Comparison of provision of maxillofacial emergency service during the two COVID-19 national lockdowns in the United Kingdom.

We previously published a study on the provision of emergency maxillofacial services during the first UK COVID-19 pandemic national lockdown. We repeated the study during the second lockdown and now present our findings that highlight the main differences and learning issues as the services have evolved.

Provision of Emergency Maxillofacial Service During the COVID-19 Pandemic : A Collaborative Five Centre UK Study.

The global pandemic of Coronavirus disease (COVID-19) represents one of the greatest challenges to healthcare systems, and has forced medical specialties to rapidly adapt their approaches to patient care. Oral and Maxillofacial Surgery is considered particularly at risk of disease transmission due to aerosol generation during surgical interventions, patient proximity and operating environment. On day 2 (26th March, 2020) of when severe restrictions in population movement were instigated in the United Kingdom, we began a study to prospectively monitor the presentation and management of maxillofacial emergencies at five hospital trusts. Data was collected onto an online live database fed through a smartphone application. Of the total 529 patients over six weeks, 395 attended for face-to-face consultations and 134 patients received remote consultations via telephone or video link. There were 255 trauma related cases, 221 infection and 48 cases of postoperative complications. Most trauma cases were minor soft tissue injury related to slip, trip or fall at home. There were 44 cases of facial fractures with a tendency for conservative treatment. 19 cases were related to domestic violence or self-harm. Of the 216 dental related emergencies, 68% could have been managed in the primary care setting. A quarter of all emergency patients were satisfactorily managed by remote consultations. There was a significant change in the provision of emergency maxillofacial service during the pandemic lockdown. We discuss the study findings as well as the potential implications in relation to planning for possible further COVID- 19 spikes and future pandemics.

Intraosseous venous malformation of the craniofacial region: diagnosis and management.

Vascular lesions mainly affect soft tissues, and less than 1% affect bone. In 1982, they were categorised by Mulliken and Glowacki as haemangiomas or vascular malformations, and an updated classification was subsequently published by the International Society for the Study of Vascular Anomalies. These lesions, however, continue to be termed haemangiomas and there is little attempt to differentiate between them. We report eight cases of intraosseous venous malformation that were inappropriately labelled as haemangioma by clinicians, pathologists, and radiologists. We highlight tailored management, and describe the clinical features, results of investigations to aid accurate designation (histological and immunohistochemical, including GLUT1 staining and cross-sectional imaging), and outcomes.

Prenatal depression, fetal neurobehavior, and infant temperament: Novel insights on early neurodevelopment from a socioeconomically disadvantaged Indian cohort.

This article extends the research focusing on the early origins of psychopathology into the prenatal period, by exploring the association between maternal prenatal depression and offspring (fetal and infant) neurobehavior. The sample is recruited from a rural population in South India where women in the third trimester of pregnancy were assessed for depression and the heart rate responses of their fetuses to extrinsically applied vibroacoustic stimuli were studied. At 2 months postbirth, infant temperament and cortisol responsivity to immunization were assessed. The association between maternal prenatal depression and fetal responsivity to vibroacoustic stimulation, and infant responsivity to immunization, was U shaped with higher levels of responsivity noted in the offspring of mothers with very high and very low depression scores, and lower levels noted in the offspring of mothers with moderate depression scores. Maternal prenatal depression was not associated with infant temperament. The findings highlight the importance of environmental influences in the developmental origins of neurobehavior, suggesting that such differences, not evident at baseline, may emerge upon exposure to stressors. The study also emphasizes the need for further investigation in low- and middle-income contexts by providing preliminary evidence of the differing patterns of association observed between high- and low-income populations.

Minimally-invasive neck dissection and free flap reconstruction in patients with cancer of the head and neck.

We describe our experience of cervical lymphadenectomy with microvascular anastomoses involving levels I to V through a minimally-invasive neck dissection. We retrospectively studied 12 patients who had levels I to IV neck dissection with free flap reconstruction between July 2013 and April 2015 at Poole Hospital (male:female ratio 8:4, mean (range) age 66 (49 - 83) years). The mean (range) operating time was 7 (5 - 8) hours, and the total volume drained from the neck was 105 (60-300) ml. The mean (range) number of harvested lymph nodes was 26 (13-39) from levels I to III, and 33 (20-42) from levels I to IV. Four patients developed weakness of the marginal mandibular nerve, but there were no serious complications. All flaps were successful, there was no regional recurrence, and most patients were discharged on postoperative day 15. This technique provides adequate exposure for lymphadenectomy and anastomosis, and we think that head and neck surgeons should include it in the armamentarium of reconstruction.

Maternal prenatal depression is associated with decreased placental expression of the imprinted gene PEG3.

BACKGROUND: Maternal prenatal stress during pregnancy is associated with fetal growth restriction and adverse neurodevelopmental outcomes, which may be mediated by impaired placental function. Imprinted genes control fetal growth, placental development, adult behaviour (including maternal behaviour) and placental lactogen production. This study examined whether maternal prenatal depression was associated with aberrant placental expression of the imprinted genes paternally expressed gene 3 (PEG3), paternally expressed gene 10 (PEG10), pleckstrin homology-like domain family a member 2 (PHLDA2) and cyclin-dependent kinase inhibitor 1C (CDKN1C), and resulting impaired placental human placental lactogen (hPL) expression. METHOD: A diagnosis of depression during pregnancy was recorded from Manchester cohort participants' medical notes (n = 75). Queen Charlotte's (n = 40) and My Baby and Me study (MBAM) (n = 81) cohort participants completed the Edinburgh Postnatal Depression Scale self-rating psychometric questionnaire. Villous trophoblast tissue samples were analysed for gene expression. RESULTS: In a pilot study, diagnosed depression during pregnancy was associated with a significant reduction in placental PEG3 expression (41%, p = 0.02). In two further independent cohorts, the Queen Charlotte's and MBAM cohorts, placental PEG3 expression was also inversely associated with maternal depression scores, an association that was significant in male but not female placentas. Finally, hPL expression was significantly decreased in women with clinically diagnosed depression (44%, p < 0.05) and in those with high depression scores (31% and 21%, respectively). CONCLUSIONS: This study provides the first evidence that maternal prenatal depression is associated with changes in the placental expression of PEG3, co-incident with decreased expression of hPL. This aberrant placental gene expression could provide a possible mechanistic explanation for the co-occurrence of maternal depression, fetal growth restriction, impaired maternal behaviour and poorer offspring outcomes.

Imaging of mesothelioma of tunica vaginalis testis.

OBJECTIVES: To describe the imaging findings in a series of patients with mesothelioma of the tunica vaginalis testis. METHODS: We reviewed clinical data, imaging findings and follow-up information in a series of 10 pathology-proven cases of mesothelioma (all had US; 2 had MR) of the tunica vaginalis. RESULTS: A variety of patterns could be observed, the most common (5/10) being a hydrocele with parietal, solid and hypervascular vegetations; one patient had a septated hydrocele with hypervascular walls; one had multiple, solid nodules surrounded by a small, physiological quantity of fluid; one a cystic lesion with thick walls and vegetations compressing the testis; two had a solid paratesticular mass. MR showed multiple small nodules on the surface of the tunica vaginalis in one case and diffuse thickening and vegetations in the other one; lesions had low signal intensity on T2-w images and were hypervascular after contrast injection. CONCLUSIONS: A preoperative diagnosis of mesotheliomas presenting as solid paratesticular masses seems very difficult with imaging. On the contrary, the diagnosis must be considered in patients in whom a hydrocele with parietal vegetations is detected, especially if these show high vascularity. KEY POINTS: Mesotheliomas of the tunica vaginalis are rare, often challenging to diagnose preoperatively. Most common finding is a complex hydrocele with hypervascular parietal vegetations. Septated hydrocele, nodules without hydrocele, a thick-walled paratesticular cyst are less common. Preoperative diagnosis may allow aggressive surgical approach and, possibly, a better prognosis.

The acute psychobiological impact of the intensive care experience on relatives.

There is a growing awareness amongst critical care practitioners that the impact of intensive care medicine extends beyond the patient to include the psychological impact on close family members. Several studies have addressed the needs of relatives within the intensive care context but the psychobiological impact of the experience has largely been ignored. Such impact is important in respect to health and well-being of the relative, with potential to influence patient recovery. The current feasibility study aimed to examine the acute psychobiological impact of the intensive care experience on relatives. Using a mixed methods approach, quantitative and qualitative data were collected simultaneously. Six relatives of patients admitted to the intensive care unit (ICU) of a District General Hospital, were assessed within 48 h of admission. Qualitative data were provided from semi-structured interviews analysed using interpretative phenomenological analysis. Quantitative data were collected using a range of standardised self-report questionnaires measuring coping responses, emotion, trauma symptoms and social support, and through sampling of diurnal salivary cortisol as a biomarker of stress. Four themes were identified from interview: the ICU environment, emotional responses, family relationships and support. Questionnaires identified high levels of anxiety, depression and trauma symptoms; the most commonly utilised coping techniques were acceptance, seeking support through advice and information, and substance use. Social support emerged as a key factor with focused inner circle support relating to family and ICU staff. Depressed mood and avoidance were linked to greater mean cortisol levels across the day. Greater social network and coping via self-distraction were related to lower evening cortisol, indicating them as protective factors in the ICU context. The experience of ICU has a psychological and physiological impact on relatives, suggesting the importance of identifying cost-effective interventions with evaluations of health benefits to both relatives and patients.

Evidence-based guidelines for treating depressive disorders with antidepressants: A revision of the 2008 British Association for Psychopharmacology guidelines.

A revision of the 2008 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken in order to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in September 2012. Key areas in treating depression were reviewed and the strength of evidence and clinical implications were considered. The guidelines were then revised after extensive feedback from participants and interested parties. A literature review is provided which identifies the quality of evidence upon which the recommendations are made. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse and stopping treatment. Significant changes since the last guidelines were published in 2008 include the availability of new antidepressant treatment options, improved evidence supporting certain augmentation strategies (drug and non-drug), management of potential long-term side effects, updated guidance for prescribing in elderly and adolescent populations and updated guidance for optimal prescribing. Suggestions for future research priorities are also made.

Maternal prenatal depressive symptoms predict infant NR3C1 1F and BDNF IV DNA methylation.

Prenatal maternal psychological distress increases risk for adverse infant outcomes. However, the biological mechanisms underlying this association remain unclear. Prenatal stress can impact fetal epigenetic regulation that could underlie changes in infant stress responses. It has been suggested that maternal glucocorticoids may mediate this epigenetic effect. We examined this hypothesis by determining the impact of maternal cortisol and depressive symptoms during pregnancy on infant NR3C1 and BDNF DNA methylation. Fifty-seven pregnant women were recruited during the second or third trimester. Participants self-reported depressive symptoms and salivary cortisol samples were collected diurnally and in response to a stressor. Buccal swabs for DNA extraction and DNA methylation analysis were collected from each infant at 2 months of age, and mothers were assessed for postnatal depressive symptoms. Prenatal depressive symptoms significantly predicted increased NR3C1 1F DNA methylation in male infants (ß = 2.147, P = 0.044). Prenatal depressive symptoms also significantly predicted decreased BDNF IV DNA methylation in both male and female infants (ß = -3.244, P = 0.013). No measure of maternal cortisol during pregnancy predicted infant NR3C1 1F or BDNF promoter IV DNA methylation. Our findings highlight the susceptibility of males to changes in NR3C1 DNA methylation and present novel evidence for altered BDNF IV DNA methylation in response to maternal depression during pregnancy. The lack of association between maternal cortisol and infant DNA methylation suggests that effects of maternal depression may not be mediated directly by glucocorticoids. Future studies should consider other potential mediating mechanisms in the link between maternal mood and infant outcomes.

Foetal exposure to maternal depression predicts cortisol responses in infants: findings from rural South India.

BACKGROUND: Maternal depression during pregnancy is associated with an increased risk of adverse child outcomes. One potential mechanism is the influence of antenatal depression on the foetal hypothalamic-pituitary-adrenal axis. This can be observed as disturbances in baseline cortisol secretion during childhood. The influence of antenatal depression on infant cortisol reactivity to a stressor may provide further insight into this association. In addition, the dose-response relationship between foetal exposure to antenatal depression and infant cortisol reactivity is unclear. METHODS: A consecutive sample of 133 pregnant women in their third trimester was recruited from an antenatal clinic in Karnataka, South India. Women were assessed for depression before and after birth on the Edinburgh Postnatal Depression Scale (EPDS) and the Kessler 10 Scale. Salivary cortisol response to immunization was measured in 58 infants at 2 months of age. We aimed (i) to investigate the association between antenatal depression and infant cortisol reactivity to immunization and (ii) to explore whether the relationship is dose-dependent. RESULTS: Exposure to antenatal depression independently predicted elevated infant cortisol responses to immunization (ß = 0.53, P = 0.04). The association was found to be U-shaped, for antenatal depression measured on the EPDS, with the infants exposed to the highest and lowest levels of maternal antenatal EPDS scores during intra-uterine life showing elevated cortisol responses to immunization (R(2) = 0.20, P = 0.02). Infants exposed to moderate levels of maternal antenatal depression showed the lowest cortisol response to immunization. CONCLUSIONS: These findings suggest that the association between antenatal depression and infant cortisol reactivity is dose-dependent and U-shaped, implying that infants exposed to both low and high levels of maternal depression showed greater reactivity. The study provides the first evidence of such an association from a low-income setting.

Prenatal risk factors for depression: a critical review of the evidence and potential mechanisms.

Exposure to adverse experiences in early life increases the risk of depression during adulthood. Recent findings have highlighted that exposure of a fetus to an adverse intrauterine environment may also have implications for later offspring depression. This review considers the status of the evidence for these associations and the potential mechanisms underlying prenatal developmental risks for later depression, addressing the challenging possibility that environmental predisposition to depression may begin before birth.

Maternal depression and foetal responses to novel stimuli: insights from a socio-economically disadvantaged Indian cohort.

Maternal stress during pregnancy has pervasive effects on stress responsivity in children. This study is the first to test the hypothesis that maternal prenatal depression, as observed in South India, may be associated with how foetuses respond to a potentially stressful stimulus. We employed measures of foetal heart rate at baseline, during exposure to a vibroacoustic stimulus, and post-stimulation, to study patterns of response and recovery in 133 third trimester foetuses of depressed and non-depressed mothers. We show that the association between maternal depression and foetal stress responsivity is U-shaped with foetuses of mothers with high and low depression scores demonstrating elevated responses, and poorer recovery, than foetuses of mothers with moderate levels. The right amount of intra-uterine stimulation is important in conditioning foetuses towards optimal regulation of their stress response. Our results imply that, in certain environmental contexts, exposure to moderate amounts of intra-uterine stress may facilitate this process.

Infant temperament and childhood psychiatric disorder: longitudinal study.

BACKGROUND: Temperamental characteristics emerge early in life and can shape children's development, adjustment and behaviour. We aimed to investigate the association between early infant temperament and later childhood psychiatric disorder in a community sample. METHODS: This prospective, population-based study used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). In a sample of 7318 children, we investigated whether temperamental characteristics assessed at the ages of 6 months and 24 months are associated with an independent diagnosis of psychiatric disorder ascertained at age 7 years. RESULTS: After adjusting for confounders, temperamental characteristics assessed at 6 and 24 months of age were associated with psychiatric disorder at age 7 years. In particular, intensity of emotional reaction at age 6 months was associated with later disorder (adjusted odds ratio = 1.56; 95% confidence interval 1.19, 2.04; P = 0.002). These associations were stronger in girls and in those children with high levels of intensity at both 6 and 24 months of age. CONCLUSIONS: Temperamental characteristics involving high levels of emotional intensity within the first year of life are longitudinally associated with psychiatric disorder in mid-childhood, suggesting that the roots of psychiatric disorder may, in some cases, lie very early in life.

Expressed emotion as an assessment of family environment with mothers and fathers of 1-year-old children.

BACKGROUND: High levels of expressed emotion (EE) in parents have been found to put children at risk for emotional and behavioural problems. However, the majority of existing studies have focused on mothers of school-aged children and adolescents rather than younger children, and have only rarely included fathers. METHODS: The present study examined the reliability of EE in mothers and fathers of 1-year old children. It also investigated whether depression and marital problems in the postnatal period predicted EE toward the child at 12 months. EE was assessed with the Preschool Five Minute Speech Sample in 163 families. RESULTS: The rater-interrater and code-recode reliability was high for most EE dimensions. Mothers and fathers were found to display quite similar EE scores. Regression analyses showed that depression and couple relationship significantly predicted EE in mothers, but not fathers. CONCLUSIONS: The findings suggest that EE provides a reliable and useful assessment of the family environment in families of young children.

Surgical management of metastases that involve the carotid artery in cases of primary squamous cell carcinoma of the head and neck.

The surgical management of advanced cervical metastases with carotid artery involvement in patients with primary squamous cell carcinoma of the head and neck can be difficult. The authors retrospectively reviewed 73 patients over a 15-year period comparing the outcomes of carotid artery resection versus peeling the tumour off the carotid artery. Based on these findings, the authors suggest that in the absence of carotid wall involvement, nodal metastatic tumour should be peeled off the carotid artery where possible. This practice appears to have a lower morbidity than that associated with arterial reconstruction. Steps to minimize cerebrovascular injury are discussed.

Disruption to the development of maternal responsiveness? The impact of prenatal depression on mother-infant interactions.

Both prenatal and postnatal maternal depression are independently associated with an increased risk of adverse infant development. The impact of postnatal depression on infants may be mediated through the effect of depression in reducing maternal responsiveness. However, the mechanisms underlying the effect of prenatal depression are unclear. Using longitudinal data from over 900 mother-infant pairs in a UK birth cohort (ALSPAC), we found that women with high depressive symptom scores during mid pregnancy, but NOT when their infants were 8 months, had a 30% increased risk of low maternal responsiveness when the infant was 12 months compared to women with consistently low depression. This may provide a mechanism to explain the independent association between prenatal depression and poorer infant development.

Depressed fathers' speech to their 3-month-old infants: a study of cognitive and mentalizing features in paternal speech.

BACKGROUND: Depression in fathers in the postnatal period is associated with an increased risk of child behaviour problems. A key potential pathway of risk transmission is exposure of the child to negative cognitions and affect in the context of early parenting. This study examines paternal speech during face-to-face father-infant interactions at 3 months. METHOD: Currently depressed (n=19) and non-depressed (n=19) fathers were individually matched on age and education. Speech was coded for cognitive biases and mentalizing statements using a modified version of previous measures of maternal speech. Paternal depression was diagnosed using a structured psychiatric interview. RESULTS: Depression in fathers was associated with more speech focused on the paternal experience and less on the infants' experience. Depressed fathers' speech comprised more negative and critical utterances, compared with non-depressed fathers. CONCLUSIONS: Important differences emerge in the speech of fathers who experience depression. Examining negative cognitions in the speech of these fathers as early as 3 months may help in understanding children's risk in relation to paternal psychopathology.

Parental depression and child outcomes--is marital conflict the missing link?

BACKGROUND: Both maternal and paternal depression during the perinatal period are associated with adverse effects on child outcomes. Attention has started to focus on the mechanisms mediating these relationships. Marital conflict may play a role in this context. METHODS: In a large cohort study, the Avon Longitudinal Study of Parents and Children (n = 14,541 pregnancies), we aimed to (i) investigate the relative influences of parental postnatal depression and marital conflict on child outcomes and to attempt to determine the pathway(s) of risk; (ii) investigate the impact of two types of antenatal stress (parental depression and marital conflict) on child outcomes; and (iii) determine the relative contributions of antenatal and postnatal risk. Parents completed the Edinburgh Postnatal Depression Scale and a marital conflict scale during the second trimester and at 8 months postnatally. Child outcomes were assessed at 42 months using the Rutter revised pre-school scales. RESULTS: Marital conflict partially mediated the relationship between postnatal depression in both mothers and fathers and child outcomes, and acted as an independent risk for adverse outcomes. Parental depression (maternal and paternal) and marital conflict in the antenatal period were both associated with adverse effects which persisted even when postnatal stresses were taken into account. CONCLUSIONS: These findings, if replicated, suggest that screening and intervention programmes targeted at parental depression and marital problems should be considered antenatally, as well as postnatally.