Testing the clinical validity of the Bemelman Rib Fracture Management Guideline.

Whilst surgical stabilization of rib fractures (SSRF) results in better outcomes, selection algorithms are lacking. We aimed to validate the Rib Fracture Management Guideline proposed by Bemelman. From a cohort of 792 patients with multiple rib fractures, 2 sequential cohorts were selected: 48 patients who underwent SSRF and 48 patients who managed conservatively. Admission computed tomography scans and records were reviewed by an investigator blinded to the SSRF outcome. Adherence to the Bemelman guideline, revised to take account of consensus rib fracture definitions, was tested. Fifty-seven patients had multiple rib fractures only, and 39 patients also had a flail segment. Thirty-nine patients with flail segment underwent SSRF, and 18 patients were managed conservatively. Of the patients that the guideline predicted should have received surgery, 87% did. Of those that it predicted should not receive SSRF, 98% did not. The guideline displayed a sensitivity (95% confidence interval) and specificity for predicting the fixation of 0.98 (0.89-0.9995) and 0.83 (0.70-0.93), respectively. The positive and negative predictive values for surgical fixation were 0.87 (0.76-0.92) and 0.98 (0.85-0.99), respectively. The Bemelman guideline was thus a good predictor of SSRF in retrospective cohort but should be used in conjunction with clinical judgement. Further validation is indicated in a prospective study.

Determining the clinical significance of the Chest Wall Injury Society taxonomy for multiple rib fractures.

BACKGROUND: The Chest Wall Injury Society (CWIS) proposals for standardized nomenclature for multiple rib fracture (MRF) classifications were derived by international expert Delphi consensus. This study aimed to validate the CWIS taxonomy using a single-instituion clinical database. METHODS: Computed tomography (CT) scans, of 539 consecutive patients with MRFs admitted to a regional major trauma center over a 33-month period, were reviewed (blinded for clinical outcomes). Every rib fracture in every patient was assessed according to each of the CWIS criteria (the degree of displacement, characterization of the fracture line, location of each fracture, and the relationship to neighboring fractures). The clinical significance of the proposed CWIS definitions were determined from independently coded, routinely collected Hospital Episodes Statistics data. RESULTS: The radiologic aspects of 3,944 individual rib fractures were assessed. Indicators of injury severity (severe displacement greater series length, and flail segment) were positively associated with other fractures (p < 0.001), hemopneumothorax (p < 0.001), pulmonary complications (p = 0.002), adverse outcomes (p = 0.006), mechanical ventilation (p < 0.001) and prolonged hospital and intensive therapy unit length of stay (p = 0.006, p = 0.007 respectively). Four of the CWIS-proposed definitions were correlated with pulmonary complications and adverse outcomes: the categories of displacement, the definition of individual fracture characterization, the presence of a flail segment. Two definitions for which there was CWIS consensus were not correlated with clinical outcomes: the definition of a series to describe associated fractures on neighboring ribs, the inclusion of a paravertebral sector for fracture localization. CONCLUSION: The CWIS rib fracture taxonomy demonstrates clinical relevance. There were associations between the severity of category groups within three of the proposed definitions, based on the clinical outcomes observed. Clinical outcome assessment proved inconclusive for four agreed definitions. Comprehensive, multiinstitutional data collection would be required to provide validation for all the CWIS-proposed definitions. LEVELS OF EVIDENCE: Level IV.

Survival of Mini Dental Implants Used to Retain Mandibular Complete Overdentures: Systematic Review.

PURPOSE: To evaluate the survival rate of mini implants used to retain mandibular overdentures. MATERIALS AND METHODS: An electronic search, supplemented by hand searching of the references, was conducted with no time or language restriction in October 2016 and updated in October 2017. The results were reviewed independently by the two authors. All randomized controlled trials, clinical trials, observational studies, and case series were included. The primary outcome measure was implant survival (months). RESULTS: The search retrieved a combined total of 391 articles. Following screening, 17 articles were included. A total of 1,715 mini implants were assessed in 475 patients. Follow-up periods ranged from 6 to 84 months (mean: 28.24 months). There were 75 failures in total. The overall survival rate was 95.63%. The majority of patients received four implants to retain their prostheses. Most studies used a flapless surgical technique, but there were vast differences in loading protocols and retention methods. Formal meta-analysis was not conducted due to the heterogeneity between studies. CONCLUSION: Based on the findings of this systematic review, mini dental implants exhibit excellent survival rates in the short to medium term. They appear to be a reasonable alternative treatment modality to retain mandibular complete overdentures from the available evidence.

Management of proliferative verrucous leukoplakia: Justification for a conservative approach.

BACKGROUND: Proliferative verrucous leukoplakia (PVL) is a progressive, multifocal, exophytic form of leukoplakia with high rates of malignant transformation. The purpose of this study was to evaluate a cohort of patients with PVL in a single tertiary referral clinic. METHOD: Cases meeting accepted diagnostic criteria were reviewed with regard to their pathology, demographic characteristics, management, and outcomes. Human papillomavirus (HPV) testing was undertaken on a subset. RESULTS: Almost half of the 48 patients with PVL (48%; n = 23) underwent malignant transformation after a median 23.4 months. The characteristics of this cohort were similar to those previously described, but management was notably more conservative. Conservative management of PVL was used in 92% of our patients, but the clinical outcomes seem comparable with previously described cohorts in which PVL was predominantly treated by surgical excision. All HPV testing was negative. CONCLUSION: Aggressive surgical intervention in the premalignant phase of PVL may not influence the rate of malignant transformation.