Management of Soft Tissue Injuries in Children-A Comprehensive Review.

Airway injury, Ocular injury and neurovascular tissue damage, burns is all a spectrum of pediatric soft tissue injury complex. Soft tissue injuries to the head and neck area in children are challenging to manage, because these injuries significantly affect the child's overall health and development. Management of such injuries requires a multidisciplinary approach involving surgical and nonsurgical interventions and close collaboration among health care professionals, parents, and caregivers. This article reviews the various causes of injuries, specific considerations for each region of the head and neck, and approaches to the surgical management of soft tissue injuries in pediatric patients, including surgical and adjuvant therapies. Specific anatomic regions reviewed include the scalp/forehead, periorbital region, nose, cheeks, lips, ears, and neck/airway.Laceration repair in the growing pediatric populations may require revisions in the future. Facial soft tissue injuries are prone to poor cosmesis as in many occasions as may be constrained by available surgical specialists, thus proper multispecialty team approach along with surgical alignment and symmetry should be considered comprehensively.

Is There a Correlation Between Comprehensive Basic Science Examination and United States Medical Licensure Examination Step 1 Performance Among Oral and Maxillofacial Surgery Residents?

PURPOSE: Oral and maxillofacial surgery (OMS) applicant Comprehensive Basic Science Examination (CBSE) scores are scrutinized by residency programs and medical schools because of their perceived predictive value for United States Medical Licensure Examination (USMLE) Step 1 performance. The purpose of this study was to answer the following question: Is there a correlation between the OMS applicant's CBSE score and his or her later USMLE Step 1 score? MATERIALS AND METHODS: We e-mailed all current 45 dual-degree OMS residency programs to request participation in the study. Participating programs submitted residents' CBSE scores and USMLE Step 1 scores. RESULTS: Of 45 United States-based, dual-degree OMS residency programs, 23 (51%) enrolled in the study, including data for 152 residents from 2012 to 2018. The mean CBSE score was 71 (range, 47 to 99). The mean USMLE Step 1 score was 220 (range, 177 to 266). The Pearson correlation coefficient for the relationship between the CBSE and USMLE Step 1 scores was 0.36. The overall USMLE pass rate was 97%. On the USMLE Step 1, OMS residents outperformed their translated CBSE score by an average of 15 points. Of the 50 residents (33%) with a translated CBSE score below the passing level, 94% passed the USMLE Step 1. Residents who had a translated passing CBSE score outscored residents with a translated failing score by 14 points when taking the USMLE Step 1 (225 vs 211). CONCLUSIONS: Although no statistically significant difference in the USMLE Step 1 pass rates was found between OMS residents with a translated passing CBSE score and those with a translated failing CBSE score, a weak positive correlation was noted between CBSE and USMLE Step 1 scores. These data do not support the use of a certain cutoff CBSE score for OMS applications by OMS program directors, especially as it pertains to interview offers.

Data-driven method to enhance craniofacial and oral phenotype vocabularies.

BACKGROUND: A significant amount of clinical information captured as free-text narratives could be better used for several applications, such as clinical decision support, ontology development, evidence-based practice, and research. The Human Phenotype Ontology (HPO) is specifically used for semantic comparisons for diagnostic purposes. All these functions require quality coverage of the domain of interest. The authors used natural language processing to capture craniofacial and oral phenotype signatures from electronic health records and then used these signatures for evaluation of existing oral phenotype ontology coverage. METHODS: The authors applied a text-processing pipeline based on the clinical Text Analysis and Knowledge Extraction System to annotate the clinical notes with Unified Medical Language System codes. The authors extracted the disease or disorder phenotype terms, which were then compared with HPO terms and their synonyms. RESULTS: The authors retrieved 2,153 deidentified clinical notes from 558 patients. Finally, 2,416 unique diseases or disorders phenotype terms were extracted, which included 210 craniofacial or oral phenotype terms. Twenty-six of these phenotypes were not found in the HPO. CONCLUSIONS: The authors demonstrated that natural language processing tools could extract relevant phenotype terms from clinical narratives, which could help identify gaps in existing ontologies and enhance craniofacial and dental phenotyping vocabularies. PRACTICAL IMPLICATIONS: The expansion of terms in the dental, oral, and craniofacial domains in the HPO is particularly important as the dental community moves toward electronic health records.

The Effect of Oral and Maxillofacial Surgery Curriculum on United States Medical Licensing Examination Step 1 Performance.

PURPOSE: Over the years, a few types of combined oral and maxillofacial surgery (OMS)-MD residency curricula have evolved that differ in how the MD is integrated. The purpose of this study was to look for a difference in United States Medical Licensure Examination (USMLE) Step 1 pass rates among these different curricula. MATERIALS AND METHODS: An anonymous electronic survey was e-mailed to the directors of all 46 United States-based OMS-MD-integrated programs, querying OMS curriculum type and USMLE Step 1 results over the years 2007-2017. Programs were then characterized by the curriculum sequence, whether USMLE Step 1 was taken before or after starting medical school, and the amount of dedicated test preparation time. RESULTS: Of 46 OMS-MD program directors, 32 (70%) responded. No statistically significant difference in the USMLE Step 1 pass rate was found among the 4 main types of OMS-MD curricula (range, 89 to 95%; P = .06). Completing some part of medical school before taking USMLE Step 1 also had no effect on OMS residents' pass rates (94% vs 92%, P = .23). However, an increasing number of weeks of dedicated test preparation time was significantly correlated with increasing USMLE Step 1 pass rates (87% with no dedicated test preparation time, increasing to 96% with ≥6 weeks of dedicated test preparation time; P = .05). Finally, only 7 of 806 total residents (0.9%) dropped out of a program because of the inability to pass USMLE Step 1. CONCLUSIONS: The data show a high overall USMLE Step 1 pass rate with a direct correlation between the duration of dedicated test preparation time and pass rate. No difference in USMLE Step 1 pass rates was observed based on the sequence of OMS-MD-integrated curricula or the completion of some pre-USMLE medical school before USMLE Step 1 among OMS residents.

The Human Phenotype Ontology in 2017.

Deep phenotyping has been defined as the precise and comprehensive analysis of phenotypic abnormalities in which the individual components of the phenotype are observed and described. The three components of the Human Phenotype Ontology (HPO; www.human-phenotype-ontology.org) project are the phenotype vocabulary, disease-phenotype annotations and the algorithms that operate on these. These components are being used for computational deep phenotyping and precision medicine as well as integration of clinical data into translational research. The HPO is being increasingly adopted as a standard for phenotypic abnormalities by diverse groups such as international rare disease organizations, registries, clinical labs, biomedical resources, and clinical software tools and will thereby contribute toward nascent efforts at global data exchange for identifying disease etiologies. This update article reviews the progress of the HPO project since the debut Nucleic Acids Research database article in 2014, including specific areas of expansion such as common (complex) disease, new algorithms for phenotype driven genomic discovery and diagnostics, integration of cross-species mapping efforts with the Mammalian Phenotype Ontology, an improved quality control pipeline, and the addition of patient-friendly terminology.

The Monarch Initiative: an integrative data and analytic platform connecting phenotypes to genotypes across species.

The correlation of phenotypic outcomes with genetic variation and environmental factors is a core pursuit in biology and biomedicine. Numerous challenges impede our progress: patient phenotypes may not match known diseases, candidate variants may be in genes that have not been characterized, model organisms may not recapitulate human or veterinary diseases, filling evolutionary gaps is difficult, and many resources must be queried to find potentially significant genotype-phenotype associations. Non-human organisms have proven instrumental in revealing biological mechanisms. Advanced informatics tools can identify phenotypically relevant disease models in research and diagnostic contexts. Large-scale integration of model organism and clinical research data can provide a breadth of knowledge not available from individual sources and can provide contextualization of data back to these sources. The Monarch Initiative (monarchinitiative.org) is a collaborative, open science effort that aims to semantically integrate genotype-phenotype data from many species and sources in order to support precision medicine, disease modeling, and mechanistic exploration. Our integrated knowledge graph, analytic tools, and web services enable diverse users to explore relationships between phenotypes and genotypes across species.

Navigating the Phenotype Frontier: The Monarch Initiative.

The principles of genetics apply across the entire tree of life. At the cellular level we share biological mechanisms with species from which we diverged millions, even billions of years ago. We can exploit this common ancestry to learn about health and disease, by analyzing DNA and protein sequences, but also through the observable outcomes of genetic differences, i.e. phenotypes. To solve challenging disease problems we need to unify the heterogeneous data that relates genomics to disease traits. Without a big-picture view of phenotypic data, many questions in genetics are difficult or impossible to answer. The Monarch Initiative (https://monarchinitiative.org) provides tools for genotype-phenotype analysis, genomic diagnostics, and precision medicine across broad areas of disease.

Routine Screening Radiography for Retained Wire Following Arch Bar Removal Is Not Indicated.

PURPOSE: To estimate the screening test value of routine radiography after arch bar wire removal by assessing the incidence of retained wires and the importance of their sequelae. MATERIALS AND METHODS: This was a retrospective medical record review. Records of arch bar removal procedures were examined and divided into those screened with radiography after removal (screen group) and those that were not screened (comparison group). The incidence of retained wire was calculated for each group. Study variables included wire-related radiographic or clinical findings. RESULTS: Records of 546 mandible fractures were reviewed; 95 met the study criteria. Most exclusions were due to lack of arch bars, missing postoperative radiographs, or insufficient postoperative documentation. Of the 55 records in the screen group, 1 wire was detected (2%); of the 40 records in the comparison group, 1 wire was detected (3%). The total incidence of retained wire findings was not statistically different between the 2 groups and there were no adverse wire-related sequelae reported by any of the 95 patients. CONCLUSION: Because of the low incidence of retained wires and wire-related sequelae, routine imaging after wire removal is probably not an effective screening test for retained wire and should be limited to situations in which there is clinical suspicion of retained wire.

Prevalence of loss of all teeth (edentulism) and associated factors in older adults in China, Ghana, India, Mexico, Russia and South Africa.

Little information exists about the loss of all one's teeth (edentulism) among older adults in low- and middle-income countries. This study examines the prevalence of edentulism and associated factors among older adults in a cross-sectional study across six such countries. Data from the World Health Organization (WHO's) Study on global AGEing and adult health (SAGE) Wave 1 was used for this study with adults aged 50-plus from China (N = 13,367), Ghana (N = 4724), India (N = 7150), Mexico (N = 2315), Russian Federation (N = 3938) and South Africa (N = 3840). Multivariate regression was used to assess predictors of edentulism. The overall prevalence of edentulism was 11.7% in the six countries, with India, Mexico, and Russia has higher prevalence rates (16.3%-21.7%) than China, Ghana, and South Africa (3.0%-9.0%). In multivariate logistic analysis sociodemographic factors (older age, lower education), chronic conditions (arthritis, asthma), health risk behaviour (former daily tobacco use, inadequate fruits and vegetable consumption) and other health related variables (functional disability and low social cohesion) were associated with edentulism. The national estimates and identified factors associated with edentulism among older adults across the six countries helps to identify areas for further exploration and targets for intervention.

Deidentification of facial images using composites.

PURPOSE: Maxillofacial surgeons rely on photography for education and documentation. Photographs of the face, unlike those of other body regions, are readily identifiable. Traditional methods of facial image deidentification decrease educational quality or fail to adequately conceal identity. In the present study, a method that uses blended facial composites to deidentify original facial images was developed. This method allows significant components of the original face to be visualized while concealing its identity. MATERIALS AND METHODS: The method was used to develop 20 different composite facial images that were viewed by student subjects. Ten of these images contained at least one third of a face that was familiar to the subjects. Subjects viewed the composite faces twice--first unaware that the faces were composites, and then primed to the presence of composites. Subjects later rated the efficacy of this method for image deidentification. RESULTS: When unaware that they were viewing composite images, no subjects recognized the familiar faces within the composites or rated them as familiar (0/120 total views, 0%). When later primed to the potential presence of familiar faces within composites, the identification rate increased significantly (74/120, 62%; P < .001). Results were similar no matter which portion of the familiar face (upper, 67%; mid, 54%; lower, 67%) was present. Subjects rated all composites as clinically realistic patient images. They also rated composites as more effective at deidentification than traditional methods. CONCLUSION: The use of composites appears to be a promising concept for facial image deidentification. Further larger-scale studies are needed to validate these findings.

Embrasure wires for intraoperative maxillomandibular fixation are rapid and effective.

PURPOSE: The management of some mandible fractures requires maxillomandibular fixation (MMF) intraoperatively but not postoperatively. Intraoperative MMF with arch bars has significant disadvantages, including duration of application and risk of disease transmission. Some surgeons have sought to minimize these disadvantages, improve efficiency, and decrease cost by omitting formal MMF altogether and manually stabilizing the occlusion. Embrasure wires are a method of intraoperative MMF with significant potential advantages. The purpose of this investigation was to compare embrasure wires with Erich arch bars (Karl Leibinger Co, Mulheim, Germany) for intraoperative stabilization of mandible fractures. PATIENTS AND METHODS: This retrospective case review comprised 50 patients with a primary diagnosis of mandible fracture requiring open reduction-internal fixation with intraoperative MMF. Patients were categorized into 2 groups: intraoperative MMF using embrasure wires (group A) or intraoperative MMF using arch bars (group B). In each group the time required to place the MMF was recorded in whole minutes. The success or failure of the technique to maintain stable MMF throughout the procedure was assessed. RESULTS: Intraoperative MMF was used with embrasure wires in 27 of 50 patients (54%) and with arch bars in 23 of 50 (46%). The mean time required for placement of embrasure wire MMF (2.51 minutes) was significantly (P < .001) less than the mean time required for placement of arch bar MMF (25.47 minutes). The quality of MMF was judged to be stable for the duration of fixation in 24 of 27 patients (89%) in the embrasure wire MMF group and 22 of the 23 patients (96%) in the arch bar group. This difference was not significant (P = .61). CONCLUSION: Embrasure wires can be placed in significantly less time than arch bars, and they provide a reliable form of intraoperative MMF during mandible fracture repair. For intraoperative MMF, embrasure wires offer significant advantages compared with arch bars by reducing application time. In addition, embrasure wires may reduce the risk of disease transmission by decreasing the number of wires required for MMF.

Anterior iliac crest, posterior iliac crest, and proximal tibia donor sites: a comparison of cancellous bone volumes in fresh cadavers.

PURPOSE: The anterior iliac crest, posterior iliac crest, and proximal tibia are common cancellous donor sites used for autogenous bone grafting. Donor site selection is partly dependent on the expected volume of available bone, but reports of cancellous bone volumes at each of these sites are variable. The goal of this study was to compare the volumes of cancellous bone harvested from donor sites within the same cadaver. MATERIALS AND METHODS: Within each of 10 fresh frozen cadavers, cancellous bone was harvested from 3 donor sites-anterior iliac crest, posterior iliac crest, and proximal tibia-using established surgical techniques. Bone volumes were measured by fluid displacement. Mean compressed cancellous bone volumes from the 3 donor sites were compared among cadavers. Within each cadaver, the 3 donor sites were given a volume rank score from 1 (least volume) to 3 (most volume). RESULTS: Among cadavers, mean compressed cancellous bone volumes from the proximal tibia (11.3 mL) and posterior iliac crest (10.1 mL) were significantly greater than the anterior iliac crest (7.0 mL). Within cadavers, the mean volume rank score of the proximal tibia (mean rank, 2.7) was statistically greater than that for the posterior iliac crest (mean rank, 2.0), which was statistically greater than that for the anterior iliac crest (mean rank, 1.2). Strong correlations in bone volume existed between the proximal tibia and iliac crests (r = 0.67) and between the anterior iliac crest and posterior iliac crest (r = 0.93). CONCLUSION: The proximal tibia and posterior iliac crest yielded a significantly greater mean volume of compressed cancellous bone than the anterior iliac crest. Within individual cadaver skeletons, the proximal tibia was most likely to yield the largest cancellous volume, whereas the anterior iliac crest was most likely to yield the smallest cancellous volume. Although the proximal tibia contains relatively large volumes of cancellous bone, further investigation is required to determine how much cancellous bone can safely be harvested.

Standardizing Clinical Document Names Using the HL7/LOINC Document Ontology and LOINC Codes.

The standardization of clinical document names is an essential first step towards the optimal use, management, and exchange of documents within and across institutions. The HL7/LOINC Document Ontology (DO) is an existing and evolving document standard developed to provide consistent naming of clinical documents and to guide the creation of LOINC codes for clinical notes. The goal of this study was to explore the feasibility and challenges of mapping local clinical document names from two institutions into the five axes of the DO and then to leverage this mapping for identifying specific LOINC codes. The results indicate that the DO is either adequate or too broad for representing a majority of the document names and that there are LOINC codes available for one- to two-thirds of the names. Through this mapping process, granularity and other issues were revealed that will be valuable for guiding next steps towards effective standardization of clinical document names.

The use of immediate bone grafting in reconstruction of clinically infected mandibular fractures: bone grafts in the presence of pus.

PURPOSE: Current approaches to the treatment of infected mandibular fractures include antibiotics, drainage, immobilization of the segments, and debridement followed by secondary bone grafting of residual defects once the infection is resolved and the wound healed. Over the past 30 years, the time from debridement to grafting has diminished from several months to a few weeks. We present our experience with a treatment model managing clinically infected fractures of the mandible with antibiotics, debridement, rigid internal fixation, and immediate autogenous bone grafting. MATERIALS AND METHODS: In this retrospective study, we present a series of 43 patients who demonstrated clinical/laboratory findings consistent with infection in one or more mandibular fractures (50 infected fractures). These patients underwent a combination of incision and drainage, fracture debridement, rigid internal fixation, and immediate bone grafting of the resulting defect in a single stage. Both transoral and transfacial approaches were used. RESULTS: Of the 50 fractures, 43 showed both resolution of infection and bony union of fractures with long-term follow-up of 2 months to 4 years. Four fractures developed recurrent infection but proved to have bony union and were successfully treated by hardware removal only. Three other patients were deemed failures with persistent infection, loss of graft, nonunion, and need for retreatment. Each of these patients was afflicted with underlying immunocompromise. CONCLUSIONS: Although careful patient selection is a must, immediate bone grafting of infected mandibular fractures, when used in conjunction with rigid internal fixation and appropriate intraoperative debridement, is an effective treatment modality which allows a single surgical procedure and dramatically shortens the course of treatment.