Heart failure (MYHF) registry: shedding light on lipid profiles and in-hospital outcome of heart failure patients

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Novartis Corporation Sdn Bhd

Background

Heart failure is a debilitating disease associated with multiple comorbidities and poor prognosis. Dyslipidemia, is the top 5 most common comorbidities, including HF patients. Nonetheless, the lipid profiles in HF population is scarcely available and poorly understood.

Purpose

This report aimed to describe the lipid profiles and in-hospital outcome of hospitalized HF patients.

Methods

MYHF registry is a prospective, observational study of symptomatic HF patients (NYHA II-IV) hospitalized in 18 tertiary care centers in Malaysia over a period of 3 years starting in 2019. Lipid profiles will be described, and in-hospital outcome will be analyzed using univariate and multivariate models.

Results

In MYHF registry, 1 out of 2 hospitalized HF patients (55.7%) had ischemic heart disease, significantly higher in patients with HFrEF and HFmrEF, as compared to HFpEF (p<0.001). Similarly, 1 in 2 (46.6%) patients had dyslipidemia as comorbidity but was comparable across EF subgroups (p=0.365). Statin utilization at discharge increased by 20% from admission (from 62.2% to 74.6%), indicating that hospitalization provides good opportunity for statin initiation in indicated HF patients. At admission, the mean total cholesterol, LDL-C, HDL, and TG levels were 4.30 mmol/L (SD 1.66), 2.62 mmol/L (SD 1.34), 1.05 (SD 0.46), and 1.37 (SD 1.08), respectively. Of those with measured LDL-C level, only 31.4% achieved LDL-C goal of <1.8 mmol/L and 39.8% of patients had LDL-C ≥2.6 mmol/L. With univariate analysis, patients with LDL-C goal of ≥ 1.8 mmol/L had lesser risk of in-hospital mortality [OR 0.42 (0.21,0.86), p-value = 0.018], indicating LDL-C paradox. Further analysis with multivariate model revealed that patients with LDL-C goal of ≥ or < 1.8 mmol/L did not differ in in-hospital mortality outcome (p-value = NS).

Conclusion

Dyslipidemia is highly common in general population and in HF patients. With statin therapy, only 31.4% achieved LDL-C < 1.8 mmol/L at admission. The finding highlights the unmet need for combination lipid lowering therapies to get patient to LDL-C target goal. Hospitalization also provided good opportunity of statin therapy initiation. The knowledge gained will be crucial for guiding management of HF patients with common comorbidity like dyslipidemia.

Performance and 12 month outcomes of a wire free fractional flow reserve system for assessment of coronary artery disease, first experience in south east asia

Funding Acknowledgements

Type of funding sources: None.

Background

Fractional flow reserve (FFR) using an invasive pressure wire has a Class 1A recommendation for guiding coronary revascularization in stable coronary artery disease (CAD). Angiography based ‘wire free’ FFR is an emerging technique which determines the physiological significance of a coronary lesion without requirement of a pressure wire or induction of hyperemia. It also eliminates potential complications associated with introduction of wires into the coronary arteries.

Objective

To assess the 12-month clinical outcomes of PCI deferral, guided by an angiography based fractional flow reserve (CAFFR) system. The primary end point was a composite of death from any cause, myocardial infarction (MI) or target vessel revascularization (TVR)

Methods

This was a prospective, single center study involving 69 patients (93 vessels) with angiographic stenosis of 30%-90%. Patients with CAFFR of <0.80 or poor image quality were excluded leaving 29 patients (31 vessels) for analysis. All recruited patients had a CAFFR >0.80 and thus, PCI deferral.

Wired FFR was done for comparison on 14 patients (48%) at the operator’s discretion.

Results

The mean age was 59 ± 12.6 years old. Majority of patients (83%) were male. 12 (42%) patients were diabetic, 18 (62%) were hypertensive, 17 (59%) had dyslipidemia and 18 (62%) had a smoking history. The mean LVEF was 52+/-11.4%. 72% of the patients had a recent acute coronary syndrome. We assessed the LAD artery in 15 (52%) vessels. The mean CAFFR and FFR was 0.87 ± 0.04 and 0.89 ± 0.05 respectively. The values showed agreement with each other with no statistically significant proportional bias on the Bland Altman plot (linear regression t test: t=-1.19, p = 0.257). CAFFR values >0.80 showed 100% correspondence to negative FFR values (>0.80). There were zero procedural complications from CAFFR measurement.

At 12 months, all 29 patients were alive. Only 1 patient (3.4%) met the primary end point (TVR for angina). 89.6% (26) patients remained in CCS class 1 on follow up.

Conclusion

CAFFR shows good agreement with wired FFR. The 12-month outcome data shows that CAFFR guided PCI deferral is safe and comparable to the gold standard of wired FFR guided PCI deferral. Further analysis with a larger patient pool and longer follow-up is warranted. Abstract Figure. Bland-Altman plot of FFR and CAFFR

Three year clinical outcomes of fractional flow reserve guided coronary revascularization using a monorail pressure sensor microcatheter

Funding Acknowledgements

Type of funding sources: None.

Background

Fractional flow reserve (FFR) has a Class 1A recommendation for guiding coronary revascularization in stable coronary artery disease. Deferral of revascularization for coronary stenosis of FFR >0.80 has shown favorable long-term outcomes, yet the adoption in real-world practice is limited. To date, there is no study on FFR guided PCI in the Malaysian population.

Objective

(1) To explore the 3-year clinical outcome of FFR guided coronary revascularization.

(2) To compare the clinical outcome of FFR guided deferral of coronary revascularization versus FFR guided revascularization. The primary outcome was a composite of all cause mortality, non fatal myocardial infarction (MI) and ischemia driven target vessel revascularization (TVR)

Results

Thirty-five patients were lost to follow up leaving 78 patients (95 vessels) for final analysis. The mean age was 59.3 ± 9.4 years old. 69 (88.5%) patients were male, 24 (30.7%) had diabetes mellitus, 58 (74.3%) had dyslipidemia, 61 (78.2%) had hypertension and 45 (57.7%) were smokers. The mean LVEF was 56.7 ± 14.7%. FFR to the LAD artery was performed in 64 (82%) patients. Based on the FFR value of 0.80, 47 (60.2%) patients had FFR guided deferral of coronary revascularization and 31 (39.7%) patients had FFR guided revascularization.

At 3 years, 11 (14.1%) patients met the primary outcome, mainly driven by all-cause mortality (11.5%). The primary outcome was met in 14.9% of FFR guided deferral versus 12.9% of FFR guided revascularization (p = 0.828). All-cause mortality was 12.7% in patients with FFR guided deferral compared to 9.7% in patients with FFR guided revascularization at 3 years (p = 0.712). 

Cox proportional hazards model did not demonstrate any independent predictors associated with the primary outcome or all cause mortality. 

Conclusion

FFR guided deferral of revascularization was safe and had comparable long-term clinical outcomes to FFR guided PCI. To our knowledge, this is the first study on long-term clinical outcome on FFR guided revascularization in Malaysia. Abstract Figure. Kaplan-Meier curve primary end point  Abstract Figure. Kaplan-Meier curve all cause mortality

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: main results of a cluster preference randomised controlled trial

PURPOSE

The patient concerns inventory (PCI) is a prompt list allowing head and neck cancer (HNC) patients to discuss issues that otherwise might be overlooked. This trial evaluated the effectiveness of using the PCI at routine outpatient clinics for one year after treatment on health-related QOL (HRQOL).

METHODS

A pragmatic cluster preference randomised control trial with 15 consultants, 8 'using' and 7 'not using' the PCI intervention. Patients treated with curative intent (all sites, disease stages, treatments) were eligible.

RESULTS

Consultants saw a median (inter-quartile range) 16 (13-26) patients, with 140 PCI and 148 control patients. Of the pre-specified outcomes, the 12-month results for the mean University of Washington Quality of Life (UW-QOLv4) social-emotional subscale score suggested a small clinical effect of intervention of 4.6 units (95% CI 0.2, 9.0), p = 0.04 after full adjustment for pre-stated case-mix. Results for UW-QOLv4 overall quality of life being less than good at 12 months (primary outcome) also favoured the PCI with a risk ratio of 0.83 (95% CI 0.66, 1.06) and absolute risk 4.8% (- 2.9%, 12.9%) but without achieving statistical significance. Other non-a-priori analyses, including all 12 UWQOL domains and at consultant level also suggested better HRQOL with PCI. Consultation times were unaffected and the number of items selected decreased over time.

CONCLUSION

This novel trial supports the integration of the PCI approach into routine consultations as a simple low-cost means of benefiting HNC patients. It adds to a growing body of evidence supporting the use of patient prompt lists more generally.

P13 Safety and efficacy of sacubitril-valsartan initiation during and after acute decompensated heart failure with reduced ejection fraction

Background

The PIONEER-HF trial has demonstrated the safety of Sacubitril-Valsartan initiation during acute decompensated heart failure (ADHF) compared to Enalapril. The efficacy outcome was also addressed by the surrogate end point of reduction in NT-proBNP. However, the safety and efficacy of Sacubitril-Valsartan initiation during ADHF compared to initiation after ADHF was unknown.

Objectives

(1) To compare the safety and efficacy of Sacubitril-Valsartan initiation during ADHF(inpatient) to initiation after ADHF(outpatient). (2) To explore the echocardiogram parameters associated with Sacubitril-Valsartan initiation during ADHF(inpatient) versus after ADHF(outpatient).

Methods

We enrolled patients diagnosed with heart failure with reduced ejection fraction (HFrEF) initiated on Sacubitril-Valsartan from February 2017 to December 2018. The baseline characteristics, echocardiogram parameters (changes in LVEF and positive remodeling), composite safety outcomes (hypotension, interruption of Sacubitril-Valsartan and worsening of renal function), and efficacy outcomes (cardiac death, readmission for heart failure) were compared.

Results

Thirty-seven patients were identified out of which 21 patients started Entresto after ADHF (outpatient group) and 16 patients during ADHF (inpatient group). The median follow-up duration was 196 days (IQR: 105 to 328days). The baseline characteristics were similar between the 2 groups. Outpatient groups achieved a significantly higher maximally tolerable dose of Sacubitril-Valsartan compared to inpatient group (median 400mg/day versus 200mg/day, p = 0.008) despite a similar starting dose (median 100mg/day versus 100mg/day, p = 0.127). The composite efficacy outcomes were similar between the 2 groups (4.8% versus 18.8%, p = 0.296). The composite safety outcome was similar between the groups (18.8% versus 4.8%, HR5.70 p = 0.054, 95%CI 0.967 to 33.60). Both groups achieved a significant improvement in LVEF after initiation of Sacubitril-Valsartan therapy: mean LVEF 23.44 ± 7.88% to 34.30 ± 13.88% (p = 0.001) in outpatient group; mean LVEF 22.99 ± 11.31% to 38.81 ± 13.91% (p = 0.002) in inpatient group. Reverse remodeling (reduction of LVESV≥15%) was similar between the 2 groups (61.9% versus 50.0%, p = 0.506).

Conclusions

Among patients with HFrEF in ADHF, initiation of Sacubitril-Valsartan therapy during or after ADHF led to similar safety and efficacy. Overall, there was a significant improvement in LVEF and positive remodeling of the LV regardless of the timing of initiation of therapy.

Our experience of a nurse-led oral and maxillofacial surgical clinic in a tertiary centre: two years on

We describe our two-year experience of a nurse led clinic (NLC) in a tertiary centre oral and maxillofacial surgical (OMFS) department. The clinic is run by a specialist nurse, in parallel with a consultant's clinic and focuses on the management and review of non-malignant lesions. Increased clinical flexibility, reduced waiting times, and tailored educational resources have contributed to an improved experience for the patients.

Phenotypic variation among siblings with arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is primarily a familial disease with autosomal dominant inheritance. Incomplete penetrance and variable expression are common, resulting in broad disease spectrum. Three patterns of phenotypic expression have been described: (1) "classic" subtype, with predominant right ventricle involvement, (2) "left dominant" subtype, with early and dominant left ventricle involvement, and (3) "biventricular" subtype, with both ventricles equally affected. Genotypephenotype associations have been described, but there are other genetic and non-genetic factors that can affect disease expression. We describe two different phenotypic expressions of ARVC in a family.

Margins and survival in oral cancer

In the surgical management of oral squamous cell carcinoma (SCC) we aim to resect the tumour with clear margins in all planes. The aim of this study was to identify and compare overall survival in a group of 591 patients who had resections, and to relate this to the clearance of margins at the tumour bed. We used life tables to calculate survival at one, two, three, five, and 10 years after diagnosis by margin (clear=5mm or more; close=2-5mm; and involved=less than 2mm). Kaplan-Meier curves were produced for the margins alone, which were defined as clear in 480 patients (81%), close in 63 (11%), and involved in 48 (8%). Five-year survival was 81%, 75%, and 54% for clear, close, and involved margins, respectively, which highlights the importance of clear margins for survival. There is a significant prognostic implication associated with close, and particularly with involved, margins.

Early experience of a nurse-led clinic in a tertiary centre

A busy head and neck or oral and maxillofacial (OMFS) National Health Service (NHS) clinic treats patients with many different conditions. A large proportion will have cancer of the head and neck, and they will be at different stages of their treatment. Their clinical needs may be different from a larger group of patients who have been referred through the "two-week wait" referral pathway, and who are present in the same clinic for their biopsy results. We present our early experience of "fast-track" referrals and their potential effect on the overall volume of work. They are only a small number of the patients who are typically seen in a nurse-led clinic.

Genomic analysis to assess disease progression and recurrence in patients with oral squamous cell carcinoma: - a preliminary study

We studied the progression from dysplasia to invasive carcinoma and subsequent second primaries or locoregional recurrences in 11 patients with recurrent squamous cell carcinoma (SCC). Between one and six samples were sequenced/patient. DNA samples were prepared, and libraries multiplexed to between 40 and 80 samples/lane of an Illumina HiSeq 3000 and sequenced with 2×100bp paired end sequencing. Copy number data were generated by CNAnorm (Bioconductor package). Samples of recurrent SCC showed unique patterns of descent when compared with earlier samples from the primary tumour, and three main patterns emerged. In four patients there was convincing evidence that the later lesion was descended directly from cells from the first, and in a further four there were no detectable genomic events between the two lesions. Three patients had some shared events between the early and later lesions, but although there were enough differences to deduce that the two lesions had a shared ancestor, they were not directly descended from each other. We present the patients' characteristics in detail, including the overall survival in each group. There was a distinct genomic pattern after a second episode of SCC in all the groups. A larger study that uses similar methods and a longer duration could provide reliable conclusions with respect to survival. With the use of new techniques, genomic data can be available to clinical teams during the planning of treatment.

Chronic Traumatic Sagittal Band Injury with Extensor Tendon Dislocation: Report of a Case and New Surgical Technique

Chronic sagittal band injury with tendon dislocation of the extensor digitorum communis in the hand often requires operative stabilization. Various surgical techniques have been reported to repair and reconstruct the sagittal band. Nonetheless, most of the techniques are technically demanding and require donor graft. In this case report, we report a novel surgical technique to centralize and stabilize the tendon by reattaching the radial sagittal band with anchor sutures. The advantages of this new technique are simple, no donor morbidity and stable repair to restore the normal biomechanics of the tendon. The patient was able to return to work in three months and no recurrent dislocation was noted at review two years after surgery.

Carotid intima media thickness and high sensitivity C-reactive protein as markers of cardiovascular risk in a malaysian population

INTRODUCTION

Carotid intima media thickness (CIMT) being a cost effective and easily performed technique is useful in the detection of subclinical atherosclerosis and has been shown to be a prognosticator of cardiovascular events. The primary objective of this study was to obtain the distribution of CIMT measurements, highly sensitive C reactive protein (hs-CRP) and assessing health awareness and attitudes of the Malaysian population at cardiovascular disease (CVD) risk and not receiving lipid lowering agents. Secondarily the study sought to assess the significance of the relationship between these measurements against various patient characteristics.

METHODS

Measurements of CIMT are obtained by ultrasonography of 12 sites within the common carotid artery was recorded for 123 subjects from a single centre tertiary hospital of Malaysia who had two or more CVD risk factors but were not receiving lipid lowering therapy. CVD risk factors and lipid and glucose profiles were analyzed with respect to distribution of CIMT and high-sensitivity Creactive protein (hs-CRP) values.

RESULTS

The mean-max CIMT was 0.916±0.129mm (minimum 0.630mm, maximum 1.28mm) and the mean-mean CIMT was 0.743±0.110mm (minimum 0.482mm, maximum 1.050mm) and mean hs-CRP was 0.191mg/dL (minimum 0.030mg/dL, maximum 5.440mg/dL). Multivariate analyses confirmed a significant association between increasing CIMT and increasing age, total and low density lipoprotein cholesterol while log-transformed hs-CRP levels showed significant association with increasing body mass index, waist circumference, high blood glucose and triglyceride levels. Our patients had good health awareness on CVD.

CONCLUSION

Newly defined CIMT measurements and hs-CRP levels may be useful adjunctive tools to screen for atherosclerosis in the Malaysian population. It may help in refining risk stratification on top of traditional clinical assessment.

Acquired factor VIII deficiency presenting as a floor of the mouth swelling

The authors report the case of a patient with previously undiagnosed acquired haemophilia A who presented to the accident and emergency department with a swollen tongue and difficulty in swallowing. There were no signs of trauma or obvious dental infection. She was admitted onto a high dependency unit for observation. Over the course of the day, the floor of her mouth and neck became increasingly swollen to the extent that she developed breathing difficulties. She was transferred to an intensive care unit, where she was intubated to protect her airway from further compromise. Acquired factor VIII deficiency was diagnosed and appropriate treatment commenced. Despite intervention, her respiratory and cardiovascular functions deteriorated. Following discussions between the medical specialities involved in her care and her family, the decision was made to withdraw support. The patient passed away 96 h after admission.

Variations in the postoperative management of free tissue transfers to the head and neck in the United Kingdom

Reliable assessment of the perfusion of free tissue transfers has always been a challenge for reconstructive microsurgeons. The complexities of flap microcirculation are often difficult to assess despite all the subjective and objective examination techniques available today, particularly when the free tissue transfer is buried, and not visible for monitoring. We investigated the post-operative management of free tissue transfers to the head and neck in the United Kingdom. Selected results from our survey show that the majority of units performed between two and five free tissue transfers to the head and neck region per month (n=60, mean=4.13, range<1-12). Clinical tests were used to monitor the flaps post-operatively in all units questioned. Hand held doppler was the most commonly used adjunctive technique, being routinely used for post-operative monitoring by twenty six units, and available for use in eighteen other units with the most common indications for use were, slow capillary refill and pale colour. Frequency and location of monitoring post-operatively was highly variable. Nurses were responsible for the routine monitoring of flaps in almost every unit. Thirty four units (57%) had a written protocol in place governing the monitoring of free tissue transfers post-operatively. We note the wide variation in practice on a national level, and make certain recommendations.

The role of thoracic computed tomography in staging newly-diagnosed oral squamous cell carcinoma

Patients who present with squamous cell carcinoma (SCC) in the head and neck have a serious risk of coincident thoracic malignancy. The aim of this study was to identify the incidence of thoracic malignancy in newly diagnosed, previously untreated, oral and oro-pharyngeal SCC, and to evaluate the role of thoracic computed tomography (CT) in its management. Of 116 consecutive patients who were identified prospectively 81(70%) had oral and 35 (30%) oropharyngeal SCC. Ten patients (9%) had suspicious thoracic CT findings. After investigation or follow up, four (3.5%) of these patients were shown to have coincident thoracic malignancies. This large prospective series of newly diagnosed oral and oropharyngeal SCC had a lower incidence of coincident thoracic malignancy than had previously been shown.

Update on dental graduates entering medicine 1986-1991

In a previous publication we reviewed the future career plans of 169 dental graduates who entered medical school from 1986 to 1991 inclusive. The aim of the present study was to find out what happened to this group after qualification from medical school. The 169 individuals were traced and a questionnaire was sent to them by mail. A reminder was sent and some data for non-respondents were obtained from public sources such as registers and directories. In the original study, 120 of the 154 respondents (78%) intended to become oral and maxillofacial surgeons. We found in this follow up survey that the overall return rate to oral and maxillofacial surgery (OMFS) had dropped to 66%. For those not returning to the speciality, a wide range of alternative specialities had been chosen, with general medical practice (n=9) and oral medicine (n=8) being the most popular. Amongst those returning to OMFS, most undertook basic surgical training in general surgery and trauma. Two thirds of those eligible possessed the FRCS, with 43 (83%) holding the FRCS (Clinical Surgery in General) and six (12%) having the FRCS Ed (oral and maxillofacial surgery). Within the group, opinions were mixed about the changes caused by 'Hospital doctors: training for the future' (Calman Report) [Working Group on Specialist Medical Training. Hospital doctors: training for the future. London: Department of Health, 1993]. Concerns were voiced about the potential reduction in clinical experience, comparatively longer training for OMFS, and particularly the abrupt end of training with no protection whilst seeking a consultant appointment. Half thought that OMFS will become concentrated in supraregional centres, or head and neck units with related specialities.

Surgical accuracy in Le Fort I maxillary osteotomies

The surgical outcome of planned movements of Le Fort I osteotomies is dependent on the surgeon's ability to achieve such movements intraoperatively. Our aim was to assess the surgical accuracy achieved for 30 consecutive patients undergoing Le Fort I osteotomies treated by one maxillofacial surgeon and his team.

METHOD

Intraoperative control of the mobilized maxilla vertically was achieved by a combination of a nasion screw as the external reference point and bony marks above and below the osteotomy cuts intraorally. Movements horizontally and transversely were controlled with occlusal wafers. The surgical accuracy of maxillary movements vertically and horizontally (anteroposteriorly) were assessed by standard lateral cephalometric tracings of radiographs taken within two weeks prior to operation and 48 hours afterwards. Audit targets were arbitrarily set to be satisfactory when the difference between planned movements and actual movements as measured on the cephalometric tracings were 2 mm or less.

RESULTS

The mean (SD) difference from planned vertical movements of the anterior maxilla was 0.37 mm (SD 0.64) and horizontal movements 0.85 mm (SD 0.91). Ninety-seven percent (29/30) of anterior maxillary movements in the vertical dimension, 90% (27/30) of anterior maxillary movements in the horizontal dimension and 87% (26/30) of movements in both dimensions had a difference of 2 mm or less. These results were comparable with the reported 'gold standard'.

CONCLUSION

Good surgical accuracy in positioning the mobilized maxilla in Le Fort I osteotomies can be achieved with the use of external and internal reference points.

Relocating the site of frozen sections--is there room for improvement?

INTRODUCTION

In an attempt to improve the marginal control of oropharyngeal carcinoma, some surgeons routinely perform frozen section analysis. Because current methods of relocating the site from which frozen section specimens are harvested can be haphazard, we studied the accuracy of a common technique used to localize specimens to the resected tumour bed.

METHODS

One surgeon was asked to identify the sites of proposed sampling in 14 consecutive cases. After approximately 5 minutes, the same surgeon was asked to relocate each site.

RESULTS

In all, 71 soft tissue points were identified. The mean error in relocating the sample site was 9 mm for those placed at mucosal margins and 12 mm for those placed deep to the tumor bed. The error exceeded 1 cm in 32% (23 of 71) of cases.

CONCLUSION

These findings highlight the need to accurately locate the position of frozen sections if samples that subsequently prove positive are to used to greatest effect.

The role of thorax imaging in staging head and neck squamous cell carcinoma

The overall survival rate for patients with head neck squamous cell carcinoma remains disappointingly static despite improved locoregional control. This has been attributed to the development of distant metastases and second primary malignancies in these patients, a large proportion of which occur in the thorax. We retrospectively analysed the incidence of thoracic malignancies in 138 patients presenting with newly diagnosed (n = 107) or recurrent (n = 31) cancer of the head and neck over a 4-year period. All 138 patients had undergone both computerised tomography of the thorax (CT) and conventional chest radiography within one month of presenting with biopsy proven squamous cell carcinoma. Seventeen percent of these were found to have simultaneous thoracic malignancies. CT thorax was more sensitive in detecting simultaneous thoracic malignancies compared with standard chest X-ray (24/138 versus 9/138, odds ratio of 3:1 in favour of CT). All thoracic malignancies detected by chest X-ray were also detected by CT thorax. Patients presenting with recurrent tumors were significantly more likely to have simultaneous thoracic malignancies than those with newly diagnosed cancer (11/31 versus 13/107, chi2 test with Yates correction, chi2 = 4.66, p = 0.03). The primary site (laryngeal, oral or pharyngeal) or presence of nodal disease did not have an effect on the incidence of simultaneous thoracic malignancies. The presence of distant metastases and second primary malignancies has major implications in the management and prognosis of patients presenting with head and neck squamous cell carcinoma, with a large proportion of such patients succumbing to their disease within one year of diagnosis. As CT scanning of the thorax was a more effective screening investigation than standard chest X-ray in the detection of simultaneous thoracic malignancy, we recommend it for use in the staging of patients presenting with cancer of the head and neck.

Craniofacial trauma presenting at an adult accident and emergency department with an emphasis on soft tissue injuries

We have retrospectively compiled data on 1000 consecutive adult patients presenting at an accident and emergency department (AED) with a total of 1048 soft tissue injuries and 151 fractures to the craniofacial region, with an emphasis on soft tissue injuries. Facial injuries were common in the AED, forming 7% of all attenders. The main cause of facial fractures was assaults (56%), whereas the largest proportion of soft tissue injuries was caused by falls/ accidents (44%). There was a left sided dominance in soft tissue injuries arising from assaults. However, when subdivided into type of soft tissue injuries, the left sided dominance was significant in contusions only, with virtually equal side distribution in open wounds. Almost half of the 458 open wounds which required treatment were in the upper third of the face. Most lacerations in the upper face can be managed by steristrips or glue but most lacerations in the lower third required suturing. 90% of these injuries were treated by AED personnel. Tertiary referrals were made in only 10% of these cases.

Survey of dental graduates entering medical schools and a comparison with previous surveys

The 169 dental graduates known to have entered UK medical schools between 1986 and 1991 inclusive were sent a questionnaire requesting personal and professional information. A total of 154 graduates (91%) responded, 126 (82%) males and 28 (18%) females, all with a mean age of 27 years. Over the 6 years studied, both the average fees paid and the number of students paying fees increased. During the same period, the average grant received and number receiving grants both decreased. Of the 154 responding, 141 (92%) intended to pursue a career in oral and maxillofacial surgery at the time they entered medical school, and this had fallen to 120 (78%) by the time of the survey. An estimate of the number of those medical students who may return to the specialty was made based on previous surveys (range of 12-26 trainees/years).

A clinical and histopathological study of osteoarthrosis of the temporomandibular joint

OBJECTIVES

The aims of this study were (i) to objectively assess the histopathological features in TMJ condylar head specimens to correlate the findings with clinical information obtained from pathology request forms and hospital notes (ii) to analyse the pre- and post operative investigation and management of patients with TMJ-OA.

DESIGN

A retrospective histological analysis of 136 specimens using a semi-quantitative scoring system.

SUBJECTS

132 patients with TMJ-OA in Trent Hospital Region (mean age 34: range 14-71) provided 136 condylar heads.

MAIN OUTCOME MEASURES

11 histological parameters were assessed. The global scores obtained were compared with the clinical data.

RESULTS

There was no clear correlation between histology and pre- and post-operative clinical data. 95% of patients were treated for at least 6 months before surgery and 94% had pain before surgery. Postoperatively, the success rate was 58% (35% painfree and 23% still in pain but better than before surgery). Non-surgical treatments were not used routinely after surgery. Only 62% of the patients were followed up for at least one year after surgery. 61% of the patients were reported to have macroscopic degenerative changes at surgery whilst all had microscopic OA.

CONCLUSION

The mean age of patients presenting with TMJ-OA is younger (M = 31/F = 34) than in some studies while there is still a female preponderance for the disease. Tomograms and arthrograms appear to have a higher specificity than orthopantomograms for diagnosing gross degenerative change. There appears to be a need for a standardised management protocol.

Measles--an experience in Sandakan Hospital, Sabah, 1990

A descriptive study of 143 cases of clinically diagnosed measles in patients under the age of 12 years admitted to the Duchess of Kent Hospital, Sandakan, Sabah, during the year 1990 was carried out. The median age of the patients was one year and 13.3% of the cases were between the ages of 6 and 9 months. The male to female ratio was 1.3:1. The majority of the cases (85.3%) were not immunised against measles while 60.0% of the cases were malnourished. Most of the cases (86.0%) had at least one complication with 32.9% of the cases having more than one complications. The main complications were pneumonia (74.1%) and diarrhea (38.5%). Other complications were convulsions, otitis media and corneal ulceration/scarring. A case of pneumonia with mediastinal emphysema and subcutaneous emphysema was noted. The case fatality rate was 1.4% while blindness was the long term morbidity in 1.4% of the cases. Measles remains an important cause of morbidity in children in Sabah.

A survey of British medical schools policies with regard to applications from dental graduates in 1992

The admission officer of 28 medical schools in the UK were circulated with a questionnaire requesting details of their policies regarding applicants who are dental graduates. Replies were received from 27 schools (96.4%). There was a wide variation amongst the intake policies between the medical schools. The number of places available for dental graduates varied from none to four per year. The entry requirements for such applicants ranged from the BDS degree to Part II FDS. Most medical schools set the upper age limit for dental graduates entering medicine as 30 years. Up to 2 years exemption in the 5-year medical course may be available for some dental graduates but 17 medical schools do not offer any reduction in the duration of the course. Only eight of the medical schools liaised with an oral and maxillofacial surgeon in vetting the dentally qualified applicants. All the medical schools operated the fees remission scheme for the self-financed student. This survey should help the prospective candidate to shortlist suitable medical schools.

Inhalation of a denture fragment complicating facial trauma

A case of facial trauma is presented, which was complicated by a denture fragment lodged in the larynx. This potentially life threatening event caused minor symptoms only. Its diagnosis and management are reported.

Treatment of genital warts by cryosurgery--a follow-up study

This is a follow-up study involving 50 patients who were treated as outpatients for genital warts using cryosurgery. Single and multiple lesions involving the vulva, vagina and cervix were treated. A cryoprobe cooled to minus 70 degrees centigrade by liquid carbon dioxide and applied to the lesion for 2 1/2 to 3 minutes was used in the treatment. Nine pregnant patients in this study treated with cryosurgery did not experience any adverse effects on their pregnancies. There were no adverse side effects noted among the rest of the patients. All the patients with single wart were treated successfully with cryosurgery whereas those with multiple lesions were successfully treated in only 82 per cent of the patients. Four patients did not respond to treatment. Recurrence after cryosurgery within 3 months of therapy was noted in 2 patients. In conclusion, the treatment of genital warts by cryosurgery was found to be a safe and effect procedure.