Near total intrathoracic airway obstruction managed with a Tritube® and flow-controlled ventilation.

We describe the management of a case of near total airway obstruction in a 79-year-old man who presented with a 2-week history of increasing shortness of breath and stridor. Computed tomography imaging revealed a mid-tracheal mass of unknown aetiology with critical airway obstruction. We secured the patient's airway using a TriTube® (Ventinova, Eindhoven, the Netherlands). While this facilitated a secure airway past the lesion, various issues were encountered which complicated the safe conduct of anaesthesia. We conclude that while the TriTube and Evone® flow-controlled ventilation (Ventinova) are useful for critical airway obstruction, they can be problematic and thorough planning is essential.

Laryngectomy with a Tritube® and flow-controlled ventilation.

We describe the novel use of the TriTube® and Evone® ventilator (Ventinova, Eindhoven, Netherlands) to facilitate curative resection of a transglottic squamous cell carcinoma. A 43-year-old man presented with acute laryngeal and subglottic airway obstruction secondary to a stage 4 transglottic squamous cell carcinoma. The patient underwent magnetic resonance imaging followed by a diagnostic panendoscopy. It was decided that tumour resection was appropriate and a management plan was established by a multi disciplinary team. A total laryngectomy was performed. It was determined that failure of translaryngeal tracheal intubation could be rescued with emergency surgical front-of-neck airway. General anaesthesia was induced using a total intravenous anaesthesia technique, oxygenation was achieved with high-flow nasal oxygen and the airway was secured using the TriTube and flow-controlled ventilation was delivered throughout the procedure using the Evone ventilator. This avoided an awake or emergency tracheostomy, with the associated theoretical risk of tumour seeding, allowed for excellent gas exchange throughout and permitted the surgeons to maintain a closed system during much of the procedure, including during fashioning of the stoma. When traditional laryngectomy tubes are used, this process ordinarily involves multiple extubations and apnoeic periods. Furthermore, the small subglottic tube allowed intra-operative assessment of the extent of the subglottic tumour, facilitating curative en bloc resection.

Sustained type 1 diabetes self-management: Specifying the behaviours involved and their influences.

AIMS: Sustained engagement in type 1 diabetes self-management behaviours is a critical element in achieving improvements in glycated haemoglobin (HbA1c) and minimising risk of complications. Evaluations of self-management programmes, such as Dose Adjustment for Normal Eating (DAFNE), typically find that initial improvements are rarely sustained beyond 12 months. This study identified behaviours involved in sustained type 1 diabetes self-management, their influences and relationships to each other. METHODS: A mixed-methods study was conducted following the first two steps of the Behaviour Change Wheel framework. First, an expert stakeholder consultation identified behaviours involved in self-management of type 1 diabetes. Second, three evidence sources (systematic review, healthcare provider-generated 'red flags' and participant-generated 'frequently asked questions') were analysed to identify and synthesise modifiable barriers and enablers to sustained self-management. These were characterised according to the Capability-Opportunity-Motivation-Behaviour (COM-B) model. RESULTS: 150 distinct behaviours were identified and organised into three self-regulatory behavioural cycles, reflecting different temporal and situational aspects of diabetes self-management: Routine (e.g. checking blood glucose), Reactive (e.g. treating hypoglycaemia) and Reflective (e.g. reviewing blood glucose data to identify patterns). Thirty-four barriers and five enablers were identified: 10 relating to Capability, 20 to Opportunity and nine to Motivation. CONCLUSIONS: Multiple behaviours within three self-management cycles are involved in sustained type 1 diabetes self-management. There are a wide range of barriers and enablers that should be addressed to support self-management behaviours and improve clinical outcomes. The present study provides an evidence base for refining and developing type 1 diabetes self-management programmes.

Severe hypoglycaemia in type 1 diabetes mellitus: underlying drivers and potential strategies for successful prevention.

Hypoglycaemia remains an over-riding factor limiting optimal glycaemic control in type 1 diabetes. Severe hypoglycaemia is prevalent in almost half of those with long-duration diabetes and is one of the most feared diabetes-related complications. In this review, we present an overview of the increasing body of literature seeking to elucidate the underlying pathophysiology of severe hypoglycaemia and the limited evidence behind the strategies employed to prevent episodes. Drivers of severe hypoglycaemia including impaired counter-regulation, hypoglycaemia-associated autonomic failure, psychosocial and behavioural factors and neuroimaging correlates are discussed. Treatment strategies encompassing structured education, insulin analogue regimens, continuous subcutaneous insulin infusion pumps, continuous glucose sensing and beta-cell replacement therapies have been employed, yet there is little randomized controlled trial evidence demonstrating effectiveness of new technologies in reducing severe hypoglycaemia. Optimally designed interventional trials evaluating these existing technologies and using modern methods of teaching patients flexible insulin use within structured education programmes with the specific goal of preventing severe hypoglycaemia are required. Individuals at high risk need to be monitored with meticulous collection of data on awareness, as well as frequency and severity of all hypoglycaemic episodes.

Training tomorrow's laryngologists - head and neck training alone is not sufficient.

BACKGROUND: Diagnostic ability is essential in laryngology. The UK Higher Surgical Training syllabus includes competencies specific to laryngology. This study aimed to identify the factors in training that lead to a consultant level of laryngology-related diagnostic ability. METHOD: An online test of training experience was constructed using laryngoscopy videos obtained from a specialist UK voice clinic. Participation was aimed at both trainees and trainers via invitation through national ENT forums. RESULTS: There were 51 complete responses. Trainees with six months of laryngology experience scored significantly higher than those without this experience (p < 0.001). There was no improvement in score demonstrated for those with head and neck specialty experience without laryngology experience. Trainees who had completed 12 months of laryngology, or 6 months of laryngology coupled with 12 months of head and neck training, scored similarly to their consultant trainers. CONCLUSION: It is recommended that all trainees have at least six months of experience in a specialist voice or laryngology placement prior to gaining the Certificate of Completion of Training.

Patient experience of hypoglycaemia unawareness in Type 1 diabetes: are patients appropriately concerned?

OBJECTIVE: Risk of severe hypoglycaemia is increased by absence of subjective awareness of hypoglycaemia and reduced by avoidance of minor hypoglycaemia. For many, problems persist despite educational strategies that work for others. We explored psychological factors that might inhibit the efforts of an individual in hypoglycaemia avoidance. METHODS: People with Type 1 diabetes and hypoglycaemia unawareness gave semi-structured interviews exploring their perceptions and experiences of their condition. Identified factors were grouped into categories and analysed to establish links and form a grounded theory in a constant comparative analysis. A questionnaire was devised from the qualitative analysis to identify patients with problematic beliefs about their hypoglycaemia. RESULTS: Saturation (no new themes emerging) was reached with 17 patients. Responses fell into two groups: high concern and low concern regarding hypoglycaemia unawareness. Those in the first group described severe hypoglycaemia as aversive and wanted to regain awareness. The second group included three patients in whom unawareness was not associated with severe hypoglycaemia, nevertheless unhelpful attitudes which inhibited hypoglycaemia avoidance were expressed. Responses from this group fell into categories: (1) normalizing the presence of unawareness; (2) underestimating its consequences; (3) wanting to avoiding the 'sick role'; and (4) overestimating the consequences of hyperglycaemia. CONCLUSIONS: A qualitative analysis of patient interviews identified deficits in education, technology and motivation in hypoglycaemia unawareness. Interventions can therefore be tailored to target underlying problems that prevent individual patients from regaining awareness. A brief assessment tool was devised to categorize patients' hypoglycaemia unawareness accordingly. Psychological interventions should be developed to address the problems of 'low concern' regarding hypoglycaemia unawareness.

Persistent otorrhoea with an abnormal tympanic membrane secondary to squamous cell carcinoma of the tympanic membrane.

OBJECTIVE: The authors present an extremely rare case of carcinoma of the tympanic membrane. METHOD: A case report and review of the literature concerning carcinoma of the tympanic membrane and temporal bone are presented and discussed. RESULTS: The authors present a patient with recurrent otorrhoea and an abnormal tympanic membrane. Biopsy was inconclusive, but resection demonstrated squamous cell carcinoma of the tympanic membrane. We also discuss the investigation, diagnosis, natural history and management of this rare condition, as well as the staging and management of tumours of the temporal bone and the differences between these closely related but prognostically different entities. CONCLUSION: This rare entity can be managed by primary surgical resection if there is no evidence of metastasis.

Manipulation of fractured nose using mallet and champagne cork.

We describe an alternative method of manipulating fractured nasal bones using a surgical mallet and a champagne cork. This method enables accurate fracture reduction with minimal skin trauma, by affording the surgeon a high level of control. This method may be applied successfully to late-presenting fractures.

Are depot antipsychotics more coercive than tablets? The patient's perspective.

Some clinicians consider depot antipsychotics to be stigmatising, coercive and unacceptable to patients. This cross-sectional study investigated patients' perspectives of coercion for depot and oral antipsychotics. In all, 72 participants with chronic mental illness on voluntary maintenance antipsychotic medication were interviewed for their views on oral and depot medication and experiences of coercion. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Mean total coercion levels were higher for those on depot (depot: mean 4.39; oral: 2.80, P = 0.027), as were perceived coercion (2.52 vs 1.73, P = 0.041) and negative pressures subscales (1.17 vs 0.33, P = 0.009). No significant differences were found for the 'voice' subscale and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, P< 0.001). Depots were perceived as more coercive than oral antipsychotics. Greater perceived coercion may explain why some consider depots to be a more stigmatising form of treatment. Although forced medication is sometimes required, the experience of coercion should be minimised by giving patients a fair say in treatment decisions, regardless of formulation.

Gustatory otorrhoea: a rare case of congenital external ear salivary fistula.

OBJECTIVE: We present an extremely rare case of a 44-year-old woman with right gustatory otorrhoea and otalgia. CASE REPORT: The patient had been initially treated for otitis externa after Pseudomonas aeruginosa was grown from a microbiological swab. The otorrhoea fluid was collected and tested positive for amylase. Sialography and computed tomography imaging of the temporal bone confirmed a sialo-aural fistula from the right parotid gland to the bony external acoustic meatus. The defect was consistent with a patent foramen of Huschke. The fistula was identified surgically via a superficial parotidectomy approach, after contrast injection of Bonney's blue dye into the parotid duct, and then ligated and divided. The patient had immediate and sustained resolution of her otorrhoea. CONCLUSIONS: Sialo-aural fistulae are extremely rare, and usually arise as a complication of surgery or as an acquired disease process. To date, only four cases have been reported. This case demonstrates the use of sensitive investigation involving sialography and computed tomography, as well as successful surgical management, with complete resolution of symptoms.

Depot and oral antipsychotics: patient preferences and attitudes are not the same thing.

Some clinicians believe that antipsychotic depot injections are unacceptable to patients. This cross-sectional study investigated patients' attitudes regarding antipsychotics, and included within-participant comparisons. Two hundred and twenty-two out-patients with schizophrenia/schizoaffective disorder completed the Drug Attitude Inventory (DAI-10), scales on insight, side effects and treatment preferences. Formulation preference was associated with current medication formulation: depots were preferred by 43% (33/76) on depot vs 6% (8/146) on orals (P < 0.001). Attitudes (DAI scores) regarding current formulation were influenced by illness duration, extrapyramidal symptoms and insight but not by formulation (depot vs oral). For those with experience of both formulations, participants currently on tablets scored depots less favourably than oral (4.27 vs 6.89, P < 0.001); those on depot did not differentiate. When voluntary patients on maintenance antipsychotics are asked about their attitudes to their current medication, those on depot respond similarly to those on oral. However, when asked to state a preference for formulation (depot vs oral), patients tend to favour their current formulation. Whatever leads some to switch from depot to oral, leaves a lasting negative impression of the depot and this may limit uptake of newer depots.

Antipsychotic depot medication and attitudes of community psychiatric nurses.

Utilization of long-acting antipsychotic injections (depots) shows wide regional variation. In many countries, community psychiatric nurses (CPNs) administer depots but their concerns and attitudes regarding these drugs are seldom considered. We aimed to investigate attitudes and knowledge towards depots in a cross-sectional survey of CPNs in London, and compare them with those of psychiatrists obtained in a previous study. Three subscales of a depot attitude/knowledge questionnaire were used with additional items which referred to aspects of the CPN role. Participants were 70 CPNs who attended an academic meeting. Most CPNs reported that they were involved in treatment decisions (78%) although some CPNs seldom asked their patients about side effects (19%) and felt that they did not have sufficient time for consultations (23%) or training (23%). Several CPNs believed that depots are old fashioned (34%) and stigmatizing (44%). Compared to psychiatrists, CPNs believed more that depots compromised patient autonomy (28%, P = 0.003) and were coercive (42%, P < 0.001). Familiarity with depots and their knowledge of side effects were positively associated with favourable attitudes. CPNs have several strongly endorsed attitudes towards depot medication. Interprofessional group differences also exist which may undermine the treatment process. Training/refresher courses about depots should highlight systematic treatment decision-making and side effect monitoring which, in turn, may improve professionals' attitudes, knowledge and clinical monitoring of depots.