Cleft Lip and Palate and Alveolar Bone Grafting in the United Kingdom: A Brief Overview for Non-specialists.

Cleft lip and palate is a common congenital defect that is associated with various functional, aesthetic and psychosocial problems. The objective of this article is to share a brief overview of cleft and lip palate classification, aetiology, complications and management, particularly aimed at non-specialists. The literature suggests that the use of iliac crest bone in secondary alveolar bone grafting (ABG) still seems to be the favoured technique for cleft lip and palate repair. In conclusion, we suggest that advances in bone morphogenic proteins may be the key to further advancement in ABG.

Retraction: Abdominal Pseudocyst: A Rare Complication of Ventriculoperitoneal Shunts.

[This retracts the article DOI: 10.7759/cureus.18956.].

2†Pathways to detection of non-infectious childhood uveitis in the UK: findings from the UNICORN cohort study.

INTRODUCTION: Prompt detection of childhood uveitis is key to minimising negative impact. From an internationally unique inception cohort, we report pathways to disease detection.UNICORNS is a national childhood non-infectious uveitis study with longitudinal collection of a standardised clinical dataset and patient reported outcomes. Descriptive analysis of baseline characteristics are reported.Amongst 150 recruited children (51% female, 31% non-white ethnicity) age at detection ranged from 2-18yrs (median 10). In 69%, uveitis was diagnosed following onset of symptoms: time from first symptoms to uveitis detection ranged from 0-739days (median 7days), with longer time to detection for those presenting initially to their general practitioner. Non symptomatic children were detected through JIA/other disease surveillance (16%), routine optometry review (5%) or child visual health screening (1%). Commonest underlying diagnoses at uveitis detection were JIA (17%), TINU (9%, higher than pre-pandemic reported UK disease frequency) and sarcoid (1%). 60% had no known systemic disease at uveitis detection. At disease detection, in at least one eye: 34% had structural complications (associated with greater time to detection - 17 days versus 4 days for uncomplicated presentation).The larger relative proportions of children with non-JIA uveitis reported here increase the importance of improving awareness of childhood uveitis amongst the wider clinical communities. There is scope for improvement of pathways to detection. Forthcoming analysis on the full cohort (251 recruited to date across 33 hospitals and 4 nations) will provide nationally representative data on management and the determinants of visual and broader developmental/well-being outcomes.

Printed titanium implants in UK craniomaxillofacial surgery. Part II: perceived performance (outcomes, logistics, and costs).

This second part explores perceptions and understanding of clinical performance, turnaround, and costs for printed titanium implants or plates in common procedures, evaluating both 'in-house' and 'outsourced' CAD-CAM pathways. A cross-sectional study, supported by the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team, was conducted over 14 weeks. A total of 132 participants took part (demographic data is reported in Part I). For fibular-flap mandibular reconstruction, most participants (69% - 91%) perceived printed titanium as superior to intraoperatively or preoperatively hand-bent plates for surgical duration, accuracy, dental restorability, and aesthetics. There was less agreement about complications and plate-failure risks. Most perceived printed plates to be superior to traditional wafer-based maxillary osteotomy for surgical duration (61%) and maxillary positioning (60%). For orbital floor repair, most perceived improvements in surgical duration (83%, especially higher-volume operators p=0.009), precision (84%), and ease of placement (69%). Rarely (less than 5%) was any outcome rated inferior to traditional techniques for any procedure. Perceived turnaround times and costs were variable, but the greatest consensus was for two-segment fibular-flap reconstructions and orbital floor repair. Industry estimates were generally consistent between two company representatives, but manufacturing-only costs differed when using in-house (departmental) designers. Costs and turnaround times are questionable barriers since few understand 'real-world' figures. Designing in-house can dramatically alter costs. Improved accuracy and surgical duration are common themes but biomechanical benefits are less-well understood. This study paints a picture of the potentially routine applications and benefits of printed titanium, capacity for uptake, understanding amongst surgeons, and areas for improvement.

Printed titanium implants in UK craniomaxillofacial surgery. Part I: access to digital planning and perceived scope for use in common procedures.

This first part of a two-part study examines perceived applications for and barriers to using printed titanium in light of current caseloads, funding pathways, and use of digital planning. It aims to demonstrate the scope for printed titanium in modern practice and to guide industry about the needs of UK surgeons. A cross-sectional study over 14 weeks was performed electronically with support from the British Association of Oral and Maxillofacial Surgeons (BAOMS) and a national trainee-led recruitment team. Ethics approval was obtained at the lead centre. A total of 132 participants joined the study (70% consultants, 25% specialty registrars, and 5% other), approximating a 29% response rate from consultant/registrar BAOMS members throughout mainland UK. Eighty-eight per cent used CAD-CAM design, with highly variable funding/access, design/manufacturing workflows (in-house/outsourced). Eighty-eight per cent were involved with trauma, 61% with orthognathic, and 52% with oncology-reconstruction surgery. Favourite applications for printed titanium were orbital floor repair (89%) and free-flap jaw reconstruction (87%). Most participants also cited maxillary/zygomatic osteotomies and cranioplasty (range 61%-73%). Although a popular application (78%), the evidence base in temporomandibular joint surgery is limited. Those performing orthognathic surgery perceived more indications than those who did not (p=0.013). Key barriers included cost, turnaround time and logistics, and the need to be trained in traditional techniques. Printed titanium was useful for both common and niche procedures, but was specifically limited in emergency trauma. Most surgeons had experience in CAD-CAM surgery but technical understanding appeared unclear. Limiting factors included variable funding and production pathways, perceived costs, and logistics, but in-house design can minimise them. In part II, we quantify perceived benefits and limitations and whether surgeons' understanding and knowledge are sufficient to rationalise them.

Thermogravimetric Analysis Properties of Cellulosic Natural Fiber Polymer Composites: A Review on Influence of Chemical Treatments.

Natural fiber such as bamboo fiber, oil palm empty fruit bunch (OPEFB) fiber, kenaf fiber, and sugar palm fiber-reinforced polymer composites are being increasingly developed for lightweight structures with high specific strength in the automotive, marine, aerospace, and construction industries with significant economic benefits, sustainability, and environmental benefits. The plant-based natural fibers are hydrophilic, which is incompatible with hydrophobic polymer matrices. This leads to a reduction of their interfacial bonding and to the poor thermal stability performance of the resulting fiber-reinforced polymer composite. Based on the literature, the effect of chemical treatment of natural fiber-reinforced polymer composites had significantly influenced the thermogravimetric analysis (TGA) together with the thermal stability performance of the composite structure. In this review, the effect of chemical treatments used on cellulose natural fiber-reinforced thermoplastic and thermosetting polymer composites has been reviewed. From the present review, the TGA data are useful as guidance in determining the purity and composition of the composites' structures, drying, and the ignition temperatures of materials. Knowing the stability temperatures of compounds based on their weight, changes in the temperature dependence is another factor to consider regarding the effectiveness of chemical treatments for the purpose of synergizing the chemical bonding between the natural fiber with polymer matrix or with the synthetic fibers.

Abdominal Pseudocyst: A Rare Complication of Ventriculoperitoneal Shunts.

We present the case of a 69-year-old man patient who was brought with a history of gait disturbances, memory impairment, and urinary incontinence with gradual worsening over the past six months. The patient underwent magnetic resonance imaging of the brain which demonstrated enlarged ventricles, widening of the Sylvian fissure, and narrow sulci at the vertex. Subsequently, the patient underwent a lumbar puncture which revealed a normal opening pressure with normal cerebrospinal fluid analysis. The diagnosis of normal pressure hydrocephalus was established. The patient underwent a ventriculoperitoneal shunt for the management of his symptoms. Three years after the placement of the shunt, the patient was brought to the emergency department with an expanding right-sided subcutaneous abdominal mass. A computed tomography scan of the abdomen showed the subcutaneous mass superficial to the right rectus muscle and was containing the coiled distal end of the shunt. Such findings were consistent with a subcutaneous cerebrospinal fluid pseudocyst. The mass was aspirated and the fluid analysis was in keeping with the cerebrospinal fluid characteristics. The fluid culture revealed no bacterial growth. The ventriculoperitoneal shunt was replaced with a minimally invasive technique.

Optimising the management of concurrent symphyseal/parasymphyseal and bilateral extracapsular condylar fractures using three-dimensional printing.

PURPOSE: Three-dimensional (3D) printing plays an important role in the diagnosis and treatment planning of many elective procedures in oral and maxillofacial surgery (OMFS). 3D printers and the associated print materials are now within the price range of most maxillofacial units, requiring less work to be sent out to commercial printers. Whilst their use in the planning of elective procedures is commonplace, acute trauma is an area where 3D printing remains underutilised. The successful management of complex fracture patterns such as concomitant symphyseal/parasymphyseal and bilateral condylar fractures often warrants this approach. METHODS: Freeware digital processing and manipulation software packages were used to view and segment structures from computed tomography (CT) data. Thereafter, fractures were digitally reduced. 3D printed models were produced from the digitally reduced models, allowing preoperative custom adaptation of osteosynthesis plates, facilitating accurate fracture fixation intraoperatively. RESULTS: For less than one hundred pounds sterling (STG), a 3D printer (with print material) capable of producing a model of sufficient quality can be purchased. The use of freeware digital processing software allows digital manipulation of CT data. Production of 3D models and plate adaptation can be carried out within hours after CT examination. CONCLUSIONS: The construction of digitally reduced 3D models and custom adapted plates enables the surgeon to achieve accurate fixation of complex fracture patterns in theatre which is clearly of benefit to patients. The potential for reduced theatre time also renders this approach more desirable, making this a worthwhile investment despite the additional non-clinical time associated with training and initial expenditure.

Outcome of patients with hematological malignancies admitted to the intensive care unit with life-threatening complications.

OBJECTIVE: To assess the outcome of patients with hematological malignancies (HM) admitted to medical intensive care unit (MICU) and to identify prognostic factors that may affect patients' outcome. METHODS: Data were collected in 44 patients with HM admitted to the MICU at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia within a 9-year period from 1993 to 2004. Demographic, physiological, clinical, laboratory and therapeutic data were collected on admission to MICU. RESULTS: Thirty-four percent of the patients had acute lymphocytic leukemia; 25% had acute myelocytic leukemia (AML) followed by non-Hodgkin's lymphoma in 20%, only 13.6% of these patients were in remission. The reasons for admission of these patients into MICU were shock (34.15%), respiratory failure (31.8%), cardiac arrest (20.4%), neurological causes (9.1%) and for other causes like small bowel perforation, hepatic failure, acute renal failure and metabolic disorders (4.5%). The overall in-hospital mortality was 72.7%, intensive care unit (ICU) mortality 61%, and the mean length of stay in the MICU was 5.4 +/- 4.8 days. A statistically significant association was demonstrated between both remission status and aspartate aminotransferase values on one side and patient's outcome on the other side. Patients with AML had poorer prognosis with mortality rate of 90.9%. CONCLUSION: Although mortality in patients with HM requiring ICU care is high, our results indicate that critical care support may be lifesaving. Apart from remission status and AML disease, no other prognostic factor could be identified.

Multilayer perceptron-based DFE with lattice structure.

The severely distorting channels limit the use of linear equalizers and the use of the nonlinear equalizers then becomes justifiable. Neural-network-based equalizers, especially the multilayer perceptron (MLP)-based equalizers, are computationally efficient alternative to currently used nonlinear filter realizations, e.g., the Volterra type. The drawback of the MLP-based equalizers is, however, their slow rate of convergence, which limit their use in practical systems. In this work, the effect of whitening the input data in a multilayer perceptron-based decision feedback equalizer (DFE) is evaluated. It is shown from computer simulations that whitening the received data employing adaptive lattice channel equalization algorithms improves the convergence rate and bit error rate performances of multilayer perceptron-based DFE. The adaptive lattice algorithm is a modification to the one developed by Ling and Proakis (1985). The consistency in performance is observed in both time-invariant and time-varying channels. Finally, it is found in this work that, for time-invariant channels, the MLP DFE outperforms the least mean squares (LMS)-based DFE. However, for time-varying channels comparable performance is obtained for the two configurations.

Vibration analysis of vessel wall motion with intra vena caval balloon pumping.

The intravenous membrane oxygenator (IMO) incorporates a centrally positioned balloon surrounded by hollow microporous fibers. Previous studies using this configuration have demonstrated that rhythmic pulsation of the balloon enhances gas exchange, presumably by three dimensional convective mixing. This study sought to characterize vessel wall vibrations imparted by intra vena caval balloon pumping. An in vitro flow loop incorporating a current IMO prototype was used for these measurements. The IMO prototype was inserted in a modeled vena cava on which ultrasonic dimension transducers were mounted on the outer surface. The flow loop was operated at physiologic flow rates. The balloon was activated, and dynamic vessel diameter measurements were recorded as the pumping frequency was varied from 40 to 120 beats per minute (bpm). A Fast Fourier Transform algorithm generated a frequency spectrum at each bpm and for two different balloon configurations; a single balloon versus a tripartite arrangement, the authors' results demonstrate that the mean amplitude of vena caval oscillations varied with bpm, and that this variation followed the trends in oxygen transfer rates. This suggests that the motion of the vessel wall may contribute to convective mixing of blood. In addition, this work demonstrated significant differences in the frequency spectra associated with our two balloon configurations.

Effect of beta-cyclodextrin on the excited state proton transfer in 1-naphthol-2-sulfonate.

The photophysical properties of 1-naphthol-2-sulfonate (1-NOH-2-S) in various solvents and in aqueous beta-cyclodextrin (CD) solution have been investigated. The fluorescence quantum yields in non-aqueous solvents are approximately 0.5, while in water the fluorescence quantum yield is 0.1. The fluorescence quantum yield doubled on the addition of beta-CD. In aqueous solution, proton transfer to water takes place efficiently leading to the formation of the anion form with its longer wavelength emission broad band at about 460 nm. Any environmental changes have been found to affect the rate of deprotonation and subsequently the band intensity at 460 nm. In non-aqueous solution the anion emission band disappears completely. Upon the addition of beta-CD to the aqueous solution of 1-NOH-2-S, the anion emission decreases with an increase in the intensity of the neutral form at 362 nm. Fluorescence measurements show 1:1 inclusion of 1-NOH-2-S in the beta-CD cavity with an association constant of 1915 M(-1) using Benesi-Heldbrand treatment. 1H NMR studies are used to confirm the inclusion and to provide information on the orientation of 1-NOH-2-S inside the cavity of beta-CD.

The effect of elastic modulus of the backing material on the fatigue notch factor and stress.

In cemented acetabular cup design it is acknowledged that bone resorption and fatigue fracture of cement may cause the most common problems after total hip replacement. Previous studies have optimized the shape of metal backing (MB) shell used in cemented acetabular components in order to minimize the fatigue notch factor (Kf) in cement, whilst at the same time maximizing Kf in bone at the central part of acetabulum to prevent stress shielding and subsequent bone resorption [1]. The optimal shape was found to be thin at the edges and thick at the dome. The present study describes the effect of changing the elastic modulus of the backing material on Kf and stresses as predicted by the initial shape of the backing shell of (3 mm) thick, and the optimized backing shape of non-uniform thickness in order to find the optimal material for the backing shell. It is recommended to use a backing shell material with elastic modulus equals 70 GPa (which can be readily attained using a fiber reinforced polymer composite). It is shown that such a material will decrease the fatigue notch factor and the stresses in cement at cup edges, at the same time it will increase the stresses and the fatigue notch factor in bone at the central part of acetabulum. Thereby, reducing the possibility of fatigue fracture of cement, whilst at the same time decreasing the stress shielding effect and the resulting bone resorption. The effect of lower bone resorption and lower probability of fatigue fracture of the cement will also reduce the incidence of loosening and premature revision operations.

Shape optimization of metal backing for cemented acetabular cup.

Stresses are generated in implant materials and bone, and at their interfaces. These stresses may affect the structural properties of the implant/bone system, or bring it to failure at some time in the postoperative period. Due to these stresses, acetabular cup loosening becomes an important problem for long term survival of total hip arthroplasty. It was found that metal backing would tend to reduce stresses in the underlying acrylic cement and bone. Yet, recent studies of load transfer around acetabular cups have shown that metal backing generates higher stress peaks in cement at the cup edges, while generates lower stress peaks in bone at the central part of acetabulum (dome), thus the bone at the dome becomes more stress shielded. In this study a numerical shape optimization procedure in combination with an axisymmetric finite element model was used in order to optimize the shape of a stainless steel metal backing shell. The design was to minimize fatigue notch factor in cement along cement/bone and cement/metal backing interfaces in order to prevent failure of cement mantel and loosening of acetabular components, at the same time increasing fatigue notch factor in bone at the center of acetabulum to prevent stress shielding. The results of this study indicate that cemented acetabular cup designs can be improved by using metal backing shells of non-uniform thickness, thick at the dome and thin at edges. Fatigue notch factor in cement was reduced by 2.3% at cement/metal backing interface and increased by 1.3% in the central bone of acetabulum. Von Mises stresses in the cement edge were reduced by 17.8% and 19.3% along cement/bone and cement/metal backing interfaces, respectively. Thus the optimal design will reduce the possibility of fatigue fracture of cement and decrease the stress shielding effect and the likely incidence of bone resorption, whereby extend the expected life of the prostheses.

Evaluation of antidiabetic effects of chlorpropamids in the presence of aspirin.

The present work has been done in an attempt to evaluate the hypoglycemic effect of Chlorpropamide in the presence of aspirin. Diabetiogenic effect of Alloxan was utilized which produced an Insulin-Dependent Diabetic State in the animals. Diabetic animals were given oral Chlorpropamide (100 mg/kg body weight) and it was seen that the drug reduced the blood sugar values although not to a significant level. Later the animals were given aspirin (30 mg/kg body weight) alongwith the daily dose of Chlorpropamide and a more significant reduction of blood sugar level took place.

Use of the Internet by patients attending hospital for oral and maxillofacial procedures.

Information obtained on the Internet regarding medical procedures is largely unregulated and can be confusing. The aims of this study were to assess use of the Internet by patients attending hospital for oral and maxillofacial procedures, and to assess the quality of information provided at consultation. Data were collected prospectively using a confidential questionnaire, which was distributed to consecutive patients attending for elective operations at 2 oral and maxillofacial units: Crosshouse Hospital, Kilmarnock, and Queen Alexandra Hospital, Portsmouth (n=100 at each unit). All the distributed questionnaires were returned. At both units, 95% of patients thought that discussion at the initial consultation was good or very good, and 84% at both units stated that they had access to the Internet. Internet access was consistently high among all age groups up to the age of 65, but in those aged over 65 it was considerably lower. A total of 22/84 patients (26%) at Crosshouse, and 14/84 (17%) at Queen Alexandra used the Internet to gain further information regarding their condition or procedure. All of those (n=14) at Queen Alexandra, and 21/22 at Crosshouse had used Google to search for the information. Those who used the Internet to find information on their medical condition or procedure found it to be a useful resource, but they also stated that the information caused some concerns. With use of the Internet and access to it increasing we highlight the need for regulated and appropriate websites to which patients should be directed.

Risk factors for failure of supraglottoplasty.

OBJECTIVES: To assess for identifiable risk factors for failed surgical intervention in children with laryngomalacia. METHODS: Retrospective case note review between September 2007 and March 2012. Case notes were reviewed for demographic data, symptoms, co-morbidities, operative technique, postoperative recovery, complications, length of hospital stay including intensive care unit (ICU) care, and resolution of symptoms. RESULTS: 148 children underwent supraglottoplasty. Case notes were available for 115 (78%) patients. 35% (41/115) of cases were females and 65% (74/115) were male. A bimodal age distribution was observed with peaks at 3 months and 3.5 years. Those over one year of age were more likely to have complications (p = 0.035). There was no significant difference in outcomes for age (p > 0.05). In patients less than one year, reflux symptoms were significantly associated with a higher likelihood of failure of the operation (p = 0.013). Patients under one year with pre-operatively identified comorbid conditions were less likely to have an improvement in breathing (p = 0.002). Cold steel was used in 55% (63/115) of cases, laser only in 17% (20/115) cases and a combination of the two techniques in 28%, (32/115). There was no association between the surgical technique used and complications (p = 0.558). There was no association between improvement in symptoms and surgical technique used (p = 0.560). There was a significant association between delayed post-operative neurological diagnosis and failure of the operation (p < 0.001). 21 (18%) patients required a second procedure. CONCLUSIONS: Pre-operative predictors of failure were patients with reflux symptoms (p = 0.013). Patients that required a second procedure were 37 times more likely to have a delayed diagnosis of an underlying neurological condition. Failure of symptoms to improve after supraglottoplasty should alert the clinician to the possibility of an underlying neurological disorder.