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However, it is results and decisions expected difference (above) divided by the standard based on the results that matter, not the number of sub- deviation of the difference gives the standardised jects. The power or desired probability of detecting the they miss the agreed and accepted level of significance. Lancet 27Whitehead J 1992 The Design Analysis of Sequential Clinical Trials, 2nd 365:1992–1994. The principles of a meta-analysis The essential feature of these designs is that the trial is ter- are that: minated when a predetermined result is attained and not • It should be comprehensive, i. Reviewing results in a continuous or interim • Only randomised controlled trials should be basis requires formal interim analysis and there are specific analysed, with patients entered on the basis of statistical methods for handling the data, which need to ‘intention to treat’. Group sequential designs are espe- • The results should be determined using clearly cially successful in large long-term trials of mortality or defined, disease-specific endpoints (this may involve major non-fatal endpoints when safety must be moni- a re-analysis of original trials). There are strong advocates and critics of the concept, its Such sequential designs recognise the reality of medical execution and interpretation. Arguments that have been practice and provide a reasonable balance between statisti- advanced against meta-analysis are: cal, medical and ethical needs. Interim analyses, however, reduce the power of statistical significance tests each time • An effect of reasonable size ought to be demonstrable that they are performed, and carry a risk of false positive re- in a single trial. Sensitivity of trials In practice, the analysis involves calculating an odds ra- Definitive therapeutic trials are expensive and on occasion tio for each trial included in the meta-analysis. This is the may be so prolonged that aspects of treatment have been ratio of the number of patients experiencing a particular superseded by the time a result is obtained. The regulatory authorities The number of deaths observed in the treatment group is give guidance as to the number and design of trials that, then compared with the number to be expected if it is as- if successful, would lead to a therapeutic claim. But chang- sumed that the treatment is ineffective, to give the observed ing clinical practice in the longer term depends on many minus expected statistic. The treatment effects for all trials other factors, of which confirmatory trials in other centres in the analysis are then obtained by summing all the ‘ob- by different investigators under different conditions are an served minus expected’ values of the individual trials to important part. From the position of drug development, the general re- The two main outcomes for therapeutic trials are to influ- quirement that scientific results have to be repeatable has ence clinical practice and, where appropriate, to make a been interpreted in the past by the Food and Drug Admin- successful claim for a drug with the regulatory authorities.

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Overall, performed for cases of complex facial paralysis these techniques successfully restore smiles and that involve skin or soft tissue defcits after tumor provide improvement in mouth function in most excision. AlloDerm grafts can be used and also appear Functioning free gracilis microneurovascular as soft tissue bands on imaging, but these do muscle transfer is a form of dynamic facial not offer dynamic facial animation (Figs. The patient had demonstrate the grafted muscle (arrows) within the right right facial paralysis after right cerebellopontine angle face subcutaneous tissues. Alternatively, the muscle of detaching and repositioning the fap approxi- can be extended using polytetrafuoroethylene. The structures, which are fastened to the orbital rim tissues superfcial to the plane of dissection can using a variety of approaches (Fig. Often, be translated superomedially and sutured to the the intraorbital fat pads are also released and fascia of the temporalis muscle. Serial axial T2-weighted suborbicularis oculi fat pad has also been raised 10 Imaging the Postoperative Neck 475 Fig. In the temporalis transposition (A), the temporalis muscle is detached from the calvarium and brought inferomedially over the zygoma toward the oral commissure and nasolabial folds. Of note, one must be particularly degrees of glossectomy may be performed, rang- vigilant for the presence of perineural tumor ing from partial, subtotal, or total, with or with- spread on imaging before and after surgery, out foor of the mouth resection, mandibulectomy, especially following resection of salivary gland and laryngectomy (Figs. Of note, composite tumor division branches of the trigeminal nerve for oral resection consisting of glossectomy, mandibulec- cavity tumors. Furthermore, since radiation often tomy, and neck dissection known as “Commando,” accompanies surgical treatment of oral cancers, an acronym for combined mandibulectomy and the mandible is at risk for osteonecrosis. This neck dissection operation, can be performed for complication tends to occur at least 1 year after advanced cancers of the oral cavity. Furthermore, radiation therapy and appears as areas of cortical the submandibular gland may be removed with irregularity and lucency (Fig.

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Thorek, 45 years: Radiographs can depict the course of the Occipital neuralgia that does not respond to con- leads, which is a nearly horizontal orientation in servative management is sometimes responsive the occipital subcutaneous tissues, perpendicular to occipital nerve stimulation. It connects the superior end of the ovary to Double in size in the lateral pelvic wall. The relative positioning of the pins and ery system appears in the operating room as hose holes is unique for each gas.

Mojok, 51 years: Unfortunately, migration of the steroid to on the heat produced by current fow from an active the site of injury may not be optimal. Valproic acid is associated with polycystic ovary syn- drome and fatal hemorrhagic pancreatitis. Ascites and extrapancreatic effusion within the left anterior pararenal space are present.

Sven, 48 years: Thus, another point of of identifying confounders is to draw a list of all possible factors that debate is whether P-values, as they are, should be stated or only a might infuence the outcome of interest. Safety surveillance To make this decision we need to understand two major concepts, statistical significance and confidence intervals. Its release can be Quality of life inhibited by ligands that act to activate receptors found on the central terminal of the nociceptors (pre-synaptic inhibition).

Chenor, 47 years: This patient’s symptoms of lightheadedness, shaking, sweating, and tremors and relief of symptoms with meals and glucose tablets suggested hypoglycemia. Following that, endoscopic ultrasound The esophagus is normal, but in the body of the stom- might be used to reveal the depth of tumor infiltra- ach (corpus region) there is a tumor with ulceration, tion. Like treatment protocols for diabetic its hyperkalaemic counterpart, Reduced intake ketoacidosis take this into account.

Tizgar, 50 years: Again, the injection should be measurements for 20–30 min or until the completed between contractions. Recurrent tumors can have variable appearances, but most Maxillectomy consists of removing at least a por- commonly appear as growing mass lesions located tion of the maxillary sinus. Once his cortisol deficiency was treated, hyperglycemia was noted and the patients’ diabetes was unmasked.

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