Addressing the communication needs of cancer patients for Magnetic Resonance Imaging (MRI) investigations-A phenomenological study on the experiences of MRI radiographers.

INTRODUCTION: A higher demand in MRI services could increase the pressure on MRI departments to increase scanning efficiency. This presents the risk of downplaying person-centred care especially for cancer patients with increased communication needs that result from anxiety associated with the nature of their disease. This study explored the experiences of MRI radiographers in addressing the communication needs of cancer patients attending for MRI examinations. METHODS: The study adopted a descriptive phenomenological methodology. Single contact interviews were conducted on eight MRI specialist radiographers, and these were recorded and transcribed using Microsoft Teams conferencing platform. Thematic analysis of the transcribed data was done through an inductive approach, breaking down the data into meaningful codes and thereafter, into themes and sub-themes. RESULTS: Common themes generated from the interview data included: identified communication needs, approach to communication needs, support for radiographers and factors affecting communication. Experiences of MRI radiographers indicated increased communication needs in anxious cancer patients and approaches adopted in addressing these were mainly through listening and use of empathetic gestures. Some radiographers admitted to using "blocking" strategies to avoid being drawn into emotionally exhausting conversations. Both intrinsic factors such as radiographers' personality and experience; and extrinsic factors such as time constraints, demanding workload, inadequate staffing, and skill mix were noted to influenced MRI radiographers in addressing these communication needs. CONCLUSION: Cancer patients can present with communication needs due to anxieties related to their disease. For the radiographer to deal with these needs, adequate support is needed, and necessary steps taken to address the identified influencing factors. IMPLICATIONS FOR PRACTICE: MRI departments should encourage enabling environment and services that address communication needs of patients with cancer.

Impact of routine urine cultures on antibiotic usage in those undergoing a routine annual spinal cord injury evaluation.

OBJECTIVE: The Veterans Health Administration (VHA), the largest single provider of spinal cord injury and disorder (SCI/D) care in the United States, currently mandates that every patient receives a screening urine culture during the annual evaluation, a yearly comprehensive history and physical examination. This testing has shown in a small subset of patients to overidentify asymptomatic bacteriuria that is then inappropriately treated with antibiotics. The objective of the current analysis was to assess the association of the annual evaluation on urine testing and antibiotic treatment in a national sample of Veterans with SCI/D. DESIGN/METHOD: A retrospective cohort study using national VHA electronic health record data of Veterans with SCI/D seen between October 1, 2017-September 30, 2019 for their annual evaluation. RESULTS: There were 9447 Veterans with SCI/D who received an annual evaluation; 5088 (54%) had a urine culture obtained. 2910 cultures (57%) were positive; E. coli was the most common organism obtained (12.9% of total urine cultures). Of the patients with positive urine cultures, 386 were prescribed antibiotics within the 7 days after that encounter (13%); of the patients with negative cultures (n = 2178), 121 (6%) were prescribed antibiotics; thus, a positive urine culture was a significant driver of antibiotic use (p < 0.001). CONCLUSION: The urine cultures ordered at the annual exam are often followed by antibiotics; this practice may be an important target for antibiotic stewardship programs in SCI.

Treatment, not delivery, of the late preterm and term fetus with supraventricular arrhythmia.

OBJECTIVE: While in-utero treatment of sustained fetal supraventricular arrhythmia (SVA) is standard practice in the previable and preterm fetus, data are limited on best practice for late preterm (34 + 0 to 36 + 6 weeks), early term (37 + 0 to 38 + 6 weeks) and term (> 39 weeks) fetuses with SVA. We reviewed the delivery and postnatal outcomes of fetuses at ≥ 35 weeks of gestation undergoing treatment rather than immediate delivery. METHODS: This was a retrospective case series of fetuses presenting at ≥ 35 weeks of gestation with sustained SVA and treated transplacentally at six institutions between 2012 and 2022. Data were collected on gestational age at presentation and delivery, SVA diagnosis (short ventriculoatrial (VA) tachycardia, long VA tachycardia or atrial flutter), type of antiarrhythmic medication used, interval between treatment and conversion to sinus rhythm and postnatal SVA recurrence. RESULTS: Overall, 37 fetuses presented at a median gestational age of 35.7 (range, 35.0-39.7) weeks with short VA tachycardia (n = 20), long VA tachycardia (n = 7) or atrial flutter (n = 10). Four (11%) fetuses were hydropic. In-utero treatment led to restoration of sinus rhythm in 35 (95%) fetuses at a median of 2 (range, 1-17) days; this included three of the four fetuses with hydrops. Antiarrhythmic medications included flecainide (n = 11), digoxin (n = 7), sotalol (n = 11) and dual therapy (n = 8). Neonates were liveborn at 36-41 weeks via spontaneous vaginal delivery (23/37 (62%)) or Cesarean delivery (14/37 (38%)). Cesarean delivery was indicated for fetal SVA in two fetuses, atrial ectopy or sinus bradycardia in three fetuses and obstetric reasons in nine fetuses that were in sinus rhythm at the time of delivery. Twenty-one (57%) cases were treated for recurrent SVA after birth. CONCLUSION: In-utero treatment of the near term and term (≥ 35-week) SVA fetus is highly successful even in the presence of hydrops, with the majority of cases delivered vaginally closer to term, thereby avoiding unnecessary Cesarean section. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

A case study of the development of a videofluoroscopy service: Integration and collaboration between the speech & language therapy and radiographer teams.

BACKGROUND: Videofluoroscopy (VFSS) is a dynamic fluoroscopic examination of swallowing function to assess oropharyngeal dysphagia. In the United Kingdom (UK), this test is typically performed by a team of Speech and Language Therapists (SLTs), radiologists and radiographers. While VFSS is undertaken across the UK, recent literature reflects wide variation in the procedure itself. OBJECTIVES: The role of the advanced practitioner gastrointestinal (GI) radiographer within a VFSS service will be illustrated by the narrative description of a VFSS service in a large NHS teaching hospital in England. The paper compares the existing VFSS service against recent literature outlining national practice, with particular focus upon the growing role of the advanced practitioner GI radiographer. Existing pressures upon the National Health Service (NHS) are examined as contributing factors. Lastly, further plans to improve the clinic are delineated. KEY FINDINGS: Recent literature shows a wide national variation in the running of VFSS services. Pertinently, the evidence suggests that radiologists are becoming progressively less involved in these clinics, with a move towards more practitioner-led services. The changes to the described VFSS service are in line with national trends, and the described clinic is an effective example of a practitioner-led service which fully utilises the role of the advanced practitioner GI radiographer. CONCLUSION: This paper demonstrates that a practitioner-led service can benefit both patients and staff. Further improvement work is ongoing, with a particular need to involve service users and collect more meaningful outcome measures. IMPLICATIONS FOR PRACTICE: The growing move towards practitioner-led clinics is likely to continue. However, the wide variation in practice nationally and lack of consistent, recognised training that meets the needs of both SLT and radiographers, needs to be addressed.

Inclusion body myositis and dysphagia. Presentation, intervention and outcome at a swallowing clinic.

OBJECTIVE: This study reviewed patients with inclusion body myositis who were referred for assessment of dysphagia at a tertiary swallow clinic. It describes symptoms at presentation, imaging and management strategies. METHOD: A retrospective review of electronic patient records was performed between 2016 and 2020. RESULTS: Twenty-four patients were included, with a mean age of 72 years. Baseline modified Sydney Swallow Questionnaires identified problems with hard or dry food, food sticking, and repeated swallowing. Twenty-two patients had a Reflux Symptom Index score that could indicate significant reflux. Video swallow identified specific problems, including tongue base retraction (96 per cent) and residual pharyngeal pooling (92 per cent). Seven patients (30 per cent) had features of aspiration on imaging despite a median penetration-aspiration scale score of 2. Four patients received balloon dilatation, and two patients underwent cricopharyngeal myotomy. CONCLUSION: This study helped to profile features of dysphagia in patients with inclusion body myositis. More evidence is needed to determine the most effective management pathway for these patients.

Periodontal disease as a primary cause of surgical site infection in fractures of the mandible: is smoking a confounding variable?

Fractures of the mandible are common in contemporary oral and maxillofacial practice. Wound infection is the most common complication after open reduction and internal fixation, and the management of these is complex and costly in terms of morbidity to the patient, and in fiscal terms. Whilst numerous epidemiological studies implicate smoking, alcohol, drug use, and adverse behaviour, as well as fracture complexity and diabetes, as important risk factors, the role of periodontal disease is only occasionally mentioned and not formally investigated. The aim of this study therefore was to assess the presence of periodontal disease and its severity according to the 2018 EFP/AAP periodontitis case classification in patients with fractured mandibles who presented to a single level 1 trauma centre, and to look for a possible association with surgical site infection. A total of 305 patients were assessed retrospectively following open reduction and internal fixation via transoral incisions with load-sharing osteosynthesis. The postoperative infection rate was 22.95%. Multivariate and multiple logistic regression revealed that there was a strong association between periodontal staging and postoperative surgical site infection. Crucially, the study predicts that patients with severe periodontal disease (periodontal stage III and IV) are over seven times more likely to develop a wound infection than disease-negative individuals. This has implications for risk adjustment, prognostication, treatment planning, and postoperative care. Surprisingly in this study, cigarette smoking, an established risk factor in the pathogenesis of periodontal disease, did not achieve statistical significance, potentially conflicting with the established literature.

Two-dimensional localization in GeSn.

Localization behaviour is a characteristic feature of thep-type GeSn quantum well (QW) system in a metal-insulator-semiconductor device. The transition to strongly localized behaviour is abrupt with thermally activated conductivity and a high temperature intercept of 0.12 ×e2h-1at a hole carrier density 1.55 × 1011cm-2. The activation energy for the conductivity in the localized state is 0.40 ± 0.05 meV compared to an activation energy of ∼0.1 meV for conductivity activation to a mobility edge at carrier densities >1.55 × 1011cm-2. Insulating behaviour can occur from a system that behaves as though it is in a minimum metallic state, albeit at high temperature, or from a conductivity greater than a minimum metallic state behaviour showing that local disorder conditions with local differences in the density of states are important for the onset of localization. In the presence of a high magnetic field, thermally activated conductivity is present down to Landau level filling factor <1/2but without a magnetic-field-dependent carrier density or a variable range hopping (VRH) transport behaviour developing even with conductivity ≪e2h-1. In the localized transport regime inp-type doped Ge0.92Sn0.08QWs the VRH mechanism is suppressed at temperatures >100 mK and this makes this two-dimensional system ideal for future many body localization studies in disordered hole gases that can be thermally isolated from a temperature reservoir.

Stratification of alopecia areata reveals involvement of CD4 T cell populations and altered faecal microbiota.

Alopecia areata (AA) is an immune-mediated disease that causes non-scarring hair loss. Autoreactive CD8 T cells are key pathogenic effectors in the skin, and AA has been associated both with atopy and with perturbations in intestinal homeostasis. This study aimed to investigate mechanisms driving AA by characterizing the circulating immunophenotype and faecal microbiome, and by stratifying AA to understand how identified signatures associated with heterogeneous clinical features of the condition. Flow cytometric analyses identified alterations in circulating B cells and CD4 T cells, while 16S sequencing identified changes in alpha and beta diversity in the faecal microbiome in AA. The proportions of transitional and naïve B cells were found to be elevated in AA, particularly in AA samples from individuals with >50% hair loss and those with comorbid atopy, which is commonly associated with extensive hair loss. Although significant changes in circulating CD8 T cells were not observed, we found significant changes in CD4+ populations. In individuals with <50% hair loss higher frequencies of CCR6+CD4 ("Th17") and CCR6+CXCR3+CD4 ("Th1/17") T cells were found. While microbial species richness was not altered, AA was associated with reduced evenness and Shannon diversity of the intestinal microbiota, again particularly in those with <50% hair loss. We have identified novel immunological and microbial signatures in individuals with alopecia areata. Surprisingly, these are associated with lower levels of hair loss, and may therefore provide a rationale for improved targeting of molecular therapeutics.

Arthroscopic Medial Meniscal Root Reconstruction With Gracilis Autograft Is Safe and Improves 2-Year Postoperative Patient-Reported Outcomes.

Purpose: To describe patient-reported clinical outcomes and complications of anatomic medial meniscal root reconstruction with gracilis autograft. Methods: Data on patients who underwent arthroscopic medial meniscal root reconstruction with gracilis autograft were prospectively collected between 2017 and 2021 and retrospectively reviewed. The inclusion criteria were symptomatic posterior medial meniscal LaPrade type 2 root tears with no more than Outerbridge grade 2 chondrosis of any knee compartment with a minimum follow-up period of 1 year. Patients with ligamentous instability and those with Workers' Compensation status were excluded. Patient-reported outcomes (12-item Short Form Survey [SF-12], visual analog scale [VAS], Western Ontario and McMaster Universities Arthritis Index [WOMAC], and Lysholm scores) were collected prospectively and analyzed retrospectively and were scored and recorded both preoperatively and at postoperative intervals. Data were analyzed using cubic spline regression models. The study was approved by the University of South Carolina Institutional Review Board. Results: A consecutive series of 27 patients treated by a single surgeon were evaluated. Twenty-one patients were included for data analysis (4 were excluded per criteria and 2 were lost to follow-up) with an average age of 48.1 years (range, 16-63 years). There were 18 female and 3 male patients. The average follow-up time was 25.2 months (range, 12-42 months). At the postoperative time points captured by the data examined, improvements in Lysholm, WOMAC, VAS, and SF-12 physical component summary scores were found to be statistically significant (P < .001, 95% confidence interval). Improvements in SF-12 mental component summary scores, however, did not reach the level of statistical significance (P = .262). Body mass index greater than 35 and age greater than 50 years were not found to be negative predictors of outcomes. Average patient-reported outcomes at 2 years' follow-up improved from preoperatively as follows: Lysholm score, from 50 to 82.9; WOMAC score, from 53.9 to 87.4; and VAS score, from 5.1 to 1.2. No serious complications were observed. Conclusions: Patients undergoing posterior medial meniscal root reconstruction showed statistically significant improvements in Lysholm, WOMAC, SF-12 physical component summary, and VAS scores but not SF-12 mental component summary scores at short-term follow-up. No serious complications or clinical failures occurred, and no patients required revision surgery. Level of Evidence: Level IV, case series.

Clinical outcomes following pharyngolaryngectomy reconstruction: a 20-year single-centre study.

BACKGROUND: Advanced malignant neoplasms of the larynx and hypopharynx pose many therapeutic challenges. Total pharyngolaryngectomy and total laryngectomy provide an opportunity to cure these tumours but are associated with significant morbidity. Reconstruction of the pharyngeal defect following total pharyngolaryngectomy demands careful consideration and remains an area of debate within surgical discussions. METHODS: This paper describes a systemic analysis of pharyngeal reconstruction following total pharyngolaryngectomy and total laryngectomy, leveraging data collected over a 20-year period at a large tertiary referral centre. RESULTS: Analysing 155 patients, the results show that circumferential pharyngeal defects and prior radiotherapy have a significant impact on surgical complications. In addition, free tissue transfer in larger pharyngeal defects showed lower rates of post-operative anastomosis leak and stricture. CONCLUSION: Pharyngeal resection carries a substantial risk of post-operative complications, and free tissue transfer appears to be an effective means of reconstruction for circumferential defects.

The epidemiology of alopecia areata: a population-based cohort study in UK primary care.

BACKGROUND: There is a lack of population-based information on the disease burden and management of alopecia areata (AA). OBJECTIVES: To describe the epidemiology of AA, focusing on incidence, demographics and patterns of healthcare utilization. METHODS: Population-based cohort study of 4·16 million adults and children, using UK electronic primary care records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, 2009-2018. The incidence and point prevalence of AA were estimated. Variation in AA incidence by age, sex, deprivation, geographical distribution and ethnicity was examined. Patterns of healthcare utilization were evaluated in people with incident AA. RESULTS: The AA incidence rate was 0·26 per 1000 person-years. AA point prevalence in 2018 was 0·58% in adults. AA onset peaked at age 25-29 years for both sexes, although the peak was broader in females. People of nonwhite ethnicity were more likely to present with AA, especially those of Asian ethnicity [incidence rate ratio (IRR) 3·32 (95% confidence interval 3·11-3·55)]. Higher AA incidence was associated with social deprivation [IRR most vs. least deprived quintile 1·47 (1·37-1·59)] and urban living [IRR 1·23 (1·14-1·32)]. People of higher social deprivation were less likely to be referred for specialist dermatology review. CONCLUSIONS: By providing the first large-scale estimates of the incidence and point prevalence of AA, our study helps to understand the burden of AA on the population. Understanding the variation in AA onset between different population groups may give insight into the pathogenesis of AA and its management.

Frontal fibrosing alopecia: survey of severity assessment methods in routine clinical practice and validation of the International Frontal Fibrosing Alopecia Cooperative Group measurement guidance.

BACKGROUND: The lack of validated and responsive outcome measures in the management of frontal fibrosing alopecia (FFA) significantly limits assessment of disease progression and treatment response over time. AIM: To understand how FFA extent and progression is currently assessed in UK specialist centres, to validate components of the International FFA Cooperative Group (IFFACG) statement on FFA assessment, and to identify pragmatic advice to improve FFA management in clinic. METHODS: Consultant dermatologists with a specialist interest in hair loss (n = 17) were invited to take part. Preferred FFA assessment methods were explored using questionnaires and clinical scenarios. Participants were asked to identify and mark the current hairline in 10 frontal and 10 temporal hairline images (Questionnaire 1), with assessment repeated 3 months later to assess intraindividual variability (Questionnaire 2) and 12 months later to test whether interindividual accuracy could be improved with simple instruction (Questionnaire 3). RESULTS: All 17 clinicians (100%) completed the questionnaire at each time interval. We identified a wide variation in assessment techniques used by our experts. Measurements were perceived as the most accurate method of assessing frontal recession whereas photography was preferred for temporal recession. Inter-rater reliability between clinicians measuring the frontal hairline scenarios indicated a moderate strength of agreement [intraclass coefficient (ICC) = 0.61; 95% CI 0.40-0.85], yet intrarater reliability was found to be poor with wide limits of agreement (-8.71 mm to 9.92 mm) on follow-up. Importantly, when clear guidance was provided on how the hairline should be identified (Questionnaire 3), inter-rater reliability improved significantly, with ICC = 0.70, suggesting moderate agreement (95% CI 0.51-0.89; P < 0.001). A similar pattern was seen with temporal hairline measurements, which again improved in accuracy with instruction. CONCLUSION: We found that accuracy of measurements in FFA can be improved with simple instruction and we have validated components of the IFFACG measurement recommendations.

Quantitative analysis of tegmen bone mineral density in obese and non-obese patients.

BACKGROUND: Certain factors have been linked to lateral skull base demineralisation or erosion, which may predispose to spontaneous cerebrospinal fluid leak. There are relatively few quantitative reports of skull base changes in patient populations. METHOD: A novel refined measurement algorithm for quantification of tegmen bone mineral density was developed, and bone mineral density between obese and non-obese patient groups was compared. Computed tomography scans were analysed by three blinded reviewers, and tegmen bone mineral densities were compared. RESULTS: There were 23 patients in the obese group and 27 matched controls in the non-obese group. Inter-rater reliability was 'strong' to 'near complete' (κ = 0.75-0.86). No differences in tegmen bone mineral density were found between the groups (p = 0.64). The number of active blood pressure medications correlated positively with lateral skull base bone mineral density. CONCLUSION: A novel, refined, quantitative measurement algorithm for the assessment of tegmen bone mineral density was developed and validated. Obesity was not found to significantly affect tegmen bone mineral density.

Going beyond the limitations of the non-patient-specific implant in titanium reconstruction of the orbit.

Reconstruction of post traumatic orbital defects has undergone a stepwise evolution following developments in reconstructive materials and surgical techniques. Advances in communication between surgical teams and design technicians have allowed provision of bespoke surgical plates with a high degree of accuracy and surgical relevance in an appropriate timeframe. We present a case series of 41 consecutive patients treated in London and BernBern Switzer between March 2019 and September 2020 with extensive defects reconstructed with patient specific orbital plates. Complexity of fracture was risk adjusted using the Jaquiery scale with one patient (J3), 14 patients (J4), and 26 Patients (J5). Outcome was assessed by accuracy of fit at the surgical margins and was 94.5%. The study group was statistically tested against a previous series by the same group and was statistically different with respect to the case complexity (p<0.001) and accuracy of fit (p<0.001) (Fisher's exact test). Complications included the removal on one plate due to patient choice, with perfect surgical position and resolving diplopia. Only one plate articulation was poor, this mitigated by the size of the defect and the orbital soft tissue swelling which prohibited seating the implant. The patient remains well with acceptable function and satisfactory aesthetics. We present design considerations including the use two part plates, and surgical pearls to achieve predictable placement. We believe that the use of custom plates for reconstruction of Jaquiery 4 and 5 should be considered. We regard this technology as a game changer in surgical management of the complex high risk orbit.

Experiences of veterans with spinal cord injury related to annual urine screening and antibiotic use for urinary tract infections.

INTRODUCTION: Antimicrobial-resistant bacterial infections are an increasing public health threat and people with spinal cord injury (SCI) are disproportionally at higher risk. National guidelines concerning urine testing after SCI are conflicting. Unnecessary urine testing in the SCI population (with high asymptomatic bacteriuria prevalence) leads to unnecessary antimicrobial use, propagating resistant infections, especially urinary tract infections (UTIs). OBJECTIVES: (a) Describe UTI antimicrobial adherence in patients with SCI. (b) Explore SCI patient knowledge and attitudes toward current urine testing and treatment practices. DESIGN: Mixed methods. SETTING: Veterans Health Administration (VHA) patients with SCI. PARTICIPANTS: Veterans identified as having SCI seen at a VHA facility nationwide. INTERVENTIONS: N/A. MAIN OUTCOME MEASURES: Self-reported medication adherence, patient beliefs and behaviors toward UTIs and antimicrobial use. RESULTS: A total of 105 Morisky Medication Adherence Scale-8 (MMAS-8) surveys were completed out of 369 distributed surveys (28% response rate). Overall, patients reported high medication adherence (mean score of 7.2/8, with 8 being a perfect adherence score). Ten qualitative interviews were completed. Themes identified include generally high adherence to prescribed antimicrobial courses and high levels of patient satisfaction with current outpatient VHA SCI bladder care. The quantitative findings converge with these themes observed in the qualitative interviews; patients were satisfied with current urine testing and treatment practices. CONCLUSIONS: Veterans with SCI are generally satisfied with their current UTI management and self-report taking antimicrobials for UTIs as prescribed. Veterans with SCI typically report high trust in their SCI providers and value their advice on bladder care management. Therefore, it is imperative for clinicians to provide evidence-based education to patients, as well as ensure that each prescribed course of antibiotics for UTI is clinically necessary. Information from this study will guide an intervention promoting appropriate urine testing and antimicrobial prescription practices by SCI providers.

The brain and behavioral correlates of motor-related analgesia (MRA).

The human motor system has the capacity to act as an internal form of analgesia. Since the discovery of the potential influence of motor systems on analgesia in rodent models, clinical applications of targeting the motor system for analgesia have been implemented. However, a neurobiological basis for motor activation's effects on analgesia is not well defined. Motor-related analgesia (MRA) is a phenomenon wherein a decrease in pain symptoms can be achieved through either indirect or direct activation of the motor axis. To date, research has focused on (a) evaluating the pain-motor interaction as one focused on the acute protection from painful stimuli; (b) motor cortex stimulation for chronic pain; or (c) exercise as a method of improving chronic pain in animal and human models. This review evaluates (1) current knowledge surrounding how pain interferes with canonical neurological performance throughout the motor axis; and (2) the physiological basis for motor-related analgesia as a means to reduce pain symptom loads for patients. A proposal for future research directions is provided.

What are the limitations of the non-patient-specific implant in titanium reconstruction of the orbit?

There is ongoing discussion about patient-specific implants (PSI) to reconstruct orbital defects. Although PSI offer excellent clinical outcome, they are expensive. Subsequently, their routine application is not indicated. The purpose of this study was to estimate the frequency of implant malposition and revision procedures after primary orbital repair with preformed plates and to identify cases where primary use of PSI would help to prevent revision surgery. All patients included in the study were operated on for orbital fractures at the Royal London Hospital between August 2017 and July 2018. Selection criteria included adult patients treated for orbital fractures with a titanium plate. Revision was planned in symptomatic patients presenting with clear implant malposition. Seventy-nine patients with 81 implants were included, 33 of whom had multiple orbital wall fractures (medial wall and floor or all four walls) and were summarised as group 2. Group 1 consisted of single orbital floor/medial wall fractures. The five patients for whom revision surgery was planned or undertaken because of radiological poorly positioned implants and substantial clinical symptoms all had multiple wall fractures. This finding was significant (p=0.006). The major reason for revision was a defect that was too large for the prescribed plate. Patients with large orbital defects needing surgical treatment are at risk of implant malposition. The orbital reconstruction with preformed plate evidences good outcome in single wall fractures. However, the risk of malposition increases massively with fracture size. We therefore postulate that in large, two-wall fractures, primary treatment with a PSI has to be considered.