Epistaxis in people with hereditary haemorrhagic telangiectasia: surgical management and psychological impact.

From the emergency management of acute epistaxis to the surgical procedures for chronic epistaxis, this article covers the options available to control the archetypal symptom of hereditary haemorrhagic telangiectasia while exploring the psychological effect such a disease has on the patient.

A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside.

BACKGROUND: There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks. METHODS: A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites. RESULTS: A total of 225 procedures were performed (range of 1.2-9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres. CONCLUSION: Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.

Aortopexy for the management of paediatric tracheomalacia - the Alder Hey experience.

BACKGROUND: Whilst aortopexy is an accepted and established procedure, there remains considerable heterogeneity within the literature, with inconsistencies in both the approach taken and the technique employed. Furthermore, limited data exist on both patient selection and long-term outcomes. This study aimed to report the experience of managing severe tracheomalacia by way of aortopexy in a large UK paediatric centre. METHOD: A retrospective case note review was conducted. Mean follow up was five years. RESULTS: Twenty-five patients underwent aortopexy for severe tracheomalacia caused by external vascular compression. Acute life-threatening events precipitated investigation in 72 per cent of cases. Twenty-one patients initially presented to ENT services for investigation, which comprised upper airway endoscopy and imaging with computed tomography angiography. Post-operatively, the majority of patients demonstrated complete resolution of symptoms and were discharged from all associated services. Only four patients required a tracheostomy. CONCLUSION: Aortopexy offers an effective method of treating severe tracheomalacia due to vascular compression.

Treatment of sialorrhoea with repeated ultrasound-guided injections of botulinum toxin A into the parotid and submandibular glands.

Botulinum toxin injections are useful in patients with refractory sialorrhoea although the optimum treatment protocol and its efficacy over a long period of follow up are controversial. The aim of our prospective study was to examine the efficacy and complications of a protocol of repeated ultrasound-guided botulinum toxin injections of fixed doses at a tertiary children's hospital. A total of 79 procedures were done in 34 patients who were followed up for two years. The overall complication rate was 3%. The outcome measures considered included the Drooling Frequency Severity Scale (DFSS), visual analogue scale (VAS), and carers' assessments of the reduction in drooling. Our study highlighted two types on non-responders (primary and secondary) of which 3/34 required definitive surgical management. In summary, this study shows that a protocol of repeated injections of fixed doses of botulinum toxin A, while not beneficial in all cases, is a potentially valuable option for the safe and effective treatment of sialorrhoea in children.

Cardiovascular risk assessments at occupational health services: employee experiences.

BACKGROUND: Across England in the UK, population screening for cardiovascular disease (CVD) primarily takes place within general practice in the form of the National Health Service Health Check. Additional screening sites such as occupational health are advocated to improve the population impact. AIMS: To investigate participant experiences with cardiovascular and type 2 diabetes risk assessment (RA) at occupational health and subsequent support-seeking at general practice. METHODS: Face-to-face interviews were conducted for this qualitative study. Participants were recruited at three workplaces; a steel works and two hospital sites. Using interpretive phenomenological analyses, themes were drawn from salient narratives and categorically organized. RESULTS: There were 29 participants. Themes (n = 16) were organized into two domains; factors that facilitated (n = 9) or thwarted (n = 7) participant engagement with the RA and general practice. All participants described the RA as worthwhile and strongly valued RA at occupational health. Those with obesity and high CVD risk highlighted their difficulties in making lifestyle changes. Participants reported confusion and anxiety when GP advice about medication appeared to contradict what participants had interpreted during RA at occupational health. CONCLUSIONS: This study highlights factors that facilitate or thwart engagement in cardiovascular RA at occupational health services and general practice follow-up. Stakeholders can integrate these factors into standard operating procedures to enhance participant engagement and enable safeguards that minimize potential harm to participants.

An analysis of the fate of 917 manuscripts rejected from Clinical Otolaryngology.

OBJECTIVES: The fate of all manuscripts rejected from the journal Clinical Otolaryngology (CO) over a three-year period was investigated. The aim was to review publication rate, delay and the impact factors of the journals that the papers went on to be published in. DESIGN: In total, 917 papers were rejected from CO between 2011 and 2013. The fate of these manuscripts was determined by searching for the corresponding author's surname, and if necessary keywords from the manuscript title, in both PubMed and Google Scholar. MAIN OUTCOME MEASURES: The main outcome measures recorded were as follows: the subsequent publication of the article, delay to publication and journal of publication. RESULTS: In all, 511 papers were subsequently published in journals, representing 55.7% of all rejected manuscripts. The average delay was 15.1 months (standard deviation [sd] = 8.8). The impact factor of CO was found to be higher than the average of the journals that accepted the rejected manuscripts in all 3 years. Only 41 (8%) papers were published in journals with a higher impact factor than CO. Of all subsequently accepted manuscripts, 60 (11.7%) were found only on Google Scholar (and not on PubMed). CONCLUSIONS: Rejection from CO certainly does not prevent subsequent publication, although the papers tend to be published after a lengthy delay and in journals with a lower impact factor than CO. When performing literature searches, it is important to search more than one database to ensure as many of the relevant articles are found as possible.

Cardiorespiratory fitness testing and cardiovascular disease risk in male steelworkers.

BACKGROUND: The workplace has been advocated as a setting to perform cardiovascular disease (CVD) risk assessments. These risk assessments usually focus on traditional risk factors rather than cardiorespiratory fitness (CRF) despite established associations between CRF and CVD. The lack of guidance on interpreting health-related CRF values has been suggested as a barrier to utilizing CRF in practice. AIMS: To assess the merits of CRF testing in the workplace and explore whether a CRF value identified male individuals above the recommended threshold for further clinical investigation. METHODS: Cross-sectional analysis of male steelworkers from Carmarthenshire, South Wales, UK who completed a workplace-based CVD risk assessment with an added CRF protocol based on heart rate responses (Chester Step Test). Receiver operating characteristic (ROC) analysis was undertaken to explore the possibility of a CRF value to identify individuals at an increased 10-year risk of CVD (QRISK2 ≥ 10%). RESULTS: There were 81 participants. ROC analysis revealed that a CRF level of 34.5ml/kg/min identified those individuals above the ≥10% QRISK2 threshold with the best sensitivity (0.800) and specificity (0.687) to discriminate against true- and false-positive rates. Further analysis revealed that individuals with either 'Average' or 'Below Average' CRF would be five times more likely to have a 10-year CVD risk above the ≥10% QRISK2 threshold than individuals with an 'Excellent' or 'Good' level of fitness [OR 5.10 (95% CI 1.60-16.3)]. CONCLUSIONS: This study suggests CRF assessments are a useful addition to a workplace CVD assessment and could identify male individuals at increased predicted risk of the condition.

A re-appraisal of publication rates of scientific papers presented at the Otorhinolaryngology Research Society meetings.

OBJECTIVES: To review the rate of publication of papers in peer-reviewed journals after oral presentations at the Otorhinolaryngology Research Society meetings between 1996 and 2013 and to compare trends with the previous review (1979-1995). DESIGN: Literature review. SETTING: Merseyside ENT Research Collaborative. PARTICIPANTS: The abstracts of presentations at Otorhinolaryngology Research Society meetings are published in Clinical Otolaryngology. A structured search of PubMed was undertaken to identify published Otorhinolaryngology Research Society presentations. MAIN OUTCOME MEASURES: Publication rates. RESULTS: A total of 460 abstracts were identified. The interobserver reliability among reviewers was 98%. Of the total, 259 (56.3%) abstracts were published in peer-reviewed journals. The average time from Otorhinolaryngology Research Society presentation to publication was 27.7 months (median 23), which was not significantly different from the previous review. Publication by subspeciality was as follows: head and neck (45.6%), otology (30.5%), rhinology (22%) and others (1.9%). Most published Otorhinolaryngology Research Society presentations were published in Clinical Otolaryngology (22.4%), followed by the Journal of Laryngology and Otology (8.1%) and the Laryngoscope (7.3%). Clinical research was the most common category of abstracts being presented at Otorhinolaryngology Research Society meetings, followed by laboratory-based research. Over half (56.5%) of laboratory research presented were head and neck themed, while otology and rhinology predominated clinical research presentations. Over half (52.1%) of Otorhinolaryngology Research Society abstracts originated from units in the North of England. Bristol presented the most abstracts (30.1%), followed by Newcastle (25.1%). CONCLUSIONS: The publication rate of Otorhinolaryngology Research Society presentations remains high and many are subsequently published in high-impact factor otolaryngology journals. More Otorhinolaryngology Research Society presentations are now published in American and European journals.

Incidental head and neck findings on 18F-fluoro-deoxy-glucose positron emission tomography computed tomography.

OBJECTIVE: The overlapping risk factors for lung and head and neck cancer present a definite risk of synchronous malignant pathology. This is the first study to specifically review incidental positron emission tomography computed tomography findings in the head and neck region in lung carcinoma patients. METHODS: A retrospective review was performed of all lung cancer patients who underwent positron emission tomography computed tomography imaging over a five-year period (January 2008 - December 2012), identified from the Liverpool thoracic multidisciplinary team database. RESULTS: Six hundred and nine patients underwent positron emission tomography computed tomography imaging over this period. In 76 (12.5 per cent) scans, incidental regions of avid 18F-fluoro-deoxy-glucose uptake were reported in the head and neck region. In the 28 patients who were fully investigated, there were 4 incidental findings of malignancy. CONCLUSION: In lung cancer patients undergoing investigative positron emission tomography computed tomography scanning, a significant number will also present with areas of clinically significant 18F-fluoro-deoxy-glucose uptake in the head and neck region. Of these, at least 5 per cent may have an undiagnosed malignancy.

'Prosiect Sir Gâr': workplace-based cardiovascular disease and diabetes risk assessments.

BACKGROUND: Cardiovascular disease (CVD) and diabetes remain two of the greatest health challenges in the UK. Government guidelines recommend screening for both of these conditions to identify individuals at high risk. Assessing individuals in the work environment for these two conditions as part of routine annual medicals could have benefits for both the employee and employer. AIMS: To introduce the Prosiect Sir Gâr workplace-based initiative for CVD and diabetes prevention and report some of the baseline measurements in regards to CVD and diabetes risk. METHODS: Individuals from two workplaces (local health board and steelworks) attended a medical health check with an added CVD and diabetes risk assessment component. Demographic and anthropometric data, systolic and diastolic blood pressure, smoking status and family and medical histories were recorded. Blood samples were analysed for total and high-density lipoprotein cholesterol and HbA1c. Ten year risk of CVD and diabetes were predicted using the QRISK2 and QDiabetes algorithms. Individuals at high risk of either condition were referred to a lifestyle intervention programme. RESULTS: Among over 800 individuals screened a high prevalence of central obesity (75%), systolic hypertension (20%) and diastolic hypertension (23%) were observed in both workforces. In addition, a substantial proportion of the workers were either 'overweight' (42%) or 'obese' (28%). CONCLUSIONS: Introducing CVD and diabetes risk assessments to routine annual medicals in the workplace uncovered significant isolated risk factors for both CVD and diabetes that may otherwise have remained undiagnosed. This approach also gave employers a more detailed awareness of the current health of their employees.

Lessons learnt from the diagnosis and antimicrobial management of necrotising (malignant) otitis externa: our experience in a tertiary referral centre.

Necrotising otitis externa is an uncommon and aggressive infection of the external auditory canal with a tendency to present in the elderly and immunocompromised patient. We report a series of twenty-five patients admitted to our institution over a four-year period with this diagnosis. We review the diagnosis and antimicrobial management of these cases, and propose a treatment algorithm based on our experience.

Mortality of workers at a nickel carbonyl refinery, 1958-2000.

BACKGROUND: Excess risks of respiratory cancer have been shown in some groups of nickel exposed workers. It is clear, however, that not all forms of nickel exposure are implicated in these excess risks. AIM: To determine whether occupational exposures received in a modern nickel carbonyl refinery lead to increased risks of cancer, in particular nasal cancer and lung cancer. METHODS: The mortality experienced by a cohort of 812 workers employed at a nickel refinery was investigated. Study subjects were all male workforce employees first employed in the period 1953-92 who had at least five years' employment with the company. Observed numbers of cause specific deaths were compared with expectations based on national mortality rates; SMRs were also calculated by period from commencing employment, year of commencing employment, and type of work. RESULTS: Overall, standardised mortality ratios (SMRs) were close to 100 for all causes (Obs 191, SMR 96, 95% CI 83 to 111), all neoplasms (Obs 63, SMR 104, 95% CI 80 to 133), non-malignant diseases of the respiratory system (Obs 18, SMR 97, 95% CI 57 to 153), and diseases of the circulatory system (Obs 85, SMR 94, 95% CI 75 to 116). There were no significantly increased SMRs for any site of cancer. There was a non-significant excess for lung cancer (Obs 28, Exp 20.17, SMR 139, 95% CI 92 to 201), and in subgroup analyses a significantly increased SMR of 231 (Obs 9) was found for those 142 workers with at least five years' employment in the feed handling and nickel extraction departments. In the total cohort there was a single death from nasal cancer (Exp 0.10). CONCLUSIONS: The non-significant excess of lung cancer deaths may well be a chance finding, but in light of previous studies some role for nickel exposures cannot be excluded.

Reducing concentrate supplementation in dairy cow diets while maintaining milk production with pea-wheat intercrops.

In the first of 2 experiments, 40 dairy cows were used to evaluate the milk production potential and concentrate-sparing effect of feeding dairy cows a basal diet of pea-wheat intercrop silages instead of perennial rye-grass silage (GS). Dairy cows were offered GS or 2 intercrop silages prepared from wheat and either Magnus peas (MW, a tall-straw variety) or Setchey peas (SW, a short-straw variety) ad libitum. The respective intercrops were supplemented with 4 kg/d of a dairy concentrate (CP = 240 g/kg dry matter; MW4 and SW4), and the GS were supplemented with 4 (GS4) or 8 (GS8) kg/d of the same concentrate. The second experiment measured the forage DM intake, digestibility, rumen function, and microbial protein synthesis from the forages by offering them alone to 3, nonlactating cows (3 x 3 Latin square design with 21-d periods). Forage dry matter intake was greater in cows fed the intercrop silages than those fed GS. Milk production was greater in cows fed SW4 than those fed GS4 or MW4, but similar to cows fed GS8. Dietary treatment did not affect milk fat, protein, or lactose concentrations. The intercrops had greater N retention, and were more digestible than the GS, and these factors probably contributed to the greater forage DM intakes and greater milk production from the intercrop silages compared with the GS. Rumen volatile fatty acid concentrations were similar across forages, but urinary purine derivative excretion was greater in the cows fed the intercrop silages than the GS, suggesting that rumen microbial protein synthesis was enhanced by feeding the intercrops. In conclusion, similar milk yield and milk composition can be obtained by feeding SW and 4 kg of concentrates as that obtained with GS and 8 kg of concentrates. Feeding intercrop silages instead of GS with the same amount of concentrates increased forage intakes, N retention, and microbial protein synthesis.

Dense nonaqueous phase liquid tracer tests: experimental results.

Two dense nonaqueous phase liquid (DNAPL) tracer tests were carried out in a shallow aquifer north of Fort Worth, TX. i-Propanol was used as the nonpartitioning tracer: n-hexanol and n-octanol were the partitioning tracers. Field data, mathematical modeling, the results of column tests, and field tracer tests with NaCl were used in designing the DNAPL tracer tests. The results indicated the presence of DNAPL at both sites tested; semi-quantitative estimates of the amounts of DNAPL present were obtained by mathematical modeling. Interpretation was complicated by heterogeneity of the aquifer and mass transport effects.

Dobutamine stress cine-MRI of cardiac function in the hearts of adult cardiomyocyte-specific VEGF knockout mice.

A mouse model of non-necrotic vascular deficiency in the adult heart was studied using cine-magnetic resonance imaging (MRI) and other techniques. The mice lacked cardiomyocyte-derived vascular endothelial growth factor (VEGF) following a targeted knockout in the ventricular cardiomyocytes. Quantitative endothelial labeling showed that the capillary density was significantly reduced in the hearts of knockout mice. Gene expression patterns suggested that they were hypoxic. Semiautomated MR image analysis was employed to obtain both global and regional measurements of left ventricular function at 10 or more time points through the cardiac cycle. MRI measurements showed a marked reduction in ejection fraction both at rest and under low- and high-dose dobutamine stress. Regional wall thickness, thickening, and displacement were all attenuated in the knockout mice. A prolonged high-dose dobutamine challenge was monitored by MRI. A maximal response was sustained for 90 minutes, suggesting that it did not depend on endogenous glycogen stores.