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.

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.

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.

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.

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.

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.

Approaches to short-acting neuromuscular blocking agents: nonsymmetrical bis-tetrahydroisoquinolinium mono- and diesters.

Nonsymmetrical bisquaternary mono- and diesters combining the potency-enhancing properties of the (1R)-laudanosinium group with a second unhindered quaternary ammonium moiety have been studied as a means of promoting short action with high-potency neuromuscular block. Atracurium-related nonsymmetrical diesters showed high potency, freedom from vagal blockade at neuromuscular blocking doses, and short action. Nonsymmetrical monoesters were short acting but showed varying degrees of vagal block.

Structure-activity relationships for a class of inhibitors of purine nucleoside phosphorylase.

Values of inhibition constants, Ki, for a family of structurally related, competitive inhibitors of calf spleen purine nucleoside phosphorylase (PNP) have been determined employing both inosine as substrate and a manual assay and 2-amino-6-mercapto-7-methylpurine ribonucleoside (MESG) as substrate and a robot-based enzyme kinetics facility. Several of the values determined robotically were confirmed employing the same substrate and a manual assay. Surprisingly, for many of the inhibitors examined, values of Ki determined with MESG as substrate are smaller than those obtained employing inosine as substrate by a factor that varies from less than 2 to 10. Values of concentrations required for 50% inhibition of PNP, IC50, have also been determined for the same family of inhibitors employing inosine as substrate. Values of IC50ino and those for Kiino and Kimesg for subsets of the inhibitors have been employed as training sets to create quantitative structure-activity relationships (QSAR) which have substantial power to predict values of IC50 and Ki for inhibitors outside the training set. These QSAR models should be useful in guiding future medicinal chemistry efforts designed to discover inhibitors of PNP having increased potency.

Elimination of fetal scalp blood sampling on a large clinical service.

OBJECTIVES: To describe the use of fetal scalp blood sampling on a large teaching service over 7 years and to assess any association between changes in use and the rates of cesarean delivery for fetal distress and of various indirect indicators of perinatal asphyxia in term infants. METHODS: We reviewed computerized and tabular data bases for fetal scalp blood sampling, cesarean delivery for fetal distress, Apgar score, and the clinical diagnoses of asphyxia and meconium aspiration syndrome for the years 1986-1992. RESULTS: Live births averaged 16,330 annually. The rate of fetal scalp blood sampling for the first 3 years of the study period was 1.76%, consistent with the rate of 1.5-2.0% noted for the preceding decade at our institution. An increase in sampling in 1987 was followed by a steady decline over the next 4 years, to a low of 0.03% in 1992. During the period of declining scalp pH usage, there was no increase in the cesarean rate for fetal distress, low Apgar score (less than 5 at 5 minutes) requiring neonatal intensive care unit admission, or the clinical diagnosis of perinatal asphyxia or meconium aspiration syndrome. CONCLUSIONS: Fetal scalp blood sampling has been virtually eliminated without an increase in the cesarean rate for fetal distress or an increase in indicators of perinatal asphyxia. The role of fetal scalp blood sampling in clinical practice is questioned.

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.

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.