Central importance of emotional and quality-of-life outcomes in the public's perception of face transplantation.

BACKGROUND: Face transplantation is a surgical innovation to manage people with severely interrupted facial function and form. How the public perceive face transplantation and its potential implications for the recipient, donor, and society is unclear. The aim of this study was to understand the public perception of face transplantation, including when it is appropriate, what information is required to feel adequately informed, and which factors influence a person's willingness to donate their face. METHODS: This was a nationwide survey of participants representative of the GB public. A quantitative analysis was performed. Free-text qualitative responses were coded with thematic content analysis and a narrative analysis was constructed. RESULTS: The survey included 2122 participants. Face transplantation was considered worth the potential risks if it improved an individual's quality of life, gave them a 'normal life', and/or increased their confidence and social interaction. Respondents were worried about the impact face transplantation might have on donor families, especially recipient families adapting to the identity of the donor. Respondents most concerned about the concept of face transplantation were aged at least 55 years (χ2(4) = 38.9, P < 0.001), women (χ2(1) = 19.8, P < 0.001) , and Indian/Asian (χ2(4) = 11.9, P = 0.016). CONCLUSION: The public perceive emotional and psychological outcomes as equally as important as, or more important than, surgical outcomes when determining the appropriateness of face transplantation. Future research should focus on measuring and describing emotional and psychological outcomes after face transplantation.

Artificial Intelligence in plastic surgery: What is it? Where are we now? What is on the horizon?

INTRODUCTION: An increasing quantity of data is required to guide precision medicine and advance future healthcare practices, but current analytical methods often become overwhelmed. Artificial intelligence (AI) provides a promising solution. Plastic surgery is an innovative surgical specialty expected to implement AI into current and future practices. It is important for all plastic surgeons to understand how AI may affect current and future practice, and to recognise its potential limitations. METHODS: Peer-reviewed published literature and online content were comprehensively reviewed. We report current applications of AI in plastic surgery and possible future applications based on published literature and continuing scientific studies, and detail its potential limitations and ethical considerations. FINDINGS: Current machine learning models using convolutional neural networks can evaluate breast mammography and differentiate benign and malignant tumours as accurately as specialist doctors, and motion sensor surgical instruments can collate real-time data to advise intraoperative technical adjustments. Centralised big data portals are expected to collate large datasets to accelerate understanding of disease pathogeneses and best practices. Information obtained using computer vision could guide intraoperative surgical decisions in unprecedented detail and semi-autonomous surgical systems guided by AI algorithms may enable improved surgical outcomes in low- and middle-income countries. Surgeons must collaborate with computer scientists to ensure that AI algorithms inform clinically relevant health objectives and are interpretable. Ethical concerns such as systematic biases causing non-representative conclusions for under-represented patient groups, patient confidentiality and the limitations of AI based on the quality of data input suggests that AI will accompany the plastic surgeon, rather than replace them.

Calcitonin-negative medullary thyroid carcinoma: the 'triple-negative' phenotype.

Calcitonin-negative medullary thyroid carcinoma is a rare, poorly understood primary neuroendocrine carcinoma of the thyroid characterised by classic medullary thyroid carcinoma morphology without raised serum calcitonin. A 24-year-old woman presented with a slow-growing, right-sided neck swelling. She underwent an ultrasound scan, cytopathological and histopathological examination, and tests for alternative diagnoses. The ultrasound showed a heterogeneous, hyperechoic nodule in the right thyroid lobe. Serum calcitonin was normal. Cytopathology and histopathology showed typical medullary thyroid carcinoma morphology but without calcitonin upon immunostaining and mRNA in situ hybridisation. A 'triple-negative' calcitonin-negative medullary thyroid carcinoma was diagnosed. A completion thyroidectomy with bilateral central lymph node dissection was performed. The patient remains well three-years post-surgery. When cytopathology suggests a medullary thyroid carcinoma, serum calcitonin, pro-calcitonin, carcinoembryonic antigen and calcitonin-gene-related peptide should be measured to identify cases of calcitonin-negative medullary thyroid carcinoma. They should also be measured post-treatment for monitoring purposes. This will aid future calcitonin-negative medullary thyroid carcinoma diagnoses and will inform prognostic stratification and influence treatment decisions.

Long term effectiveness of electrochemotherapy for the treatment of lower lip squamous cell carcinoma.

PURPOSE: Electrochemotherapy (ECT) is a therapeutic approach based on the local application of electrical pulses that permeabilize cell membranes to enhance the uptake of low-permeant chemotherapeutic agents, thus increasing their cytotoxic effects. MATERIALS AND METHODS: Twenty-one patients with SCC of the lower lip were treated according to the European Standard Operating Procedures of Electrochemotherapy. Bleomycin (15,000 IU/m2 body surface area) was administered intravenously over a 1-min period. Eight electrical pulses (amplitude, 1000 V/cm; duration, 100 µs) were generated and delivered at a repetition frequency of 5 kHz. Changes in tumor volume were used to assess treatment response. RESULTS: Objective response (OR), complete response (CR), and partial response (PR) rates of 100%, 71.4%, and 28.6% respectively were demonstrated following a single session of ECT. ECT was well tolerated, and no adverse events occurred. CONCLUSIONS: Intravenous bleomycin-based ECT is a safe and effective therapy for SCC of the lower lip. ECT improves the quality-of-life of patients by preserving the function and the aesthetic appearance of the affected area. ECT provides a therapeutic option for elderly and frail patients who, due to their state of health, are not suitable for, or refuse surgical interventions.

The afterglow and elliptical host galaxy of the short gamma-ray burst GRB 050724.

Despite a rich phenomenology, gamma-ray bursts (GRBs) are divided into two classes based on their duration and spectral hardness--the long-soft and the short-hard bursts. The discovery of afterglow emission from long GRBs was a watershed event, pinpointing their origin to star-forming galaxies, and hence the death of massive stars, and indicating an energy release of about 10(51) erg. While theoretical arguments suggest that short GRBs are produced in the coalescence of binary compact objects (neutron stars or black holes), the progenitors, energetics and environments of these events remain elusive despite recent localizations. Here we report the discovery of the first radio afterglow from the short burst GRB 050724, which unambiguously associates it with an elliptical galaxy at a redshift z = 0.257. We show that the burst is powered by the same relativistic fireball mechanism as long GRBs, with the ejecta possibly collimated in jets, but that the total energy release is 10-1,000 times smaller. More importantly, the nature of the host galaxy demonstrates that short GRBs arise from an old (> 1 Gyr) stellar population, strengthening earlier suggestions and providing support for coalescing compact object binaries as the progenitors.

Ergonomic considerations for the care of special patients.

Ergonomics is an applied science concerned with the design of products that improve the way in which people and technology interface. The applications to dentistry are numerous given the fact that modern dental care is a complex blend of human skills and sophisticated technology. This article explores the impact of ergonomic principles on dental care for the special and physically challenged patient.

Occupational exposures to blood in a dental teaching environment: results of a ten-year surveillance study.

Evaluation of occupational exposures can assist with practice modifications, redesign of equipment, and targeted educational efforts. The data presented in this report has been collected as part of a ten-year surveillance program of occupational exposures to blood or other potentially infectious materials in a large dental teaching institution. From 1987 to 1997, a total of 504 percutaneous/non-intact skin and mucous membrane exposures were documented. Of these, 494 (98 percent) were percutaneous, and 10 (2 percent) were mucosal, each involving a splash to the eye of the dental care worker (DCW). Among the 504 exposures, 414 (82.1 percent) occurred among dental students, 60 (11.9 percent) among staff, and 30 (6 percent) among faculty. One hundred ninety-one (37.9 percent) exposures were superficial (no bleeding), 260 (51.6 percent) were moderate (some bleeding), and 53 (10.5 percent) were deep (heavy bleeding). Regarding the circumstances of exposure, 279 (54.5 percent) of the injuries occurred post-operatively (after the use of the device), and most were related to instrument clean-up; 210 (41.0 percent) occurred intra-operatively (during the use of the device); and 23 (4.5 percent) occurred when a DCW collided with a sharp object in the dental operatory (eight cases involved more than one circumstance). The overall exposure rate for the college was 2.46+/-0.11 SD per 10,000 patient visits. The average rate for the student population was 4.02+/-0.20 SD per 100 person-years, with the highest rates being observed among junior year students. The observed rates of occupational exposures to blood and body fluids in this report are consistent with published reports from several other educational settings. Dental teaching institutions are faced with the unique challenge of protecting the student and patient populations against bloodborne infections. Educational efforts must go beyond mere teaching of universal precautions and should include the introduction of safer products and clinical procedures that can minimize the risks associated with the hands-on aspects of the students' learning process.

Mobile health units. Design and implementation considerations.

The decision to provide health care services with a mobile van is one which educational and service facilities are increasingly pursuing. The benefits include: The potential to increase the availability of services to underserved populations where access to care is perceived to be one reason for underuse of available services. The opportunity to increase and broaden the educational experiences of students in a training program. The opportunity to develop a sense of social responsibility in the health care provider. The process of deciding to pursue a van purchase is complicated, and administrators may best be served by obtaining experienced consultants to help them fully comprehend the issues involved. After the decision to purchase a mobile unit is made, it is necessary to focus on van requirements and design to meet federal, state, and city codes concerning motor vehicles and health requirements. Some modifications of one's standard practices are needed because of these codes. Being aware of them in advance will allow a smooth project completion. This article provides information about some of the steps required to implement a mobile unit. The approximate time from initial concept to van delivery was 1 year, with one fully dedicated project coordinator working to assure the project's success in such a short time frame. Seeing the gratified personnel and students who serve the children on the "Smiling Faces, Going Places" Mobile Dental Van of the NYUCD (see Figure 2), and knowing the children would otherwise not have received such services, allows the health care professionals involved to feel the development of this van is an exciting mechanism for delivery of health care to individuals who would otherwise go without.

Open surgical biopsy for nonpalpable mammographic abnormalities: still an option compared with core needle biopsy.

OBJECTIVE: Our purpose was to present information about open surgical biopsy. It is hoped that this will be helpful when reviewing information about core needle biopsy STUDY DESIGN: Review of 461 open surgical biopsies for nonpalpable mammographic abnormalities was performed. All patients were managed by the Women's Health Center of Logansport. Core needle biopsy data came from the literature. RESULTS: Open surgical biopsy compared favorably to core needle biopsy with regard to accuracy, cost, patient convenience, recovery, adequacy of specimen, identification of primary site, and cosmetics. CONCLUSION: Despite core needle biopsy marketing, open surgical biopsy has its advantages and should not be relegated to the museum.

Ergonomics and dentistry.

Since 1992 the Occupational Safety and Health Administration (OSHA) has been preparing Federal legislation concerned with ergonomic hazards in at-risk workplaces. Although multifactorial in nature, there is sufficient evidence in the scientific literature to document an association between the practice of dentistry and a variety of musculoskeletal disorders. There are preventive strategies already known and available to us. Should dentistry be considered an at-risk profession and be required to comply with the forthcoming standard, or is self-monitoring sufficient?

Risk of tuberculosis transmission in dentistry. Results of a retrospective chart review.

This pilot project was conducted for the purpose of performing a retrospective chart review on selected clients and using the results for evaluating purified protein derivative (PPD) conversion rates among the student population. The occupational risk of exposure to active tuberculosis was assessed in a large dental educational setting. Charts of clients seen in the College's Oral Medicine Clinic, referred out for health care consultation for one of several reasons potentially associated with active tuberculosis disease over a 1 year period, were reviewed. Data sources included the medical consultation log and the tuberculosis log, which were maintained by faculty in the Oral Medicine Clinic. Ninety-six clients met the authors' criteria. However, compiling data was severely hampered for two reasons: missing charts (19 of 96, or 19.8%) and non-returning clients (55, or 57%). Four clients with potentially active cases of tuberculosis were identified. Follow up revealed, however, that none of these four clients was contagious when seen at the Dental Center. The protocol and definition recommended by the Centers for Disease Control and Prevention 1994 Guidelines, and the results of PPD screening and chart audit conducted by the authors, suggest that the employees and students of the College of Dentistry are at low risk for workplace exposure to active tuberculosis.

Obstacles encountered in application of the Centers for Disease Control and Prevention guidelines for control of tuberculosis in a large dental center.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration have designated five categories of workplaces as carrying higher than normal risk for exposure to tuberculosis (TB); "health care facilities" is one of these categories. To assist all health care facilities in developing an appropriate and effective control plan, the CDC has listed various components to be included in the overall plan-however, the components needed cannot be determined until the level of risk has been determined. The published criteria for risk assessment are more appropriately applicable to a hospital-based facility. In complying with CDC's guidelines and adopting the recommended components of the TB control program at a large, educational, ambulatory care dental facility, several obstacles were identified. METHODS: As part of the risk assessment for TB transmission and to determine the significance of purified protein derivative of tuberculin (PPD) skin-test conversions observed among the student and employee populations, we implemented a strategy that consisted of surveying all accredited dental schools in the country, performing a controlled PPD screening study involving predoctoral dental students in their junior year, and reviewing and evaluating all patient registration records for the same period. RESULTS: Forty-four percent of the dental schools contacted agreed to participate in the survey. Of these, 58% had no information available on student PPD conversion rates and 29% either had no data available yet or were unwilling to share their information. Three schools (12%) that had some data and were willing to share it reported PPD conversion rates for faculty, students, or staff of 1% to 2%. The student PPD study showed a 10.7% conversion rate, but the registration record reviews showed no convincing evidence of patients with active TB having been registered at the dental school for the period of the student PPD study. CONCLUSION: Development of a TB control program relies heavily on assessment of risk within a health care facility. The sporadic reports of PPD conversion rates among dental care workers are not adequate to determine the magnitude of exposure to TB in educational dental settings. Further studies are necessary to establish the true risk and to assist dental care facilities in developing TB control programs.

TB and dentistry.

Tuberculosis (TB) has reemerged as a major public health problem. Although dental care providers are considered to be at low risk of exposure to patients with active TB, they should be familiar with the recent recommendations for preventing transmission of tuberculosis in health care settings. Dental practitioners should be able to recognize and evaluate signs and symptoms of active TB in their patient population and initiate appropriate medical referrals for any patient in whom active TB is suspected. Furthermore, education of the dentist and the office staff about the transmission, signs and symptoms of the disease, and methods of protection is one of the most effective components on an overall TB control program.

Challenges associated with assessment of risk for tuberculosis in a dental school setting.

BACKGROUND: Reported risk among health care workers, related to tuberculosis exposure, motivated us to accurately assess this occupational risk at our College of Dentistry. METHODS: Our sample population included all dental students entering their junior (third) year (beginning of maximum patient exposure). Screening for tuberculosis infection, with the standardized Mantoux test (purified protein derivative [PPD]), was conducted by the authors; several variables, previously associated with inaccurate test results in the literature, were controlled for during the study. RESULTS: Among the study population of 158 students, the PPD conversion rate, as determined by one-step testing, after one academic year was 10.6%. To further investigate factors (other than possible workplace exposure) contributing to PPD conversion in the study population, the authors also examined PPD results from previous employee and student screenings and conducted a retrospective chart review of selected patients registered at the college for the same period. CONCLUSIONS: We found that being born outside of the United States and having previously received bacille Calmette-Guérin vaccine are associated with positive PPD test results. In addition, PPD conversion among the study group may not be associated with occupational exposure at the College but, in fact, may be related to other factors, including community- and hospital-based clinical exposure. Finally, we recommend further research that examines the possible systemic effects of periodic testing with PPD on test subjects.

Mammographic abnormalities and the detection of carcinoma of the breast.

OBJECTIVE: In an attempt to reduce the number of unnecessary breast biopsies, the yield rate of cancer relative to specific types of mammographically detected abnormality was investigated. STUDY DESIGN: Between 1989 and 1991, 169 patients with an abnormality as detected by mammogram but with no palpable mass were reviewed. Abnormalities detected by mammogram were divided into four types. The rate of biopsy-confirmed cancer per type of abnormality was calculated. RESULTS: The incidence of cancer per type of mammographically detected abnormality was as follows: mass 11%, mass with abnormal calcification 21%, abnormal calcification 22%, and asymmetric density 2%. CONCLUSION: Biopsy is recommended for mammographically detected abnormalities of a mass, a mass with abnormal calcification, and abnormal calcification without mass. Consideration should be given to deferring biopsy in favor of a follow-up study for asymmetric densities.

Designing a respirator fit testing program.

The requirements for adequate respiratory protection for the employees of this agency vary. Therefore, accurate, updated job descriptions are a critical piece of information. Although the agency has made an effort to establish a respiratory protection program, a number of limitations exist when compared to the program components defined in ANSI, NIOSH, and OSHA guidance documents. In response to a request from the agency, the nurse consultant evaluated the existing respiratory protection program and made specific recommendations for improvement. At this time, the agency has signed a formal agreement with the Division of Federal Occupational Health to request continued assistance with "overhauling" their program. Top management has begun assigning responsibilities for the program to specific individuals, and a centralized database is being set up. The agency has implemented two new DFOH developed forms to improve the testing process, and the nurse consultant has revised the educational/training session to more adequately meet the needs of the work force. The Agency and DFOH are collaborating on reassessment of employees to correctly assign them to appropriate respiratory risk categories. This will, in turn, affect the medical monitoring needs as well as the educational needs of each individual.

Surgical management of breast disease in an obstetrics and gynecology group.

The surgical management of breast disease from 1978 through 1988 by the Women's Health Center of Logansport is reviewed. Three hundred twelve biopsy procedures resulted in the diagnosis of 59 cancers. Biopsy and mastectomy procedures were performed by the authors (obstetrician-gynecologists). There were no significant complications and all patients had an adequate surgical result. Preoperative needle localization techniques proved to be a safe and effective method to identify and remove nonpalpable mammographic abnormalities. Because women depend on their gynecologist for advice regarding reproductive organs including the breasts, it is logical for the gynecologic surgeon to become involved in the surgical management of breast disease.

The primary care role in occupational health nursing.

Primary care is a valid, legal responsibility of the practicing occupational health nurse and accounts for a high percentage of the occupational health nurse's daily activities when considered on a local, national, and international level. Historically, the varying definitions of primary care presented have led to confusion among practitioners who are attempting to categorize their services. The author attempts to express a workable interrelationship among these numerous terms including, "primary care," "health promotion," and "disease prevention." The legal, economic, and professional climate is right for the occupational health nurse to assert her role in primary care; the scope and depth in which the occupational health nurse may currently provide primary care has greatly expanded with two current examples being the Employee Assistance Programs (EAP) and safety and accident prevention programs.