Tracheal Invasion and Cardiopulmonary Compromise From Primary Thyroid Lymphoma.

Rapidly expanding thyroid lesions with tracheal invasion are typical characteristics of anaplastic and undifferentiated thyroid carcinomas, but primary thyroid lymphoma (PTL) must also be considered as a differential. Aggressive thyroid lesions can compromise the airway through compression and/or direct invasion of the tracheal wall. We present a rare case of PTL in a 57-year-old female patient who presented with worsening orthopnoea and hoarseness, followed by shortness of breath, secondary to direct invasion and compression of the trachea resulting in pulmonary edema and cardiomyopathy, requiring intensive care input. In view of the extent of the disease and associated repercussions, the patient underwent total thyroidectomy and chemotherapy, as part of her therapeutic regime, with metabolic and cardiovascular remission achieved. Histological diagnosis confirmed diffuse large B-cell lymphoma (DLBCL). PTL is a rare condition, with few cases reported in the literature. Fine needle aspiration cytology (FNAC) used traditionally in the diagnosis of thyroid lesions is less informative in PTL and core needle and incisional biopsy techniques, coupled with CT, can provide diagnostic clarity. Due to the unusual nature of PTL, it can pose diagnostic and management difficulties. Further studies are required and a multi-professional tailored approach should be adopted for each patient until a therapeutic consensus can be reached.

A systematic review of outcomes of remote consultation in ENT.

AIMS: Remote or tele-consultation has become an emerging modality of consultation in many specialities, including ENT. Advantages include increasing accessibility, potential to reduce costs and, during the COVID-19 pandemic, reduced risk of infection transmission. Here, we systematically collate and synthesise the evidence base on outcomes from remote consultation in adult and paediatric ENT services. METHODS: We performed a review in accordance with PRISMA guidelines. We searched Medline and Embase for relevant articles. Outcomes include specific patient pathway efficiency measures (including number of healthcare visits, lead time, touch time and handoff), patient/clinician satisfaction, cost analysis and safety implications. RESULTS: From 6325 articles screened, 53 met inclusion criteria. Publications included studies on remote consultation for initial, preoperative and follow-up assessment (including postoperative). In most instances, remote consultation reduced costs and time from referral to assessment and was associated with high patient satisfaction. However, a face-to-face follow-up appointment was required in 13%-72% of initial consultations, suggesting that remote consultation is only appropriate in selected cases. CONCLUSION: Remote consultation is appropriate and preferable for ENT consultation in specific conditions and circumstances. Future research should look to better define those conditions and circumstances, and report using recognised quality standards and outcome measures.

Future Interventional Radiologists and Where to Find Them-Insights from Five UK Interventional Radiology Symposia for Junior Doctors and Medical Students.

BACKGROUND: The interventional radiology (IR) trainee recruitment in the UK is lagging behind the pace of service expansion and is potentially hindered by underrepresented undergraduate curricula. Understanding the contributing factors that encourage junior doctors and medical students to consider an IR career will help the IR community to better focus the efforts on recruiting and nurturing the next generation. METHODS: Anonymised questionnaires on undergraduate and postgraduate IR exposure were distributed to attendees of five UK IR symposia between 2019 and 2020. RESULTS: 220 responses were received from 103 (47%) junior doctors and 117 (53%) medical students. Prior IR exposure strongly correlates with individuals' positive views towards an IR career (Pearson's R = 0.40, p < 0.001), with involvement in clinical activities as the most important independent contributor (OR 3.6, 95%CI 1.21-10.50, p = 0.021). Longer time spent in IR (especially as elective modules) and IR-related portfolio-building experiences (such as participating in research, attending conferences and obtaining career guidance) demonstrate strong association with willingness to pursue an IR career for the more motivated (p values < 0.05). The symposia had overall positive effects on subjective likelihood to pursue an IR career, particularly among junior doctors who face near-term career choices (p < 0.001). CONCLUSION: Our study, focusing on a self-selected cohort, identified contributing factors to individuals' willingness to pursue an IR career. Symposia have additional recruitment effects in extra-curricular settings. Active engagement with junior doctors and medical students through clinical activities and non-clinical portfolio-related experiences are key to generate informed and motivated candidates for the future of IR.

Scalpel Please! A Scoping Review Dissecting the Factors and Influences on Professional Identity Development of Trainees Within Surgical Programs.

Professional identity development is a multifaceted process that has recently sparked interest in medical education. Literature in professional identity development has focused predominantly on medical students and postgraduate medical training and much less on surgery, despite the unique challenges faced by surgical trainees while trying to emulate the identity of a self-actualized surgeon. A scoping review was performed to explore the factors and influences on professional identity development of surgeons in training. MEDLINE, PubMed, and OpenGrey databases were initially screened for relevant existing literature of professional identity development in surgical trainees, including quantitative, qualitative, and gray literature, followed by a hand search of references that appeared to be of pertinence. Seven hundred and five records were initially identified. Following the removal of duplicates and application of study selection criteria, 11 studies were included in the review. Professional identity development in surgical trainees was found to be influenced by a variety of intricately interrelating factors. Gaps in the literature were identified, highlighting possible areas of future research to better elucidate the overall process of identity development in budding surgeons and help guide interventions and programs to facilitate the transition of trainees to qualified and independently practicing surgeons.

Temporospatial aggregation of three individuals with idiopathic sudden onset low-tone sensorineural hearing loss.

OBJECTIVE: To report temporospatial aggregation of low-tone sudden onset sensorineural hearing loss (SSNHL) and provide plausible aetiological explanations. DESIGN: Retrospective analysis of records of patients, including medical notes, clinic letters, audiology reports, blood test and imaging results after occurrence of low-tone SSNHL. STUDY SAMPLE: Three patients working in the same department and presenting with low-frequency SSNHL between March and July 2019. RESULTS: There was complete symptom resolution in two of the three cases, one treated with oral and one with intratympanic steroid administration, whereas low-tone SSNHL persisted in the third case. Probability of events occurring randomly was calculated and it was suggested that the three cases were highly unlikely to be independent events. CONCLUSIONS: This is the first report of temporospatial aggregation of acute low-tone idiopathic SSNHL. Our findings support that an environmental or transmissible agent could underlie aetiology in at least a proportion of such cases.

A structured tool for delivering feedback on medical student clinical clerkings.

This article was migrated. The article was marked as recommended. Introduction: The initial history and examination is a fundamental aspect of clinical practice. Most medical students cultivate this skill through regular undertaking of 'clerkings' during their clinical placements. We designed a written, structured, proforma-based approach to delivery of feedback on student clerkings which also promoted the undertaking of a 'complete clerking' encouraging students to maintain a whole-system holistic approach. Within this paper, we present our findings following its introduction at a London teaching hospital. Methods: Sixty-one medical students on their first clinical attachment within acute medicine were asked to submit at least one full medical clerking for objective appraisal using the structured clerking feedback proforma by a clinical teaching fellow. Students completed a 'pre' and 'post' assessment using Likert Scales at the time of receiving their clerking feedback. Structured interviews of randomly selected students and senior medical educators were also undertaken. Results: Following introduction of the structured feedback proforma, there was a significant increase across all indices of student-perceived utility and satisfaction compared to previously received feedback (which was mostly ad-hoc verbal). Using Likert Scales (1 to 10: 1 representing least effect and 10 representing greatest effect) student assessment of usefulness was 9.0 (versus 6.34 for previous feedback); likelihood of influencing future practice was 8.8 (versus 6.47); extent to which it reinforced the message of a complete clerking was 9.5 (versus 6.13) and extent to which the feedback would encourage them to undertake complete clerkings was 9.0. Free text comments and subsequent interviews of randomly selected students and senior medical educators reinforced the positive perception of this approach. Conclusions: The introduction of a structured clerking feedback proforma can improve the quality and utility of the feedback delivered to medical students on their acute medical clerkings and can promote and reinforce the value of maintaining a whole-system holistic approach.

Parental perceptions and understanding of information provision, management options and factors influencing the decision-making process in the treatment of children with glue ear.

OBJECTIVES: Otitis media with effusion (OME) is a common cause of hearing loss and possible developmental delay in children, and there are a range of 'preference sensitive' treatment options. We aimed to evaluate the attitudes and beliefs of parents of affected children to treatment options including watchful-waiting, hearing aids, grommets, and, oral steroids with the intention of developing our understanding of decision-making and the factors influencing it, sources of parental information, and satisfaction with information provision. DESIGN: We recruited a convenience sample of twelve parents of eleven children with OME at a single ENT department of a teaching hospital into a qualitative research study. The children of the parents interviewed had already been recruited into the Oral Steroids for the Resolution of Otitis Media with effusion In Children (OSTRICH) study. Semi structured interviews were audio recorded, transcribed and then coded using an inductive, thematic approach. RESULTS: Parents were satisfied with the verbal provision of information during the treatment consultation, although many were keen to receive supplementary printed information. Discussion with family and friends helped the decision-making process, whereas insufficient information and a paternalistic approach were viewed as obstacles. Parents were particularly influenced by the following: the immediacy of the treatment option effect, perceived efficacy, perceived risks and adverse effects, social implications (especially with hearing aids) and past personal and informant experience. CONCLUSIONS: Parents appreciate clinicians tailoring information provision to parents' information needs and preferred format. Clinicians should also elicit parental attitudes towards the different management options for OME and the factors influencing their decisions, in order to optimise shared-decision making and ultimately provide a better standard of clinical care.

Coronary endarterectomy: The current state of knowledge.

Coronary artery endarterectomy (CE) is a procedure performed adjunctive to coronary artery bypass grafting in patients with diffuse coronary artery disease (CAD). This review was conducted in order to assess the safety of the procedure, the associated complications as well as short- and long-term patient outcomes. A literature search was performed via Pubmed, and 50 articles were included in the review based on our inclusion and exclusion criteria. The mortality and morbidity rates were found to be acceptable in a highly selected group of patients. Therefore, CE may have an important role to play in the surgical management of patients with complicated CAD and should be incorporated to the armamentarium of the cardiologist and the cardiac surgeon following careful consideration by a multi-disciplinary approach.