Singly-qualified medical senior house officer in oral and maxillofacial surgery: perspectives from a unit.

Despite constituting a minority of senior house officers (SHO) in oral and maxillofacial surgery (OMFS), the number of singly-qualified medical trainees is growing. We describe the experience of a singly qualified medical trainee in OMFS and the unique benefits and opportunities for potential trainees and the department. Overall, the advantages of synergistic training outweigh any deficiencies in knowledge, and in our experience, having both medical and dental trainees in our unit has maximised training opportunities and provided a more holistic approach to patient care. Increased exposure to conditions in the head and neck also benefits trainees who wish to pursue careers in other specialties such as ear, nose, and throat (ENT), neurosurgery, ophthalmology, and plastic surgery.

Are we following an algorithm for managing chronic anal fissure? A completed audit cycle.

BACKGROUND: Anal fissure is one of the commonest proctological diseases with considerable national variation in sequential treatment. We aimed to audit our compliance of chronic anal fissure (CAF) management with national guidance provided by the Association of Coloproctology of Great Britain and Ireland (ACPGBI). METHODS: We retrospectively audited patients presenting to outpatient clinics with CAF over a 6-month period. Using electronic patient records, notes and clinic letters, we compared their management with ACPGBI algorithm. A prospective re-audit was then performed. RESULTS: Forty-one patients were included in the analysis (59% male). Sixty-eight percent (n = 28/41) of patients were appropriately started on conservative dietary therapy, of whom only 7.1% (n = 2/28) had treatment success. Eighty-nine percent (n = 25/28) were then appropriately treated with either topical diltiazem 2% or GTN 0.4%. Overall, 43.9% (n = 18/41) of all patients' entire management strategy adhered to the ACPGBI guidelines. In total, 48.8% (n = 20/41) patients had surgical treatment (excluding Botox), of which only 15% (n = 3/20) had undergone ACPGBI-compliant management. After local dissemination of results and education, the re-audit of 20 patients showed significant improvement in adherence to the guidelines (43.9% vs. 95%; P = 0.0001). CONCLUSIONS: Topical creams were the most successful treatments (50%; n = 9/18) in ACPGBI-compliant strategies. Importantly, these data suggests that compliance with the ACPGBI algorithm leads to healing without surgery in 83.3% (n = 15/18) of patients, compared to 26.1% (n = 6/23) with non-compliant methods (P = 0.0004). This highlights the benefit of early conservative and medical management of CAF, before attempting surgery.

The surgical admissions proforma: Does it make a difference?

Admissions records are essential in communicating key information regarding unwell patients and at handover of care. We designed, implemented and evaluated the impact of a standardised surgical clerking proforma on documentation and clinician acceptability in comparison to freehand clerking. A clerking proforma was implemented for all acute general surgical admissions. Documentation was assessed according to 32 criteria based on the Royal College of Surgeons of England guidelines, for admissions before (n = 72) and after (n = 96) implementation. Fisher's exact test and regression analysis were used to compare groups. Surgical team members were surveyed regarding attitudes towards the new proforma. Proforma uptake was 73%. After implementation, documentation increased in 28/32 criteria. This was statistically significant in 17 criteria, including past surgical history (p < 0.01), medication history (p = 0.03), ADLs (p = 0.02), systems review (p < 0.01), blood pressure (p < 0.01), blood results (p = 0.02) and advice given to the patient (p = 0.02). The proforma remained beneficial after regression analysis accounted for differences in time of day, seniority of the doctor and nights or weekends (coefficient = 0.12 [p < 0.01]). 89% of the surgical team felt the form improved quality of documentation and preferred its use to freehand clerking. 94% felt it was beneficial on the post-take ward-round. Audit quality control was also more reliable with the proforma (inter-observer agreement = 99.3% [κ = 0.997]) versus freehand clerking (97.1% [κ = 0.941]). Our study demonstrates that a standardised surgical clerking proformas improves the quantity and quality of documentation in comparison to freehand clerking, is preferred by health professionals and improves reliability of the audit quality control process.

Infiltrative mass of the skull base and nasopharynx: A diagnostic conundrum.

Inflammatory skull base masses are enigmatic and often behaviourally unpredictable. We present a case of idiopathic hypertrophic pachymeningitis (IHP) forming a central skull base mass to illustrate the process required when one investigates such skull base lesions. This is the first description of mass forming or tumefactive IHP extending into the nasopharynx. A 32-year old woman presented with frontal headaches and nasal discharge. She then deteriorated and was admitted with worsening headaches, serosanguinous nasal discharge and bilateral ophthalmoplegia. Multimodality imaging confirmed a destructive central skull base soft tissue mass involving the posterior clivus, floor of sphenoid sinus, nasopharynx and extending into both cavernous sinuses. Unfortunately, the patient continued to deteriorate despite treatment with broad-spectrum antibiotics. Cerebrospinal fluid, blood tests and transnasal biopsies for histology and microbiology did not reveal a diagnosis. Further neuroimaging revealed extension of the mass. Early corticosteroid treatment demonstrated radical improvement although an initial reducing regime resulted in significant rebound deterioration. She was stable on discharge with slowly reducing low dose oral prednisolone and azathioprine. We discuss the complexity of this case paying special attention to the process followed in order to arrive at a diagnosis of idiopathic hypertrophic pachymeningitis based on both the clinical progression and the detailed analysis of serial skull base imaging. Knowledge of the potential underlying aetiologies, characteristic radiological features, common pathogens and the impact on blood serology can narrow the potential differentials and may avoid the morbidity associated with extensive resective procedures.

Serious neonatal airway obstruction with massive congenital sublingual ranula and contralateral occurrence.

BACKGROUND: Congenital ranulas seldom occur, with bilateral presentation and prenatal diagnosis reported very rarely. We believe this is the first reported case of a neonate with a antenally diagnosed massive congenital ranula, who went on to develop a non-contiguous contralateral ranula, both contributing to obstruction in a complex paediatric airway. CASE REPORT: A female neonate was born to a non-primagravid mother via a planned elective caesarean section due to a lower facial defect and oral cyst. Antenatal aspiration of the pseudocyst was performed under ultrasound guidance with limited success. In the immediate post-natal period a poor airway was observed and the cyst was subsequently marsupialised. With the development of macroglossia secondary to oedema and tongue base collapse the airway was secured through surgical tracheostomy. A subsequent ultrasound scan revealed the presence of a second solitary cystic mass on the contralateral side. After careful excision of the contralateral pseudocyst, tongue function improved, with the resolution of a safe airway which permitted successful decannulation. A planned definitive procedure antenatally did not result in the anticipated improvement in function. However the subsequent development of a second non-contiguous pseudocyst and further surgical management resulted in a safe airway, improved masticator function and the ability to thrive. CONCLUSIONS: The prenatal diagnosis of congenital ranulas have been seldom reported, with no reported cases of contralateral occurrence and airway obstruction from an intraoral ranula. This rare case highlights the need for a well considered contingency plan when surgery is required for a neonatal airway at risk.

Basic surgical skills training in United Kingdom foundation year doctors: can we do more?

OBJECTIVE: Recent changes to the structure of medical training have placed increasing pressure on foundation year 1 (FY1) doctors to decide upon careers earlier. The deadline for application to core surgical training (CST) at the start of the foundation year 2 (FY2) may deter doctors from pursuing careers in surgery due to insufficient experience and confidence in its practical aspects. We piloted a four-week basic surgical skills (BSS) programme near the start of the FY1 year to a small cohort of FY1s and assessed its impact on confidence in basic surgical competencies and attitudes to a career in surgery. METHODS: FY1 doctors at Whipps Cross University Hospital (WXUH) were selected to participate in a four week BSS programme within three months of starting their posts. We devised the BSS programme based on relevant key competencies in the Intercollegiate Surgical Curriculum Programme (ISCP). Using questionnaires we assessed confidence in basic surgical skills, competencies and attitudes to surgery before, immediately after and at 8 months after completion of the course and compared this with non-participating FY1s. RESULTS: Out of 31 FY1 doctors, 14 (4 males, 10 females) participated in the BSS programme and 17 (10 males, 7 females) were non-participants (control group). Using the Mann-Whitney test, there was a statistically significant increase in confidence at 8 month follow-up of course participants (versus control group) in tying knots (p = 0.0112), suturing skills (p = 0.0455) performing fine needle aspiration (FNA) cytology (p = 0.0017), obtaining tru-cut biopsy samples (p = 0.0031), suturing lacerations in accident and emergency (A&E) (p = 0.0009), incising and draining abscesses (p = 0.0034), performing skin closure (p = 0.0042), surgical sharps handling (p = 0.0402) and surgical instrument handling (p = 0.0066). Course participants were significantly more likely than non-participants to receive additional training in BSS from senior members of the team (p = 0.0076). Importantly, they also demonstrated a statistically significant increase in interest in a career in surgery at 8 month follow-up in comparison to non-participants (p = 0.0016). CONCLUSIONS: A structured, challenging BSS teaching programme early on during the FY1 year increases confidence in key surgical skills and competencies and can increase interest in surgery as a career.