Extra-mandibular Osteoradionecrosis after the Treatment of Head and Neck Cancer.

AIMS: Osteoradionecrosis (ORN) is a serious toxicity of head and neck radiotherapy. It predominantly affects the mandible. Extra-mandibular ORN is rare. The aim of this study was to report the incidence and outcomes of extra-mandibular ORNs from a large institutional database. MATERIALS AND METHODS: In total, 2303 head and neck cancer patients were treated with radical or adjuvant radiotherapy. Of these, extra-mandibular ORN developed in 13 patients (0.5%). RESULTS: Maxillary ORNs (n = 8) were a consequence of the treatment of various primaries (oropharynx = 3, sinonasal = 2, maxilla = 2, parotid = 1). The median interval from the end of radiotherapy to the development of ORN was 7.5 months (range 3-42 months). The median radiotherapy dose in the centre of the ORN was 48.5 Gy (range 22-66.5 Gy). Four patients (50%) healed in 7, 14, 20 and 41 months. All temporal bone ORNs (n = 5) developed after treatment to the parotid gland (of a total of 115 patients who received radiotherapy for parotid gland malignancy). The median interval from the end of radiotherapy to the development of ORN was 41 months (range 20-68 months). The median total dose in the centre of the ORN was 63.5 Gy (range 60.2-65.3 Gy). ORN healed in only one patient after 32 months of treatment with repeated debridement and topical betamethasone cream. CONCLUSION: Extra-mandibular ORN is a rare late toxicity and this current study provides useful information on its incidence and outcome. The risk of temporal bone ORN should be considered in the treatment of parotid malignancies and patients should be counselled. More research is required to determine the optimal management of extra-mandibular ORN, particularly on the role of the PENTOCLO regimen.

Patient perceptions of costs in the NHS: an evaluation.

The cost of the NHS, wastage within it and how much trusts have overspent is a national obsession. Despite these widespread opinions, the costs of individual treatments and impacts of non-attendance appear to be little understood. There is a paucity of literature with regards to patients' awareness of costs associated with services provided by the NHS. The authors aim to ascertain whether patients are aware of the costs associated with care services provided, and if these data could aid educating patients on NHS costs to reduce missed appointments. A questionnaire was randomly distributed to new and review patients in our Oral and Maxillofacial outpatient and emergency departments from November-December 2017 asking them to estimate the cost of common services they may encounter, such as an outpatient appointment, an orthopantomogram (OPT), a CT head, and a full blood count test (FBC). The results demonstrate that 81% of patients surveyed underestimated the cost of their new patient appointment, with 34% underestimating the cost of their review appointment. The cost of an overnight stay in hospital was underestimated by 65% of patients, with 89% of patients underestimating the cost of an hours's operating. The costs of a full blood count, an OPT and a CT head have been mostly overestimated by 89%, 77%, and 54% of patients respectively. The results show there is a wide variation in patients' estimates of costs, with over 50% of patients overestimating the costs of investigations but underestimating the cost of their appointment/A&E attendance.

The future of OMFS lies in creating pathways to implement the PMETB recommendations and inspiring our trainees. Enough time has been spent debating, we need to deliver!: Re: Newman L, Brown J, Kerawala C, et al. Our specialty. The future. Is the writing on the wall? Br J Oral Maxillofac Surg 2020 (online ahead of print).

The British Association of Oral and Maxillofacial Surgeons (BAOMS) has been at the centre of the transition of our specialty in the UK from a branch of dentistry to one of the 10 UK surgical specialties. In this role it has, at different times, pushed boundaries against resistance from other specialties, and redirected the ambitions of the deputy chair of the Postgraduate Medical Education and Training Board (PMETB) review to produce recommendations that were exactly what OMFS needed. The editorial Our specialty. The future. Is the writing on the wall? is just the most recent iteration of half a century of internal debate. Whilst there are some issues with how the authors have presented recruitment data (their figures omit ST1 run-through and do not recognise that the same single, unfilled post may be present for two or more national selection rounds) their first paragraph A debate that we feel is long overdue presents the greatest concern. In this short communication, we illustrate that in the last 20 years the specialty has not been short of debate. In the absence of new and specific evidence that any other route forward would be supported by our national training committee (OMFS SAC), our regulator (GMC), the breadth of our specialty (including our current specialists and our current and future trainees) and, most importantly, would actually address our problems, we should avoid putting energy into an empty debate. Our focus should be on delivering the PMETB recommendations and inspiring our future trainees.

Changing the Oral and Maxillofacial Surgery (OMFS) training pathway in the United Kingdom - an illustrative retrospective.

OMFS training is perceived as a long and expensive pathway although papers have shown it compares favourably with other surgical specialties. Every OMFS clinician has a vested interest and duty continually to improve the quality of training and minimise costs, especially to trainees at junior levels. Any serious proposal to fundamentally change the format of training, must be given due consideration by all stakeholders. In 2016, a British Medical Journal article whose authors included the BAOMS President of that year and OMFS Specialty Advisory Committee (SAC) Chair, posed the question - should the future of OMFS training revert to single dental degree, change to single medical degree - or continue as a dual degree specialty? The BMJ publication was discussed at the British Association of Oral and Maxillofacial Surgeons (BAOMS) Council in March 2016 and all present unanimously supported the dual degree pathway. Later that year a formal proposal was made by the BAOMS immediate past President that training in the UK change to single medical degree 'Maxillofacial Surgery' similar to the training in Spain, France or Italy. Evidence around the risks and benefits of making this change to OMFS training was assembled and reviewed by BAOMS Council in March 2017. BAOMS Council once again unanimously supported continuing OMFS as a dual degree specialty with the observation that the quality of patient care which this training provided was the specialty's Unique Selling Point or USP. The requirement for both degrees to provide care for OMFS patients had been confirmed by external scrutiny on two separate occasions by the responsible regulators. In this paper, we outline the key steps to be considered when making major changes in the OMFS training pathways using this event as an example and the suggestion that those proposing changes should assemble and present evidence to support their proposal using the template provided.

Choosing the best method to utilise single positron emission computed tomography (SPECT) scans in the management of unilateral condylar hyperplasia.

Facial asymmetry secondary to unilateral condylar hyperplasia can be a diagnostic challenge to oral and maxillofacial surgeons. Single positron emission computed tomography (SPECT) scans provide a useful adjunct. We report a brief summary of the evidence describing the effectiveness of different methods of analysing SPECT scans and compare it with the results of a 10-year study at Sunderland Royal Hospital. Overall, both the evidence base and our study strongly favour use of the condyle:condyle ratio over the condyle:reference bone ratio, suggesting that no further comparisons are needed.

The real penalty: number of OMFS patients presenting to the emergency department at Sunderland Royal Hospital after England fixtures before and during the 2018 FIFA Football World Cup.

The aim of this study was to establish a link between a large televised sporting event and the incidence of patients presenting to the emergency department with oral and maxillofacial injuries. When compared with daily attendances throughout the year, the mean (SD) number rose from 2.53 (1.69) to 4.00 (1.53) (p=0.005) between 1 November 2017 and 31 July 2018 on the day after an England fixture, an increase of 58%. These data show the need for workforce planning during large-scale national sporting events because of the rise in the number of patients presenting. They show that the increase in workload is caused by a higher number of both traumatic and non-traumatic injuries.

Condylar hyperplasia: current thinking.

Unilateral condylar hyperplasia is a rare disease that causes facial asymmetry as a result of excessive vertical or horizontal growth, or both, of the mandibular condyle. Investigation should address the patient's concerns, and establish whether the disease is active with the use of single positron emission tomography (PET). Proportional reduction of the condyle arrests active disease and restores mandibular height, and any residual asymmetry can be corrected according to conventional orthognathic principles. We recommend the use of 3-dimensional virtual planning for such complex movements. The rarity of the disease means that, to our knowledge, high-quality evidence is lacking and further research is needed.

Improving pneumococcal vaccine uptake in veterans with chronic lymphocytic leukemia through a virtual clinic.

Through a "virtual clinic," we used the electronic medical record to identify and intervene upon patients with chronic lymphocytic leukemia (cll) who were not current for pneumococcal vaccines. Within 180 days, 100/160 patients (62%) received the recommended pneumococcal vaccine. A virtual clinic may improve vaccination rates among high-risk patient populations.

Evolving gene banks: improving diverse populations of crop and exotic germplasm with optimal contribution selection.

We simulated pre-breeding in evolving gene banks - populations of exotic and crop types undergoing optimal contribution selection for long-term genetic gain and management of population genetic diversity. The founder population was based on crosses between elite crop varieties and exotic lines of field pea (Pisum sativum) from the primary genepool, and was subjected to 30 cycles of recurrent selection for an economic index composed of four traits with low heritability: black spot resistance, flowering time and stem strength (measured on single plants), and grain yield (measured on whole plots). We compared a small population with low selection pressure, a large population with high selection pressure, and a large population with moderate selection pressure. Single seed descent was compared with S0-derived recurrent selection. Optimal contribution selection achieved higher index and lower population coancestry than truncation selection, which reached a plateau in index improvement after 40 years in the large population with high selection pressure. With optimal contribution selection, index doubled in 38 years in the small population with low selection pressure and 27-28 years in the large population with moderate selection pressure. Single seed descent increased the rate of improvement in index per cycle but also increased cycle time.

Erratum to: Frailty has a stronger association with inflammation than age in older veterans.

[This corrects the article DOI: 10.1186/s12979-016-0082-z.].

From hygroscopic aerosols to cloud droplets: The HygrA-CD campaign in the Athens basin - An overview.

The international experimental campaign Hygroscopic Aerosols to Cloud Droplets (HygrA-CD), organized in the Greater Athens Area (GAA), Greece from 15 May to 22 June 2014, aimed to study the physico-chemical properties of aerosols and their impact on the formation of clouds in the convective Planetary Boundary Layer (PBL). We found that under continental (W-NW-N) and Etesian (NE) synoptic wind flow and with a deep moist PBL (~2-2.5km height), mixed hygroscopic (anthropogenic, biomass burning and marine) particles arrive over the GAA, and contribute to the formation of convective non-precipitating PBL clouds (of ~16-20µm mean diameter) with vertical extent up to 500m. Under these conditions, high updraft velocities (1-2ms-1) and cloud condensation nuclei (CCN) concentrations (~2000cm-3 at 1% supersaturation), generated clouds with an estimated cloud droplet number of ~600cm-3. Under Saharan wind flow conditions (S-SW) a shallow PBL (<1-1.2km height) develops, leading to much higher CCN concentrations (~3500-5000cm-3 at 1% supersaturation) near the ground; updraft velocities, however, were significantly lower, with an estimated maximum cloud droplet number of ~200cm-3 and without observed significant PBL cloud formation. The largest contribution to cloud droplet number variance is attributed to the updraft velocity variability, followed by variances in aerosol number concentration.

Frailty has a stronger association with inflammation than age in older veterans.

BACKGROUND: Upregulation of pro-inflammatory cytokines has not only been associated with increased morbidity and mortality in older adults but also has been linked to frailty. In the current study we aimed to compare the relative relationship of age and frailty on inflammation and thrombosis in older veterans. RESULTS: We analyzed 117 subjects (age range 62-95 years; median 81) divided into 3 cohorts: non-frail, pre-frail and frail based on the Fried phenotype of frailty. Serum inflammatory markers were determined using commercially available ELISA kits. Frail and pre-frail (PF) subjects had higher levels than non-frail (NF) subjects of IL-6 (NF vs. PF: p = 0.002; NF vs. F: p < 0.001), TNFR1 (NF vs. F: p = 0.012), TNFRII (NF vs. F: 0.002; NF vs. PF: p = 0.005) and inflammatory index: = 0.333*log(IL-6) + 0.666*log(sTNFR1) (NF vs. F: p = 0.009; NF vs. PF: p < 0.001). Frailty status explained a greater percent of variability in markers of inflammation than age: IL-6 (12 % vs. 0.3 %), TNFR1 (5 % vs. 4 %), TNFR2 (11 % vs. 6 %), inflammatory index (16 % vs. 8 %). Aging was significantly associated with higher fibrinogen (p = 0.04) and D-dimer levels (p = 0.01) but only among NF subjects. CONCLUSION: In conclusion, these data suggest that among older veterans, frailty status has a stronger association with inflammation and the inflammatory index than age does. Larger studies, in more diverse populations are needed to confirm these findings.

Impact of WRF model PBL schemes on air quality simulations over Catalonia, Spain.

Here we analyze the impact of four planetary boundary-layer (PBL) parametrization schemes from the Weather Research and Forecasting (WRF) numerical weather prediction model on simulations of meteorological variables and predicted pollutant concentrations from an air quality forecast system (AQFS). The current setup of the Spanish operational AQFS, CALIOPE, is composed of the WRF-ARW V3.5.1 meteorological model tied to the Yonsei University (YSU) PBL scheme, HERMES v2 emissions model, CMAQ V5.0.2 chemical transport model, and dust outputs from BSC-DREAM8bv2. We test the performance of the YSU scheme against the Assymetric Convective Model Version 2 (ACM2), Mellor-Yamada-Janjic (MYJ), and Bougeault-Lacarrère (BouLac) schemes. The one-day diagnostic case study is selected to represent the most frequent synoptic condition in the northeast Iberian Peninsula during spring 2015; regional recirculations. It is shown that the ACM2 PBL scheme performs well with daytime PBL height, as validated against estimates retrieved using a micro-pulse lidar system (mean bias=-0.11km). In turn, the BouLac scheme showed WRF-simulated air and dew point temperature closer to METAR surface meteorological observations. Results are more ambiguous when simulated pollutant concentrations from CMAQ are validated against network urban, suburban, and rural background stations. The ACM2 scheme showed the lowest mean bias (-0.96µgm-3) with respect to surface ozone at urban stations, while the YSU scheme performed best with simulated nitrogen dioxide (-6.48µgm-3). The poorest results were with simulated particulate matter, with similar results found with all schemes tested.

International cancer seminars: a focus on kidney cancer.

Recent years have seen important advances in our understanding of the etiology, biology and genetics of kidney cancer. To summarize important achievements and identify prominent research questions that remain, a workshop was organized by IARC and the US NCI. A series of 'difficult questions' were formulated, which should be given future priority in the areas of population, genomic and clinical research.

Juvenile xanthogranuloma: unusual intraoral finding.

Juvenile xanthogranuloma is a rare non-Langerhans cell histiocytosis that usually presents as a self-limiting dermatological condition in young children. Rarely, extracutaneous sites may also be involved. We report a case in a 3-year-old girl that presented intraorally as a solitary, well-defined, soft, purple palatal swelling. Patients with these rare intraoral lesions may present to dentists and subsequently to oral and maxillofacial surgeons. Diagnosis requires histopathological analysis and immunohistochemical staining. Further investigation from other specialties is required to rule out involvement of other organ systems.

Assessment of online visibility of the British Association of Oral and Maxillofacial Surgeons (BAOMS): a strategic study.

The Internet is a powerful method of acquiring and sharing information. In marketing and business, online visibility is vital for publicity and the reputation of an organisation. To our knowledge, the importance of such visibility in medicine in general, and in Oral and Maxillofacial Surgery (OMFS) services in the UK, has not previously been investigated. We aimed to provide a better understanding of the way that patients use the Internet by asking 450 patients to complete a questionnaire when they attended outpatient OMFS departments at 2 centres. We also assessed the online visibility of the British Association of Oral and Maxillofacial Surgeons (BAOMS) and investigated the correlation between the strength of online visibility and professional reputation. Results from the self-administered, anonymous, validated questionnaires showed that 82% of patients agreed that the Internet was a powerful source of information, and two-thirds associated online visibility with a good reputation. However, the perceived online visibility of the BAOMS was poor (2%). This study mirrors findings in business publications, and confirms the link between online visibility and professional reputation. It also shows that there is a gap between patients' perceptions and the level of uptake of professional resources. We propose various strategies to bridge this gap and to promote the online visibility and professional reputation of the BAOMS and of OMFS services in the UK.

Translating science into the next generation meat quality program for Australian lamb.

This paper introduces a series of papers in the form of a special edition that reports phenotypic analyses done in parallel with genotypic analyses for the Australian Sheep Industry Cooperative Research Centre (Sheep CRC) using data generated from the information nucleus flock (INF). This has allowed new knowledge to be gained of the genetic, environment and management factors that impact on the carcase and eating quality, visual appeal, odour and health attributes of Australian lamb meat. The research described involved close collaboration with commercial partners across the supply chain in the sire breeding as well as the meat processing industries. This approach has enabled timely delivery and adoption of research results to industry in an unprecedented way and provides a good model for future research.