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The incidence of metastases following neck dissection in the apparent lymph node negative neck in oral cancer is between 7% and 33%; early resection of cervical metastases may well increase survival. Modern imaging techniques can reduce the yield of previously undiagnosed metastatic nodes in elective neck dissection (END). An audit of 112 consecutive cases was conducted to determine the proportion of undiagnosed nodal metastases, after END. There were neck metastases in 10 cases (9%), which were mainly (but not all) micrometastic. The 20% likelihood of nodal metastases was only apparent in primary tumours greater than 6 mm thick. The length of inpatient stay was increased from 3.7 to 16.5 days with free vascularised transfer. There were complications including cranial nerve damage. There were two peri-operative deaths. No ipsilateral neck failures occurred, median follow up was 937 days. To reduce unnecessary END, resection can be undertaken as a prior procedure, subsequently only carrying out END on tumours greater than 6 mm, or with unfavourable tumour characteristics.

Salivary gland tumours present a pleomorphic and complex morphology and, apart from the most common neoplasms with well-established histopathological criteria, may create diagnostic difficulty for histopathologists. The majority of salivary gland tumours occur in the parotid gland and the use of ultrasound guided parotid biopsy (US-PB) has increased. US-PB in contrast with fine needle aspiration (FNA), which is an easy and relatively painless technique, is performed under local anaesthesia, usually by radiologists. US-PB offers some advantages over the FNA such as tumour grading and the possibility of performing immunohistochemistry. We report our experience of the diagnostic value of US-PB in a large, referral centre in the United Kingdom.

BACKGROUND In the UK, core surgical training (CST) is the first specialty experience that early-career surgeons receive but training differs significantly across CST deaneries. To identify the impact these differences have on trainee performance, we assessed whether success at the Membership of the Royal College of Surgeons (MRCS) examinations is associated with CST deanery. METHODS A retrospective cohort study of UK trainees in CST who attempted MRCS between 2014 and 2020 (n = 1104). Chi-squared tests examined associations between locality and first-attempt MRCS performance. Multivariate logistic regression models identified the likelihood of MRCS success depending on CST deanery. RESULTS MRCS Part A and Part B pass rates were associated with CST deanery (p

Females are under-represented in surgery, including in leadership roles within academia. The Royal College of Surgeons of England and British Association of Oral and Maxillofacial Surgery (BAOMS) have both initiated programmes aiming to promote equality, diversity and inclusion in gender representation. This article quantifies the gender representation amongst editorial boards of oral and maxillofacial journals and further reinforces that there is more work to be done to promote gender parity.

In 2008, to create a rapid route for information transfer in relation training and recruitment for OMFS trainees, the British Association of Oral and Maxillofacial Surgeons (BAOMS) created a website to "Register Your Interest in OMFS" (RYIO). From 2011 a Mentoring and Support Programme (MSP) was created to provide focussed guidance for trainees aiming for specialty training. This paper reviews the effectiveness and cost of these programmes. Between 2008 and 2020, 1744 individuals used RYIO on 2715 occasions. Of these registrations, 1772 were by dentists, 193 dental students, 589 doctors and 161 medical students. 2354 were from UK and Ireland and 351 from the rest of the world. 188 registrants subsequently became UK OMFS trainees or specialists. All registrants valued the information provided. In response to RYIO trainee feedback the new ‘Taste of OMFS 2020’ programme was created. The MSP was originally called the Junior Trainee Programme (JTP). The MSP scheme provides a layer of mentorship/support which runs parallel to the medical/dental training post or period of study. Of 180 members of MSP, 72 have obtained specialty training posts in OMFS. There are 88 current members. Full information is available on the BAOMS website www.baoms.org.uk . Reviewing both programmes, participant feedback is excellent with tangible results whilst cost effectiveness is high.

Background CD30 is variably expressed in diffuse large B cell lymphoma (DLBCL), but its prognostic potential for the affected patients remains debatable and unclear. Therefore, we aimed to determine the frequency of CD30 expression in DLBCL and its potential for prognostic determination. Methods An electronic systematic review was performed using multiple databases, followed by a quantitative meta-analysis to assess the frequency of CD30 expression with a positivity cut-off values of > 0% and > 20%, and to determine its association with clinicopathological features and patients' survival. Results Using a cut-off value > 0%, we observed that 3.5% to 59.1% of the cases were considered positive for CD30. There was a significant association of the protein expression with a lower number of extra-nodal sites affected by the neoplasm, with Ann Arbor advanced stage, the absence of B-symptoms, the lack of MYC and BCL2 translocations, and a lower ECOG performance. Using a cut-off value > 20%, we observed that 2.5% to 36.7% of the cases were considered positive for CD30, being significantly associated with a lower number of extra-nodal sites affected by the neoplasm, Ann-Arbor stages III/IV, non-GCB tumors, the lack of MYC and BCL2 translocations, and a lower ECOG value. CD30 expression was significantly associated with a better survival rate, regardless of what cut-off parameter was used. Conclusion Despite variations in the cut-off values used to determine CD30 positivity in DLBCL, the expression of this protein seems to be associated with a higher survival rate and better prognosis.

Over the decades we have witnessed legal cases influencing the government to develop the statutory duty of candour (DoC) in the medical profession. A duty that for a long time existed only in tort (civil) law. The purpose of the statutory DoC is understandingly important. For the public it simply reinforces an ethical duty already enforced by most professional regulators. For the medical profession, it is rather complex in ways that the courts can interpret and use it leaving uncertain legal ramifications for doctors. In this chapter, we explore the law in relevance with DoC in the United Kingdom, and the limitations and controversies around it for a better clarification and understanding. For organizations, we advocate the avoidance of bureaucracy in the DoC process and consideration of human factors before a regulatory response that avoids the fear of penalties, litigation and defensive practice among doctors undermining the development of culture of DoC. For the legal profession, is it time to change their outlook, where they are most able to support process of DoC and avoid the use of open disclosures to support a case of clinical negligence and its legal ramifications for doctors?

Tumour metastasis is one of the leading cause of cancer-related mortality. Circulating tumour cells (CTCs) have been implicated in loco-regional and distant metastasis and its role is being extensively studied in various malignancies, including those from the head and neck region. The main challenge in understanding their significance lies in the rarity of these cells in the blood. However, newer technologies have attempted to overcome these pitfalls. This review explores the evolution of CTC research and other related areas, including its biological significance, sustainability within the circulating vascular environment and possible clinical implications.

Oral cancer is easily detectable by physical (self) examination. However, many cases of oral cancer are detected late, which causes unnecessary morbidity and mortality. Screening of high-risk populations seems beneficial, but these populations are commonly located in regions with limited access to health care. The advent of information technology and its modern derivative artificial intelligence (AI) promises to improve oral cancer screening but to date, few efforts have been made to apply these techniques and relatively little research has been conducted to retrieve meaningful information from AI data. In this paper, we discuss the promise of AI to improve the quality and reach of oral cancer screening and its potential effect on improving mortality and unequal access to health care around the world.

Oral squamous cell carcinoma is one of the commonest head and neck malignancies with approximately 350 000 cases reported annually and a mortality rate of 50% often attributed to late clinical presentation. Due to the close relationship between saliva bio-fluid and tumour lesions, optimizing salivary biomarkers for disease detection and screening provides a major new research direction in diagnostic oral oncology. As inter-tumour heterogeneity and intra-tumour heterogeneity are common within oral cavity neoplasms, it is unlikely that a single diagnostic or "risk-stratifying" saliva biomarker will suffice for universal translation to clinical practice. Therefore, this article highlights a number of promising saliva biomarker combinations for oral cavity cancer detection that require further research and validation to determine their true diagnostic potential.

Background Salivary gland disease includes a wide range of unique and rare conditions that are treated by ear, nose and throat (ENT), oral and maxillofacial surgeons (OMFS) and oral medicine specialists. Histopathological diagnosis is pivotal to making a diagnosis and treatment planning. There is a vast range of conditions and controversies in the histopathological assessment of salivary gland diseases. Most colleagues in oral pathology and oral medicine work closely with the OMFS but might have missed some of the recent articles published by the speciality. Methods We reviewed articles thought to be relevant to oral medicine and pathology specialists published over an 8-year period between 2012 and 2019 in the leading British Journal of Oral and Maxillofacial Surgery (BJOMS). Results A total of 44 published articles relating to the histopathology of salivary glands disease were selected. Papers were published on population studies, benign and malignant tumours, sialadenitis, metastasis to the parotid gland and cytology. The publication type and numbers published were as follows: review (n = 9), meta-analysis/randomised controlled study (n = 1), retrospective study (n = 10) and case report/technical notes (n = 23). Conclusions The greatest proportion of publications published in BJOMS were case reports. This emphasises the paucity of consensus and the need for development in this field. Salivary gland disease remains an area with many controversies and would benefit from further research.

Completion of the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination is a prerequisite for completion of specialty surgical training in UK. The aim of this study was to compare MRCS performance of OMFS trainees to trainees in other specialities over the past 13 years. Differential attainment (DA) was noted in MRCS Part A (MCQ) pass rates. There was no statistically significant difference in MRCS Part B pass rates. The reasons for this DA are currently unknown and require further investigation. It has been suggested that this may be due at least in part to competing time, family and financial obligations, which increase over time.

ObjectiveOver many decades, studies on histopathological features have not only presented high-level evidence of contribution for treatment directions and prognosis of oral squamous cell carcinoma (OSCC) but also provided inconsistencies, making clinical application difficult. The 8th TNM staging system of OSCC has acknowledged the importance of some histopathological features, by incorporating depth of invasion (DOI) to T category and extranodal extension (ENE) to N category. The aim of this systematic review with meta-analysis is to determine the most clinically relevant histopathological features for risk assessment and treatment planning of OSCC and to elucidate gaps in the literature.MethodsA systematic review was conducted using PRISMA guidelines, and the eligibility criteria were based on population, exposure, comparison, outcome, and study type (PECOS). PubMed, Cochrane, Scopus, and Web of Science were searched for articles exploring the impact of histopathological features on OSCC outcomes with Cox multivariate analysis. Pooled data were subjected to an inverse variance method with random effects or fixed effect model, and the risk of bias was evaluated using quality in prognosis studies (QUIPS). Quality of evidence was assessed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.ResultsThe study included 172 articles published from 1999 to 2021. Meta-analyses confirmed the prognostic potential of DOI, ENE, perineural invasion, lymphovascular invasion, and involvement of the surgical margins and brought promising results for the association of bone invasion, tumor thickness, and pattern of invasion with increased risk for poor survival. Although with a small number of studies, the results also revealed a clinical significance of tumor budding and tumor-stroma ratio on predicted survival of patients with OSCC. Most of the studies were considered with low or moderate risk of bias, and the certainty in evidence varied from very low to high.ConclusionOur results confirm the potential prognostic usefulness of many histopathological features and highlight the promising results of others; however, further studies are advised to apply consistent designs, filling in the literature gaps to the pertinence of histopathological markers for OSCC prognosis.Systematic Review RegistrationInternational Prospective Register of Systematic Reviews (PROSPERO), identifier CRD42020219630.

Mistakes will always happen whether at work or in our personal lives. We can never completely eliminate error, but learning and disseminating lessons from these mistakes to others is essential. Human factors application for colleagues in healthcare, particularly in low- and medium-income countries (LMIC) can greatly improve patient safety and aid better team working and staff morale. Factors such as hunger, dehydration anger, and tiredness, all reduce personal performance and can raise the risk of personal error. It is vital that we understand and optimize interaction within the healthcare team members. As part of this, ineffective communication, steep hierarchy and loss of situational awareness can lead to compromised patient safety and potentially serious error. In this paper, we provide a brief overview of human factors for healthcare colleagues in LMIC. We highlight ways to reduce the chances of error and improve patient safety by recognizing and applying various human factors to our day to day practices.

Superficial parotidectomy has been the gold standard for surgical removal of benign mobile parotid gland tumours. The comparatively newer technique of extracapsular dissection, which involves careful dissection of the tumour itself without the need for formal gland excision, has gained popularity in recent years. Tumours can be removed via smaller incision, and the technique reduces the risk of Frey's syndrome (gustatory sweating) and hollowing at the site of surgery. The risk of facial nerve damage can also be lower with extracapsular dissection. If done carefully, the incidence of tumour recurrence, particularly for pleomorphic adenomas, is comparable with formal parotidectomy. We provide a brief update overview of the current evidence for extracapsular dissection in the treatment of benign parotid tumours and include several meta-analyses which provide evidence for the safety of the technique. We have also included our audited results of over 100 recent extracapsular dissections, with 0% incidence of permanent facial nerve weakness, reported Frey's syndrome and recurrence rates over the last 5 years.

The aim of this study was to assess the extent of cortical perforation in millimetres (mm) in inferior alveolar nerve (IAN) canal on coronal section of cone beam computed tomography (CBCT) to predict IAN injury in high risk patients. We also analysed relation of position of canal and number of roots with likelihood injury to IAN. We conducted a prospective clinical study of 100 high risk patients in which 78 patients had cortical perforation which was verified by CBCT. 13/78 of 3rd molars were associated with IAN injury at 1 month post extraction. Out of those, only 3 had a permanent decrease in sensation and remaining 10 had temporary paraesthesia. Owing to the large number of patients with cortical defects, we further sub-categorised them into five groups based on cortical perforation: Type 1 – No involvement, Type 2–1 - 3 mm, Type 3–4 - 6 mm, Type 4–7 - 9 mm, Type 5 – more than 9 mm. All of the 8 patients who had more than 6 mm (Type 4 and Type 5) had some sensory disturbance whereas no IAN injury was found in patients of type 1 and type 2. There were 5/23 who had nerve injury in type 3. The association between cortical perforation and IAN injury was statistically significant (p

Aims Identifying predictors of success in post-graduate examinations can help guide the career choices of medical students and may aid early identification of trainees requiring extra support to progress in specialty training. We assessed whether performance at medical school as quantified by the Educational Performance Measurement (EPM) and scores from the Situational Judgement Test (SJT) used for selection into Foundation Training predicted success at the Membership of the Royal College of Surgeons (MRCS) examination. Methods We analysed data from the UKMED Database for UK graduates who had attempted MRCS Part A (n = 1,975) and Part B n = 630) between 2013-2017. Univariate analysis examined the relationship between performance and the likelihood of passing MRCS at first-attempt. Logistic regression identified independent predictors of MRCS success. Results For every additional EPM decile point gained the chances of passing MRCS at first attempt increased by 52% for Part A (odds ratio 1.52 [95% confidence interval (CI) 1.46-1.60]) and 27% for Part B (1.27 [1.18-1.38]). For every point awarded for additional degrees in the EPM, candidates were 29% more likely to pass MRCS Part A first time (1.29 [1.12-1.48]). SJT score was not a statistically significant independent predictor of MRCS Part A or Part B success after adjusting for sociodemographic factors (P = 0.182 and P = 0.125 respectively). Conclusions This, the first study to investigate the relationship between medical school and success at a high stakes UK postgraduate surgical examination found that medical school performance deciles are the most significant measure of predicting later success in the MRCS.

Aims Selection into UK medical school involves a combination of three measures: prior academic attainment, selection tests (e.g. the University Clinical Aptitude Test (UCAT), Biomedical Admissions Test (BMAT), or Graduate Medical School Admissions Test (GAMSAT)) followed by interview. We investigated the predictive power of current UK medical selection tests and measures of prior attainment on success in the Membership of the Royal College of Surgeons (MRCS) examination. Methods The UKMED database was used to analyse A-Levels and medical school selection data for all UK graduates who attempted the MRCS Part A written examination (n = 9729) and Part B clinical examination (n = 4644) between 2007 and 2017. Univariate analysis and Pearson correlation coefficients examined the relationship between selection scores and first attempt MRCS success. Results Successful MRCS Part A candidates scored higher in A-Levels, UCAT, BMAT and GAMSAT examinations (p Conclusions This, the first study to investigate the relationship between all UK medical school selection tests and success in a postgraduate examination found statistically significant correlations between selection test scores and performance on Part A of the MRCS. The strength of correlations found in this study are similar to those of other validated selection tests used in the United States.

Aims Successful completion of the MRCS examination is mandatory for progression into higher surgical (registrar) training in the UK. National selection for training programmes is a highly competitive process. Despite this, the ranking of applicants does not currently include MRCS performance scores. This offers a unique opportunity to compare two independent assessments of surgical trainees to establish whether MRCS performance can predict future surgical career outcomes and competitiveness in training. Methods All UK candidates who attempted MRCS between 2007-2020 were matched to career outcome data using the GMC list of registered medical practitioners and anonymised (n = 2910). Chi-squared tests determined associations with first attempt MRCS pass/fail outcomes. Multinomial regression models were developed to establish the predictive power of success at MRCS in determining surgical specialty and training deanery choices. Results There was statistically significant variability in MRCS Part A pass rates, ranging from 55.1%-76.7% between surgical specialties (P = 0.001) but no significant variability in Part B pass rates (P = 0.655). There was significant variability in Part A and Part B pass rates between training deaneries (P = 0.010 and P = 0.036 respectively). Pass rates ranged from 59.9%-77.7% for Part A and 70.1%-85.0% for Part B between training deaneries. Those in more competitive specialties and training deaneries performed better in MRCS in terms of first attempt pass rate, scores and number of attempts taken to pass. Conclusion MRCS performance is an early predictor of surgical career choice and competitiveness. Trainees who perform well at MRCS are more likely to enter competitive surgical specialties and training deaneries.

Aims To describe the impact of the COVID-19 pandemic on the well-being of surgeons and allied health professionals across the world and assess the support provided by their institutions. Methods An online survey was distributed through medical organisations, social media platforms and collaborators from the 15th of July to the 15th of December 2020. Results 1590 responses were received. 80.0% were surgeons, 6.4% nurses, 5.3% assistants, 3.1% anaesthetists, 1.4% operating department practitioners and 3.8% classed as other. Of participants, 64.0% had found difficulty gaining access to personal protective equipment (PPE), 29.8% had not received training on its use and 32.0% had become physically ill since the start of the pandemic (59.9% of which were due to COVID-19 symptoms). 29.0% saw a decrease in salary and 35.2% a decrease in time spent with family. Between a time two weeks before the start of the pandemic and after, there was a significant increase in mean scores for depression (4.22 (CI = 3.98-4.46)) and anxiety (2.24 (CI = 2.01-2.46)), based on the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder Assessment (GAD-7) respectively (p Conclusions This work has highlighted a need and ways in which to improve conditions for the health workforce. This will inevitably have a positive effect on the care received by patients.

Aims UK medical schools vary in their mission, curricula and pedagogy, but little is known of the effect of this on postgraduate examination performance. We explored differences in outcomes at the Membership of the Royal College of Surgeons examination (MRCS) between medical schools, course types, national ranking and candidate sociodemographic factors. Methods A retrospective longitudinal study of all UK medical graduates who attempted MRCS Part A (n = 9730) and MRCS Part B (n = 4645) between 2007 and 2017, utilising the UK Medical Education Database (https://www.ukmed.ac.uk). We examined the relationship between medical school and success at first attempt of the MRCS using univariate analysis. Logistic regression modelling was used to identify independent predictors of MRCS success. Results MRCS pass rates differed significantly between medical schools (P Conclusion Medical school, course type and socio-demographic factors are associated with success on the MRCS. This information will help to identify surgical trainees at risk of failing the MRCS in order for schools of surgery to redistribute resources to those in need.

Background This paper is a synopsis of the Crispian Scully Lecture, presented by one of the authors (PAB), at the 2021 European Association of Oral Medicine (EAOM) Conference in Lisbon, Portugal. It provides an overview of human factors that affect individuals and teams, highlighting ways to reduce the chances of error and improve patient safety. Discussion and conclusion Error is an inevitable and 'normal' part of being human, and it can never be completely eliminated, though learning from mistakes is essential. Human factor application in health care can greatly improve patient safety and lead to better team working and staff morale. Personal factors including tiredness, hunger, dehydration and stress can all reduce performance and raise the risk of clinical error. It is also important to understand and optimise interaction within the clinical team. Poor communication, steep hierarchy and loss of situational awareness can all potentially compromise patient safety.

Aim Fitness to practice (FtP) investigations by the General Medical Council (GMC) can be one of the most stressful experiences in a surgeon’s career. Demographic factors are known to alter the likelihood of GMC investigation. Despite this there are no studies assessing risk factors in surgeons for FtP sanctions. Thus, we used the newly created Intercollegiate Membership of Royal College of Surgeons (MRCS) examination database to identify risk factors for and the prevalence of GMC sanctions in early-career surgeons. Method FtP sanction data contained in the GMC list of registered medical practitioners (LRMP) database was linked at person-level to all UK graduates who had attempted MRCS Part A or Part B between September 2007 and January 2020. Data were anonymised by the Royal College of Surgeons of England prior to analysis. Results f 11,660 candidates who had attempted the MRCS within the study period only 31 (0.3%) candidates had GMC FtP sanctions within the last two years. Of these, 12 had active conditions on their registration, 7 had active undertakings and 14 had warnings. Candidate demographics were similar between cohorts and there were no significant differences between MRCS performance identified. Conclusions In this, the largest study of MRCS candidates to date, the prevalence of active FtP sanctions in early-career surgeons was 0.3%, significantly lower than the prevalence of sanctions across more experienced UK surgeons (0.9%). These data highlight early-career surgeons as a low-risk group for disciplinary action and should reassure patients and medical professionals of the rarity of FtP sanctions.

BackgroundIdentifying predictors of success in postgraduate examinations can help guide the career choices of medical students and may aid early identification of trainees requiring extra support to progress in specialty training. We assessed whether performance on the educational performance measurement (EPM) and situational judgement test (SJT) used for selection into foundation training predicted success at the Membership of the Royal College of Surgeons (MRCS) examination.MethodsThis was a longitudinal, cohort study using data from the UK Medical Education Database (https://www.ukmed.ac.uk). UK medical graduates who had attempted Part A (n=2585) and Part B (n=755) of the MRCS between 2014 and 2017 were included. χ2 and independent t-tests were used to examine the relationship between medical school performance and sociodemographic factors with first-attempt success at MRCS Part A and B. Multivariate logistic regression was employed to identify independent predictors of MRCS performance.ResultsThe odds of passing MRCS increased by 55% for Part A (OR 1.55 (95% CI 1.48 to 1.61)) and 23% for Part B (1.23 (1.14 to 1.32)) for every additional EPM decile point gained. For every point awarded for additional degrees in the EPM, candidates were 20% more likely to pass MRCS Part A (1.20 (1.13 to 1.29)) and 17% more likely to pass Part B (1.17 (1.04 to 1.33)). For every point awarded for publications in the EPM, candidates were 14% more likely to pass MRCS Part A (1.14 (1.01 to 1.28)). SJT score was not a statistically significant independent predictor of MRCS success.ConclusionThis study has demonstrated the EPM’s independent predictive power and found that medical school performance deciles are the most significant measure of predicting later success in the MRCS. These findings can be used by medical schools, training boards and workforce planners to inform evidence-based and contemporary selection and assessment strategies.

BACKGROUND Electronic cigarettes (e-cigarettes) and other electronic vaping devices are commonly used as a method to help tobacco smoking cessation. However, the data on their safety and efficacy are currently scarce. The aim of this review was to explore the role of e-cigarettes in tobacco cessation among tobacco users. TYPES OF STUDIES REVIEWED PubMed, EMBASE, Scopus, Web of Science, and grey literature from January 1990 were searched up to and including September 2018. Two independent reviewers performed the study selection according to eligibility criteria. RESULTS A total of 13 studies that met the eligibility criteria were included. The majority of studies were done in the USA, and all studies were longitudinal cohort studies. The odds of increased smoking cessation in association with e-cigarette use ranged from onefold to sixfolds. No significant increase in smoking cessation was found among e-cigarette users compared with non-e-cigarette users. Pattern of e-cigarette had positive influence on smoking cessation among users. CONCLUSIONS AND PRACTICAL IMPLICATIONS E-cigarette use was not significantly associated with increased smoking cessation among cigarette smokers. We also found that pattern of e-cigarette may have significant effect on smoking cessation capability of e-cigarettes. Well-designed randomized controlled clinical trials are needed to assess the clinical efficacy of e-cigarettes in comparison with approved smoking cessation therapies.

INTRODUCTION Toombak is a form of smokeless tobacco that is not well known in Western Society but is widely used by the Sudanese population and many others in the sub-Sahara region. However, unlike other smokeless tobacco products, information on the carcinogenic potential of toombak is scarce. The present review explored any potential epidemiological association between the use of toombak and oral leukoplakia and oral squamous cell carcinoma (OSCC). METHODS Databases including the Web of Science, SCOPUS, EMBASE and PubMed were searched for literature on the potential association between toombak and oral leukoplakia and OSCC. The search also included grey literature. The search period extended from 1990 to 2018. Following data mining, the study selection was conducted by two reviewers independently. RESULTS Eight studies that satisfied the inclusion criteria were included. Based on these results, there was a threefoldto sevenfold increased risk of developing the oral leukoplakia and oral squamous cell carcinoma among toombak users compared with non-users. CONCLUSION Based on the results of the systematic review, there is a strong epidemiological evidence to suggest toombak to be a major risk factor for both oral leukoplakia and OSCC. Further studies are necessary to evaluate the molecular pathway of toombak-induced oral carcinogenesis.

The current three-tier grading system (well, moderate and poorly differentiated) used to morphologically classify head and neck squamous cell carcinoma (HNSCC) is inadequate for categorisation of oropharyngeal squamous cell carcinoma (OPSCC) owing to the lack of prognostic value. The aim of this study was to assess the validity of a classification system for OPSCC based on morphology and human papilloma virus (HPV) infection status. Haematoxylin and eosin slides of 121 patients (100 M, 21 F, age range 40-89 years) with OPSCC were reviewed and categorised as histological types I, II and III. The presence of HPV was assessed by immunohistochemistry with p16 and RNAscope In situ hybridization (ISH). The follow-up period was 36 months. Ninety-six patients were p16+ and clinical stage I. Patient survival with types I, II and III was 93%, 50% and 96%, respectively. Twenty-five patients were p16-: 10 clinical stage I and 15 stage III. Amongst this group, no type I morphology was identified. At follow-up, 65% of type II and 75% of type III patients were alive. All p16+ cases were also positive for E6/E7 mRNA high-risk HPV by ISH, while 23 p16- cases were negative and two were positive. Cox regression identified three predictors of mortality: older age (HR = 1.14, 95% CI = 1.06-1.23, P = .001); female gender (HR = 0.22.95% CI 0.05-0.88, P = .033); and type II morphology (HR = 13.1, 95% CI = 1.09-157.0, P = .043). OPSCC morphological classification in three sub-types, along with HPV infection status, seems to reflect the outcome of patients with OPSCC.

Purpose Hyperbaric oxygen (HBO) has been advocated in the prevention and treatment of osteoradionecrosis (ORN) of the jaw after head and neck radiation therapy, but supporting evidence is weak. The aim of this randomized trial was to establish the benefit of HBO in the prevention of ORN after high-risk surgical procedures to the irradiated mandible. Methods and Materials HOPON was a randomized, controlled, phase 3 trial. Participants who required dental extractions or implant placement in the mandible with prior radiation therapy >50 Gy were recruited. Eligible patients were randomly assigned 1:1 to receive or not receive HBO. All patients received chlorhexidine mouthwash and antibiotics. For patients in the HBO arm, oxygen was administered in 30 daily dives at 100% oxygen to a pressure of 2.4 atmospheres absolute for 80 to 90 minutes. The primary outcome measure was the diagnosis of ORN 6 months after surgery, as determined by a blinded central review of clinical photographs and radiographs. The secondary endpoints included grade of ORN, ORN at other time points, acute symptoms, pain, and quality of life. Results A total of 144 patients were randomized, and data from 100 patients were analyzed for the primary endpoint. The incidence of ORN at 6 months was 6.4% and 5.7% for the HBO and control groups, respectively (odds ratio, 1.13; 95% confidence interval, 0.14-8.92; P = 1). Patients in the hyperbaric arm had fewer acute symptoms but no significant differences in late pain or quality of life. Dropout was higher in the HBO arm, but the baseline characteristics of the groups that completed the trial were comparable between the 2 arms. Conclusions The low incidence of ORN makes recommending HBO for dental extractions or implant placement in the irradiated mandible unnecessary. These findings are in contrast with a recently published Cochrane review and previous trials reporting rates of ORN (non-HBO) of 14% to 30% and challenge a long-established standard of care.

Multidisciplinary team (MDT) meetings are widely used throughout medicine and dentistry, bringing together expertise and different opinions across many disciplines to benefit patient care. Depending on the cancer site and specialties involved, some MDTs can last for several hours, especially if there are many complex patients to discuss. However, concentration and attention can vary and distraction is almost inevitable with separate conversations between MDT members and the ever-increasing use of smartphones. The role of human factors (HF) in contributing to error is well known in high-risk activities including medicine and surgery. Surprisingly, while there is increasing awareness of their importance by medical and dental professionals to enhance patient safety, to our knowledge nothing to date has been published about the possible effect and role of HF at MDTs. Here we provide a brief HF overview and focus on the factors at an MDT that could lead to distraction, providing suggestions (including some from aviation) for possible ways to enhance and improve discussion during these often-long meetings. It is hoped that this paper will generate some thought and discussion around the current "normal" MDT practice in head and neck and other specialties and challenge colleagues to embrace HF and safety principles in a just and learning culture.

INTRODUCTION Shammah is a form of smokeless tobacco commonly used in the Arabian Peninsula. The data on the harmful effects of shammah on oral health, particularly oral malignancies, are scarce. The aim of this review was to explore the association between shammah use and development of oral potentially malignant disorders (OPMD) and/or oral cancer. MATERIALS AND METHODS PubMed, EMBASE, Scopus, Web of Science and grey literature from January 1990 up to and including April 2018 were searched. Two independent reviewers performed the study selection according to eligibility criteria. RESULTS A total of 10 studies that met the eligibility criteria were included. The odds of developing OPMD and/or oral cancer in relation to shammah use varied, with one study reporting a 39 increased risk (39, 95% CI: 14-105). The associated increased risk was relatively low among those that have stopped using shammah and ranged from threefold (3.65; 95% CI: 1.40-9.50) to 12-fold (12.6; 95% CI: 3.3-48.2). CONCLUSION Shammah use seems to increase the risk of development of OPMD and/or oral cancer.

Background Oral and Maxillofacial Surgery (OMFS) has been increasing in popularity amongst medicine first trainees. Despite this, there is still limited exposure at the undergraduate level. This study aimed to: evaluate the experience of medical students in the field of OMFS, the awareness of medical students to OMFS resources/societies and to determine the greatest motivators and deterrents for students in pursuing a career in OMFS. Methodology An online survey was distributed to 198 students spread across two English universities. 131 students (66.2%) were from University A and 67 (33.8%) students were from University B. Results A total of 61.1% of undergraduate medical students had no exposure to OMFS up until their current stage of training with no statistically significant differences in OMFS exposure between the year groups (p>0.05) . 37% of students considered OMFS as a potential career path with dual qualification being the deterrent in 44% of cases. 97.0% of students were not able to state any organisations/resources available to support them in pursuing a career in OMFS. Conclusion within our cohort exposure to OMFS was greater than earlier reports, however; undergraduate exposure to OMFS is still very limited in UK medical schools.. Conducting a dental degree following the primary medical qualification appears to be the greatest obstacle to students considering OMFS training. OMFS remains unknown to medical students and healthcare professionals. We need grass root changes at undergraduate level to improve the future of OMFS training.

Unicystic ameloblastoma is a distinct pathological variant with varying evidence published about its behaviour and surgical management. Due to a paucity of large studies in the literature with long-term follow up, the aim of this study was to analyse its surgical management and identify clinicopathological features associated with recurrences. All histopathologically confirmed lesions diagnosed at two referral centres between 1995 and 2020 were retrospectively analysed. Demographic, clinical, radiological, and histopathological features were analysed along with surgical methods and follow-up data. Univariate regression analyses were performed to identify risk factors for recurrence. Sixty-three patients were included in the study with mean age of 26.3 years and a male to female ratio of 1:0.75. The majority of lesions occurred in the posterior mandible (57.1%) and were unilocular (88.9%). Most lesions were managed with enucleation followed by application of Carnoy's solution (ferric chloride: 1g; chloroform: 3 mL; glacial acetic acid: 1 mL; ethyl alcohol 96%: 6 mL) and burring of the peripheral bone margin which resulted in the lowest recurrences (9.1%) besides resection. Significantly associated clinicopathological features with recurrences included patients who were male, large lesions (90 mm), presence of root resorption, cortical perforation, mural subtype, and retention of associated teeth. In conclusion, decision making in the management of unicystic ameloblastoma should be based on the clinicopathological features and not be solely based on the histopathological subtype. Enucleation followed by application of Carnoy's solution and burring of the peripheral bone margin was demonstrated to be the least invasive method with an acceptable low recurrence rate.

Objective Despite rising numbers of doctors in the workforce with disabilities, little is known about the impact of disabilities on postgraduate performance. To ensure all groups are treated fairly in surgical training, it is essential to know whether any attainment differences exist in markers of surgical performance. To address this gap, we assessed the impact of disabilities on performance on the Intercollegiate Membership of the Royal College of Surgeons examination (MRCS). Design Retrospective cohort study. Setting Secondary care. Participants All UK MRCS candidates attempting Part A ( n = 9600) and Part B ( n = 4560) between 2007 and 2017 with linked disability data in the UK Medical Education Database ( https://www.ukmed.ac.uk ) were included. Main outcome measures Chi-square tests and correlation coefficients established univariate associations with MRCS performance, while multiple logistic regressions identified independent predictors of success. Results Though MRCS Part B pass rates were similar ( p = 0.339), candidates with registered disabilities had significantly lower first-attempt Part A pass rates (46.3% vs. 59.8%, p 0.05). Conclusion Although candidates with registered disabilities performed less well in formal, written examinations, our data indicate that they are as likely to pass MRCS at first attempt as their peers who achieved similar grades at high school and medical school. In order to enable equity in career progression, further work is needed to investigate the causes of attainment differences in early career assessments.

An area critical to safety in an organisation is the perceived and actual culture. National Air Traffic Services (NATS) work closely with large safety-critical industries including various aviation companies to enable them to identify strengths and vulnerabilities with the aim of improving safe practice. NATS have developed a simple free downloadable self-assessment App that individuals can use to assess their own culture perception in their organisation. The App has 16 questions arranged in four domains but to our knowledge it has not been used to date in healthcare. As part of the initiatives to improve staff culture, we evaluated operating theatre colleagues’ safety perception in our large acute NHS Trust in a pilot study using the NATS safety App. Staff downloaded the App to their smart device before completing it. Responses were sent anonymously through the App and collated by NATS. A total of 146 colleagues downloaded and completed the questionnaire. One hundred and seventeen staff (80%) felt encouraged to report safety concerns, but 86% (n = 126) confirmed a lack of available support from healthcare managers. Only 43% of respondents (n = 63) would find it easy to challenge colleagues if they observed unsafe behaviour. This pilot study has identified positive indicators of an evolving NHS safety culture, and some concerns about speaking up, support, and challenging colleagues without fear. These issues are known to occur across healthcare. Further work is needed in the NHS to provide a supportive environment to improve patient safety, and lower hierarchy in surgical teams.

Phosphoinositide 3-kinase δ (PI3Kδ) plays a key role in lymphocytes and inhibitors targeting this PI3K have been approved for hematological malignancies. While studies in hematological and solid tumor models in mice have demonstrated that PI3Kδ inhibitors (PI3Kδi) can induce anti-tumor immunity, the impact of PI3Kδi on solid tumors in humans remains unclear. Here, we assessed the effects of the PI3Kδi AMG319 in patients with resectable head and neck cancer in a neoadjuvant, double-blind, placebo-controlled randomised phase-II trial. We find that PI3Kδ inhibition decreases tumor-infiltrating immunosuppressive TREG cells and causes heightened cytotoxic potential of tumor-infiltrating CD8+ and CD4+ T cells. Loss of intratumoral TREG cells and an increase in the frequency of activated TREG cells in the blood post-treatment are indicative of systemic effects on TREG tissue retention and maintenance. At the tested AMG319 doses, immune-related adverse events caused treatment discontinuation in 12/21 of AMG319-treated patients, further suggestive of systemic effects on TREG cells. Consistent with this notion, in a murine syngeneic tumor model, PI3Kδi decreased TREG cells in both tumor and non-malignant tissues and affected TREG subtype composition, maintenance and functionality. Our data demonstrate the cancer-immunotherapy potential of PI3Kδ inhibition in humans, but its modulation will need to be carefully balanced to harness its anti-tumor capacity while minimizing immune related toxicity.

Medical schools in the UK typically use prior academic attainment and an admissions test (University Clinical Aptitude Test (UCAT), Biomedical Admissions Test (BMAT) or the Graduate Medical School Admissions Test (GAMSAT)) to help select applicants for interview. To justify their use, more information is needed about the predictive validity of these tests. Thus, we investigated the relationship between performance in admissions tests and the Membership of the Royal College of Surgeons (MRCS) examination. The UKMED database (https://www.ukmed.ac.uk) was used to access medical school selection data for all UK graduates who attempted MRCS Part A (n=11 570) and Part B (n=5690) between 2007 and 2019. Univariate and multivariate logistic regression models identified independent predictors of MRCS success. Pearson correlation coefficients examined the linear relationship between test scores and MRCS performance. Successful MRCS Part A candidates scored higher in A-Levels, UCAT, BMAT and GAMSAT (p The utility of admissions tests is clear with respect to helping medical schools select from large numbers of applicants for a limited number of places. Additionally, these tests appear to offer incremental value above A-Level performance alone. We expect this data to guide medical schools' use of admissions test scores in their selection process.

Human error and organisational mistakes are a significant cause of morbidity for patients. It is important to recognise and address human factors (HF) in the context of our own performance optimisation, enhancing team working to improve patient safety, and better working lives for clinicians across surgery and medicine.

Lipomas are common benign tumours that can occur in most parts of the body. Lipomas arising from the deep temporal fat pad, found between the two layers of the deep temporal fascia, are rare, however; there has been only one documented case report to our knowledge. We describe a second case arising from the temporal fat pad in a patient treated at our unit, having previously reported the first one, and discuss the relevant anatomy and management.

Long-term follow-ups after receiving lycopene therapy for management of oral submucous fibrosis (OSMF) are scarce. The study aimed to assess the long-term efficacy of lycopene for management of OSMF symptoms.In this prospective clinical study, 400 clinically diagnosed early OSMF patients were assessed for the efficacy of lycopene in alleviation of burning sensation (BS) and reduced mouth opening (MO) symptoms in comparison to placebo. After 1-year follow-up, group A (lycopene group) was divided equally into group A1 and group A2. group A1 patients were retreated with lycopene and the A2 group was followed without retreatment. After 2-year follow-up, the Group A2 patients were advised retreatment but not followed as most of the patient did not agree for follow-up. However, group A1 patients were continued to follow-up every 6 months for a total three years. Statistical analysis was by independent sample t-test and P-value.05 were considered as significant.A statistically significant difference (P.05) in BS and MO was found between group A and B with lycopene showing better results. At one-year follow-up, a statistically significant recurrence in the symptoms was found (P.05) in the lycopene group (group A). After the second intervention, there was a statistically significant difference in the improvement of symptoms between the group A1 and A2 at 6 months and 1 year (P.05) with group A1 (retreatment) showing better results.Treatment with lycopene led to improvement in the symptoms of OSMF in the present study. The results highlight the importance of retreatment of lycopene for its long-term effect on alleviation the symptoms of OSMF.

Background Guidelines remain unclear over whether patients with early stage oral cancer without overt neck disease benefit from upfront elective neck dissection (END), particularly those with the smallest tumours. Methods We conducted a randomised trial of patients with stage T1/T2 N0 disease, who had their mouth tumour resected either with or without END. Data were also collected from a concurrent cohort of patients who had their preferred surgery. Endpoints included overall survival (OS) and disease-free survival (DFS). We conducted a meta-analysis of all six randomised trials. Results Two hundred fifty randomised and 346 observational cohort patients were studied (27 hospitals). Occult neck disease was found in 19.1% (T1) and 34.7% (T2) patients respectively. Five-year intention-to-treat hazard ratios (HR) were: OS HR = 0.71 (p = 0.18), and DFS HR = 0.66 (p = 0.04). Corresponding per-protocol results were: OS HR = 0.59 (p = 0.054), and DFS HR = 0.56 (p = 0.007). END was effective for small tumours. END patients experienced more facial/neck nerve damage; QoL was largely unaffected. The observational cohort supported the randomised findings. The meta-analysis produced HR OS 0.64 and DFS 0.54 (p Conclusion SEND and the cumulative evidence show that within a generalisable setting oral cancer patients who have an upfront END have a lower risk of death/recurrence, even with small tumours. Clinical Trial Registration NIHR UK Clinical Research Network database ID number: UKCRN 2069 (registered on 17/02/2006), ISCRTN number: 65018995, ClinicalTrials.gov Identifier: NCT00571883.