"Should Pediatric Septal Surgery and Septorhinoplasty Be Performed for Nasal Obstruction?"-A Systematic Review of the Literature.

Corrective septal surgery for children with nasal obstruction has historically been avoided due to concern about the impact on the growing nose, with disruption of midfacial growth. However, there is a paucity of data evaluating complication and revision rates post-nasal septal surgery in the pediatric population. In addition, there is evidence to suggest that failure to treat nasal obstruction in children may itself result in facial deformity and/or developmental delay. The aim of this systematic review is to evaluate the efficacy and safety of septal surgery in pediatric patients with nasal obstruction. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. MEDLINE, Embase, and the Cochrane Library were searched. Original studies in pediatric patients (<18 years of age) with nasal obstruction were eligible for inclusion. Patients with cleft lip or palate as their primary diagnosis were excluded. Our primary outcomes were patient-reported outcome measures (PROMs), postsurgical complications, and revision rates. Secondary outcomes included surgical technique, anatomical considerations, and anthropometric measurements. Eighteen studies were included (1,080 patients). Patients underwent septoplasty, septorhinoplasty, rhinoplasty, or a combination of procedures for nasal obstruction. Obstruction was commonly reported secondary to trauma, nasal septal deviation, or congenital deformity. The mean age of the patients was 13.04 years with an average follow-up of 41.8 months. In all, 5.6% patients required revision surgery and there was an overall complication rate of 7.8%. Septal surgery for nasal obstruction in children has low revision and complication rates. However, a pediatric-specific outcome measure is yet to be determined. Larger prospective studies with long-term follow-up periods are needed to determine the optimal timing of nasal surgery for nasal obstruction in the pediatric population.

The role of ANCA in the management of cocaine-induced midline destructive lesions or ENT pseudo-granulomatosis with polyangiitis: a London multicentre case series.

OBJECTIVE: In this multicentric study involving three London hospitals, we compared ANCA-positive and ANCA-negative cocaine-induced midline destructive lesions (CIMDL) patients to assess how presence of antineutrophil cytoplasmic antibodies (ANCA) may correlate with disease severity. Our secondary aims are to better classify etiology centered around ANCA positivity and, consequently, better disease management. METHODS: A retrospective review was performed to identify patients with CIMDL seen between January 2019 and December 2022. Population data including age, sex, presentation, endoscopic findings, duration of cocaine use and active use of cocaine, type of treatment, laboratory (including ANCA serology), radiological, and histological findings were collected. RESULTS: Forty CIMDL patients (25 male, median age of 42 years) were identified. The majority of them (72.5%) presented with either a septal perforation, a saddle nose deformity (22.5%), and/or a palatal fistula (20.0%). ANCA was positive in 71.1% of cases (66.7% p-ANCA). No statistically significant differences in the general characteristics, type of treatment, laboratory results, radiological or histological findings were observed when comparing ANCA-positive and ANCA-negative CIMDL patients or when comparing p-ANCA and c-ANCA patients. Similarly, no statistically significant difference was obtained when comparing the pattern of distribution of lesions between the two groups. CONCLUSIONS: A large percentage of CIMDL patients showed positive ANCA test (71.1%) and in the majority of the cases a p-ANCA pattern specifically targeting PR3 (p-ANCA, PR3 + MPO-). However, ANCA positivity or presence of a specific ANCA pattern was not associated with more severe presentation or more aggressive disease. Given its similarities to granulomatosis with polyangiitis (GPA), we recommend the use of the term "cocaine-induced ENT pseudo-GPA" instead of CIMDL. LEVEL OF EVIDENCE: IV Laryngoscope, 2023.

Clinical factors influencing olfactory performance in patients with persistent COVID-19 smell loss longer than 1 year.

Objectives: Factors affecting persistence of COVID-19-related olfactory dysfunction (OD) remain partially unknown. We aim to evaluate the clinical factors which could influence olfactory performance in patients with persistent COVID-19-related smell loss. Methods: A retrospective analysis of 100 patients with persistent COVID-19-related OD was performed between October 2020 and December 2022 at a single-center long-COVID smell clinic. All subjects underwent smell assessment using Sniffin' Sticks (S'S) extended test, nasal endoscopy, nasal airflow evaluation (peak nasal inspiratory flow [PNIF]), allergy test (skin prick test [SPT]) for common aeroallergens, MRI of the head and patient-reported outcome measures (PROMs-VAS, SF-36, Short QOD-NS, SNOT-22). Based on S'S score, subjects were divided into normosmics (TDI ≥ 30.75) and dysosmics (TDI < 30.75). Results: The median age was 42 years and the median length of patient-reported OD was 1.4 years. 20 patients (20.0%) were normosmic at the time of S'S assessment. Dysosmic patients were found to have significantly lower scores at the SF-36 health domains for energy/fatigue (p = .0004) and emotional wellbeing (p = .04) when compared to normosmics. A moderate correlation (r = .45-.59) between S'S scores and some PROMs was also demonstrated. At the multivariate analysis higher PNIF scores positively influenced odor threshold (p = .001) while positivity to SPT negatively influenced odor identification (p = .04). Conclusions: Impairment of nasal airflow and sensitivity to aeroallergens can negatively affect olfactory performance in COVID-19-related OD. Long-COVID smell loss deeply affects QoL although recovery of olfaction can bring it back to a normal range. Level of Evidence: IV.

Endoscopic Endonasal Repair and Reconstruction of Traumatic Anterior Skull Base Defects.

Eighty percent of cerebrospinal fluid leaks (CSF) occur following trauma and complicate 12 to 13% percent of all basilar skull fractures (Prosser, Vender, and Solares, 2011). An endoscopic endonasal approach (EEA) is often the preferred method of repair with greater than 90% success rates (Prosser, Vender, and Solares, 2011). We report a case of a 37-year-old man who presented to our regional level 1 trauma centre with multiple facial injuries. Initial cross-sectional imaging revealed multiple, continuous anterior skull base fractures with associated pneumocephalus. Though initially managed conservatively, the patient represented five days later with unilateral left-sided rhinorrhoea. An endoscopic endonasal repair with a multilayer fat, tensor fascia lata, free mucosal graft, and vascularised local flap reconstruction was undertaken. This case highlights the importance of maintaining a high level of suspicion for delayed CSF leak in traumatic base of skull injury. The EEA enables meticulous dissection and thorough inspection of the skull base, facilitating multilayered repair and reconstruction of defects.

Litigation in thyroid surgery: a pan-specialty review of National Health Service (UK) data.

OBJECTIVE: Thyroid surgery carries risks that significantly impact patients. This paper describes the landscape of thyroid surgery related litigation claims in the National Health Service from April 2015 to April 2020, to establish learning points in order to improve patient care and minimise litigation risk. METHODS: Data were requested from National Health Service Resolution and Hospital Episode Statistics. Claims were classified into operative and non-operative causes. Subspecialty information, incident details and claim costings were analysed. RESULTS: Sixty claims were identified. Thirty-eight claims (63.3 per cent) were closed, with an average total claim cost of £68 816 and average damages paid of £36 349. Claims related to diagnostic issues were most common (n = 19); of claims associated with operative causes (n = 30), those relating to nerve injury were most common (n = 8), with issues of nerve monitoring and consent being cited. CONCLUSION: Utilisation of well-established protocols will likely reduce litigation in thyroid surgery, as we move towards a landscape in which the patient journey is thoroughly scrutinised for targeted improvements.

Role of hospital strain in determining outcomes for people hospitalised with COVID-19 in England.

BACKGROUND: In England, reported COVID-19 mortality rates increased during winter 2020/21 relative to earlier summer and autumn months. This study aimed to examine the association between COVID-19-related hospital bed-strain during this time and patient outcomes. METHODS: This was a retrospective observational study using Hospital Episode Statistics data for England. All unique patients aged ≥18 years in England with a diagnosis of COVID-19 who had a completed (discharged alive or died in hospital) hospital stay with an admission date between 1 July 2020 and 28 February 2021 were included. Bed-strain was calculated as the number of beds occupied by patients with COVID-19 divided by the maximum COVID-19 bed occupancy during the study period. Bed-strain was categorised into quartiles for modelling. In-hospital mortality was the primary outcome of interest and length of stay a secondary outcome. RESULTS: There were 253 768 unique hospitalised patients with a diagnosis of COVID-19 during a hospital stay. Patient admissions peaked in January 2021 (n=89 047), although the crude mortality rate peaked slightly earlier in December 2020 (26.4%). After adjustment for covariates, the mortality rate in the lowest and highest quartile of bed-strain was 23.6% and 25.3%, respectively (OR 1.13, 95% CI 1.09 to 1.17). For the lowest and the highest quartile of bed-strain, adjusted mean length of stay was 13.2 days and 11.6 days, respectively in survivors and was 16.5 days and 12.6 days, respectively in patients who died in hospital. CONCLUSIONS: High levels of bed-strain were associated with higher in-hospital mortality rates, although the effect was relatively modest and may not fully explain increased mortality rates during winter 2020/21 compared with earlier months. Shorter hospital stay during periods of greater strain may partly reflect changes in patient management over time.

The volume-outcome relationship for endoscopic transsphenoidal pituitary surgery for benign neoplasm: analysis of an administrative dataset for England.

BACKGROUND: Setting minimum annual volume thresholds for pituitary surgery in England is seen as one way of improving outcomes for patients and service efficiency. However, there are few recent studies from the UK on whether a volume-outcome effect exists, particularly in the era of endoscopic surgery. Such data are needed to allow evidence-based decision making. The aim of this study was to use administrative data to investigate volume-outcome effects for endoscopic transsphenoidal pituitary surgery in England. METHODS: Data from the Hospital Episodes Statistics database for adult endoscopic transsphenoidal pituitary surgery for benign neoplasm conducted in England from April 2013 to March 2019 (inclusive) were extracted. Annual surgeon and trust volume was defined as the number of procedures conducted in the 12 months prior to the index procedure. Volume was categorised as < 10, 10-19, 20-29, 30-39 and ≥40 procedures for surgeon volume and < 20, 20-39, 40-59, 60-79 and ≥80 procedures for trust volume. The primary outcome was repeat ETSPS during the index procedure or during a hospital admission within one-year of discharge from the index procedure. RESULTS: Data were available for 4590 endoscopic transsphenoidal pituitary procedures. After adjustment for covariates, higher surgeon volume was significantly associated with reduced risk of repeat surgery within one year (odds ratio (OR) 0.991 (95% confidence interval (CI) 0.982-1.000)), post-procedural haemorrhage (OR 0.977 (95% CI 0.967-0.987)) and length of stay greater than the median (0.716 (0.597-0.859)). A higher trust volume was associated with reduced risk of post-procedural haemorrhage (OR 0.992 (95% CI 0.985-0.999)), but with none of the other patient outcomes studied. CONCLUSIONS: A surgeon volume-outcome relationship exists for endoscopic transsphenoidal pituitary surgery in England.

Safety of day-case endoscopic sinus surgery in England: An observational study using an administrative dataset.

INTRODUCTION: As elective surgical services recover from the COVID-19 pandemic a movement towards day-case surgery may reduce waiting lists. However, evidence is needed to show that day-case surgery is safe for endoscopic sinus surgery (ESS). The aim of this study was to investigate the safety of day-case ESS in England. DESIGN: Secondary analysis of administrative data. METHODS: We extracted data from the Hospital Episodes Statistics database for the 5 years from 1 April 2014 to 31 March 2019. Patients undergoing elective ESS procedures aged ≥17 years were included. Exclusion criteria included malignant neoplasm, complex systemic disease and trans-sphenoidal pituitary surgery. The primary outcome was readmission within 30 days post-discharge. Multilevel, multivariable logistic regression modelling was used to compare outcomes for those operated on as day-cases and those with an overnight stay after adjusting for demographic, frailty, comorbidity and procedural covariates. RESULTS: Data were available for 49 223 patients operated on across 129 NHS hospital trusts. In trusts operating on more than 50 patients in the study period, rates of day-case surgery varied from 20.6% to 100%. Nationally, rates of day-case surgery increased from 64.0% in the financial year 2014/2015 to 78.7% in 2018/2019. Day-case patients had lower rates of 30-day emergency readmission (odds ratio 0.71, 95% confidence interval 0.62 to 0.81). Outcomes for patients operated on in trusts with ≥80% day-case rates compared with patients operated on in trusts with <50% rates of day-case surgery were similar. CONCLUSIONS: Our data support the view that ESS can safely be performed as day-case surgery in most cases, although it will not be suitable for all patients. There appears to be scope to increase rates of day-case ESS in some hospital trusts in England.

Litigation in Septorhinoplasty Surgery: A Pan-Specialty Review of National Health Service (the United Kingdom) Data.

Success in septorhinoplasty surgery can be difficult to assess due to a lack of objective and measurable outcomes. If patients' expectations are not met, it places surgeons performing septorhinoplasty at risk of litigation which can be stressful and costly. The National Institute of health (NHS) Resolution is a government-funded organization in the United Kingdom that provides expertise to the NHS on resolving patient concerns. Data were requested from NHS Resolution for claims involving septorhinoplasty surgery over a period of 5 years between April 2015 and April 2020. Rhinoplasty claims performed by all specialties were included. Data included the claim status, incident details, alleged injury, damages claimed, and damages paid. A total of 31 claims were identified by the study, equating to a total cost of £1,347,336.10. Of the 31 claims for rhinoplasty or septorhinoplasty, 9 cases were open (29%, £962,361.00) and 22 cases were closed (71%, £384,975.10). The common causes for claims were "intraoperative problems (32%)," "failure to warn-informed consent (19%)," and "foreign body left in situ (13%)." The most common injuries were "cosmetic disfigurement (39%)," "unnecessary pain (29%)," and "additional/ unnecessary operation (29%)." This study highlights the need for improved awareness of clinical negligence claims among surgeons who perform septorhinoplasty. Results are applicable to all specialties who perform the procedure. The study highlights the importance of assessing patients' motives and expectations prior to surgery and emphasizes the need for a well-documented rigorous consent process.

Frailty, Comorbidity, and Associations With In-Hospital Mortality in Older COVID-19 Patients: Exploratory Study of Administrative Data.

BACKGROUND: Older adults have worse outcomes following hospitalization with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes. OBJECTIVE: We aimed to identify the key comorbidities and domains of frailty that were associated with in-hospital mortality in older patients with COVID-19 using models developed for machine learning algorithms. METHODS: This was a retrospective study that used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for hospitalized patients in England aged 65 years or older. The data set was split into separate training (70%), test (15%), and validation (15%) data sets during model development. Global frailty was assessed using the Hospital Frailty Risk Score (HFRS) and specific domains of frailty were identified using the Global Frailty Scale (GFS). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Additional features employed in the random forest algorithms included age, sex, deprivation, ethnicity, discharge month and year, geographical region, hospital trust, disease severity, and International Statistical Classification of Disease, 10th Edition codes recorded during the admission. Features were selected, preprocessed, and input into a series of random forest classification algorithms developed to identify factors strongly associated with in-hospital mortality. Two models were developed; the first model included the demographic, hospital-related, and disease-related items described above, as well as individual GFS domains and CCI items. The second model was similar to the first but replaced the GFS domains and CCI items with the HFRS as a global measure of frailty. Model performance was assessed using the area under the receiver operating characteristic (AUROC) curve and measures of model accuracy. RESULTS: In total, 215,831 patients were included. The model using the individual GFS domains and CCI items had an AUROC curve for in-hospital mortality of 90% and a predictive accuracy of 83%. The model using the HFRS had similar performance (AUROC curve 90%, predictive accuracy 82%). The most important frailty items in the GFS were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items in the CCI were cancer, heart failure, and renal disease. CONCLUSIONS: The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with COVID-19.

A novel technique to repair orbital roof defects: irradiated homologous cadaveric rib (Tutoplast ®) graft in a recurrent frontal sinus ossifying fibroma.

Ossifying fibroma in the fronto-ethmoidal sinuses is a rare, benign condition. In symptomatic cases, surgical excision is often undertaken and bony defects may be repaired using alloplastic grafts. We present a novel method of repairing an orbital roof defect using irradiated homologous cadaveric rib (Tutoplast ®) graft, overlaid with a pericranial flap. The patient made an excellent recovery, concluding that it is a viable and safe option with lower morbidity.

Litigation in pediatric otorhinolaryngology: Lessons in improving patient care.

OBJECTIVE(S): Medico-legal claims involving children place a substantial financial burden on health services and have a profound emotional and psychological impact on clinicians. Our objective was to analyze both the common causes and cost of litigation in pediatric otorhinolaryngology. METHODS: A retrospective review of all clinical negligence claims within pediatric otolaryngology (0-17 years inclusive) in NHS (National Health Service) England held by the clinical negligence service 'NHS Resolution between' 4/2013 and 4/2020. RESULTS: There were 100 claims in pediatric otorhinolaryngology accounting for an estimated potential total cost of just under £49 million with an average of 14 claims per year. Over half (52%) of claims were related to an operation with cause codes "Operator Error/Intra-Op Problem", "Diathermy Injury" and "Failure to Warn - Consent" most cited. The most common operation cited in a claim was tonsillectomy with an average cost per claim of £47,084. There were 21 claims coded as either "failure to diagnose" or "failure to treat" in relation to cholesteatoma, with an average cost per claim of £61,086. CONCLUSION: This is the largest study to date analyzing the reasons and potential cost of clinical negligence claims within pediatric otolaryngology. Many learning opportunities exist to reduce patient morbidity, mortality and improve the patient experience through litigation data analysis.

Hospital dentistry litigation in England: clinical negligence claims against the NHS 2015-2020.

Introduction Litigation against the NHS in England is rising. The aim of this study was to determine the incidence and characteristics of hospital dentistry clinical negligence claims in England.Methods A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to hospital dentistry between April 2015 and April 2020. Analysis was performed using the information for cause, patient injury and claim cost.Results A total of 492 claims were identified, with an estimated potential cost of £14 million. The most frequent causes for clinical negligence claims included failure/delay in treatment (n = 175; £3.9 million), inappropriate treatment (n = 56; £1.8 million) and failure to warn/obtain informed consent (n = 37; £1.5 million). Wrong site surgery was cited in 33 claims. The most frequent injury reported was dental damage (n = 197; £4.3 million), unnecessary pain (n = 125; £2.3 million) and nerve damage (n = 52; £2.4 million).Conclusion Clinical negligence claims in hospital dentistry are related to several different aspects of patient management and are not limited to treatment complications alone. Human ergonomics and patient perception of dentistry cannot be controlled but a focus on patient safety measures and effective communication can serve as tools to combat these factors.

Respiratory support for patients with COVID-19: A national survey of respiratory departments in England.

OBJECTIVE: We developed a national survey to assess the changes implemented by respiratory departments across England in response to the first wave of the COVID-19 pandemic. METHODS: An online survey was sent to the respiratory clinical leads in 132 NHS trusts in England. The survey was open between 10 August 2020 and 25 September 2020. RESULTS: Fifty-three responses (42%) are included in our results. The total number of non-critical care led Level 2 beds (requiring care for single organ failure-capable of managing continuous positive airways pressure, CPAP) increased by 159% at peak COVID activity from levels prior to COVID-19. CPAP was used solely in side-rooms in 9% of sites, and 57% and 31% of sites used CPAP in closed bays and closed wards, respectively. Fifteen sites (28%) reported shortages of non-vented non-invasive ventilation (NIV) masks and 12 sites (23%) CPAP machines. There was regional variation. CONCLUSIONS: The number of beds capable of managing patients requiring CPAP increased significantly. We found deviations from previous standards of care, which likely reflects the pressure faced by hospitals in managing patients with COVID-19. The regional variation in equipment shortages suggests moving resources between regions may have been beneficial.

Volume-Outcome Associations for Parathyroid Surgery in England: Analysis of an Administrative Data Set for the Getting It Right First Time Program.

Importance: Previous studies have suggested an association between surgical volume and patient outcomes for parathyroid surgery. However, most previous studies are relatively small and the literature is dominated by studies form the US, which might not be readily generalizable to other settings. Objective: To investigate volume-outcome associations for parathyroid surgery in England. Design, Setting, and Participants: Cohort study that included all National Health Service hospital trusts in England with secondary analysis of administrative data using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Participants included all adult, elective hospital admissions for parathyroid surgery without a diagnosis of multiple endocrine neoplasia, parathyroid cancer, or kidney disease over a 5-year period (April 2014-March 2019 inclusive). Exposures: The number of procedures conducted in the year prior to the index procedure by each surgeon and each hospital trust. Main Outcomes and Measures: Repeat parathyroid surgery within 1 year of the index procedure. Results: This study included data for 17 494 participants who underwent parathyroidectomies conducted across 125 hospital trusts. The median (IQR) age of patients was 62 (53-71) years, and 13 826 were female (79.0%). Across the period, the number of surgeons conducting parathyroid surgery changed little (280 in 2014-2015 and 2018-2019), although the number of procedures conducted rose from 3331 to 3848 per annum. Repeat parathyroid surgery at 1 year was significantly associated with surgeon volume (odds ratio [OR], 0.99; 95% CI, 0.98-0.99), but not trust volume, in the previous 12 months. Extended length of stay (OR, 0.98; 95% CI, 0.98-0.99), hypoparathyroidism/calcium disorder (OR, 1.0; 95% CI, 0.99-1.0), and postprocedural complications (OR, 0.99; 95% CI, 0.99-1.0) were also associated with lower surgeon volume. Conclusions and Relevance: In this cohort study, higher surgeon annual volume was associated with decreased rates of repeat parathyroid surgery. A minimum volume threshold of 20 procedures per annum should improve patient outcomes, although possible negative effects on access to services should be monitored.

Venous thromboembolism in patients hospitalised with COVID-19 in England.

BACKGROUND: The aim of this study was to detail the incidence of venous thromboembolism (VTE) in patients hospitalised with COVID-19 in England. METHODS: This was an exploratory retrospective analysis of observational data from the Hospital Episode Statistics dataset for England. All patients aged ≥18 years in England with a diagnosis of COVID-19 who had a hospital stay that was completed between 1st March 2020 and 31st March 2021 were included. A recorded diagnosis of VTE during the index stay or during a subsequent admission in the six weeks following discharge was the primary outcome in the main analysis. In secondary analysis, VTE diagnosis was the primary exposure and in-hospital mortality the primary outcome. RESULTS: Over the 13 months, 374,244 unique patients had a diagnosis of COVID-19 during a hospital stay, of whom 17,346 (4.6%) had a recorded diagnosis of VTE. VTE was more commonly recorded in patients aged 40-79 years, males and in patients of Black ethnicity, even after adjusting for covariates. Recorded VTE diagnosis was associated with longer hospital stay and higher adjusted in-hospital mortality (odds ratio 1.35 (95% confidence interval 1.29 to 1.41)). CONCLUSIONS: VTE was a common complication of hospitalisation with COVID-19 in England. VTE was associated with both increased length of stay and mortality rate.

The Role of Social Media in Improving Patient Recruitment for Research Studies on Persistent Post-Infectious Olfactory Dysfunction.

Background and Objectives: Since the COVID-19 pandemic, the number of cases of post-infectious olfactory dysfunction (PIOD) has substantially increased. Despite a good recovery rate, olfactory dysfunction (OD) becomes persistent in up to 15% of cases and further research is needed to find new treatment modalities for those patients who have not improved on currently available treatments. Social media has emerged as a potential avenue for patient recruitment, but its role in recruiting patients with smell dysfunction remains unexplored. We conducted a survey using the AbScent Facebook page to evaluate the feasibility of using this platform for future studies on smell dysfunction. Materials and Methods: Between 26 October and 4 November 2021, we conducted an online survey to evaluate propensity of patients with PIOD who would be willing to participate in research studies on smell dysfunction. Results: Sixty-five subjects were surveyed with a response rate of 90.7%. The median visual analogue scale (VAS) for sense of smell was 0 at infection and 2 at survey completion. The median length of OD was 1.6 years, and the main cause of OD was SARS-CoV-2 (57.6%). Parosmia was reported in 41 subjects (69.5%) whilst phantosmia in 22 (37.3%). The median length of olfactory training (OT) was 6 months but subjectively effective in 15 subjects (25.4%). Twenty-seven subjects (45.8%) tried other medications to improve olfaction, but only 6 participants (22.2%) reported an improvement. All subjects expressed their propensity to participate in future studies with most of them (38; 64.4%) willing to be enrolled either in medical and surgical studies or to be part of a randomised study design (11; 18.6%). Conclusions: Using the AbScent Facebook platform we successfully selected a population of subjects with persistent and severe OD that have failed to improve on available treatments and are willing to participate in further clinical trials.

Utilisation of tracheostomy in patients with COVID-19 in England: Patient characteristics, timing and outcomes.

OBJECTIVES: We aimed to characterise the use of tracheostomy procedures for all COVID-19 critical care patients in England and to understand how patient factors and timing of tracheostomy affected outcomes. DESIGN: A retrospective observational study using exploratory analysis of hospital administrative data. SETTING: All 500 National Health Service hospitals in England. PARTICIPANTS: All hospitalised COVID-19 patients aged ≥18 years in England between 1 March and 31 October 2020 were included. MAIN OUTCOMES AND MEASURES: This was a retrospective exploratory analysis using the Hospital Episode Statistics administrative data set. Multilevel modelling was used to explore the relationship between demographic factors, comorbidity and use of tracheostomy and the association between tracheostomy use, tracheostomy timing and the outcomes. RESULTS: In total, 2200 hospitalised COVID-19 patients had a tracheostomy. Tracheostomy utilisation varied across the study period, peaking in April-June 2020. In multivariable modelling, for those admitted to critical care, tracheostomy was most common in those aged 40-79 years, in males and in people of Black and Asian ethnic groups and those with a history of cerebrovascular disease. In critical care patients, tracheostomy was associated with lower odds of mortality (OR: 0.514 [95% CI 0.443 to 0.596], but greater length of stay OR: 41.143 [95% CI 30.979 to 54.642]). In patients that survived, earlier timing of tracheostomy (≤14 days post admission to critical care) was significantly associated with shorter length of stay. CONCLUSIONS: Tracheostomy is safe and advantageous for critical care COVID-19 patients. Early tracheostomy may be associated with better outcomes, such as shorter length of stay, compared to late tracheostomy.

Learning lessons from the paediatric critical care response to the SARS-CoV-2 pandemic in England and Wales: a qualitative study.

OBJECTIVES: To explore the experiences of clinical leads in paediatric critical care units (PCCUs) in England and Wales during the reorganisation of services in the initial surge of the SARS-CoV-2 pandemic and to learn lessons for future surges and service planning. METHODS: A qualitative study design using semistructured interviews via virtual conferencing was conducted with consultant clinical leads and lead nurses covering 21 PCCUs. Interviews were conducted over a period of 2 weeks, 2 months after the initial SARS-CoV-2 surge. Interview notes underwent thematic analysis. RESULTS: Thematic analysis revealed six themes: leadership, management and planning; communication; workforce development and training; innovation; workforce experience; and infection prevention and control. Leadership was facilitated through clinician-led local autonomy for decision-making and services were better delivered when the workforce was empowered to be flexible in their response. Communication was preferred through collaborative management structures. Further lessons include recognising workforce competencies in surge preparations, the use of virtual technology in facilitating training and meetings, the importance of supporting the well-being of the workforce and the secondary consequences of personal protective equipment use. CONCLUSIONS: During the 2020 SARS-CoV-2 pandemic, an agile response to a rapidly changing situation was enabled through effective clinical leadership and an adaptive workforce. Open systems of communication across senior clinical and management teams facilitated service planning. Support for all members of the workforce through implementation of appropriate and innovative education and well-being solutions was vital in sustaining resilience. This learning supports planning for future surge capacity across paediatric critical care locally and nationally.