Complex Head Research Articles

MO-FG-202-02: Automated Plan Quality Assurance Integrated with Eclipse Using Varian's ESAPI Interface

Purpose: Treatment plan compliance to physician's intent is still assessed by hand in clinical practice by visually comparing prescription details against corresponding plan values. We report on a script that uses the Varian's programming interface to automate the scoring of treatment plan dose values to the physician's prescribed constraints. Methods: The Eclipse Scripting Advance Programming Interface (ESAPI) is a FDA-approved scripting environment written in C# that allows programming access to a patient's record in Aria and Eclipse. With the ESAPI, it is possible to create customized add-on software libraries that can be installed in the planning system as a pull-down menu item. We used the flexibility of ESAPI to parse plan quality metrics from the prescription and compare them automatically against the corresponding plan values. The script can check fractionation as well as minimum, mean and maximum doses to an organ specified in the prescription, DVHs metrics such as volume or dose coverage for both targets and critical organs, conformity indexes specific to radio surgery and biological indexes such as EUD, TCP and NCTP. Lists of generally accepted constraints limits, such as QUANTEC or clinical trials constraints are implemented in the script and can be invoked to automatically fill the prescription. Results: The script interprets the prescription and compares plan quality indices parsed from it against the counterpart values extracted from the plan. A coloring scheming is employed to automatically mark with green, yellow or red plan quality metrics that meet, are borderline fail (10%) or fail the prescription criteria. While manually performing this task can take 30 minutes for a complex head and neck case with many constraints, the script takes approximately 1 minute. Conclusion: The script provided easy to understand feedback on quality metrics in a simple and practical solution that significantly streamline plan double-checks in clinical practice.

A comparable study of the diagnostic performance of orbital ultrasonography and CBCT in patients with suspected orbital floor fractures.

To compare the diagnostic performance of ultrasonography and CBCT against CT in detecting orbital floor fractures. A total of 120 orbits with clinical suspicion of isolated orbital floor fractures underwent multislice CT scanning with coronal reconstruction; orbital ultrasonography using a standard machine equipped with a 7- to 10-MHz linear transducer; and CBCT. Patients with severe head and face injuries were not included. The diagnostic performance of ultrasonography and CBCT was reported assuming conventional CT as the imaging method of choice. According to CT findings, fractures of the floor were present in 39 orbits. The sensitivity, specificity, positive-predictive value and negative-predictive value of ultrasonography in detecting orbital floor fractures were 87.2%, 100%, 100% and 94.2%, respectively. The corresponding values for CBCT were 97.4%, 97.5%, 95.0%, and 98.8%, respectively. Areas under the receiver operator characteristics curves of orbital floor fracture detection were 0.94 for ultrasonography and 0.98 for CBCT. When conventional CT cannot be performed in patients with clinically suspected orbital floor fracture and no severe or complex head and face injuries, CBCT could be used in detecting fractures as a reliable surrogate. Because of a lower sensitivity of ultrasonography, however, its use is limited in this regard.

Development and Feasibility of a Specialty-Specific National Surgical Quality Improvement Program (NSQIP): The Head and Neck-Reconstructive Surgery NSQIP.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) serves the need for continual quality assessment in general surgery. Previously, no parallel mechanism specific to head and neck oncologic surgery existed. To address the need for continual quality assessment in subspecialty surgery by adapting the ACS NSQIP platform for complex head and neck oncologic surgical procedures. With an institutional ACS NSQIP team's guidance, surgeons from the departments of head and neck surgery and plastic and reconstructive surgery developed disease- and procedure-specific preoperative, intraoperative, and postoperative variables specific to head and neck surgery requiring reconstruction. Collection occurred with 100% sampling and standard ACS NSQIP 30-day follow-up. After a pilot period, long-term functional outcomes were added to this platform. A total of 312 patients underwent head and neck surgery requiring reconstruction at an academic medical center between August 1, 2012, and June 30, 2013. Development of a specialty-specific head and neck surgery ACS NSQIP platform. The feasibility of adapting the ACS NSQIP platform to capture complex head and neck surgery metrics in all patients. Head and neck surgery-specific preoperative, intraoperative, and postoperative variables were added to the ACS NSQIP platform and evaluated in 312 patients (201 [64.4%] male). Only 42 patients (13.5%) had no preoperative risk factors, and 136 (43.6%) had 3 or more risk factors. The mean (SD) duration of operation was 9.4 (3.0) hours (range, 1.7-19.3 hours). The mean (SD) postoperative length of stay was 7.9 (4.7) days (range, 1-40 days), 58 patients (18.6%) had an unplanned return to the operating room, 23 patients (7.4%) were readmitted within 30 days, and 3 patients (1.0%) died within 30 days. More than half of the patients (160 [51.3%]) did not experience a postoperative occurrence. To our knowledge, this is the first comprehensive complex oncologic surgery outcomes platform derived from ACS NSQIP methods. The initial pilot demonstrates the ability to systematically capture head and neck surgery-specific variables with complete sampling. With multi-institutional expansion, increased accrual, and long-term patient-reported outcomes, we hope to set risk-adjusted benchmarks that may underpin quality improvement efforts in complex head and neck surgery.

The Role of Skull Modeling in EEG Source Imaging for Patients with Refractory Temporal Lobe Epilepsy.

We investigated the influence of different skull modeling approaches on EEG source imaging (ESI), using data of six patients with refractory temporal lobe epilepsy who later underwent successful epilepsy surgery. Four realistic head models with different skull compartments, based on finite difference methods, were constructed for each patient: (i) Three models had skulls with compact and spongy bone compartments as well as air-filled cavities, segmented from either computed tomography (CT), magnetic resonance imaging (MRI) or a CT-template and (ii) one model included a MRI-based skull with a single compact bone compartment. In all patients we performed ESI of single and averaged spikes marked in the clinical 27-channel EEG by the epileptologist. To analyze at which time point the dipole estimations were closer to the resected zone, ESI was performed at two time instants: the half-rising phase and peak of the spike. The estimated sources for each model were validated against the resected area, as indicated by the postoperative MRI. Our results showed that single spike analysis was highly influenced by the signal-to-noise ratio (SNR), yielding estimations with smaller distances to the resected volume at the peak of the spike. Although averaging reduced the SNR effects, it did not always result in dipole estimations lying closer to the resection. The proposed skull modeling approaches did not lead to significant differences in the localization of the irritative zone from clinical EEG data with low spatial sampling density. Furthermore, we showed that a simple skull model (MRI-based) resulted in similar accuracy in dipole estimation compared to more complex head models (based on CT- or CT-template). Therefore, all the considered head models can be used in the presurgical evaluation of patients with temporal lobe epilepsy to localize the irritative zone from low-density clinical EEG recordings.

Prospective Analysis of Payment per Hour in Head and Neck Reconstruction: Fiscally Feasible or Futile?

The authors assess the fiscal viability of complex head and neck reconstructive surgery by evaluating its financial reimbursement in the setting of resources used. The authors prospectively assessed provider reimbursement for consecutive patients undergoing head and neck reconstruction. Total care time was determined by adding 15 minutes to the operative time for each postoperative hospital day and each postoperative follow-up appointment within the 90-day global period. Physician reimbursement was divided by total care time hours to determine an hourly rate of reimbursement. A control group of patients undergoing carpal tunnel release was evaluated using the same methods described. A total of 50 patients met the inclusion criteria for study. The payer was Medicaid for nine patients (18 percent), Medicare for 19 patients (38 percent), and commercial for 22 patients (44 percent). The average provider revenue per case was $3241.01 ± $2500.65. For all patients, the mean operative time was 10.6 ± 3.87 hours and the mean number of postoperative hospital days was 15.1 ± 8.06. The mean reimbursement per total care time hour was $254 ± $199.87. Statistical analysis demonstrated difference in reimbursement per total care time hour when grouped by insurance type (p = 0.002) or flap type (p = 0.033). Of the 50 most recent patients to undergo carpal tunnel release, the average revenue per case was $785.27. Total care time analysis demonstrates that physician reimbursement is not commensurate with resources used for complex head and neck reconstructive surgery.

Greater sperm complexity in the Australasian old endemic rodents (Tribe: Hydromyini) is associated with increased levels of inter-male sperm competition.

Spermatozoa exhibit considerable interspecies morphological variation across mammals, especially among murid rodents. In Australasia, most murids in the tribe Hydromyini have a spermatozoon with a highly complex head exhibiting an apical hook, characteristic of most murids, and two projections that extend from its upper concave surface, the ventral processes. In the present study we performed a phylogenetically controlled comparison of sperm morphology across 45 species of hydromyine rodents to test the hypothesis that the length and angle of both the apical hook and ventral processes, as well as the length of the sperm tail, increase with relative testes mass as a proxy for differences in levels of inter-male sperm competition. Although both sperm head protrusions exhibited considerable variation in their length and angle across species, only the angles increased significantly in relation to relative testes mass. Further, the length of the sperm flagellum was positively associated with relative testes mass. These results suggest that, in hydromyine rodents, the angle of the apical hook and ventral processes of the sperm head, as well as the sperm tail length, are likely to be sexually selected traits. The possible functional significance of these findings is briefly discussed.

Outcomes and radiographic findings of anatomic press-fit radial head arthroplasty

Radial head arthroplasty (RHA) is a popular method of treatment for complex fractures of the radial head. The purpose of this study was to investigate patient outcomes and radiographic findings associated with a single anatomic monopolar press-fit radial head system commonly used for the treatment of radial head fractures. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with a press-fit anatomically designed RHA between November 2007 and April 2014. The most recent radiographs were evaluated for loosening, stress shielding, and instability. Postoperative motion and outcomes were reported at most recent follow-up. At an average follow-up of 30 months, 6 of the 15 patients (40%) demonstrated radiographic loosening. Six of the 9 patients (67%) without loosening demonstrated stress shielding (average, 6 mm). Functional outcome scores included a mean American Shoulder and Elbow Surgeons score of 70, Mayo Elbow Performance Score of 85, visual analog scale score for pain of 2, visual analog scale score for function of 7, and Single Assessment Numeric Evaluation score of 75. Average flexion-extension arc was 14° to 138°, and average pronation-supination was 75° to 74°. All 6 of the patients with radiographic loosening had undergone RHA with an associated ligamentous injury repair. Satisfaction among patients was high as no patient reported an unsatisfactory outcome. The use of an anatomic, press-fit monopolar RHA in the management of acute complex radial head fractures has yielded excellent clinical outcomes despite high rates of radiographic loosening and stress shielding. Press-fit RHA in the setting of ligamentous injury warrants further investigation because of a high rate of implant loosening observed.

Critical Care Admissions following Total Laryngectomy: Is It Time to Change Our Practice?

Critical Care Unit (CCU) beds are a limited resource and in increasing demand. Studies have shown that complex head and neck patients can be safely managed on a ward setting given the appropriate staffing and support. This retrospective case series aims to quantify the CCU care received by patients following total laryngectomy (TL) at a District General Hospital (DGH) and compare patient outcomes in an attempt to inform current practice. Data relating to TL were collected over a 5-year period from 1st January 2010 to 31st December 2015. A total of 22 patients were included. All patients were admitted to CCU postoperatively for an average length of stay of 25.5 hours. 95% of these patients were admitted to CCU for the purpose of close monitoring only, not requiring any active treatment prior to discharge to the ward. 73% of total complications were encountered after the first 24 hours postoperatively at which point patients had been stepped down to ward care. Avoiding the use of CCU beds and instead providing the appropriate level of care on the ward would result in a potential cost saving of approximately £8,000 with no influence on patient morbidity and mortality.

Interactive talk and discussion on latest techniques in veterinary surgery

Event Abstract Back to Event Interactive talk and discussion on latest techniques in veterinary surgery Tom Mariën1* 1 Equitom Equine Hospital, Head of Surgery, Belgium ABSTRACT Significant advances in Equine Head Surgery have been made the last years. However, radiographic and ultrasonographic examination provide insufficient information in major head pathologies. The use of CT-scan images on the other hand, allow more accurate visualization and even 3D imaging of head pathologies. This information is of great help for the surgeon not only to decide if a surgical intervention is possible, but also to plan and prepare complex head surgeries. In this regard, different important pathologies will be discussed, such as soft tissue cysts, osteosarcoma of the orbit, maxillary squamous cell carcinoma, infection of the temporomandibular joint and complex ectopic teeth in the sinus. Indeed, the clinical signs, diagnostic imaging, differential diagnosis, treatment and outcome will be presented of all these cases. The main goal of this talk is to assist the equine practitioner to recognize and identify different head pathologies in an early stage so that even life-threatening pathologies can be managed with a positive outcome. AUTHOR BIOGRAPHY Tom began his career at the University of Ghent, where he started veterinary medicine training at the age of 18 and finished six years later with honors. He worked for one year as an assistant at the Department of Surgery from the same University. Tom decided to specialize in surgery and moved to the USA (Kentucky, Ohio, San Francisco) to be trained by renown surgeons. He developed several new surgical techniques that have been published in recognized veterinary journals (such as closing the spleen-kidney area and reducing internal inguinal rings). He has been invited to speak at several international conferences and wrote several books chapters on equine surgery. In 2000, Tom returned to Belgium and opened his own clinic: Equitom. This clinic, has been recently renewed and expanded to include CT, MRI and scintigraphy. Keywords: Head, Surgery, Veterinary, Equine, medical imaging Conference: First and Second Conference on Current Veterinary Practices, Meldert-Lummen and Evergem, Belgium, 5 Mar - 26 Mar, 2016. Presentation Type: Oral Presentation Topic: Current Veterinary Practices Citation: Mariën T (2016). Interactive talk and discussion on latest techniques in veterinary surgery. Front. Vet. Sci. Conference Abstract: First and Second Conference on Current Veterinary Practices. doi: 10.3389/conf.FVETS.2016.01.00006 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 27 Jan 2016; Published Online: 29 Jan 2016. * Correspondence: DVM. Tom Mariën, Equitom Equine Hospital, Head of Surgery, Meldert-Lummen, 3560, Belgium, tom@equitom.be Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Tom Mariën Google Tom Mariën Google Scholar Tom Mariën PubMed Tom Mariën Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Cascaded Elastically Progressive Model for Accurate Face Alignment

While recently published face alignment algorithms mainly focused on occlusion, low image quality, and complex head poses, subtle variances of facial components were often overlooked. In this correspondence paper, we propose a new approach called cascaded elastically progressive model aiming for pixel-wise landmark localization. First of all, elastically progressive model (EPM) is designed to synthesize the prior knowledge of face shape and appearance of test image. More specifically, a novel framework referred to as inherent linear structure (ILS) is explored for capturing the characteristics of the shape, which is more plastic and flexible than extensively used principle component analysis-based modeling. A locally linear support vector machine (LL-SVM) is used as local expert for searching candidate feature points. In order to optimally integrate ILS with localization results of LL-SVM, we introduce Kalman filter (KF) to dynamically estimate the true shape in the sense of least mean square error. Two schemes are utilized based on our modeling of KF. First, we embedded heuristic line-like search strategy into the framework to guarantee and accelerate the convergence. Second, Kalman gain is manipulated adaptively in accordance with the confidence of the localizers so that poorly localized points are more subject to global constraint than well localized ones. To further improve robustness to initializations, two EPMs are cascaded, in which primary EPM detects the global structure and secondary EPM captures the details. Validation experiments are conducted on in-the-wild LFPW and HELEN databases. Our method shows advantages for accurate landmark localization compared with prevailing methods.

Evaluating the effect of pupil dilation on spectral-domain optical coherence tomography measurements and their quality score.

BackgroundSpectral-domain optical coherence tomography (SD-OCT) provides fast scan speed and high scan resolution improving its diagnostic accuracy. The purpose of this study was to evaluate if SD-OCT measurements and their quality score are influenced by pupil dilation.MethodsRetinal nerve fiber layer thickness (RNFL), ganglion cell complex (GCC) and optic nerve head (ONH) were measured in one eye of 57 glaucoma patients and 36 healthy subjects using spectral domain optical coherence tomography (SD-OCT) before and after pupil dilation. Comparisons were made between measurements and their quality score pre- and post dilation (Signal Strength Index, SSI). Overall RNFL, average GCC and ONH rim volume were considered in the analysis.ResultsNo statistically significant differences were found between pre- and post-dilation measurements in both groups (glaucoma: RNFL 80 ± 15 μm vs 80 ± 16 μm, p = 0.87; GCC 81.35 ± 13.4 μm vs 81.10 ± 13.14 μm, p = 0.92; ONH 0.05 ± 0.11 mm3 vs 0.04 ± 0.07 mm3, p = 0.74; controls RNFL 99 ± 12 μm vs 98 ± 14 μm, p = 0.70; GCC 92.12 ± 6.7 μm vs 91.54 ± 7.05 μm, p = 0.72; ONH 0.11 ± 0.1 mm3 vs 0.04 ± 0.07 mm3, p = 0.36) nor between pre- and post-dilation quality score (glaucoma SSI RNFL 54.3 ± 10.3 vs 51.7 ± 18.1, p = 0.12; SSI GCC 58 ± 9.5 vs 57 ± 8.09, p = 0.55; SSI ONH 48.5 ± 7.6 vs 46.6 ± 7.2, p = 0.16; controls SSI RNFL 57 ± 10.3 vs 54 ± 9.31, p = 0.2; SSI GCC 60.9 ± 8.1 vs 58.8 ± 7.3, p = 0.3; SSI ONH 51.5 ± 8.9 vs 50.4 ± 8.3, p = 0.59).ConclusionPupil dilation doesn’t affect SD-OCT measurements and their quality score.

“Reanalysis” Is Raising to Object

AbstractWe propose a Case‐driven account of the “reanalysis” operation assumed by some researchers to underlie pseudopassivization. Contra previous analyses, we argue that reanalyzed prepositions do not form a unit with the verb at any level of representation. Rather, reanalyzed prepositions raise to a v/V‐medial Agr head, and the complement of the preposition raises to the specifier of this complex head to receive Case. This places the erstwhile complement in essentially the same structural configuration as an ordinary direct object, so that passivization proceeds normally. Preposition stranding, although it does not require reanalysis as such, is tied to one of the prerequisites for reanalysis: the presence of independent Agr projections. This explains why all languages with pseudopassives also permit preposition stranding. Reanalysis also accounts for certain instances of anaphoric binding in the apparent absence of c‐command.

Outcomes of Vacuum-Assisted Therapy in the Treatment of Head and Neck Wounds.

Head and neck wounds can present a reconstructive challenge for the plastic surgeon. Whether from skin cancer, trauma, or burns, there are many different treatment modalities used to dress and manage complex head and neck wounds. Vacuum-assisted closure (VAC) therapy has been used on wounds of nearly every aspect of the body but not routinely in the head and neck area. This study was conducted to demonstrate our results using the VAC in the treatment of complex head and neck wounds. This is an IRB-approved, retrospective review of 69 patients with 73 head and neck wounds that were managed using the VAC between 1999 and 2008. The wound mechanism, location, and size, length of VAC therapy, patient comorbidities, use of radiation, complications, and ultimate outcome were assessed. In this patient population, the VAC was utilized because the standard reconstructive ladder was not a good option or had previously failed. Sixty-nine patients with complex head and neck wounds were treated with the wound VAC. The mean age of the patients was 66 years, with a range of 5-96 years. Males outnumbered females in this study nearly 2:1. Eighty-six percent of patients had wounds secondary to cancer, 8% secondary to trauma, 3% secondary to infection, and 3% secondary to burns. The VAC was used as a dressing over skin grafts in 50%, over Integra in 21%, and over open debrided wounds in 29%. Wounds healed without complication in 44% of the skin grafts, 67% of Integra-covered wounds, and 71% of debrided wounds. Minor complications included failure of complete graft take, failure of granulation tissue formation in open debrided wounds, infection, and hematoma formation under skin grafts. Major complications included positive cancer margins requiring reexcision and death secondary to pulmonary embolism, sepsis, and metastatic cancer. Most complications resolved with dressing changes, repeat grafting, or the administration of antibiotics. Our results demonstrate that the wound VAC provides a reliable, effective, and durable dressing for a multitude of complex head and neck wounds. Additionally, it is a valuable tool when traditional surgical procedures are not a viable option.

Predictive Factors for Preoperative Percutaneous Endoscopic Gastrostomy Placement: Novel Screening Tools for Head and Neck Reconstruction.

The treatment of head and neck cancer has varying impact on postoperative recovery and return of swallowing function. The authors aim to establish screening tools to assist in preoperatively determining the need for gastrostomy tube placement. The authors prospectively assessed all patients undergoing complex head and neck reconstructive surgery during a 1-year study period. Only patients tolerating an oral diet, without preoperative gastrostomies, were enrolled for study. Eight parameters were assessed including: body mass index (BMI), prealbumin, albumin, smoking history, comorbidities [including coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM)], age, use of microvascular reconstruction, and type of defect. Two specific screening tools were assessed. In the first, a multivariate logistic regression model was employed to determine factor(s) that predict postoperative gastrostomy tube. In a second screening tool, the 8 parameters were scored between 0 to 1 points. The total score obtained for each patient was correlated with postoperative gastrostomy placement. Out of the 60 study patients enrolled in the study, 24 patients (40%) received a postoperative gastrostomy. In the logistic regression model, albumin level was the only factor that was significantly associated with need for postoperative gastrostomy (P < 0.0023). A score of 4 or greater was determined to have a sensitivity of 83% and specificity of 61% for postoperative gastrostomy. Patients with a score of 4 or more with this screening scoring system or those patients with an albumin level <3.5 g/dL were at high risk for postoperative feeding tube placement.

Head and Neck Reconstruction with Chimeric Anterolateral Thigh Free Flap

Chimeric anterolateral thigh free flaps are composed of multiple skin paddles or muscular components that allow for the reconstruction of complex 3-dimensional defects. We present our experience with the technique and applications for various head and neck defects. Retrospective chart review. Academic tertiary care center. Subjects include 24 consecutive patients undergoing reconstruction with a chimeric anterolateral thigh free flap by a single surgeon. Our algorithm for pharyngeal reconstruction with this technique is described. Data include demographics, indications, comorbidities, operative findings, and surgical outcomes. The most frequent defects were pharyngocutaneous (n = 12, 50%) and skull base (n = 6, 25%). The flap consisted of a double skin paddle in 11 cases (45.3%) and a skin paddle with an independent component of vastus lateralis muscle in 13 cases (54.7%). Revision surgery was required in 4 cases and was associated with malnutrition (P = .022). There were no total flap losses, but partial loss (distal skin paddle in all the cases) was observed in 3 patients and was related to severe congestive heart failure (P = .021) and malnutrition (P = .021). All except 1 patient who underwent pharyngeal reconstruction resumed oral diet and achieved alaryngeal speech. Chimeric anterolateral thigh free flaps represent an excellent option for reconstruction of complex head and neck defects. Modifications to the technique are proposed in patients at high risk of surgical complications.

Use of Dual, Tubularized Supraclavicular Artery Island Flaps in Series to Restore Gastrointestinal Continuity After a Failed Ileocolic Esophageal Reconstruction

The supraclavicular artery island flap (SCAIF) is a versatile pedicled flap that can be an excellent alternative to free flap reconstruction in complex head and neck defects. We use the SCAIF routinely as a first-line option for many of our soft tissue head and neck reconstructions. Here we describe a novel application of dual SCAIFs used in series for proximal esophageal reconstruction. This followed esophagectomy for neoplastic disease and failed gastric pull-up and colonic interposition procedures.

False-negative rate of intraoperative frozen section margin analysis for complex head and neck nonmelanoma skin cancer excisions.

Intraoperative frozen section analysis (IFSA) is traditionally performed for complex and high-risk non-melanoma skin cancer (NMSC) resections, particularly when surgery under a general anaesthetic and a complex reconstruction is required, and where Mohs micrographic surgery (MMS) is not available. A retrospective audit of 253 cases between 1999 and 2009 was undertaken, investigating the accuracy and efficacy of IFSA for the treatment of NMSC in our tertiary skin tumour unit based in a university hospital setting. The combined incomplete and very narrow (<1 mm) excision margin rates were 28.7% and 27.5% for basal cell and squamous cell carcinoma, respectively. Unrepresentative sampling of the excision margins intraoperatively was the overwhelming cause of error (94%). After a thorough audit of our data, IFSA has been abandoned for the treatment of NMSC in our unit. MMS is practised intraoperatively, even in advanced cases. We believe that IFSA no longer has any role in our complex, multidisciplinary skin cancer practice.

Obesity and perioperative complications in head and neck free tissue reconstruction.

Free tissue transfer is a mainstay in reconstruction of complex head and neck defects. The purpose of this study was to determine if perioperative complications were more common in patients with body mass index (BMI) >30 kg/m(2) undergoing free flap reconstruction. A multi-institutional retrospective cohort was created. Medical complications, surgical complications, and procedural variables were recorded. Logistic regression was used to investigate univariate and multivariate associations between outcomes and predictors. Of 582 cases, 128 patients (22%) had BMI >30. Surgical complications occurred in 153 cases (26.3%), with an adjusted odds ratio (OR) for association of surgical complications with BMI >30 of 0.92 (p = .71). Medical complications occurred in 178 cases (30.6%), with an adjusted OR of 0.78 (p = .26). Age and advanced comorbidity status (Adult Comorbidity Evaluation-27 [ACE-27] 2 or 3) were associated with medical complications (p < .0001). BMI >30 does not predict medical or surgical complications in patients undergoing head and neck free flap surgery. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1188-E1191, 2016.

Virtual endoscopy—a new assessment tool in difficult airway management

Preemptive mapping of the airway is a useful adjunct to conventional clinical assessments when airway management planning for patients with complex head and neck pathology. Nasendoscopy is frequently used for this purpose but is also invasive and poorly tolerated in a subset of patients and, even in expert hands, may not allow complete visualization of the glottis and subglottic structures. We present a novel tool for difficult airway management planning in the form of virtual endoscopy by applying free online OsiriX software to head and neck computed tomographic scans to generate a “fly-through” airway reconstruction. To highlight how well virtual endoscopy correlates to conventional fibreoscopy, we compare both of these assessment tools in 3 patients with glottic, subglottic, and multilevel airway pathologies. Virtual endoscopy represents a unique, noninvasive, safe, and accurate airway assessment and educational resource, which warrants further exploration.

Material optimization and post-processing of sand moulds manufactured by the selective laser sintering of binder-coated Al2O3 sands

Novel binder-coated Al2O3 sands were prepared for selective laser sintering (SLS) to manufacture complex sand moulds for metal casting. The solidification mechanisms of the coated sands during the SLS and post-curing processes were provided, and effects of binder content, raw sand type and post-curing parameters on the strength and gas evolution were investigated. At the same binder content, the strength of the Al2O3 sand SLS specimen is much higher than that of commonly used quartz sand. Therefore, the binder-coated Al2O3 sands are very suitable for building large sand moulds with thin walls and delicate structures. On the other hand, to meet the same strength requirement for metal casting process, the Al2O3 sands need less binder content, consequently reducing gas evolution and thus improving the quality of final castings. Finally, a large sand mould for casting a complex six-cylinder diesel engine cylinder head was successfully manufactured by the SLS of the binder-coated Al2O3 sands, and the final casting with the surface quality and dimensional accuracy meeting the specific design requirements was obtained. The materials and method proposed in this paper not only shortened the trial production cycle of the six-cylinder engine from five months of the traditional casting method to 10 days, but also reduced the cost and improved the casting quality.