Conversational artificial intelligence: the interface with the patient concerns inventory.

The patient concerns inventory (PCI) allows patients to highlight the issues they would like to discuss at their outpatient consultation. It improves patient-clinician communication and has proven benefits. While the PCI is effective, patient experiences could be improved with better access to it and the ability to more easily and frequently express their concerns. This, of course, is in the context of ever-increasing healthcare challenges and limited resources. Use of conversational artificial intelligence (CAI) represents an opportunity to improve information flow between patients and professionals remote from the consultation. This paper highlights the potential for CAI to provide an 'always-on' platform, using natural language interface technology and based on the PCI, which patients can access via their mobile devices. We also discuss potential pitfalls and concerns, along with outlining a current clinical trial assessing, in the first instance, usability of this technology.

A 31-year review of composite radial forearm free flaps for head and neck reconstruction.

The aim of this study was to report the patient characteristics and radial fracture rates in a consecutive series of composite radial forearm free flap (CRFFF) for head and neck reconstruction over a 31-year period. The patients were identified from between 1990 to 2020 inclusive from theatre records and records from previous analyses at the Unit on free flap outcomes. Electronic case notes were accessed where available, to gather information on the operation, histopathology, and radiographs. Patients were categorised into three groups for analysis: (1) new oral cancers with a composite radial being the first choice of flap, (2) new oral cancers with a composite radial being the choice of flap following compromise of another bony flap, (3) osteoradionecrosis (ORN) cases. There were 103 CRFFF cases, median (IQR) age 69 (59-80) years, comprising 78 (Group 1), 5 (Group 2) and 20 (Group 3). The CRFFF failure rate was 6% (6/103) and the radius fracture rate was also 6% (6/103), both with 95% confidence interval 2.2-12.2%. Of the 6 radius fractures, 1 underwent surgical management (rush nailing), 1 died in hospital and the others managed with cast immobilisation. Two-year overall survival after surgery for the103 patients was 54% (SE 5%), while 5-year survival was 40% (SE 5%). In conclusion, in spite of the familiarity with other bone flaps such as fibular free flap, DCIA, scapula, and the limited bone stock and potential fracture related morbidity associated with the CRFFF, this flap still has a place in the surgical reconstructive armamentarium.

Prognostic indicators and outcomes following surgical management of metastatic cutaneous squamous cell carcinoma of the head and neck.

Metastatic cutaneous SCC carries a poor prognosis with five-year survival of 25%-57%. The aim of this study is to examine the outcomes following surgery with adjuvant therapy for management of metastatic cSCC in a UK-based population. This is a retrospective review of patients with metastatic cSCC of the head and neck who underwent primary surgery at a regional center during a six-year period. Overall and disease specific survival were calculated using Kaplan-Meier and log-rank tests. Results were reported as hazard ratios (HR) with 95% confidence intervals. Forty-five patients met the inclusion criteria. The mean time to discovery of metastases was 9.3 months (range, 0-40 months). Only two patients (4%) had discovery of metastases after two years, with none after 3.3 years. The overall five5-year survival was 31% (95% CI 15%to 48%) with two-year survival at 48% (95% CI 31%to 63%). The median OS survival was 722 days (95% CI 607to 1359). Patients aged >80 years had a decreased OS. This is the largest UK based study documenting the overall and disease specific survival associated with metastatic cutaneous SCC of the head and neck. Our overall survival is comparable to similar studies, but remains poor. Total number of involved nodes, and lymph node ratio were not statistically significant.

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.

Management of an aggressive giant cell granuloma of the mandible with denosumab: a case report.

The management of giant cell granulomas is challenging, and aggressive lesions have a high tendency to recur after enucleation alone. Based on assumptions regarding cell type and receptors, multiple pharmacological adjuncts have been used to manage them. We describe the use of denosumab, which was successfully used as a single method of treatment, suggesting that it may be a viable alternative or adjunct to operation on giant cell granulomas of the jaws.

Orthognathic surgery in Melnick-Needles syndrome: a review of the literature and report of two siblings.

Melnick-Needles syndrome (MNS) is a rare congenital X-linked dominant skeletal dysplasia, characterized by exophthalmos, a prominent forehead, and mandibular hypoplasia and retrognathism. Dental features may include anodontia, hypodontia, or oligodontia. Increased collagen content, unpredictable collagen synthesis, and abnormal bony architecture have raised concerns regarding bone splitting intraoperatively and bone healing postoperatively. This report describes the cases of two sisters with MNS, who successfully underwent orthognathic surgery consisting of bilateral mandibular ramus osteotomies combined with advancement genioplasty and iliac crest bone grafting, to correct the classical MNS facial deformity of mandibular retrognathia.

Buccal mucosa urethroplasty: a 10-year retrospective review of maxillofacial and urological outcomes.

BACKGROUND: Reconstruction of a urethral stricture poses a difficult surgical problem. Anastomotic repair remains the gold standard. Strictures longer than 2 cm may require substitution urethroplasty. This is a retrospective review of all patients who underwent urethral reconstruction with an autologous free buccal mucosa graft at a Regional hospital between 1998 and 2009. METHODS: Variables recorded included; demographics: patient gender/age; follow-up period. Urology: pre-operative diagnosis/aetiology; presenting complaint; previous urological surgery, pre-operative retrograde urethrogram, stricture length, graft size, operative time/blood loss, morbidity, complications. Maxillofacial: pre-/post-operative inter-incisal opening, patency of Stenson's parotid duct, ipsilateral parotid swelling, sensory nerve deficit. RESULTS: A total of eight male patients were included. Mean age was 33 years. Two patients had one-stage dorsal onlay urethroplasty, and the remaining six had a two-stage BMG urethroplasty. All patients underwent a urethrogram 20 days post-operatively, which demonstrated no leak, and a good caliber grafted urethra in all cases. A flexible cystoscopy scope was accommodated in all patients 8 weeks post-operatively. Mean follow-up was 42 months. At long-term follow-up, there was no evidence of stricture formation, and all patients were voiding well. There were no long-term intra-oral complications. CONCLUSION: This study suggests that anterior urethral strictures up to 6 cm in length may be predictably and safely managed with buccal mucosal urethroplasty. The buccal mucosa is easy to harvest, and can be used successfully in one- and two-stage grafting procedures. The rate of complications, from both a urological and maxillofacial perspective, in the group of patients studied was low.

Submental intubation: a retrospective review of 45 cases.

BACKGROUND: Airway management in patients undergoing maxillofacial surgery requires special consideration. A number of options including oro- or naso-tracheal intubation and tracheostomy are available. Submental intubation is now a recognised method of airway control during maxillofacial surgery. It provides a secure airway and does not interfere with maxillomandibular fixation or access to naso-orbito-ethmoid fractures. It avoids potential complications associated with nasotracheal intubation and tracheostomy in patients with multiple facial fractures, and obviates the need to alternate between oral and nasal intubation intra-operatively. METHODS: This is a ten year retrospective review of patients who underwent submental intubation in a Regional Oral and Maxillofacial Surgery Department. The following variables were recorded: patient gender and age, preoperative diagnosis, duration of intubation, and complications associated with the intubation technique. RESULTS: Submental intubation was performed 45 times on 45 patients. There were no complications relating to the submental intubation procedure. CONCLUSION: Submental intubation should be considered as an option for airway management in selected cases of craniomaxillofacial surgery. It is a quick and safe technique with minimal morbidity and a low complication rate. It allows access to the maxillofacial skeleton intra-operatively and does not preclude the use of intermaxillary fixation.

Aggressive giant cell granuloma of the jaws treated with interferon alpha: a report of two cases.

BACKGROUND: Giant cell granulomas (GCGs) are benign tumours of the jaws of unknown aetiology. Aggressive lesions are difficult to manage and demonstrate a tendency to recur after surgical curettage. In the early 1980s, interferon alpha-2a was found to inhibit angiogenesis through a series of laboratory experiments and was subsequently used to treat a child with pulmonary haemangiomatosis. It has been hypothesised that GCGs are proliferative vascular lesions and would, therefor, be expected to respond to antiangiogenic therapy. The purpose of this study is to report a treatment protocol consisting of enucleation, followed by subcutaneous interferon alpha. METHODS: Patients with a biopsy-confirmed giant cell lesion satisfying criteria for "aggressive" giant cell tumours were included. All lesions were enucleated, and the patients commenced interferon alpha-2a (3,000,000 units/m(2)) 48-72 h post-operatively. RESULTS: Two patients satisfied the criteria for aggressive giant cell lesions. All tumours were enucleated. There were no post-operative complications, and all patients tolerated the interferon therapy well. To date, there has been no evidence of tumour recurrence. The follow-up periods were 144 and 81 months, respectively. CONCLUSION: Antiangiogenic therapy, in combination with curettage, has proven to be a useful strategy for the management of these tumours. The use of interferon alpha-2a, following enucleation of these lesions, resulted in complete remission of all lesions, and decreased operative morbidity compared with conventional treatment.

A role for C-terminal cross-linking telopeptide (CTX) level to predict the development of bisphosphonate-related osteonecrosis of the jaws (BRONJ) following oral surgery?

BACKGROUND: Bisphosphonates are a class of chemical compounds used in the treatment of a variety of bone-related conditions. Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is a well-recognised complication. C-terminal cross-linking telopeptide (CTX) estimation has been suggested as an indicator for the risk of BRONJ. It was reported that values <100 pg/ml represent a high risk of developing BRONJ following surgery and those between 100 and 150 pg/ml, a moderate risk. The aim of this study was to determine the effectiveness of the CTX test in predicting the development of BRONJ. METHODS: This is an 18-month-prospective study of patients taking bisphosphonates, referred to a regional Maxillofacial Surgery Unit for dento-alveolar surgery. The following variables were recorded: age, gender, reason for referral, bisphosphonate type, indication for and duration of bisphosphonate treatment, medical co-morbidities, CTX value, development of BRONJ, and follow-up period. RESULTS: 23 patients underwent a fasting CTX test. The mean age was 59 years (range, 44-78 years). Nineteen were taking alendronic acid, two risedronate sodium and two zoledronic acid. The mean duration of bisphosphonate treatment was 30 months (range, 8-72 months). The mean CTX value was 180 pg/ml (range, 50-370 pg/ml), with 11 patients having a value at or less than 150 pg/ml. The mean follow-up period was 5 months (range, 3-11 months). None of the patients, who underwent removal of one or more teeth, subsequently developed BRONJ. CONCLUSION: The CTX test was not predictive for the development of BRONJ following oral surgery.

Spontaneous maxillary sinus rupture in the absence of pre-existing sinus disease: case report.

INTRODUCTION: Spontaneous fracture of the maxillary sinus is usually associated with enophthalmos and pre-existing sinus disease. CASE REPORT: We present a case of spontaneous maxillary sinus fracture without enophthalmos and with no preceding history of trauma or evidence of sinusitis. DISCUSSION: The closest condition to that presented is silent sinus syndrome. The differences between our case and this syndrome are reviewed. There are no previously reported cases of lateral wall maxillary fracture and associated facial surgical emphysema following nose-blowing.

Association behavior of beta-casein.

The association behavior of beta-casein, a protein with a distinct amphipathic character, was studied. beta-Casein exhibits markedly temperature-dependent association behavior; at low temperatures (<10-15 degrees C), monomers predominate, but as the temperature is increased, monomers associate, via hydrophobic bonding, into micelles. beta-Casein micelles have a hydrodynamic radius of approximately 12 nm, a radius of gyration of approximately 8.3 nm, and an interaction radius of approximately 15 nm. These data are fully consistent with a previous fluffy particle. The association behavior of beta-casein is also strongly affected by concentration and solvent quality. At low concentrations beta-casein exhibits a critical micelle concentration (CMC) of approximately 0.05%, w/v, at 40 degrees C. In the presence of 6 M urea the temperature dependence of beta-casein's association behavior is eliminated, leaving monomers predominantly. Temperature-dependent transformations in micelle morphology can be explained by changes in solvent quality, i.e., the temperature-protein hydrophobicity and temperature-voluminosity profiles of beta-casein. The results obtained are consistent with the shell model as developed by Kegeles, in which a distribution of micelle sizes is formed. They contrast with the traditional description of the micellization of beta-casein by a two-state model or by the closed-association model, i.e., monomers if micelles.

Beta blockers in older persons with heart failure: tolerability and impact on quality of life.

OBJECTIVE: To determine tolerability and symptom changes associated with the introduction of bisoprolol treatment in older patients with heart failure. DESIGN: Prospective observational cohort study. SETTING: Geriatric medicine outpatient department of a university hospital. PATIENTS: 51 patients (mean age 78 years, range 70-89 years) with stable symptomatic heart failure caused by left ventricular systolic dysfunction. INTERVENTIONS: Bisoprolol tablets, 1.25-10.0 mg. MAIN OUTCOME MEASURES: Tolerability; changes in symptoms and exercise tolerance. RESULTS: 69% of patients tolerated bisoprolol. Mean tolerated dose was 7.6 mg. There was no change in symptoms or exercise capacity in those who tolerated bisoprolol. Perceived health status and symptoms of anxiety and depression improved during the titration period. CONCLUSIONS: The rate of withdrawal from bisoprolol treatment in older patients with congestive heart failure was twice that previously reported in younger patients. The mean tolerated dose was similar to that found in trials reporting clinical efficacy. There was no evidence of a negative impact on symptoms or exercise capacity in patients who tolerated bisoprolol.

Ethanol-dependent heat-induced dissociation of casein micelles.

The dissociation of casein micelles when heated to approximately 65 degrees C in the presence of ethanol [1:1 mixture (v/v) of milk and 65% (w/w) aqueous ethanol] was investigated using L* values and transmission measurements. Mixtures of milk and ethanol became transparent on heating, which suggests dissociation of casein micelles. Results of experiments using confocal laser scanning microscopy, light scattering (static and dynamic), and dialysis to examine the changes of milk during heating in the presence of ethanol supported the assertion that such treatments result in dissociation of casein micelles, as did studies of model beta-casein micellar systems.

Mechanism for the ethanol-dependent heat-induced dissociation of casein micelles.

An explanation as to how casein micelles dissociate when heated in the presence of ethanol is presented. Dissociation of casein micelles in milk-ethanol mixtures was studied using (1)H NMR, and the effects of addition of CaCl(2), NaCl, or EDTA or alteration of milk pH on this dissociation were studied. It is proposed that at low temperatures, ethanol reduces the solvent quality of milk serum, but above a critical temperature (approximately 30 degrees C in a 35% ethanol solution), ethanol enhances solvent quality and dissociates the casein micelles. Ethanol reduced protein hydrophobicity and increased the pK(a) value of phosphoserine, effects that are likely to be significant in the dissociating effect of ethanol at elevated temperatures.