The importance of attentive primary care in the early identification of mild cognitive impairment: case series.

Background: Mild cognitive impairment (MCI) is a condition often preceding Alzheimer's disease and other dementias, characterized by subtle changes in cognitive function. While the importance of early detection is recognised, MCI is frequently underdiagnosed, especially when patients consult primary care physicians for non-cognitive health concerns. The case series aims to investigate the incidental identification of MCI in older patients who visit primary care settings for reasons unrelated to memory issues. Case Description: This is a retrospective case series comprising eight patients, ranging in age from 67 to 77 years, who initially presented in primary care settings for diverse non-memory-related concerns such as headaches, urinary tract infection (UTI) symptoms, and knee pain. Despite the lack of memory-related complaints, incidental findings suggestive of MCI were observed during clinical evaluations. The study explores the distinctions in clinical presentations and diagnostic pathways through thorough history taking and cognitive assessments, including the Montreal Cognitive Assessment (MoCA) and brain magnetic resonance imaging (MRI). Conclusions: The study highlights the critical role that primary care settings can play in the early detection of MCI, even when patients present with non-cognitive complaints. It emphasizes the importance of comprehensive history taking as a tool for incidental identification of cognitive impairment. Although limited by sample size, the study calls for increased vigilance in primary care settings and suggests the need for future research aimed at optimizing early detection and management strategies for MCI in a primary care context.

The multifaceted roles of GP trainers in guiding trainee transition to portfolio general practice.

The journey of transitioning from a GP trainee to a portfolio GP is a complex and transformative process. This article explores the multi-dimensional roles that GP trainers play in guiding trainees through this key transition. This article, also, aims to challenge readers to consider how GP trainers can further enhance their role in minimising barriers and maximising opportunities for trainees, inviting contributions to the educational discussion on this topic.Serving as mentors, GP trainers navigate trainees through the particulars of general practice, ensuring they are equipped with both skills and resilience. They also play the role of confidantes, offering emotional and psychological support in times of doubt and uncertainty. As anchors, GP trainers provide stability, helping trainees find their footing in the vast domain of general practice and instilling core professional values. Furthermore, bridging the gap between academic knowledge and real-world practice, GP trainers guide trainees in effectively applying theoretical knowledge in clinical scenarios.Despite the inherent challenges, the bond between trainer and trainee is rewarding, ensuring a holistic evolution into competent portfolio GPs, thereby significantly influencing the future of primary care and patient outcomes.

Effect of chronic heavy tobacco smoking on ankle fracture healing.

INTRODUCTION: Tobacco smoking is linked to an elevated risk of osteomyelitis and delayed healing in long bone fractures. However, the impact of smoking on bone union and soft tissue recovery following ankle fractures remains unclear. This study presents a retrospective comparative analysis evaluating the effects of chronic heavy tobacco smoking on the healing process and outcomes of ankle fractures after surgical interventions. MATERIALS AND METHODS: We examined 220 consecutive cases of chronic heavy smokers (CHS) with closed ankle fractures who were referred to our unit for further treatment. A control group, consisting of 220 age- and sex-matched individuals (non-smokers with closed ankle fractures), was identified for comparative analysis. We collected clinical data, including pre-existing comorbidities, Lauge-Hansen fracture classification, necessity for surgery, and the surgical procedures performed. The primary outcomes investigated were the time required for fracture union and wound healing. Secondary outcomes included postoperative complications such as prolonged pain, bleeding, swelling, infection, compartment syndrome, and neurovascular impairment, as well as the incidence of delayed union, non-union, and the need for further intervention. Both cohorts were monitored for a minimum of 24 months. RESULTS: Our analysis revealed that the surgical cohort of chronic heavy smokers exhibited a statistically significant delay in fracture union compared to both the conservatively managed smokers and the control group. Further scrutiny of the surgical cohort of chronic smokers indicated a significant correlation between smoking and extended postoperative pain duration, persistent swelling at the fracture site, and both superficial and deep wound infections. Additionally, these patients experienced delays in both fracture union and wound healing when compared to the control group. Similarly, the conservatively managed chronic smokers showed a marginal increase in the incidence of post-injury pain duration, extended swelling at the fracture site, and delayed union compared to the control group. CONCLUSION: Patients who are chronic heavy smokers and require surgical intervention for ankle fractures should be made aware of their increased risk for delayed fracture union and poor wound healing. Orthopedic surgeons should proactively encourage these patients to participate in smoking cessation programs.

Mental Health Polypharmacy in "Non-Coded" Primary Care Patients: The Effect of Deprescribing.

Background: Mental health (MH) polypharmacy, defined as prescribing multiple mental health medications for the same condition, presents significant challenges in clinical practice. With varying prevalence rates and an increasing trend, particularly in the UK, this deprescribing prospective quality improvement project aimed to address the complexities and risks associated with MH polypharmacy. Patients and Methods: A large primary care centre in London was selected for this project. Electronic records of 667 patients (non-coded in mental health lists) were analysed as a result of the absence of a Systematised Nomenclature of Medicine Clinical Terms (SNOMED CT) for mental health. Seventy-two non-coded patients exhibiting "same-class" as well as "adjunctive" and "augmentation" polypharmacy were identified. Their demographic and health data, including MH diagnoses, physical status, and lifestyle habits, were evaluated. This deprescribing prospective project included 68 patients and employed a model inspired by the Plan-Do-Study-Act (PDSA) cycle, focusing on reducing psychotropic, adjunctive, and augmentative medications while monitoring mental health control through face-to-face consultations using the Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder Assessment-7 (GAD-7) scores, alongside physical health parameters. Results: The project revealed a significant decrease in the average number of psychotropic and adjunct medications from initial consultations to the end of the 18-month period. Additionally, a marked reduction in reported side effects and drug interactions was observed. Improvements in mental health control, as evidenced by PHQ-9 and GAD-7 scores, were noted. Physical health parameters, including BMI, blood pressure, heart rate, HbA1c, and cholesterol levels, also showed significant improvements. Educational initiatives for patients and clinicians were successfully implemented, contributing to these positive outcomes. Discussion: The project faced challenges like balancing medication reduction with mental health stability, patient apprehension, and the absence of standardised protocols. However, the successful reduction in medication numbers and the improvement in health outcomes highlight the effectiveness of the model. This project underscores the necessity of a tailored approach to MH polypharmacy, emphasising continuous education, clinical titration, and adherence to guidelines. Future research is needed to develop clear guidelines for medication combination in mental health care and to understand the long-term effects of polypharmacy in mental health populations. Conclusions: This project demonstrates the potential for significant improvements in the management of MH polypharmacy. By carefully managing medication reductions and employing a comprehensive care approach, including patient education and clinician training, the project achieved improvements in both mental and physical health outcomes. These findings suggest a promising direction for future practices in MH polypharmacy management.

Quality of life following photodynamic therapy for head and neck pathologies: An exploratory study.

INTRODUCTION: Healthcare related quality of life (QoL) is defined as the impact one's level of health and wellbeing has on a number of domains, including physical, mental, spiritual and social functions. Photodynamic therapy (PDT), a cancer treatment modality, is increasingly used to treat or palliate head and neck pathologies. Due to the complex nature of this area of the body, both the pathology and the treatment of it can severely affect the quality of life. Thus far, no questionnaire has been developed which focuses on quality-of-life post-PDT of head and neck pathologies. PATIENTS AND METHODS: We have developed the University College London Quality of Life Questionnaire for Patients undergoing PDT in the Head and Neck, using meta-tetra(hydroxyphenyl)chlorin (mTHPC) as the photosensitiser. This was modified from the University of Washington quality of life (UW-QOL) questionnaire. Thirty-eight patients who received mTHPC-PDT for various head and neck pathologies completed the questionnaire, with a mean follow-up of 56 days. RESULTS: All patients reported improved QoL following mTHPC-PDT. The main problem that was reported was post-PDT pain, which is a common side effect. Visual symptoms, breathing, speaking and swallowing problems improved significantly in the 4th week following treatment and significant improvement in activities of daily living, social life, mood and anxiety were reported in the subsequent weeks. CONCLUSIONS: mTHPC-PDT confers improvement in QoL score in selected head and neck cancer patients with figures comparable to other treatment modalities. This exploratory study demonstrated patterns of QoL outcome. Further work needs to be done for survey validation and inclusion of a larger cohort which will allow optimal sub-group analysis and help guide further interventions.

From Basic Mechanisms to Clinical Research: Photodynamic Therapy Applications in Head and Neck Malignancies and Vascular Anomalies.

Head and neck cancers are largely squamous cell carcinomas derived from the epithelial lining of the structures in the region, and are often classified anatomically into oral, oropharyngeal, nasopharyngeal and laryngeal carcinomas. The region's component structures serve complex and intricate functions, such as speaking, swallowing and breathing, which are often compromised by these neoplasms. Such lesions may also cause disfigurement, leading to distressing social and psychological issues. Conventional treatments of these neoplasms usually involve surgical intervention with or without chemoradiotherapy. These have shown to be efficacious; however, they can also cause damage to healthy as well as diseased tissue, exacerbating the aforementioned problems. Access to a given region to deliver the treatments is also often a problem, due to the complex anatomical structures involved. The use of photodynamic therapy in the head and neck region has been established for about two decades. In this review, we looked at the basic mechanisms of this intervention, examined its use in common head and neck malignancies and vascular anomalies, and reported on the most recent clinical studies. We further included a clinical guide which can help replicate the use of this technology by any unit. Based on this review, photodynamic therapy has been shown to be efficacious in the treatment of head and neck malignancies and vascular tumours. This therapy can be targeted to the diseased tissue and causes no damage to underlying structures. Recent studies have shown this therapy to be as effective as conventional therapies, without causing major adverse effects.

The consequences and outcomes associated with dental implants encroaching on adjacent teeth.

BACKGROUND: Dental implant placement carries a risk of iatrogenic damage to adjacent root surfaces. PURPOSE: To classify and understand different types of trauma to the tooth root body by dental implants. MATERIALS AND METHODS: This prospective case series included 43 implants placed between February 2017 and June 2020 that had primary stability and were in a position that accidentally invaded the adjacent teeth. The type and degree of the injury were evaluated clinically and radiographically. Tenderness, mobility, and sensitivity tests of the injured teeth were conducted at different visits. Implant failure was confirmed by the presence of implant mobility during the healing period. RESULTS: Overall, 43 patients had root injuries due to dental implant surgeries. Regarding the 43 injured roots, 32 developed transient tenderness to percussion, 16 developed variable degrees of resorption in the cementum, three lost pulp sensitivity and one had persistent tenderness to percussion. No injured teeth were lost. In three patients, implant periapical lesions were confirmed radiographically as radiolucency near the apex of the involved implants. Out of the 43 implants, 11 failed and were removed within 6 months, with an implant failure rate of (25%). CONCLUSIONS: Root damage after implant surgery varies depending on the type and severity of injury. Periodic clinical and radiographical examination is necessary to monitor root resorption and implant integration and to rule out pulp necrosis.

In vivo optical coherence tomography-guided photodynamic therapy for skin pre-cancer and cancer.

BACKGROUND: The primary aim of this prospective study is to demonstrate the technical feasibility of OCT to map real tumor margins and to monitor skin changes that occurred post- PDT. Moreover, to optimize PDT efficacy based on the relationship between measured OCT features and treatment outcome. MATERIAL AND METHODS: A series of 12 patients with overall 18 facial skin lesions were investigated by OCT before surface illumination by PDT to determine tumor free margins. Monitoring of the healing process was undertaken at 3, 6 and 12 months post-PDT. Parameters measured by the in vivo OCT during healing phase were the organization of skin layer and the degree skin fibroses for the active center and peripheral transit zone of the treated lesion. Clinical and aesthetics assessment was carried out at 12-month post-PDT. RESULTS: Distinct microstructural differences between normal skin, pre-cancer, cancer, and the transition zone between the two tissues were observed on OCT images. In the subsequent healing phase, OCT demonstrate marked delineation and organization of skin layer at late stage of healing. Early features showing bizarre non-homogenous disorganized layering (scab) but afterwards, OCT was able to differentiate between different histological layers. One lesion demonstrated clinical healing by fibrosis (scar) without sign of recurrence. Another lesion demonstrated skin erythema. Only one lesion did not response to treatment despite margins clearance. The CR rate was 95% at the end of the study. The cosmetic effect was "excellent" in 89% of the patients. CONCLUSIONS: This feasibility study lays the groundwork for using OCT as a real-time, noninvasive monitoring device for PDT in patients with skin cancer.

Squamous cell carcinoma of the ear treated by photochemical internalization.

A 77-year-old Caucasian male was diagnosed with squamous cell cancer of the right ear. The patient elected to take part in the first-in-man phase I TPCS2a based bleomycin photochemical internalization (PCI). On Day 0, The patient received the photosensitiser [Amphinex (TPCS2a)], by slow intravenous injection. Four days later, surface illumination based (PCI) was implemented 3 h after the slow infusion of Bleomycin. Four weeks following the infusion of the photosensitiser, the cancerous area turned into black rigid mass with clear demarcation from the macroscopically normal skin. The size of the treated area has been substantially reduced. Histopathologic assessment of the excised necrotic mass revealed no viable tumour and the excised margins (PCI-treated margins) were tumour-free. This case was a clear indication that PCI is a clinically relevant technique that has potential in the treatment of such cancers to avoid radical intervention.

In vivo optical coherence tomography in assessment of suspicious facial lesions: A prospective study.

BACKGROUND: Skin cancer continues to be the most common cancer in the Caucasian population. Over the past two decades, researchers around the world started assessing the possibility of diagnosing tissue pathologies by using optical systems. In this study, we aimed to use in vivo optical coherence tomography (OCT) technology to describe the morphologic features of normal and pathologic skin conditions. MATERIALS AND METHODS: In this study, 72 patients with suspected skin pre-cancer/cancer were recruited. The lesions were subjected to in vivo OCT scanning using compact size probe. The main scanned areas were the centre of the lesion, periphery of the lesion and control reading at least 2cm from the lesion periphery but within the same dermatomal distribution. Following assessment, each lesion was surgically excised. All acquired OCT images were correlated with the corresponding histopathology images to ensure an accurate diagnosis and appropriate co-localisation of abnormal lesion on both OCT image and pathology slide. This was achieved in every resected lesion. RESULTS: Histopathological analysis revealed that of the 96 macroscopically suspicious scanned lesions 26 were actinic keratosis (AK), 51 were basal cell carcinoma (BCC) and 19 were cutaneous squamous cell carcinoma (SCC). Different layers of healthy skin can be distinguished with clear demarcation between the epidermis and papillary dermis. An increase in epidermal thickness was observed in OCT images in AK that appeared relatively hyperintense. Cutaneous SCC was characterized by hypoechoic signal free spaces within the dermis and damaged of dermal-epidermal junction. BCCs were visualized as hypoechoic structures but showed a mixed echogenicity. Solid nodular BCC appeared as single or multiple areas with no clear arrangement surrounding low-reflectivity lobular structures surrounded. Cystic structures were identifiable by signal-free areas adjacent to healthy skin. Sensitivity and specificity for in vivo OCT in diagnosing these lesions were impressive, based on this small sample size. CONCLUSIONS: OCT have shown that there are qualitative differences in OCT image features of skin with varying degrees of pathology, and between normal and pathological skin. This study indicates that in vivo OCT shows a good promise as a useful optical diagnostic technique in diagnosing skin pathologies.

Evaluation of different surgical approaches to remove dental implants from the maxillary sinus.

Dental implant surgery on atrophied maxilla has many risks; in some patients, simultaneous sinus lifting with implant placement must be performed to increase the chances of successful implantation; this procedure can cause implant migration. Eleven patients were diagnosed with implant migration into the maxillary sinus in four anatomical areas: the sinus floor above the alveolar bone, near the junction of the sinus and nasal floor, near the floor of the orbit, and the most posterior aspect of the sinus. Surgical removal was performed through four different direct non-endoscopic transoral approaches depending on the location of the displaced implant. Surgical challenges, surgery duration and postoperative complications were reported. The least challenging surgical intervention was noted when removing the displaced implants from the floor of the sinus through the crestal approach. More challenges were experienced during the surgical removal of anteriorly displaced implants near the roof of the orbital floor due to surgical access and the proximity of vital anatomical structures. Bleeding from the pterygoid venous plexus was profound with the posterior lateral approach. The choice of an appropriate surgical approach to retrieve displaced dental implants from the maxillary sinus depends on the location of the implant and the surrounding vital anatomical structures.

Post COVID-19 lockdown: measures and practices for dental institutes.

Resuming regular clinical activities at dental premises after the COVID-19 lockdown period or post COVID-19 is likely to be a challenge for all dental institutes. When returning to the dental practice or training, staff and students alike should abide by the new rules and regulations. In the process of controlling viral spread, clinical dental facilities face a higher risk of disease transmission among patients as well as clinical and non-clinical staff. Aerosols formation and diffusion into the surrounding air can be a real concern of viral transmission, if no protective measures are established. We aim in this review to present the currently implemented measures and propose changes in clinical dental facilities to minimize the risk of transmission. Dental professionals should be prepared to treat every patient as a suspected COVID-19 carrier and be ready to receive and manage an overwhelming number of patients. We suggest that dental practices establish a sensible workforce shift schedule, improve ventilation levels, reduce dental aerosol generating procedures, and develop a comprehensive guidance to Healthcare Workers to reduce the risk of COVID-19 transmission.

Photochemical Internalization for Intracellular Drug Delivery. From Basic Mechanisms to Clinical Research.

Photochemical internalisation (PCI) is a unique intervention which involves the release of endocytosed macromolecules into the cytoplasmic matrix. PCI is based on the use of photosensitizers placed in endocytic vesicles that, following light activation, lead to rupture of the endocytic vesicles and the release of the macromolecules into the cytoplasmic matrix. This technology has been shown to improve the biological activity of a number of macromolecules that do not readily penetrate the plasma membrane, including type I ribosome-inactivating proteins (RIPs), gene-encoding plasmids, adenovirus and oligonucleotides and certain chemotherapeutics, such as bleomycin. This new intervention has also been found appealing for intracellular delivery of drugs incorporated into nanocarriers and for cancer vaccination. PCI is currently being evaluated in clinical trials. Data from the first-in-human phase I clinical trial as well as an update on the development of the PCI technology towards clinical practice is presented here.

Apparent Complete Response of a Treatment Refractory and Recurrent Squamous Cell Carcinoma Lesion to Photochemical Internalization: A Clinical Case Study.

Photochemical internalization (PCI) depends on the delivery of sublethal photodynamic reaction to facilitate the work of a chemotherapeutic agent. We discuss our experience in managing a patient with extensive squamous cell carcinoma of the right face and scalp under the TPCS2a -based bleomycin PCI treatment protocol. In this case, an 84-year-old Caucasian received 0.25 mg kg-1 of TPCS2a (Amphinex® , PCI Biotech AS, Oslo, Norway). Surface illumination photochemical internalization was carried out after 4 days, which was preceded by the chemotherapeutic agent infusion (Bleomycin). After one week from the illumination time, tissue necrosis was evident and tumor shrinkage was most noticeable at day 14 postillumination. Follow-up at 6 weeks continued to show tissue healing and regeneration with no clinical evidence of recurrence. Multiple surgical biopsies were taken at 1 and 3 months postillumination and found to be tumor free. PCI's depth of effect has been very significant with negligible damage to the collateral tissues. This technology has a role in interventional oncology especially when managing challenging cases.