An Investigation of Procedural Radiation Dose Level Awareness and Personal Training Experience in Communicating Ionizing Radiation Examinations Benefits and Risks to Patients in Two European Cardiac Centers.

PURPOSE: Cardiac interventional practitioners need to be appropriately informed regarding radiation dose quantities and risks. Communicating benefit-risk information to patients requires attention as specified in Basic Safety Standards Directive 2013/59/Eurotom. This study investigated the awareness of procedural radiation dose levels and the impact of personal training experience in communicating ionizing radiation benefit-risks to patients. METHODOLOGY: A questionnaire, consisting of 28 questions, was distributed directly to adult and pediatric interventional cardiology specialists at specialized cardiovascular imaging centers in Dublin, Ireland and Milan, Italy. RESULTS: A total of 18 interventional cardiologists (senior registrar to consultant grades with between 2 y to over 21 y experience in cardiac imaging) participated. The majority of participants (n = 17) stated that parents of pediatric and adult patients should be informed of the potential benefits and risk. All participants indicated they had radiation safety training; however, 50% had not received training in radiation examination benefit-risk communication. Despite this, 77.8% (n = 14) participants indicated a high confidence level in successfully explaining risks and/or benefits of cardiac imaging procedures. When asked to estimate effective dose (ED) values for common cardiac imaging procedures less than 50% identified appropriate dose ranges. All participants underestimated procedural dose values based on recent European data. 50% (n = 9) participants answered all questions correctly for a number of true or false radiation risk statements. CONCLUSION: Benefit-risk communication training deficits and inaccurate understanding of radiation dose levels was identified. Further research and training to support clinicians using radiation on a daily basis is required.

Out-patient flexible carbon dioxide laser surgery for benign laryngopharyngeal pathologies via transnasal flexible laryngo-oesophagoscopy.

OBJECTIVE: To assess the feasibility and outcomes of flexible carbon dioxide laser surgery in a clinic-based setting. METHODS: A prospective study was conducted in a tertiary centre. Clinical indications, clinical outcomes and patient satisfaction were assessed in patients treated with flexible carbon dioxide laser surgery via transnasal endoscopy and followed up over a period of up to nine months. Patients who were not fit for general anaesthesia or those with lesions that cannot be accessed by micro-laryngoscopy were included. RESULTS: A total of 13 patients (14 procedures) were included. Clinical indications for surgery were small-to-medium sized benign pathologies in the upper aero-digestive tract. Patient satisfaction was assessed using a validated questionnaire. CONCLUSION: Early data suggest that flexible carbon dioxide laser is a versatile and feasible instrument with potential applications for a range of benign pathologies in the upper aero-digestive tract.

Role of transnasal flexible laryngo-oesophagoscopy (TNFLO) in investigating patients with globus symptoms.

OBJECTIVE: To explore the rationale for investigating patients presenting with globus symptoms. In this regard, we also assess the efficacy and safety of transnasal flexible laryngo-oesophagoscopy (TNFLO). METHODS: A prospective study in a head and neck cancer centre of patients with persistent globus symptoms with normal flexible nasoendoscopy/indirect mirror laryngoscopy and failure of first-line medical treatment. The role of TNFLO in investigating these patients was assessed. RESULTS: A total of 218 patients were recruited in this study. Positive findings included upper aerodigestive cancers in two patients, other pathologies included reflux (four patients), cricopharyngeus-related pathologies (19 patients), candida (five patients). There were only five re-referrals of patients who were discharged following normal examination with TNFLO. In nine patients, TNFLO could not be completed and they went on to have other diagnostic procedures CONCLUSION: This article is the largest to date in the UK to assess the role of TNFLO in investigating patients with globus symptoms. TNFLO is equal to rigid endoscopy as a diagnostic tool. However, it is superior in terms of image clarity, ability to record video images and safety.

Outpatient-based injection laryngoplasty for the management of unilateral vocal fold paralysis - clinical outcomes from a UK centre.

OBJECTIVE: To assess voice outcomes in patients undergoing vocal fold injection (VFI) augmentation laryngoplasty in a clinic-based setting. METHODS: A prospective study of patients with unilateral vocal cord palsy undergoing Radiesse(®) vocal cord augmentation. We used the ten-item voice handicap index (VHI-10) as a postal survey before and after the intervention. RESULTS: A total of 43 patients were referred to our ENT clinic from June 2011 to October 2014 with unilateral vocal cord palsy. The majority were referred from the oncology department with mediastinal tumours. Fifteen patients died of malignant disease. Twenty-one patients responded to our survey. VHI-10 scores were analysed using one-way analysis of variance (anova), and the results suggest a sustained improvement before and after the intervention (pre-injection versus 3 months post-injection P < 0.01; pre-injection versus 6 months post-injection P < 0.033). CONCLUSION: This is the largest case series of patients who had a local anaesthetic vocal cord injection with calcium hydroxylapaptite using the trans-thyrohyoid approach. Early data would suggest that the results are similar to injections performed under general anaesthesia when performed by an experienced laryngologist. VFI in a clinic-based (awake) setting has the distinct advantage of providing instant feedback of vocal fold closure and voice outcome during the procedure, avoiding general anaesthesia with its inherent risks and cost and also the limitations of difficult exposure.

Image-guided sinus surgery: practical and financial experiences from a UK centre 2001-2009.

BACKGROUND: Image guidance surgery is an emerging technology that may allow more efficient treatment of sinus disease. This retrospective study examines National Health Service and military patients who underwent procedures using image guidance surgery during the period 2001-2009. METHODS: Medical records were reviewed in terms of indications for surgery, incidence of major complications and need for revision following image guidance surgery. An attempt was also made to determine the cost-effectiveness of purchasing this navigational system. RESULTS: A total of 132 patients underwent 147 procedures using image guidance surgery over the 8-year period. The indications for surgery ranged from severe nasal polyposis and chronic rhinosinusitis to malignant tumours in the paranasal sinus and skull base region. Average length of follow up was 17.6 months. Four patients had a major complication. Fourteen patients underwent revision surgery. The cost of providing an image guidance surgery service was estimated to be £110,000-120,000 during the study period. The economic model for the subgroup of nineteen military patients (with non-polypoid chronic rhinosinusitis) suggests that use of this technology will reduce overall costs by approximately £70,000 when compared with conventional sinus surgery. CONCLUSION: This study provides some evidence that image-guided sinus surgery is cost effective, safe and may decrease surgical revision rates.

Weight in infancy and adult calcium absorption as determinants of bone mineral density in adult men: the Hertfordshire cohort study.

Adult bone mass is modified by early life environmental influences, but the mechanism of this association is uncertain. Data support an inverse relationship between intestinal calcium absorption (αCa) and birth weight in women. However, little is known regarding determinants in men. This study examines the association between weight in infancy and adult αCa in healthy men and whether this could be a mechanism by which the early life environment may influence bone mass. Men were recruited from the MRC Hertfordshire Cohort Study, for whom detailed early life records were available. Areal bone mineral density (aBMD) was measured using a Hologic QDR 4500 at the femoral neck (FN) and lumbar spine. We randomly selected 123 men stratified by birth weight and assessed αCa using the stable strontium absorption test. The mean age was 63.6 (SD 2.5) years. αCa was not associated with birth weight or weight at 1 year. FN aBMD was associated with both weight at 1 year (r = 0.20, p = 0.03) and αCa (r = 0.20, p = 0.03). Both of these associations remained statistically significant in a mutually adjusted, multivariable model but would account for only ~4 % variance in BMD. We demonstrated a positive association between weight at 1 year and aBMD and between αCa and FN BMD, but no association was found between birth weight and αCa. This suggests that in men, although αCa is a contributing factor in FN bone density, it is not the main mechanism whereby the early environment modifies adult BMD.

Outcomes from penetrating ballistic cervical injury.

AIMS: Ballistic cervical injury has become a significant source of both morbidity and mortality for the deployed UK soldier. The aim of this paper was to document a case series of ballistic cervical wounds to describe the pattern of these injuries and relate them to outcome. METHODS: The records of all UK service personnel sustaining wounds to the neck in Iraq or Afghanistan between 01 August 2004 and 01 January 2008 were analysed following identification by the Joint Theatre Trauma Registry. Blunt or thermal injuries were excluded. RESULTS: The records of 75/76 service personnel sustaining penetrating cervical injury during this period were available for analysis. 56/75 (75%) were due to explosive fragmentation and the remainder due to gunshot wounds (GSW). 33/75 (44%) of soldiers sustained vascular injury, 32/75 (43%) injury to the spine or spinal cord, 29/75 (39%) injury to the larynx or trachea and 11/75 (15%) injury to the pharynx or oesophagus. 14/75 (19%) patients in this series underwent surgery in a hospital facility for treatment of potentially life threatening cervical injuries, with a survival rate after surgery of 12/14 (86%). The overall mortality from this series of battlefield penetrating neck injury was 63%. CONCLUSIONS: Penetrating cervical ballistic injury is a significant source of injury to deployed UK service personnel, predominantly due to neurovascular damage. Neck collars if worn would likely prevent many of the injuries in this case series but such protection is uncomfortable and may interfere with common military tasks. Newer methods of protecting the neck should be investigated that will be acceptable to the deployed UK soldier.

Cochlear implant failures: lessons learned from a UK centre.

OBJECTIVES: To review our experience of cochlear implant failure and subsequent revision surgery, and to illustrate the experience we have gained by presenting a series of lessons learned. METHODS: A combined retrospective and prospective study of revision surgery in a UK regional cochlear implant centre. RESULTS: Of the 746 cochlear implantations undertaken, 33 (4.7 per cent of adults and 4.1 per cent of children) had a registered failure requiring re-implantation. The mean time to device failure was 60 months in adults and 35 months in children. Causes of cochlear implant failure were medical (n = 11), electrode displacement (n = 2), 'hard device failure' (n = 15) and 'soft device failure' (n = 5). Chronic suppurative otitis media and post-auricular mastoid abscess were the commonest causes of medical failure. There was one case of electrode array displacement as a direct result of skin flap revision surgery. In 80 per cent of cases, audiological performances were stable or improved following re-implantation. CONCLUSION: As the number of cochlear implants increase and patients outlive the lifespan of their devices, we will face a growing number of revision procedures. Audiologists and otologists should be competent in diagnosing and managing device failure and medical complications requiring cochlear re-implantation.

Autoimmune disease as a risk factor for globus pharyngeus: a cross-sectional epidemiological study.

OBJECTIVE: To assess the prevalence and severity of globus-type symptoms in individuals who have a prior diagnosis of autoimmune disease. DESIGN: Cross-sectional questionnaire. PARTICIPANTS AND SETTING: One hundred and nine patients with autoimmune disease (rheumatoid arthritis, seronegative spondarthritis, connective tissue disease, systemic vasculitis) and 41 patients with non-autoimmune disease (osteoarthritis/osteoporosis) attending a rheumatology tertiary referral clinic at Norfolk & Norwich University Hospitals NHS Foundation Trust. The results from this study were compared to previous published figures in patients with globus pharyngeus (n = 105) and normal population (n = 174). MAIN OUTCOME MEASURES: Glasgow Edinburgh Throat Scale questionnaire; Reflux Symptom Index; Anxiety/Depression Scale. RESULTS: Patients with autoimmune disease demonstrate a significantly higher prevalence for 5/10 symptoms on the Glasgow Edinburgh Throat scale score when compared to the non-autoimmune control group (P ≤ 0.01). This significant difference increases to 9/10 symptoms when compared to published results for the normal population (P = 0.01). No significant difference was found when comparing the autoimmune and non-autoimmune control group reflux symptom index (P = 0.64) or anxiety depression scale (P = 0.71). CONCLUSION: Patients with autoimmune disease have a significantly increased prevalence of globus symptoms when compared to the healthy population. A further prospective study is required to decipher the effect of pharmacotherapy as a possible causative factor.

Nasal tuberculosis--an update of current clinical and laboratory investigation.

OBJECTIVE: To report a case of primary nasal tuberculosis, and to discuss the diagnostic difficulties encountered. SETTING: A teaching hospital in Norwich, UK. METHOD: Case report and review of the English language literature concerning tuberculosis affecting the head and neck region. RESULT: The diagnosis of nasal tuberculosis is based on: histological identification of granulomatous inflammation; positive testing for acid-alcohol resistant bacilli; and positive culture. Newer diagnostic tests have the advantage of speed and improved accuracy, but are not as yet completely evaluated for the diagnosis of extra-pulmonary tuberculosis. CONCLUSION: It is important to consider nasal tuberculosis in the initial differential diagnosis. The quest to exclude a malignancy may lead to unacceptable delays in treatment.

Immunoglobulin G4 related systemic sclerosing disease involving the temporal bone.

OBJECTIVE: To report a rare condition affecting the temporal bone. Immunoglobulin G4 related systemic sclerosing disease is a recently described autoimmune condition with manifestations typically involving the pancreas, biliary system, salivary glands, lungs, kidneys and prostate. Histologically, it is characterised by T-cell infiltration, fibrosis and numerous immunoglobulin G4-positive plasma cells. This condition previously fell under the umbrella diagnosis of inflammatory pseudotumour and inflammatory myofibroblastic tumour. CASE REPORT: We present the case of a 58-year-old woman with multiple inflammatory masses involving the pharynx, gall bladder, lungs, pelvis, omentum, eyes and left temporal bone, over a seven-year period. We describe this patient's unusual clinical course and pathological features, which resulted in a change of diagnosis from metastatic inflammatory myofibroblastic tumour to immunoglobulin G4 related systemic sclerosing disease. We also review the literature regarding the management of inflammatory pseudotumours of the temporal bone, and how this differs from the management of immunoglobulin G4 related systemic sclerosing disease. CONCLUSION: We would recommend a full review of all histological specimens in patients with a diagnosis of temporal bone inflammatory pseudotumour or inflammatory myofibroblastic tumour. Consideration should be given to immunohistochemical analysis for anaplastic lymphoma kinase and immunoglobulin G4, with measurement of serum levels of the latter. Management of the condition is medical, with corticosteroids and immunosuppression, rather than surgical excision.

Self assessment questions in ear, nose & throat surgery.

Ear, nose and throat conditions make up a large amount of a Medical Officer's clinical workload. The examples given here illustrate some principles that should be employed when dealing with such problems.

Facile solid-phase synthesis of C-terminal peptide aldehydes and hydroxamates from a common Backbone Amide-Linked (BAL) intermediate.

C-Terminal peptide aldehydes and hydroxamates comprise two separate classes of effective inhibitors of a number of serine, aspartate, cysteine, and metalloproteases. Presented here is a method for preparation of both classes of peptide derivatives from the same resin-bound Weinreb amide precursor. Thus, 5-[(2 or 4)-formyl-3,5-dimethoxyphenoxy]butyramido-polyethylene glycol-polystyrene (BAL-PEG-PS) was treated with methoxylamine hydrochloride in the presence of sodium cyanoborohydride to provide a resin-bound methoxylamine, which was efficiently acylated by different Fmoc-amino acids upon bromo-tris-pyrrolidone-phosphonium hexafluorophosphate (PyBrOP) activation. Solid-phase chain elongation gave backbone amide-linked (BAL) peptide Weinreb amides, which were cleaved either by trifluoroacetic acid (TFA) in the presence of scavengers to provide the corresponding peptide hydroxamates, or by lithium aluminum hydride in tetrahydrofuran (THF) to provide the corresponding C-terminal peptide aldehydes. With several model sequences, peptide hydroxamates were obtained in crude yields of 68-83% and initial purities of at least 85%, whereas peptide aldehydes were obtained in crude yields of 16-53% and initial purities in the range of 30-40%. Under the LiAlH4 cleavage conditions used, those model peptides containing t-Bu-protected aspartate residues underwent partial side chain reduction to the corresponding homoserine-containing peptides. Similar results were obtained when working with high-load aminomethyl-polystyrene, suggesting that this chemistry will be generally applicable to a range of supporting materials.

Investigating the role of the growth hormone-insulin-like growth factor (GH-IGF) axis as a determinant of male bone mineral density (BMD).

INTRODUCTION: The GH-IGF axis has profound effects on bone metabolism and may be important in the etiology of idiopathic osteoporosis. Serum IGF-I is often low in men with osteoporosis, which may be attributable to GH hypo-secretion or hepatic GH insensitivity. We studied the GH-IGF axis in depth to look for evidence to support these hypotheses. MATERIALS AND METHODS: 28 healthy 60- to 70-year-old men with low, intermediate, or normal BMD were studied. GH secretion was measured by overnight urine collection. GH reserve was assessed by exercise and glucagon stimulation tests. Hepatic IGF-I production was investigated using a GH-IGF-I generation test. Data were analyzed using Pearson's correlation coefficient, linear regression, and analysis of variance. RESULTS: Serum IGF-I was reduced in subjects with low BMD (P = 0.009). There was no difference in GH secretion or reserve between the groups. Overall, GH reserve and IGF-I were positively related but this was attenuated in the low BMD group. However, no statistically significant difference in IGF-I generation capacity between BMD groups was found. CONCLUSIONS: Men with reduced BMD have low IGF-I but normal GH secretion and reserve. Our data suggested, but could not confirm, hepatic resistance to GH as a mechanism for this association.