Oral and maxillofacial surgery: a view from the East

As our regular contributor takes up a new academic role at Hong Kong University, he reflects on the evolution of the specialty in the region.

Using the Five Domains Model to Assess the Adverse Impacts of Husbandry, Veterinary, and Equitation Interventions on Horse Welfare

Simple Summary

Using an adaptation of the domain-based welfare assessment model, a panel of horse welfare professionals (with professional expertise in psychology, equitation science, veterinary science, education, welfare, equestrian coaching, advocacy, and community engagement) assessed the perceived harms, if any, resulting from 116 interventions that are commonly applied to horses. Scores for Domain 5 (the integrated mental impact) gathered after extensive discussion during a four-day workshop aligned well with overall impact scores assigned by the same panellists individually before the workshop, although some rankings changed after workshop participation. Domain 4 (Behaviour) had the strongest association with Domain 5, whilst Domain 1 (Nutrition) had the weakest association with Domain 5, implying that the panellists considered commonly applied nutritional interventions to have less of a bearing on subjective mental state than commonly applied behavioural restrictions. The workshop defined each intervention, and stated assumptions around each, resulting in a set of exemplar procedures that could be used in future equine welfare assessments.

Abstract

The aim of this study was to conduct a series of paper-based exercises in order to assess the negative (adverse) welfare impacts, if any, of common interventions on domestic horses across a broad range of different contexts of equine care and training. An international panel (with professional expertise in psychology, equitation science, veterinary science, education, welfare, equestrian coaching, advocacy, and community engagement; n = 16) met over a four-day period to define and assess these interventions, using an adaptation of the domain-based assessment model. The interventions were considered within 14 contexts: C1 Weaning; C2 Diet; C3 Housing; C4 Foundation training; C5 Ill-health and veterinary interventions (chiefly medical); C6 Ill-health and veterinary interventions (chiefly surgical); C7 Elective procedures; C8 Care procedures; C9 Restraint for management procedures; C10 Road transport; C11 Activity—competition; C12 Activity—work; C13 Activity—breeding females; and C14 Activity—breeding males. Scores on a 1–10 scale for Domain 5 (the mental domain) gathered during the workshop were compared with overall impact scores on a 1–10 scale assigned by the same panellists individually before the workshop. The most severe (median and interquartile range, IQR) impacts within each context were identified during the workshop as: C1 abrupt, individual weaning (10 IQR 1); C2 feeding 100% low-energy concentrate (8 IQR 2.5); C3 indoor tie stalls with no social contact (9 IQR 1.5); C4 both (i) dropping horse with ropes (9 IQR 0.5) and forced flexion (9 IQR 0.5); C5 long-term curative medical treatments (8 IQR 3); C6 major deep intracavity surgery (8.5 IQR 1); C7 castration without veterinary supervision (10 IQR 1); C8 both (i) tongue ties (8 IQR 2.5) and (ii) restrictive nosebands (8 IQR 2.5); C9 ear twitch (8 IQR 1); C10 both (i) individual transport (7.00 IQR 1.5) and group transport with unfamiliar companions (7 IQR 1.5); C11 both (i) jumps racing (8 IQR 2.5) and Western performance (8 IQR 1.5); C12 carriage and haulage work (6 IQR 1.5); C13 wet nurse during transition between foals (7.5 IQR 3.75); and C14 teaser horse (7 IQR 8). Associations between pre-workshop and workshop scores were high, but some rankings changed after workshop participation, particularly relating to breeding practices. Domain 1 had the weakest association with Domain 5. The current article discusses the use of the domain-based model in equine welfare assessment, and offers a series of assumptions within each context that future users of the same approach may make when assessing animal welfare under the categories reported here. It also discusses some limitations in the framework that was used to apply the model.

VetCompass Australia: A National Big Data Collection System for Veterinary Science

VetCompass Australia is veterinary medical records-based research coordinated with the global VetCompass endeavor to maximize its quality and effectiveness for Australian companion animals (cats, dogs, and horses). Bringing together all seven Australian veterinary schools, it is the first nationwide surveillance system collating clinical records on companion-animal diseases and treatments. VetCompass data service collects and aggregates real-time, clinical records for researchers to interrogate, delivering sustainable and cost-effective access to data from hundreds of veterinary practitioners nationwide. Analysis of these clinical records will reveal geographical and temporal trends in the prevalence of inherited and acquired diseases, identify frequently prescribed treatments, revolutionize clinical auditing, help the veterinary profession to rank research priorities, and assure evidence-based companion-animal curricula in veterinary schools. VetCompass Australia will progress in three phases: (1) roll-out of the VetCompass platform to harvest Australian veterinary clinical record data; (2) development and enrichment of the coding (data-presentation) platform; and (3) creation of a world-first, real-time surveillance interface with natural language processing (NLP) technology. The first of these three phases is described in the current article. Advances in the collection and sharing of records from numerous practices will enable veterinary professionals to deliver a vastly improved level of care for companion animals that will improve their quality of life.

Demographics, farm and reproductive management strategies used in Australian automatic milking systems compared with regionally proximal conventional milking systems

OBJECTIVE

To determine the management practices utilised in automatic milking systems (AMS) that affect reproductive management and performance and how these compare with the management practices used in regionally proximal conventional milking systems (CMS).

METHODS

This study examined demographic and management data from AMS and CMS dairy farms through a survey, with a specific focus on reproductive management procedures.

RESULTS

Overall, responses from AMS and CMS dairy farms showed little difference in terms of respondent demographics, farm size, herd structure and most farm management strategies. AMS dairies were more likely to use activity meters or other electronic oestrus detection aids than CMS dairies (P < 0.001) and were also more likely to have changed to electronic recording systems (P = 0.007). Although many respondents indicated that they used key monitoring parameters to assess reproductive performance (e.g. days in milk, conception vs pregnancy rate etc.), the format of responses varied significantly, indicating a relatively widespread (among the respondents) lack of knowledge regarding the meaning and usage of some of these common parameters/terminology.

CONCLUSIONS

Ultimately, reproductive management practices of AMS dairies were largely similar to those of CMS dairies, indicating that such practices can be implemented in a practical sense, even though the resultant reproductive performance is not yet understood. Understanding that the key reproductive management strategies do not need to change vastly is important to ensure that new adoptees are well informed. Further work is needed to objectively measure AMS performance to increase the knowledge base and generate the confidence that will facilitate further adoption of this innovation.

Evaluation of the effect of a highly soluble calcium source in broiler diets supplemented with phytase on performance, nutrient digestibility, foot ash, mobility and leg weakness

High inclusion concentrations of dietary calcium (Ca) from limestone may have detrimental effects on broiler performance, such as increased gastric pH and a reduction in phosphorus (P) and amino acid digestibility. To assess the potential for feeding diets with lower total Ca concentrations, the effect of a novel highly soluble source of calcium (HSC) on bird performance, nutrient digestibility and skeletal integrity of 1120 male Cobb-500 broilers was compared with that of limestone. Eight dietary treatments in a 2 × 2 × 2 factorial design consisted of two sources of Ca (limestone or HSC), two concentrations of Ca (6.0 or 7.7 g/kg in the starter and 4.0 or 5.7 g/kg in the grower), two phytase levels (0 or 500 FTU/kg). The effect of dietary treatments on growth performance and feed intake were measured from Day 1 to Day 40 and foot ash and leg health on Day 40. At the end of the starter period, in the absence of phytase, changing Ca source from limestone to HSC at 6.0 g/kg total Ca decreased both bodyweight gain and feed intake (P < 0.05). The addition of phytase to diets containing 6.0 g/kg total Ca provided by HSC increased bodyweight gain (P < 0.05), as well as increasing feed intake (P < 0.05). At the end of the grower period, diets supplemented with phytase increased bodyweight gain (P < 0.001), birds fed the higher Ca concentration were also observed to have an increased bodyweight gain (P < 0.001). Apparent ileal Ca digestibility significantly increased with the addition of phytase to diets containing 4.0 g/kg total Ca provided by HSC (P < 0.05), this was also observed for P digestibility. Replacement of limestone with HSC when fed in conjunction with phytase has the potential to be an effective strategy to improve broiler performance and bone mineralisation.

A national follow-up survey of UK graduates opinion of undergraduate oral surgery teaching

INTRODUCTION

A national follow-up survey was undertaken to determine whether dental graduates from 2009 perceived that their undergraduate oral surgery education had equipped them for general dental practice 4 years after graduating.

MATERIALS AND METHODS

Graduates from the same 13 United Kingdom dental schools who had taken part in the original survey were invited to take part in this follow-up online survey. Their contact details were identified via the general dental council register, social media and alumni groups.

RESULTS

In total, 161 responded (2009b) which represents 16% of the graduates of the original survey in 2009a. A similar percentage of these respondents perceived that the teaching in oral surgery had given them sufficient knowledge to undertake independent practice (83% and 79% in 2009a and 2009b, respectively). Most respondents (99% in both years) reported confidence in undertaking simple forceps exodontia. Confidence in surgical exodontia was poor in both surveys, but one area that appeared improved in the follow-up related to the sectioning of teeth (84% in 2009b compared with 49% in 2009a). Areas of weakness identified in 2009 were reported to be improved in the follow-up.

CONCLUSION

This follow-up survey supports the findings of the original survey. Future longitudinal studies would allow institutions to identify possible weaknesses in their curriculum and to track the career development of their graduates and facilitate robust data collection.

Fitting hidden semi-Markov models to breakpoint rainfall data

The paper proposes a hidden semi-Markov model for breakpoint rainfall data that consist of both the times at which rain-rate changes and the steady rates between such changes. The model builds on and extends the seminal work of Ferguson (1980) on variable duration models for speech. For the rainfall data the observations are modelled as mixtures of log-normal distributions within unobserved states where the states evolve in time according to a semi-Markov process. For the latter, parametric forms need to be specified for the state transition probabilities and dwell-time distributions.

Recursions for constructing the likelihood are developed and the EM algorithm used to fit the parameters of the model. The choice of dwell-time distribution is discussed with a mixture of distributions over disjoint domains providing a flexible alternative. The methods are also extended to deal with censored data. An application of the model to a large-scale bivariate dataset of breakpoint rainfall measurements at Wellington, New Zealand, is discussed.

Changes in Epidermal Growth Factor Receptor Gene Copy Number during Oral Carcinogenesis

BACKGROUND

Oral squamous cell carcinoma (OSCC) is a global healthcare problem associated with poor clinical outcomes. Early detection is key to improving patient survival. OSCC may be preceded by clinically recognizable lesions, termed oral potentially malignant disorders (OPMD). As histologic assessment of OPMD does not accurately predict their clinical behavior, biomarkers are required to detect cases at risk of malignant transformation. Epidermal growth factor receptor gene copy number (EGFR GCN) is a validated biomarker in lung non-small cell carcinoma. We examined EGFR GCN in OPMD and OSCC to determine its potential as a biomarker in oral carcinogenesis.

METHODS

EGFR GCN was examined by in situ hybridization (ISH) in biopsies from 78 patients with OPMD and 92 patients with early-stage (stages I and II) OSCC. EGFR ISH signals were scored by two pathologists and a category assigned by consensus. The data were correlated with patient demographics and clinical outcomes.

RESULTS

OPMD with abnormal EGFR GCN were more likely to undergo malignant transformation than diploid cases. EGFR genomic gain was detected in a quarter of early-stage OSCC, but did not correlate with clinical outcomes.

CONCLUSION

These data suggest that abnormal EGFR GCN has clinical utility as a biomarker for the detection of OPMD destined to undergo malignant transformation. Prospective studies are required to verify this finding. It remains to be determined if EGFR GCN could be used to select patients for EGFR-targeted therapies.

IMPACT

Abnormal EGFR GCN is a potential biomarker for identifying OPMD that are at risk of malignant transformation. Cancer Epidemiol Biomarkers Prev; 25(6); 927-35. ©2016 AACR.

Combined effects of smoking and HPV16 in oropharyngeal cancer

BACKGROUND

Although smoking and HPV infection are recognized as important risk factors for oropharyngeal cancer, how their joint exposure impacts on oropharyngeal cancer risk is unclear. Specifically, whether smoking confers any additional risk to HPV-positive oropharyngeal cancer is not understood.

METHODS

Using HPV serology as a marker of HPV-related cancer, we examined the interaction between smoking and HPV16 in 459 oropharyngeal (and 1445 oral cavity and laryngeal) cancer patients and 3024 control participants from two large European multi-centre studies. Odds ratios and credible intervals [CrI], adjusted for potential confounders, were estimated using Bayesian logistic regression.

RESULTS

Both smoking [odds ratio (OR [CrI]: 6.82 [4.52, 10.29]) and HPV seropositivity (OR [CrI]: 235.69 [99.95, 555.74]) were independently associated with oropharyngeal cancer. The joint association of smoking and HPV seropositivity was consistent with that expected on the additive scale (synergy index [CrI]: 1.32 [0.51, 3.45]), suggesting they act as independent risk factors for oropharyngeal cancer.

CONCLUSIONS

Smoking was consistently associated with increase in oropharyngeal cancer risk in models stratified by HPV16 seropositivity. In addition, we report that the prevalence of oropharyngeal cancer increases with smoking for both HPV16-positive and HPV16-negative persons. The impact of smoking on HPV16-positive oropharyngeal cancer highlights the continued need for smoking cessation programmes for primary prevention of head and neck cancer.

Low frequency of cigarette smoking and the risk of head and neck cancer in the INHANCE consortium pooled analysis

BACKGROUND

Cigarette smoking is a major risk factor for head and neck cancer (HNC). To our knowledge, low cigarette smoking (<10 cigarettes per day) has not been extensively investigated in fine categories or among never alcohol drinkers.

METHODS

We conducted a pooled analysis of individual participant data from 23 independent case-control studies including 19 660 HNC cases and 25 566 controls. After exclusion of subjects using other tobacco products including cigars, pipes, snuffed or chewed tobacco and straw cigarettes (tobacco product used in Brazil), as well as subjects smoking more than 10 cigarettes per day, 4093 HNC cases and 13 416 controls were included in the analysis. The lifetime average frequency of cigarette consumption was categorized as follows: never cigarette users, >0-3, >3-5, >5-10 cigarettes per day.

RESULTS

Smoking >0-3 cigarettes per day was associated with a 50% increased risk of HNC in the study population [odds ratio (OR) = 1.52, 95% confidence interval (CI): (1.21, 1.90). Smoking >3-5 cigarettes per day was associated in each subgroup from OR = 2.01 (95% CI: 1.22, 3.31) among never alcohol drinkers to OR = 2.74 (95% CI: 2.01, 3.74) among women and in each cancer site, particularly laryngeal cancer (OR = 3.48, 95% CI: 2.40, 5.05). However, the observed increased risk of HNC for low smoking frequency was not found among smokers with smoking duration shorter than 20 years.

CONCLUSION

Our results suggest a public health message that low frequency of cigarette consumption contributes to the development of HNC. However, smoking duration seems to play at least an equal or a stronger role in the development of HNC.

Managing oral potentially malignant disorders:A question of risk

The concept of an oral disease process that presents as a ‘potentially malignant state’ that is neither entirely benign nor frankly malignant is a difficult concept both for clinicians and their affected patients. While it is recognised that a range of oral mucosal conditions, now collectively termed ‘potentially malignant disorders’, harbour an increased risk of squamous carcinoma, we remain frustratingly unable in contemporary clinical practice to predict individual lesion behaviour, quantify the risk of malignant transformation or objectively plan interventions.

Identification of the high risk emergency surgical patient: Which risk prediction model should be used?

Introduction

National guidance states that all patients having emergency surgery should have a mortality risk assessment calculated on admission so that the ‘high risk’ patient can receive the appropriate seniority and level of care. We aimed to assess if peri-operative risk scoring tools could accurately calculate mortality and morbidity risk.

Methods

Mortality risk scores for 86 consecutive emergency laparotomies, were calculated using pre-operative (ASA, Lee index) and post-operative (POSSUM, P-POSSUM and CR-POSSUM) risk calculation tools. Morbidity risk scores were calculated using the POSSUM predicted morbidity and compared against actual morbidity according to the Clavien–Dindo classification.

Results

The actual mortality was 10.5%. The average predicted risk scores for all laparotomies were: ASA 26.5%, Lee Index 2.5%, POSSUM 29.5%, P-POSSUM 18.5%, CR-POSSUM 10.5%.

Complications occurred following 67 laparotomies (78%). The majority (51%) of complications were classified as Clavien–Dindo grade 2–3 (non-life-threatening).

Patients having a POSSUM morbidity risk of greater than 50% developed significantly more life-threatening complications (CD 4–5) compared with those who predicted less than or equal to 50% morbidity risk (P = 0.01).

Discussion

Pre-operative risk stratification remains a challenge because the Lee Index under-predicts and ASA over-predicts mortality risk. Post-operative risk scoring using the CR-POSSUM is more accurate and we suggest can be used to identify patients who require intensive care post-operatively.

Conclusions

In the absence of accurate risk scoring tools that can be used on admission to hospital it is not possible to reliably audit the achievement of national standards of care for the ‘high-risk’ patient.

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Emergency surgical patients require a mortality risk assessment upon admission.

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There is wide variability of risk prediction in the available risk scoring methods.

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Pre-operative risk scores do not reliably identify the high risk surgical patient.

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The CR-POSSUM score predicts mortality risk accurately in emergency laparotomy.

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The CR-POSSUM may be a useful tool in guiding the level of post-operative care.