Comparison of primary care doctors and dentists in the referral of oral cancer: a systematic review.

Oral cancer is referred to specialists by both general practitioners (GPs) and dentists, with varying proportions reported in different studies. However, some have noted that dentists more commonly refer oral cancer in the absence of patient-perceived symptoms and may refer at an earlier stage. Unfortunately, approximately half the UK adult population do not receive regular dental care. We have conducted a systematic review of studies that compare GPs and dentists in the referral of oral cancer and have focused on three aspects: the proportion of diagnosed oral cancers, stage on presentation, and delay. Searches of the databases Medline, Embase, Scopus, Google Scholar, Web of Science, and CINAHL, together with additional searches of reference lists, authors, and conference proceedings, found 22 studies from 10 countries, which included a total of 4953 oral cancers. The percentage of medical referrals ranged from 13% to 86%; dental referrals ranged from 15% to 80%. Random-effects meta-analysis indicated a combined relative risk of medical referral to dental referral of 1.36 (95% CI: 0.99 to 1.86). For UK-based studies, the relative risk was also 1.36 (95% CI: 1.05 to 1.76). There was considerable heterogeneity for all studies and for a subgroup of UK studies: I296.4% (95% CI 95.4 to 97.1) and 81.0% (95% CI 63.3 to 90.1), respectively. Several studies showed a lower stage for dentally-referred cancers; the combined risk for dentists and GPs referring early (stages 1 and 2) disease was 1.37 (95% CI: 1.17 to 1.60), and one cause may be the much higher number of cases referred by dentists in the absence of symptoms. No studies showed a significant difference in delay. Oral cancer is referred by both GPs and dentists, typically about 50% and 40%, respectively, although there is a wide range, probably depending on local circumstances. Both groups require skills in oral examination, recognition of lesions, and knowledge of the risk factors. Effectively, regular dental attenders are a select group that is regularly screened for oral cancer, and it is likely that screening is not delivered to those with the highest risk. We suggest that further work is required on how to access high-risk individuals both for possible screening and preventive interventions.

Audit of the two-week pathway for patients with suspected cancer of the head and neck and the influence of socioeconomic status.

Rates of head and neck cancer are high in patients with a low socioeconomic status (SES) and outcomes are often poor. The degree to which people from different socioeconomic groups use the fast-track, two-week suspected cancer referral system is, however, unclear. The aim of this audit was therefore to analyse these referrals with reference to SES, and to focus on differences in clinical characteristics, source of referral, and rates of disease. The sample included all patients who were referred to the head and neck department at an inner-city hospital in the northwest of England between July and September 2017. According to the Index of Multiple Deprivation (IMD), most (62%) of them lived in the most deprived quintile. A total of 390 referrals were analysed of which 60% were female, 53% were under 60 years of age, 33% smoked, and 69% consumed fewer than 10 units of alcohol/week. Only 24 were referred by dentists, but these accounted for almost one quarter of those referred to maxillofacial surgery. Common symptoms included a swelling or lump (n=153, 39%), hoarseness (n=101, 26%), ulcer (n=29, 7%), and sore throat (n=23, 6%). Forty-five per cent were referred with other symptoms. A total of 28 (7%) were diagnosed with cancer of the head and neck. Rates were higher in patients referred by dentists (p=0.02) and in those who drank more alcohol (p=0.02). The positive predictive value was higher in the least deprived (17%) than in the most deprived (6%). In primary care, more education that is aimed specifically at people of lower SES might reduce the number of "worried well" and lessen the pressure on departments to achieve the two-week target.

Referrals for head and neck cancer in England and The Netherlands: an international qualitative study of the views of secondary-care surgical specialists.

One-year survival after head and neck cancer in England has been reported to be worse than that in Europe, despite five-year conditional survival being similar, which implies that patients present later in England. One country with better rates is The Netherlands. There are many possible causes, one of which may be the system of referral from primary to secondary care. We have compared the views of secondary care specialists in the two countries about their systems for referral, and identified aspects that might have an impact on outcomes. We organised semistructured qualitative interviews of surgical specialists in head and neck cancer in England and The Netherlands (n=12 in each). The most common theme was communication between primary care and specialists. Surgeons in England identified this as the aspect most lacking under the English "two-week" rule, while Dutch specialists felt that the good communication in their system was one of its best points. Other themes included the educational needs of primary care practitioners, criticism of "tick box" referrals in England, and too many patients referred who do not have cancer. Overall, specialists in both countries identified good aspects of their respective referral systems, but those in England felt strongly that the "two-week" rule/NICE guidance system could be improved with better direct communication between primary and secondary care, which might improve the speed and quality of referrals, reduce unnecessary ones, and assist in educating primary care physicians. It is not clear whether such improvements would improve survival, but further research and piloting of such a system should be considered in England.

Registered Replication Report: Schooler and Engstler-Schooler (1990).

Trying to remember something now typically improves your ability to remember it later. However, after watching a video of a simulated bank robbery, participants who verbally described the robber were 25% worse at identifying the robber in a lineup than were participants who instead listed U.S. states and capitals-this has been termed the "verbal overshadowing" effect (Schooler & Engstler-Schooler, 1990). More recent studies suggested that this effect might be substantially smaller than first reported. Given uncertainty about the effect size, the influence of this finding in the memory literature, and its practical importance for police procedures, we conducted two collections of preregistered direct replications (RRR1 and RRR2) that differed only in the order of the description task and a filler task. In RRR1, when the description task immediately followed the robbery, participants who provided a description were 4% less likely to select the robber than were those in the control condition. In RRR2, when the description was delayed by 20 min, they were 16% less likely to select the robber. These findings reveal a robust verbal overshadowing effect that is strongly influenced by the relative timing of the tasks. The discussion considers further implications of these replications for our understanding of verbal overshadowing.

Effect of induction dose, lactation stage and body condition on tiletamine-zolazepam anaesthesia in adult female grey seals (Halichoerus grypus) under field conditions.

Tiletamine-zolazepam (TZ) was used at a mean (sd) dose of 1.18 (0.15) mg/kg administered intramuscularly to anaesthetise adult female grey seals (Halichoerus grypus) under field conditions at three different stages during their lactation period. A significant correlation was observed between the induction dose and time to induction (r=-0.582, P=0.011). Stage of lactation had a significant effect on condition index (CI), calculated as axial girth divided by length (P<0.001), and time to induction (P=0.009). No effect of CI on induction or recovery time was demonstrated. Respiratory rate decreased during induction and increased significantly (P<0.001) during surgical biopsy of blubber. Recovery occurred after 32.5 (11.9) minutes. Minor complications (tremor, vocalisation and mild dyspnoea) were observed in a small number of cases, none of which required treatment.

Bisphosphonate induced osteochemonecrosis of the jaw mimicking a tumour.

Osteonecrosis has been well-documented in the past. We present an example of this complication that we recently saw in our department which on initial presentation appeared to be squamous cell carcinoma. This case is particularly important as the condition will become more and more prevalent and therefore it is imperative that GDPs in primary care are aware of it.

Estimating the rate of poisoning by insecticide-treated seeds in a bird population.

Poisonings of granivorous birds by cereal seed treatments have been reported in the UK, but the true frequency of poisonings is unknown. We aimed to measure the rate of mortality due to poisoning by seed treatments in woodpigeons (Columba palumbus) in an area of East Anglian farmland where the risk from these compounds appeared high. Woodpigeons were fitted with temperature-sensing radio-tags and monitored daily during the winters of 1994/95 and 1995/96. Birds' deaths were detected and attempts made to retrieve carcasses for post-mortem examination including, where possible, analysis for pesticide residues. Ninety-one woodpigeons were monitored. Eleven birds died, but the causes of their deaths were uncertain: one contained a low residue of insecticide and in the other ten cases, no carcass was recovered, so no analysis was possible. Therefore, the number poisoned by pesticides could lie anywhere between zero and eleven. During 1994/95, estimated mortality ranged from 0% to 52%, depending on how many (if any) of the 11 casualties were poisoned. During 1995/96 there were no casualties. Using conservative diagnostic rules for classifying birds as poisoned by OP seed treatments, no link was found between the availability of treated fields in the study area and the rate of poisonings, and there were no significant differences between the two study years. For reasons discussed in the paper, true mortality resulting from exposure to insecticide seed treatments was considered likely to lie in the range 0-5%.

Telemedicine in oral surgery and maxillofacial trauma: a descriptive account.

Trauma patients presenting to emergency rooms (ER) in rural or remote locations have significantly less access to oral and maxillo-facial surgery (OMFS) specialists. In this case, OMFS services at four hospitals were rearranged to concentrate expertise, inpatients, and 24/7 cover on a single site. A Federation (managed clinical network) model was used that improved the management of inpatients and made better use of a small team of junior medical staff. New government standards limiting the on-call burden for U.K. junior doctors (The New deal) were met under this service model. Despite the success of the Federation, the loss of on-site OMFS support to the three peripheral ER departments was problematic. Sites that do not have OMFS support used a simple telephone referral to transfer patients to the OMFS center. The degree to which referrals were considered inappropriate led to operational and patient satisfaction difficulties. The introduction of an OMFS telemedicine system linking the three peripheral/"spoke" ER departments to the OMFS center/"hub" succeeded in increasing the appropriateness of patient transfers, developed the skills of the ER medical staff, and was believed to have led to an overall improvement in the early-stage management of this group of patients. The telemedicine system augmented the overall success of the Federation model. New uses for telemedicine within the OMFS service soon developed.

Analysing collaborative trials for qualitative microbiological methods: accordance and concordance.

In qualitative (detection) food microbiology, the usual measures of repeatability and reproducibility are inapplicable. For such studies, we introduce two new measures: accordance for within laboratory agreement and concordance for between laboratory agreement, and discuss their properties. These measures are based on the probability of finding the same test results for identical test materials within and between laboratories, respectively. The concordance odds ratio is introduced to present their relationship. A method to test whether accordance differs from concordance is discussed.

Occult lymph node metastases posterior to the internal jugular vein.

Supraomohyoid neck dissection is a reliable staging procedure in patients with oral or oropharyngeal squamous cell carcinoma and no clinical evidence of node metastases. We have recorded the yield and distribution of occult lymph node metastases in the fibro-fatty strip of tissue posterior to the internal jugular vein and beneath the sternomastoid in 35 neck dissections. Occult lymph node metastases were found in 12/35 (34%); 3 of these had metastases in the posterior strip, which were never in isolation. We think that it is worthwhile to sample the posterior strip. Firstly it removes tumour that would have been left behind in a small number of cases had a conventional supraomohyoid neck dissection been done, and secondly it enables postoperative radiotherapy to be targeted at the anterior triangle alone when the posterior strip is clear of tumour.

Recurrent neck disease in oral cancer.

PURPOSE: The goals were to examine the clinical and pathologic features of patients who developed metastatic squamous cell carcinoma in the cervical lymph nodes after initial treatment and to identify any common patterns. PATIENTS AND METHODS: A retrospective analysis of 35 patients of varying initial tumor stage was performed. There were 18 patients who had an initial neck dissection and 17 patients whose neck was managed by a "watch and wait" policy. RESULTS: Recurrence frequently involved level II nodes, and extracapsular spread was invariably present. The time taken for recurrence to develop was the same in both groups of patients (15 months, P =.35), and the overall median survival time after recurrence was 18 months (12 to 25 months, 95% confidence interval). In 27 of 29 patients (93%) who had the primary tumor resected, the thickness of tumor was greater than 5 mm. CONCLUSION: Neck recurrence may represent residual disease; it has histologically unfavorable features and consequently a poor prognosis. The frequency of recurrence at level II emphasizes the need for meticulous dissection in this region, and tumor thickness needs to be considered in planning treatment of the clinically negative neck.

The estimation of density dependence using census data from several sites.

The discussion of density dependence in the ecological literature has tended to concentrate on significance testing, whereas estimation is often of more importance. In this paper we use simulation to investigate the bias and precision of a number of methods for estimating density dependence using census data from several sites. The estimation methods examined were a modification of an existing maximum likelihood approach, a regression method, and a new approach using restricted (or residual) maximum likelihood (REML). Simulations indicated that the REML method produced the most accurate estimates, with negligible bias for most parameter combinations. A further advantage of the REML method is that it can be easily implemented using standard statistical software. Using a second series of simulations we investigated the relationship between accuracy of estimation and sample size for the REML method. The results indicated that using more than one site gave substantial improvement in accuracy, but that using more than five sites gave little further improvement unless in excess of 10 years of data were available for each site. Where a standard error is required for the density dependence estimate we suggest using bootstrapping at the site level. Where this is not possible, a parametric bootstrap or a randomisation test may be used instead. The REML method is demonstrated using bag totals of red-legged partridges Alectoris rufa and grey partridges Perdix perdix for shoots on estates in East Anglia in the United Kingdom. This paper shows that combining information from several sites can give improved estimation of density dependence, particularly if REML estimation is adopted.

Opposing offspring sex ratio variations with increasing age and weight in mouflon mothers (Ovis musimon).

There are two main theories explaining offspring sex biases in polygynous mammals. Trivers and Willard (1973) argue that mothers with greater reproductive resources should invest in the sex with the greater variance in reproductive success, usually sons. In contrast, because daughters in many polygynous mammals stay with their mother and compete with her for food, Local Resource Competition theory (e.g. Clark, 1978; Silk, 1983) predicts that the mothers with the greatest reproductive resources should invest in daughters. We investigated the strategy of sex allocation of a captive, outdoor population of 139 mouflon mothers, Ovis musimon, kept in a game state. A complex picture emerged in which, despite weight and body condition being correlated with age in female mouflons, mothers lambed more daughters with increasing age but also, within a given age, gave birth to more sons with increasing weight. Results may be useful in game management aimed at increasing the recruitment or quality of males in managed populations.

Survival of poliovirus on soft fruit and salad vegetables.

A series of studies were performed, using poliovirus, to ascertain the potential for enteric pathogenic viruses to survive on various foodstuffs. The extraction protocols, which could be performed in just a few hours, were developed for use with quantities of food that would normally constitute a portion for consumption. The protocols were based on elution of viruses from food surfaces, followed by differential centrifugation to remove food debris and concentrate viruses. The studies were mostly performed using fresh produce stored at refrigeration temperature for 2 weeks or so, which was considered to represent the maximum time elapsing between purchase and consumption. Each food sample was inoculated with a viral suspension, and samples were analyzed immediately and at intervals throughout the experiment. Statistical analyses were performed on the results, and the decimal reduction times (D-values), or number of days after which the initial virus numbers had declined by 90%, were calculated. In summary, the resulting D-values were as follows: lettuce, 11.6 days; green onion, no decline; white cabbage, 14.2 days; fresh raspberries, no decline; and frozen strawberries, 8.4 days. The results showed that enteric viruses may persist on fresh fruit and vegetables for several days under conditions commonly used for storage in households. Therefore, if contamination has occurred before purchase, there will always be a risk of infection from consumption of the food.

Validation of ISO method 11290 part 1--detection of Listeria monocytogenes in foods.

The European and International Standard method for the detection of Listeria monocytogenes, described in EN ISO 11290 Part 1: 1997 (International Organisation for Standardisation, Geneva) was validated by order of the European Commission (Standards, Measurement and Testing Fourth Framework Programme Project SMT4-CT96-2098). Nineteen laboratories in 14 countries in Europe participated in a collaborative trial to determine the performance characteristics of the method, which are intended for publication in the corresponding standard. An additional objective of this project was to devise a new series of parameters to indicate the 'precision' of microbiological qualitative methods. The method was challenged with three food types, namely fresh cheese, minced beef and dried egg powder and a reference material. Inoculation levels ranged from 5 to 100 cfu/25 g. Each participant examined five replicates of each food type at three inoculum levels and five reference materials. Both PALCAM and Oxford media were assessed. All test materials were subjected to stringent homogeneity and stability testing before being used in the collaborative trial. The results demonstrated that the method prescribed in EN ISO 11290-1 had an overall sensitivity of 85.6% and a specificity of 97.4%. L. monocytogenes was detected in most cases after primary enrichment, although secondary enrichment often yielded further positives. However, a significant number of false-negative results were obtained with all food types when large numbers of L. innocua were present in the test materials. L. innocua tended to dominate L. monocytogenes during the selective enrichment stages and thus masked small numbers of colonies of L. monocytogenes on the isolation media. There was no evidence from this collaborative study to demonstrate a significant difference in performance between Oxford and PALCAM media. Due to the problem of false-negative results with this method as highlighted in this trial, recommendations have been made to ISO to launch a revision of the standard to improve the detection of low numbers of L. monocytogenes in foods. New statistical methods devised to advance the measurement of the performance of qualitative microbiological methods are also described.

Validation of ISO method 11290 part 2. Enumeration of Listeria monocytogenes in foods.

The European and International Standard method for the enumeration of Listeria monocytogenes, described in EN ISO 11290 Part 2: 1998 [EN ISO 11290-2 Microbiology of Food and Animal Feedingstuffs-Horizontal Method for the Detection and Enumeration of L. monocytogenes: Part 2. Enumeration; International Organisation for Standardisation, Geneva.] was validated by order of the European Commission (Standards, Measurement and Testing Fourth Framework Programme Project SMT4-CT96-2098). The objective was to determine the precision of the method in terms of repeatability (r) and reproducibility (R) using three different food types inoculated with various levels of L. monocytogenes and a typical background flora. The results are intended for publication in the associated standards. Cheese, meat, dried egg powder and reference materials were examined by 21 laboratories in 16 countries in Europe. Each participant received eight test materials per food type: blind duplicates at four inoculum levels (0, 10(2), 10(3), 10(4) cfu/g). In addition, two reference materials containing L. monocytogenes were included in the study. All test materials were subjected to stringent homogeneity and stability testing before being used in the collaborative trial. Participants were required to use only PALCAM agar for enumeration of L. monocytogenes, as prescribed by the reference method. Statistical analyses has been performed using a newly introduced approach for food microbiology (draft standard prEN ISO 16140 [prEN ISO 16140 Microbiology of Food and Animal Feedingstuffs-Protocol for the Validation of Alternative Methods, International Organisation for Standardisation, Geneva.], the precision data being calculated using robust estimates. Overall values for repeatability (r) of EN ISO 11290-2 when used with food test materials were r = log10 0.58 (expressed as an absolute difference between log10-transformed test results) or r = 3.8 (expressed as an absolute ratio between test results on the normal scale). For the reference materials (capsules containing approximately 5000 cfu), r = log10 0.34 (expressed as an absolute difference between log10-transformed test results) or r = 2.2 (expressed as an absolute ratio between test results on the normal scale). Overall values for reproducibility (R) of EN ISO 11290-2 when used with food test materials were R = log10 0.81 (expressed as a difference between log10-transformed test results) or R = 6.5 (expressed as an absolute ratio between test results on the normal scale). For the reference materials, R = log10 0.51 (expressed as a difference between log10-transformed test results) or R = 3.2 (expressed as an absolute ratio between test results on the normal scale). Further studies have been initiated by ISO TC34/SC9 to try to enhance the isolation of L. monocytogenes from foods and improve the confirmation procedures.