Complex systems, part I: why 42 is rarely, if ever, the ultimate answer.

We describe the different categories of systems and systems thinking, and illustrate why almost all clinical interactions constitute simultaneously complex and complicated systems, so-called "wicked systems". We also discuss why they are not amenable to quantitative analysis. With the use of comparisons and illustrations we show some of the problems that reductionist metrics create, and support concerns regarding quantitative fallacy. The systematic correlation of data in medicine was one of the earliest achievements of the discipline. Recently, however, the overwhelming bias towards an evidence base, which relies almost entirely on randomised controlled trials, has created a reductionist view that often excludes important aspects of medicine and, in particular, surgery. We must now move away from thinking that is controlled by the "tyranny of metrics" to embrace complex-systems thinking, and work across disciplines. We outline the arguments for this and give clinical examples from oral and maxillofacial surgery.

The efficacy, safety and acceptability of emergency embedded Psychiatry Assessment and Planning Units: An evaluation of Psychiatry Assessment and Planning Units in close proximity to their associated emergency departments.

OBJECTIVE: To determine the efficacy, safety and acceptability as well as the patient demographics of three newly developed emergency department-embedded Psychiatric Assessment and Planning Units located in Metropolitan Melbourne at Austin, Peninsula and Eastern Health Services. METHODS: The evaluation reviewed a 12-month period of service activity from 1 September 2017 to 31 August 2018, when all three Psychiatric Assessment and Planning Units services were operational. A 12-month period from 1 September 2014 to 31 August 2015 was compared as the pre-Psychiatric Assessment and Planning Units period. Mixed qualitative and quantitative methods were used. This included semi-structured interviews of 30 Psychiatric Assessment and Planning Units patients and 30 emergency department staff (10 of each for all 3 sites), patient survey, statistical analysis of Client Management Interface data for the emergency department and related Psychiatric Assessment and Planning Units as well as audit of RISKMAN registers. RESULTS: There were 365 Austin, 567 Eastern and 791 Peninsula Psychiatric Assessment and Planning Units admissions. Psychiatric Assessment and Planning Units were generally well accepted by patients and emergency department staff, relatively safe, operating within the Key Performance Indicators with mixed effect on emergency department flow. Austin emergency department processing times improved post-Psychiatric Assessment and Planning Units (4 hours 57 minutes to 4 hours 19 minutes; p < 0.001) while deteriorating at Eastern and Peninsula. Adjustment Disorder and Depression and Borderline Personality Disorder were the most common admission diagnoses. While the Psychiatric Assessment and Planning Units had mixed utility on emergency department processing times, they appear to serve a demographic not previously accommodated in traditional emergency department psychiatry models. CONCLUSION: The emergency department-embedded Psychiatric Assessment and Planning Unit model of care appears effective on some measures, safe and acceptable to patients and staff. The Psychiatric Assessment and Planning Units seem to service a group not previously accommodated in traditional emergency psychiatry models.

Simulation-based training in maxillofacial surgery: are we going to be left behind?

Simulation is an important way both to optimise a trainee's learning time and reduce morbidity and operating time for patients. We have reviewed the current use of simulation in training for maxillofacial surgery, and provide an overview of areas of practice where it may be useful. A web-based survey of trainees' opinions of it was made in February 2018, and disseminated using the Junior and Fellows in Training group mailing lists. We also reviewed popular current simulation courses that are available. A total of 45 of the 57 trainees who replied agreed that simulation-based training would be beneficial in maxillofacial surgery, particularly with regard to maxillofacial surgical emergencies. A total of 54 of the 57 also agreed that simulation-based training would be a useful adjunct to their clinical training. However, most of the simulation-based courses available were priced beyond the budgets available to UK-based trainees for study, although funding changed in April 2018. While other surgical disciplines have adopted simulated clinical teaching and its benefits, maxillofacial surgery has limited the use of all types of formal simulation. Surgical simulation training is increasingly being used to complement the traditional surgical apprenticeship in other specialties, and ours needs to consider ways in which we can use it, given that trainees within the specialty think that it would be useful. Other specialties have shown that there is good transfer of skills from simulation to the actual clinical operating environment, and this increases satisfaction, decreases morbidity, and reduces the time required for intraoperative teaching.

Mitchell-Hoole-Kanatas (MHK) questionnaire: the first to measure patient-reported outcomes relating to problems with intimacy after diagnosis and treatment of head and neck cancer.

Patient-reported outcomes are increasingly used by clinical teams as indicators of quality when assessing treatment after a diagnosis of head and neck cancer. About a third of patients report reduced sexual interest or enjoyment after such treatment but, despite that, there is no questionnaire about intimacy that has been developed specifically for them. The aim of this study was to develop such a questionnaire, to gain an indication of the relative incidence of individual items, and to compare characteristics such as age, stage, treatment, time since treatment for an established head and neck cancer, and a health-related quality of life (QoL) measure (European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-C30 with the Head and Neck 35 module). The development of the new instrument was based on an exploratory observational study that included quantitative and qualitative methods. The qualitative element was achieved by the generation of items - from published studies, the comments of patients and carers, and a cross-sectional survey of patients with head and neck cancer who were alive and free of disease. The quantitative element comprised analysis of exploratory and confirmatory factors, internal reliability assessment (Cronbach's alpha), and a correlation analysis. Forty-two patients were included in the focus groups, and 101 patients participated in the cross-sectional survey (both male and female, in a relationship and single, age range 30-70 years for the focus group, and 62-117 in the cross-sectional survey). All treatments were included. We found that the ability to enjoy a sex life had been adversely affected in about half the sample and that this had significantly changed from before their cancer in a third. The qualitative part of the study resulted in 22 items that covered a range of domains from dry mouth and thick saliva to loss of sensation (lips, fingertips), restricted head/neck movement, fatigue, and pain. The exploratory analysis covered four domains (physical, sensation, movement, and communication) from 12 of 22 items. Cronbach's alphas ranged from 0.62 to 0.84, and the correlation analysis indicated "good fit" statistics for these domains. In terms of the EORTC QoL Questionnnaire - Head and Neck 35, the four MHK domains showed good levels of association with anticipated domains. Head and neck cancer and its associated treatments significantly adversely affect intimacy and sexuality in half the population sampled. The MHK tool may be used to identify specific issues related to intimacy in patients with a history of diagnosis and treatment of head and neck cancer. Further work is essential to identify its precise role and to help develop specific interventions.

Margins and survival in oral cancer.

In the surgical management of oral squamous cell carcinoma (SCC) we aim to resect the tumour with clear margins in all planes. The aim of this study was to identify and compare overall survival in a group of 591 patients who had resections, and to relate this to the clearance of margins at the tumour bed. We used life tables to calculate survival at one, two, three, five, and 10 years after diagnosis by margin (clear=5mm or more; close=2-5mm; and involved=less than 2mm). Kaplan-Meier curves were produced for the margins alone, which were defined as clear in 480 patients (81%), close in 63 (11%), and involved in 48 (8%). Five-year survival was 81%, 75%, and 54% for clear, close, and involved margins, respectively, which highlights the importance of clear margins for survival. There is a significant prognostic implication associated with close, and particularly with involved, margins.

Low Altitude Solar Magnetic Reconnection, Type III Solar Radio Bursts, and X-ray Emissions.

Type III solar radio bursts are the Sun's most intense and frequent nonthermal radio emissions. They involve two critical problems in astrophysics, plasma physics, and space physics: how collective processes produce nonthermal radiation and how magnetic reconnection occurs and changes magnetic energy into kinetic energy. Here magnetic reconnection events are identified definitively in Solar Dynamics Observatory UV-EUV data, with strong upward and downward pairs of jets, current sheets, and cusp-like geometries on top of time-varying magnetic loops, and strong outflows along pairs of open magnetic field lines. Type III bursts imaged by the Murchison Widefield Array and detected by the Learmonth radiospectrograph and STEREO B spacecraft are demonstrated to be in very good temporal and spatial coincidence with specific reconnection events and with bursts of X-rays detected by the RHESSI spacecraft. The reconnection sites are low, near heights of 5-10 Mm. These images and event timings provide the long-desired direct evidence that semi-relativistic electrons energized in magnetic reconnection regions produce type III radio bursts. Not all the observed reconnection events produce X-ray events or coronal or interplanetary type III bursts; thus different special conditions exist for electrons leaving reconnection regions to produce observable radio, EUV, UV, and X-ray bursts.

Making and working of a new electronic resource for patients, carers and professionals: maxfacts.uk.

Many maxillofacial patients have serious short, medium, or long-term problems, as well as having to make informed decisions about often life-changing interventions. Validated comprehensive information, at the right time and the right level for a diverse group of users (patients, carers, and professionals), is vital if patients are to make a serious contribution to their treatment. We describe the development of an online resource for this purpose. Maxfacts.uk aims to cover every aspect of oral and maxillofacial surgery and care, from neck dissection and ballistic wounds to physiotherapy and texture-modified foods. The principles of design, and the multilayered structure, interface, and functions of such a multiuser website are outlined, including accessibility and engagement. The maxfacts model and design could easily be adapted for other users with similar, complex, long-term needs.

Medial approach for minimally-invasive harvesting of a deep circumflex iliac artery flap for reconstruction of the jaw using virtual surgical planning and CAD/CAM technology.

Donor site morbidity is the most common limitation of the deep circumflex iliac artery (DCIA) flap, so the purpose of this paper is to describe a new, minimally-invasive, approach to its harvest using virtual surgical planning and CAD/CAM technology to reduce functional and aesthetic morbidity at the donor site. Virtual surgical planning was based on preoperative computed tomographic data. A newly-designed surgical guide made using CAD/CAM technology was used to transfer the virtual surgical plan to the site of operation. This enabled us to raise a bicortical flap from the pelvis with preservation of the anterior superior iliac crest from the medial side with minimal muscular stripping. The guide, designed at slightly less than 90° to the lateral cortex, allowed the cut segment of bone to be raised medially. The new virtual surgical planning guide allowed a medial approach with reduced stripping of muscle and lower morbidity. No complications were encountered during the operation or the healing phase. Patients treated in this way had a shorter recovery period, with minimal complaints about walking or loss of profile of the hip. We conclude that virtual surgical planning can aid a minimally-invasive approach with predictable results. This allows a medial approach to the harvest of DCIA with preservation of important anatomical structures, and a reduction in donor site morbidity.

Survival after surgery for oral cancer: a 30-year experience.

Oral squamous cell carcinoma is the most common intraoral malignancy, for which we advocate radical primary resection with adjuvant treatment where indicated. The main aims of this paper are to identify the overall survival of a consecutive series of patients and to relate survival to clinical and pathological factors. Kaplan-Meier curves were produced for site, sex, TNM status, and use of postoperative radiotherapy. The data were analysed using IBM SPSS Statistics for Windows and probabilities of less than 0.05 were accepted as significant. A total of 921 patients were recorded in the database with a diagnosis of oral squamous cell carcinoma out of a total of 1958 with salivary gland conditions or other cancers of the head and neck (43.1%). The earliest date of diagnosis was 1973, and the data were censored at 31 March 2016. The database comprised 340 women (36.9%) and 581 men (63.1%). A total of 339 patients died (34.5%): 117 women (33.7%) and 222 men (65.5%). The mean (range) age at death was 73.4 (31.4-97.5) years for women and 68.7 (33.3-95.5) years for men (t (337)=3.28, p=0.001). Our overall survival was somewhat better than the 56% five-year survival reported for oral cancer in England in 2010, which may be a reflection of the treatment. This work supports the view that aggressive management may improve overall survival.

Ternary graph as a questionnaire: a new approach to assessment of quality of life?

This study was prompted by awareness of the importance of research into quality of life (QoL) for patients with diseases of the head and neck, the important part questionnaires currently play in this field, and awareness of the "questionnaire fatigue" experienced by many patients. Our multidisciplinary research group raised coincidental awareness of the widespread use of ternary graphs in the sciences, social sciences, and humanities as a graphical tool for quantitative, semiquantitative, or purely graphical characteristics of ternary mixtures. We explored how the basic properties of ternary graphs could be translated into an interactive electronic tool as an alternative to conventional questionnaires. We have described how this was done, and offered open access to an interactive ternary-graph based (self) assessment tool, specifically designed for the needs of patients with conditions of the head and neck. Finally, have we made open-source code available for those who may wish to adapt or develop the tool for further applications.

Effect of noise on tasks in operating theatres: a survey of the perceptions of healthcare staff.

Noise in the operating theatre has an adverse impact on healthcare professionals, both physically and psychologically. It can be distracting, make communication difficult, and contribute to a perceived increase in stress. Staff in theatre must deliver high quality care, and overlook noise as a potentially damaging influence. The aim of this survey was to obtain further information about the perspective of healthcare professionals on how noise can affect their practice and whether it affects their work in theatre. We distributed six closed-ended questions in the form of a Survey Monkey® questionnaire to about 50 hospitals across the UK and target groups such as medical students, the Leeds Advanced Trauma Life Support faculty group, the Court of Examiners of the Royal College of Surgeons of England, and surgical trainees sitting the Member of the Royal College of Surgeons examination. We received 519 responses of which 415 respondents (83%) thought that noise contributed to human errors. A total of 282 participants (57%) thought that the theatre was the noisiest area within the theatre suite. Both communication among staff (n=400, 80%) and concentration (n=384, 77%) were thought to be adversely affected by noise. However, 385 (78%) did not feel that music adversely affected their performance. The results provide insights into the interplay of noise and its effect on people. Although the role of music remains contentious, our results suggest that it might have a calming influence.

Leading article: how can I optimise my role as a leader within the surgical team?

Leadership is uncommonly taught formally at any level in surgical training, and is not often evaluated formally either within assessment programmes or during appraisal. Good leadership skills in oral and maxillofacial surgery (OMFS) include professionalism, technical competence, motivation, innovation, ability to communicate, resilience, and effective teaching. They also include the recognition of when and how to "follow" when appropriate. Such skills can be developed through experience, observation, and education using a framework that can include mentoring, coaching, and feedback. This review provides some guidance in how to improve leadership skills in OMFS, which we hope will to improve the quality of training and care of patients.

Leading article: Use of smartphones to pass on information about patients - what are the current issues?

Many doctors now use mobile devices such as smartphones to communicate with one another about their patients, and sometimes this is without the knowledge and approval of their employer. We know of little information about the use of texting and other web-based messaging services by doctors in hospitals, so we reviewed relevant published studies to assess the safety and usefulness of current methods of digital communication.