Cannabis and Driving in Older Adults

Importance

Epidemiological studies have found that cannabis increases the risk of a motor vehicle collision. Cannabis use is increasing in older adults, but laboratory studies of the association between cannabis and driving in people aged older than 65 years are lacking.

Objective

To investigate the association between cannabis, simulated driving, and concurrent blood tetrahydrocannabinol (THC) levels in older adults.

Design, Setting, and Participants

Using an ecologically valid counterbalanced design, in this cohort study, regular cannabis users operated a driving simulator before, 30 minutes after, and 180 minutes after smoking their preferred legal cannabis or after resting. This study was conducted in Toronto, Canada, between March and November 2022 with no follow-up period. Data were analyzed from December 2022 to February 2023.

Exposures

Most participants chose THC-dominant cannabis with a mean (SD) content of 18.74% (6.12%) THC and 1.46% (3.37%) cannabidiol (CBD).

Main outcomes and measures

The primary end point was SD of lateral position (SDLP, or weaving). Secondary outcomes were mean speed (MS), maximum speed, SD of speed, and reaction time. Driving was assessed under both single-task and dual-task (distracted) conditions. Blood THC and metabolites of THC and CBD were also measured at the time of the drives.

Results

A total of 31 participants (21 male [68%]; 29 White [94%], 1 Latin American [3%], and 1 mixed race [3%]; mean [SD] age, 68.7 [3.5] years), completed all study procedures. SDLP was increased and MS was decreased at 30 but not 180 minutes after smoking cannabis compared with the control condition in both the single-task (SDLP effect size [ES], 0.30; b = 1.65; 95% CI, 0.37 to 2.93; MS ES, -0.58; b = -2.46; 95% CI, -3.56 to -1.36) and dual-task (SDLP ES, 0.27; b = 1.75; 95% CI, 0.21 to 3.28; MS ES, -0.47; b = -3.15; 95% CI, -5.05 to -1.24) conditions. Blood THC levels were significantly increased at 30 minutes but not 180 minutes. Blood THC was not correlated with SDLP or MS at 30 minutes, and SDLP was not correlated with MS. Subjective ratings remained elevated for 5 hours and participants reported that they were less willing to drive at 3 hours after smoking.

Conclusions and relevance

In this cohort study, the findings suggested that older drivers should exercise caution after smoking cannabis.

Optimizing the Cell Painting assay for image-based profiling

In image-based profiling, software extracts thousands of morphological features of cells from multi-channel fluorescence microscopy images, yielding single-cell profiles that can be used for basic research and drug discovery. Powerful applications have been proven, including clustering chemical and genetic perturbations on the basis of their similar morphological impact, identifying disease phenotypes by observing differences in profiles between healthy and diseased cells and predicting assay outcomes by using machine learning, among many others. Here, we provide an updated protocol for the most popular assay for image-based profiling, Cell Painting. Introduced in 2013, it uses six stains imaged in five channels and labels eight diverse components of the cell: DNA, cytoplasmic RNA, nucleoli, actin, Golgi apparatus, plasma membrane, endoplasmic reticulum and mitochondria. The original protocol was updated in 2016 on the basis of several years' experience running it at two sites, after optimizing it by visual stain quality. Here, we describe the work of the Joint Undertaking for Morphological Profiling Cell Painting Consortium, to improve upon the assay via quantitative optimization by measuring the assay's ability to detect morphological phenotypes and group similar perturbations together. The assay gives very robust outputs despite various changes to the protocol, and two vendors' dyes work equivalently well. We present Cell Painting version 3, in which some steps are simplified and several stain concentrations can be reduced, saving costs. Cell culture and image acquisition take 1-2 weeks for typically sized batches of ≤20 plates; feature extraction and data analysis take an additional 1-2 weeks.This protocol is an update to Nat. Protoc. 11, 1757-1774 (2016): https://doi.org/10.1038/nprot.2016.105.

Modeling transport and fate of heavy metals at the watershed scale: State-of-the-art and future directions

A predictive understanding of the source-specific (e.g., point and diffuse sources) land-to-river heavy metal (HM) loads and HM dynamics in rivers is essential for mitigating river pollution and developing effective river basin management strategies. Developing such strategies requires adequate monitoring and comprehensive models based on a solid scientific understanding of the watershed system. However, a comprehensive review of existing studies on the watershed-scale HM fate and transport modeling is lacking. In this review, we synthesize the recent developments in the current generation of watershed-scale HM models, which cover a wide range of functionalities, capabilities, and spatial and temporal scales (resolutions). Existing models, constructed at various levels of complexity, have their strengths and weaknesses in supporting diverse intended uses. Additionally, current challenges in the application of watershed HM modeling are covered, including the representation of in-stream processes, organic matter/carbon dynamics and mitigation practices, the issues of model calibration and uncertainty analysis, and the balance between model complexity and available data. Finally, we outline future research requirements regarding modeling, strategic monitoring, and their combined use to enhance model capabilities. In particular, we envisage a flexible framework for future watershed-scale HM models with varying degrees of complexity to accommodate the available data and specific applications.

The truth is in the stream: Use of tracer techniques and synoptic sampling to evaluate metal loading and remedial options in a hydrologically complex setting

Two synoptic sampling campaigns were conducted to quantify metal loading to Illinois Gulch, a small stream affected by historical mining activities. The first campaign was designed to determine the degree to which Illinois Gulch loses water to the underlying mine workings and to determine the effect of these losses on observed metal loads. The second campaign was designed to evaluate metal loading within Iron Springs, a subwatershed that was responsible for the majority of the metal loading observed during the first campaign. A continuous, constant-rate injection of a conservative tracer was initiated prior to both sampling campaigns and maintained throughout the duration of each study. Tracer concentrations were subsequently used to determine streamflow in gaining stream reaches using the tracer-dilution method, and as an indicator of hydrologic connections between Illinois Gulch and subsurface mine workings. Streamflow losses to the mine workings were quantified during the first campaign using a series of slug additions in which specific conductivity readings were used as a surrogate for tracer concentration. Data from the continuous injections and slug additions were combined to develop spatial streamflow profiles along each study reach. Streamflow estimates were multiplied by observed metal concentrations to yield spatial profiles of metal load that were in turn used to quantify and rank metal sources. Study results indicate that Illinois Gulch loses water to subsurface mine workings and that remedial measures that reduce flow loss (e.g. channel lining) could lessen metal loading from the Iron Springs area. The primary sources of metals to Illinois Gulch include diffuse springs and groundwater, and a draining mine adit. Diffuse sources were determined to have a much larger effect on water quality than other sources that had been the subject of previous investigations due to their visual appearance, supporting the idea that "the truth is in the stream." The overall approach of combining spatially intensive sampling with a rigorous hydrological characterization is applicable to non-mining constituents such as nutrients and pesticides.

Clinical outcomes following intraoperative pedicle disruption in fibula free flaps

OBJECTIVES

Iatrogenic injury of the fibula free flap pedicle is rare. Postoperative flap survival and reconstructive outcomes following intraoperative pedicle severance are unknown. This study assesses free flap outcomes following accidental severance of the peroneal vessels.

METHODS

Multi-institutional retrospective chart review from 2000 to 2020.

RESULTS

Of 2975 harvested fibula free flaps, 26 had a history of pedicle severance during surgical reconstruction. Reasons for intraoperative pedicle severance included transection during muscular dissection 10/26 (39%), accidental severance with the bone saw 12/26 (46%), and other 4/26 (15.6%). The surgeon responsible for pedicle severance included residents 5/26 (19%), fellows 10/26 (39%), attendings 10/26 (39%), and unknown 1/26 (3.9%). The pedicle artery and vein were severed 10/26 (39%), artery 8/26 (31%), and vein 8/26 (31%). Truncated pedicle vessels were used 3/26 (11.7%), intraoperative anastomoses were performed 23/26 (89%). Postoperative revision in the OR within 7 days of surgery was required 6/26 (23%); 4 flaps were salvaged and 2 flaps failed, both arterial thrombosis. Flap failure was attributed to vascular thrombosis. Long-term flap survival and successful reconstructions were reported 24/26 (92%).

CONCLUSION

Accidental severance of fibula free flap pedicle vessels can be corrected with intraoperative repair, without affecting long-term flap survival or reconstructive outcomes. Protecting the flap vessels while using the bone saw and during intramuscular dissection prevents accidental severance.

Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity-modulated radiotherapy era

BACKGROUND

Resected oral cavity carcinoma defects are often reconstructed with osteocutaneous or soft-tissue free flaps, but risk of osteoradionecrosis (ORN) is unknown.

METHODS

This retrospective study included oral cavity carcinoma treated with free-tissue reconstruction and postoperative IMRT between 2000 and 2019. Risk-regression assessed risk factors for grade ≥2 ORN.

RESULTS

One hundred fifty-five patients (51% male, 28% current smokers, mean age 62 ± 11 years) were included. Median follow-up was 32.6 months (range, 1.0-190.6). Thirty-eight (25%) patients had fibular free flap for mandibular reconstruction, whereas 117 (76%) had soft-tissue reconstruction. Grade ≥2 ORN occurred in 14 (9.0%) patients, at a median 9.8 months (range, 2.4-61.5) after IMRT. Post-radiation teeth extraction was significantly associated with ORN. One-year and 10-year ORN rates were 5.2% and 10%, respectively.

CONCLUSIONS

ORN risk was comparable between osteocutaneous and soft-tissue reconstruction for resected oral cavity carcinoma. Osteocutaneous flaps can be safely performed with no excess concern for mandibular ORN.

The Utility of THC Cutoff Levels in Blood and Saliva for Detection of Impaired Driving

Background: Δ9-Tetrahydrocannabinol (THC) is the psychoactive component in cannabis and a relationship of THC to driving impairment is expected. Despite this, there are discrepant findings with respect to the relationship of blood THC to driving. This study investigated the relationship of blood, urine, and saliva THC/THC-COOH levels to "weaving," as measured by a driving simulator. Methods: Participants smoked cannabis alone or with alcohol. THC/THC-COOH levels in blood, urine, and saliva were correlated with standard deviation of lateral position (SDLP), measuring "weaving." In addition, SDLP after cannabis and/or alcohol were compared with SDLP after placebo when THC/THC-COOH levels were above or below specified thresholds in blood (5 ng/mL), urine (50 ng/mL), or saliva (25 ng/mL). Results: A clear linear relationship between blood THC concentration and SDLP was not observed based on calculation of Spearman coefficients. When compared with placebo, SDLP was significantly increased after cannabis and cannabis combined with alcohol when THC in the blood was above the legal limit. SDLP was increased in drug conditions when saliva cutoffs were above the legal limit. Conclusions: The findings of this study suggest that specified thresholds for THC in blood and saliva may be able to detect driving impairment, but future studies are needed. ClinicalTrials.gov ID: NCT03106363.

Policies and Price Tags: The Public's Perception of Face Transplantation and Its Funding

Study Design

Survey study.

Objective

Facial vascularized composite allotransplantation (FVCA) can cost over 1 million dollars per procedure and is usually not covered by insurance, yet this financial burden and public opinion surrounding this procedure are not well understood. This study is the first to evaluate the layperson's opinions on the allocation of financial responsibility for FVCA and its inclusion in organ donation registries.

Methods

Eight hundred and fifteen laypersons were surveyed through MTurk to assess their agreement with 11 statements about FVCA perceptions, funding, and inclusion on organ donation registries. Responses were analyzed with the Wilcoxon Signed-Rank test, the Kruskal-Wallis test, and the Dunn's test.

Results

The majority of respondents were supportive of FVCA in 10 out of 11 statements (P < 0.0001). They would be willing to undergo FVCA if they suffered from facial disfigurement; believe FVCA is as important as other organ transplants; believe faces should be included on the organ donation registry; support insurance companies providing coverage for FVCA regardless of trauma etiology; support tax dollars funding the procedure; and believe FVCA improves physical appearance and quality of life. Although respondents generally supported their tax dollars funding the procedure, fewer supported this for self-inflicted trauma (P > 0.01).

Conclusions

This study highlights a disconnect between public preference for insurance coverage of FVCA and current lack of coverage in practice. Respondents' acceptance of including faces in organ donation registries may help alleviate the issue of locating a donor, and increasing financial coverage may broaden this procedure's accessibility to a wider range of individuals.

92 CONTINUING TO ‘BE HIP’: ORTHOGERIATRIC SERVICE IMPROVEMENTS IN 2021

Background

Scotland first demonstrated that adherence to nationally agreed hip fracture standards improve patient survival, reduces the duration of admission, and reduces the need for high dependency care. Our study aims to assess adherence to the Irish Hip Fracture Standards (IHFS) in our hospital for 2021 amidst the COVID-19 pandemic, translating to improved clinical outcomes for our patients.

Methods

The IHF database was retrospectively analysed, comparing quarters 1-4 in 2021 with our 2020 results.

Results

IHFS1, patient time to the ward < 4hours, was maintained at 67% in 2021 versus 71% overall in 2020. There was improvement in IHFS2, time to surgery within 48 hours, up to 73% in 2021 versus 66% in 2020. IHFS3 was 4% in 2021 versus 3% overall in 2020. Further improvements were noted for IHFS4, with 95% of patients reviewed by a Geriatrician in 2021 versus 87% in 2020. IHFS5 also improved with 97% of patients receiving a bone health assessment in 2021 versus 87% in 2020. Moreover, IHFS6, improved with 97% of patients undergoing a specialised falls assessment in 2021 versus 87% in 2020.

Conclusion

The improvement in 2021 figures is reflective of the return of redeployed services during the COVID-19 pandemic inclusive of the Orthogeriatric Service, the Fracture Liaison Service Advanced Nurse Practitioner, the Trauma Co-ordinator, and the specialist Orthopaedic ward complete with its Orthopaedic nurses and Multi-Disciplinary Team, and improved Emergency Department pathways. These continued improvements in the IHFS further emphasise that success is dependent on a team that is joined at the hip

258 RISING TO THE CHALLENGE: ORTHOGERIATRIC SERVICE IMPROVEMENT AND COVID-19

Background

Nationally agreed hip fracture standards have contributed to the improvement of outcomes in hip fracture patients. In 2020, our hospital was awarded “The Golden Hip” for achieving highest compliance with Irish Hip Fracture Standards (IHFS) nationally for 2019.

Methods

Data from the Irish Hip Fracture Database (IHFD)was retrospectively analysed to assess our performance in 2020 versus 2019 in hip fracture patients over sixty. Multiple quality improvement interventions were put in place throughout 2019 to ensure improvement in IHFS1-6 compliance: Creation of the Hip Fracture Pathway Subgroup, IHFS 1 Breaches Audit, Orthogeriatric input at Orthopaedic inductions, weekly Multi-disciplinary Team meetings, a Nutritional Hip Fracture Pathway and addition of the Fracture Liaison Service Advanced Nurse Practitioner.

Results

There were 239 hip fracture patients in 2020 vs 249 in 2019. IHFS1 compliance improved with the percentage of patients admitted to the Orthopaedic ward within 4 hours increasing to 71% in 2020 from 56% in 2019. There was improvement in IHFS2-time to surgery &lt;48 hours- 66% in 2020 vs 60% in 2019. IHFS3-pressure ulcer rate-was at the national average, 3% in 2020 vs 2% in 2019. IHFS4 (reviewed by a Geriatrician), IHFS5 (received a bone health assessment) and IHFS6 (received a specialised falls assessment) were lower overall; 87% in 2020 vs 98% in 2019. For all quarters (Q),43% of patients met all IHFS in our hospital in 2020 vs 32% in 2019, resulting in €90,000 in Best Practice Tariff funding.

Conclusion

Lower results for IHFS 4,5 and 6 reflect the arrival of the COVID-19 pandemic which led to redeployment of the Orthogeriatric Service and redeployment of the MDT from end of Q1 to Q3. When services in 2020 were preserved,1 in 2 hip fracture patients met all IHFS, vs 1 in 3 patients in 2019. Despite the pandemic, we continued to achieve the highest level of IHFS compliance nationally, being awarded a second consecutive “Golden Hip” for 2020.

Identification and validation of a QTL for spikelet number on chromosome arm 6BL of common wheat (Triticum aestivum L.)

To provide food security for a growing world population, it will be necessary to increase yields of staple crops such as wheat (Triticum aestivum L.). Yield is a complex, polygenic trait influenced by grain weight and number, which are negatively correlated with one another. Spikelet number is an important determinant of grain number, but allelic variants impacting its expression are often associated with heading date, constraining their use in wheat germplasm that must be adapted for specific environments. Identification and characterization of genetic variants affecting spikelet number will increase selection efficiency through their deployment in breeding programs. In this study, a quantitative trait locus (QTL) on chromosome arm 6BL for spikelet number was identified and validated using an association mapping panel, a recombinant inbred line population, and seven derived heterogeneous inbred families. The superior allele, QSn.csu-6Bb, was associated with an increase of 0.248 to 0.808 spikelets per spike across multiple environments that varied for mean spikelet number. Despite epistatic interactions between QSn.csu-6B and three other loci (WAPO-A1, VRN-D3, and PPD-B1), genotypes with a greater number of superior alleles at these loci consistently exhibit higher spikelet number. The frequency of superior alleles at these loci varies among winter wheat varieties adapted to different latitudes of the US Great Plains, revealing opportunities for breeders to select for increased spikelet number using simple molecular markers. This work lays the foundation for the positional cloning of the genetic variant underlying the QSn.csu-6B QTL to strengthen our understanding of spikelet number determination in wheat.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11032-022-01288-7.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

103 ORTHOGERIATRIC SERVICES IN THE FACE OF COVID-19

Background

Nationally agreed standards improve the level of care delivered to all older, frail, multi-morbid patients presenting with hip fractures. Dedicated Orthogeriatric services allow for these standards to be achieved in a multi-disciplinary team (MDT) setting. As the COVID-19 pandemic reached our shores, the model of care set out by the Irish Hip Fracture Standards (IHFS) was under threat. Our dedicated Orthopaedic Trauma ward became an acute COVID ward and the Orthogeriatric service was re-deployed to acute medicine for Quarter 2.

Methods

Using the Irish Hip Fracture Database, local data was analysed and compared with national data from Quarter 1 to 4 (Q1–4) in 2020.

Results

When comparing local IHFS’s with national figures, ongoing challenges and future goals are highlighted.

In 2020, there were 222 hip fracture patients (mean age 81.8 years) in our hospital. Standard 1, time to the ward <4 hours, stands at 71% locally (national average 33%). Standard 2, time to theatre <48 hours, is an ongoing challenge and remains at 66% (national average 75%). Standard 3, pressure ulcer rate, was the same as the national average at 3%. Standards 4, 5 and 6 in our hospital stand at 87% (national averages of 82%, 91% and 85% respectively).

In Q1, 56%, or over 1 in every 2 patients with hip fractures, met all of the Irish Hip Fracture Standards in our hospital. In Q2, only 18% of patients met all of the IHFS’s. Q3 saw improvements with 47% of all hip fracture patients achieving all IHFS’s. Q4 showed maintenance with 45% of all patients achieving all IHFS’s.

Conclusion

These findings highlight the need for a dedicated Orthogeriatric Service and Orthopaedic ward at all times. Going forward with the risk of future waves and the emergence of new variants, every effort should be made to maintain a comprehensive orthogeriatric service to minimise a negative impact on patient care.

Control of osteocyte dendrite formation by Sp7 and its target gene osteocrin

Some osteoblasts embed within bone matrix, change shape, and become dendrite-bearing osteocytes. The circuitry that drives dendrite formation during "osteocytogenesis" is poorly understood. Here we show that deletion of Sp7 in osteoblasts and osteocytes causes defects in osteocyte dendrites. Profiling of Sp7 target genes and binding sites reveals unexpected repurposing of this transcription factor to drive dendrite formation. Osteocrin is a Sp7 target gene that promotes osteocyte dendrite formation and rescues defects in Sp7-deficient mice. Single-cell RNA-sequencing demonstrates defects in osteocyte maturation in the absence of Sp7. Sp7-dependent osteocyte gene networks are associated with human skeletal diseases. Moreover, humans with a SP7R316C mutation show defective osteocyte morphology. Sp7-dependent genes that mark osteocytes are enriched in neurons, highlighting shared features between osteocytic and neuronal connectivity. These findings reveal a role for Sp7 and its target gene Osteocrin in osteocytogenesis, revealing that pathways that control osteocyte development influence human bone diseases.

Evaluating rapid review provision to inform policy during the COVID-19 pandemic

Background

Evidence based decision making is central to population health, particularly during a pandemic. Few studies examine the production and use of evidence in decision-making during crisis management. This study describes and evaluates the provision of rapid evidence products by a single agency to support national decision making.

Methods

Semi-structured interviews were conducted with a convenience sample of evidence providers (who gathered and disseminated the required evidence) and service users (policy makers). Interviews were transcribed verbatim and analysed using thematic analysis. Quantitative data of work activity were summarised descriptively.

Results

Three themes were generated from the data: the work, the use and the future, with a fourth theme cross-cutting across these: the team. The work followed clear protocols and was centrally managed. The scope and changing nature of the evidence were highlighted as issues. The service providers reported a strong sense of team work and ‘being in this together', however, the majority of the participants felt that the workload was huge and exhausting and not sustainable long-term. Overall the service users thought the rapid evidence synthesis was indispensable to the decision-making process and had trust and confidence in the work, largely based on existing working relationships with the team. While they recognised that the evidence synthesis support would be an essential component of the continued pandemic response, they did query the sustainability of the process and reflected on the amount of work the team performed.

Conclusions

This evaluation, drawing on qualitative data, has highlighted that, across the services users and evidence providers, the support provided by HIQA was generally perceived as positive. From the service users' perspective, having access to the team was indispensable to the decision making process. However, the sustainability of the work load was identified as a major challenge.

COVID-19 - Interventions and lifestyle factors that prevent infection or minimise progression to severe disease

Background

This evidence summary synthesised the evidence relating to pharmacological and non-pharmacological interventions in the community to prevent COVID-19/progression to severe disease. An additional aim was to identify potentially modifiable lifestyle factors associated with reduced risk of infection/progression to severe disease.

Methods

A systematic search of published peer-reviewed articles and non-peer-reviewed pre-prints was undertaken from 1 January 2020 to 19 April 2021; no language restrictions were applied. All potentially eligible papers were exported to Covidence. Titles/abstracts and full texts were single screened for relevance. Data extraction and quality appraisal of included studies was completed by a single reviewer and checked by a second.

Results

In total, 50 studies, three randomised controlled trials (RCTs), one non-RCT and 46 cohort studies were included. The four included controlled trials tested variations of the pharmacological intervention, ivermectin. While these controlled trials reported a protective effect for ivermectin use, these trials were of poor quality and had serious risk of bias. Across 46 cohort studies, the modifiable lifestyle risk factors identified were obesity, smoking, vitamin D status, physical activity, alcohol consumption and processed meat consumption. These studies reported mixed results in terms of the association between modifiable lifestyle risk factors and poor COVID-19 outcomes.

Conclusions

At the time of writing there is no high quality evidence of benefit to support pharmacological interventions to prevent COVID-19. Although there were mixed results for the risk factors identified, maintenance of healthy weight, smoking cessation, engaging in physical activity and moderation of alcohol and processed meat consumption are likely to be beneficial to health and should continue to be encouraged.

Transport and speciation of uranium in groundwater-surface water systems impacted by legacy milling operations

Growing worldwide concern over uranium contamination of groundwater resources has placed an emphasis on understanding uranium transport dynamics and potential toxicity in groundwater-surface water systems. In this study, we utilized novel in-situ sampling methods to establish the location and magnitude of contaminated groundwater entry into a receiving surface water environment, and to investigate the speciation and potential bioavailability of uranium in groundwater and surface water. Streambed temperature mapping successfully identified the location of groundwater entry to the Little Wind River, downgradient from the former Riverton uranium mill site, Wyoming, USA. Diffusive equilibrium in thin-film (DET) samplers further constrained the groundwater plume and established sediment pore water solute concentrations and patterns. In this system, evidence is presented for attenuation of uranium-rich groundwater in the shallow sediments where surface water and groundwater interaction occurs. Surface water grab and DET sampling successfully detected an increase in river uranium concentrations where the groundwater plume enters the Little Wind River; however, concentrations remained below environmental guideline levels. Uranium speciation was investigated using diffusive gradients in thin-film (DGT) samplers and geochemical speciation modelling. Together, these investigations indicate uranium may have limited bioavailability to organisms in the Little Wind River and, possibly, in other similar sites in the western U.S.A. This could be due to ion competition effects or the presence of non- or partially labile uranium complexes. Development of methods to establish the location of contaminated (uranium) groundwater entry to surface water environments, and the potential effects on ecosystems, is crucial to develop both site-specific and general conceptual models of uranium behavior and potential toxicity in affected ground and surface water environments.

Clinical Excellence in Otolaryngology-Head and Neck Surgery: Examples from the Published Literature

OBJECTIVE/HYPOTHESIS

To apply the domains of clinical excellence, as published by the Miller-Coulson Academy of Clinical Excellence, to the field of otolaryngology-head and neck surgery (OHNS) as a framework for evaluating and improving clinical excellence.

METHODS

A search of PubMed, Scopus, the Cochrane Library, and the National Institute for Health and Care Excellence (NICE) databases was performed and 229 publications were reviewed.

RESULTS

Case reports and other articles were selected that exemplify each of the distinct domains of clinical excellence within our specialty.

CONCLUSIONS

The Miller-Coulson Academy's domains of clinical excellence are relevant to OHNS and can provide a framework for fostering clinical excellence in otolaryngologists. The many examples of excellent care by otolaryngologists found in the published literature can inspire otolaryngologists to provide outstanding care to all patients consistently and to advance our specialty.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:E2153-E2158, 2021.

OHNS Residency Program and Applicant Social Media Presence During the COVID-19 Pandemic

OBJECTIVES

In addition to clinical and social disruption, the Coronavirus Disease 2019 (COVID-19) pandemic has affected many aspects of the otolaryngology residency application process. With delays in the 2021 Electronic Residency Applications Service (ERAS) timeline, students and programs have had more time to interact prior to the formal application process. This communication will report recent trends in social media presence by OHNS residency programs, and discuss mechanisms to compensate for decreased applicant-program interactions using social media ahead of the 2021 Match.

METHODS

In a cross-sectional study of the accredited otolaryngology residency programs in the United States, the number of social media profiles on Twitter, Instagram, and Facebook from 2009 to 2019 were recorded and compared.

RESULTS

Most programs (61%) have at least 1 social media profile. Over the past 10 years, the number of programs on social media has increased. During the COVID-19 pandemic, Twitter and Instagram showed higher rates of growth compared to Facebook. With the reduction of in-person opportunities for interactions, both applicants and programs are utilizing social media to showcase their values and their research. Twitter, in particular, also serves as a platform for professional networking.

CONCLUSION

Both Twitter and Instagram are growing in popularity among programs and applicants to enhance networking. Social media is a powerful tool for networking and may help compensate for limitations imposed on the residency match process by the COVID-19 pandemic while maintaining professionalism considerations. The impact of social media on the 2021 otolaryngology residency match is an evolving phenomenon.

Critical Shifts in Trace Metal Transport and Remediation Performance under Future Low River Flows

Exceptionally low river flows are predicted to become more frequent and more severe across many global regions as a consequence of climate change. Investigations of trace metal transport dynamics across streamflows reveal stark changes in water chemistry, metal transformation processes, and remediation effectiveness under exceptionally low-flow conditions. High spatial resolution hydrological and water quality datasets indicate that metal-rich groundwater will exert a greater control on stream water chemistry and metal concentrations because of climate change. This is because the proportion of stream water sourced from mined areas and mineralized strata will increase under predicted future low-flow scenarios (from 25% under Q45 flow to 66% under Q99 flow in this study). However, mineral speciation modelling indicates that changes in stream pH and hydraulic conditions at low flow will decrease aqueous metal transport and increase sediment metal concentrations by enhancing metal sorption directly to streambed sediments. Solute transport modelling further demonstrates how increases in the importance of metal-rich diffuse groundwater sources at low flow could minimize the benefits of point source metal contamination treatment. Understanding metal transport dynamics under exceptionally low flows, as well as under high flows, is crucial to evaluate ecosystem service provision and remediation effectiveness in watersheds under future climate change scenarios.

Predicting Resting Oral Commissure Tone Outcomes Following Masseter Nerve Transfer in Facial Reanimation

Objective: To quantify the degree of oral commissure resting tone improvement in patients undergoing masseter to facial nerve transfer. Methods: A retrospective cohort study was completed in a tertiary academic medical practice. Consecutive cases of masseter nerve transfer patients within a patient database were evaluated from 6/2012 to 9/2017. Inclusion criteria were patients >18 years of age, with complete unilateral paralysis, receiving a masseter to facial nerve transfer, with at least 12 months of recovery, and possessing complete pre- and postoperative data. Patients were excluded if a simultaneous adjunctive procedure was performed so that tone could not be attributed to masseter transfer alone. The main outcome measure was the facial asymmetry index (FAI): the measured difference in distance between the medial canthus and oral commissure of the healthy and paralyzed sides. Results: Twenty-nine patients met inclusion and exclusion criteria and were further analyzed for this study. The oral commissure symmetry improved from 4.7 ± 2.8 mm preoperatively to 2.2 ± 2.3 mm postoperatively. In multivariate analysis, the preoperative FAI was the only significant predictive factor for improvement in commissure symmetry at rest (r = 0.589). This suggests that for each 1.0 mm of worse preoperatively oral commissure asymmetry, the improvement postoperatively was 0.6 mm. Age, gender, body mass index, side of paralysis, duration of paralysis, and recipient branch of facial nerve were not significant predictors in a multivariate analysis. Conclusion: Masseter to facial nerve transfer yields an estimated 60% correction in the oral commissure asymmetry. This estimation may be helpful in determining if adjunctive procedures should be utilized.

Coronavirus disease 2019: What could be the effects on Road safety?

In March 2020, the World Health Organization declared COVID-19 a world-wide pandemic. Countries introduced public health measures to contain and reduce its spread. These measures included closures of educational institutions, non-essential businesses, events and activities, as well as working from and staying at home requirements. These measures have led to an economic downturn of unprecedented proportions. Generally, as economic activity declines, travel decreases and drivers are exposed to a lower risk of collisions. However, research on previous economic downturns suggests economic downturns differentially affect driver behaviours and situations. COVID-19 pandemic effects on road safety are currently unknown. However, preliminary information on factors such as the increased stress and anxiety brought about by the COVID-19 pandemic, more "free" (idle) time, increased consumption of alcohol and drugs, and greater opportunities for speeding and stunt driving, might well have the opposite effect on road safety. Using an interactionist model we identify research questions for researchers to consider on potential person and situation factors associated with COVID-19 that could affect road safety during and after the pandemic. Collaborative efforts by researchers, and public and private sectors will be needed to gather data and develop road safety strategies in relation to the new reality of COVID-19.

Personalising screening of sight-threatening diabetic retinopathy - qualitative evidence to inform effective implementation

Background

Internationally, systematic screening for sight-threatening diabetic retinopathy (STDR) usually includes annual recall. Researchers and policy-makers support extending screening intervals, citing evidence from observational studies with low incidence rates. However, there is little research around the acceptability to people with diabetes (PWD) and health care professionals (HCP) about changing eye screening intervals.

Methods

We conducted a qualitative study to explore issues surrounding acceptability and the barriers and enablers for changing from annual screening, using in-depth, semistructured interviews analysed using the constant comparative method. PWD were recruited from general practices and HCP from eye screening networks and related specialties in North West England using purposive sampling. Interviews were conducted prior to the commencement of and during a randomised controlled trial (RCT) comparing fixed annual with variable (6, 12 or 24 month) interval risk-based screening.

Results

Thirty PWD and 21 HCP participants were interviewed prior to and 30 PWD during the parallel RCT. The data suggests that a move to variable screening intervals was generally acceptable in principle, though highlighted significant concerns and challenges to successful implementation. The current annual interval was recognised as unsustainable against a backdrop of increasing diabetes prevalence. There were important caveats attached to acceptability and a need for clear safeguards around: the safety and reliability of calculating screening intervals, capturing all PWD, referral into screening of PWD with diabetic changes regardless of planned interval. For PWD the 6-month interval was perceived positively as medical reassurance, and the 12-month seen as usual treatment. Concerns were expressed by many HCP and PWD that a 2-year interval was too lengthy and was risky for detecting STDR. There were also concerns about a negative effect upon PWD care and increasing non-attendance rates. Amongst PWD, there was considerable conflation and misunderstanding about different eye-related appointments within the health care system.

Conclusions

Implementing variable-interval screening into clinical practice is generally acceptable to PWD and HCP with important caveats, and misconceptions must be addressed. Clear safeguards against increasing non-attendance, loss of diabetes control and alternative referral pathways are required. For risk calculation systems to be safe, reliable monitoring and clear communication is required.

The Maudsley Early Onset Schizophrenia Study: The effect of age of onset and illness duration on fronto-parietal gray matter

Objective

In Early Onset Schizophrenia (EOS; onset before the 18th birthday) late brain maturational changes may interact with disease mechanisms leading to a wave of back to front structural changes during adolescence. To further explore this effect we examined the relationship between age of onset and duration of illness on brain morphology in adolescents with EOS.

Subjects and methods

Structural brain magnetic resonance imaging scans were obtained from 40 adolescents with EOS. We used Voxel Based Morphometry and multiple regressions analyses, implemented in SPM, to examine the relationship between gray matter volume with age of onset and illness duration.

Results

Age of onset showed a positive correlation with regional gray matter volume in the right superior parietal lobule (Brodmann Area 7). Duration of illness was inversely related to regional gray matter volume in the left inferior frontal gyrus (BA 11/47).

Conclusions

Parietal gray matter loss may contribute to the onset of schizophrenia while orbitofrontal gray matter loss is associated with illness duration.

A Review of and Algorithmic Approach to Soft Palate Reconstruction

Importance

The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity.

Objective

To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review.

Evidence Review

A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded.

Findings

The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases.

Conclusions and Relevance

Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

Assessment of Casual Observers' Willingness to Pay for Increased Attractiveness Through Rhinoplasty

Importance

Contingent valuation, or willingness to pay, is an established economic concept that has been applied in other areas of medicine and may be useful for understanding the economic forces that determine the cost of cosmetic procedures.

Objective

To determine the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society.

Design, Setting, and Participants

Cross-sectional survey administered via public online forums to 228 casual observers.

Main Outcomes and Measures

Participants were shown preoperative and postoperative photographs of 12 patients who underwent cosmetic rhinoplasty and 4 patients who did not undergo any surgery. They were asked to rate (1) the change in overall attractiveness of the patients, and (2) the monetary value they would associate with these changes.

Results

Completed surveys were obtained from 228 casual observers; 144 were female (63.2%); median age, 25 years (median income bracket, $50 000-$75 000). Multilevel, mixed-effects, linear regression was used to characterize the association between monetary value and change in attractiveness. There was a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 standard deviation in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 standard deviations in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001).

Conclusions and Relevance

There is a significant association between the societally perceived value of cosmetic rhinoplasty and the change in attractiveness after surgery. The average value of a rhinoplasty in our study approximates the actual average cost of cosmetic rhinoplasty, suggesting that willingness to pay may be a useful concept for studying the value of cosmetic procedures.

Level of Evidence

NA.

The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation

Importance

A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis.

Objective

To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone.

Design, Setting, and Participants

Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital.

Interventions

The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation.

Main Outcomes and Measures

The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling.

Results

There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P < .001). The mean exposed maxillary gingival scaffold width improved from 31.5 mm to 43.7 mm (95% CI, 1.9 to 4.3; P < .001). There was no significant difference in interlabial exposure at midline (7.1 mm vs 7.7 mm; CI, -1.5 to 2.7; P = .56) but a 56.4% improvement at the level of the canines (3.9 vs 6.1; CI, 0.1 to 4.3; P = .04). The mean FAI when smiling was reduced from 9.1 mm to 4.5 mm (CI, -8.0 to -1.2; P = .01). Dynamic wrinkling of the periorbital area with smiling was noted in 4 patients.

Conclusions and Relevance

The gracilis flap can be reliably designed as a functional double paddle muscle flap for a multivector facial reanimation. The multivector gracilis flap design is effective in improving all components of the smile display zone and has the potential for producing periorbital-wrinkling characteristic of a Duchenne smile.

Level of Evidence

4.

Analysis of the operative utilization of concurrent rhinoplasty and endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Cross-sectional analysis.

METHODS

Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared.

RESULTS

Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes).

CONCLUSIONS

RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:E311-E319, 2020.

Origin and Fate of Vanadium in the Hazeltine Creek Catchment following the 2014 Mount Polley Mine Tailings Spill in British Columbia, Canada

Results from the analysis of aqueous and solid-phase V speciation within samples collected from the Hazeltine Creek catchment affected by the August 2014 Mount Polley mine tailings dam failure in British Columbia, Canada, are presented. Electron microprobe and X-ray absorption near-edge structure (XANES) analysis found that V is present as V³⁺ substituted into magnetite and V³⁺ and V⁴⁺ substituted into titanite, both of which occur in the spilled Mount Polley tailings. Secondary Fe oxyhydroxides forming in inflow waters and on creek beds have V K-edge XANES spectra exhibiting E1/2 positions and pre-edge features consistent with the presence of V⁵⁺ species, suggesting sorption of this species on these secondary phases. PHREEQC modeling suggests that the stream waters mostly contain V⁵⁺ and the inflow and pore waters contain a mixture of V³⁺ and V⁵⁺. These data, and stream, inflow, and pore water chemical data, suggest that dissolution of V(III)-bearing magnetite, V(III)- and V(IV)-bearing titanite, V(V)-bearing Fe(-Al-Si-Mn) oxhydroxides, and V-bearing Al(OH)₃ and/or clay minerals may have occurred. In the circumneutral pH environment of Hazeltine Creek, elevated V concentrations are likely naturally attenuated by formation of V(V)-bearing secondary Fe oxyhydroxide, Al(OH)₃, or clay mineral colloids, suggesting that the V is not bioavailable. A conceptual model describing the origin and fate of V in Hazeltine Creek that is applicable to other river systems is presented.

Environmental risk of severely Pb-contaminated riverbank sediment as a consequence of hydrometeorological perturbation

Metal mining activities have resulted in the widespread metal pollution of soils and sediments and are a worldwide health concern. Pb is often prolific in metal-mining impacted systems and has acute and chronic toxic effects. Environmental factors controlling diffuse pollution from contaminated riverbank sediment are currently seen as a "black box" from a process perspective. This limits our ability to accurately predict and model releases of dissolved Pb. Previous work by the authors uncovered key mechanisms responsible for the mobilisation of dissolved Zn. The current study identifies key mechanisms controlling the mobilisation of dissolved Pb, and the environmental risk these releases pose, in response to various sequences of "riverbank" inundation/drainage. Mesocosm experiments designed to mimic the riverbank environment were run using sediment severely contaminated with Pb, from a mining-impacted site. Results indicated that, although Pb is generally reported as less mobile than Zn, high concentrations of dissolved Pb are released in response to longer or more frequent flood events. Furthermore, the geochemical mechanisms of release for Zn and Pb were different. For Zn, mechanisms were related to reductive dissolution of Mn (hydr)oxides with higher concentrations released, at depth, over prolonged flood periods. For Pb, key mechanisms of release were related to the solubility of anglesite and the oxidation of primary mineral galena, where periodic drainage events serve to keep sediments oxic, particularly at the surface. The results are concerning because climate projections for the UK indicate a rise in the occurrence of localized heavy rainfall events that could increase flood frequency and/or duration. This study is unique in that it is the first to uncover key mechanisms responsible for dissolved Pb mobilisation from riverbank sediments. The mineralogy at the mining-impacted site is common to many sites worldwide and it is likely the mechanisms identified in this study are widespread.

Facial Asymmetry Index: Validation and Applications in Various Smile Restoration Techniques

Consistent and objective evaluation of the paralyzed face is imperative for documenting preoperative findings and assessing postoperative outcomes of reanimation techniques. Static and dynamic facial asymmetry are the key features of the paralyzed face. To date, there is no consensus among surgeons on how best to document facial asymmetry. The authors propose a Facial Asymmetry Index (FAI) as an objective measure of facial asymmetry and validate its use and reliability across numerous reanimation techniques. Frontal photographs of patients with unilateral facial nerve paralysis were analyzed. The length from the medial canthus to the ipsilateral oral commissure was compared between affected and nonaffected sides. The FAI is the difference between the two values, with a higher value reflecting poorer facial symmetry. Validation and reliability testing was then performed. There was a consistent decrease in the FAI with procedural intervention (FAI pre = 10.1, FAI post = 3.17; p < 0.0001). Furthermore, there was excellent inter- and intrarater reliability among independent judges. The FAI is a powerful and accessible tool to quantify operative outcomes for many lower facial nerve reanimation techniques.

Compact DD generator-based in vivo neutron activation analysis (IVNAA) system to determine sodium concentrations in human bone

OBJECTIVE

This study presents the development of a noninvasive method for monitoring Na in human bone. Many diseases, such as hypertension and osteoporosis, are closely associated with sodium (Na) retention in the human body. Na retention is generally evaluated by calculating the difference between dietary intake and excretion. There is currently no method to directly quantify Na retained in the body. Bone is a storage for many elements, including Na, which renders bone Na an ideal biomarker to study Na metabolism and retention.

APPROACH

A customized compact deuterium-deuterium (DD) neutron generator was used to produce neutrons for in vivo neutron activation analysis (IVNAA), with a moderator/reflector/shielding assembly optimized for human hand irradiation in order to maximize the thermal neutron flux inside the irradiation cave and to limit radiation exposure to the hand and the whole body.

MAIN RESULTS

The experimental results show that the system is able to detect sodium levels in the bone as low as 16 µg Na g^-1 dry bone with an effective dose to the body of about 27 µSv. The simulation results agree with the numbers estimated from the experiment.

SIGNIFICANCE

This is expected to be a feasible method for measuring the change of Na in bone. The low detection limit indicates this will be a useful system to study the association between Na retention and related diseases.

Image-Guided Osteoplastic Frontal Sinusotomy

Background

A 6-ft Caldwell radiograph template and transillumination, typically, are used to elucidate the frontal sinus outline for osteoplastic frontal sinusotomy (OFS). These techniques can be fraught with imprecision. The consequences of imprecise OFS may result in significant complications. Computer-aided surgery may offer a safe and accurate alternative to these techniques in selected cases. Several disadvantages were noted with early computer-aided assistance. Current infrared and electromagnetic systems have eliminated many of these disadvantages. We describe our technique and experience with an infrared image-guidance system (The LandmarX Evolution; Medtronic Xomed, Jacksonville, FL) to create a precise OFS that maximizes exposure while minimizing morbidity.

Methods

We describe the use of an infrared image guidance system, the LandmarX Evolution for OFS in three cases.

Results

The LandmarX Evolution allowed for accurate placement of the OFS in each of the three cases and successful treatment of two symptomatic frontal sinus osteomas and a recurrent inverted papilloma. No complications were encountered.

Conclusion

Image-guided OFS results in a confident and accurate entry into the frontal sinus. Image-guided OFS creation should be considered for select cases (i.e., complete opacification and altered anatomy) where performing an OFS by standard techniques may increase the complication rate. More experience with the technique and increased accessibility to image-guided equipment must be made possible before establishing this technique as a standard.

Association Between Patient Value Systems and Physician and Practice Attributes Available Online

IMPORTANCE

The relative value of facial plastic surgeon personal and practice attributes is relevant to the broader health care system because of increasing out-of-pocket expenses to patients.

OBJECTIVE

To determine the relative value of specific facial plastic surgeon personal and practice attributes available online from the perspective of patients.

DESIGN, SETTING, AND PARTICIPANTS

This study consisted of an electronic survey sent to patients by email using choice-based conjoint analysis; surveys were sent between December 2015 and March 2016. Participants had agreed to join email registries to be sent email surveys and promotions at 3 private facial plastic and reconstructive surgery practices. The following surgeon personal and practice attributes and levels were compared: (1) outcome transparency (above average, average, not available); (2) surgical training affiliations (US News and World Reports rankings); (3) online rating site scores (2 [poor], 3, or 4 [excellent] stars); and (4) price ($1×, $2×, and $3× [× = $1500; average cost was set at $2×]).

MAIN OUTCOMES AND MEASURES

The relative importance of outcome transparency, surgical training affiliations, online rating scores, and price to prospective patients.

RESULTS

Overall, 291 patients participated for a completion rate of 68%. Outcome transparency was the most valued attribute (attribute utility range = 141; attribute importance = 35.2%). Price was the least valued attribute (attribute utility range = 58.59; attribute importance = 15.1%). Assuming top-tier affiliations and 4-star ratings, share of market (SOM) was 75.5% for surgeons with above-average outcome transparency priced at $3× compared with those surgeons with no outcomes available priced at $1×. Holding price constant at $2×, surgeons with middle-tier affiliations and 2-star online ratings but above average outcomes achieved 48.4% SOM when compared with those surgeons with top-tier affiliations and 4-star online ratings without available outcomes.

CONCLUSIONS AND RELEVANCE

Facial plastic surgery patients most value surgeons who publish outcomes. Moreover, they are willing to discount poor rating scores and lower-ranked institutional affiliations when outcome transparency is high. This study demonstrates that outcome transparency is crucial in facial plastic surgery markets.

LEVEL OF EVIDENCE

NA.

Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics

Importance

Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented.

Objective

To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD.

Design, Setting, and Participants

This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016.

Methods

All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE).

Results

Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; P = .01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE.

Conclusions and Relevance

Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care.

Level of Evidence

NA.

Synoptic sampling and principal components analysis to identify sources of water and metals to an acid mine drainage stream

Combining the synoptic mass balance approach with principal components analysis (PCA) can be an effective method for discretising the chemistry of inflows and source areas in watersheds where contamination is diffuse in nature and/or complicated by groundwater interactions. This paper presents a field-scale study in which synoptic sampling and PCA are employed in a mineralized watershed (Lion Creek, Colorado, USA) under low flow conditions to (i) quantify the impacts of mining activity on stream water quality; (ii) quantify the spatial pattern of constituent loading; and (iii) identify inflow sources most responsible for observed changes in stream chemistry and constituent loading. Several of the constituents investigated (Al, Cd, Cu, Fe, Mn, Zn) fail to meet chronic aquatic life standards along most of the study reach. The spatial pattern of constituent loading suggests four primary sources of contamination under low flow conditions. Three of these sources are associated with acidic (pH <3.1) seeps that enter along the left bank of Lion Creek. Investigation of inflow water (trace metal and major ion) chemistry using PCA suggests a hydraulic connection between many of the left bank inflows and mine water in the Minnesota Mine shaft located to the north-east of the river channel. In addition, water chemistry data during a rainfall-runoff event suggests the spatial pattern of constituent loading may be modified during rainfall due to dissolution of efflorescent salts or erosion of streamside tailings. These data point to the complexity of contaminant mobilisation processes and constituent loading in mining-affected watersheds but the combined synoptic sampling and PCA approach enables a conceptual model of contaminant dynamics to be developed to inform remediation.

The use of cold coagulation for the treatment of cervical intraepithelial neoplasia

In 2015, Cold Coagulation was introduced as a treatment for cervical intraepithelial neoplasia (CIN) at our colposcopy clinic. We reviewed the 6-month follow up data of the first 200 women who underwent Cold Coagulation using cytology and HPV status as tests of cure (TOC). A random sample of 200 patients treated by Large Loop Excision of the Transformation Zone (LLETZ) during the same period was used to compare treatment outcome. Six months following treatment,173 (86.5%) of the women treated by CC and 167 (83.5%) treated by LLETZ had negative cytology. (x2= P>0.05). 148 (74%) treated by Cold Coagulation and 166 (83%) treated by LLETZ were HPV negative (x2= P<0.05). One hundred and thirty-nine (70%) women treated by Cold Coagulation and 152 (76%) treated with LLETZ had normal cytology and were HPV negative. This audit of our initial experience supports the observation that Cold Coagulation is as effective as LLETZ in the management of CIN when cervical cytology is used as a test of cure.

Transposition of the Intratemporal Facial to Hypoglossal Nerve for Reanimation of the Paralyzed Face: The VII to XII TranspositionTechnique

IMPORTANCE

The hypoglossal nerve has long been an axonal source for reinnervation of the paralyzed face. In this study, we report our experience with transposition of the intratemporal facial nerve to the hypoglossal nerve for facial reanimation.

OBJECTIVES

To determine the feasibility and outcomes of the transposition of the infratemeporal facial nerve for end-to-side coaptation to the hypoglossal nerve for facial reanimation.

DESIGN, SETTINGS, AND PARTICIPANTS

A case series of 20 patients with facial paralysis who underwent mobilization and transposition of the intratemporal segment of the facial nerve for an end-to-side coaptation to the hypoglossal nerve (the VII to XII technique). Participants were treated between January 2007 and December 2014 at a tertiary care center.

MAIN OUTCOMES AND MEASURES

Outcome measures include paralysis duration, facial tone, facial symmetry at rest, and with smile, oral commissure excursion, post-reanimation volitional smile, and synkinesis.

METHODS

Demographic data, the effects of this technique on facial tone, symmetry, oral commissure excursion and smile recovery were evaluated. Preoperative and postoperative photography and videography were reviewed. Facial symmetry was assessed with a facial asymmetry index. Smile outcomes were evaluated with a visual smile recovery scale, and lip excursion was assessed with the MEEI-SMILE system.

RESULTS

All 20 patients had adequate length of facial nerve mobilized for direct end-to-side coaptation to the hypoglossal nerve. The median duration of facial paralysis prior to treatment was 11.4 months. Median follow-up time was 29 months. Three patients were excluded from functional analysis due to lack of follow-up. Facial symmetry at rest and during animation improved in 16 of 17 patients. The median (range) time for return of facial muscle tone was 7.3 (2.0-12.0) months. A significant reduction in facial asymmetry index occurred at rest and with movement. The MEEI FACE-gram software detected a significant increase in horizontal, vertical, overall lip excursion and smile angle. No patient developed significant tongue atrophy, impaired tongue mobility, or speech or swallow dysfunction.

CONCLUSIONS AND RELEVENCE

Mobilization of the intratemporal segment of the facial nerve provides adequate length for direct end-to-end coaptation to the hypoglossal nerve and is effective in restoring facial tone and symmetry after facial paralysis. The resulting smile is symmetric or nearly symmetric in the majority of patients with varying degree of dental show. The additional length provided by utilizing the intratemporal segment of the facial nerve reduces the deficits associated with complete hypoglossal division/splitting, and avoids the need for interposition grafts and multiple coaptation sites.

LEVEL OF EVIDENCE

4.

Nasal Unit Transplantation: A Cadaveric Anatomical Feasibility Study

Background The science and technical acumen in the field of vascularized composite allotransplantation has progressed rapidly over the past 15 years, and transplantation of specialized units of the face, such as the nose, appears possible. No study to date has evaluated the technical feasibility of isolated nasal unit transplantation (NUT). In this study, we explore the anatomy and technical specifics of NUT. Methods In this study, four fresh cadaver heads were studied. Bilateral vascular pedicle dissections were performed in each cadaver. The facial artery was cannulated and injected with food dye under physiologic pressure in two cadavers, and with lead oxide mixture in two cadavers to evaluate perfusion territories supplied by each vascular pedicle. Results The facial artery and vein were found to be adequate pedicles for NUT. Divergent courses of the vein and artery were consistently identified, which made for a bulky pedicle with necessary inclusion of large amounts of subcutaneous tissue. In all cases, the artery remained superficial, while the vein coursed in a deeper plane, and demonstrated consistent anastomoses with the superior transverse orbital arcade. While zinc oxide injection of the facial artery demonstrated filling of the nasal vasculature across the midline, dye perfusion studies suggested that unilateral arterial inflow may be insufficient to perfuse contralateral NUT components. Discrepancies in these two studies underscore the limitations of nondynamic assessment of nutritive perfusion. Conclusion NUT based on the facial artery and facial vein is technically feasible. Angiosome evaluation suggests that bilateral pedicle anastomoses may be required to ensure optimal perfusion.

CT findings in two cats with broncholithiasis

Case series summary

Chronic inflammatory airway disease with secondary broncholithiasis was diagnosed in two cats from CT and bronchoalveolar lavage cytological findings. In one cat with progressively worsening lower respiratory tract signs, more than 80 discrete, highly attenuating endobronchial opacities were detected on thoracic CT. The broncholiths were distributed throughout the right middle, and left and right caudal lung lobes, and the caudal part of the left cranial and accessory lobes. In the other cat broncholithiasis was an incidental finding on thoracic radiographs taken during diagnostic investigation of inappetence. On thoracic CT, 25 calcified endobronchial opacities were detected in the left caudal lung lobe in secondary and tertiary bronchi. CT features of chronic inflammatory airway disease were present in both cases, including bronchiectasis, atelectasis, flattening of the diaphragm and bronchial wall thickening.

Relevance and novel information

This is the first report to document CT features of broncholithiasis in cats. Feline broncholithiasis should be considered as a differential diagnosis in any case where calcified endobronchial material is evident on thoracic radiographs or CT.

Early Nerve Grafting for Facial Paralysis After Cerebellopontine Angle Tumor Resection With Preserved Facial Nerve Continuity

IMPORTANCE

Preserving facial nerve function is a primary goal and a key decision factor in the comprehensive management of vestibular schwannoma and other cerebellopontine angle (CPA) tumors.

OBJECTIVE

To evaluate the use of the pattern of facial paralysis recovery in the early postoperative months as a sole predictor in selecting patients for facial nerve grafting after CPA tumor resection when cranial nerve VII is uninterrupted.

DESIGN, SETTING, AND PARTICIPANTS

Sixty-two patients with facial paralysis and uninterrupted cranial nerve VII who developed facial paralysis after CPA tumor resection at The Johns Hopkins Hospital were followed up prospectively to assess for spontaneous recovery and to determine candidacy for facial reanimation surgery. The study dates and dates of analysis were January 1, 2009, to March 31, 2015.

INTERVENTIONS

After a minimum of 6 months of clinical follow-up and no signs of clinical recovery, patients underwent facial nerve exploration and a masseteric or hypoglossal nerve transfer. Intraoperative direct nerve stimulation was performed to assess for the presence of subclinical reinnervation. Patients were followed up for a minimum of 18 months after surgery to evaluate outcomes.

MAIN OUTCOMES AND MEASURES

Facial function and recovery were studied objectively with a Smile Recovery Scale, Facial Asymmetry Index, and House-Brackmann (HB) grading system. Other outcome measures included the duration of paralysis, time to recovery, and evidence of synkinesis.

RESULTS

Sixty-two patients (33 men, 29 women; mean age 51.8 years) with uninterrupted facial nerves after CPA tumor resection developed HB grade IV, V, or VI facial paralysis. Ten patients underwent nerve grafting by 12 months, 9 patients received grafting after 12 months, and 8 patients had no intervention. Thirty-five patients spontaneously recovered. In all patients who underwent nerve grafting, there were no detectable facial muscle movements or electromyographic response to direct facial nerve stimulation suggestive of occult reinnervation. Overall, early facial reanimation surgery resulted in a shorter total duration of paralysis. Masseteric nerve grafting resulted in earlier recovery compared with hypoglossal nerve grafting (5.6 vs 10.8 months, P = .005). Patients who showed no signs of recovery by 6 months after CPA surgery but declined facial reanimation surgery demonstrated at best HB grade V recovery after 18 months of observation.

CONCLUSIONS AND RELEVANCE

The recovery pattern in the early postoperative period among patients who develop facial paralysis after CPA tumor resection is a useful clinical tool in selecting patients for facial reanimation surgery. Patients can be counseled for facial reanimation surgery as early as 6 months after surgery because satisfactory facial functional recovery is unlikely to occur when there is no clinical evidence of spontaneous nerve regeneration in the first 6 months.

LEVEL OF EVIDENCE

3.

The study of in vivo quantification of aluminum (Al) in human bone with a compact DD generator-based neutron activation analysis (NAA) system

The feasibility and methodology of using a compact DD generator-based neutron activation analysis system to measure aluminum in hand bone has been investigated. Monte Carlo simulations were used to simulate the moderator, reflector, and shielding assembly and to estimate the radiation dose. A high purity germanium (HPGe) detector was used to detect the Al gamma ray signals. The minimum detectable limit (MDL) was found to be 11.13 μg g(-1) dry bone (ppm). An additional HPGe detector would improve the MDL by a factor of 1.4, to 7.9 ppm. The equivalent dose delivered to the irradiated hand was calculated by Monte Carlo to be 11.9 mSv. In vivo bone aluminum measurement with the DD generator was found to be feasible among general population with an acceptable dose to the subject.

Tips for Junior Doctors and Medical Students: Writing and Publishing Undergraduate Textbooks

NA

Medfest: the effect of a national medical film festival on attendees' attitudes to psychiatry and psychiatrists and medical students' attitudes to a career in psychiatry

OBJECTIVE

The authors proposed that a national film festival organized by psychiatrists could change attendees' views toward psychiatry and psychiatrists positively and increase the numbers of medical students considering psychiatry as a career.

METHODS

Medfest held events at nine UK universities in 2011. The program consisted of short films (The Family Doctor, Shadowscan, Beards & Bow Ties) and panelist discussions. Data were gathered using an anonymous "before and after" questionnaire.

RESULTS

A total of 450 attendees across all sites returned 377 feedback forms (84 % response rate). Views of psychiatry and psychiatrists changed for the better for 42 % (98 % of those who answered the question) and 40 % (96 % of those who answered the question) of all respondents, respectively. Respondents' views were significantly more likely to change for the better than for the worse toward both psychiatry (p < 0.001) and psychiatrists (p < 0.001). Post-event, 46 % of the 232 medical students that attended were more likely to consider a career in psychiatry (48 % of those who answered the question).

CONCLUSIONS

A multicenter film festival organized by psychiatrists was associated with more positive attitudes to psychiatry and psychiatrists and an increase in students considering psychiatry as a career. The festival is now an annual event, continuing to expand.