Evaluation of A Post-Treatment Follow-Up Program in Patients with Oral Squamous Cell Carcinoma

Objectives The duration and the frequency of follow-up after treatment of oral squamous cell carcinoma are not standardized in the current literature. The purpose of this study was to evaluate our local standard post-treatment and follow-up protocol. Materials and methods Overall, 228 patients treated curatively from 01/2006 to 07/2013 were reviewed. To evaluate the follow-up program, data on the secondary event were used. To determine risk groups, all patients with tumor recurrence were specifically analyzed. Relapse-free rate were estimated by the Kaplan-Meier product limit method. The chi-square test was used to identify independent risk factors for tumor relapse. Results In total, 29.8 % patients had a secondary event. The majority of the relapse cases (88.2 %) were detected within 2 years postoperatively, 61.8 % of them within the first year. Most events were local recurrences (34.7 %). UICC-stage IV was significantly associated with tumor recurrence (p = 0.001). Gender (p = 0.188), age (p = 0.195), localization (p = 0.739), T-stage (p = 0.35), N-stage (p = 0.55), histologic grade (p = 0.162), and tobacco and alcohol use (p = 0.248) were not significantly associated with tumor recurrence. Patients with positive neck nodes relapsed earlier (p = 0.011). The majority of relapses (86.3 %) were found in asymptomatic patients at routine follow-up. Conclusions The results of this study suggest an intensified follow-up within the first 2 years after surgery. Clinical relevance Given the higher relapse rate of patients exhibiting an UICC-stage IV and/or positive neck nodes, it seems to be from special interest to perform in this group a risk-adapted follow-up with monthly examinations also in the second year

Oral Health and Dental Anxiety in a German Practice-based Sample

Objective Does dental anxiety have an effect on dental and periodontal health? Methods Survey data was collected from n = 200 adults (53 % females, average age 49 years) in a cross-sectional study. Dental anxiety was measured with the modified dental anxiety scale (MDAS, score 1–5, the greater the score, the greater the anxiety). Clinical parameters including probing depth (PD), clinical attachment level (CAL), plaque index (SLI), and bleeding on probing (BoP) as well as the DMFT index were recorded and statistically analyzed. Results Rating of dental anxiety was higher in women than in men (65 vs 35 %). Subjects with higher MDAS values visited the dentist less frequently (p = 0.001) and had more decay (DT 6.7 ± 4.2 vs 1.7 ± 2.4; p \u3c 0.001) but fewer filled teeth than subjects with lower ratings of dental anxiety (FT 7.1 ± 4.5 vs 9.8 ± 5.7; p = 0.042). There were no differences in PD or CAL between subjects with or without dental anxiety, while patients with higher MDAS value showed significantly more BoP (50 ± 19 vs 34 ± 20 %; p = 0.002) than patients with low MDAS scores (no or low dental anxiety). Conclusions Patients with higher ratings of dental anxiety had significantly more caries experience and gingivitis. Therefore, dental anxiety is associated with negative effect on dental and periodontal health. Clinical relevance Identifying patients with high dental anxiety and helping to manage this anxiety has important implications to improve oral health in adults. The MDAS appears to be an easy and efficient tool that can be used to identify patients with dental anxiety in dental practices

The Isolated Orbital Floor Fracture from a Transconjunctival or Subciliary Perspective-A Standardized Anthropometric Evaluation

Background: The influence of orbital fractures and their repair on the rate of deformities of the lower eyelid is an ongoing source of discussion in the literature. Most of the present studies include isolated blow-out as well as combined orbital fractures. Material and Methods: We present a retrospective evaluation of a series of 100 patients after isolated blow-out fracture repair using reference anthropometric data on standardized photographs. Analysis included eye fissure width and height, lid sulcus height, upper lid height, upper and lower iris coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion and entropion. It was clearly distinguished between operated and contralateral eyelid, whether a transconjunctival or a subciliary approach was performed and amount of fracture. Our main interests were changes of the aforementioned parameters with regards to eyelid deformities. Results: Surgery per se did not significantly influence eyelid deformities. However, the surgical approach selected significantly affected eye fissure index, lower iris coverage and rate of scleral show, indicating retraction of the lower eyelid. Conclusions: The standardized measurements described here are accurate and objective to evaluate postoperative results. The subciliary approach included the highest risk of lower lid retraction as compared to transconjunctival approaches

Quality of Postoperative Pain Management after Midfacial Fracture Repair—An Outcome-oriented Study

Objectives There is a lack of literature regarding the procedure-specific quality of acute postoperative pain management after midfacial fracture repair. The purpose of the presented prospective clinical study was to evaluate postoperative pain management after surgical repair of midfacial fractures. Materials and methods Eighty-five adults were evaluated on the first postoperative day following midfacial repair using the questionnaire of the Quality Improvement in Postoperative Pain Management (QUIPS) project. The main outcome measures were patients’ characteristics and clinical- and patient-reported outcome parameters. Results Overall, pain on the first postoperative day was moderate. A significant correlation between process and outcome parameters could be shown. Duration of surgery above the calculated median was significantly associated with higher maximum pain intensity (p = 0.017). Patients requiring opioids in the recovery room presented significantly higher pain on activity (p = 0.029) and maximum pain (p = 0.035). Sleeping impairment (p = 0.001) and mood disturbance (p = 0.008) were significantly more prevalent in patients undergoing repair of a centrolateral midfacial fracture. Conclusions QUIPS is a simple and qualified tool to evaluate the procedure specific quality of acute postoperative pain management. Pain on the first postoperative day following midfacial fracture repair seems overall to be moderate. Nearly a third of the patients showed inadequate postoperative pain management. To prevent inadequate postoperative pain management, it is necessary to establish a continued procedure-specific outcome measurement

Quality of Postoperative Pain Management After Maxillofacial Fracture Repair

Background: Effective pain management is an essential component in the perioperative care of surgical patients. However, post-operative pain after maxillofacial fracture repair and its optimal therapy has not been described in detail. Materials and Methods: In a prospective cohort study, 95 adults rated their pain on the first postoperative day after maxillofacial fracture repair using the questionnaire of the Quality Improvement in Postoperative Pain Management (QUIPS) project. Quality Improvement in Postoperative Pain Management allowed for a standardized assessment of patients’ characteristics and pain- related parameters. Results: Overall, the mean maximal pain and pain on activity (numeric rating scales) were significantly higher in patients with mandibular fractures than in patients with midface fractures (P = 0.002 and P = 0.045, respectively). In patients with mandibular fractures, a longer duration of surgery was significantly associated with higher satisfaction with pain intensity (P = 0.015), but was more frequently associated with postoperative vomiting (P = 0.023). A shorter duration of surgery and an absence of preoperative pain counseling in these patients were significantly correlated to desire for more pain medication (P = 0.049 and P = 0.004, respectively). Patients with mandibular fractures that received opioids in the recovery room had significantly higher strain-related pain (P = 0.017). In patients with midface fractures, a longer duration of surgery showed significantly higher levels of decreased mobility (P = 0.003). Patients receiving midazolam for premedication had significantly less minimal pain (P = 0.021). Conclusions: Patients with mandibular fractures seem to have more postoperative pain than patients with midface fractures. Monitoring of postsurgical pain and a procedure-specific pain-treatment protocol should be performed in clinical routine

Bilateral Sagittal Split Osteotomy-parameters and Correlations of Postoperative Pain Management

Objectives Postoperative pain management is of utmost interest for patients undergoing orthognathic surgery. Currently, there is a lack of information regarding process and outcome parameters of postoperative pain management after bilateral sagittal split osteotomy. Materials and methods In a prospective clinical study, 31 adults were evaluated on the first postoperative day following bilateral sagittal split osteotomy using the standardized questionnaire of the Germany-wide project Quality Improvement in Postoperative Pain Management (QUIPS). It allows a standardized assessment of patients’ characteristics, pain parameters, outcome, and pain therapy process parameters. Results Pain management consisted mainly of premedication with midazolam, sufentanil, and metamizol intraoperatively; piritramide in the recovery room; and metamizol and tramadol on ward. Twenty patients (64.5%) showed inadequate pain management with pain levels ≥4. Patients receiving tramadol as opioid on ward presented significantly higher maximum pain levels (p = .037). Significantly lower satisfaction with postoperative pain intensity (p \u3e .001) and significantly higher desire for additional pain medication (p = .023) were detected, when duration of surgery was above the median of 107.5 min. Conclusions Inadequate pain management on the first postoperative day following bilateral sagittal split osteotomy was widespread on our ward. QUIPS helped us to identify it and thereby gave us the possibility to improve the situation. Prolonged duration of surgery seems to be a predictor of an elevated postoperative pain medication demand. Clinical relevance Only the establishment of an ongoing monitoring of postoperative pain management can help to reduce or even avoid inadequate postoperative pain management. In accordance to the existing literature, we found inadequate postoperative pain management more widespread than thought

Cranio-Maxillofacial Reconstruction with Microvascular Radialis Flaps—Parameters and Correlations of Postoperative Pain Management

Objectives Postoperative pain management is of highest interest for patients undergoing maxillofacial surgery including microvascular reconstructive surgery. Currently, there is a lack of information regarding process and outcome of postoperative pain management after microvascular reconstruction. Materials and methods In a prospective clinical study, 31 adults were evaluated on the first postoperative day following microvascular reconstruction with a radial forearm flap using the standardized questionnaire of the Germany-wide project Quality Improvement in Postoperative Pain Management (QUIPS). It enables a standardized assessment of patients’ characteristics, pain parameters, outcome and pain therapy process parameters. Results Pain management consisted predominately of premedication with midazolam, sufentanil and metamizol intraoperatively, piritramid in the intensive care unit and metamizol, tramadol and fentanyl patches on ward. Nineteen patients (61.3 %) showed inadequate pain management with pain levels ≥4. Among other significant relations, patients exhibiting an age below the median presented significant higher levels of pain under strain (p = .041) and maximum pain (p = .006) as well as rate of breathing (p = .009) and mood (p = .006) disturbance. Performance of pain counselling showed specific impact on pain under strain (p = .008), maximum pain (p = .004) and satisfaction with pain intensity (p = .001). Whether microvascular reconstruction was performed with primary or secondary intention or performance of a neck dissection did not show significant influence. Conclusions QUIPS helped us to adequately evaluate the procedure-specific quality of postoperative management following microvascular reconstruction with a radial forearm flap. It helped us to identify a surprisingly high amount of inadequate pain management. Postoperative pain levels seem to be primarily influenced by the performed reconstruction. Clinical relevance Establishment of a continuous and procedure-specific evaluation of postoperative pain levels should help to avoid inadequate pain management, which is widely prevalent according to the literature and our study. Preoperative pain counselling is essential and should be procedure specific to be its best

Measurement of the Crab Nebula Spectrum Past 100 TeV with HAWC

We present TeV gamma-ray observations of the Crab Nebula, the standard reference source in ground-based gamma-ray astronomy, using data from the High Altitude Water Cherenkov (HAWC) Gamma-Ray Observatory. In this analysis we use two independent energy-estimation methods that utilize extensive air shower variables such as the core position, shower angle, and shower lateral energy distribution. In contrast, the previously published HAWC energy spectrum roughly estimated the shower energy with only the number of photomultipliers triggered. This new methodology yields a much improved energy resolution over the previous analysis and extends HAWC's ability to accurately measure gamma-ray energies well beyond 100 TeV. The energy spectrum of the Crab Nebula is well fit to a log parabola shape $\left(\frac{dN}{dE} = \phi_0 \left(E/\textrm{7 TeV}\right)^{-\alpha-\beta\ln\left(E/\textrm{7 TeV}\right)}\right)$ with emission up to at least 100 TeV. For the first estimator, a ground parameter that utilizes fits to the lateral distribution function to measure the charge density 40 meters from the shower axis, the best-fit values are $\phi_o$=(2.35$\pm$0.04$^{+0.20}_{-0.21}$)$\times$10$^{-13}$ (TeV cm$^2$ s)$^{-1}$, $\alpha$=2.79$\pm$0.02$^{+0.01}_{-0.03}$, and $\beta$=0.10$\pm$0.01$^{+0.01}_{-0.03}$. For the second estimator, a neural network which uses the charge distribution in annuli around the core and other variables, these values are $\phi_o$=(2.31$\pm$0.02$^{+0.32}_{-0.17}$)$\times$10$^{-13}$ (TeV cm$^2$ s)$^{-1}$, $\alpha$=2.73$\pm$0.02$^{+0.03}_{-0.02}$, and $\beta$=0.06$\pm$0.01$\pm$0.02. The first set of uncertainties are statistical; the second set are systematic. Both methods yield compatible results. These measurements are the highest-energy observation of a gamma-ray source to date.Comment: published in Ap

Non-canonical Hedgehog signaling mediates profibrotic hematopoiesis-stroma crosstalk in myeloproliferative neoplasms.

The role of hematopoietic Hedgehog signaling in myeloproliferative neoplasms (MPNs) remains incompletely understood despite data suggesting that Hedgehog (Hh) pathway inhibitors have therapeutic activity in patients. We aim to systematically interrogate the role of canonical vs. non-canonical Hh signaling in MPNs. We show that Gli1 protein levels in patient peripheral blood mononuclear cells (PBMCs) mark fibrotic progression and that, in murine MPN models, absence of hematopoietic Gli1, but not Gli2 or Smo, significantly reduces MPN phenotype and fibrosis, indicating that GLI1 in the MPN clone can be activated in a non-canonical fashion. Additionally, we establish that hematopoietic Gli1 has a significant effect on stromal cells, mediated through a druggable MIF-CD74 axis. These data highlight the complex interplay between alterations in the MPN clone and activation of stromal cells and indicate that Gli1 represents a promising therapeutic target in MPNs, particularly that Hh signaling is dispensable for normal hematopoiesis