Major Neck Research Articles

Infection Control With Topical Antimicrobial Prophylaxis for Mucosal Head and Neck Surgery: A Meta-analysis.

To assess for differences in surgical site infection (SSI) rates and bacterial load after major mucosal head and neck surgery between patients who received topical antimicrobial prophylaxis and those who did not. Ovid Medline, Embase, SCOPUS, Cochrane Library, and ClinicalTrials.gov from inception to May 20, 2021, with cross-referencing of retrieved studies per PRISMA guidelines. Inclusion criteria captured clinical trials, cohort studies, and case-control studies with infectious outcomes of adults who underwent major mucosal head and neck surgery and received perioperative topical antimicrobial therapy to the oral cavity and/or pharynx. Studies of dental procedures were excluded. The primary outcome was SSI rate, and the secondary outcome was bacterial load. Two blinded investigators screened each text. Of 265 unique citations, 9 studies of 470 total patients were included. Topical treatments included numerous antibiotics and antiseptics directly applied over mucosa. Pooled SSI rates of 252 patients in the intervention cohort and 218 in the control cohort were 8% (95% CI, 3%-14%; I 2 = 61.2%) and 29% (95% CI, 16%-43%; I 2 = 79.5%), respectively. A meta-analysis of 7 comparative studies totaling 192 patients receiving topical therapy and 218 control patients revealed a pooled relative risk of 0.44 (95% CI, 0.28-0.68; I 2 = 0.0%) in favor of the treatment group. The studies demonstrated a short-term decrease in bacterial counts after topical antimicrobial prophylaxis. Patients who underwent prophylactic topical antimicrobial therapy had less than half the risk of developing SSI after mucosal head and neck surgery when compared with those who received no topical prophylaxis.

Effects of intravenous dexmedetomidine on perioperative haemodynamics and quality of emergence in patients undergoing head and neck surgery following general anaesthesia—a comparative randomized, double-blind placebo-controlled study

BackgroundDexmedetomidine is a widely used alpha-2 adrenoreceptor agonist in perioperative patient care. Its postsynaptic activation of the receptors in the central nervous system is responsible for reduced neuronal firing with resultant sedation, anxiolysis, analgesia, hypotension and bradycardia leading to effective stress response attenuation seen during laryngoscopy and orotracheal intubation. Major head and neck surgeries demand nasotracheal intubation which is more stressful than orotracheal as it traverses through the nasopharynx which is very pain-sensitive. This is to protect the airway in the immediate postoperative period from oedema or haematoma in the oral cavity or neck. Though its stress response attenuation, haemodynamic stability during the intraoperative period following orotracheal intubation has been well studied, its role in the prevention of emergence delirium and tube tolerance following nasotracheal intubation in major head and neck surgery is not found in the literature. Our aim was to evaluate whether dexmedetomidine effectively attenuates the stress response following nasotracheal intubation, perioperative haemodynamic fluctuations and quality of emergence in patients undergoing head and neck oncosurgeries.MethodsA total of 150 patients were randomly assigned to one of the two groups; group D (dexmedetomidine group) and group S (control group with saline). Group D patients received a bolus dose of dexmedetomidine 1 μg/kg in 10 ml saline over 10 mts before induction of GA followed by an infusion at 0.4 μ/kg/h during surgery. Statistical analysis was done using SPSS version 11.0 (SPSS Ltd., Chicago, IL). Categorical data were represented using frequencies and percentages. Continuous variables were represented using mean and standard deviation. The association between categorical variables was assessed using the chi-square or Fisher’s exact test, and continuous variables following normality assumption with respect to the two groups were assessed using an independent sample t-test. P value < 0.05 was considered to be statistically significant.ResultsPatients in the D group showed statistically significant attenuation of heart rate (P < 0.05) and blood pressure (P < 0.05) throughout the surgical period compared to saline. Also, there was a significant reduction in blood loss (P = 0.042), cough score (P = 0.001) and sedation score (P = 0.001) in the D group.ConclusionsWe conclude that a bolus dose of dexmedetomidine 1 μg/kg given 10 min before induction of anaesthesia followed by an infusion at 0.4 μg/kg/h during surgery effectively attenuates the haemodynamic responses during nasotracheal intubation and provides smooth emergence as evidenced by reduced coughing, agitation and arousable sedation without respiratory depression which facilitates tube tolerance following major head and neck oncosurgeries. Blood loss was also found to be significantly reduced.

Development of a Vibration Based-Heating Neckband for Cervical Spondylosis

The post-pandemic working pattern has changed a lot due to the change in the mode of working and ease of flexibility as almost all the works are done online. This is affecting the lifestyle of the human due to continuing online working and due to this many health issues are being recorded. The main problem seen is in the postural change of the neck which results in minor or major neck pain problems. According to a study currently, the rate of neck pain is around 30% in adults, around 50% of individuals are facing a minor neck problem to some extent and 20% of humans experienced this neck pain in their daily activities. Different types of neck diseases can be occurred due to this such as osteoarthritis, pinched nerves, postural pain, and also some problems related to cervical vertebrae, for the same the existing collar belt is modified and tried to make an affordable massager belt to have relief during this pain which helps the blood flow to maintain and can stimulate nerves. Advanced treatment is embedded in this collar which has vibration motions and a heating pad that helps for the neck. According to their requirement, we can adjust the intensity of the motion. And also, this helps the improvement in the neck posture. Keywords: [Cervical Spondylosis, Neck pain, Physiotherapy, Healthcare, Ultrasonic Heating Pad, Vibration effect]

Incidence of Persistent Tracheocutaneous Fistula After Pediatric Tracheostomy Decannulation.

To determine the incidence of tracheocutaneous fistula (TCF) and identify characteristics associated with persistence. Prospective cohort. All successfully decannulated children (<18 years) between 2014 and 2020 at a tertiary children's hospital were included. Revision tracheostomies, concomitant major neck surgery, or single-stage laryngotracheal reconstructions were excluded. A persistent TCF was defined as a patent fistula at 6 weeks after decannulation. A total of 77 children met inclusion criteria with a persistent TCF incidence of 65% (50/77). Children with a persistent TCF were younger at placement (1.4 years (SD: 3.3) vs. 8.5 years (SD: 6.5), p < 0.001) and tracheostomy-dependent longer (2.8 years (SD: 1.3) vs. 0.9 years (SD: 0.7), p < 0.001). On univariate analysis, placement under 12 months of age (86% vs. 26% p < 0.001), duration of tracheostomy more than 2 years (76% vs. 11% p < 0.001), short gestation (64% vs. 26%, p=0.002), congenital malformations (64% vs. 33%, p=0.02), newborn complications (58% vs. 26%, p=0.009), maternal complications (40% vs. 11%, p=0.009) and chronic respiratory failure (72% vs. 41%, p=0.01) were associated with persistent TCF. Logistic regression analysis associated duration of tracheostomy (OR: 0.14, 95% CI: 0.05-0.35, p < 0.001) and congenital malformations (OR: 0.25, 95% CI: 0.06-0.99, p=0.049) with failure to spontaneously close. Two-thirds of children will develop a persistent TCF after tracheostomy decannulation. Persistent TCF is correlated with a longer duration of tracheostomy and congenital malformations. Anticipation of this event in higher-risk children is necessary when caring for pediatric tracheostomy patients. 3 Laryngoscope, 133:417-422, 2023.

A 5-year experience with midline catheters in the management of major head and neck surgery patients.

In the perioperative management of major head and neck surgery (HNS) patients, the performance of midline catheters (MCs) has been never tested. We present here our 5-year experience by reporting MC-related complications and by identifying the preoperative risk factors associated with their development. Clinical variables were extracted and the dwell time, the number, and the type of postprocedural complications of MCs were retrieved. Complications were classified into major (needing MCs removal and including catheter-related bloodstream infection or deep vein thrombosis or catheter occlusion) and into minor (accidental dislodgement, leaking, etc.). Descriptive statistics and logistic regression models were used in order to identify the predictors of complications. A total of 265 patients were included, with a mean age of 67.4 years. Intraprocedural complications occurred in 1.1% of cases, while postprocedural complications occurred in 13.9% of cases (12.05/1000 days), but they were minor in more than 7.0% (5.4/1000 catheter-days). There were 19 minor complications (7.1% or 5.4/1000 catheter-days) while 18 (7%, 5.1/1000 catheter-days) patients experienced at least one major complication. Female sex (OR = 1.963, 95% CI 1.017-3.792), insertion in the right arm (OR = 2.473, 95% CI 1.150-5.318), and an ACE-27 score >1 (OR = 2.573, 95% CI 1.295-5.110) were independent predictors of major complications. MCs appear to represent an effective option in the setting of major HNS. The identification of patients most at risk for MC-related complications should prompt a postoperative watchful evaluation.

Need for tracheostomy in major head and neck ablative surgery: a paradigm shift during the COVID-19 pandemic.

Management of the airway in the perioperative period for patients requiring major head and neck ablative surgery has commonly included the performance of elective surgical tracheostomy. This has been standard practice in most maxillofacial units across the UK, including ours. However, the COVID-19 pandemic and emerging guidelines on aerosol-generating procedures required us to revisit the need for a perioperative tracheostomy. We present our series of 29 consecutive cases, cared for during the first wave of the COVID-19 pandemic, that were managed either using surgical tracheostomy or overnight tracheal intubation. Out of 29 patients 3 received a surgical tracheostomy. The average duration of tracheostomy use was 8 days. Twenty patients were managed using a period of overnight tracheal intubation. Average duration of tracheal intubation was 1.2 days, with an average intensive care unit stay of 1.7 days. The average duration of hospital stay was 15.8 days for patients managed with overnight tracheal intubation and 30.1 days for patients who received a surgical tracheostomy. The return to theatre rate was 13.8% for reasons including flap failure and neck space infection. There were no airway issues reported in this series of patients. Our findings suggest that overnight tracheal intubation can be a safe alternative to surgical tracheostomy in the majority of cases.

Towards Development of Specular Reflection Vascular Imaging.

Specular reflection from tissue is typically considered as undesirable, and managed through device design. However, we believe that specular reflection is an untapped light-tissue interaction, which can be used for imaging subcutaneous blood flow. To illustrate the concept of subcutaneous blood flow visualization using specular reflection from the skin, we have developed a ray tracing for the neck and identified conditions under which useful data can be collected. Based on our model, we have developed a prototype Specular Reflection Vascular Imaging (SRVI) device and demonstrated its feasibility by imaging major neck vessels in a case study. The system consists of a video camera that captures a video from a target area illuminated by a rectangular LED source. We extracted the SRVI signal from 5 × 5 pixels areas (local SRVI signal). The correlations of local SRVIs to the SRVI extracted from all pixels in the target area do not appear to be randomly distributed, but rather form cohesive sub-regions with distinct boundaries. The obtained waveforms were compared with the ECG signal. Based on the time delays with respect to the ECG signal, as well as the waveforms themselves, the sub-regions can be attributed to the jugular vein and carotid artery. The proposed method, SRVI, has the potential to contribute to extraction of the diagnostic information that the jugular venous pulse can provide.

Readmission Rates Following Major Head and Neck Surgery With Concurrent Tracheostomy.

To determine the influence of major head and neck procedures on readmission and complication rates following tracheostomy. A retrospective cohort study using the 2005 to 2017 National Surgical Quality Improvement Program (NSQIP) database. Current Procedural Terminology codes were used to identify tracheostomy patients and to define the underlying head and neck procedure. Patients under the age of 18 and with unknown pre-operative variables were excluded. Univariate and multivariable analyses were performed. A total of 3240 tracheostomy patients undergoing major head and neck surgery were identified in NSQIP. The 30-day mortality rate was 104 (3.2%) and 258 (9.0%) patients were readmitted. 637 (19.7%) patients had an unplanned return to the operating room. There were 1606 (49.6%) non-tracheostomy specific complications, which included 850 (26.2%) medical and 1142 (35.2%) surgical complications. On multivariable analysis, we found that the underlying procedures did not impact the risk of readmission (P > .05 for all). The underlying procedure was also not associated with unplanned return to the operating room except for thyroidectomies, which had a lower risk than free tissue graft reconstruction (OR = 0.53 (95%CI 0.31, 0.88), P = .018). While almost 1 in every 2 patients had a complication following major head and neck surgery that included creation of a tracheostomy, the rate of readmission is comparatively low and is not associated with the underlying procedure. These findings should reassure head and neck surgeons that properly managed tracheostomies do not constitute a disproportionate risk of readmission.

Analysis of a Consecutive Retrospective Cohort of Strangulation Victims Evaluated by a Sexual Assault Nurse Examiner Consult Service

ObjectiveThe purpose of this study was to review the evaluation of strangulation victims assessed by a sexual assault nurse examiner (SANE) service. The primary objective was to produce observational results on documented injury frequency and secondarily to explore advanced imaging use, outcomes, signs/symptoms, and documentation. MethodsThis was a retrospective analysis of a cohort of 130 consecutive strangled patients over a 42-month period evaluated by a SANE consult service in a metropolitan area. A single investigator extracted medical records for demographics, history, imaging, injuries, disposition, and both presence and documentation of a number of signs/symptoms. A second investigator independently extracted greater than 30% of the total charts with universal agreement. Data were analyzed with descriptive statistics. ResultsPatients were primarily female (129:1) and their age averaged 30.6 years. Time from event to presentation varied. There were no major brain or neck injuries detected (0%; 95 confidence interval, 0-2.31), and all patients were discharged in stable condition. Imaging was used in 23 patients (17.7%). Certain signs and symptoms were more common than others, and documentation frequency of signs and symptoms varied. ConclusionIn this retrospective cohort of 130 consecutive nonfatally strangled awake patients seen as SANE consults in a single emergency department, there were no major injuries documented. The most common signs or symptoms were neck pain, neck markings, and loss of consciousness. Imaging was used in 17.7% of the patients. Presence or absence of neck pain, neck markings, and altered mental status were most consistently documented. Seizure, subcutaneous emphysema, and carotid bruit were least consistently documented.

\u201cMYH9 mutation and squamous cell cancer of the tongue in a young adult: a novel case report\u201d

BackgroundThe incidence of tongue cancer in young adults is on the rise. This trend is more pronounced in females. Although the aetiology is still unclear, there is mounting evidence that genetic syndromes can play a key role in development of oral cancers in this patient group. We report the first case of oral squamous cell carcinoma (oSCC) in a young adult with an MYH9-related disorder (MYH9-RD).Case presentationA 19-year-old female with a germline MYH9 variant (missense variant in exon 2: c.287C > T, (p.Ser96Leu)) was referred to the head and neck surgery department for investigation of a painful, thick right tongue ulcer. She was diagnosed with Epstein syndrome, an MYH9-RD, at 12 years of age. Her main phenotypic features were profound thrombocytopenia and marked renal impairment. The tongue biopsy confirmed SCC. Preoperative positron emission tomography (PET) revealed avidity in the right tongue and ipsilateral level 2A neck lymph node. With substantial preoperative multidisciplinary input, she underwent cancer ablation and microvascular free flap reconstruction. Her pathology showed a 35 mm diameter, 14 mm thick moderately differentiated SCC with perineural and lymphovascular invasion. Two out of 38 right neck nodes were positive for metastasis with extranodal extension. None of the 34 left neck nodes was involved.She had an uneventful recovery and was discharged home on day 6 postoperative day. On day 15 postoperative day, she had catastrophic bleeding in the neck with a respiratory arrest after a forceful cough. She required an emergency tracheostomy and returned to the theatre for haemostasis. Following a short inpatient stay, she was again discharged home and underwent adjuvant therapy consisting of external beam radiotherapy of 60Gy in 30 fractions. On clinical examination and PET at 6 months after surgery, she had no evidence of disease recurrence.ConclusionsMYH9-RD can present with advanced locoregional oral cavity malignancy at an early age. The combination of profound thrombocytopenia and marked renal impairment can impact heavily on routine major head and neck cancer surgery and adjuvant treatment. This rare and challenging condition underlines the importance of early detection of cancer and multidisciplinary team input.

Sarcopenia and its impact in head and neck cancer treatment.

The aim of this review is to discuss recent studies on the assessment of sarcopenia and its predictive and prognostic value in head and neck cancer (HNC) patients. There is increasing evidence that low skeletal muscle mass (SMM), often named sarcopenia, can easily be assessed on cross-sectional imaging of the head and neck and is associated with chemotherapy (dose limiting) and radiotherapy toxicity and survival. SMM measurement at the level of the third cervical vertebra (C3) on routine computed tomography and magnetic resonance imaging is easy and robust to perform. Several studies have shown a significantly higher incidence of cisplatin dose limiting toxicity in HNC patients with a low SMM. In HNC patients pretreatment low SMM is associated with acute and late toxicity and adverse events of radiotherapy, complications of major head and neck surgery and decreased disease-specific and overall survival. This information can be used for individualized treatment planning in HNC patients with low SMM.

Predicted difficult mask ventilation in a patient with huge upper-lip mass succeeds with bag-LMA ventilation

We present a case of adult male patient with enormous swelling of upper lip and scheduled for major head and neck cancer surgery. The mass poses significant challenge of difficult bag mask ventilation at induction of anaesthesia which we managed by bag‐LMA ventilation. This avoided hypoxia that may happen due to failed ventilation and bleeding that may occur by due to improperly fitted face mask. Airway management in such patients requires meticulous planning and consider every option.

The Predictive Value of Elliptical Neck Parameters and Oversizing Ratio for Type Ia Endoleaks after Endovascular Aneurysm Repair

PurposeTo assess the predictive value of geometric parameters for type Ia endoleak (T1AEL) after endovascular abdominal aortic aneurysm repair and to determine the range of optimal oversizing ratio (OSR) in patients with an elliptical cross-section of the aneurysm neck. Materials and MethodsA propensity score-matched case-control study was conducted. Case patients were those who were diagnosed with T1AEL and control patients were those who did not have T1AEL after endovascular aneurysm repair during the period from 2012 to 2018. Geometric and oversizing parameters were compared based on both 2-dimensional (2D) and 3-dimensional measurements. Net reclassification improvement was used to measure the prediction increment of an elliptical model (major axis OSR, neck length, and severe neck angulation) compared with that of the conventional model (OSR 2D, neck length, and severe neck angulation). ResultsNineteen case patients and 111 control patients were included. The median OSR 2D of patients with T1AEL was 17% (interquartile range, 15%–22%), but the median major axis OSR was only 7% (interquartile range, 5%–12%). For the geometric parameters, axis difference had the highest area under the curve (AUC) (0.74; 95% CI, 0.63–0.84) for predicting T1AEL. For the elliptical oversizing parameters, the major axis OSR had an AUC of 0.89 (95% CI, 0.78–0.97), with a cutoff value of 13%. The elliptical model had a higher discriminating ability for T1AEL than the conventional model (AUC 0.91 vs 0.86, respectively; P = .045), with an improved reclassification ability (net reclassification improvement, 27.93%; 95% CI, 19.22%–36.64%; P < .0001). ConclusionsElliptical aneurysm neck cross-section, assessed by the difference between axis dimensions in the plane orthogonal to the centerline, was associated with an increased risk of T1AEL. The prescription of major axis oversizing of at least 13% can significantly reduce the risk of T1AEL formation in patients with an elliptical aneurysm neck.

Increasing sustainability for rice production systems

Rice (Oryza sativa L.) is the staple food for millions of people in Asia and the world; however, it is also the largest consumer of freshwater resources worldwide. More than 75% of the world's rice is grown under flooded conditions. However, the long-term sustainability of this flooded system is threatened by the rapid changes in climatic events causing erratic rainfall and abiotic stresses, looming water and energy crisis, low nitrogen use efficiency, increasing micronutrient deficienties, increasing labor costs and reduced labor availability, increased methane emissions, yield stagnation, and the negative effects of rice crops on post-rice crops. The narrow genetic background in rice has also slowed the pace of breeding rice cultivars tolerant to abiotic and biotic stresses which has resulted in yield stagnation. While direct-seeded rice has become popular in developed countries, saving water and labor resources and reducing methane emissions, developing countries in Asia struggle to disseminate direct seeding technologies due to the lack of government support and policy. Weed management in direct seeded rice is still a major bottle neck in wide scale adoption of this rice system in developing world. Mechanical transplanting of rice is gaining momentum in Asia, reducing labor requirements, ensuring timely transplantation, and saving water during initial growth. Nonetheless, government support and strong policy are needed to boost its uptake by providing subsidies to purchase mechanical transplanters and training farmers to use this technology. With deteriorating soil health due to continuous cultivation of rice with cereals in rotation, overuse of synthetic fertilizers, and increased co-occurrence of abiotic and biotic stresses in rice, there is a need to adopt integrated crop management techniques, and to identify genes of interest and quantitative trait loci (QTL) for their introgression into desired plants. These interventions will improve the improve biotic and abiotic stress tolerance in rice. There is also a need for extensive campaign and policy support from the government to force farmers to harvest their rice crops using specific rice harvesters that can save the yield losses that occur when using wheat combine harvesters—a common practice in many developing countries.

The increasing need of salvage and palliative surgery with microvascular free flaps for advanced head and neck cancers during COVID19 era

Major head and neck oncologic surgery is a high resource-demanding activity. The aim of this manuscript was to highlight the challenges encountered in the management of oncologic head and neck patients undergoing large cancer resection and immediate reconstruction with microvascular free flaps, in a COVID-19 dedicated hospital.

The contralateral based Cervico-pectoral rotation flap for large neck defects

PurposeWe here describe our technique of contralateral based cervico-pectoral (CCP) flap for the reconstruction of large neck defect following resection of primary tumour or recurrence particularly due to the lymph node mass.MethodsThe study included the patients who underwent major head and neck surgical ablative procedures followed by CCP flap reconstruction between July 2020 and November 2020. Patients were kept on rigorous regular follow-up to evaluate for flap related complications like flap necrosis, flap dehiscence and oro-cutaneous fistula. Among the 5 patients included and presented in the series, 2 patients were salvage cases post adjuvant treatment.ResultsFive patients who have undergone head and neck reconstruction using CCP flap were included. No major flap related complications occurred in post-operative period.ConclusionThe CCP flap is simple to perform and reproducible and can be added to the armamentarium for the reconstruction of large upper neck defect following resection of primary tumour or recurrence involving the cervical skin in resource limited setting and in contraindication for microvascular reconstruction. Proper planning, meticulous dissection and adequate release or rotation and tension free closure would provide best outcomes.

Risk of Postoperative Gastrointestinal Bleeding and Its Associated Factors: A Nationwide Population-Based Study in Korea.

Postoperative gastrointestinal bleeding (PGIB) is a serious complication with expensive medical costs and a high mortality rate. This study aims to analyze the incidence of PGIB and its associated factors, including its relationship with postoperative analgesic use. Patients aged ≥20 years who received various kinds of surgery from 2013 to 2017 were included (n = 1,319,807). PGIB was defined by admission with ICD-10 codes of gastrointestinal bleeding plus transfusion within 2 months after surgery. A total of 3505 (0.27%) subjects had PGIB, and the incidence was much higher for those who underwent major gastrointestinal and major cardiovascular surgery (1.9% for both), followed by major head and neck (0.7%), major genitourinary (0.5%), and orthopedic surgery (0.45%). On multivariate analysis, older age, male sex, lower income, comorbidities, peptic ulcer disease, and congestive heart failure were associated with a higher risk of gastrointestinal bleeding. Among analgesics, steroid use was associated with increased postoperative bleeding risk (adjusted OR: 1.36, 95% CI: 1.25–1.48). Acetaminophen/nonsteroidal anti-inflammatory drugs, cyclooxygenase 2 inhibitors, anticonvulsants, antidepressants, and opioids were not associated with increased risk. PGIB is considerable for major surgeries, and its risk should be considered, especially for patients with older age and comorbidities and use of steroids.

Electromyography-Assisted Neuromusculoskeletal Models Can Estimate Physiological Muscle Activations and Joint Moments Across the Neck Before Impacts.

Knowledge of neck muscle activation strategies before sporting impacts is crucial for investigating mechanisms of severe spinal injuries. However, measurement of muscle activations during impacts is experimentally challenging and computational estimations are not often guided by experimental measurements. We investigated neck muscle activations before impacts with the use of electromyography (EMG)-assisted neuromusculoskeletal models. Kinematics and EMG recordings from four major neck muscles of a rugby player were experimentally measured during rugby activities. A subject-specific musculoskeletal model was created with muscle parameters informed from MRI measurements. The model was used in the calibrated EMG-informed neuromusculoskeletal modeling toolbox and three neural solutions were compared: (i) static optimization (SO), (ii) EMG-assisted (EMGa), and (iii) MRI-informed EMG-assisted (EMGaMRI). EMGaMRI and EMGa significantly (p < 0.01) outperformed SO when tracking cervical spine net joint moments from inverse dynamics in flexion/extension (RMSE = 0.95, 1.14, and 2.32 N·m) but not in lateral bending (RMSE = 1.07, 2.07, and 0.84 N·m). EMG-assisted solutions generated physiological muscle activation patterns and maintained experimental cocontractions significantly (p < 0.01) outperforming SO, which was characterized by saturation and nonphysiological "on-off" patterns. This study showed for the first time that physiological neck muscle activations and cervical spine net joint moments can be estimated without assumed a priori objective criteria before impacts. Future studies could use this technique to provide detailed initial loading conditions for theoretical simulations of neck injury during impacts.

Difficult issues in the management of patients with atrial fibrillation: a neurologist's point of view

The article evaluates recent perspectives about the role of oral anticoagulants in the secondary prevention of cardioembolic stroke. The timing of prescribing drugs for ischemic stroke and transient ischemic attack is discussed in accordance with current clinical guidelines and the results of clinical trials. The issues of prescribing oral anticoagulants in some problematic situations, such as the elderly and senile age, reperfusion therapy, presence of hemorrhagic transformation, combined atherosclerosis of major head and neck arteries, cerebral microangiopathy, history of intracerebral hemorrhage, cryptogenic stroke, and low patient compliance are considered. Finally, an anticoagulant therapy algorithm in the acute period of cardioembolic stroke is presented.

1119 Readdressing Consent in Head &amp; Neck Free Flap Surgery: The Nottingham Experience

Abstract Aim The Montgomery vs NHS Lanarkshire case in 2015 led to a paradigm shift in the consent process within surgery. It became incumbent upon clinicians to outline all “material risks” prior to a procedure. Within head and neck surgery, the Enhanced Recovery After Surgery (ERAS) pathway addresses this obligation through a multi-disciplinary approach. The aim of this audit was to assess the effect of the existing ERAS pathway on the consent process. Method 35 head and neck oncology cases involving free flap reconstruction were identified across two audit cycles. Cases pre- and post-introduction of the ERAS pathway were analysed to assess whether the existing pathway led to improvement in consent quality. 8 key consent elements were identified based on a review of current literature and guidelines. This was our gold standard. A tick-box system was devised, and each case assigned a percentage score based on compliance with these criteria. A consent checklist was introduced within the ERAS pathway file alongside multi-disciplinary documentation which would follow the patient from the pre-operative environment through to discharge. Results Prior to the introduction of the ERAS pathway, there was a 58% compliance with the gold standard. Upon implementation of the ERAS protocol, compliance rose to 65%. Following introduction of the checklist, compliance rose further to 85%. This resulted in an overall increase in compliance of 27%. Conclusions We recommend the introduction of a focused consent checklist within any unit providing major head and neck reconstruction procedures in order to ensure informed consent, mitigating medico-legal risks post-operatively.