On the brink: The climate and nature crisis and risks of nuclear war

@#The Russian military invasion of Ukraine on February 24, 2022, and Hamas’ terror attack on Israel on October 7, 2023, signaled the beginning of two of the most recent wars to make international headlines. To date, over 110 armed conflicts are taking place: over 45 in the Middle East and North Africa (Cyprus, Egypt, Iraq, Israel, Libya, Morocco, Palestine, Syria, Turkey, Yemen, Western Sahara); over 35 in Africa (Burkina Faso, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Ethiopia, Mali, Mozambique, Nigeria, Senegal, Somalia, South Sudan, Sudan); 21 in Asia (Afghanistan, India, Myanmar, Pakistan, the Philippines); seven in Europe (Russia, Ukraine, Moldova, Georgia, Armenia, Azerbaijan); and six in Latin America (three each in Mexico and Colombia); with two more international armed conflicts (between India and Pakistan, and between India and China) in Asia.1 This list does not even include such problematic situations as those involving China and the South East Asia region. As though these situations of armed violence were not enough, mankind has already passed or is on the verge of passing several climate tipping points – a recent review lists nine Global core tipping elements (and their tipping points) - the Greenland Ice Sheet (collapse); West Antarctic Ice Sheet (collapse); Labrador-Irminger Seas / SPG Convection (collapse); East Antarctic Subglacial Basins (collapse); Amazon Rainforest (dieback); Boreal Permafrost (collapse); Atlantic M.O. Circulation (collapse); Arctic Winter Sea Ice (collapse); and East Antarctic Ice Sheet (collapse); and seven Regional impact tipping elements (and their tipping points) – Low-latitude Coral Reefs (die-off); Boreal Permafrost (abrupt thaw); Barents Sea Ice (abrupt loss); Mountain Glaciers (loss); Sahel and W. African Monsoon (greening); Boreal Forest (southern dieback); and Boreal Forest (northern expansion).2 Closer to home, how can we forget the disaster and devastation wrought by Super Typhoon Haiyan (Yolanda) 10 years ago to date? Whether international or non-international, armed conflicts raise the risk of nuclear war. Russia has already “rehearsed its ability to deliver a ‘massive’ nuclear strike,” conducting “practical launches of ballistic and cruise missiles,” and stationed a first batch of tactical nuclear weapons in Belarus,3 and the possibility of nuclear escalation in Ukraine cannot be overestimated.4 Meanwhile, in a rare public announcement, the U.S. Central Command revealed that an Ohio- class submarine (560 feet long, 18,750 tons submerged and carrying as many as 154 Tomahawk cruise missiles) had arrived in the Middle East on November 5, 2023.5 Indeed, “the danger is great and growing,” as “any use of nuclear weapons would be catastrophic for humanity.”

Management of isolated mandibular body fractures in adults

Objective@#The mandible is the most common fractured craniofacial bone of all craniofacial fractures in the Philippines, with the mandibular body as the most involved segment of all mandibular fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and management of mandibular body fractures in particular. General guidelines include the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic Review on interventions for the management of mandibular fractures. On the other hand, a very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and management, this clinical practice guideline focuses on the management of isolated mandibular body fractures in adults.@*Purpose@#This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as well as primary care and specialist physicians, nurses and nurse practitioners, midwives and community health workers, dentists, and emergency first-responders) who may provide care to adults aged 18 years and above that may present with an acute history and physical and/or laboratory examination findings that may lead to a diagnosis of isolated mandibular body fracture and its subsequent medical and surgical management, including health promotion and disease prevention. It is applicable in any setting (including urban and rural primary-care, community centers, treatment units, hospital emergency rooms, operating rooms) in which adults with isolated mandibular body fractures would be identified, diagnosed, or managed. Outcomes are functional resolution of isolated mandibular body fractures; achieving premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing use of ineffective interventions; avoiding co-morbid infections, conditions, complications and adverse events; minimizing cost; maximizing health-related quality of life of individuals with isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in patients and occurrence in others.@*Action Statements@#The guideline development group made strong recommendationsfor the following key action statements: (6) pain management- clinicians should routinely evaluate pain in patients with isolated mandibular body fractures using a numerical rating scale (NRS) or visual analog scale (VAS); analgesics should be routinely offered to patients with a numerical rating pain scale score or VAS of at least 4/10 (paracetamol and a mild opioid with or without an adjuvant analgesic) until the numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- prophylactic antibiotics should be given to adult patients with isolated mandibular body fractures with concomitant mucosal or skin opening with or without direct visualization of bone fragments; penicillin is the drug of choice while clindamycin may be used as an alternative; and (14) prevention- clinicians should advocate for compliance with road traffic safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor vehicle, cycling and pedestrian accidents and maxillofacial injuries.The guideline development group made recommendations for the following key action statements: (1) history, clinical presentation, and diagnosis - clinicians should consider a presumptive diagnosis of mandibular fracture in adults presenting with a history of traumatic injury to the jaw plus a positive tongue blade test, and any of the following: malocclusion, trismus, tenderness on jaw closure and broken tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray as the initial imaging tool in evaluating patients with a presumptive clinical diagnosis; (3) radiographs - where panoramic radiography is not available, clinicians may recommend plain mandibular radiography; (4) computed tomography - if available, non-contrast facial CT Scan may be obtained; (5) immobilization - fractures should be temporarily immobilized/splinted with a figure-of-eight bandage until definitive surgical management can be performed or while initiating transport during emergency situations; (8) anesthesia - nasotracheal intubation is the preferred route of anesthesia; in the presence of contraindications, submental intubation or tracheostomy may be performed; (9) observation - with a soft diet may serve as management for favorable isolated nondisplaced and nonmobile mandibular body fractures with unchanged pre - traumatic occlusion; (10) closed reduction - with immobilization by maxillomandibular fixation for 4-6 weeks may be considered for minimally displaced favorable isolated mandibular body fractures with stable dentition, good nutrition and willingness to comply with post-procedure care that may affect oral hygiene, diet modifications, appearance, oral health and functional concerns (eating, swallowing and speech); (11) open reduction with transosseous wiring - with MMF is an option for isolated displaced unfavorable and unstable mandibular body fracture patients who cannot afford or avail of titanium plates; (12) open reduction with titanium plates - ORIF using titanium plates and screws should be performed in isolated displaced unfavorable and unstable mandibular body fracture; (13) maxillomandibular fixation - intraoperative MMF may not be routinely needed prior to reduction and internal fixation; and (15) promotion - clinicians should play a positive role in the prevention of interpersonal and collective violence as well as the settings in which violence occurs in order to avoid injuries in general and mandibular fractures in particular.

Otorhinolaryngology Out-Patient Practice in the “Post”-COVID-19 Era: Ensuring a Balance Between Service and Safety

Objective@#To review available resources and provide evidence-based recommendations that may optimize otorhinolaryngologic out-patient health care delivery in the “post”-COVID-19 era while ensuring the safety of our patients, healthcare workers and staff.@*Data Sources@#Relevant peer-reviewed journal articles; task force, organizational and institutional, government and non-government organization recommendations; published guidelines from medical, health-related, and scientific organizations.@*Methods@#A comprehensive review of the literature on the COVID-19 pandemic as it pertained to “post”-COVID 19 out-patient otorhinolaryngologic practice was obtained from peer-reviewed articles, guidelines, recommendations, and statements that were identified through a structured search of the data sources for relevant literature utilizing MEDLINE (through PubMed and PubMed Central PMC), Google (and Google Scholar), HERDIN Plus, the World Health Organization (WHO) Global Health Library, and grey literature including social media (blogs, Twitter, LinkedIn, Facebook). In-patient management (including ORL surgical procedures such as tracheostomy) were excluded. Retrieved material was critically appraised and organized according to five discussion themes: physical office set-up, patient processing, personal protection, procedures, and prevention and health-promotion.@*Conclusion@#These recommendations are consistent with the best available evidence to date, and are globally acceptable while being locally applicable. They address the concerns of otorhinolaryngologists and related specialists about resuming office practice during the “post”-COVID-19 period when strict quarantines are gradually lifted and a transition to the “new” normal is made despite the unavailability of a specific vaccine for SARS-CoV-2. While they target practice settings in the Philippines, they should be useful to ENT (ear, nose & throat) surgeons in other countries in ensuring a balance between service and safety as we continue to serve our patients during these challenging times.

An initial survey of septorhinoplasty in crooked nose deformities

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> Crooked  nose  deformity  is  a  commonly  seen  reason  for  septorhinoplasty  in  the otolaryngology clinic. The purpose of this study is to initially determine the different etiologies of  patients  with  crooked  nose  deformities  who  underwent  septorhinoplasty,  and  to  describe the different types of crooked nose by their level of deviation and surgical management in our institution.<br /><strong>METHODS:</strong><br /> <strong>  Design:</strong> Case Series<br />  <strong> Setting:</strong> Tertiary Public University Hospital<br /> <strong> Participants:</strong> A chart review of all patients with a crooked nose deformity who were admitted  at the otorhinolaryngology ward of the National University Hospital and underwent septorhinoplasty from January 2012 to January 2015 was conducted, and data consisting of age, sex, etiology of crooked nose deformity, level of deviation, cartilage source, and surgical intervention were obtained and analyzed.<br /><strong>RESULTS:</strong> A total of 21 patients underwent septorhinoplasty for crooked nose deformity  in  the study period. The most common etiology for crooked nose was physical violence (13/21 or 62%), followed by sports injury (4/21 or 19%), vehicular accidents (2/21 or 9%), and accidental fall (1/21 or 5%). There were more upper and middle third deviations than lower third deviations. Sixteen out of 21patients  (76%) underwent  open  rhinoplasty,  while  the  rest underwent an endonasal approach. Twelve (57%) underwent intervention  on  the  nasal  fracture after at least a year (old or  neglected  fracture) as compared to the 9 (43%) who had  immediate intervention after less than two weeks. Thirteen used septal cartilage, while 4 used conchal cartilage, and 1 used tragal cartilage. The most common grafts used were spreader  and camouflage, followed closely by dorsal onlay, and columellar strut grafts.<br /><strong>CONCLUSION:</strong> The majority of crooked nose deformities that were subjected to septorhinoplasty in our department were secondary to old nasal bone fractures caused by physical violence. Upper and middle  third level deviations were more common, and most underwent open rhinoplasty with autologous cartilage grafts. Future studies may increase our understanding of, and improve our techniques in septorhinoplasty for crooked nose deformities in Filipino noses in particular, and Asian noses in general. </p>

Advancing access to health information and publication: shifting paradigms, trends and innovations

@#<p>The World Health Organization Constitution "enshrines the highest attainable standard of health as a fundamental right of every human being. The right to health includes access to timely, acceptable, and affordable health care of appropriate quality ... as well as the underlying determinants of health, such as ... access to health-related education and information."1 On the other hand, "social determinants of health can themselves pose barriers to education ... and 'damaged brains and bodies' cannot learn optimally."2 While there are no clear-cut solutions to such multifactorial issues involving complex-systems, the sustainable developmental goals of the United Nations development agenda beyond 2015 address both health and education.3<br /> <br /> Health research fundamentally underpins the key aspiration of the sustainable development goals to realize universal health coverage.3 It is the responsibility of researchers and publishers to make this research available and accessible to all those who need it, in order to assist policymakers and practitioners to progressively realize the right to health of every global citizen. It would seem that the speed and reach of present-day information and communication technology would have facilitated the dissemination of health information. "However, despite the promises of the information revolution, and some successful initiatives, there is little if any evidence that the majority of health professionals in the developing world are any better informed than they were 10 years ago."4 This observation made over a decade ago still holds true today. <br /> <br /> How can we advance access to health information and publication in our current "glocal" situation? How can the health information produced by research conducted by our students, residents and fellows, be shared with all those who may need and use the information? The Philipp J Otolaryngol Head Neck Surg has been actively pursuing multiple means of ensuring the availability of our research and innovation through traditional means, including indexing on various Index Medici and databases. While our visibility has increased dramatically in the 10 years of my editorship, we need to explore new paradigms, trends and innovations, especially with regard the social media. This includes using Facebook, Twitter, LinkedIn and RSS feeds, to name a few. It also calls us to consider the transition to a full open access model and adopting Creative Commons licenses.<br /> <br /> It is timely that the Asia Pacific Association of Medical Journal Editors (APAME) will explore this very theme of shifting paradigms, trends and innovations in advancing access to health information and publication in the forthcoming APAME2015 Annual Convention and Joint Meeting with the Western Pacific Region Index Medicus at the Sofitel Philippine Plaza and WHO Western Pacific Region Office from August 24-26 (http://apame2015.healthresearch.ph) in conjunction with the Global Health Forum 2015 at the Philippine International Convention Center (http://www.forum2015.org). <br /> <br /> Close to a thousand editors, reviewers, authors, researchers, librarians, and publishers of medical journals from Asia Pacific states, local delegates representing various institutions and organizations, including the Department of Science and Technology - Philippine Council for Health Research and Development (PCHRD), Department of Health, University of the Philippines Manila, Medical and Health Librarians Association of the Philippines (MAHLAP), the Philippine Medical Association, the Philippine Nursing Association, the Philippine Dental Association and others will exchange ideas in three days of meetings, scientific sessions and workshops. At the same time, the over 70 conjoint Forum 2015 sessions across 2 tracks covering 6 themes will provide "a platform where several other thousand key global actors in health gather to learn, debate and shape the global agenda on research and innovation for health, to arrive at new solutions that are driving health equity and socio-economic development."<br /> <br /> Whether you are a beginning researcher or a seasoned scientist, a novice trainee or senior subspecialist, a community-based health worker or health policy-maker, there will be something for you to learn and share at these meetings that recognize "people (are) at the center of health research and innovation." Medical and health professions students, ORL-HNS residents and consultants of all training and academic institutions are particularly enjoined to participate in this rare opportunity that will benefit us as well as the people we serve. <br /> <br /> Meet me at the Forum!</p>

Epithelial-myoepithelial carcinoma of the salivary gland

@#The World Health Organization (2005) defines an epithelial-myoepithelial carcinoma (EMC) as a malignancy composed of two cell types that typically form duct-like structures.1 We present herein an archival case from the parotid gland. EMC occurs primarily in the major salivary glands particularly in the parotid where it presents as a painless, slow-growing mass.1 Microscopic examination shows bi-layered tubular duct-like structures with pale to clear areas (Figure 1). The inner luminal layer is composed of cuboidal cells that are of epithelial derivation while the outer layer is composed of polygonal cells that are of myoepithelial derivation (Figures 2 and 3). The latter typically have abundant clear cytoplasm.1,2 The epithelial-myoepithelial dualism is confirmed using immunohistochemical stains; the epithelial cells being immunoreactive for low molecular weight keratin and the myoepithelial cells for S-100 protein, muscle specific actin, vimentin and p63.1, 3 EMC is primarily a tumor of adulthood with peak incidence in the sixth and seventh decades. First described by Donath et al. in 1972,3 they are rare salivary gland neoplasms with an incidence of less than 1% arising mainly in the parotid gland4 although they have been documented in the lungs.5 Perineural and vascular invasion are frequent and recurrence occurs in around 40% of cases and metastasis in 14%.1 Although thought to be of low-grade malignancy, fatal courses have been described4 and “analysis of the various series have demonstrated that tumors with a solid growing pattern, nuclear atypia, DNA aneuploidy and high proliferative activity, generally have a more aggressive behavior and a higher frequency of local recurrences and metastases.”3

On research integrity and ethical publication, authorship and accreditation

@#In 2013, multiple articles reporting the clinical trial of valsartan, an antihypertensive drug of more than US$ 1 billion annual sales from Novartis, were retracted due to data falsification.1,2 These included the Kyoto Heart Study presented by Dr. Hiroaki Matsubara at the European Society of Cardiology 2009 Congress and subsequently published in the European Heart Journal (EHJ).3,4 Aside from retraction of this article by EHJ, the American Heart Association (AHA) also retracted five papers published in three of its journals -- Circulation, Circulation Research, and Hypertension.4 Novartis employees were involved in the conduct and analysis of the Kyoto Heart Study and a second investigator-initiated trial, the Jikei Heart Study,5 although their participation was not acknowledged in publications and presentations of the data, while a Novartis employee who allegedly manipulated statistical data was listed as one of the academic authors, without disclosing the relation with the company.