The Otolaryngology Consultant Workforce in England: A Survey Update and Future Repercussions.

INTRODUCTION: Effective medical staffing is pivotal for a successful healthcare system, demanding strategic planning to ensure a high-quality service. Although the UK's doctor to population ratio has improved over time, it remains below global averages. The COVID-19 pandemic has exacerbated existing challenges, resulting in an unprecedented NHS waiting list with Ear, Nose, and Throat (ENT) surgeries ranking third highest in waiting times amongst all specialties. METHODS: This study utilized a national jotform survey to gather data from ENTUK members, primarily focusing on consultant staffing within ENT departments across the UK. Additional information collected encompassed registration status, part-time roles, gender, vacancies, locum roles, associate specialists, registrars and other junior doctors, and advanced nurse practitioners. When survey responses were inadequate, direct communication was established with departmental consultants or secretaries, followed by Freedom of Information requests as necessary. All data were compiled using Microsoft Excel. RESULTS: Among the 65 responses to the ENTUK survey, 53 individual trusts were identified. These included 41 English acute trusts, with supplementary participation from Scotland, Wales, and Northern Ireland. Data from 749 consultants across 115 English acute trusts were collected in combination with a Freedom of Information request. CONCLUSION: Despite an increased number of ENT consultants, the persistence of unfilled posts coincides with mounting waiting lists. The pandemic's effects, including early retirements and part-time roles, emphasise the urgency of expanding training positions to counterbalance these shifts. Local and national interventions are essential to fortify and diversify the ENT workforce through a variety of strategies.

Energetic Electron Precipitation Driven by Electromagnetic Ion Cyclotron Waves from ELFIN's Low Altitude Perspective.

We review comprehensive observations of electromagnetic ion cyclotron (EMIC) wave-driven energetic electron precipitation using data collected by the energetic electron detector on the Electron Losses and Fields InvestigatioN (ELFIN) mission, two polar-orbiting low-altitude spinning CubeSats, measuring 50-5000 keV electrons with good pitch-angle and energy resolution. EMIC wave-driven precipitation exhibits a distinct signature in energy-spectrograms of the precipitating-to-trapped flux ratio: peaks at >0.5 MeV which are abrupt (bursty) (lasting ∼17 s, or ΔL∼0.56) with significant substructure (occasionally down to sub-second timescale). We attribute the bursty nature of the precipitation to the spatial extent and structuredness of the wave field at the equator. Multiple ELFIN passes over the same MLT sector allow us to study the spatial and temporal evolution of the EMIC wave - electron interaction region. Case studies employing conjugate ground-based or equatorial observations of the EMIC waves reveal that the energy of moderate and strong precipitation at ELFIN approximately agrees with theoretical expectations for cyclotron resonant interactions in a cold plasma. Using multiple years of ELFIN data uniformly distributed in local time, we assemble a statistical database of ∼50 events of strong EMIC wave-driven precipitation. Most reside at L∼5-7 at dusk, while a smaller subset exists at L∼8-12 at post-midnight. The energies of the peak-precipitation ratio and of the half-peak precipitation ratio (our proxy for the minimum resonance energy) exhibit an L-shell dependence in good agreement with theoretical estimates based on prior statistical observations of EMIC wave power spectra. The precipitation ratio's spectral shape for the most intense events has an exponential falloff away from the peak (i.e., on either side of ∼1.45 MeV). It too agrees well with quasi-linear diffusion theory based on prior statistics of wave spectra. It should be noted though that this diffusive treatment likely includes effects from nonlinear resonant interactions (especially at high energies) and nonresonant effects from sharp wave packet edges (at low energies). Sub-MeV electron precipitation observed concurrently with strong EMIC wave-driven >1 MeV precipitation has a spectral shape that is consistent with efficient pitch-angle scattering down to ∼ 200-300 keV by much less intense higher frequency EMIC waves at dusk (where such waves are most frequent). At ∼100 keV, whistler-mode chorus may be implicated in concurrent precipitation. These results confirm the critical role of EMIC waves in driving relativistic electron losses. Nonlinear effects may abound and require further investigation.

In vitro measurement of ciliary beat frequency in 92 children with recurrent respiratory tract problems.

BACKGROUND: Chronic or recurrent mucoid respiratory tract symptoms may be difficult to diagnose. METHOD: Ninety-two children with chronic respiratory symptoms were divided into 4 groups: 18 children with refractory asthma, 10 with bronchiectasis without dextrocardia, 18 with dextrocardia and 46 with recurrent respiratory tract infections. Except for five neonates, cytology samples were taken under general anaesthesia. Ciliary beat frequency was measured photometrically and analysed by in-house computer software. RESULTS: Nasal polyps were found in one child with normal ciliary beat frequency. Twenty-six children had no beating cilia (male to female ratio, 15:11). The effect of increasing temperature on the ciliary beat frequency of the remaining 66 patients was evaluated (42 patients, more than 30°C, median, 8.3 Hz; 24 patients, 30-37°C, median, 11.8 Hz; p = 0.0003). CONCLUSION: The measurement of ciliary beat frequency is part of the diagnostic work up of patients with persistent or recurrent respiratory tract infections.

Nasal chondromesenchymal hamartoma: an update.

OBJECTIVE: Nasal chondromesenchymal hamartoma is a rare pathology that can present with a myriad of symptoms to ENT, maxillofacial and ophthalmology departments. This study reviewed the literature on nasal chondromesenchymal hamartoma as well as adding three new cases to the reported literature. METHOD: This study was an up-to-date review of the world literature with the addition of three new cases to provide the most comprehensive review to date. RESULTS: A total of 56 patients with nasal chondromesenchymal hamartoma were identified, ranging from children to adults. Nasal symptoms and ocular symptoms were most common, and surgical resection was the most frequent treatment modality. CONCLUSION: This study advocates for increased awareness of the condition associations for nasal chondromesenchymal hamartoma, multi-specialty treatment and the role for the ENT surgeon in treatment of the condition.

Virus Detection: A Review of the Current and Emerging Molecular and Immunological Methods.

Viruses are ubiquitous in the environment. While many impart no deleterious effects on their hosts, several are major pathogens. This risk of pathogenicity, alongside the fact that many viruses can rapidly mutate highlights the need for suitable, rapid diagnostic measures. This review provides a critical analysis of widely used methods and examines their advantages and limitations. Currently, nucleic-acid detection and immunoassay methods are among the most popular means for quickly identifying viral infection directly from source. Nucleic acid-based detection generally offers high sensitivity, but can be time-consuming, costly, and require trained staff. The use of isothermal-based amplification systems for detection could aid in the reduction of results turnaround and equipment-associated costs, making them appealing for point-of-use applications, or when high volume/fast turnaround testing is required. Alternatively, immunoassays offer robustness and reduced costs. Furthermore, some immunoassay formats, such as those using lateral-flow technology, can generate results very rapidly. However, immunoassays typically cannot achieve comparable sensitivity to nucleic acid-based detection methods. Alongside these methods, the application of next-generation sequencing can provide highly specific results. In addition, the ability to sequence large numbers of viral genomes would provide researchers with enhanced information and assist in tracing infections.

'Everything was just getting worse and worse': deteriorating job quality as a driver of doctor emigration from Ireland.

BACKGROUND: Medicine is a high-status, high-skill occupation which has traditionally provided access to good quality jobs and relatively high salaries. In Ireland, historic underfunding combined with austerity-related cutbacks has negatively impacted job quality to the extent that hospital medical jobs have begun to resemble extreme jobs. Extreme jobs combine components of a good quality job-high pay, high job control, challenging demands, with those of a low-quality job-long working hours, heavy workloads. Deteriorating job quality and the normalisation of extreme working is driving doctor emigration from Ireland and deterring return. METHODS: Semi-structured qualitative interviews were conducted with 40 Irish emigrant doctors in Australia who had emigrated from Ireland since 2008. Interviews were held in July-August 2018. RESULTS: Respondents reflected on their experiences of working in the Irish health system, describing hospital workplaces that were understaffed, overstretched and within which extreme working had become normalised, particularly in relation to long working hours, fast working pace, doing more with less and fighting a climate of negativity. Drawing on Hirschman's work on exit, voice and loyalty (1970), the authors consider doctor emigration as exit and present respondent experiences of voice prior to emigration. Only 14/40 respondent emigrant doctors intend to return to work in Ireland. DISCUSSION: The deterioration in medical job quality and the normalisation of extreme working is a key driver of doctor emigration from Ireland, and deterring return. Irish trained hospital doctors emigrate to access good quality jobs in Australia and are increasingly likely to remain abroad once they have secured them. To improve doctor retention, health systems and employers must mitigate a gainst the emergence of extreme work in healthcare. Employee voice (about working conditions, about patient safety, etc.) should be encouraged and used to inform health system improvement and to mitigate exit.

Combinatorial morphogenetic and mechanical cues to mimic bone development for defect repair.

Endochondral ossification during long bone development and natural fracture healing initiates by mesenchymal cell condensation, directed by local morphogen signals and mechanical cues. Here, we aimed to mimic development for regeneration of large bone defects. We hypothesized that engineered human mesenchymal condensations presenting transforming growth factor-ß1 (TGF-ß1) and/or bone morphogenetic protein-2 (BMP-2) from encapsulated microparticles promotes endochondral defect regeneration contingent on in vivo mechanical cues. Mesenchymal condensations induced bone formation dependent on morphogen presentation, with BMP-2 + TGF-ß1 fully restoring mechanical function. Delayed in vivo ambulatory loading significantly enhanced the bone formation rate in the dual morphogen group. In vitro, BMP-2 or BMP-2 + TGF-ß1 initiated robust endochondral lineage commitment. In vivo, however, extensive cartilage formation was evident predominantly in the BMP-2 + TGF-ß1 group, enhanced by mechanical loading. Together, this study demonstrates a biomimetic template for recapitulating developmental morphogenic and mechanical cues in vivo for tissue engineering.

Thermal Inactivation of Listeria monocytogenes in Crab Meat.

Listeria monocytogenes is an important bacterial pathogen in seafood products, but limited information is currently available on the thermal resistance of relevant isolates in seafood. Thermal inactivation studies were undertaken (i) to provide much needed thermal inactivation data for L. monocytogenes in crab meat and (ii) to investigate whether tryptone soya broth (TSB) is representative of crab meat in thermal inactivation studies involving L. monocytogenes. D-values were obtained for a cocktail of two crab isolates (serotypes 1/2a and 4b) at 50, 55, and 60°C. In crab meat, D-values were 174.4, 28.2, and 1.6 min, respectively. Similar D-values of 176.4, 28.8, and 1.4 min were obtained in TSB. The corresponding z-values were 4.9°C (crab meat) and 4.8°C (TSB), respectively. The conclusions were that (i) current pasteurization conditions (e.g., 70°C for 2 min) would achieve complete destruction of any L. monocytogenes present in crab meat and (ii) TSB could be used as a model matrix for assessing the thermal inactivation of L. monocytogenes in crab meat.

Will children ever learn? Removal of nasal and aural foreign bodies: a study of hospital episode statistics.

Introduction Foreign body removal is a common reason for children to attend the emergency department. Generally, aural and nasal foreign bodies are not associated with immediate morbidity unless they are button batteries. There can be consequences of migration and removal. Methods Hospital Episode Statistics for 2010-2016 were used to calculate the number of nasal and aural foreign bodies that have been removed in hospital. Data for adults and children have been compared. Results 8752 nasal and 17,325 aural foreign bodies have been removed from adults and children over the course of 6 years. Children were responsible for 95% of the 8353 nasal and 85% of the 14,875 aural foreign body presentations. Children aged 1-4 years are most at risk of injury. Conclusion Children are more likely to present to hospital than adults with a foreign body in the ear or nose. Aural bodies were more likely to need removal in hospital for both populations. Authors believe that these require identification and removal by an ear, nose and throat specialist to prevent morbidity. The overall number of procedures performed annually in children has not reduced over the study period; an average of 1218 nasal and 2479 aural foreign body removals are performed each year with an annual cost of £2,880,148 to NHS England.

Genetic and nongenetic factors associated with milk color in dairy cows.

Milk color is one of the sensory properties that can influence consumer choice of one product over another and it influences the quality of processed dairy products. This study aims to quantify the cow-level genetic and nongenetic factors associated with bovine milk color traits. A total of 136,807 spectra from Irish commercial and research herds (with multiple breeds and crosses) were used. Milk lightness (Lˆ*), red-green index (aˆ*) and yellow-blue index (bˆ*) were predicted for individual milk samples using only the mid-infrared spectrum of the milk sample. Factors associated with milk color were breed, stage of lactation, parity, milking-time, udder health status, pasture grazing, and seasonal calving. (Co)variance components for Lˆ*,aˆ*, and bˆ* were estimated using random regressions on the additive genetic and within-lactation permanent environmental effects. Greater bˆ* value (i.e., more yellow color) was evident in milk from Jersey cows. Milk Lˆ* increased consistently with stage of lactation, whereas aˆ* increased until mid lactation to subsequently plateau. Milk bˆ* deteriorated until 31 to 60 DIM, but then improved thereafter until the end of lactation. Relative to multiparous cows, milk yielded by primiparae was, on average, lighter (i.e., greater Lˆ*), more red (i.e., greater aˆ*), and less yellow (i.e., lower bˆ*). Milk from the morning milk session had lower Lˆ*,aˆ*, and bˆ* Heritability estimates (±SE) for milk color varied between 0.15 ± 0.02 (30 DIM) and 0.46 ± 0.02 (210 DIM) for Lˆ*, between 0.09 ± 0.01 (30 DIM) and 0.15 ± 0.02 (305 DIM) for aˆ*, and between 0.18 ± 0.02 (21 DIM) and 0.56 ± 0.03 (305 DIM) for bˆ* For all the 3 milk color features, the within-trait genetic correlations approached unity as the time intervals compared shortened and were generally <0.40 between the peripheries of the lactation. Strong positive genetic correlations existed between bˆ* value and milk fat concentration, ranging from 0.82 ± 0.19 at 5 DIM to 0.96 ± 0.01 at 305 DIM and confirming the observed phenotypic correlation (0.64, SE = 0.01). Results of the present study suggest that breeding strategies for the enhancement of milk color traits could be implemented for dairy cattle populations. Such strategies, coupled with the knowledge of milk color traits variation due to nongenetic factors, may represent a tool for the dairy processors to reduce, if not eliminate, the use of artificial pigments during milk manufacturing.

Processing characteristics of dairy cow milk are moderately heritable.

Milk processing attributes represent a group of milk quality traits that are important to the dairy industry to inform product portfolio. However, because of the resources required to routinely measure such quality traits, precise genetic parameter estimates from a large population of animals are lacking for these traits. Milk processing characteristics considered in the present study-rennet coagulation time, curd-firming time, curd firmness at 30 and 60 min after rennet addition, heat coagulation time, casein micelle size, and milk pH-were all estimated using mid-infrared spectroscopy prediction equations. Variance components for these traits were estimated using 136,807 test-day records from 5 to 305 d in milk (DIM) from 9,824 cows using random regressions to model the additive genetic and within-lactation permanent environmental variances. Heritability estimates ranged from 0.18 ± 0.01 (26 DIM) to 0.38 ± 0.02 (180 DIM) for rennet coagulation time; from 0.26 ± 0.02 (5 DIM) to 0.57 ± 0.02 (174 DIM) for curd-firming time; from 0.16 ± 0.01 (30 DIM) to 0.56 ± 0.02 (271 DIM) for curd firmness at 30 min; from 0.13 ± 0.01 (30 DIM) to 0.48 ± 0.02 (271 DIM) for curd firmness at 60 min; from 0.08 ± 0.01 (17 DIM) to 0.24 ± 0.01 (180 DIM) for heat coagulation time; from 0.23 ± 0.02 (30 DIM) to 0.43 ± 0.02 (261 DIM) for casein micelle size; and from 0.20 ± 0.01 (30 DIM) to 0.36 ± 0.02 (151 DIM) for milk pH. Within-trait genetic correlations across DIM weakened as the number of days between compared intervals increased but were mostly >0.4 except between the peripheries of the lactation. Eigenvalues and associated eigenfunctions of the additive genetic covariance matrix for all traits revealed that at least the 80% of the genetic variation among animals in lactation profiles was associated with the height of the lactation profile. Curd-firming time and curd firmness at 30 min were weakly to moderately genetically correlated with milk yield (from 0.33 ± 0.05 to 0.59 ± 0.05 for curd-firming time, and from -0.62 ± 0.03 to -0.21 ± 0.06 for curd firmness at 30 min). Milk protein concentration was strongly genetically correlated with curd firmness at 30 min (0.84 ± 0.02 to 0.94 ± 0.01) but only weakly genetically correlated with milk heat coagulation time (-0.27 ± 0.07 to 0.19 ± 0.06). Results from the present study indicate the existence of exploitable genetic variation for milk processing characteristics. Because of possible indirect deterioration in milk processing characteristics due to selection for greater milk yield, emphasis on milk processing characteristics is advised.

Cow and environmental factors associated with protein fractions and free amino acids predicted using mid-infrared spectroscopy in bovine milk.

The objective of the present study was to identify the factors associated with both the protein composition and free amino acid (FAA) composition of bovine milk predicted using mid-infrared spectroscopy. Milk samples were available from 7 research herds and 69 commercial herds. The spectral data from the research herds comprised 94,286 separate morning and evening milk samples; the spectral data from the commercial herds comprised 40,260 milk samples representing a composite sample of both the morning and evening milkings. Mid-infrared spectroscopy prediction models developed in a previous study were applied to all spectra. Factors associated with the predicted protein and FAA composition were quantified using linear mixed models. Factors considered in the model included the fixed effects of calendar month of the test, milking time (i.e., morning, evening, or both combined), parity (1, 2, 3, 4, 5, and ≥6), stage of lactation, the interaction between parity and stage of lactation, breed proportion of the cow (Friesian, Jersey, Norwegian Red, Montbéliarde, and other), and both the general heterosis and recombination coefficients of the cow. Contemporary group as well as both within- and across-lactation permanent environmental effects were included in all models as random effects. Total proteins (i.e., total casein, CN; total whey; and total ß-lactoglobulin) and protein fractions (with the exception of α-lactalbumin) decreased postcalving until 36 to 65 days in milk and increased thereafter. After adjusting the statistical model for differences in crude protein content and milk yield separately, irrespective of stage of lactation, younger animals produced more total proteins (i.e., total CN, total whey, and total ß-lactoglobulin) as well as more total FAA, Glu, and Asp than their older contemporaries. The concentration of all protein fractions (except ß-CN) in milk was greatest in the evening milk, even after adjusting for differences in the crude protein content of the milk. Relative to a purebred Holstein cow, Jersey cows, on average, produced a greater concentration of all CN fractions but less total FAA, Glu, Gly, Asp, and Val in milk. Relative to their respective purebred parental average, first-cross cows produced more total CN and more ß-CN. Results from the present study indicate that many cow-level factors, as well as other factors, are associated with protein composition and FAA composition of bovine milk.

Using Patient-Reported Outcome Measures for Quality Improvement in Clinical Genetics: an Exploratory Study.

International advocacy of patient-centred healthcare delivery has led to emphasis on the (re)design and evaluation of healthcare processes and outcomes from a patient perspective. Patient-reported outcome measures (PROMs) have significant potential to inform such attempts. However there is limited understanding of the processes by which this can be achieved. This exploratory study followed attempts to utilise two different PROMs measures to support service quality improvement in clinical genetics. PROMs used were the Genetic Counseling Outcome Scale (GCOS-24), a well-validated clinical genetics-specific PROM and Euroqol (EQ-5D), a generic PROM favoured by the UK National Institute for Health and Excellence (NICE). Both of these PROMs enable pre/post intervention comparison. A service audit tool was also used, premised on a patient-reported experience measure. In addition, the study draws on interviews with clinical staff to identify challenges associated with the use of PROMs (response rate, data collection, analysis). Benefits are also explored and include the provision of insight into patients' needs; complementing clinical judgement; identification of needs being met, evidencing the benefit of services provided; prompting consideration of areas requiring attention; and encouraging professional development.

Factors associated with milk processing characteristics predicted by mid-infrared spectroscopy in a large database of dairy cows.

Despite milk processing characteristics being important quality traits, little is known about the factors underlying their variability, due primarily to the resources required to measure these characteristics in a sufficiently large population. Cow milk coagulation properties (rennet coagulation time, curd-firming time, curd firmness 30 and 60 min after rennet addition), heat coagulation time, casein micelle size, and pH were generated from available mid-infrared spectroscopy prediction models. The prediction models were applied to 136,807 spectra collected from 9,824 Irish dairy cows from research and commercial herds. Sources of variation were investigated using linear mixed models that included the fixed effects of calendar month of test; milking time in the day; linear regressions on the proportion of Friesian, Jersey, Montbéliarde, Norwegian Red, and "other" breeds in the cow; coefficients of heterosis and of recombination loss; parity; stage of lactation; and the 2-way interaction parity × stage of lactation. Within- and across-parity cow effects, contemporary group, and a residual term were also included as random effects in the model. Supplementary analyses considered the inclusion of either test-day milk yield or milk protein concentration as fixed-effects covariates in the multiple regression models. Milk coagulation properties were most favorable (i.e., short rennet coagulation time and strong curd firmness) for cheese manufacturing in early lactation, concurrent with the lowest values of both pH and casein micelle size. Milk coagulation properties and pH deteriorated in mid lactation but improved toward the end of lactation. In direct contrast, heat coagulation time was more favorable in mid lactation and less suitable (i.e., shorter) for high temperature treatments in both early and late lactation. Relative to multiparous cows, primiparous cows, on average, yielded milk with shorter rennet coagulation time and longer heat coagulation time. Milk from the evening milking session had shorter rennet coagulation time and greater curd firmness, as well as lower heat coagulation time and lower pH compared with milk from the morning session. Jersey cows, on average, yielded milk more suitable for cheese production rather than for milk powder production. When protein concentration was included in the model, the improvement of milk coagulation properties toward the end of lactation was no longer apparent. Results from the present study may aid in decision-making for milk manufacturing, especially in countries characterized by a seasonal supply of fresh milk.

Motivating systems-oriented research on environmental and policy changes for obesity prevention.

BACKGROUND: Research on the types of interventions needed for population-level prevention of childhood obesity in complex societal systems can benefit from greater use of systems-science concepts and tools. OBJECTIVES: We report outcomes of a funding programme promoting incorporation of systems-science approaches into studies of imminent policy or environmental changes potentially impacting childhood obesity. METHODS: Seven funding cycles over 3 years yielded 172 initial submissions from 29 US states and 25 other countries were analyzed. RESULTS: Submissions focused primarily on aspects of school or child-care settings, parks and recreational settings, or access to healthy food; about half reflected attention to systems perspectives. CONCLUSIONS: Analysis of initial submissions as well as the 15 funded projects showed some success in motivating use of systems concepts and tools but suggested the need for a more focused effort to educate and prepare the childhood obesity prevention research community for this potentially crucial type of research.

Pseudodacryocystitis: paediatric case series of infected atypical ethmoid air cells masquerading as recurrent dacryocystitis.

PurposeTo highlight the clinical and surgical considerations in treating patients with apparent recurrent acute dacryocystitis with a patent lacrimal system.MethodsThree children referred to a tertiary unit as recurrent acute dacryocystitis were reviewed retrospectively. Imaging and subsequent surgical intervention revealed the underlying diagnosis.ResultsAll three cases presented with recurrent abscesses in the region of the lacrimal sac that failed to respond to incision and drainage. The lesions were lower and more lateral to the usual location of a sac abscess and closer to the inferior orbital rim. All three cases were found to have patent lacrimal systems on syringing, and all were found to have infected, low-lying, anteriorly placed aberrant ethmoid air cells on computed tomography and magnetic resonance imaging. These were confirmed on subsequent surgical exploration.ConclusionsInfected low-lying ethmoid air cells can mimic dacryocystitis with recurrent abcesses. In cases where a patent nasolacrimal system is demonstrated and a more inferolateral location of the swelling than would be expected in dacryocystitis is seen, imaging is warranted to ensure the appropriate intervention is undertaken. Anterior ethmoidectomy as opposed to dacryocystorhinostomy is the appropriate treatment in these cases.

Critical Airway Compromise due to a Massive Vagal Schwannoma.

We describe the case of a 37-year-old man with a slowly enlarging neck lump and compressive symptoms. He presented to a separate institution 10 years prior where an observational approach was advocated. Following preoperative investigations and embolization, an 11cm vagal schwannoma was excised and vagus nerve was sacrificed. Although conservative management is appropriate for a select patient population, surgical excision is treatment of choice for cervical neurogenic tumours and paraganglionomas and must be considered in young patients or rapidly expanding tumours to avoid compressive symptoms, as in this case.