| We are in new territory—like many companies—trying to navigate racial and systemic bias in order to build a truly diverse, equitable and inclusive organizations. There is no one path forward—and there is certainly no standard path forward in business. Here is the path we’ve outlined for ourselves at Starbucks, based on what we know about what motivates our company culture to engage. We’re taking agile step after agile step, adjusting from every learning, action that worked and misstep. | |
A massive design effort, color brave, not color blind, shared experiences are the motivation and common language, whole-human design: the only hope, realization #1: the role of starbucks as a welcoming ‘third place’ needed a serious examination. , realization #2: leaders are learners, too., realization #3: building a sense of goodwill would be vital—we had to create a safe space., realization #4: representation has to become our modus operandi., realization #5: when given the chance, humans rise to their best selves., may 29: a day of conversation, personal reflection and peace.
WE’LL SEE YOU TOMORROW At Starbucks we are proud to be a third place—a place between home and work where everyone is welcome. A place where everyone feels they belong. Today, our store team is reconnecting with our mission and with each other. We are sharing our ideas about how to make Starbucks even more welcoming. We look forward to seeing you when we reopen at ___________.
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May 18, 2018
On May 29, Starbucks will close more than 8,000 U.S. stores for an afternoon of racial bias training for 175,000 employees. The move, expected to cost $12 million, comes after an April 12 incident when two black men were arrested after asking to use a Philadelphia Starbucks restroom without making a purchase.
While it’s unlikely the company will be able to eradicate the effects of unconscious racial bias among its employees in a single afternoon, MIT Sloan senior lecturer Roberta Pittore said the decision to close the stores for training was the right call. As recently as Friday afternoon, the company issued another apology after an employee at a California store wrote a racial slur on a customer's cup.
“Something is better than nothing, more is better than less, and sooner is better than later,” Pittore, who studies communication as it influences decision-making in organizations, said. “I think what it does achieve from Starbucks’ point of view is that it changes the discussion from ‘What did our employee do that was offensive,’ to ‘How can we learn and how can we change?’”
Swift, specific, and sincere
The rise of social media has given people the ability to spread news in milliseconds, and a corporate response needs to match that pace, Pittore said. But, any response also needs to be specific and sincere.
In its initial attempt to address the controversy that day, the company fell flat on at least two of those counts. In releasing a general statement acknowledging the situation and promising a policy review, but failing to mention concerns about racial bias, the company’s response was swift, but it wasn’t specific or sincere enough.
That first statement was followed later in the day by a longer one from CEO Kevin Johnson, who took a more targeted tone, describing the outcome as “reprehensible” and reaffirming the company’s opposition to discrimination and racial profiling. Johnson also released a video in which he took personal ownership for the incident.
Pittore said the revised response indicates Starbucks’ realization that the incident carried more gravity than the company’s leadership had initially thought.
“[A generalized statement] doesn’t seem as sincere — and it isn’t. It isn’t addressing the problem. It’s just saying, ‘We’re good guys … we have good intentions,’” Pittore said. “Well, everyone has good intentions, so what are your good intentions about this very real, very specific, very tangible incident?”
Soon after, Johnson traveled to Pennsylvania to meet with the two men and offer a face-to-face apology. Pittore said that move, too, was appropriate, given the climate surrounding the incident. In May, the company also reached a financial settlement with the pair for an undisclosed amount of money and a promise to help them complete their bachelor’s degrees through the company’s employee tuition assistance program.
“The company appropriately should find out from them, ‘How do we make this up to you?’” Pittore said.
When public access is part of your business model
At the core of Starbucks’ brand is the idea that its coffee shops can serve as a “third place” for meet-ups, studying, or work on the go. With the arrests, a single store manager’s decision saw that carefully-crafted persona of a socially progressive and inclusive community hangout begin to unravel.
“They’re not selling you a cup of coffee. They’re saying, ‘We’re the part of the community that you’re in when you’re not at the office and you’re not at home,’” Pittore said. “When you think about that, you have to think about the larger community and about ‘How do we, as a public, want that third place to be. Bottom line, it should feel safe. It should feel welcoming, and that’s really the crux of the problem.”
That problem isn’t unique to Starbucks, either, Pittore noted — it’s a societal problem that came to a head in a very visual way in Philadelphia.
“The specific actions of that one specific employee uncovered a larger issue of racial bias, frankly, in our culture. If you narrow it down, you have an incident that you can’t sweep under the rug,” she said. “The question for Starbucks is ‘What do we do? We didn’t create this problem, but we’re part of this society where this is happening, and if we’re going to be that third place, what is that third place going to look like?’”
Moving forward, Pittore said Starbucks should review its policies, the composition of its board and leadership, its gender, race, and age demographics among its employees, and its wage structures to determine how socially conscious the company really is and decide where, on that spectrum, it wants to be.
This SWOT analysis of Starbucks Corporation (Starbucks Coffee Company) examines the results of the company’s strategies that employ business strengths to overcome weaknesses, exploit opportunities, and protect the business against threats and barriers to success in the coffee and coffeehouse industry environment. The SWOT Analysis model is a strategic management tool for assessing the strengths, weaknesses, opportunities, and threats (SWOT) relevant to the business and its internal and external environments. This SWOT analysis of Starbucks considers the strengths and weaknesses (internal strategic factors) inherent in the coffee and coffeehouse business. This business analysis case also considers the opportunities and threats (external strategic factors) related to the competitive landscape, which involves the strong force of competition, as determined in the Five Forces analysis of Starbucks . This competitive environment and the factors in this SWOT analysis require that the company continuously improve its business strengths to optimize its financial performance and growth trajectory.
Starbucks faces challenges to business growth as it develops products to complement its core coffeehouse business. Starbucks’ marketing mix or 4P indicates product mix expansion to include tea, food, and merchandise, in addition to coffee. In the SWOT analysis framework, this business condition creates a challenging environment where the company needs to use different sets of strategies and competencies that match various industries and markets. Strategic planning that accounts for the internal and external factors shown in this SWOT analysis can increase Starbucks’ success against competing coffeehouse firms and food-service businesses, like Tim Hortons, Dunkin’, McDonald’s , Subway , Burger King , and Wendy’s .
This component of the SWOT analysis model deals with the internal factors that the company can use as strengths to address weaknesses and protect the business against competition. Starbucks’ main strengths are as follows:
Starbucks is one of the world’s strongest and most popular brands. The company has a growing population of loyal customers, which adds to the stability of the coffeehouse business. In the SWOT analysis model, effective capabilities for managing a global supply chain strengthen Starbucks by supporting operations that connect production (e.g., Arabica coffee beans in plantations) to consumption (e.g., caffeinated drinks in coffeehouses). Also, the company gradually diversifies its business through new products and new subsidiaries, resulting in the current product mix and brands of Ethos Water, Teavana, and others. Diversification makes the effects of market and industry risks on Starbucks’ coffee business more manageable. The internal strategic factors in this part of the SWOT analysis show that the business has strengths that promote resilience, through diversification and a global supply chain, for the achievement of business goals derived from Starbucks’ mission statement and vision statement .
Business weaknesses are identified in this component of the SWOT analysis. Weaknesses are internal factors that reduce or limit the capabilities of the coffeehouse company. Starbucks’ weaknesses are as follows:
Starbucks has high price points that maximize profit margins but reduce the affordability of its products. The related pricing strategy, an internal strategic factor, is a weakness because it limits the coffee company’s market share, especially in areas with relatively lower disposable incomes. Also, this SWOT analysis considers Starbucks’ generalized standards a weakness that limits the flexibility of the coffeehouse chain’s business organization. For example, the company’s generalized standards for crafted beverages reduce these products’ cultural alignment with local target markets and consumer preferences. In addition, many Starbucks products are imitable. For instance, small local competitors can develop beverages like the company’s products. Even the design and ambiance of the company’s cafés are imitable. Imitability is a weakness that empowers competitors. The internal factors in this part of the SWOT analysis of Starbucks Coffee Company show that the business must develop strengths to reduce the adverse effects of imitation and high price points on the company’s market share in the global industry.
This part of the SWOT analysis model focuses on external factors that present opportunities for business growth and development. In this case, the main opportunities available to Starbucks are as follows:
Starbucks Corporation can increase its revenues by increasing its operations in developing markets, many of which have high economic growth rates. This opportunity draws attention away from the U.S. market, where most of the coffeehouse company’s revenues are generated. Also significant in this SWOT analysis is higher business diversification, which can improve Starbucks’ long-term stability. For example, further diversification can reduce the coffee company’s dependence on a single market, market segment, or industry, thereby reducing risks and improving revenue growth opportunities. Diversification is currently a minor growth strategy, as shown in Starbucks’ generic competitive strategy and intensive growth strategies . The industry environment considered in this SWOT analysis also presents the opportunity to strengthen the company’s market position through additional partnerships or alliances with other firms. For instance, additional or reinforced alliances with major retailers can improve the distribution and market share of Starbucks’ consumer goods, such as ready-to-drink coffee. The external strategic factors in this part of the SWOT analysis show that Starbucks can improve its industry position by exploiting the opportunities, such as diversification and alliances in the global industry environment.
Threats to the coffeehouse business are identified in this part of the SWOT analysis. These threats are external factors that reduce or limit business performance. In this company analysis case, the following are the main threats relevant to Starbucks:
Starbucks Corporation competes with many firms in the international market. For example, the company’s products compete with lower-cost coffee products from restaurant chains, like McDonald’s and Dunkin’. This external strategic factor threatens Starbucks because such competitors can reduce the company’s market share by competing based on low prices. Also, this SWOT analysis considers imitation as a threat to the coffeehouse business. This threat of imitation involves firms that try to copy the taste, look, and feel of Starbucks products. In addition, the industry environment is subject to independent coffeehouse movements. These movements are sociocultural efforts that support the operations of small independent local coffeehouses and oppose the expansion of multinational coffeehouse chains, like Starbucks. Such sociocultural trends influence consumer perception and purchasing behaviors, as shown in the PESTEL/PESTLE analysis of Starbucks . Successful marketing campaigns and branding strategies are needed to counteract the effects of these trends. This part of the SWOT analysis of Starbucks Coffee Company identifies external strategic factors that impose challenges to international expansion and market penetration.
The industry environment of Starbucks involves diverse challenges, especially because of the company’s moderate diversification. The coffeehouse chain business faces issues, such as competition, imitation, and social trends that oppose international players in local markets. Based on the current condition of the business, some of the most notable strategic management concerns enumerated in this SWOT analysis of Starbucks Coffee Company are the imitability of products and the corresponding threat of imitation, the threat of competition involving low-cost sellers, and independent coffeehouse movements.
Based on this SWOT analysis, a recommendation for protecting Starbucks’ business against imitation is to aggressively innovate, especially in product development. Innovation can make the company’s products more difficult to imitate. It is also recommended that Starbucks Corporation consider pricing strategies that attract more customers. For instance, bundle pricing can help address the threat of competition involving low-cost sellers. Furthermore, a suitable recommendation in this SWOT analysis case is to implement creative marketing and branding strategies that build Starbucks’ corporate image as a contributor to community development. Such an image can help reduce sociocultural opposition against the company’s expansion. These recommendations focus on minimizing the negative impacts of the internal and external factors enumerated in this SWOT analysis of Starbucks.
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BMC Oral Health volume 24 , Article number: 973 ( 2024 ) Cite this article
Metrics details
Patients with mild oral and maxillofacial space infection (OMSI) usually need only antimicrobial therapy. However, surgical intervention is eventually needed after using antibiotics for a period. The objective of this study was to explore the risk factors for drug therapy failure in OMSI.
A retrospective case‒control study was designed. From August 2020 to September 2022, patients at Shanghai Jiao Tong University Affiliated Ninth People’s Hospital who were diagnosed with OMSI were retrospectively reviewed. The outcome variable was surgical intervention after the use of antibiotics. We collected common biological factors, including demographic characteristics, routine blood test results, C-reactive protein (CRP) levels and composite indicators, such as neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR). The χ2 test and binary logistic regression were used to examine the association between biological factors and the outcome variable.
Forty-six patients were included in this study. Further surgical intervention was needed in 20 patients (43.5%). The NLR showed a significant association with further surgical drainage ( p = 0.01). A binary logistic regression equation was found by using stepwise regression based on the Akaike information criterion (R2 = 0.443), which was associated with sex (odds ratio [OR], 0.216; p = 0.092), NLR (OR, 1.258; p = 0.045), red blood cell (RBC) count (OR, 4.372; p = 0.103) and monocyte (MONO) count (OR, 9.528, p = 0.023). Receiver operating characteristic analysis produced an area under the curve for NLR of 0.725 ( p = 0.01) and for the binary logistic regression model of 0.8365 ( p < 0.001).
Surgical interventions are needed in some mild OMSI patients when antimicrobial therapy fails to stop the formation of abscesses. The binary logistic regression model shows that NLR can be used as an ideal prognostic factor to predict the outcome of antimicrobial therapy and the possibility of requiring surgical intervention.
Using simple, inexpensive, and easily achieved biological parameters (such as routine blood test results) and composite indicators calculated by them (such as NLR) to predict whether surgical intervention is needed in the future provides a reference for clinical doctors and enables more cost-effective and efficient diagnosis and treatment.
Peer Review reports
Oral and maxillofacial space infection (OMSI) primarily originates from odontogenic infection and can also occur as a result of adenogenic, haematogenous or latrogenic factors. The infection can spread widely through cellular-adipose tissue and fascial planes in the maxillofacial region. This allows the infection to penetrate deeper into the tissues and can result in the development of OMSI cellulitis or the formation of abscess [ 1 ]. When an abscess has formed with purulent collection during infection evolution, surgical intervention is needed to expel pus and necrotic tissue from the body. It is necessary and effective in reducing local pain and swelling, as well as preventing apnoea. It also guards against infection diffusion to the craniocerebral region or blood circulation, causing serious complications, including brain abscess, Ludwig’s angina and descending necrotizing mediastinitis [ 2 ]. These complications can have detrimental effects on the patient’s health and may require additional interventions for management.
If a contrast CT scan does not reveal obvious signs of abscess, the common practice is to administer antimicrobial therapy. After a few days of treatment, medical staff need to monitor the patient closely to assess if the cellulitis is shrinking or if the infection is worsening to the extent of developing one or multiple abscesses. Once a contrast CT scan confirms the presence of purulent collection after antibiotherapy, surgical intervention is required to achieve the therapeutic goals mentioned above.
Patients who require surgery often experience more severe clinical symptoms, accompanied by a higher risk of complications. For some of them, the infection may become severe enough to warrant hospitalization. This not only adds to the physical and emotional burden experienced by patients but also leads to increased financial expenses. Moreover, the prolonged absence from work or school due to hospitalization further adds to the financial burden and can have negative consequences on the patients’ professional or academic life. In addition, intraoral surgical incisions for drainage tend to be less concerning aesthetically for patients; however, extraoral incisions may result in aesthetic sequelae that could impact the patient’s self-esteem and quality of life. Furthermore, more medical resource inputs are placed in these patients since they require specialized care, including frequent monitoring and wound dressing [ 3 ]. Consequently, the surgical intervention should be well indicated and justified. However, to our knowledge, few studies have explored risk factors associated with surgical intervention in patients with mild infection. Further studies in this area can improve patient care and outcomes.
The neutrophil to lymphocyte ratio (NLR) is a systemic inflammatory indicator derived from routine haematological parameters, which currently has been reported as an independent predictor in inflammation-associated diseases such as malignant tumours, cardiovascular diseases, and neurological diseases [ 4 , 5 , 6 , 7 ]. NLR has attracted considerable attention for its ease and low cost in prediction. Research has reported that during inflammatory stress, neutrophils increase, and lymphocytes undergo apoptosis, resulting in an elevated NLR [ 8 ]. In terms of OMSI, NLR has been mentioned as an emerging predicator. Research has reported that the NLR contributes to the severity of infection in terms of the involved spaces and complications in severe and extremely severe oral and maxillofacial space infection patients [ 9 ]. It is also regarded as a prognostic marker of deep neck space infections second to odontogenic infection [ 10 , 11 ]. There is evidence that NLR significantly decreases after surgical drainage in odontogenic cervicofacial phlegmon patients, while it remains at a high level on admission to the hospital [ 12 ]. Higher NLR values may lead to unfavourable prognoses in sepsis patients [ 13 ].
Some routine haematological parameters are associated with severity in OMSI, such as white blood cell (WBC) count, neutrophil (NEU) count and C-reactive protein (CRP) level. Utilizing these haematological parameters, previous studies have attempted to predict clinical outcomes such as the length of hospital stay and reoperation rate [ 14 , 15 , 16 , 17 ].
The purpose of the study was to explore the diagnostic value of common haematological parameters and composite parameters, such as NLR, in predicting the possibility that surgical intervention may eventually be required in mild OMSI patients to assist clinicians in making accurate early diagnoses.
From August 2020 to September 2022, 46 patients at Shanghai Jiao Tong University Affiliated Ninth People’s Hospital diagnosed with OMSI were included in a retrospective study (Fig. 1 ).
Flow chart of the retrospective study
The inclusion criteria for patients with OMSI were as follows: (1) clinical manifestations of typical inflammation, including local redness, swelling, pain, increased skin temperature, and local dysfunction; (2) inflammatory indicators at a high level supporting the diagnosis of inflammation; (3) a contrast CT scan showing no obvious evidence for abscess formation at the first visit; and (4) treatment with antimicrobial therapy received from hospital for no less than 3 days.
The exclusion criteria were as follows: (1) malignant tumour-related infection; (2) previous surgical intervention before the first visit at our hospital; (3) pregnancy; and (4) self-medication with antibiotics before or after the first visit.
All the procedures of the study were in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital (SH9H-2021-T400-2).
The outcome variable was surgical intervention after antimicrobial therapy failure.
Surgical intervention was performed when there was presence of abscess formation, which was detected by a contrast CT. The potential predictor variables consisted of demographic characteristics and laboratory examination. Demographic characteristics included patient age at first visit to the hospital and gender (male or female). Laboratory examination comprised both routine full and differential blood cell counts (lymphocytes, leukocytes, neutrophils, eosinophils, basophils, and monocytes) (categorized as normal or abnormal), CRP levels (categorized as normal or abnormal), and composite indicators, including NLR and platelet to lymphocyte ratio (PLR). The clinical laboratory of Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital conducted thorough examinations to determine whether the laboratory test results fell within the normal range or exhibited abnormalities.
The study variables were acquired from each patient’s medical records. Multiple imputation was used to fill 4 missing data points. Continuous variables are reported as the mean and standard deviation. The Mann‒Whitney U test was used to test the association between continuous predictor variables and the outcome variable. Categorical variables are reported as percentages and were tested by the χ2 test. p < 0.05 was considered statistically significant. All variables with p < 0.2 were included in the multicollinearity test, and then the selected variables were used to build a binary logistic regression model by stepwise selection based on the Akaike information criterion (AIC).
Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive effect and diagnostic value of different biological variables and the combination of multiple factors on surgical intervention. We used a calibration curve to assess calibration accuracy, accompanied by the Hosmer‒Lemeshow test. We also used forest plots and nomograms to visualize the comprehensive results of the model.
Analyses were performed using R statistical software.
A total of 46 patients diagnosed with OMSI were enrolled in this study. None of the patients had formed an abscess by their first visit. Table 1 presents the study variables, encompassing the population characteristics and haematological parameters of the patients. The study population consisted of 27 males (58.7%) and 19 females (41.3%), resulting in an almost equal distribution in terms of gender. Their ages ranged from 8 to 94 years, with a mean age of 53.6 (± 19.0) years. Abnormal haematological results accounted for 73.9% (34) of WBC counts, 80.4% (37) of neutrophil cell (NEU) counts, and 82.6% (38) of CRP levels. Additional details can be found in Table 1 . The specific data of the haematological examination results are provided in Table S1 in the Supplementary Materials. In Table S2 in the Supplementary Materials, abnormal value markers for all haematological indicators are provided, indicating whether the abnormal values are higher or lower relative to the normal values. Except for HCT, EOS count, and MONO percentage, the abnormal values for all other indicators uniformly demonstrate a consistent trend of being either higher or lower in comparison to the normal values. The mean NLR was 7.7 ± 4.9.
Twenty patients underwent surgical drainage, resulting in a surgery rate of 43.5% in the study population. The results of the association between the study variables and the outcome variable are presented in Table 2 . Four variables (WBC count, NEU count, MONO count and NLR) exhibited a significant correlation with surgical intervention ( p < 0.05). Additionally, there was a tendency for RBC count, EOS percentage (0.05 < p < 0.1), sex, NEU count and LYM count (0.1 < p < 0.2) to be correlated with surgical intervention. The abnormal values of the above haematological variables all show the same trend of being either higher or lower relative to the normal values.
After including the correlated variables ( p < 0.2) into the binary logistic regression analysis as mentioned earlier, we found that four variables, including sex, NLR, RBC count and MONO count, remained significant in the final model (Table 3 ).
An increase in NLR and abnormalities in RBC count and MONO count were found to increase the likelihood of undergoing surgical intervention; however, being female was associated with a decreased likelihood of undergoing surgical intervention.
The ROC curve was used to analyse the performance of the regression model and independent variables in the model in predicting surgical intervention (Fig. 2 ).
The ROC curve indicated that NLR was able to effectively distinguish the rate of surgical intervention after antimicrobial therapy failure. NLR demonstrated a 72.5% accuracy (AUC 0.725 [95% CI 0.578–0.872], p = 0.01), with a cut-off value of 5.50 predicting surgical intervention with 80.0% sensitivity and 61.5% specificity.
Moreover, the ROC curve revealed that the predictive ability of multiple variables was superior to that of a single factor. The regression model had 83.7% accuracy (AUC 0.837 [95% CI 0.720–0.953], p < 0.001).
We also used forest plots and nomograms to visually present the comprehensive results of the regression model. In the forest plot, the influence of various variables is graphically depicted, providing a comprehensive overview of the effect size for each individual variable as well as the collective effect size. It becomes evident that an elevation in the count of MONO, RBC, and NLR is indicative of a risk factor. Conversely, being female is associated with a protective effect. Additionally, NLR, as an influential factor within the multifactorial model, exhibits a relatively narrow confidence interval and a statistically significant p -value (Fig. 3 ). Utilizing logistic regression, a scoring criterion is established within the nomogram, based on the regression coefficients of the independent variables. The ‘risk’ indicated on the final line, derived from the ‘total points’, serves to represent the model’s predicted risk level, thereby enhancing the comprehensibility and interpretability of the predictive outcomes (Fig. 4 ).
Forest plot. *The dashed line (x = 1) represents an invalid line. The solid horizontal line represents the results of each study variable. Lines on the left side of the valid line indicate protective factors, while lines on the right side indicate risk factors. The size of the diamond represents the weight of each variable in the model, and the colour indicates the p value. The length of the solid lines represents the 95% CI
Nomogram. *To determine the risk of undergoing surgical intervention predicted by the logistic regression model, these steps were followed: a vertical line was made from the axis of each parameter, and the corresponding value on the line labelled ‘Points’ was located. The points of all the parameters were added together. Then, another vertical line was drawn from the axis labelled ‘Total Points’, and the corresponding number on the ‘Risk’ axes was found. The number on the line labelled ‘Risk’ represents the predicted risk of undergoing surgical intervention
Next, we utilized the calibration curve to demonstrate a strong agreement between the prediction and observation in the study cohort (Fig. 5 ). Additionally, the Hosmer‒Lemeshow test yielded a nonsignificant statistic ( p = 0.693), indicating no deviation from a perfect fit.
Calibration curve. *The calibration curve illustrates the agreement between the predicted risks of surgical intervention and the observed actual risks of surgical intervention. The x-axis represents the predicted probability of surgical intervention, while the y-axis represents the observed probability of surgical intervention. The diagonal dotted line represents the ideal predicted results of a perfect model. On the other hand, the solid line represents the predictions made by our bias-corrected regression model. The closer the solid line is to the diagonal dotted line, the more accurate the calibration of the model
The aim of the study was to explore risk factors associated with surgical intervention in OMSI patients. Although we found that several variables showed a correlation tendency with the outcome in the single-factor screening, binary logistic regression ultimately identified 4 key variables: male sex showed negative associations, increased NLR showed positive associations, and abnormal MONO count and RBC count showed positive associations. Among all the factors, NLR, as a composite index, was found to have a significant association with surgical intervention. When used as an independent predictor, the NLR showed good discrimination between outcomes. Additionally, when included as a component in the multivariable regression model, it improved the prediction performance, making the model’s ability to predict superior to that of a single factor.
The proportion of male and female patients in the study was relatively balanced, and males comprised 58.7% of the study population. The average age was 53.6 years, which was also close to the population characteristics in other studies on OMSI [ 18 , 19 ].
Gender differences are a controversial risk factor related to OMSI. Samuel et al. analysed 1002 hospitalized patients diagnosed with OMSI and found that the probability of males needing immediate airway management was significantly higher than that of females (male 7% vs. female 2%, p = 0.001), the WBC count in males was significantly higher than that in females (male 12.4*10 9 /L vs. female 11.1*10 9 /L, p = 0.000), and C-reactive protein was also significantly higher than that in females (male 78 mg/L vs. female 59 mg/L, p = 0.001) [ 20 ]. Multiple studies have indicated that male patients face a higher risk of hospitalization following surgeries and a greater likelihood of requiring intensive care unit (ICU) treatment [ 14 , 21 ]. However, there were also studies showing little correlation between gender and OMSI severity in terms of length and cost of hospitalization, severe complications and reoperation risk [ 3 , 10 , 17 ]. The final regression model of our study retained gender as a risk factor associated with the outcome. The OR value of sex was 0.21 < 1, indicating that female sex was a protective factor, which was consistent with previous studies. The final regression model of our study found that gender was not statistically significant in relation to the outcome ( p = 0.092). However, importantly, insignificance does not necessarily mean that the variable should be removed from the model, as a small sample size could also contribute to this result. The use of backwards stepwise selection based on AIC made the result acceptable.
Serum laboratory tests are relatively simple and inexpensive. They are easy to perform and widely accepted by most individuals. We selected routine blood tests and CRP levels as the parameters to be examined, which can provide results quickly. Since these parameters are routinely tested in almost every infection patient who visits the hospital, the prediction can be made at no additional cost. In summary, the prediction can be done quickly and does not impose any extra financial or time burden on the patients.
The NLR has been widely used in prognostic prediction in inflammation-associated diseases such as malignant tumours. In the context of OMSI, it is commonly used as a predictive factor for severe complications and the length of hospitalization [ 9 , 10 , 22 ]. However, we have not come across any research related to NLR in relation to mild OMSI. Our study demonstrated that the NLR significantly influenced surgical intervention and acted as a risk factor ( p = 0.045, OR = 1.26 [95% CI 1.01–1.57]). The ROC curve analysis revealed that NLR had higher accuracy than other risk factors (AUC = 0.725, p = 0.01), indicating its ability to correctly identify patients in need of surgical intervention. The determined cut-off value was 5.50, which may provide a reference for clinical work. Furthermore, the final regression model showed even better discrimination (AUC = 0.837, p < 0.001), suggesting that multiple variables have a stronger impact on the outcome and yield higher discrimination in the results. This provides a reliable basis for determining further surgery and can be considered a criterion for judgement in subsequent clinical decisions. The forest plot and nomogram were used to visualize the results of the regression model. The nomogram, in particular, makes it easy and quick to use the model. These tools provide reliable references for clinical doctors and enable a higher level of nurse care for patients. Additionally, they can help decrease unnecessary consumption of medical resources.
During infection, MONOs further differentiate into tissue macrophages and dendritic cells, thereby mediating the immune response. They also possess the ability to be recruited to the site of infection and directly engage in antibacterial activity. Additionally, they participate in the initial inflammatory response by releasing factors such as tumour necrosis factor (TNF) and chemokines [ 23 , 24 ]. All 32 abnormal MONO counts in our study were higher than the normal range. In our statistical analysis, MONO count was found to be significantly associated with the outcome ( p = 0.023), suggesting that a higher MONO count could be regarded as a risk factor (OR = 9.53 [95% CI 1.37–66.17]). However, the confidence interval for this association was wide, possibly due to the use of categorical variables in the statistical analysis or the small sample size and unstable distribution. In further studies, it is recommended to increase the sample size and report MONO count as a continuous variable to better observe its impact on the outcome.
RBCs undergo activation during inflammation triggered by bacterial infection, leading to a sequence of pathological alterations such as erythrocyte deformation and programmed cell death [ 25 ]. E. Pretorius et al. reported that the erythrocyte membrane interacts with inflammatory molecules, resulting in erythrocyte deformation and programmed cell death. These processes have an impact on haemorheology and can serve as a parameter for identifying the presence and extent of inflammation [ 26 ]. In our study, all 17 abnormal RBC counts were found to be lower than the normal range, which is consistent with previous studies. The final model in our study included RBC count as a risk factor (OR = 4.37 [95% CI 1.37–66.17], p = 0.103]). Similar to the MONO count, the confidence interval was also wide, indicating that further confirmation is needed to determine its specific impact on the outcome.
In addition, we observed a lack of correlation between surgical drainage and CRP levels. This finding is in contrast to previous studies that have demonstrated a relationship between CRP levels and factors such as the length of hospitalization, the number of spaces involved, and the rate of reoperation in OMSI patients [ 15 , 17 , 27 ]. In our study cohort, 82.6% of patients had abnormal CRP levels. This high prevalence can be attributed to the fact that CRP is a highly sensitive and responsive indicator of acute infection [ 28 , 29 ]. Furthermore, we treated CRP level as a categorical variable in our analysis, so the results we obtained showed no significant difference between the group that underwent a surgical intervention and the group that did not.
The study is an exploratory retrospective case‒control study, which inherently has limitations. The small sample size resulted in some statistical results being unstable. Only population characteristics and simple serum laboratory test results were analysed, while other potential risk factors, such as spaces involved, potential systemic diseases, clinical symptoms at admission (fever, pain, mouth opening, etc.), and basic vital signs (blood pressure, pulse, temperature, etc.), were not included in the analysis.
Within limitations associated to the present study, NLR has been found as an effective parameter for predicting surgical intervention in mild OMSI patients. Additionally, sex, MONO count and RBC count also contributed to the outcome. The application of simple and easily accessible serum tests to predict surgical intervention enables the efficiency and effectiveness of medical resources while also providing more opportunities to deliver higher quality care to patients.
All data generated or analysed during this study are included in this published article and its supplementary information files.
Akaike information criterion
Area under curve
Basophil granulocyte
Confidence Interval
C-reactive protein
Eosinophils
Haemoglobin
Haematocrit
Intensive care unit
Lymphocyte cell
Neutrophil cell
Platelet to lymphocyte ratio
Red blood cell
Receiver operating characteristic
Tumour necrosis factor
White blood cell
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This study was supported by the National Natural Science Foundation of China (Grant No.82174041, 82302553, 82370976), Shanghai Young Science and Technology Talents Sailing Program (Grant No. 22YF1422300) and the Biological Sample Bank Project of Ninth People’s Hospital Affiliated with Shanghai Jiao Tong University School of Medicine (Grant No.YBKB202107, YBYB202212).
Yimin Liu and Hanyi Zhu contributed equally to this work.
College of Stomatology, Shanghai Jiao Tong University, Shanghai, China
Yimin Liu, Hanyi Zhu, Xin Bao, Lingyan Zheng & Huan Shi
Department of Oral Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, No. 639, ZhiZaoJu Road, Shanghai, 200011, China
Yimin Liu, Hanyi Zhu, Xin Bao, Zhiyuan He, Lingyan Zheng & Huan Shi
National Center for Stomatology, Shanghai, China
National Clinical Research Center for Oral Diseases, Shanghai, China
Shanghai Key Laboratory of Stomatology, Shanghai, China
Shanghai Research Institute of Stomatology, Shanghai, China
Department of Health Statistics, Second Military Medical University, Shanghai, China
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Lingyan Zheng and Huan Shi made substantial contributions to the conception. Yimin Liu and Huan Shi designed the work. Yimin Liu, Hanyi Zhu, Xin Bao and Zhiyuan He acquired the data. Yinyi Qin, Yimin Liu and Hanyi Zhu analyzed and interpreted the data. Yimin Liu, Hanyi Zhu and Xin Bao drafted the work. Lingyan Zheng and Huan Shi substantively revised it. All authors approved the submitted version, agreed both to be personally accountable for the own contributions and to ensure that questions related to the accuracy or integrity of any part of the work. Yimin Liu and Hanyi Zhu contributed equally to this work.
Correspondence to Lingyan Zheng or Huan Shi .
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The study was approved by the Ethics Committee of Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital (SH9H-2021-T400-2). The Ethics Committee of Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital waived the informed consent.
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Liu, Y., Zhu, H., Bao, X. et al. When is surgical intervention needed in oral and maxillofacial space infection patients? A retrospective case control study in 46 patients. BMC Oral Health 24 , 973 (2024). https://doi.org/10.1186/s12903-024-04737-1
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