The utility of lateral neck radiographs in the management of fish bones.

BACKGROUND: Lateral neck radiographs are commonly used in the investigation and management of patients presenting with suspected fish bone impaction. The effectiveness of these is questioned, as many fish do not have radio-opaque bones. OBJECTIVE: This study evaluated the utility of lateral neck radiographs in the management of patients presenting with fish bones retained in the upper aerodigestive tract, with the creation of a treatment algorithm to guide further management. METHODS: An audit of practice was undertaken at the University Hospital of Southampton, identifying all patients admitted with potential fish bone impaction in the upper aerodigestive tract. Following analysis, a treatment algorithm was constructed for use by junior doctors. RESULTS: In total, 34 per cent of patients with a normal radiograph were subsequently found to have a fish bone present under local or general anaesthetic assessment. The sensitivity of radiographs in the detection of fish bones was found to be 51.6 per cent. CONCLUSION: Lateral neck radiographs have limited value in the management of suspected fish bone impaction, and should only be used following detailed clinical examination of the upper aerodigestive tract.

The use of visual distraction to improve the tolerability of flexible laryngoscopy.

BACKGROUND: Flexible laryngoscopy is a commonly performed procedure in otolaryngology. Although this procedure is not considered painful, many patients describe it as uncomfortable. This study investigated the role of visual distraction as a form of pain relief during flexible laryngoscopy. METHODS: The study included patients undergoing flexible laryngoscopy at the University Hospital Southampton. Patients were self-allocated to one of four groups: with or without co-phenylcaine anaesthetic spray; and with and without visual distraction. Visual distraction involved the patient watching the procedure concurrently with the clinician, via a video monitor. Pre- and post-procedural discomfort was assessed using a visual analogue scale. RESULTS: The use of topical anaesthetic spray was not associated with significantly reduced discomfort scores (p > 0.05). Discomfort scores were significantly reduced in the visual distraction groups (p = 0.04), irrespective of the use of topical anaesthetic spray. CONCLUSION: This small study showed that visual distraction should be considered as a simple and cost-effective alternative to local anaesthetic for flexible laryngoscopy.

Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients.

BACKGROUND: There is uncertainty regarding the safety of different volume replacement solutions. The aim of this study was systematically to review evidence of crystalloid versus colloid solutions, and to determine whether these results are influenced by trial design or clinical setting. METHODS: PubMed, Embase and the Cochrane Central Register of Controlled Trials were used to identify randomized clinical trials (RCTs) that compared crystalloids with colloids as volume replacement solutions in patients with traumatic injuries, those undergoing surgery and in critically ill patients. Adjusted odds ratios (ORs) for mortality and major morbidity including renal injury were pooled using fixed-effect and random-effects models. RESULTS: Some 59 RCTs involving 16 889 patients were included in the analysis. Forty-one studies (69 per cent) were found to have selection, detection or performance bias. Colloid administration did not lead to increased mortality (32 trials, 16 647 patients; OR 0·99, 95 per cent c.i. 0·92 to 1·06), but did increase the risk of developing acute kidney injury requiring renal replacement therapy (9 trials, 11 648 patients; OR 1·35, 1·17 to 1·57). Sensitivity analyses that excluded small and low-quality studies did not substantially alter these results. Subgroup analyses by type of colloid showed that increased mortality and renal replacement therapy were associated with use of pentastarch, and increased risk of renal injury and renal replacement therapy with use of tetrastarch. Subgroup analysis indicated that the risks of mortality and renal injury attributable to colloids were observed only in critically ill patients with sepsis. CONCLUSION: Current general restrictions on the use of colloid solutions are not supported by evidence.

Reporting guidelines and journal quality in otolaryngology.

OBJECTIVES: Journals increasingly use reporting guidelines to standardise research papers, partly to improve quality. Although defining journal quality is difficult, various calculated metrics are used. This study investigates guideline adoption by otolaryngology journals and whether a relationship exists between this and journal quality. DESIGN, SETTING, PARTICIPANTS: Retrospective MEDLINE database review for English language, Index Medicus, journals of interest to otolaryngologists (October 2013). MAIN OUTCOME MEASURES: The resulting journals were examined for the number of guidelines endorsed and then tabulated against surrogate measures of journal quality (Impact factor, Eigenfactor, SCImago, Source-Normalised rank). The primary outcome measure was the number of recognised reporting guidelines endorsed per journal. This was then correlated against journal quality scores. For comparison, a further small sample correlation was performed with 6 randomly selected and 6 high-profile clinical non-otolaryngology journals. RESULTS: 37 otolaryngology journals were identified. Number of guidelines used and quality scores were not normally distributed. Mean guideline usage was 1.0 for otolaryngology journals, 1.5 for randomly selected, and 5.5 for the high-profile journals. Only 18/37 (49%) otolaryngology journals endorsed any guidelines, compared with 11/12 non-otolaryngology journals. Within otolaryngology, Eigenfactor positively correlated with guideline use (r = 0.4, n = 44, p < 0.01) otherwise no correlation was found between guideline endorsement and journal quality. CONCLUSIONS: Reporting guideline endorsement within otolaryngology journals is low. Although it might be expected that use of reporting guidelines improved quality, this is not reflected in the derived quality scores in otolaryngology. This may reflect low levels of use/enforcement, that quality indicators are inherently flawed, or that generalised guidelines are not always appropriate or valued by editors.

Participation in sport and physical activity in head and neck cancer survivors: associations with quality of life.

BACKGROUND: Head and neck cancer (HNC), and its treatment, is associated with significant side-effects which can affect quality of life (QOL). Physical activity (PA) is known to improve a number of QOL measures. We aimed to determine the prevalence of PA pre- and post-treatment of HNC and to determine associations with QOL. METHODS: A questionnaire-based survey of 172 patients pre- and post-treatment for HNC. RESULTS: A total of 62.2% of patients met current UK PA guidelines pre-treatment, reducing to 40.1% following treatment. There was a significant decrease in Metabolic equivalent task minutes/week post-treatment, with 71% of participants reporting less PA after diagnosis (P < 0.001). Swimming and cycling remained the two most practiced sports. There was a positive correlation between the post-treatment PA and QOL (P < 0.001). CONCLUSION: These data suggest that PA may improve QOL following treatment for HNC. We believe that further studies are warranted.

Structural and optical investigations of Fe1.03Se0.5Te0.5 under high pressure.

Optimally doped iron-chalcogenide superconductor Fe1.03Se0.5Te0.5 has been investigated under high pressures using synchrotron-based x-ray diffraction and mid-infrared reflectance measurements at room temperature. The superconducting transition temperature (Tc) of the same sample has been determined by temperature-dependent resistance measurements up to 10 GPa. The tetragonal phase (P4/nmm) is found to exist in phase-separated states where both the phases have remarkably high compressibility. A first-order structural transition to the orthorhombic phase (Pbnm) is reported above 10 GPa. For the tetragonal phase, a strong correlation is observed between the Fe(Se,Te)4 tetrahedral deformation and the sharp rise of Tc up to ∼ 4 GPa, above which Tc shows marginal pressure dependence at least up to 10 GPa. The evolution with pressure of the optical conductivity shows that with increasing pressure the tetragonal phase approaches towards a conventional metallic state. Above ∼ 6 GPa, the Drude term reduces drastically, indicating poor metallic character of the high-pressure orthorhombic phase.

Tumour-infiltrating lymphocytes predict for outcome in HPV-positive oropharyngeal cancer.

BACKGROUND: Human papillomavirus (HPV)-positive oropharyngeal cancer (OPSCC) is associated with improved survival compared with HPV-negative disease. However, a minority of HPV-positive patients have poor prognosis. Currently, there is no generally accepted strategy for identifying these patients. METHODS: We retrospectively analysed 270 consecutively treated OPSCC patients from three centres for effects of clinical, pathological, immunological, and molecular features on disease mortality. We used Cox regression to examine associations between factors and OPSCC death, and developed a prognostic model for 3-year mortality using logistic regression analysis. RESULTS: Patients with HPV-positive tumours showed improved survival (hazard ratio (HR), 0.33 (0.21-0.53)). High levels of tumour-infiltrating lymphocytes (TILs) stratified HPV-positive patients into high-risk and low-risk groups (3-year survival; HPV-positive/TIL(high)=96%, HPV-positive/TIL(low)=59%). Survival of HPV-positive/TIL(low) patients did not differ from HPV-negative patients (HR, 1.01; P=0.98). We developed a prognostic model for HPV-positive tumours using a 'training' cohort from one centre; the combination of TIL levels, heavy smoking, and T-stage were significant (AUROC=0·87). This model was validated on patients from the other centres (detection rate 67%; false-positive rate 5.6%; AUROC=0·82). INTERPRETATION: Our data suggest that an immune response, reflected by TIL levels in the primary tumour, has an important role in the improved survival seen in most HPV-positive patients, and is relevant for the clinical evaluation of HPV-positive OPSCC.

Should prophylactic antibiotics be used routinely in epistaxis patients with nasal packs?

INTRODUCTION: The current mainstream practice in otolaryngology departments relating to the use of prophylactic antibiotics in epistaxis patients requiring nasal packing is highly variable. This is due primarily to the lack of any validated guidelines. As such, we introduced a new treatment algorithm resulting in significant reduction of use in the systemic antibiotics, with emphasis instead on the use of topical antibiotics. The results were validated through a complete audit cycle. METHODS: A total of 57 patients undergoing nasal packing for spontaneous epistaxis were studied. Reaudit occurred after the implementation of new guidelines. Telephone surveys were conducted six weeks after hospital discharge, assessing infective nasal symptoms as well as rebleeding and readmission rates. RESULTS: Systemic antibiotic prescribing in anterior nasal packing fell by 58.2% between audit cycles with no statistically significant associated increase in infective nasal symptoms, rebleeding or readmission rates six weeks following hospital discharge. CONCLUSIONS: Systemic prophylactic antibiotics are unnecessary in the majority of epistaxis patients with nasal packs. The use of topical antibiotics such as Naseptin may be more appropriate, cheaper and as effective. Implementation of this treatment algorithm will help standardise systemic antibiotic usage in epistaxis patients with nasal packing and should reduce costs associated with unnecessary use of such medication.

High pressure structural and vibrational properties of the spin-gap system Cu2PO4(OH).

The structural and vibrational properties of the spin-gapped system Cu(2)PO(4)(OH) have been investigated at room temperature under high pressure up to ~20 GPa by Raman scattering and synchrotron-based x-ray diffraction and infrared (IR) spectroscopic measurements. The orthorhombic phase (space group Pnnm, z = 4) remains stable up to at least 7 GPa where it undergoes a weakly first order structural transition (with negligible volume drop) to a monoclinic phase (space group P2(1)/n, z = 4) with an abrupt monoclinic distortion. Refinement of atomic positions has been performed for the low pressure phase. The conspicuous changes in the vibrational spectra (Raman as well as far-IR) confirm this phase transition. At further higher pressures the monoclinic angle increases rapidly and the system transforms irreversibly into a disordered phase. Detailed vibrational analyses have been performed in the orthorhombic phase and pressure-induced structural evolution has been correlated with the vibrational modes corresponding to the Cu-O bonds. A strong negative pressure dependence of hydroxyl mode frequencies (as observed from the mid-IR absorption spectra) supports the pressure-induced structural disordering at higher pressures.

Pharmacokinetics of gatifloxacin in broiler chickens following intravenous and oral administration.

1. The pharmacokinetics of gatifloxacin were investigated following intravenous and oral administration of a single dose at a rate of 10 mg/kg body weight in broiler chicks. 2. Drug concentration in plasma was determined using High Performance Liquid Chromatography with ultraviolet detection on samples collected at frequent intervals after drug administration. 3. Following intravenous administration, the drug was rapidly distributed (t(1/2α): 0·33 ± 0·008 h) and eliminated (t(1/2ß): 3·62 ± 0·03 h; Cl(B): 0·48 ± 0·002 l/h/kg) from the body. 4. After oral administration, the drug was rapidly absorbed (C (max): 1·74 ± 0·024 µg/mL; T (max): 2 h) and slowly eliminated (t(1/2ß): 3·81 ± 0·07 h) from the body. The apparent volume of distribution (V(d(area))), total body clearance (Cl(B)) and mean residence time (MRT) were 3·61 ± 0·04 l/kg, 0·66 ± 0·01 l/h/kg and 7·16 ± 0·08 h, respectively. The oral bioavailability of gatifloxacin was 72·96 ± 1·10 %. 5. Oral administration of gatifloxacin at 10 mg/kg is likely to be highly efficacious against susceptible bacteria in broiler chickens.

Advances in the understanding of chondrodermatitis nodularis chronica helices: the perichondrial vasculitis theory.

OBJECTIVES: Chondrodermatitis nodularis chronica helicis (CNCH) usually presents as a painful nodule affecting the pinna. The aetiology of the disease is unknown. Several theories have been suggested. We suggest a possible explanation based upon pathophysiological treatment correlations to new histopathological evidence. DESIGN: A detailed histopathological review of 16 confirmed cases of CNCH was undertaken by two pathologists, independently and together, using a qualitative grading of arteriolar narrowing. RESULTS: Review of cases revealed arteriolar narrowing in perichondrium region of pinna most remote from arterial blood supply, i.e. helix. This has lead to ischaemic changes and death of the metabolically active underlying cartilage with necrosis and extrusion. CONCLUSION: This is the first report of specific perichondrial arteriolar changes as the possible cause of underlying cartilage necrosis resulting in CNCH.

Prioritisation of vascular outpatient appointments cannot be based on referral letters alone.

BACKGROUND: Vascular referrals include patients with conditions varying from varicose veins of cosmetic nuisance to patients with critical ischaemia, transient ischaemic attacks and abdominal aortic aneurysms. A large number of such referrals are received each week from general practitioners. It is important to prioritise patients with conditions that need to be dealt with quickly. OBJECTIVE: We prospectively reviewed referral letters to two vascular units, one in South Wales and one in the Oxford region to assess whether prioritisation can be made on the basis of referral letters. MATERIAL AND METHODS: All GP referral letters were studied for four months. Only patients with lower limb ischaemic symptoms were included. Degree of urgency requested by the GP was also noted. RESULTS: Of 174 referrals for potential lower limb ischaemia analysed, 145 (83%) proved to be due to peripheral vascular disease. Of these 145 referrals, 72% were referred for claudication. Only 37% and 13% respectively mentioned claudication distance and/or rest pain. Risk factors with reference to diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, atrial fibrillation, cerebrovascular disease and smoking were made in 19%, 43%, 23%, 23%, 10%, 14%, 31% of letters respectively. Clinical signs were poorly documented, with 90% of referrals failing to mention presence or absence of critical ischaemic signs. The GP's own assessment of urgency was not stated in 66% of letters, without which only 3% of patients were seen in the clinic within four weeks, compared with 22% in those in whom urgency was stated. Six per cent of patients when reviewed in outpatients were found to have sufficiently severe symptoms to warrant immediate admission. Regional variation was observed with 57% of Royal Glamorgan Hospital referral letters documenting degree of urgency compared with only 23% of Royal Berkshire Hospital letters (p = < 0.0001). CONCLUSION: Most referral letters were poorly documented with regard to key symptoms, risk factors and clinical signs. The degree of urgency was often not stated. The creation of referral protocols is now being considered.

Management of cardiovascular risk factors by primary care physicians in patients with peripheral arterial disease.

BACKGROUND: Patients with significant coronary artery disease (CAD) are now intensively treated by primary care physicians predominantly because of government pressure and remuneration to prescribe anti-platelet and anti-hyperlipidaemic drugs. Peripheral arterial disease (PAD) with the identical risk factors appeared to us to be less intensively investigated and treated by primary care physicians. OBJECTIVE: To review the treatment of risk factors in all patients referred to two vascular clinics with a diagnosis of suspected PAD. DESIGN: Cross-sectional survey. SETTING: Vascular outpatient clinic in two district general hospitals. PARTICIPANTS: 124 consecutive new patients were studied to determine risk factors and appropriate treatment. RESULTS: Of the 124 patients, 85 (68%) were confirmed to have PAD without evidence of symptomatic CAD. In the PAD alone group, less than 25% received anti-smoking advice (p < 0.0001) and only 36% were prescribed anti-platelet drugs (p = 0.016). Seventy-three per cent of the overall referred patients with hypertension had been treated for this condition and the blood pressure was normal in 71% of the patients with PAD. In patients with hyperlipidaemia, statins had been prescribed in 92% of patients with coexistent symptomatic CAD, but only in 64% of patients with PAD alone (p = 0.009). In the patients with diabetes, only 66% of the PAD alone group had adequate control of their blood sugar (p = 0.185). CONCLUSIONS: It would appear that patients with CAD and PAD are being treated successfully for their risk factors, but patients with PAD alone, sharing the same common risk factors, are being less than optimally treated.

Effect of gender, dose, and time on 3-(3,5-dichlorophenyl)-2,4-thiazolidinedione (DCPT)-induced hepatotoxicity in Fischer 344 rats.

1. The thiazolidinedione ring present in drugs available for type II diabetes can contribute to hepatic injury. Another thiazolidinedione ring-containing compound, 3-(3,5-dichlorophenyl)-2,4-thiazoli-dinedione (DCPT), produces liver damage in rats. Accordingly, the effects of gender, dose, and time on DCPT hepatotoxicity were therefore evaluated. 2. Male rats were more sensitive to DCPT (0.4-1.0 mmol kg(-1) by intraperitoneal administration) as shown by increased serum alanine aminotransferase levels and altered hepatic morphology 24 h post-dosing. Effects in both genders were dose dependent. In males, DCPT (0.6 mmol kg(-1)) produced elevations in alanine aminotransferases and changes in liver sections 3 h after dosing that progressively worsened up to 12 h. DCPT-induced renal effects were mild. 3. It is concluded that male rats are more susceptible to DCPT hepatotoxicity and that damage occurs rapidly. DCPT primarily affects the liver and can be a useful compound to investigate the role of the thiazolidinedione ring in hepatic injury. However, the gender dependency and rapid onset of DCPT hepatotoxicity require further investigation.