist. Using the Cochrane protocol for systematic reviews, we have looked at the reported evidence of the molecular aetiology and pathogenesis of PVL and compared it with that of conventional oral epithelial dysplasia (OED). Of the 43 papers studied, 19 met the inclusion criteria including 13 proteins assayed in 344 tissues, and genes investigated were TP53, p14ARF, and p16INK4A. In all studies the research objectives were defined and outcomes were clearly stated. This review has shown that the transformation of PVL does not follow the same pathway as that of OED. There was weak evidence to suggest possible correlations between DNA aneuploidy, loss of heterozygosity at locus 9p21, and specific expression of Mcm (mini chromosome maintenance) protein, to transformation of PVL. To show important or distinct pathways of this condition, further studies are needed to access the somatic genomic alterations that are found in malignancies.

Characteristics of a protocol to collect objective physical activity/sedentary behaviour data in a large study: Seniors USP (understanding sedentary patterns).

The Seniors USP study measured sedentary behaviour (activPAL3, 9 day wear) in older adults. The measurement protocol had three key characteristics: enabling 24-hour wear (monitor location, waterproofing); minimising data loss (reducing monitor failure, staff training, communication); and quality assurance (removal by researcher, confidence about wear). Two monitors were not returned; 91% (n=700) of returned monitors had 7 valid days of data. Sources of data loss included monitor failure (n=11), exclusion after quality assurance (n=5), early removal for skin irritation (n=8) or procedural errors (n=10). Objective measurement of physical activity and sedentary behaviour in large studies requires decisional trade-offs between data quantity (collecting representative data) and utility (derived outcomes that reflect actual behaviour).

Systematic comparative validation of self-report measures of sedentary time against an objective measure of postural sitting (activPAL).

BACKGROUND: Sedentary behaviour is a public health concern that requires surveillance and epidemiological research. For such large scale studies, self-report tools are a pragmatic measurement solution. A large number of self-report tools are currently in use, but few have been validated against an objective measure of sedentary time and there is no comparative information between tools to guide choice or to enable comparison between studies. The aim of this study was to provide a systematic comparison, generalisable to all tools, of the validity of self-report measures of sedentary time against a gold standard sedentary time objective monitor. METHODS: Cross sectional data from three cohorts (N = 700) were used in this validation study. Eighteen self-report measures of sedentary time, based on the TAxonomy of Self-report SB Tools (TASST) framework, were compared against an objective measure of postural sitting (activPAL) to provide information, generalizable to all existing tools, on agreement and precision using Bland-Altman statistics, on criterion validity using Pearson correlation, and on data loss. RESULTS: All self-report measures showed poor accuracy compared with the objective measure of sedentary time, with very wide limits of agreement and poor precision (random error > 2.5 h). Most tools under-reported total sedentary time and demonstrated low correlations with objective data. The type of assessment used by the tool, whether direct, proxy, or a composite measure, influenced the measurement characteristics. Proxy measures (TV time) and single item direct measures using a visual analogue scale to assess the proportion of the day spent sitting, showed the best combination of precision and data loss. The recall period (e.g. previous week) had little influence on measurement characteristics. CONCLUSION: Self-report measures of sedentary time result in large bias, poor precision and low correlation with an objective measure of sedentary time. Choice of tool depends on the research context, design and question. Choice can be guided by this systematic comparative validation and, in the case of population surveillance, it recommends to use a visual analog scale and a 7 day recall period. Comparison between studies and improving population estimates of average sedentary time, is possible with the comparative correction factors provided.

Telehealth and telenursing using simulation for pre-licensure USA students.

An innovative simulation was used to teach pre-licensure USA nursing students about telenursing for screening, assessment, and patient education during a home visit. The students used telepresence technology to deliver nursing care to a homebound geriatric patient. After the simulation, students (N = 73) felt increased confidence with the skills needed to deliver telenursing care and in using telepresence technology. Students reported that they modified and improved their communication in order to adapt to perceived barriers posed by the new technology. As telenursing becomes more prevalent for managing patient care at a distance, nursing programs will need to incorporate educational strategies to reflect this change.

Refining the indications for scapula tip in mandibular reconstruction.

Mandibular reconstruction in osteoradionecrosis or salvage surgery can often be complicated by the lack of suitable recipient vessels in the ipsilateral neck and the associated requirement for significant extraoral skin reconstruction. The scapula tip with its long vascular pedicle and option of a chimeric soft tissue component offers a versatile reconstructive solution in such cases. This article reports four consecutive cases of mandibular reconstruction with poor ipsilateral vascular options and additional soft tissue requirements in which the scapula tip was justified and preferred. The blood supply to the lateral scapula through the circumflex scapular system is well established in the literature and this would be the preferred reconstruction in class I mandibular defects associated with a significant soft tissue requirement. The scapula tip would suit cases where the ipsilateral recipient vessels are compromised, and so justify the potential for mandibular reconstruction with inferior bone stock.

Fibrin sealants in soft tissue surgery of the head and neck: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Fibrin sealants (FS) are commercially available products used in surgical wounds as adjuncts to haemostasis and closure of dead space. The role of FS in soft tissue head and neck surgery has not been established. OBJECTIVES: To assess whether FS improves wound-related outcomes in patients undergoing soft tissue surgery of the head and neck anatomical region that would commonly require a drain. TYPE OF REVIEW: Systematic review and meta-analysis of randomised controlled trials (RCTs). SEARCH STRATEGY: MEDLINE (1946-2016), EMBASE (1974-2016), PubMed (2016), CENTRAL (2016), ClinicalTrials.gov (2016), WHO International Clinical Trials Registry and Platform (2016), Research Gate (2016). EVALUATION METHOD: Two independent reviewers screened and selected studies. Included studies were assessed for risk of bias and data extracted using a predetermined data collection form. RESULTS: Of the 421 studies that were screened, 11 RCTs met the inclusion criteria. There were two RCTs on thyroidectomy, three on "surgery involving neck dissection" (central or lateral), five on rhytidectomy and one on parotidectomy. There was a tendency for FS to reduce "mean total drainage volume" (mean difference -26.86 mL, 95% CI -43.41 to -10.31, I2 =97%, P=.001). Subgroup analysis of thyroidectomy (mean difference -36.36 mL, 95% CI -72.82 to 0.10, I2 =79%, P=.05), "surgery involving neck dissection" (mean difference -33.21 mL, 95% CI -70.01 to 3.59, I2 =94%, P=.08) and rhytidectomy (mean difference -13.79 mL, 95% CI -17.57 to -10.01, I2 =0%, P < .00001) concurred with the overall analysis. There was a suggestion that FS may reduce "mean retention time of drains" by 1.24 days (95% CI -3.32 to 0.85, I2 =99%, P=.25) and "hospital length of stay" by 2.09 days (95% CI -5.18 to 0.99, I2 =97%, P=.18), but this was not statistically significant. There was also a suggestion that FS may protect against adverse events (RR 0.69, 95% CI 0.35 to 1.38, I2 =0%, P=.29) and haematoma/seroma formation (RR 0.49, 95% CI 0.22 to 1.07, I2 =0%, P=0.07). CONCLUSIONS: There was considerable heterogeneity within the RCTs included in this study, thus restricting definitive conclusions. FS has however shown a definite benefit in rhytidectomy and potential benefit in other soft tissue head and neck surgical procedures. Further pragmatic trials are required particularly in the field of lateral neck dissection.

Thoracodorsal artery perforator - scapular flap in oromandibular reconstruction with associated large facial skin defects.

The reconstruction of oromandibular defects associated with extensive loss of external skin is surgically challenging. We describe 2 cases where such defects were reconstructed with a chimeric thoracodorsal artery perforator and scapular (TDAP-Scap) free flap based on the subscapular system. The flap is a reliable option in the reconstruction of through-and-through oromandibular defects.

The determinants of receiving social care in later life in England.

Demographic change and policy changes in social care provision can affect the type of social care support received by older people, whether through informal, formal state or formal paid-for sources. This paper analyses the English Longitudinal Study of Ageing data (wave 4) in order to examine the relationship between demographic and socio-economic characteristics, and the receipt of support from different sources by older people who report difficulty with daily activities. The research outlines three key results with implications for the future organisation of social care for older people. Firstly, the number of instrumental activities of daily living (IADLs) an older person reports having difficulty with, followed by the number of activities of daily living (ADLs) are the strongest determinants of receiving support from any source. Secondly, there are significant gender differences in the factors associated with receiving support from different sources; for example, physical health is a strong determinant of informal support receipt by men, while mental health status is a strong determinant of informal support receipt by women. Finally, the research shows that different kinds of impediments in everyday life are associated with receiving support from different sources. This 'link' between particular types of difficulties and support receipt from particular sources raises questions about the way social care provision can or should be organised in the future.

SERPINE1 and SMA expression at the invasive front predict extracapsular spread and survival in oral squamous cell carcinoma.

BACKGROUND: Extracapsular spread (ECS) in cervical lymph nodes is the single-most prognostic clinical variable in oral squamous cell carcinoma (OSCC), but diagnosis is possible only after histopathological examination. A promising biomarker in the primary tumour, alpha smooth muscle actin (SMA) has been shown to be highly prognostic, however, validated biomarkers to predict ECS prior to primary treatment are not yet available. METHODS: In 102 OSCC cases, conventional imaging was compared with pTNM staging. SERPINE1, identified from expression microarray of primary tumours as a potential biomarker for ECS, was validated through mRNA expression, and by immunohistochemistry (IHC) on a tissue microarray from the same cohort. Similarly, expression of SMA was also compared with its association with ECS and survival. Expression was analysed separately in the tumour centre and advancing front; and prognostic capability determined using Kaplan-Meier survival analysis. RESULTS: Immunohistochemistry indicated that both SERPINE1 and SMA expression at the tumour-advancing front were significantly associated with ECS (P<0.001). ECS was associated with expression of either or both proteins in all cases. SMA+/SERPINE1+ expression in combination was highly significantly associated with poor survival (P<0.001). MRI showed poor sensitivity for detection of nodal metastasis (56%) and ECS (7%). Both separately, and in combination, SERPINE1 and SMA were superior to MRI for the detection of ECS (sensitivity: SERPINE1: 95%; SMA: 82%; combination: 81%). CONCLUSION: A combination of SMA and SERPINE1 IHC offer potential as prognostic biomarkers in OSCC. Our findings suggest that biomarkers at the invasive front are likely to be necessary in prediction of ECS or in therapeutic stratification.

Rationale for the use of the implantable Doppler probe based on 7 years' experience.

In head and neck microvascular reconstruction, a proportion of patients are at a higher risk of flap failure. These include salvage surgery after chemoradiotherapy, reconstruction for osteoradionecrosis and when difficulty is encountered in achieving flap perfusion intraoperatively. Several studies have shown that the Cook-Swartz Doppler (Cook Medical Inc, Bloomington, USA) enabled earlier detection of a compromised flap. We retrospectively reviewed microvascular reconstructions monitored with the Cook-Swartz implantable Doppler (2006-2012) and included patients' characteristics, comorbidity (American Society of Anesthesiologists' (ASA) grade), indication for operation, type of reconstruction, and indication for implantable Doppler. We also included details of surgical exploration, free flap salvage, and outcomes of flap salvage. These outcomes were compared with a group of low-risk patients (2005-2009) whose flaps were monitored clinically. A total of 75 free flaps in 73 patients were monitored with the implantable Doppler: 40 (53%) were in cases which required reconstruction following previous surgery/radiotherapy or flap perfusion difficulties, 10 (13%) buried flaps, 13 (17%) as routine flap monitors and 12 (17%) for other indications. The false negative rate was 5%, sensitivity 67%, the false positive rate was 25%, and specificity was 95%. Higher risk flaps monitored with the doppler had a higher return to theatre rate, 21% compared with 4% (p<0.001) and flap failure rate, 7% compared with 1% (p=0.002). Salvage rates for free flaps were similar in both groups (62% compared with 60%, p=1.0). There is not enough evidence to suggest that the implantable doppler reduces the rate of failed flaps in routine low-risk cases, and its value in monitoring high-risk reconstructions require evaluation in a prospective randomised study.

Observations on the phenotypic relationships between anti-CarLA salivary IgA antibody response, nematode infection levels and growth rates in farmed red (Cervus elaphus) and wapiti hybrid deer (Cervus elaphus canadensis).

Nematode parasites are one of the most significant production limiting factors in farmed deer in New Zealand. One long term strategy to reduce reliance on anthelmintics is to select deer that develop resistance to parasites. It has been shown in sheep that secretory antibody (IgA) in the saliva against a Carbohydrate Larval Antigen (CarLA) on infective larvae (L3) of a wide range of gastro-intestinal nematodes protects against reinfection. This paper describes a longitudinal slaughter study undertaken to measure anti-CarLA IgA antibody (CarLA-IgA) levels in the saliva of 5-12 month old farmed red and wapiti-cross-red deer (wapx) grazed together and to attempt to relate these levels to parasite burdens and productivity. The study showed that salivary CarLA-IgA levels peaked in June (late autumn) and October (mid spring), but the levels in wapx deer were significantly lower than in red deer. Over the May-December period 55% of red deer had CarLA-IgA values ≥2 units compared with 26% of wapx deer and over this period red deer had consistently lower adult abomasal parasite burdens than wapx deer. The average number of adult abomasal nematodes was significantly lower at each slaughter from May to December for all deer with CarLA-IgA ≥2 units vs <2 units. There were no demonstrable correlations with liveweight gain in these small groups of deer.

Analysis of time taken to discuss new patients with head and neck cancer in multidisciplinary team meetings.

Multidisciplinary team (MDT) meetings have an important role in the management of head and neck cancer. Increasing incidence of the disease and a drive towards centralised meetings on large numbers of patients mean that effective discussions are pertinent. We aimed to evaluate new cases within a single high volume head and neck cancer MDT and to explore the relation between the time taken to discuss each case, the number of discussants, and type of case. A total of 105 patients with a new diagnosis of head and neck malignancy or complex benign tumour were discussed at 10 head and neck cancer MDT meetings. A single observer timed each discussion using a stopwatch, and recorded the number of discussants and the diagnosis and characteristics of each patient. Timings ranged from 15 to 480 s (8 min) with a mean of 119 s (2 min), and the duration of discussion correlated closely with the number of discussants (rs=0.63, p<0.001). The longest discussions concerned patients with advanced T stage (p=0.006) and advanced N stage (p=0.009) disease, the elderly (p=0.02) and male patients (p=0.05). Tumour site and histological findings were not significant factors in the duration of discussion. Most discussions on patients with early stage tumours were short (T1: 58% less than 60s, mean 90) and fewer people contributed. Many patients, particularly those with early stage disease, require little discussion, and their treatment might reasonably be planned according to an agreed protocol, which would leave more time and resources for those that require greater multidisciplinary input. Further studies may highlight extended discussions on patients with head and neck cancer, which may prompt a review of protocols and current evidence.

Genetic and phenotypic relationships between carbohydrate larval antigen (CarLA) IgA, parasite resistance and productivity in serial samples taken from lambs after weaning.

Genetic selection for enhanced levels of protective antibody to specific nematode antigens may be a more user-friendly means of selecting animals for resistance to gastrointestinal nematodes than obtaining faecal samples and selecting on the basis of faecal egg counts. Saliva IgA antibody levels to the L3-specific surface glycan known as carbohydrate larval antigen were measured on six occasions over a 5 month period in approximately 350 lambs. The carbohydrate larval antigen IgA response increased markedly with time as the lambs grazed on pasture naturally contaminated with nematode parasite larvae. The monthly loge transformed carbohydrate larval antigen IgA levels were moderately heritable at all samplings, with a combined value of 0.28±0.10 and a repeatability of 0.35±0.03. The genetic correlations between all samplings were high (0.86), suggesting that testing for a carbohydrate larval antigen IgA response could be carried out at any time in the 5 months post-weaning. The transformed carbohydrate larval antigen IgA levels were genetically and phenotypically correlated negatively with loge transformed (faecal egg count+50), averaging -0.57±0.20 and -0.12±0.03 (P<0.05), respectively. The correlations between carbohydrate larval antigen IgA and breech-soiling (dag score) never reached significance. However, genetic correlations between carbohydrate larval antigen IgA and live weight were always positive and significantly so, especially at the beginning and end of the trial, indicating that carbohydrate larval antigen IgA production may be an important genetic determinant of growth rate for lambs experiencing a larval challenge. The data suggest that the ideal time to sample for a carbohydrate larval antigen IgA response and maximise selection for lowered faecal egg count and increased live-weight would be in the first 2 months after weaning.