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Gastrointestinal stromal tumors (GISTs) form commonly in the stomach, small intestine, colorectum, and esophagus. Metastatic GIST occurs in up to 50% of patients at presentation. The liver and peritoneal cavity are the most common (93%) metastatic sites; head and neck metastases are extremely rare. This report describes a unique case of a 77-year-old man who was diagnosed with a duodenal GIST that had been completely resected 15 years ago. Eleven years after complete resection, he presented with liver metastases and then received multiple lines of systemic therapy and ablative radiotherapy. In 2015, he presented to our oral and maxillofacial surgery department with a left exophytic maxillary mass that filled the left maxillary sinus. Incisional biopsy confirmed metastatic GIST. Further evaluation revealed extensive metastases in the patient's liver, lungs, spleen, abdominal wall, and lymph nodes. After adequate staging, the patient's condition was deemed palliative, and he was referred to the radiation oncology department for palliative treatment of the symptomatic maxillary lesion. To our knowledge, this is the first reported case of maxillary metastasis from a duodenal GIST. Inclusion of GIST in the differential diagnosis of jaw tumors in patients with nonoral malignancies is recommended. The literature on oral metastasis of GIST is reviewed and discussed in this case report.

Massive segmental bone defects (SBD) are mostly treated by removing the fibula and transplanting it complete with blood supply. While revolutionary 50 years ago, this remains the standard treatment. This review considers different strategies to repair SBD and emerging potential replacements for this highly invasive procedure. Prior to the technical breakthrough of microsurgery, researchers in the 1960s and 1970s had begun to make considerable progress in developing non autologous routes to repairing SBD. While the breaktthrough of vascularised bone transplantation solved the immediate problem of a lack of reliable repair strategies, much of their prior work is still relevant today. We challenge the assumption that mimicry is necessary or likely to be successful and instead point to the utility of quite crude (from a materials technology perspective), approaches. Together there are quite compelling indications that the body can regenerate entire bone segments with few or no exogenous factors. This is important, as there is a limit to how expensive a bone repair can be and still be widely available to all patients since cost restraints within healthcare systems are not likely to diminish in the near future. Statement of Significance This review is significant because it is a multidisciplinary view of several surgeons and scientists as to what is driving improvement in segmental bone defect repair, why many approaches to date have not succeeded and why some quite basic approaches can be as effective as they are. While there are many reviews of the literature of grafting and bone repair the relative lack of substantial improvement and slow rate of progress in clinical translation is often overlooked and we seek to challenge the reader to consider the issue more broadly.

The purpose of this paper is to outline a simple and effective digital protocol for in-house 3D-printing of orthognathic splints for use during single-jaw orthognathic surgery. Using this protocol, an intraoral scanner, and virtual planning software, computer-designed splints were fabricated by a rapid prototyping machine in-house. The protocol was utilized for 35 consecutive patients requiring single-jaw orthognathic surgery between January 2019 and March 2020. The total time from initial scan to splint fabrication for each case was between 5 and 9 hours, including 3 minutes for scanning of models, 4.5 minutes for development of the splint, and 4–8 hours for rapid prototyping and post-processing. This time varied based on the complexity of the design and the number of splints printed simultaneously. The average cost of raw materials for each splint was $0.73 Canadian dollars.

We aimed to describe the safety and effectiveness of nasotracheal intubation (NTI) in a cohort of patients undergoing reconstruction of oral cavity defects with free tissue transfer (FTT).We implemented a retrospective cohort study and enrolled a sample composed of consecutive patients undergoing FTT reconstruction of oral cavity, maxillary, or mandibular defects between 2013 and 2017. These patients were all subject to a newly developed enhanced recovery-after-surgery protocol. The primary outcome measurement was hospital length of stay (LOS). The secondary outcome variables were the duration of mechanical ventilation, intensive care unit (ICU) LOS, need for gastrostomy, and airway-related complications directly associated with either NTI or tracheostomy. Descriptive statistics and a multivariate logistic regression analysis were completed.The sample was composed of 141 patients who had undergone oral cavity FTT for both benign and malignant diseases (NTI, n = 111; tracheostomy, n = 30). Patients managed with NTI had a statistically significantly shorter hospital LOS (8 days vs 15.5 days, P .0001) and ICU LOS (1 day vs 2 days, P = .0006), as well as a decreased requirement for gastrostomy (17.1% vs 76.7%, P .0001). Airway-related complications were rare in both the tracheostomy (13.3%) and NTI (3.6%) groups. Multivariate analysis showed that patients undergoing tracheostomy were 3.14 (P = .004) times more likely to have a prolonged hospitalization and 10.4 (P .0001) times more likely to require a gastrostomy. A sensitivity analysis of only patients with malignant diagnoses had similar statistically significant results. The delayed tracheostomy rate in the NTI group was 3.6%.To date, this is the largest study to evaluate the use of NTI in patients undergoing oral cavity reconstruction with FTT. Our results suggest that in the appropriate institutional setting, most patients can be safely managed with NTI. This approach results in a decreased hospital LOS and ICU LOS and an earlier resumption of oral intake with less need for gastrostomy.

Background Overdentures retained by a single implant in the midline have arisen as a minimal implant treatment for edentulous mandibles. The success of this treatment depends on the performance of a single stud attachment that is susceptible to wear-related retention loss. Recently developed biomaterials used in attachments may result in better performance of the overdentures, offering minimal retention loss and greater patient satisfaction. These biomaterials include resistant polymeric matrixes and amorphous diamond-like carbon applied on metallic components. The objective of this explanatory mixed-methods study is to compare Novaloc, a novel attachment system with such characteristics, to a traditional alternative for single implants in the mandible of edentate elderly patients. Methods/design We will carry out a randomized cross-over clinical trial comparing Novaloc attachments to Locators for single-implant mandibular overdentures in edentate elderly individuals. Participants will be followed for three months with each attachment type; patient-based, clinical, and economic outcomes will be gathered. A sample of 26 participants is estimated to be required to detect clinically relevant differences in terms of the primary outcome (patient ratings of general satisfaction). Participants will choose which attachment they wish to keep, then be interviewed about their experiences and preferences with a single implant prosthesis and with the two attachments. Data from the quantitative and qualitative assessments will be integrated through a mixed-methods explanatory strategy. A last quantitative assessment will take place after 12 months with the preferred attachment; this latter assessment will enable measurement of the attachments’ long-term wear and maintenance requirements. Discussion Our results will lead to evidence-based recommendations regarding these systems, guiding providers and patients when making decisions on which attachment systems and implant numbers will be most appropriate for individual cases. The recommendation of a specific attachment for elderly edentulous patients may combine positive outcomes from patient perspectives with low cost, good maintenance, and minimal invasiveness. Trial registration ClinicalTrials.gov, NCT03126942. Registered on 13 April 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2606-7) contains supplementary material, which is available to authorized users.

This Point/Counterpoint article addresses a long-standing but still-unresolved debate on the advantages and disadvantages of using live patients in dental licensure exams. Two contrasting viewpoints are presented. Viewpoint 1 supports the traditional use of live patients, arguing that other assessment models have not yet been demonstrated to be viable alternatives to the actual treatment of patients in the clinical licensure process. This viewpoint also contends that the use of live patients and inherent variances in live patient treatment represent the realities of daily private practice. Viewpoint 2 argues that the use of live patients in licensure exams needs to be discontinued considering those exams' ethical dilemmas of exposing patients to potential harm, as well as their lack of reliability and validity and limited scope. According to this viewpoint, the current presence of viable alternatives means that the risk of harm inherent in live patient exams can finally be eliminated and those exams replaced with other means to confirm that candidates are qualified for licensure to practice.

Purpose Virtual surgical planning (VSP) and custom fabricated cutting guides for maxillofacial reconstruction have been shown to improve the accuracy of bony reconstruction and overall surgical efficiency and decrease the ischemia time. Our aim was to describe an in-house VSP technique for maxillofacial reconstructive procedures. Materials and Methods We used 2 free software applications. 3DSlicer (available at: http://www.3dslicer.org ) was used to extract the bones of interest for the recipient and the donor sites from the computed tomography scan's DICOM (digital imaging and communications in medicine) data. The Autodesk Meshmixer (Autodesk Inc, San Rafael, CA) was used to perform VSP and fabrication of the cutting guides. A reconstructed jaw model was printed in-house using a commercially available fused deposition modeling-based desktop 3-dimensional (3D) printer (Qidi Technology, Zhejiang, China) and used to prebend the reconstruction plate. The cutting guides were printed using a commercially available resin-based stereolithography apparatus desktop 3D printer (Form 2, Dental SG Resin; Formlabs, Somerville, MA) to allow for sterilization of the guides. We performed this technique for 19 consecutive patients with maxillofacial benign or malignant tumors requiring microvascular bony reconstruction. We calculated the average time and associated costs using this in-house VSP technique. Results The technique was found to be simple and repeatable. The average time required for VSP was 158 minutes (2 hours, 38 minutes). The average cost for printing the reconstructed model per case was $5.21 Canadian dollars (CAD), and the average cost for printing the cutting guides per case was $12.80 CAD. Conclusions Using this technique, in-house VSP and 3D printing can be performed by the treating surgeon, without an engineering background, within a reasonable period.

The local environment and the defect features have made the skull one of the most difficult regions to repair. Finding alternative strategies to repair large cranial defects, thereby avoiding the current limitations of autograft or polymeric and ceramic prostheses constitute an unmet need. In this study, the regeneration of an 8 mm critical-sized calvarial defect treated by autograft or by a monetite scaffold directly placed in the defect or preimplanted (either cranial bone transplant or subcutaneous pocket) and then transplanted within the bone defect is compared. The data reveal that transplantation of preimplanted monetite transplant scaffolds greatly improves the skull vault closure compared to subcutaneously preimplanted or directly placed materials. Autografts, while clearly filling the defect volume with bone appear effective since bone volume inside the defect volume is obviously high, but are not well fused to the skull. The preimplantation site has a large influence on the regeneration of the defect. Transplantation of induced bone inside materials has the potential to reduce the need for autograft harvest without damaging the skeleton. This first demonstration indicates that cranial repair may be possible without recourse to bioactives or cultured cell therapies.

Causing a large diameter blood vessel to sprout branches and a capillary network on demand to create a new angiosome is key to harnessing to potential of regenerative medicine and advancing reconstructive surgery. Currently this can only be achieved by connecting a vein graft to an artery by microsurgery, the arteriovenous loop technique (AVL). The arterial blood pressure in the thin-walled vein is thought to drive remodelling to create branches, however the surgical complexity limits the application of the technique. In this study we demonstrate that unexpectedly, a vessel density of luminal branches in excess of that achieved by the surgical AVL approach can be induced simply by placing a vein in contact with a microporous calcium phosphate. Only osteoinductive biomaterials have been reported previously, this is thought to be the first report of an angio-inductive material. Pilot studies indicated that the material type greatly affected the degree of luminal vascularization. Material contact with the vein is not a requirement for luminal angiogenesis of the vein and together these findings point to a bioinorganic effect, wherein the degradation of the material both releases a stimulatory ionic milieu and creates space for the developing angiosome.

While the prognosis for early-stage oral cavity cancer is relatively good; the majority of patients are still diagnosed with advanced-stage disease on presentation with an associated poorer prognosis. The aims of this review are to summarize our current understanding of delays in oral cavity cancer and their impact on stage at diagnosis and survival. The delays pathway can be subdivided into three components: patient, professional, and treatment delays. Patient delay represents the longest interval in the delays pathway usually lasting between 2 and 5 months and being most influenced by cognitive and psychosocial factors. Professional and treatment delays are shorter in most studies, but highly variable depending on the respective healthcare system. Most studies indicate that advanced stage at diagnosis, primary treatment with radiotherapy, treatment at an academic center, and transitions in care are associated with an increased treatment delay. Based on our current understanding, a delay between definitive diagnosis and treatment of 4-6 weeks seems acceptable from an oncologic perspective. Further studies are needed to better define what a 'safe' waiting time is and to understand the psychological impact of delays for patients.

Causing a large diameter blood vessel to sprout branches and a capillary network on demand to create a new angiosome is key to harnessing to potential of regenerative medicine and advancing reconstructive surgery. Currently this can only be achieved by connecting a vein graft to an artery by microsurgery, the arteriovenous loop technique (AVL). The arterial blood pressure in the thin-walled vein is thought to drive remodelling to create branches, however the surgical complexity limits the application of the technique. In this study we demonstrate that unexpectedly, a vessel density of luminal branches in excess of that achieved by the surgical AVL approach can be induced simply by placing a vein in contact with a microporous calcium phosphate. Only osteoinductive biomaterials have been reported previously, this is thought to be the first report of an angio-inductive material. Pilot studies indicated that the material type greatly affected the degree of luminal vascularization. Material contact with the vein is not a requirement for luminal angiogenesis of the vein and together these findings point to a bioinorganic effect, wherein the degradation of the material both releases a stimulatory ionic milieu and creates space for the developing angiosome.

This chapter describes a simplified method that allows the systematic isolation of multiple types of dental stem cells such as dental pulp stem cells (DPSC), periodontal ligament stem cells (PDLSC), and stem cells of the apical papilla (SCAP) from a single tooth. Of specific interest is the modified laboratory approach to harvest/retrieve the dental pulp tissue by minimizing trauma to DPSC by continuous irrigation, reduction of frictional heat from the bur rotation, and reduction of the bur contact time with the dentin. Also, the use of a chisel and a mallet will maximize the number of live DPSC for culture. Steps demonstrating the potential for multiple cell differentiation lineages of each type of dental stem cell into either osteocytes, adipocytes, or chondrocytes are described. Flow cytometry, with a detailed strategy for cell gating and analysis, is described to verify characteristic markers of human mesenchymal multipotent stromal cells (MSC) from DPSC, PDLSC, or SCAP for subsequent experiments in cell therapy and in tissue engineering. Overall, this method can be adapted to any laboratory with a general setup for cell culture experiments.

The development of alternatives to vascular bone grafts, the current clinical standard for the surgical repair of large segmental bone defects still today represents an unmet medical need. The subcutaneous formation of transplantable bone has been successfully achieved in scaffolds axially perfused by an arteriovenous loop (AVL) and seeded with bone marrow stromal cells or loaded with inductive proteins. Although demonstrating clinical potential, AVL‐based approaches involve complex microsurgical techniques and thus are not in widespread use. In this study, 3D‐printed microporous bioceramics, loaded with autologous total bone marrow obtained by needle aspiration, are placed around and next to an unoperated femoral vein for 8 weeks to assess the effect of a central flow‐through vein on bone formation from marrow in a subcutaneous site. A greater volume of new bone tissue is observed in scaffolds perfused by a central vein compared with the nonperfused negative control. These analyses are confirmed and supplemented by calcified and decalcified histology. This is highly significant as it indicates that transplantable vascularized bone can be grown using dispensable vein and marrow tissue only. This is the first report illustrating the capacity of an intrinsic vascularization by a single vein to support ectopic bone formation from untreated marrow.

Propranolol, a non-selective β-blocker widely used to treat cardiovascular conditions, favors bone accrual. Accordingly, we hypothesized that propranolol could be useful for improving bone healing and osseointegration. This in-vivo study was designed to investigate the effect of propranolol on bone healing and osseointegration in rats’ tibiae. Methods On 24 Sprague-Dawley rats, a unicortical defect was created in the right tibial metaphysis of each rat and a custom made titanium implant was placed in the left tibia. Animals were then assigned into two groups (n=12, each group) and treated daily with either propranolol (5 mg/kg: subcutaneous) or saline, for 2 weeks. Then, after euthanasia, the volume of the cortical defects (mm3) and the percentages of newly formed bone in the defects, were assessed with microcomputed tomography; bone-implant contact percentage and peri-implant bone volume/tissue volume were assessed by histomorphometry. Result Propranolol-treated rats presented smaller cortical defects (1.56+0.28mm3 vs. 2.04+0.29mm3, p

Hydrogels composed of two-dimensional (2D) nanomaterials have become an important alternative to replace traditional inorganic scaffolds for tissue engineering. Here, we describe a novel nanocrystalline material with 2D morphology that was synthesized by tuning the crystallization of the sodium-magnesium-phosphate system. We discovered that the sodium ion can regulate the precipitation of magnesium phosphate by interacting with the crystal's surface causing a preferential crystal growth that results in 2D morphology. The 2D nanomaterial gave rise to a physical hydrogel that presented extreme thixotropy, injectability, biocompatibility, bioresorption, and long-term stability. The nanocrystalline material was characterized in vitro and in vivo and we discovered that it presented unique biological properties. Magnesium phosphate nanosheets accelerated bone healing and osseointegration by enhancing collagen formation, osteoblasts differentiation, and osteoclasts proliferation through up-regulation of COL1A1, RunX2, ALP, OCN, and OPN. In summary, the 2D magnesium phosphate nanosheets could bring a paradigm shift in the field of minimally invasive orthopedic and craniofacial interventions because it is the only material available that can be injected through high gauge needles into bone defects in order to accelerate bone healing and osseointegration.

Extracranial carotid artery aneurysms are rare. Treatment options for these lesions include endovascular interventions, such as coiling and stenting, or surgical reconstruction, such as resection and primary reanastomosis, or interposition bypass grafting. In this report, we describe the surgical technique used to perform surgical repair of an internal carotid artery aneurysm extending up to the base of the skull. Anterior exposure of the infratemporal fossa and distal control of the carotid artery at the level of the carotid canal was achieved through a transcervical approach, performing double mandibular osteotomies with superior reflection of the middle mandibular section.

Objectives: Gastric tonometry is an established minimally invasive procedure for measurement of intramucosal pCO2, and it can foretell hemodynamic instability long before other common signs. The objectives of the present work were to monitor gastric mucosal acidity in patients intensively treated for exacerbated chronic obstructive pulmonary disease (COPD), to examine its relationship with other hemodynamic factors and its correlation with outcome.Design: Prospective uncontrolled study.Settimg: Respiratory and General Intensive Care Units (ICUs) in a general hospital.Subjects: Twenty-two patients were recruited from those admitted to the ICUs with exacerbated COPD requiring ventilation.Interventions: The intramucosal pCO2 (PrCO2) was measured by tonometry from 30 min to 72 hours post admission every 12 hours. At each time point, arterial and venous blood gases and pH, and respiratory variables were also determined.Measurements and main results: During the study period, 17 patients were weaned from the ven...

The purpose of this study was to evaluate the demographics, training satisfaction, and career plans of Canadian oral and maxillofacial surgery (OMS) residents. A cross-sectional study was conducted using an anonymous online survey that was distributed via e-mail to all current Canadian OMS residents. The completion rate of this survey was 88.9%. Eighty percent of residents were satisfied with their surgical education overall. Residents were most satisfied with their training in the areas of facial trauma and orthognathic surgery. Satisfaction was lowest in the areas of facial cosmetic surgery, maxillofacial reconstructive surgery, cleft and craniofacial surgery, and dental implantology. A majority of residents, 78.1%, indicated that they would prefer to be trained in an MD-integrated OMS certificate program. Seventy-two percent of residents indicated that they would like to complete a fellowship following graduation. The most desirable career path was a combination of private practice and academic practice, with 75.0% of residents selecting this option. Overall, Canadian OMS residents were pleased with their training in the traditional scope of OMS, apart from dental implantology. Among the current generation of trainees, there appears to be a proclivity for a broader scope of practice, dual-degree training, and post-graduate fellowship training.

Objective: To analyse and compare the infusion of frusemide by different modes of administration. Design: Prospective clinical survey of patients suffering from acute respiratory failure due to cardiogenic pulmonary oedema. Setting: A seven-bed general intensive care unit. Patients: Group A comprised 10 patients treated with intravenous frusemide several times daily at a dose of 1 mg/kg. Group B comprised 10 patients treated with continuous infusion of frusemide for 24 hours at an initial dose of 1 mg/kg, and 0.1 mg/kg/hr thereafter, with an option of increasing the dose every 2 hours. Group C comprised 10 patients treated with albumin and frusemide combined in continuous infusion over 24 hours at a dose of 250 mg frusemide diluted in 12.5 g albumin at a rate of 0.1 mg frusemide/kg/hr. Measurements: i) Serum electrolytes, creatinine, blood urea nitrogen (BUN) and protein; ii) urinary electrolytes; iii) hourly urinary output during the first 24 hours after admission. Results: There were no differences in t...

In this unusual case we report the history of two persons who were hospitalized after the ingestion of wild mushrooms identified as Amanita Phalloides. The two individuals developed severe symptoms until acute renal failure and liver injury resolved completely due to the rapid diagnosis and the intensive immediate treatment within 24 hours using new methods including hemodialysis and Molecular Adsorbent Recycling System (MARS).

We describe an elderly woman with a hyperphosphatemic hypocalcemic coma, hypernatremia, hypokalemia, metabolic acidosis, convulsions and respiratory and renal failure, following the administration of hypertonic sodium phosphate enemas. Physicians and pharmacists should be aware of the possible adverse effects that can be caused by these enemas.

We report the unusual occurrence of 3 cases of Laugier-Hunziker syndrome in the same family.

Two patients with primary angiosarcoma of the heart were treated. The first patient presented with spinal cord compression syndrome secondary to metastatic angiosarcoma of the lumbar spine. The primary tumour was found to be a right atrial mass. In contrast, the second patient presented with repeated episodes of pleural and pericardial hemorrhage resulting in effusive constrictive pericardial physiology. Repeated diagnostic attempts failed, and an open thoracotomy found an infiltrative type of pericardial angiosarcoma involving the right atrial wall. For both patients, the angiosarcoma proved to be rapidly fatal. The clinical spectrum of these two cases and a review of the literature suggest two major clinicopathological forms most commonly arising from the right atrium: a large obstructing mass and a less common, less symptomatic, locally infiltrative tumour, offering a greater diagnostic challenge. The prognosis is usually poor. However, a more aggressive diagnostic approach -- especially in the locally infiltrative tumours -- may offer hope for improving survival.

We report the case of a misplacement of a jugular venous catheter into the dorsal subarachnoid space through an intervertebral foramen. The error was demonstrated on plain radiograph, and on both radiograph and computed tomographic examination after injection of ionic iodinated contrast material. The catheter was removed and the patient recovered with no neurological sequelae.

Benign and malignant neoplasms of the temporomandibular joint are uncommon. Their presence poses a diagnostic and therapeutic challenge for clinicians. The central giant cell granuloma is a relatively common lesion of the jaws; however, it has been reported rarely to originate from the mandibular condyle. To date, only 5 such cases have been documented. We report a case of a large central giant cell granuloma of the condylar head with extension into the infratemporal fossa in a 29-year-old male. The patient was treated with resection and reconstruction using a costochondral graft. The signs, symptoms, and radiographic features are described and compared with the previous reports in the literature. The therapeutic options detailed in the literature have been focused mainly on lesions occupying the dentate regions of the maxilla and mandible. As such, we will review the surgical and pharmacologic options available to the surgeon and discuss their appropriateness with regard to this unique presentation of the central giant cell granuloma.

A new case of late bacterial endocarditis caused by Cardiobacterium hominis is reported. The infection developed on an aortic valve prosthesis and responded favourably to medical treatment. The main characteristics of the micro-organism and of the oslerian graft are reviewed in the light of published data. The problem of endocarditis with negative blood cultures is discussed since C. hominis is reputed difficult to cultivate, although this was not the case in our patient.

Mitogenic doses of membranes purified from Mycoplasma pneumoniae as well as concanavalin A (ConA) were tested for their ability to induce production of interleukin-2 (IL-2) and granulocyte-macrophage colony-stimulating activity (GM-CSA) by human peripheral blood mononuclear cells. Unlike ConA, M. pneumoniae exhibited a significantly lower mitogenic effect and lacked the ability to induce production of IL-2. On the other hand, peak levels of GM-CSA produced in the presence of M. pneumoniae and detected in colony assays of human target marrow cells were approximately 80% of those produced in the presence of ConA. Whereas ConA induced a similar time-related effect upon [3H]thymidine uptake and GM-CSA production, maximal GM-CSA production preceded the peak proliferative response to M. pneumoniae, thereby indicating that M. pneumoniae-induced production of GM-CSA is not quantitatively correlated with DNA synthesis. These findings may contribute to the understanding of the inflammatory manifestations induced by this organism.