The Effect of the COVID-19 Pandemic on HbA1c Testing: Prioritization of High-Risk Cases and Impact of Social Deprivation.

INTRODUCTION: Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics. METHODS: In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics. RESULTS: In April 2020, monthly requests dropped to 7.9-18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7-86.9% of 2019 levels. During April-June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4-63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April-June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April-June 2020; trend test p < 0.001) and two subsequent periods (July-September and October-December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group. CONCLUSION: Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59-86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality.

Operative management of external auditory canal cholesteatoma: case series and literature review.

OBJECTIVES: To describe the clinical features of external auditory canal cholesteatoma, and to assess the outcome following bony meatoplasty with tragal cartilage and perichondrium graft repair. METHODS: A retrospective review was carried out, comprising all patients with external auditory canal who presented between January 2007 and December 2011. Patients underwent pre-operative audiometry and computed tomography imaging of the temporal bones, before undergoing bony meatoplasty via a postauricular incision. Pre- and post-operative comparisons were made of patients' otological symptoms and the otoscopic appearance of the external ear canal. RESULTS AND CONCLUSION: Eight patients were included in the analyses. The median age of patients was 46.5 years (range 14­68 years), with a male to female ratio of 1:1. The median length of follow up was 16 months. The most common presenting features were unilateral otalgia and purulent otorrhoea. All patients had relatively advanced disease at presentation, with erosion of the temporal bone. All patients underwent bony meatoplasty via a postauricular approach to eradicate the disease. Bony meatoplasty was successful in the definitive management of external ear canal cholesteatoma.

Bilateral Dupuytren's contractures of the thumb interphalangeal joints.

Dupuytren's disease was first described by Baron Guillaume Dupuytren in 1831. He outlined the pathology of palmar fascia thickening and contracture resulting in flexion of one or more digits. Dupuytren's disease usually affects the little or ring fingers, with the thumb rarely affected. Furthermore, the thumb in isolation is only affected in 0.5% of cases, with contracture at the metacarpophalangeal joint. We present a unique and interesting case of Dupuytren's disease predominantly of the thumbs, with isolated contractures bilaterally at the interphalangeal joints, in a 59 year old lady with epilepsy who was otherwise fit and well. To our knowledge this disease pattern has never been reported in the literature. Furthermore a relevant literature review of Dupuytren's disease affecting the thumb, in particular the interphalangeal joint, is presented. Our interesting and unique case reinforces the notion that the disease pathogenesis is diverse and multifactorial, and provides a further interesting example for the literature.

Subungual melanoma: an important tip.

Acral lentiginous melanoma is rare, representing approximately 1% of malignant melanomas. Overall 5 year survival is disproportionately poor (25-51%) compared to other histological subtypes. This has been attributed to diagnostic delay resulting in more advanced presentation. Subungual presentation in the fingers is uncommon, reported in 1-13% of all acral lentiginous melanomas. We report a unique and diagnostically challenging case. Contrary to previously reported examples in the literature, the actual neoplastic pathology was detected in the less pigmented finger tip skin rather than the deeply pigmented nail bed germinal and sterile matrix that showed no evidence of malignancy. We therefore advocate that in cases where skin surrounding the nail is involved, this surrounding skin should also be biopsied, even if it is less pigmented than the primary lesion.

Rectus sheath plication in abdominoplasty: assessment of its longevity and a review of the literature.

BACKGROUND: Correction of rectus diastasis during abdominoplasty is controversial. Few published studies have investigated the long-term value of plication. This prospective study aims to assess the long-term durability of plication of the rectus sheath in abdominoplasty using ultrasound. METHODS: A total of 28 consecutive abdominoplasty patients underwent rectus plication by the senior author (FSF) since 2006, using a 0/0 looped nylon suture. Rectus diastasis was measured preoperatively and postoperatively at 3, 6 and 12 month's intervals using a standardised ultrasound (7.5 MHz) probe, by the single senior radiologist (GJD). Diastasis of the recti was assessed at three fixed points: at the umbilicus, 6 cm above and 6 cm below the umbilicus. Diastasis was categorised using the Beer classification. RESULTS: All patients were female with a mean age of 36 years and average of body mass index (BMI) 26 kg m(-2). The majority of subjects had previous abdominal surgery including caesarean sections (82%, n = 23) and had at least one previous pregnancy (87%), with only two patients (8.7%) in the study being nulliparous. Correction of diastasis was maintained in all patients despite previous pregnancies and abdominal surgery. Postoperative follow-up time averaged 28 months (range 12-43 months). According to the Beer classification, there was no recurrence of rectus diastasis at the 12-month postoperative ultrasound measurements. A significant reduction in the mean distance between rectus muscles before surgery and 12 months postoperatively was noted. Previous surgery did not have a statistically significant affect on preoperative rectus distance. CONCLUSIONS: Vertical rectus plication with a non-absorbable suture demonstrates long-term durable results without any suture-related complications. Patient factors such as extent of preoperative rectus diastases and previous abdominal surgery did not appear to have a significant effect on the durability of the corrected diastasis.

Late presentation of congenital tracheo-oesophageal fistula.

Congenital tracheo-oesophageal fistula presenting in adulthood is extremely rare. Such a case is presented in a patient who suffered repeated chest problems as an infant, which persisted through the years, and was ultimately diagnosed as 'bakers lung' due to his occupation. He was referred with persistent cough to the ENT department, and an upper endoscopy located a tracheo-oesophageal fistula, which was subsequently resected with complete resolution of his symptoms. Unresolving chest problems or persisting cough should alert the doctor to such a possible diagnosis.

Management of serum calcium levels in post-thyroidectomy patients.

Otolaryngologists are increasingly performing thyroid surgery and are responsible for optimising parathyroid function postoperatively. The aim of this study was to establish an evidence-based algorithm for the management of postoperative calcium levels and to try and answer some relevant postoperative management issues. These include the following: (1) What is the risk of hypocalcaemia both temporary and permanent? (2) When should calcium replacement be commenced and in what form? (3) What is the best method for calcium replacement without suppressing a recovering parathyroid? (4) How to identify recovering parathyroid function if the patient is already on calcium replacement? A systematic review of the literature was carried out supported by a retrospective analysis of postoperative calcium levels obtained from clinical records of patients undergoing thyroidectomy under our care (n = 167). We present an evidence based, user-friendly algorithm for the management of the serum calcium in patients undergoing thyroid surgery.

Intramuscular capillary hamartoma of the tongue.

Intramuscular vascular lesions in the tongue are rare and are usually the capillary form of haemangioma. A case is described of a lingual mass that resembled intramuscular haemangioma but had unique histological features that do not appear to have been described previously. The term intramuscular capillary hamartoma is suggested to describe it.

Sino nasal assessment questionnaire, a patient focused, rhinosinusitis specific outcome measure.

It is becoming increasingly important for clinicians to be able to demonstrate the effectiveness of their interventions. We have developed a rhinosinusitis--specific outcome measure (SNAQ-11) that avoids the shortcomings of the existing tools. This paper compares its use with the widely used Sinonasal Outcome Test (SNOT-20). We carried out a prospective study that involved forty patients undergoing endoscopic sinus surgery. Their SNAQ-11 and SNOT-20 scores were compared pre and post operatively. We also recorded individual symptom scores pre and post operatively in order to study the impact of surgery. The study shows a larger change in the postoperative SNAQ score compared to that in SNOT-20 (21% c.f. 11%) Although the pre and post-op changes in SNOT-20 are significant at the p = 0.005 level, the changes in the SNAQ-11 are highly significant at the p = 0.0001 level. Furthermore we have statistically confirmed that the change seen with SNAQ-11 is larger in relation to the variation in change as compared with SNOT-20 (-1.08 c.f. -0.59). Our results show that SNAQ-11 is a valid and highly relevant rhinosinusitis outcome tool. The results also confirm that Endoscopic Sinus Surgery seems especially effective at addressing nasal obstruction, congestion and facial pain/pressure, fair at anterior nasal discharge, sneezing, hyposmia and sleep disturbance and poor for post nasal drip, cough and earache.

Osseous haemangioma of inferior turbinate.

We present a case of osseous haemangioma arising within the inferior turbinate.

Influence of free radicals on cardiovascular risk due to occupational exposure to mercury.

This study was designed to investigate the relation between occupational exposure to mercury and cardiovascular risk, as well as free radicals. The study subjects included 30 male workers exposed to mercury from a fluorescent lamp plant in Alexandria after exclusion of 12 workers with conditions that may bias the results. A matched control group of 20 male subjects were selected from a food industrial plant. The participants were subjected to interview, clinical examination, electrocardiography and R-R deep breathing variability test as a measure of cardiac autonomic function. Spot urine and venous blood samples were collected to measure mercury levels. Free radicals related markers were measured in serum namely lipid peroxide, superoxide dismutase (SOD) activity, catalase activity and glutathione S-transferase. Results showed significant longer electrocardiographic Q-Tc interval, which is corrected to heart rate, in exposed workers than in controls (p=0.002). The R-R deep breathing variability indices were significantly increased among exposed workers in comparison to controls (maximal variation (MV) ratio, p=0.024 & MV rate, p=0.019). The mercury levels in both urine and blood of exposed workers were significantly higher than controls (p<0.0001), with mean levels exceeding the permissible limits. Free radicals related markers revealed significant higher level of lipid peroxide, as well as significant lower levels of SOD activity, catalase activity and glutathione S-transferase among exposed workers than among controls (p<0.0001 for all). Independent relations were observed between Q-Tc and lipid peroxide, and between MV rate and SOD and catalase activities among exposed workers after adjustment for the confounders by multivariate regression analyses. These findings may suspect a cardiac autonomic dysfunction probably related to free radicals in mercury exposed workers. Also, it may through light on some preventive implications.

Environmental factors and health problems among workers of the national project in Toshka.

The National Project in Toshka is a recognized agricultural one, as well as a comprehensive developmental project. The present study was carried out to investigate environmental factors and health problems among workers in this National Project. Environmental levels of vibration, noise, heat stress, total suspended particulates and respirable dust were measured in the different activities of the project during May 2000. The health records of Behera Company Incorporation, the project main implementing contractor, in the period 1997-1999 were analyzed. Workers were classified according to the nature of occupational exposure into three groups namely; earth workers, concrete workers, and services and administration workers. Records of occupational accidents of the same group of workers and in the same period were analyzed as well. Results showed that all the measured environmental factors were within the permissible levels of exposure in the different project activities. Workers showed a significant lower rate of total health problems in the last studied year (1999) as compared to the previous two years (1997-1998) (p=0.001). Prevalence rates of musculoskeletal disorders, urinary tract troubles, ear-nose-throat (ENT) problems and chest problems were significantly higher in earth and concrete workers than in services and administration workers (p=0.001, 0.011, 0.036 and 0.044, respectively). Both occupational accident frequency and severity rates were very low in comparison to other major construction projects such as the High Dam. These rates showed decreasing trends throughout the studied years; however, relatively higher rates were observed among earth workers than the other groups. Miscellaneous wounds were the commonest presentation of occupational injuries among the three occupational groups. In conclusion, the current use of modern technology accounted for the low levels of enviro mental exposure factors, as well as the high safety standards. Workers showed a significant degree of acclimatization to work in this region; therefore, inhabitants and workers should be encouraged to engage this new community. The low rates of health problems among workers observed in this study reflected a satisfactory level of medical services. Preplacement and periodic medical examinations of construction workers aught to consider musculoskeletal, urinary tract, ENT and chest conditions among them.