Implementation of an acute tonsillitis management protocol within a clinical decisions unit.

INTRODUCTION: With tonsillectomy surgery subject to increasingly strict commissioning criteria over the past 20 years in the UK, the total number of admissions for acute tonsillitis has been rising steadily. Multiple single-centre studies have demonstrated how introduction of a standardised management protocol can be effective in improving the delivery of treatment for acute tonsillitis in the emergency department. METHODS: Using a novel approach, we aimed to implement an acute tonsillitis management protocol within a formal clinical decisions unit (CDU) pathway. Following a retrospective baseline audit, we carried out two post-intervention cycles of data collection to assess safety and efficacy. RESULTS: The median number of initial treatments increased significantly from two of five at baseline, to three of five in both the first (U = 86, p = 0.004) and second (z = 2.959, p = 0.003) audit cycles. Admission rate was reduced from 0.79 to 0.44 in the first cycle, representing a 44.6% relative risk reduction [95% confidence interval (CI) 0.304-1.012; p = 0.0547]. Admission rate remained reduced at 0.48 in the second cycle, with a relative risk reduction of 39.2% compared with baseline (95% CI 0.380-0.972; p = 0.038). CONCLUSIONS: Utilisation of the CDU led to an improvement in the delivery of initial treatment, an extended period of observation and subsequently a greater percentage of patients being discharged. An acute tonsillitis management protocol within a CDU appears to be a safe and effective model and is now standard practice in our hospital.

The changing face of rhinology in the NHS: a study of septoplasty, septorhinoplasty and rhinoplasty hospital episode statistics.

INTRODUCTION: In 2011, septorhinoplasty and rhinoplasty were reclassified as procedures of limited clinical value in the NHS. The criteria for funding these operations varies across England. We used hospital episode statistics and freedom of information requests to review the total number of rhinology procedures performed across the previous decade, looking at trends in practice related to time, demographics and commissioning policy. MATERIALS AND METHODS: Hospital episode statistics for 2012-2019 were used to calculate the number of septoplasty, septorhinoplasty, rhinoplasty and reduction rhinoplasty procedures performed in children and adults. Freedom of information requests were also made to all clinical commissioning groups in England asking for number of procedures performed and number of individual funding requests made. RESULTS: A total of 158,031 procedures were performed over this period; the majority were in adult (99.0%) men (65.7%). Septoplasty was the most frequently performed operation; however, the total numbers declined by 5.4% over this period. There was a yearly reduction in the overall number of septorhinoplasty, rhinoplasty and reduction rhinoplasty operations. Four clinical commissioning groups provided a detailed breakdown of data by year and procedure. Those that required individual funding requests for all cases saw septorhinoplasty numbers fall by 81% and 75% over the period. Those that did not, saw numbers increase or remain the same. CONCLUSIONS: We found an overall year-on-year reduction in the number of rhinology operations being performed in the NHS, but variation in trends between different clinical commissioning groups. A reduction in operative activity likely represents the effect of underlying restrictions on commissioning rather than reduced clinical need.

The usefulness of the platelet function analyser (PFA-100) in screening for underlying bleeding disorders in women with menorrhagia.

The prevalence of underlying bleeding disorders is common in women with menorrhagia. This was a prospective study to screen for the underlying bleeding disorders in women presenting with menorrhagia by using the PFA-100 and comparing the accuracy of the results with the complete haematological assays. A total of 62 women referred to gynaecology outpatients with a history of heavy, regular periods had blood collected for analysis by the PFA-100 and also a full coagulation profile including von Willebrand factor. PFA-100 analysis suggested platelet defects in 10 (16%) women. This included five (8%) identified with von Willebrand disease, two (3.2%) with storage pool disorders and three (4.8%) without any recognisable platelet or bleeding disorders after a full coagulation profile, including von Willebrand factor, was carried out. PFA-100 results had a sensitivity of 100% and specificity of 94.8% in our study. We conclude that PFA-100 is a quick and reliable method of screening for impaired haemostasis in patients with menorrhagia.

Structured review of the patient-reported outcome instruments used in clinical trials in head and neck surgery.

The number of clinical trials that relate to patients with cancer of the head and neck is growing. Patient-reported outcomes, which are rarely the primary outcome, are now an important component, and in this structured review to identify and report the characteristics of the questionnaires that have been used in these trials, we summarise the findings reported. We searched several online databases using the key terms: head and neck oncology, head and neck surgery, reconstruction, clinical trials patient-reported outcomes, questionnaires, quality of life (QoL), validated instruments, and patients' satisfaction. We screened 1342 papers to collect information about the topic of the paper, sample size, selection criteria, main advantages and disadvantages of the patient-reported outcome used, and if it was used in conjunction with another measure. A total of 54 were eligible, and from them we identified 22 questionnaires. The primary reason for using a questionnaire was its relevance to the focus of the paper, such as xerostomia, pain, or swallowing. To allow the experience of patients to be the focus of the primary outcome in a clinical trial, we recommend that the measures used should be appropriate, reliable, valid, responsive, precise, interpretable, acceptable, and feasible. The trials used validated questionnaires, but the patient-reported outcome measures tended not to be the focus. There is merit in such measures being the primary outcomes in future trials and these should be designed around an explicit hypothesis.

A rare presentation of zygomycosis (mucormycosis) and review of the literature.

Zygomycosis (mucormycosis) is a rare fungal infection seen most often in association with prolonged neutropenia. Intestinal zygomycosis is extremely rare and difficult to diagnose, but it is important not to miss, because early medical and surgical treatment can improve survival. This report describes a 56 year old woman who developed this infection while receiving chemotherapy for acute lymphoblastic leukaemia. Medical and surgical measures proved unsuccessful because there was a delay in diagnosis and institution of appropriate treatment.

Life events and breast cancer prognosis.

OBJECTIVE: To determine whether psychosocial stress, in the form of adverse life events and social difficulties, depressive illness, or lack of confiding relationships, shortens the postoperative disease free interval in breast cancer patients. DESIGN: Prospective follow up of a cohort of newly diagnosed breast cancer patients for 42 months after primary surgical treatment, using a life events and social difficulties schedule (LEDS) and assessment of depressive symptomatology (DSM-III). SETTING: Patients recruited from breast clinics in Southampton and Portsmouth were interviewed in their homes. PATIENTS: 204 women (83% of 246 consecutive cases) treated either by mastectomy or wide excision followed by radiotherapy interviewed four, 24, and 42 months after operation. MAIN OUTCOME MEASURES: Hazard ratios for relapse of breast cancer in relation to various measures of psychosocial stress. Relapse was defined as local recurrence or distant metastasis, or both, with histological or radiological confirmation and timed from the month when clinical symptoms began. RESULTS: After adjustment for age and axillary lymph node involvement, the hazard ratio associated with severe life events or social difficulties (excluding "own health" ones), or both, during the year before breast cancer surgery was 0.43 (95% confidence interval 0.20 to 0.93); for those during the follow up period it was 0.88 (0.48 to 1.64). For prolonged major depression before surgery and during the follow up period, hazard ratios were 1.26 (0.49 to 3.26) and 0.85 (0.41 to 1.79) respectively. For absence of a full confidant the figures were 0.93 (0.42 to 2.09) and 0.86 (0.38 to 1.93). CONCLUSION: These results give no support to the theory that psychosocial stress contributes to relapse of breast cancer.

Unusual complication following trauma to a bone-anchored hearing aid: case report and literature review.

OBJECTIVE: We report the second published case of a child with a serious traumatic injury involving the fixture and abutment of their bone-anchored hearing aid. METHOD: Case reports and review of the world literature concerning unusual complications following trauma to bone-anchored hearing aids. RESULTS: A nine-year-old girl with Dubowitz syndrome sustained an intrusion injury of her bone-anchored hearing aid fixture and abutment following a fall. No other injury was sustained, and there was no neurological complication. The patient underwent immediate removal of the implant and subsequently made a full recovery. Such serious and unusual complications are fortunately very rare. On review of the literature, four cases of similar complications were identified. Only one involved a traumatic injury in a child. CONCLUSION: Provision of bone-anchored hearing aids involves many clinicians. All clinicians involved in this procedure must be aware of the need to monitor their patients carefully, and to remember that unusual and unexpected complications, although rare, do happen. The patient's need for care continues long after the surgery is complete.

Extradural haematoma presenting as a contralateral sixth nerve palsy after cochlear implantation.

Intracranial complications after cochlear implantation are rare. The authors present the case of a 13 month old boy with a contralateral abducens nerve palsy following cochlear implantation that led to the diagnosis of an extradural haematoma on computerised tomography scanning. The abducens palsy resolved after evacuation of the haematoma and the patient made an excellent recovery. The literature is reviewed and the mechanism of injury discussed.

True aneurysm of the facial artery.

We present a case of true facial artery aneurysm with no associated risk factors, which was non-pulsatile on presentation. This case is unique as the lesion was identified using computed tomography scanning, due to the unusual presentation. The vast majority of aneurysms of the head and neck have a traumatic aetiology, giving rise to false aneurysms; true aneurysms are extremely rare. We discuss the implications of such a lesion and its management.

A new method of construction of obturators for nasal septal perforations and evidence of outcomes.

Septal obturators and buttons for nasal septal perforations are often poorly tolerated. We describe a new method of obturator construction using three-dimensional imaging which more closely replicates the true anatomy of the defect. Patients were assessed using a questionnaire relating to how symptoms had changed between having no obturator, a conventional obturator and the new CT obturator. Eight of nine patients had an improvement in total symptom scores comparing old obturators to new CT obturators and this was significant with a P-value of 0.018 using Student's paired t-test. The majority of patients were satisfied with the new obturators and reported an overall improvement of symptoms.

Psycho-oncology and the role of the psychiatrist in cancer patient care.

Cancer and its treatment lead to emotional distress for most patients and their families, and to psychiatric illness for some. Psychiatrists can contribute to the prevention, recognition and treatment of these problems. Educational and supportive group work, for both patients and staff, complements the assessment and management of individually referred cases. Psychiatrists in this setting require a good understanding of medical matters, and good working relationships with colleagues both in cancer services and mental health services. The nature of the clinical work will be illustrated by case vignettes.