Patient perceptions of costs in the NHS: an evaluation.

The cost of the NHS, wastage within it and how much trusts have overspent is a national obsession. Despite these widespread opinions, the costs of individual treatments and impacts of non-attendance appear to be little understood. There is a paucity of literature with regards to patients' awareness of costs associated with services provided by the NHS. The authors aim to ascertain whether patients are aware of the costs associated with care services provided, and if these data could aid educating patients on NHS costs to reduce missed appointments. A questionnaire was randomly distributed to new and review patients in our Oral and Maxillofacial outpatient and emergency departments from November-December 2017 asking them to estimate the cost of common services they may encounter, such as an outpatient appointment, an orthopantomogram (OPT), a CT head, and a full blood count test (FBC). The results demonstrate that 81% of patients surveyed underestimated the cost of their new patient appointment, with 34% underestimating the cost of their review appointment. The cost of an overnight stay in hospital was underestimated by 65% of patients, with 89% of patients underestimating the cost of an hours's operating. The costs of a full blood count, an OPT and a CT head have been mostly overestimated by 89%, 77%, and 54% of patients respectively. The results show there is a wide variation in patients' estimates of costs, with over 50% of patients overestimating the costs of investigations but underestimating the cost of their appointment/A&E attendance.

Changing the Oral and Maxillofacial Surgery (OMFS) training pathway in the United Kingdom - an illustrative retrospective.

OMFS training is perceived as a long and expensive pathway although papers have shown it compares favourably with other surgical specialties. Every OMFS clinician has a vested interest and duty continually to improve the quality of training and minimise costs, especially to trainees at junior levels. Any serious proposal to fundamentally change the format of training, must be given due consideration by all stakeholders. In 2016, a British Medical Journal article whose authors included the BAOMS President of that year and OMFS Specialty Advisory Committee (SAC) Chair, posed the question - should the future of OMFS training revert to single dental degree, change to single medical degree - or continue as a dual degree specialty? The BMJ publication was discussed at the British Association of Oral and Maxillofacial Surgeons (BAOMS) Council in March 2016 and all present unanimously supported the dual degree pathway. Later that year a formal proposal was made by the BAOMS immediate past President that training in the UK change to single medical degree 'Maxillofacial Surgery' similar to the training in Spain, France or Italy. Evidence around the risks and benefits of making this change to OMFS training was assembled and reviewed by BAOMS Council in March 2017. BAOMS Council once again unanimously supported continuing OMFS as a dual degree specialty with the observation that the quality of patient care which this training provided was the specialty's Unique Selling Point or USP. The requirement for both degrees to provide care for OMFS patients had been confirmed by external scrutiny on two separate occasions by the responsible regulators. In this paper, we outline the key steps to be considered when making major changes in the OMFS training pathways using this event as an example and the suggestion that those proposing changes should assemble and present evidence to support their proposal using the template provided.

Choosing the best method to utilise single positron emission computed tomography (SPECT) scans in the management of unilateral condylar hyperplasia.

Facial asymmetry secondary to unilateral condylar hyperplasia can be a diagnostic challenge to oral and maxillofacial surgeons. Single positron emission computed tomography (SPECT) scans provide a useful adjunct. We report a brief summary of the evidence describing the effectiveness of different methods of analysing SPECT scans and compare it with the results of a 10-year study at Sunderland Royal Hospital. Overall, both the evidence base and our study strongly favour use of the condyle:condyle ratio over the condyle:reference bone ratio, suggesting that no further comparisons are needed.

Condylar hyperplasia: current thinking.

Unilateral condylar hyperplasia is a rare disease that causes facial asymmetry as a result of excessive vertical or horizontal growth, or both, of the mandibular condyle. Investigation should address the patient's concerns, and establish whether the disease is active with the use of single positron emission tomography (PET). Proportional reduction of the condyle arrests active disease and restores mandibular height, and any residual asymmetry can be corrected according to conventional orthognathic principles. We recommend the use of 3-dimensional virtual planning for such complex movements. The rarity of the disease means that, to our knowledge, high-quality evidence is lacking and further research is needed.

Assessment of online visibility of the British Association of Oral and Maxillofacial Surgeons (BAOMS): a strategic study.

The Internet is a powerful method of acquiring and sharing information. In marketing and business, online visibility is vital for publicity and the reputation of an organisation. To our knowledge, the importance of such visibility in medicine in general, and in Oral and Maxillofacial Surgery (OMFS) services in the UK, has not previously been investigated. We aimed to provide a better understanding of the way that patients use the Internet by asking 450 patients to complete a questionnaire when they attended outpatient OMFS departments at 2 centres. We also assessed the online visibility of the British Association of Oral and Maxillofacial Surgeons (BAOMS) and investigated the correlation between the strength of online visibility and professional reputation. Results from the self-administered, anonymous, validated questionnaires showed that 82% of patients agreed that the Internet was a powerful source of information, and two-thirds associated online visibility with a good reputation. However, the perceived online visibility of the BAOMS was poor (2%). This study mirrors findings in business publications, and confirms the link between online visibility and professional reputation. It also shows that there is a gap between patients' perceptions and the level of uptake of professional resources. We propose various strategies to bridge this gap and to promote the online visibility and professional reputation of the BAOMS and of OMFS services in the UK.

Unrecognised displacement of mandibular molar root into the submandibular space.

We describe a case of swelling in the right submandibular and sublingual space caused by displacement of a lower second molar root in the submandibular space. This displacement was not recognised at the time of extraction. The techniques used to minimise the risk of accidental displacement of teeth and roots, during extraction are discussed. The importance of recognising this complication and methods of retrieval are highlighted.

Ergonomic risks and musculoskeletal disorders in production agriculture: recommendations for effective research to practice.

Musculoskeletal disorders (MSDs) are increasingly recognized as a significant hazard of agricultural occupation. In agricultural jobs with significant physical labor, MSDs are typically the most frequently reported injury. Although not as lethal as tractor roll-overs, MSDs can result in disability, lost work time, and increased production costs. MSDs increase production costs as a result of worker absence, medical and insurance costs, decreased work capacity, and loss of employees to turnover and competition from other less physically demanding industries. This paper will provide an overview of what is currently known about MSDs in agriculture, including high-risk commodities, tasks and work practices, and the related regulatory factors and workers' compensation costs. As agricultural production practices evolve, the types of MSDs also change, as do ergonomic risk factors. One example is the previous higher rates of knee and hip arthritis identified in farmers in stanchion dairies evolving into upper extremity tendonitis, arthritis, and carpal tunnel syndrome now found in milking technicians in dairy milking parlors. This paper summarizes the presentation, "Musculoskeletal Disorders in Labor-Intensive Operations," at the Agricultural Safety and Health Council of America/National Institute for Occupational Safety and Health conference, "Be Safe, Be Profitable: Protecting Workers in Agriculture," January 27-28, 2010, Dallas/Fort Worth, Texas. The primary focus of the paper is to address current research on ergonomic solutions for MSDs in agriculture. These include improved tools, carts or equipment, as well as work practices. One of the key challenges in this area pertains to measurement, due to the fact that musculoskeletal strain is a chronic condition that can come and go, with self-reported pain as its only indicator. Alternative measurement methods will be discussed. Finally, the implementation of research into practice is reviewed, with an emphasis on best practices that have been demonstrated to be effective in the agricultural setting, based on worker acceptance and comfort, improved productivity, and decreased MSDs. The paper will provide an overview for agricultural stakeholders as to the current science and practice of ergonomics in agriculture.

Fracture of the radial donor site after composite free flap harvest: a ten-year review.

The options for donor sites as a source of tissue for free vascularised osteocutaneous flaps are numerous, however, the radial forearm still has an important role. This series reports the largest published record of radial donor site fracture following the harvesting of osteocutaneous radial forearm free flaps used for reconstruction after ablative surgery for malignant disease. The relevant literature is reviewed. A retrospective review of cases treated using these flaps from 1991-2000 (inclusive) is carried out. Factors involved in the aetiology of fractures are discussed. Thirteen fractures are identified from seventy one osteocutaneous flaps (18%). A statistically significant majority of fractures occur in females. Limiting the percentage of radius diameter harvested is important and beveling of the osteotomy cuts may be advantageous in minimising weakening. Prophylactic plating of the donor site, particularly in the female patient, should be actively considered. The earlier the fracture occurs in the post-operative period, the more likely the need for operative intervention.

Surgical accuracy in Le Fort I maxillary osteotomies.

UNLABELLED: 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.

Motor and somatosensory deficits following uni- and bilateral lesions of the cortex induced by aspiration or thermocoagulation in the adult rat.

We have previously shown that lesions of the sensorimotor cortex induced by either thermocoagulation or aspiration produce different effects on axonal plasticity. We have now investigated whether these methods of lesion also influence the behavioral outcome. The behavioral effects of unilateral and bilateral lesions of the sensorimotor cortex induced by either aspiration or by thermocoagulation of pial blood vessels were examined in adult Sprague-Dawley rats. Rats were tested to determine limb use asymmetry by analyzing (1) coordinated forelimb placement and (2) paw use preference when rearing. Their responsiveness to somatosensory stimulation was tested by analyzing (1) the latency to remove sticky tape on the ventral surface of the paw, and (2) vibrissae-stimulated forelimb placing. Behavioral tests were performed prior to surgery and on day 4, 8, 12, 16, and 20 after surgery. Both unilateral lesions resulted in an over-reliance on the nonimpaired forelimb as early as 4 days after the surgery; functional recovery occurred after 16 days. Animals with bilateral lesions did not use either forelimb for support in postural support behaviors. However, this effect was more apparent in the animals with a thermocoagulatory lesion and, in contrast to the animals with an aspiration lesion, these animals did not show functional recovery. Animals with a unilateral aspiration, but not a thermocoagulatory lesion, showed a slowed response to tactile stimulation applied to the contralateral forelimb. After bilateral lesions, animals showed a slowed response to tactile stimulation applied to either forelimb at early time points after the lesion and recovery of function at later time points. These data indicate that, for the most part, lesions of the sensorimotor cortex by aspiration or thermocoagulation produce very similar effects on the behaviors examined in this study. However, unexpectedly, thermocoagulatory lesions induced a more severe (unilateral lesion) or prolonged (bilateral lesion) deficit in forelimb use than aspiration lesions. Conversely, the effect on tactile stimulation is more prominent after unilateral aspiration than thermocoagulatory lesions.

The angiotensin converting enzyme inhibitors captopril and enalapril inhibit apomorphine-induced oral stereotypy in the rat.

The possible functional interaction between angiotensin and dopamine mechanisms in the rat was investigated by examining the effects of the angiotensin converting enzyme inhibitors captopril and enalapril on apomorphine-induced stereotypy. Apomorphine-induced behaviour was observed, and recorded using a keypad linked to a microcomputer. In agreement with previous findings, low doses of apomorphine induced a syndrome of vacuous mouth movements, penile grooming, yawning and immobility whereas at higher doses the yawning syndrome disappeared to be replaced with sniffing, licking and gnawing. Two antagonism studies were carried out. In the first the effects of captopril on apomorphine-induced behaviour were compared with those of the classical neuroleptic haloperidol, and in the second dose-response curves for the effects of captopril and enalapril on apomorphine-induced behaviour were determined. Captopril had no effect on the apomorphine-induced yawning syndrome whereas this was blocked by haloperidol. In contrast, both captopril and haloperidol blocked oral stereotypy (licking and gnawing) induced by apomorphine but had no effect on sniffing induced by the dopamine agonist. Selective blockade of apomorphine-induced oral stereotypy by angiotensin converting enzyme inhibition was confirmed in the second study in which both captopril and enalapril were observed to antagonize apomorphine-induced gnawing. The inhibition of apomorphine-induced gnawing by enalapril correlated with inhibition of brain angiotensin converting enzyme, but not lung angiotensin converting enzyme, by the drug as assessed by ex vivo penetration studies. These data suggest that angiotensin converting enzyme inhibition modulates the expression of apomorphine-induced oral stereotypy, a response that is thought to be mediated by postsynaptic dopamine receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Drinking induced by subcutaneous injection of angiotensin II in the rat is blocked by the selective AT1 receptor antagonist DuP 753 but not by the selective AT2 receptor antagonist WL 19.

The role of AT1 and AT2 receptors in mediating the drinking response induced by angiotensin II in the rat was examined. Angiotensin II (0.1-1.0 mg/kg s.c.) caused a dose-dependent increase in drinking in water-replete rats. The angiotensin Il-induced drinking response was dose dependently blocked by the selective AT1 receptor antagonist DuP 753 (1-30 mg/kg s.c.). In contrast, the selective AT2 receptor antagonist WL 19 failed to block angiotensin II-induced drinking up to doses of 100 mg/kg s.c. and significantly enhanced the response at 3 and 100 mg/kg. These data suggest that drinking induced by angiotensin II is mediated by AT1 receptors and that AT2 receptor activation may inhibit the drinking response.