Development of a patient-reported outcomes and experience measure for Orthognathic surgery: validation of the Northwick Park Orthognathic Questionnaire (NOQ)

Orthognathic surgery aims to correct dentoskeletal and facial discrepancies. The expected benefits are functional, cosmetic, and psychological. In a previous publication, this group assessed the determinants of patient satisfaction to formulate the Northwick Park Orthognathic Questionnaire (NOQ). The aim of the present study was to validate this questionnaire. A total of 118 postoperative patients prospectively completed the NOQ, 30 of whom completed the questionnaire a second time. The mean completion rate was 87.6 ± 10%. Response reproducibility was high: 92% of patients gave identical responses (range 81-100%). The intra-class correlation coefficient (ICC) was 0.96 (0.96 ± 0.072). Average test-retest scores for each domain were as follows (range in parenthesis): reasons for treatment 93% (60-100%), preoperative experience 96% (81-100%), preparation for surgery 95% (81-100%), inpatient experience 89% (55-100%), post-discharge experience 83% (55-100%), benefits of treatment 92% (71-100%), overall patient education 91% (62-100%). Internal validity using Cronbach's alpha was 0.72 (standard deviation 0.23, range 0.5-1). The results confirm the consistency of responses and the reliability of the information collected with the NOQ. The NOQ is a novel questionnaire and a valid metric to quantify a patient's perception of their experience. Its adoption may aid in making targeted improvements to patient care.

Neck failure following pathologically node-negative neck dissection (pN0) in oral squamous cell carcinoma: a systematic review and meta-analysis

Due to the risk of occult cervical metastasis, elective neck dissection (END) is recommended in the management of patients with early oral cavity squamous cell carcinoma (OSCC) and a clinically node-negative (cN0) neck. This paper presents a systematic review and meta-analysis of studies that recorded isolated regional recurrence (RR) in the pathologically node-negative neck dissection (pN0) neck following END in order to quantify the failure rate. Pubmed and Ovid databases were systematically searched for relevant articles published between January 2009 and January 2019. Studies reporting RR following END in patients with OSCC who had no pathological evidence of lymph node metastasis were eligible for inclusion in this meta-analysis. In addition, a selection of large head and neck units were invited to submit unpublished data. Search criteria produced a list of 5448 papers, of which 18 studies met the inclusion criteria. Three institutions contributed unpublished data. This included a total of 4824 patients with median follow-up of 34 months (2.8 years). Eight datasets included patients staged T1-T4 with RR 17.3% (469/2711), 13 datasets included patients staged T1-T2 with RR 7.5% (158/2113). Overall across all 21 studies, isolated neck recurrence was identified in 627 cases giving a RR of 13.0% (627/4824) on meta-analysis. Understanding the therapeutic effectiveness of END provides context for evaluation of clinical management of the cN0 in these patients. A pathologically negative neck does not guarantee against future recurrence.

Condylectomy: treatment of recurrent unilateral dislocation of the temporomandibular joint in a patient with Ehlers-Danlos syndrome

We report the use of unilateral condylectomy to treat the recurrent dislocation of the temporomandibular joint (TMJ) in a 21-year-old woman with Ehlers-Danlos syndrome. Eighteen months after operation the patient had no further dislocation on full mouth opening, and no surgical complications.

Patient expectations and satisfaction following orthognathic surgery

Orthognathic surgery aims to correct dentoskeletal and facial discrepancies. Treatment usually requires a minimum of 18 months, necessitating that patients are adequately satisfied with the treatment provided. This study aimed to assess the determinants of patient satisfaction following treatment. One hundred and eighteen patients who had undergone orthognathic surgery were included prospectively. All participants completed a questionnaire regarding their reasons for undergoing treatment, treatment logistics, treatment outcomes, and satisfaction throughout their journey. Most patients were 'very satisfied' (71.2%) or 'satisfied' (19.5%) with the overall treatment. The majority wished to improve their smile (78.0%); post-treatment, 89.0% of patients reported an improved smile. Almost half of the patients (46.6%) stayed in hospital for only one night, and 41.5% took over 4 weeks off work or school post-surgery. People with postoperative breathing difficulties spent more days in hospital (P=0.021), but importantly, the duration of hospital stay did not differ between maxillary advancement, bilateral sagittal split osteotomy, and bimaxillary surgery (P=0.78). In conclusion, patient satisfaction was high following orthognathic treatment. The results highlight areas for improvement, such as information delivery to the patient throughout the treatment journey, and show that the presence of ongoing problems is an important predictor of patient satisfaction.

Sentinel lymph node biopsy for oral squamous cell carcinoma. Where are we now?

Recent data have confirmed that elective surgical management of the cN0 neck improves survival in patients with early (T1-T2) oral squamous cell carcinoma (SCC), and is better than watchful waiting. However, elective neck dissection (END) may not always be necessary. Sentinel node biopsy (SNB), which is a reliable staging test for patients with early disease and a radiologically N0 neck, can detect occult metastases with a sensitivity of 86%-94%. Patients with no sign of metastases on SNB could avoid neck dissection, and individual treatment should reduce both morbidity and cost. Currently, SNB for oral SCC is available at a limited number of centres in the UK, but this is likely to change as national guidelines have recommended that it is incorporated into the standard treatment pathway. It is therefore important to understand the current evidence that supports its use, its limitations and related controversies, and to plan for a validated training programme.

Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre

There is a subgroup of patients with mandibular fractures who could safely and effectively be managed in an outpatient day-care unit. Suitability depends on medical, social, and operative factors, and identification of the correct criteria will govern management after that in the emergency department. Reduced use of beds would lead to less money being spent on emergency treatment, and increased capacity for elective surgery. The aims of this study were to identify a group of patients with mandibular fractures whose duration of operation and period of recovery would be suitable for treatment in the day-care unit, and to evaluate the potential financial benefits. Inpatients were assessed for day surgery using medical, social, and surgical criteria. Each patient's suitability for discharge was assessed two, three, and five hours postoperatively. A financial feasibility study was made retrospectively on a larger sample of patients with mandibular fractures. The discharge criteria from the day-care unit were fully met by 26/40 patients at five hours postoperatively, mean (range) duration of operation was 145 (40-285) minutes, and mean (SD) Mandibular Injury Severity Score was 13 (3), range 7-20. When all the criteria were combined (n=100), 12 of the patients were suitable for day care. With 24 bed-day savings/100 patients, potential earnings would increase to around £80 000/year at this hospital. In conclusion, we have identified a group of patients who were suitable for management of mandibular fractures in the day-care unit. Considerable cost savings are anticipated.

Hemodialysis central venous catheter tip fracture with embolization into the pulmonary artery

We describe the first reported case of spontaneous hemodialysis catheter fracture and embolization. We also include a summary of similar cases not previously reported in the literature that appear in the Food and Drug Administration records as medical equipment malfunctions. Our patient presented with a cough and was initially treated for presumptive pneumonia. A chest radiograph indicated that the tip of the catheter had fractured and migrated into a distal branch of the pulmonary artery. The catheter was replaced, but the tip could not be retrieved because of its peripheral location. Possible causes and consequences of this underreported complication are discussed.

Vertebral column and spinal cord malformation in children with exstrophy of the cloaca, with emphasis on their functional correlates

Exstrophy of the cloaca is a dramatic malformation whose embryology is poorly understood. While the management of this disorder has received significant attention in the urology and general surgery literature, the neurologic status of these children has been poorly addressed. In order to better characterize the spinal cord and vertebral column malformations found in children with exstrophy of the cloaca, we undertook a clinical review of 26 consecutive children with exstrophy of the cloaca who had been seen at a single institution over 28 years. The prevalence of vertebral malformations in the 25 children who could be evaluated was 25/25 (100%). Twenty (80%) of the children had at least one vertebral fusion, most frequently at T-7. Twenty-two (88%) of the children had at least one vertebra with deficient posterior elements, and the spinal levels most frequently involved were S-2, S-3, S-4 and S-5. Nine (36%) of the children had at least one vertebra with a narrowed interpedicular distance, most frequently at T-7. Nine (36%) of the children had at least one vertebra with atrophic facet anatomy, most frequently at L-3. The prevalence of myelodysplasia in the 19 children for whom spinal magnetic resonance imaging or intraoperative findings were available was 100%. Of these 19 children, 15 (79%) had myelocystocele, 2 (11%) had a lipomeningocele, 2 (11%) had a meningocele, 2 (11%) had hydromyelia, and 4 (21%) had a tethered cord. These data suggest that spinal cord and vertebral column malformations are very common in children with exstrophy of the cloaca.

Direct enzyme-linked immunosorbent assay and a radioimmunoassay for melatonin compared

A novel commercially available ELISA for direct measurement of melatonin concentration in serum was evaluated and compared with an RIA routinely used in our laboratory. The direct ELISA is technically simpler, requires a smaller sample volume (0.1 mL), and compares well with RIA in terms of stability of the calibration curve and intra- and interassay CVs. Correlation with RIA measurements is, however, suboptimal (y = 0.39x + 56; r = 0.65, P < 0.001; n = 138), which may be due to a serum effect, as evidenced by dilution studies. Furthermore, the detection range of the ELISA does not cover the physiological daytime melatonin concentrations in humans. Adding an extraction and 10-fold concentration step shifted the detection range of the ELISA to include low physiological concentrations as well. Correlation with RIA measurements also improved significantly (y = 0.97x-23; r = 0.95, P < 0.001; n = 105), probably due to removal of the serum effect. Although extraction increases the required sample volume (1.5 mL), work load, and procedure time, this step is necessary for the ELISA to compete successfully with RIA.

Direct enzyme-linked immunosorbent assay and a radioimmunoassay for melatonin compared

A novel commercially available ELISA for direct measurement of melatonin concentration in serum was evaluated and compared with an RIA routinely used in our laboratory. The direct ELISA is technically simpler, requires a smaller sample volume (0.1 mL), and compares well with RIA in terms of stability of the calibration curve and intra- and interassay CVs. Correlation with RIA measurements is, however, suboptimal (y = 0.39x + 56; r = 0.65, P < 0.001; n = 138), which may be due to a serum effect, as evidenced by dilution studies. Furthermore, the detection range of the ELISA does not cover the physiological daytime melatonin concentrations in humans. Adding an extraction and 10-fold concentration step shifted the detection range of the ELISA to include low physiological concentrations as well. Correlation with RIA measurements also improved significantly (y = 0.97x-23; r = 0.95, P < 0.001; n = 105), probably due to removal of the serum effect. Although extraction increases the required sample volume (1.5 mL), work load, and procedure time, this step is necessary for the ELISA to compete successfully with RIA.

CD58 (LFA-3) stimulation provides a signal for human isotype switching and IgE production distinct from CD40

Induction of an IgE response involves several discrete steps: 1) induction of epsilon germ line transcription, 2) DNA recombination, and 3) mature RNA transcription/translation. Here we show that ligation of B cell CD58 by CD2, its natural ligand on T cells, or by mAb, provides a novel IL-4-dependent signal for the latter two steps. Highly purified human B cells were induced to produce IgE by costimulation with IL-4 and CD58 mAb. Although CD58 ligation alone was unable to induce epsilon germ-line transcription, in concert with IL-4-stimulated epsilon germ-line transcription it induced the appearance of productive epsilon transcripts and IgE production. The direct involvement of CD2 was demonstrated: B cells cultured with IL-4 plus murine T hybridoma cells transfected with human CD2 produced IgE. A CD40 Fc fusion protein had no effect on CD58-driven IgE production while inhibiting CD40-dependent responses. Furthermore, cells from patients with common variable immunodeficiency produced IgE in response to IL-4 plus CD40 mAb but not to IL-4 plus CD58 mAb. CD58-driven IgE synthesis was IFN-gamma independent and was not enhanced by exogenous IL-6. Functional differences between CD40 and CD58 IgE stimulation were demonstrated. Thus, the CD2:CD58 ligand/counterligand system provides an alternative pathway by which cell contact signaling may regulate IgE. Given the relative importance of CD2 triggering on mucosal T cells and the mucosal location of IgE production, this may be especially true on mucosal surfaces.

CD58 (LFA-3) stimulation provides a signal for human isotype switching and IgE production distinct from CD40

Induction of an IgE response involves several discrete steps: 1) induction of epsilon germ line transcription, 2) DNA recombination, and 3) mature RNA transcription/translation. Here we show that ligation of B cell CD58 by CD2, its natural ligand on T cells, or by mAb, provides a novel IL-4-dependent signal for the latter two steps. Highly purified human B cells were induced to produce IgE by costimulation with IL-4 and CD58 mAb. Although CD58 ligation alone was unable to induce epsilon germ-line transcription, in concert with IL-4-stimulated epsilon germ-line transcription it induced the appearance of productive epsilon transcripts and IgE production. The direct involvement of CD2 was demonstrated: B cells cultured with IL-4 plus murine T hybridoma cells transfected with human CD2 produced IgE. A CD40 Fc fusion protein had no effect on CD58-driven IgE production while inhibiting CD40-dependent responses. Furthermore, cells from patients with common variable immunodeficiency produced IgE in response to IL-4 plus CD40 mAb but not to IL-4 plus CD58 mAb. CD58-driven IgE synthesis was IFN-gamma independent and was not enhanced by exogenous IL-6. Functional differences between CD40 and CD58 IgE stimulation were demonstrated. Thus, the CD2:CD58 ligand/counterligand system provides an alternative pathway by which cell contact signaling may regulate IgE. Given the relative importance of CD2 triggering on mucosal T cells and the mucosal location of IgE production, this may be especially true on mucosal surfaces.

Uptake and endocytic pathway of transferrin and iron in perfused rat liver

Uptake and distribution of transferrin and iron in perfused rat liver are dependent on perfusion temperature, time and uptake affinity. Transferrin passes at least two different compartments on its receptor-mediated recycling pathway, which are separable by centrifugation in a shallow Nycodenz gradient. Perfusion at lowered temperature (16 degrees C) is sufficient for internalization of transferrin and iron. Passage of radiolabelled iron to other than endosomal compartments as well as recycling of labelled transferrin are largely suppressed at this perfusion temperature, as much less is released by further perfusion with unlabelled transferrin than at 4 degrees C where the ligand is largely washed off the surface, or 37 degrees C, where the recycling pathway is operating. But also at lowered temperature only a part of the iron in endosomal fractions can be assigned to transferrin. A considerable part of the total uptake of transferrin and iron can be attributed to low-affinity mechanisms even at very low transferrin concentrations. Transferrin receptors are concentrated in endosomal fractions in comparison to fractions representing different plasma membrane domains of the liver. Endosomal fractions specifically display detergent-activated NADH-acceptor oxidoreductase which may be part of the iron uptake system.

Biochemical properties of the outer membrane of Treponema denticola

The outer membranes (OMs) from serovars a, b, and c of Treponema denticola, originally isolated from periodontal patients, were prepared. Dialysis of the OMs against 20 mM MgCl2 yielded the aggregable (A) and the nonaggregable (NA) moieties of the OMs. The absence of muramic acid, adenosine triphosphatase, hexokinase, and nucleic acid as well as electron microscopy indicated that the OM preparations were homogeneous. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the A and NA moieties of the OMs showed approximately 25 Coomassie brilliant blue R-250 stain-positive bands or 47 silver-stained polypeptides. The relative molecular masses ranged between 14 and 97 kDa. The electrophoretic polypeptide profiles of the A and NA moieties shared many similarities among serovars a, b, and c. However, they exhibited variation in the overall pattern, intensity, or location of the polypeptide stained zones. This was especially true for serovar b. Two-dimensional electrophoretic studies showed an excess of 100 silver-stained spots with isoelectric points of 4.6 to 7.0 and relative molecular masses in the 14- to 97-kDa range. The OMs contained simple proteins, glycoproteins, and lipoproteins. The NA moieties of the OMs contained 4 to 6, 10 to 12, and 4 to 6 glycopeptides as well as two, seven, and two lipoprotein bands for serovars a, b, and c, respectively. The A moieties of the OMs showed 7 to 9, 11 to 13 and 5 to 6 glycopeptides as well as four, five, and three lipoprotein bands for serovars a, b, and c, respectively. Lipopolysaccharide was detected in the OMs of the three serovars following removal of proteins with proteinase K, pronase and silver staining of sodium dodecyl sulfate-polyacrylamide gels, or removal of lipopolysaccharide from the OMs by hot phenol extraction. The 66- and 53-kDa bands were present in serovars b and c, while a band with a relative molecular mass of 45 kDa was present only in serovar c. Endotoxin-like activity was also shown in the OMs of the three serovars by the Limulus amebocyte clotting assay and the chick embryo lethality test. This is the first report on selected biochemical properties of the OM macromolecules of three known serovars of T. denticola.

Lack of direct evidence for a functional role of voltage-operated calcium channels in juxtaglomerular cells

In this study we have examined the role of voltage-gated calcium channels in the regulation of calcium in juxtaglomerular cells. Using a combination of patch-clamp and single-cell calcium measurement we obtained evidence neither for voltage-operated calcium currents nor for changes of the intracellular calcium concentration upon acute depolarizations of the cell membrane. Increases of the extracellular concentration of potassium to 80 mmol/l depolarized the juxtaglomerular cells close to the potassium equilibrium potential, but did not alter the intracellular calcium concentration neither in patch-clamped nor in intact Furaester-loaded cells. Moreover, basal renin secretion from a preparation enriched in mouse juxtaglomerular cells and from rat glomeruli with attached juxtaglomerular cells was not inhibited when extracellular potassium was isoosmotically increased to 56 mmol/l. In mouse kidney slices, however, depolarizing potassium concentrations caused a delayed inhibition at 56 mmol/l and a delayed stimulation of renin secretion at 110 mmol/l. Taken together, our study does not provide direct evidence for a role of voltage-activated calcium channels in the regulation of calcium and renin secretion in renal juxtaglomerular cells.