Telephone versus face-to-face clinics for the management of new rhinology referrals: a retrospective cohort study.

OBJECTIVE: This study aimed to compare outcomes of telephone and face-to-face consultations for new rhinology referrals and discuss the wider use of telemedicine in rhinology. METHOD: This was a retrospective cohort study of new rhinology referrals seen in either a telephone or face-to-face clinic. Primary outcome was the proportion of patients given a definitive outcome at initial appointment (discharged or added to waiting list) versus those requiring follow up. RESULTS: A total of 137 patients (70 telephone, 67 face-to-face) were included. A total of 45 of 67 patients (67 per cent) undergoing a face-to-face consultation received a definitive outcome following initial review, versus 11 of 70 (16 per cent) telephone patients. Of 70 telephone patients 57 (81 per cent) were followed up face-to-face for examination. CONCLUSION: The role of telephone clinics in the assessment of new rhinology referrals is currently limited by the lack of clinical examination. Further research on developing remote assessment pathways that incorporate asynchronous review of recorded examinations are needed before telemedicine can become established within the rhinology clinic.

A systematic review on efficacy, safety and cost-effectiveness of office-based laryngeal biopsy.

OBJECTIVE: Laryngeal cancer is the second most prevalent head and neck malignancy in the USA. With recent advances in technology, this procedure is increasingly performed under local anaesthesia. This study aimed to identify the efficacy, safety and cost-effectiveness of laryngeal biopsy in out-patients by conducting a systematic review. METHOD: A literature search was conducted using PubMed, Medline, Google Scholar and Embase over a 20-year period. Inclusion criteria were: studies performed on out-patient diagnostic biopsy procedures of the larynx. Exclusion criteria included all therapeutic procedures. The outcome measures were sensitivity and specificity, complication rate and cost-savings. RESULTS: Thirty-five studies were included in the analysis. The sensitivity and specificity varied from 60 to 100 per cent with a low complication rate and cost savings. CONCLUSION: Office-based laryngeal biopsies are increasingly used in the diagnosis of laryngeal cancers, resulting in earlier diagnosis and commencement of treatment. The barrier to undertaking this procedure is low sensitivity.

Evaluating the perceptions of workplace-based assessments in surgical training: a systematic review.

INTRODUCTION: Workplace-based assessments (WBAs) are intended to maximise learning opportunities in surgical training. There is speculation as to whether mandatory assessments in this form contribute to a tick-box culture. The objective of this review was to investigate surgical trainees' attitudes towards WBAs. METHODS: This systematic review of qualitative studies was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. The literature was searched on the Medline®, Embase™, PubMed and Web of Science™ databases on 22 March 2022. RESULTS: Sixteen studies were included in the review, mostly carried out on users of the Intercollegiate Surgical Curriculum Programme portfolio in the UK. Trainees felt that WBAs were educationally useful, providing opportunity for feedback, but this was overshadowed by a pressure to reach a set annual quota for WBAs and achieve high scores. Other themes included inaccurate recording of WBAs, the role of WBAs as formative or summative assessments, engagement and accessibility of trainers, and lack of time to complete WBAs. CONCLUSIONS: Negative perceptions about WBAs were widespread among surgical trainees despite a recognition of their capacity to facilitate learning. This review supports the recent removal of the annual quota for WBAs in UK surgical training programmes.

Retrospective analysis of the risk of neoplasia associated with unilateral maxillary sinus opacification on computed tomography.

BACKGROUND: Unilateral maxillary sinus opacification on computed tomography may reflect an inflammatory or neoplastic process. The neoplasia risk is not clear in the literature. METHODS: In this retrospective study, computed tomography sinus scans performed over 12 months were screened for unilateral maxillary sinus opacification, and the rates of inflammatory and neoplastic diagnoses were calculated. RESULTS: Of 641 computed tomography sinus scans, the rate of unilateral maxillary sinus opacification was 9 per cent. Fifty-two cases were analysed. The risk of neoplasia was 2 per cent (inverted papilloma, n = 1). No cases of unilateral maxillary sinus opacification represented malignancy, but one case of lymphoma had an incidental finding of unilateral maxillary sinus opacification on the contralateral side. Patients with an antrochoanal polyp (n = 3), fungal disease (n = 1), inverted papilloma and lymphoma all had a unilateral nasal mass. CONCLUSION: Our neoplasia rate of 2 per cent was lower than previously reported. A unilateral mass was predictive of pathology that required operative management. Clinical findings, rather than simple findings of opacification on computed tomography, should drive the decision to perform biopsy.

Senior triaging of ENT emergency clinic referrals alleviates pressures on the outpatient department.

INTRODUCTION: The ear, nose and throat (ENT) emergency clinic is managed by foundation year (FY) doctors from taking referrals to discharging patients, under the supervision of a registrar. FYs learn essential skills and knowledge on how to manage common ENT problems. The clinic is often overloaded because of a high patient demand, and this limits the opportunities for teaching. We hypothesised that the clinic bookings would be better managed if referrals from general practitioners (GPs) were triaged by registrars. METHODS: Telephone referrals from GPs for the ENT emergency clinic were directed to the on-call ENT registrar, between 8am and 1pm from Monday to Friday, and to the FY outside of this period. Consecutive referrals to the emergency clinic were analysed in a baseline audit and a post-intervention cycle. RESULTS: A total of 646 and 611 patients were given clinic appointments in the first and second cycles, respectively. Clinic session overbookings decreased from 85% to 46.3%. Appointments for referrals that were deemed inappropriate had reduced from 22% to 12.1%. DISCUSSION AND CONCLUSION: Involvement of a registrar in taking referrals for the ENT emergency clinic was associated with a reduction in clinic overbookings. It is feasible and productive to involve a senior decision maker in the operational management of the emergency clinic, while preserving the delivery of this service by FYs for its training value.

Senior triaging of ENT emergency clinic referrals alleviates pressures on the outpatient department.

INTRODUCTION: The ear, nose and throat (ENT) emergency clinic is managed by foundation year (FY) doctors from taking referrals to discharging patients, under the supervision of a registrar. FYs learn essential skills and knowledge on how to manage common ENT problems. The clinic is often overloaded because of a high patient demand, and this limits the opportunities for teaching. We hypothesised that the clinic bookings would be better managed if referrals from general practitioners (GPs) were triaged by registrars. METHODS: Telephone referrals from GPs for the ENT emergency clinic were directed to the on-call ENT registrar, between 8am and 1pm from Monday to Friday, and to the FY outside of this period. Consecutive referrals to the emergency clinic were analysed in a baseline audit and a post-intervention cycle. RESULTS: A total of 646 and 611 patients were given clinic appointments in the first and second cycles, respectively. Clinic session overbookings decreased from 85% to 46.3%. Appointments for referrals that were deemed inappropriate had reduced from 22% to 12.1%. DISCUSSION AND CONCLUSION: Involvement of a registrar in taking referrals for the ENT emergency clinic was associated with a reduction in clinic overbookings. It is feasible and productive to involve a senior decision maker in the operational management of the emergency clinic, while preserving the delivery of this service by FYs for its training value.

Test, test, test - a complication of testing for coronavirus disease 2019 with nasal swabs.

BACKGROUND: Coronavirus disease 2019, a highly transmissible respiratory infection, has created a public health crisis of global magnitude. The mainstay of diagnostic testing for coronavirus disease 2019 is molecular polymerase chain reaction testing of a respiratory specimen, obtained with a viral swab. As the incidence of new cases of coronavirus disease 2019 increases exponentially, the use of viral swabs to collect nasopharyngeal specimens is anticipated to increase drastically. CASE REPORT: This paper draws attention to a complication of viral swab testing in the nasopharynx and describes the premature engagement of a viral swab breakpoint, resulting in impaction in the nasal cavity. CONCLUSION: This case highlights a possible design flaw of the viral swab when used to collect nasopharyngeal specimens, which then requires an aerosol-generating procedure in a high-risk patient to be performed. The paper outlines a safe technique of nasal foreign body removal in a suspected coronavirus disease 2019 patient and suggests alternative testing materials.

Perfoation of the gallbladder: 'bait' for the unsuspecting laparoscopic surgeon.

INTRODUCTION Cholecystectomy is one of the most common elective procedures carried out by general surgeons. Most patients present with typical biliary anatomy and simple gallstone disease. Intraoperative and postoperative courses are frequently predictable and uncomplicated. Nevertheless, a small but significant number of patients experience complicated disease with rare presentations and complex biliary anatomy. Unfortunately, consensus on appropriate care for such patients is lacking. CASE HISTORY We describe three patients who presented with complex manifestations of gallbladder perforation: acute perforation of the gallbladder; a spontaneous cholecystocutaneous fistula; a cholecystoduodenal fistula. The initial presentation, preoperative investigations, and selected surgical strategy for each case are described. CONCLUSIONS The case studies described here illustrate the need for a low index of suspicion for gallbladder perforation. Caution should be exercised in preoperative and intraoperative phases in this patient population.

Comparative efficacy of Prolene and Prolene-Vicryl composite mesh for experimental ventral hernia repair in dogs.

In this study, efficacy of two hernia mesh implants viz. conventional Prolene and a novel Prolene-Vicryl composite mesh was assessed for experimental ventral hernia repair in dogs. Twelve healthy mongrel dogs were selected and randomly divided into three groups, A, Band C (n=4). In all groups, an experimental laparotomy was performed; thereafter, the posterior rectus sheath and peritoneum were sutured together, while, a 5 × 5 cm defect was created in the rectus muscle belly and anterior rectus sheath. For sublay hernioplasty, the hernia mesh (Prolene: group A; Prolene-Vicryl composite mesh: group B), was implanted over the posterior rectus sheath. In group C (control), mesh was not implanted; instead the laparotomy incision was closed after a herniorrhaphy. Post-operative pain, mesh shrinkage and adhesion formation were assessed as short term complications. Post-operatively, pain at surgical site was significantly less (P<0.001) in group B (composite mesh); mesh shrinkage was also significantly less in group B (21.42%, P<0.05) than in group A (Prolene mesh shrinkage: 58.18%). Group B (composite mesh) also depicted less than 25% adhesions (Mean ± SE: 0.75 ± 0.50 scores, P≤0.013) when assessed on the basis of a Quantitative Modified Diamond scale; a Qualitative Adhesion Tenacity scale also depicted either no adhesions (n=2), or, only flimsy adhesions (n=2) in group B (composite mesh), in contrast to group A (Prolene), which manifested greater adhesion formation and presence of dense adhesions requiring blunt dissection. Conclusively, the Prolene-Vicryl composite mesh proved superior to the Prolene mesh regarding lesser mesh contraction, fewer adhesions and no short-term follow-up complications.

Vitamin D and tuberculosis: review and association in three rural provinces of Afghanistan.

OBJECTIVES: 1) To update the 2006 systematic review and meta-analysis by Nnoaham & Clarke exploring the association between serum vitamin D and risk of active tuberculosis (TB) following discrepant evidence; and 2) to identify whether TB and vitamin D are associated in rural Afghanistan. METHODS: Systematic review and meta-analysis of studies published between January 1980 and June 2014 using Nnoaham & Clarke's methodology. For this case-control study, 90 age- and sex-matched pairs were recruited from rural provinces, and blood 25-hydroxyvitamin D concentrations were measured using enzyme-linked immunosorbent assay. RESULTS: Sixteen studies were eligible for review. Eleven showed differences between vitamin D levels in TB patients and controls, two showed partial differences and three showed none. Studies on African and European populations show lower vitamin D levels in TB patients, but results from Asia vary. No significant differences were found in vitamin D levels in our rural Afghan population. Controls had a higher body mass index (BMI) (mean control BMI 21.50 kg/m(2), mean case BMI 18.86 kg/m(2), P < 0.001), and were more likely to have been employed (40% of controls, 15.6% of cases, P = 0.002). CONCLUSION: Genetic differences may account for the differences among study results in the systematic review. Vitamin D levels are not associated with TB among Afghans living in these rural provinces.

Z-score comparability of bone mineral density reference databases for children.

PURPOSE: The diversity of pediatric dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) reference databases raises questions as to whether they are interchangeable in their application. This study examined the comparability of BMD Z-scores generated from the largest available Hologic DXA databases, applied on BMD results of a large series of unselected pediatric patients. METHODS: A total of 2027 BMD scans were extracted from Hologic QDR-4500A machines. Age- and sex-specific BMD Z-scores of children aged 8-17 yr, calculated from six Hologic databases, were compared for lumbar spine (LS) and total body (TB). The final dataset included 708 scans (307 of girls). RESULTS: BMD Z-scores calculated from the six databases were highly correlated but differed significantly (P < 0.001) in both scan regions. Interdatabase Z-score differences (boys/girls, respectively) were up to 0.54/0.55 for LS and 1.0/0.83 for TB. These differences also varied significantly among age groups. In girls, the percentage of LS BMD Z-scores of -2 or below ("low BMD for age") varied between 15.4 and 27.9% (P < 0.012). The percentage of TB BMD Z-scores of -2 or below varied similarly in boys (P < 0.009). CONCLUSIONS: Clinically relevant differences in BMD Z-scores exist between the Hologic databases, revealing a significant potential for misdiagnosis. Ideally, Z-scores should be calculated using model-, brand-, and software-specific reference curves for age, sex, and ethnic group. However, our results can be used to estimate converted values. There are other differences in children's bone mass, shape, strength, and body size that are not detected by DXA.

Childhood asthma knowledge among first year nursing students in three European cities.

BACKGROUND: There are no available studies that assess and compare knowledge of childhood asthma among subjects living in different European countries. The objective of this study was to determine knowledge of childhood asthma among first year nursing students during the first week of their training in three European countries. The participants' sources of information and other factors that might influence their asthma knowledge score (AKS) were also evaluated. METHODS: Cross-sectional design using a modified version of a previously validated questionnaire. The study was undertaken in 261 students in Cartagena (Spain), 202 in Manchester (UK) and 94 in Cologne (Germany). RESULTS: AKS (maximum score, 27) was significantly higher in students from Manchester (18.3 +/- 2.6) than in those from Cartagena (15.9 +/- 3.1) and Cologne (15.1 +/- 3.6). In all three cities, more than 70 % of the students answered 10 out of the 27 questions correctly. Knowledge of asthma relievers or preventers was very limited. AKS showed a positive but marginal correlation with student age (r = 0.11, p = 0.07). Only knowledge gained from personal experience was significantly associated (r = 0.27, p < 0.001) with AKS. CONCLUSIONS: This study provides valuable new information about the variations, sources and factors that influence knowledge of asthma among educated individuals living in three European countries. The better AKS of Manchester students might be due to the higher prevalence of asthma in the UK.

Effect of diabetes mellitus on rat placenta cellularity.

Transcellular placental maternofetal flux of calcium and magnesium is reduced in diabetic pregnancy in the rat which might be due to changes in placental cellularity. In order to investigate this wet and dry weight, DNA and protein content were measured in placentas from untreated diabetic (D(O)), insulin-treated diabetic (D(I)) and control rats (C) on day 21 of gestation (term=23 days). Wet and dry weights (mg; mean+/-S.E.M.) were 418+/-13, 474+/-19, 416+/-14 and 66+/-3, 75+/-3, 67+/-3 in C, D(O) and D(I) groups, respectively. Total DNA and protein content (mg) was 1.8+/-0.2, 1.7+/-0.1, 1.5+/-0.1 and 50.4+/-2.4, 54.9+/-2.6, 51.9+/-3.3 in C, D(O) and D(I) groups, respectively. The data suggest that placental cellularity is unaffected by maternal diabetes mellitus in the rat and is unlikely to directly affect maternofetal flux of calcium and magnesium.

Urinary excretion of pyridinium crosslinks in healthy 4-10 year olds.

Urinary pyridinoline and deoxypyridinoline, pyridinium crosslinks released during breakdown of mature collagen, might serve as useful markers of bone resorption. Before their role can be identified, reference values must be established. In this study, free pyridinoline (f-Pyr), free deoxypyridinoline (f-DPyr), and creatinine (Cr) were measured in first morning void urine samples from 250 girls and 265 boys between the ages of 4 and 10 years. Overall, there was a decrease in f-Pyr:Cr and f-DPyr:Cr ratios with increasing age in both sexes, but there was a wide range of values for individuals of similar ages. Further studies are required to assess whether urinary pyridinium crosslink excretion is sufficiently deranged in conditions affecting bone metabolism for the measurement of these compounds to be of clinical value.

Effect of maternal oxygen therapy on placental calcium transport in intrauterine growth retarded rats.

OBJECTIVE: We tested the hypothesis that continuous maternal oxygen (O2) therapy leads to an increase in fetal survival, improvement in fetal growth, and correction of decreased placental calcium (Ca) transport, in pregnant rats who underwent uterine artery ligation. STUDY DESIGN: We measured on Day 21 of pregnancy, the unidirectional maternofetal clearance of 45Ca (Kmf45Ca) and 51Cr-EDTA (Kmf51Cr-EDTA) across in-situ perfused placentas of rats randomized on Day 17 to a modified Wigglesworth (bilateral uterine artery ligation) procedure (group WW, n = 8), to modified Wigglesworth and supplemental maternal O2 treatment (FiO2 0.40) (group WWO2, n = 8), or to a sham operation (group Sh, n = 8). Kmf51Cr-EDTA provides a measure of placental "porosity" or passive permeability. RESULTS: Maternal O2 therapy did not improve fetal survival, fetal growth, or placental Ca transport. CONCLUSION AND SPECULATION: Bilateral uterine ligation in the pregnant rat leads to IUGR and decreased placental Ca transport which cannot be corrected by maternal O2 therapy.

Placental calcium transport during acute maternal hypermagnesemia in the rat.

OBJECTIVE: Our aim was to test the hypothesis that maternofetal placental calcium transfer rate decreases in experimentally induced acute maternal hypermagnesemia in the rat. STUDY DESIGN: We measured the unidirectional maternofetal clearance of calcium 45 and chromium 51-ethylenediaminetetraacetic acid across in situ perfused placentas of rats randomized to intravenous treatment with saline solution and magnesium sulfate (n = 5) or to saline solution only (n = 5) before placental perfusion. The maternofetal clearance of chromium 51-ethylenediaminetetraacetic acid provides a measure of placental "porosity" or passive permeability. RESULTS: The mean serum magnesium concentration increased to 5.3 +/- 0.6 mg/dl (2.18 +/- 0.25 mmol/L) in magnesium-infused rats, staying at 1.8 +/- 0.1 mg/dl (0.74 +/- 0.04 mmol/L) in control rats (p < 0.001). Neither the maternofetal clearance of calcium 45 nor that of chromium 51-ethylenediaminetetraacetic acid was affected by acute maternal hypermagnesemia. CONCLUSION: Within the range of hypermagnesemia studied, placental calcium transport remains unaffected.