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Patient-specific, additively manufactured (printed) titanium reconstruction plates have been widely used to improve accuracy and efficiency of fibular flap reconstruction of the mandible. Miniplates possess some potential advantages over single-piece reconstruction plates, however multiple-miniplate fixation can be more technically demanding and may lengthen the duration of surgery. Furthermore, incremental angulation errors in screw placement for each miniplate could compromise overall dimensional accuracy of the neomandibular reconstruction. This preliminary article reports the first clinical use of a new patient-specific, printed titanium miniplate-jig system in a patient undergoing hemimandibulectomy for osteoradionecrosis of the mandible withfibular flap reconstruction. Our initial experience with the new deviceand technique demonstratesa quick, user friendly, and precise method for the placement and fixation of multiple miniplates in fibular-flap reconstruction of the mandible.

Facial trauma accounts for 5%-10% of all presentations to emergency departments (ED) in the UK, and it is often referred to the oral and maxillofacial surgery (OMFS) department by ED physicians. Undergraduate medical students often have limited exposure to OMFS, and this is likely to translate to reduced exposure to facial trauma. We investigated the exposure of undergraduate clinical medical students to facial trauma teaching and asked about their confidence to manage facial lacerations and their ability to diagnose common facial fractures. An online survey was completed by 237 medical students across two English universities, 154 (65%) from University A and 83 (35%) from University B. Of the students, 68% reported no exposure to any teaching in facial trauma up to their current year of medical school; no statistically significant differences were found among the year groups (p0.05). The majority of facial fractures within our cohort were referred to ear, nose and throat (ENT) (43%), followed by OMFS (31%), and plastic surgery (12%). In total, 84% of students did not feel competent to manage facial lacerations, and 95% were not confident to present a facial injuries examination to a senior colleague. Exposure to facial trauma teaching remains poor. Future work should aim to devise a clear OMFS curriculum with objective teaching on facial trauma.

Total joint arthroplasty (TJA) implants are composed of metal components. Although they are regarded safe, the long-term immunological effects of chronic exposure to the specific implant materials are unknown. We recruited 115 hip and/or knee TJA patients (mean age 68 years) who provided a blood draw for measurement of chromium, cobalt, titanium concentrations, inflammatory markers and systemic distribution of immune cells. We examined differences between the immune markers and the systemic concentrations of chromium, cobalt and titanium. CD66-b neutrophils, early natural killer cells (NK), and eosinophils were present in higher percentages in patients with chromium and cobalt concentrations greater than the median. The opposite pattern was observed with titanium where the percentages of CD66-b neutrophils, early NK, and eosinophils were higher in patients with undetectable titanium. Cobalt concentrations were positively correlated with a higher percentage of gamma delta T cells. Both chromium and cobalt concentrations were positively correlated with higher percentages of plasmablasts. Titanium concentrations were positively correlated with higher CD4 effector memory T cells, regulatory T cell count and Th1 CD4 helper cells. In this exploratory study, we observed altered distribution of immune cells in TJA patients with elevated systemic metal concentrations. Although these correlations were not strong, these exploratory findings warrant further investigation into the role of increased metals circulating in blood and its role in immune modulation.

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.

Head and neck ultrasonography with fine-needle aspiration cytology (FNAC) is recommended by the National Institute for Health and Care Excellence (NICE) and the British Association of Head and Neck Oncologists (BAHNO) for investigating neck masses. Finite specialist radiologists and increased demands on services have increased waiting lists and breached targets. Many patients are on a two-week cancer pathway and accurate investigation cannot be delayed. The implementation of a sonographer trained in neck ultrasound-guided FNAC was analysed together with its impact on the service. Over a 21-month period we have demonstrated a fall in waiting lists from 310 to 28 patients, without compromise to diagnostic accuracy. Additionally, a cost-saving of £60,000 was made. Improvements in efficiency and waiting lists can be achieved through targeted specialist training for allied health professionals, liberating specialists for other duties.

Females remain under-represented in surgery in the United Kingdom and around the globe. Gender representation on journal editorial boards is one of the key metrics of gender representation within academic surgery. The aim of this study was to quantify gender representation within the editorial leadership of journals affiliated with UK surgical specialties. A web-based search for each of the UK surgical specialty associations was conducted, followed by identification of the endorsed journals for each one. As of August 2022, data on the gender of the editor-in-chief and other journal leadership positions, including associate, section, and deputy editors, were collated. Gender classification was completed using first-name recognition, verified by a web search using the name and institution provided. Managing editors without clinical backgrounds were excluded. Ten journals were identified for the following surgical specialties: General Surgery, Trauma and Orthopaedics, Neurosurgery, Cardiothoracic, Urology, Paediatric Surgery, Ear Nose and Throat, Oral and Maxillofacial, Plastic and Reconstructive Surgery, and Vascular Surgery. In total, 242 editorial positions were identified: 207 were held by males (82.8%) and 35 by females (17.2%). There were no female editors-in-chief. The average female proportion of editorial leadership per journal was 18.8%. One journal had no female editorial leadership representation. Overall, the number of females in editorial leadership positions is comparable to the current proportion of UK female consultant surgeons (13.7%). Journals with an under-representation of females in senior editorial leadership positions compared with the parent specialty should consider initiatives that will encourage diversity, promote greater gender parity, and champion female representation.

Aim Surgical training experiences differ across Foundation Programme (FP) and Core Surgical Training (CST) deaneries in the UK. We, therefore, assessed whether MRCS success is associated with FP and CST deaneries. Method UK FP (n=553) and CST (n=1104) trainees who attempted MRCS over a three-year period were included. Chi-squared tests examined univariate associations. Multivariate logistic regression identified the likelihood of MRCS success depending on deanery, adjusted for socio-demographic factors. Results MRCS Part A success was associated with FP deanery (P Conclusions MRCS success is associated with FP and CST deanery; however, MRCS performance does not correlate with subjective assessment of teaching or training quality. Academic ability likely has a larger impact on MRCS performance than training experiences with the more popular deaneries attracting the highest performing candidates. These results will be of interest to trainees, trainers, and training deaneries.

While the relevance of the World Health Organization histopathological grading system as a prognostic tool for oral squamous cell carcinoma has received many critics, other histopathological features such as tumor-stroma ratio, tumor-infiltrating lymphocytes, and tumor budding are displaying promising results. Here, we evaluated the prognostic impact of the incorporation of tumor-stroma ratio, tumor-infiltrating lymphocytes, and tumor budding into World Health Organization histopathological grading for patients with oral squamous cell carcinoma.A total of 95 patients with early-stage oral squamous cell carcinoma were enrolled in the study, and World Health Organization tumor grading, tumor-stroma ratio, tumor-infiltrating lymphocytes, and tumor budding were evaluated in surgical slides stained with hematoxylin and eosin. Survival analyses for cancer-specific survival and disease-free survival were performed using Cox regression models, and receiver operating characteristic curves were applied for assessment of the performance of the combinations.Tumor-stroma ratio (stroma-rich) was significantly and independently associated with both shortened cancer-specific survival and poor disease-free survival, individually and in combination with World Health Organization histopathological grading. The combination of tumor-stroma ratio with World Health Organization grading did not improve the discriminatory ability compared to tumor-stroma ratio alone. Although low tumor-infiltrating lymphocytes were associated with shortened cancer-specific survival, the association did not withstand multivariate analysis. However, in combination with World Health Organization grading, low tumor-infiltrating lymphocytes were independently associated with poor cancer-specific survival. The combination of tumor-infiltrating lymphocytes and World Health Organization histopathological grading displayed a better discrimination of poor cancer-specific survival than tumor-infiltrating lymphocytes alone, but not at a significant level.Our findings support tumor-stroma ratio as a potential prognostic marker for patients with oral squamous cell carcinoma, and the incorporation of tumor-infiltrating lymphocytes into the World Health Organization grading system improves the prognostic ability of the tumor grading alone.

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.

BACKGROUND A diverse healthcare system is required to meet the needs of an increasingly cosmopolitan patient population. One barrier to this is the differential attainment in educational outcomes between Black and Minority Ethnicity (BME) and white medical students and doctors in the U.K. Several factors have been identified, however there has been limited evidence to date looking specifically at surgical training experiences and its relationship to differential attainment. OBJECTIVE The “vAriation in experiences and aTTainment In surgery between ethNicities of UK medical students and doctors” (ATTAIN) study aims to describe and compare the factors and outcomes of attainment between different ethnicities of doctors and medical students. METHODS This protocol describes a nationwide cross-sectional study of medical students and non-consultant grade doctors. Participants will complete an online questionnaire that will collect data on experiences and perceptions of surgical placements as well and self-reported academic attainment data. A comprehensive data collection strategy will be employed to collect a representative sample of the population. RESULTS The primary aim will be to determine any potential differences in the experiences and perceptions of medical students and junior doctors in surgery and its link to surgical attainment. A set of surrogate markers relevant to surgical training will be used to establish a primary outcome to determine variation in attainment. Regression analyses will be used to identify potential causes for the variation in attainment. CONCLUSIONS Drawing upon the conclusions of this study we aim to make recommendations on educational policy reforms. Additionally, the creation of a large, comprehensive dataset can be used for further research. CLINICALTRIAL The protocol was approved by the University College London Research Ethics Committee on 16/09/2021 (Ethics approval reference 19071/004).

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.

Summary Objective A recent independent review on diversity and inclusivity highlighted concerns that barriers to surgical career progression exist for some groups of individuals and not others. Group-level differences in performance at the Intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examinations have been identified but are yet to be investigated. We aimed to characterise the relationship between sociodemographic differences and performance at MRCS. Design Retrospective cohort study. Setting Secondary care. Participants All UK MRCS candidates attempting Part A ( n = 5780) and Part B ( n = 2600) between 2013 and 2019 with linked sociodemographic data in the UK Medical Education Database ( https://www.ukmed.ac.uk ). Main outcome measures Chi-square tests established univariate associations with MRCS performance. Multiple logistic regression identified independent predictors of success, adjusted for medical school performance. Results Statistically significant differences in MRCS pass rates were found according to gender, ethnicity, age, graduate status, educational background and socioeconomic status (all p Conclusions There is significant group-level differential attainment at MRCS, likely to represent the accumulation of privilege and disadvantage experienced by individuals throughout their education and training. Those leading surgical education now have a responsibility to identify and address the causes of these attainment differences.

Project Wingman is a novel initiative conceived early in the COVID-19 pandemic by two airline captains and a psychologist, which brings airline style lounges, staffed by volunteer air crew to NHS Trusts. The aim was to boost morale by providing airline style customer service for staff while on breaks. Over 50 lounges were opened across the NHS, staffed by up to 5000 volunteers. In this pilot study of one large Trust, we surveyed staff who visited the Wingman lounge. 100 completed questionnaires were used as an end point. All staff felt that the lounge was beneficial during COVID. 62% reported that they would visit the lounge even it was not attended by aircrew. 57% felt their wellbeing had suffered during the pandemic. A national study would be useful to assess the impact of the Wingman Lounges, but our pilot study highlights the importance of staff wellbeing and the value of taking breaks while at work. Many of the lessons learned in supporting colleagues during the pandemic could be used and adapted to help future wellbeing initiatives and aid retention of staff across the NHS.

Anatomy is a pillar of medical knowledge and essential for safe medical and surgical practice. The literature highlights concerns regarding anatomy knowledge, and knowledge of the head and neck in particular, in medical students and newly qualified doctors. We investigated medical students' confidence to be assessed on head and neck anatomy, the amount of teaching they received, and its mode of delivery, through an online survey completed by 185 medical students across two English Universities (122 (66%) students from University A and 63 (34%) from University B). Students were in their third to fifth year of medical school. A total of 126 (68%) had received two to four sessions on head and neck anatomy, and 56 (30%) had received one or two sessions. A total of 113 (61%) had received prosection teaching, and 44 (24%) had received computer/virtual anatomy teaching. In total, 140 (76%) did not feel confident to be assessed on head and neck anatomy, and 137 (74%) did not feel they had received an adequate amount of head and neck anatomy teaching. Despite formal head and neck anatomy teaching most of our cohort did not feel confident to be assessed on the topic. Further work is required to integrate anatomy into the clinical years and to devise a national undergraduate curriculum to enhance an interest in head and surgery as a career.