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Diabetes mellitus (DM) is thought to be associated with poor outcomes in cervicofacial infections (CFI), yet little is known about the prevalence of DM in these cases. Stress hyperglycaemia (SHG), a normal physiological response to inflammation, is distinct from DM, though they overlap and may be conflated. We aimed to establish the prevalence of DM and SHG in CFI, and to determine the effect of each on severity of disease and outcome measures. The Maxillofacial Surgery Trainee Research Collaborative (MTReC) carried out an audit of all patients with CFI admitted to 25 hospitals between May and October 2017. To the best of our knowledge this created the largest prospective database on CFI, with information collected on presentation, source of infection, biological data, and outcomes. We recorded 1002 admissions, of which 78 (7.8%) had DM. Random blood glucose was measured on admission in 401 patients (40%), of which 45 (11%) displayed SHG. Patients diagnosed with DM were more likely to have infections arising from a salivary source (13% vs 4%, p0.00), more returns to theatre (9% vs 2%, p0.00), and a longer hospital stay (median (range) 2 (0-34) vs 1 (0-139) day, p=0.01) than non-DM patients. In contrast, patients with SHG had more severe disease (multiple fascial spaces involved in 59% vs 19%, p=0.01, and systemic inflammatory response syndrome present in 66% vs 45% p=0.03), but did not have significantly more returns to theatre (2% vs 3%, p=0.91) or longer stays in hospital (median (range) 1 (0-63) vs 1 (0-6), p=0.55) than normoglycaemic patients. The prevalence of DM in our cohort was only marginally higher than in the general population, despite previous retrospective case reviews suggesting a significantly higher prevalence. SHG was not associated with poor outcomes in our cohort, but is likely to be associated with a small increased risk of subsequent diagnosis of DM, which can be quantified using a calculator tool. On discharge, it is important to give appropriate advice about diet, lifestyle, exercise, and weight loss to all patients with CFI.

Background We assess the effect of Coronavirus disease 2019 (COVID-19) on UK oral and maxillofacial (OMF) trauma services and patient treatment during the first wave of the pandemic. Materials and Methods From April 1st 2020 until July 31st 2020, OMF Surgery units in the UK were invited to prospectively record all patients presenting with OMF trauma. Information gathered included clinical presentation, mechanism of injury, and how it was managed and whether or not treatment included surgery. Participants were also asked to compare the patient’s care with the treatment, which would have usually been given prior to the crisis. Results Twenty-nine units across the UK contributed with 2229 entries. The most common aetiology was mechanical fall (39%). The most common injuries were soft tissue wounds (52%) and mandible fractures (13%) for hard tissues. Of 876 facial fractures, 79 patients had treatment, which differed from that which would be normal pre-COVID and 33 had treatment deferred meaning 112 (14%) patients received care at variance to normal practice because of COVID restrictions. Conclusions The pattern of OMFS injuries changed during the first COVID-19 lockdown period. For the majority, best practice and delivery of quality trauma care continued in spite on-going operational challenges. Changes to treatment affected only a small proportion of patients. The lessons learnt from the first wave combined with adequate resources and pre-operative patient testing should allow those facial injuries in the second wave to receive best practice care.

The role of corticosteroids in the management of cervicofacial infections continues to cause controversy. Systemic anti-inflammatory and immunomodulatory effects that reduce swelling and improve symptoms in the head and neck may make these agents an effective addition to the antibiotics used and to surgical management, although this same effect may dull the physiological response to infection, and allow infections to progress. We have systematically reviewed the evidence for the use of corticosteroids in common cervicofacial infections following the PRISMA guidelines. MeSH terms included "head", "neck", "infection", and "glucocorticoid". In total, 31 papers were identified. Eight reported the use of corticosteroids for peritonsillar abscess (PTA), 10 for pharyngitis, four for deep neck space infection (DNSI), four for periorbital cellulitis, and five for supraglottitis. Whilst there is an established evidence base for their use in the treatment of PTA and pharyngitis, other indications need further study, and we highlight the potential pitfalls. The evidence suggests that the use of adjunctive, short-term, high-dose corticosteroids in cervicofacial infections may be safe and effective.

Inguinal ultrasound (US) has a high sensitivity and specificity for the diagnosis of inguinal hernias but is often performed unnecessarily, adding cost and time to treatment. The aim of our study was to assess the rate and necessity of US before clinical examination by a hernia surgeon. Medical records of patients referred for an inguinal hernia from April through July 2017 were reviewed. These cases were analyzed for patient demographics, physical examination (PE) findings, previsit imaging, health-care system of surgeon, and case outcome. Twenty-nine per cent of patients had an inguinal US before visiting a surgeon. Sixty-three per cent of patients who underwent an US had a palpable hernia on PE, and 76 per cent had a positive PE by the surgeon. Patients without a hernia on referring provider's PE underwent US 59 per cent of the time. Inguinal USs are being ordered unnecessarily by referring providers. Physical examination by referring providers and surgeons should be the primary tool for diagnosis of an inguinal hernia.

BACKGROUND The Lyell McEwin Hospital entered into a public-private collaborative agreement in 2019 in order to access Da Vinci® Xi Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) in private hospitals. This study aimed to examine the costs associated with usage of robot surgical systems under the agreement, and the potential for acquisition in the public hospital. METHODS Retrospective data on robotic-assisted and equivalent operations performed between 1 May 2019 and 30 April 2020 were collected and formed subsequent model inputs. Cost data were from hospital records and the local Da Vinci® Xi distributor. Clinical workflow of operations was simulated with a decision-analytic model, with output being costs incurred. The model's base case scenario assumed 5% of cases were robotically assisted. RESULTS A total of 35 robotic-assisted, 101 laparoscopic and 34 open operations were performed. Patients were predominantly male and overweight with multiple comorbidities. Length of stay and duration of operation were associated with increased costs (p

Introduction Gender differences have been documented in prevalence and morbidity of caries, gingivitis and oral health, but not previously in cervicofacial infection. Identification and minimisation of gender inequalities is a World Health Organisation priority, and there are physiological, behavioural and cultural reasons to suspect that sex and gender differences may be present.Methods Analysis was carried out of the MTReC National Snapshot audit of cervicofacial infections. This database was created by oral and maxillofacial surgery trainees in 2017 and records over 400 variables in 1,002 individual patients admitted to hospital with severe odontogenic infection.Results Records were available for 1,002 patients with cervicofacial infection (456 females and 546 males). There were significant differences between recorded gender in those presenting with airway compromise (male 7% vs female 2%, p = 0.001), severe inflammatory response syndrome (male 60% vs female 39%, p = 0.007) and requirement for awake fibre-optic intubation on admission (male 4% vs female 1%, p = 0.014).Discussion These results suggest that male patients access healthcare later in their disease than female patients, and with more severe systemic compromise. This may be due to prevalent cultural and behavioural norms. As equality of access is the responsibility of the administrator, we discuss methods which might improve timely presentation in males with cervicofacial infections.

Background: Intestinal stomas are formed for emergency, elective, benign and malignant conditions. They may be temporary or permanent. The complication rates of intestinal stomas are reported as high as 56%. Objective: The aim of this article is to provide an overview of intestinal stomas and common related issues, to inform general practitioners (GPs) and improve stoma-related care. Discussion: There are a variety of early and late complications associated with intestinal stomas. It is important that patients have access to an informed GP, stomal therapy nurse and surgeon to provide optimal ongoing care. Good stoma care contributes to good quality of life for patients.

Mesiodens is the most common type of supernumerary tooth, located between the maxillary central incisors in close relation to the nasopalatine canal. A 20-year-old man presented with right-sided nasal blockage, nasal discharge and collapsed nose without history of trauma. Imaging revealed a calcified mass in the inferior meatus extending into dilated nasopalatine canal. Endoscopic removal of the mass revealed tuberculate appearance of an incompletely developed tooth, consistent with mesiodens. Based on the history of septal cartilage collapse with right-sided mucopurulent discharge, endoscopic findings of the right inferior turbinate being adherent to the septal cartilage and the underlying mesiodens, we believe that the patient developed a septal abscess secondary to infection in nasal mucosa surrounding the mesiodens causing collapse of septal cartilage. While a tooth or tooth-like mass causing nasal passage air-flow obstruction is uncommon, we believe that this is the first reported case of mesiodens presenting with septal cartilage collapse.

Many common prescription and over-the-counter medications have antimuscarinic effects. Antimuscarinics are a well recognized cause of dry mouth, with potential to cause other physical and cognitive adverse effects. A comprehensive medication review in a patient presenting with dry mouth can lead to overall health improvements. Scoring systems can be helpful in identifying antimuscarinic drugs and their adverse effects. CPD/Clinical Relevance: Antimuscarinic drug use is prevalent and a common cause of dry mouth. Older people are particularly susceptible to antimuscarinic adverse effects.

An external fixator is an essential tool for treating unstable pelvic ring injuries but its use carries risks, including pin-site infections and injury to the lateral femoral cutaneous nerve (LFCN). Surgeons currently lack data regarding these risks for patient counseling. This study aimed to identify the incidence of and risk factors for superficial and deep pin-site infection and LFCN damage. Fifty-two patients who underwent pelvic external fixation with anterior pin placement as part of definitive treatment for unstable pelvic ring disruption were retrospectively evaluated to identify factors associated with the development of infection. Ten (19%) patients developed superficial pin-site infections, with none developing a deep infection. Five were treated with oral antibiotics alone, 5 with additional intravenous antibiotics, and 1 underwent superficial surgical debridement at the time of external fixator removal. Three (6%) patients had temporary symptoms consistent with irritation to their LFCN that all resolved by 3 months. One (2%) patient had residual mild and intermittent LFCN dysesthesias at the 6-month follow-up. Adjusted logistic regression models identified no specific factors that were associated with increased risk of infection. The incidence of superficial infections related to pelvic external fixation was 19%, which can usually be treated with antibiotics with low risk of deep infection. In addition, there remains a low risk of long-term LFCN damage. Patients should be counseled on these risks during the perioperative period. [ Orthopedics. 2017; 40(6):e959–e963.]

We describe the case of a gall bladder torsion in an elderly female patient, which was discovered during laparoscopic exploration for presumed acute cholecystitis. The rising incidence of this relatively uncommon process can be attributed to increasing life expectancy. Gall bladder torsion typically manifests in septuagenarians and octogenarians of the female gender, as seen in the presented case. It is thought that local mesenteric redundancy predisposes to the development of mechanical organoaxial torsion along the gall bladder’s longitudinal axis involving the cystic duct and artery. Clinicians must have a high index of suspicion for gall bladder torsion, as a mimicker of acute cholecystitis, in the described patient demographic. Preoperative diagnosis is challenging with the vast majority of reported cases being diagnosed intraoperatively, and only five cases preoperatively. Prompt surgical intervention results in an overall mortality rate of approximately 5%, while a delay in diagnosis can lead to catastrophic patient outcomes.

Imiquimod 5% (Aldara, 3M Healthcare Ltd.) is a topically applied immune response modifier used in the treatment of superficial basal cell carcinoma, actinic keratosis, and genital warts. We reviewed the casenotes of 5 patients with histologically confirmed dysplastic lower lips who had been treated with topical imiquimod. Each patient was provided with a specially designed lower lip retractor to prevent spread of the cream. Treatment was stopped after 6 weeks or if an acute inflammatory reaction developed. The lower lip was biopsied 4 weeks later, and histologically the dysplastic changes had been reversed in all 5 patients. The lip retractor was well-tolerated, and prevented spread of the cream. Imiquimod 5% cream offers an alternative method to manage dysplastic lips. Our lip retractor is a simple and cost-effective method of isolating the lower lip and allowing application of topical agents. The method could equally well be used for agents other than imiquimod.

The retinal oxygenation response to a hyperoxic challenge measured using MRI appears to be an early and accurate marker of retinopathy risk in experimental models, with promising clinical potential. However, the application of this technique in humans is limited by blinking artifacts that can confound detection of subtle signal intensity changes. We asked subjects to refrain from blinking during a 12-s fast low-angle shot (FLASH) image, and to blink if needed during the following 3-s rest period. This no-blink blink cycle was repeated sequentially 20 times during either room-air or 100% oxygen breathing. Significant change (P < 0.05) was detected for the first time from the resultant blinking-artifact-free images in the preretinal vitreous oxygen tension (upper limit of about 13 mm Hg (1.8 KPa, N = 3)) following a 10-min hyperoxic inhalation challenge. These results provide the proof-of-concept data needed for future MRI evaluation of the retinal oxygenation response and human retinopathy, such as diabetic retinopathy.

The phage shock protein (Psp) systems found in bacteria, archaea and higher plants respond to extracytoplasmic stresses that damage the cytoplasmic membrane and enable cells to repair their membranes. The conserved membrane-associated effector protein PspA has four α-helical domains (HD1–HD4) and helps to repair the membrane as a high-order oligomer. In enterobacteria, under non-stress conditions, PspA as a low-order assembly directly inhibits its cognate transcription activator PspF. Here we show that N-terminal amphipathic helices ahA and ahB in PspA HD1 are functional determinants involved in negative gene control and stress signal perception and its transduction via interactions with the PspBC membrane stress sensors and the inner membrane (IM). The amphipathic helices enable PspA to switch from a low-order gene regulator into an IM-bound high-order effector complex under membrane stress. Conserved residue proline 25 is involved in sequential use of the amphipathic helices and ahA–IM interaction. Single molecule imaging of eGFP-PspA and its amphipathic helices variants in live Escherichia coli cells show distinct spatial and temporal organisations of PspA corresponding to its negative control and effector functions. These findings inform studies on the role of the Psp system in persister cell formation and cell envelope protection in bacterial pathogens and provide a basis for exploring the specialised roles of PspA homologues such as YjfJ, LiaH and Vipp1.