Trainee-trainer outcomes in mastoid surgery: a comparative study.

BACKGROUND: Mastoid exploration remains an advanced, mainstay operation within ENT, in which the surgical trainees' role has been debated. This audit compares mastoid exploration outcomes between trainees and consultants. METHODS: Cortical mastoidectomy, atticotomy, atticoantrostomy, modified radical mastoidectomy, combined-approach tympanoplasty and revision mastoidectomy operations performed between 2009 and 2020 were reviewed. Complications assessed were: facial palsy, labyrinth injury, dead ear, disease recurrence and time to recurrence. The chi-square test was used to determine significant associations. RESULTS: A total of 118 operations were surveyed. Thirty-five per cent of procedures (n = 41) were performed by trainees under supervision, and 65 per cent (n = 77) were carried out solely by consultants. Patients from 5 per cent of trainees' operations (n = 2) developed recurrence, compared with 7.8 per cent of consultants' (n = 6) (p = 0.55). No other complications developed in either group. CONCLUSION: The results corroborate those of other studies, indicating no significant increase in complication rate from consultants to trainees. Trainees likely completed less complicated cases. The stepwise incorporation of trainees did not compromise patient safety.

Non-technical skills in oral and maxillofacial and head and neck surgery: systematic review.

The importance of teams' and individuals' non-technical skills in reducing adverse events is well-recognised. We undertook a systematic review of the published literature to assess the research undertaken to date on non-technical skills and behaviours within oral and maxillofacial, and head and neck (OMFS-H&N) surgery. The aim was to assess the applicability of published studies to current practice, to look at how these studies could guide future research, and look for areas that could be developed further. The search terms included 'non technical skills', 'nontechnical skills', 'NOTSS', 'non-technical skills for surgeons', 'oral surgery', 'oral maxillofacial surgery', 'OMFS', 'maxillofacial surgery', 'head and neck surgery', 'microsurgery', 'behavioural markers', 'behavioural assessment tool', and 'behavioural ratings system'. Three publications were included, involving 83 participants. Participants consistently achieved the highest scores in the 'situational awareness' category and showed a tendency to achieve lower mean scores in the 'communication and teamwork' and 'decision-making' categories. The majority of research into surgeons' non-technical skills has occurred in simulated environments and not in the genuine environments in which actual surgery is being performed on patients. Research involving 'real' patients has been done in the field of OMFS-H&N and this places the specialty in a stronger position than many other surgical specialties.

Parotid incidentalomas: a systematic review.

OBJECTIVE: Parotid incidentalomas on fluorodeoxyglucose positron emission tomography/computed tomography imaging are rare. A systematic review was performed to assess their aetiology and association with scanning indication, and to develop an evidence-based algorithm for their management. METHODS: A literature search was performed on 25 August 2020 using the keywords 'incidentaloma', 'incidental finding', 'parotid', 'parotid gland', 'salivary gland' and 'head and neck'. Articles were reviewed by two authors before their inclusion. RESULTS: Forty articles were included, totalling 558 incidentalomas. The mean incidence was 0.74 per cent. Lung cancer was the most common imaging indication. The most common aetiologies were cystadenolymphoma, pleomorphic salivary adenoma and metastases. Only cystadenolymphoma (p = 0.015) and pleomorphic salivary adenoma (p = 0.011) were significantly associated with a primary malignancy (lung). The most common further investigations were aspiration cytology, ultrasound imaging and core biopsy, usually prior to parotidectomy. CONCLUSION: If appropriate, parotid incidentalomas should be followed up with flexible endoscopy, skin examinations, and head and neck examinations. Ultrasound-guided core biopsy provides higher accuracy, avoiding repeat sampling and excision biopsy.

Benign parotid mass and facial palsy: systematic review.

INTRODUCTION: Parotid masses causing facial palsy are highly indicative of malignancy. A significant number of cases describing benign parotid disease causing facial palsy have been reported. MATERIALS AND METHODS: We performed a systematic review of the literature to establish the aetiology, clinical features, investigations and management undertaken during these presentations to assess how these factors differed from malignant presentations and to establish an evidence-based algorithm for their management. RESULTS: A total of 85 cases were identified from 78 articles. Cystadenolymphomas were the most common histopathological type (p = 0.034). Mean facial palsy recovery duration in neoplastic aetiology was longer than for infective aetiology (p = 0.033). A significant association existed between uncommon infective organisms and development of facial palsy (p = <0.0001). CONCLUSION: Uncommon benign aetiologies are associated with facial palsy. Investigations and management should be guided by patients' clinical presentations, avoiding excessive treatment. Complete facial palsy recovery rates are high, although not immediate.

Non-technical skills and otolaryngology: systematic review.

OBJECTIVES: This study aimed to assess the published literature on non-technical skills in otolaryngology surgery and examine the applicability of any research to others' practice, and to explore how the published literature can identify areas for further development and guide future research. METHODS: A systematic review was conducted using the following key words: 'otolaryngology', 'otorhinolaryngology', 'ENT', 'ENT surgery', 'ear, nose and throat surgery', 'head and neck surgery', 'thyroid surgery', 'parathyroid surgery', 'otology', 'rhinology', 'laryngology' 'skull base surgery', 'airway surgery', 'non-technical skills', 'non technical skills for surgeons', 'NOTSS', 'behavioural markers' and 'behavioural assessment tool'. RESULTS: Three publications were included in the review - 1 randomised, controlled trial and 2 cohort studies - involving 78 participants. All were simulation-based studies involving training otolaryngology surgeons. CONCLUSION: Little research has been undertaken on non-technical skills in otolaryngology. Training surgeons' non-technical skill levels are similar across every tested aspect. The research already performed can guide further studies, particularly amongst non-training otolaryngology surgeons and in both emergency and elective non-simulated environments.

Morphologies of tungsten nanotendrils grown under helium exposure.

Nanotendril "fuzz" will grow under He bombardment under tokamak-relevant conditions on tungsten plasma-facing materials in a magnetic fusion energy device. We have grown tungsten nanotendrils at low (50 eV) and high (12 keV) He bombardment energy, in the range 900-1000 °C, and characterized them using electron microscopy. Low energy tendrils are finer (~22 nm diameter) than high-energy tendrils (~176 nm diameter), and low-energy tendrils have a smoother surface than high-energy tendrils. Cavities were omnipresent and typically ~5-10 nm in size. Oxygen was present at tendril surfaces, but tendrils were all BCC tungsten metal. Electron diffraction measured tendril growth axes and grain boundary angle/axis pairs; no preferential growth axes or angle/axis pairs were observed, and low-energy fuzz grain boundaries tended to be high angle; high energy tendril grain boundaries were not observed. We speculate that the strong tendency to high-angle grain boundaries in the low-energy tendrils implies that as the tendrils twist or bend, strain must accumulate until nucleation of a grain boundary is favorable compared to further lattice rotation. The high-energy tendrils consisted of very large (>100 nm) grains compared to the tendril size, so the nature of the high energy irradiation must enable faster growth with less lattice rotation.

Airway and head and neck high dependency unit: a single-centre experience.

OBJECTIVE: Dedicated otolaryngology high dependency units are uncommon. This paper reports the first experiences of such a facility in the UK, assessing reason for admission, duration of stay, occupancy rate and need for care escalation. The study sought to assess the presence of similar units in the UK. METHODS: A retrospective review of high dependency unit admissions over an 18-month period and a national survey of otolaryngology departments in the UK were conducted to establish the overall presence and location of similar high dependency units. RESULTS: A total of 128 patients were admitted during the study period, mainly following surgery and because of airway compromise. The average duration of stay was 2-3 days (range, 1-12 days). The occupancy rate was 31.7 per cent. No patients required their care to be escalated to the intensive care unit. Seven similar high dependency units were identified in the UK. CONCLUSION: The care provided prevented the need for escalation of care to an intensive care unit. This challenges the need for patient management on intensive care units following major surgery or airway compromise for those not requiring assisted ventilation. High dependency units similar to ours are not widespread.

Emergency presentations of head and neck cancer: a modern perspective.

BACKGROUND: Head and neck cancer emergency presentations are uncommon but persistent. However, there is little published literature on this aspect of cancer and patient demographics. This study aimed to assess the incidence, patient profile, tumour site and stage of emergency cancer presentations in our region. METHOD: Retrospective review of regional cancer database over a five-year period. RESULTS: Emergency presentations accounted for 7 per cent of all cases. There was no difference in patient age and risk factors between the emergency and non-emergency presentations. The emergency presentation group showed a greater proportion of female patients compared to the non-emergency presentation group (30 vs 15 per cent). In all emergency presentations, the cancer was at advanced stages. Oropharyngeal cancer was the commonest emergency presentation of cancer, but the third commonest in the non-emergency group. CONCLUSION: Emergency presentations are increasing annually. Female patients and oropharyngeal cancer showed greater representation compared to male patients and laryngeal cancer.

Evidenced-based management of haemoptysis by otolaryngologists.

BACKGROUND: Haemoptysis is an uncommon presenting symptom to the ENT clinic and ward, but has potentially sinister aetiology. This article aims to provide a systematic and evidence-based method of managing patients with haemoptysis. METHODS: The data in this article are based on a literature search performed using PubMed in August 2013. The keywords used included 'haemoptysis' in combination with 'otolaryngology', 'ENT', 'head & neck', 'diagnosis', 'management', 'investigations' and 'treatment'. RESULTS: The majority of published literature on the subject is level IV evidence. However, this can guide ENT specialists in assessing, investigating and managing presentations of haemoptysis. CONCLUSION: Understanding the different causes of haemoptysis is important for the otolaryngologist. The main concern is the detection of a malignant lesion in the upper aerodigestive tract or tracheobronchial tree. A thorough history and systematic examination can aid diagnosis.

Enhanced recovery programmes in head and neck surgery: systematic review.

OBJECTIVE: To review the literature on enhanced recovery programmes in head and neck surgery. METHOD: A systematic review was performed in May 2013. RESULTS: Thirteen articles discussing enhanced recovery after laryngectomy, neck dissection, major ablative surgery and microvascular reconstruction were identified. Articles on general pre-operative preparation and post-operative care were also reviewed. CONCLUSION: Considerable evidence is available supporting enhanced recovery in head and neck surgery that could be of benefit to patients and which surgeons should be aware of.

Percutaneous gastrostomy tube site pain as a manifestation of liver metastases.

BACKGROUND: Complications are possible following percutaneous enteral feeding in head and neck cancer patients and otolaryngologists should be aware of these as well as the possibility of liver metastases from these cancers. CASE REPORT: A 53-year-old lady was treated by our service for metastatic squamous cell carcinoma of unknown primary origin. During radiotherapy treatment, a percutaneous endoscopic gastrostomy (PEG) tube was inserted to facilitate patient feeding. Severe abdominal pain developed and persisted around site of PEG tube insertion, the cause of which was discovered to be newly developed liver metastases from the tumor being compressed by the tube. CONCLUSION: Liver metastases should be considered in patients developing persistent abdominal pain after PEG insertion.

Clinical use and efficacy of biphasic insulin lispro 50/50 in people with insulin treated diabetes - a nationwide evaluation of clinical practice.

OBJECTIVES: This study aims to investigate the metabolic effects of biphasic insulin lispro 50/50 in routine clinical practice. A total of 229 patients who were ≥18 years old with diabetes, newly treated with biphasic insulin lispro 50/50, were sourced from six secondary care services in England. METHODS: Detailed clinical parameters were compared at baseline, and 3 and 6 months post-initiation. Responders was defined as those with HbA1c <7.5% (58 mmol/mol) and/or an HbA1c reduction of >1% (11 mmol/mol) at 6 months. RESULTS: HbA1c showed significant reduction: -0.93% (-10 mmol/mol) and -1.2% (-13 mmol/mol) at 3 and 6 months respectively, while no significant change was noted for all the other parameters. When analyzed according to frequencies of injections/day, the greatest reduction was observed with the three times a day regimen (-1.0% [-11.0 mmol/mol] and -1.3% [-14.6 mmol/mol] at 3 and 6 months respectively). HbA1c reduction was greatest in the group who previously received a basal-bolus insulin regimen: (-0.8% [-9.0 mmol/mol] and -1.5% [-16.2 mmol/mol] at 3 and 6 months respectively). Reduction in weight was observed at 3 months (-1.8 kg ± 4.3) only for those who were previously on a basal-bolus insulin regimen. Insulin doses increased following conversion to biphasic insulin lispro 50/50, irrespective of the types of insulin used prior to biphasic insulin lispro 50/50, but this was not associated with weight gain. The independent predictors of response to biphasic insulin lispro 50/50 were baseline HbA1c, Caucasian, presence of nephropathy, prior use of basal-bolus insulin and prior use of other premixed combination. CONCLUSION: Biphasic insulin lispro 50/50 is therefore an effective therapeutic option for achieving glycemic control in patients with suboptimal HbA1c levels, especially among those who were previously on a basal-bolus insulin regimen and those who received it three times daily, with a neutral effect on weight parameters. LIMITATIONS: This was a retrospective study of routine clinical practice and is therefore limited by allocation bias and some missing data. Information on rates of hypoglycemia and quality of life are not available.

Nutritional status of long-term patients in the acute care setting.

The nutritional status of 926 patients (51.4% female) at an acute tertiary private hospital with a length of stay ≥14 days was assessed using Subjective Global Assessment. The prevalence of malnutrition was 42.5% (37.2% length of stay of 14-27 days, 51.6% ≥28 days). From logistic regression analysis, length of stay and age were independent predictors of malnutrition. It is important that the nutritional status of longer stay patients is monitored and appropriate nutrition support is commenced.

Whiplash injury: 30-year follow-up of a single series.

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.

Hot water from cold. The dissociative recombination of water cluster ions.

Dissociative recombination of the Zundel cation D(5)O(2)(+) almost exclusively produces D + 2 D(2)O with a maximum kinetic energy release of 5.1 eV. An imaging technique is used to investigate the distribution of the available reaction energy among these products. Analysis shows that as much as 4 eV can be stored internally by the molecular fragments, with a preference for producing highly excited molecular fragments, and that the deuteron shows a nonrandom distribution of kinetic energies. A possible mechanism and the implications for these observations are addressed.

Three-body breakup in the dissociative recombination of the covalent triatomic molecular ion O3+.

We report the first observation of almost exclusive three-body breakup in the dissociative recombination of a covalent triatomic molecular ion O3+. The three-body channel, constituting about 94% of the total reactivity, has been investigated in detail. The atomic fragments are formed in only the first two electronic states, 3P and 1D, while formation in the 1S state has not been observed. The breakup predominantly proceeds through dissociative states with linear geometry.

Evaluation of a diabetes referral pathway for the management of hypoglycaemia following emergency contact with the ambulance service to a diabetes specialist nurse team.

OBJECTIVES: To evaluate the effectiveness of ambulance crew referral of patients treated for acute hypoglycaemia, to a diabetes specialist nurse (DSN) team. Patients were assessed by the ambulance service and did not attend an emergency department. METHODS: For a 3 month period patients were referred from two areas of West Yorkshire by the ambulance service to specialist diabetes teams. The DSNs contacted the patients within 7 days by telephone and arranged further review if necessary. Satisfaction questionnaires were sent to patients. RESULTS: Thirty eight patients were referred and all were reviewed by telephone; 30 (79%) also required a clinic review appointment. Warning signs of hypoglycaemia were identified by 21 (55%) patients, but 14 (37%) had none (three had incomplete data). Twelve patients had had a self-treated episode in the previous 6 months; nine patients had had three or more. Fifteen (39%) patients had called an emergency ambulance for similar reasons in the previous 6 months (27 "999" calls). Twenty patients (53%) had their drug treatment altered at a clinic appointment and 14 (37%) required ongoing review. Twenty six patients returned the satisfaction questionnaire; of these 88% agreed or strongly agreed that they had improved their understanding of hypoglycaemia and 73% felt more able to treat a hypoglycaemic episode in the future. Patient satisfaction with this care pathway was high. CONCLUSIONS: The ambulance service can coordinate successful referral of patients with episodes of acute hypoglycaemia to a DSN-led service. Patients often required treatment review. They valued this service and felt more confident managing their diabetes.

Observation of trielectronic recombination in Be-like Cl ions.

Recombination involving the core excitation of two electrons, which may be termed trielectronic recombination, has been experimentally identified for the first time. Using Cl13+ ions circulating in the TSR heavy-ion storage ring, we have observed surprisingly strong low-energy trielectronic recombination resonances, comparable to the dielectronic process. At higher electron-ion collision energies, trielectronic recombination is suppressed due to the autoionization of the triply excited intermediate state into excited final states. The formation of the intermediate state depends sensitively on configuration mixing, making trielectronic recombination a challenge to atomic-structure calculations.

Experimental link of photoionization of Sc2+ to photorecombination of Sc3+: an application of detailed balance in a unique atomic system.

The principle of microscopic time reversal of physical processes, detailed balance, is widely used and depended upon in the theoretical community as a connection between photorecombination (PR) and photoionization (PI). This paper reports on a novel use of detailed balance and the comparison of experimental results obtained by two very distinct techniques to determine both the metastable fraction of an ion beam and partial Sc3+ PR cross sections and partial Sc2+ PI cross sections for the ground state and for two metastable states. The Sc2+ to Sc3+ system presents a unique opportunity to obtain comprehensive state-selective information by combining results from PR and PI experiments.