Cost-comparison study of reusable and disposable rhinolaryngoscopes in a large English teaching hospital.

OBJECTIVE: This study aimed to compare the cost per use of video-rhinolaryngoscopy using reusable and disposable devices in a tertiary referral centre. METHODS: A cost-comparison study was performed that utilised retrospective cost data and prospective utilisation data to compare the total costs of using reusable video-rhinolaryngoscopes versus a single-use alternative. RESULTS: It was estimated that 4776 and 1821 procedures were performed annually with reusable and disposable video-rhinolaryngoscopes, respectively. The cost per use was £66.61 for reusable devices versus £150.00 for disposable devices. The break-even point (i.e. when cost per use was equal, occurred at 1374 procedures per year). Thereafter, it was cheaper to use reusable devices. CONCLUSION: Disposable rhinolaryngoscopes may present a cheaper solution to services with low rates of rhinolaryngoscope utilisation. However, for larger services considering replacement of their reusable rhinolaryngoscopes with disposable units, it is likely that the recurring costs will be prohibitive in the medium to long term.

Comparing complex perspectives on obesity drivers: action-driven communities and evidence-oriented experts.

INTRODUCTION: The Foresight obesity map represents an expert-developed systems map describing the complex drivers of obesity. Recently, community-led causal loop diagrams have been developed to support community-based obesity prevention interventions. This paper presents a quantitative comparison between the Foresight obesity systems map and a community-developed map of the drivers of obesity. METHODS: Variables from a community-developed map were coded against the thematic clusters defined in the Foresight map to allow comparison of their sizes and strength of adjoining causal relationships. Central variables were identified using techniques from network analysis. These properties were compared to understand the similarities and differences between the systems as defined by the two groups. RESULTS: The community map focused on environmental influences, such as built physical activity environment (18% of variables) and social psychology (38%). The Foresight map's largest cluster was physiology (23%), a minimal focus in the community map (2%). Network analysis highlighted media and available time within both maps, but variables related to school and sporting club environments were unique to the community map. CONCLUSION: Community stakeholders focus on modifiable social and environmental drivers of obesity. Capturing local perspectives is critical when using systems maps to guide community-based obesity prevention.

Guidelines for timely initiation of chemotherapy: a proposed framework for access to medical oncology and haematology cancer clinics and chemotherapy services.

These guidelines, informed by the best available evidence and consensus expert opinion, provide a framework to guide the timely initiation of chemotherapy for treating cancer. They sit at the intersection of patient experience, state-of-the-art disease management and rational efficient service provision for these patients at a system level. Internationally, cancer waiting times are routinely measured and publicly reported. In Australia, there are existing policies and guidelines relating to the timeliness of cancer care for surgery and radiation therapy; however, until now, equivalent guidance for chemotherapy was lacking. Timeliness of care should be informed, where available, by evidence for improved patient outcomes. Independent of this, it should be recognised that shorter waiting periods are likely to reduce patient anxiety. While these guidelines were developed as part of a proposed framework for consideration by the Victorian Department of Health, they are clinically relevant to national and international cancer services. They are intended to be used by clinical and administrative staff within cancer services. Adoption of these guidelines, which are for the timely triage, review and treatment of cancer patients receiving systemic chemotherapy, aims to ensure that patients receive care within a timeframe that will maximise health outcomes, and that access to care is consistent and equitable across cancer services. Local monitoring of performance against this guideline will enable cancer service providers to manage proactively future service demand.

A study of the physiology of Bacillus anthracis Sterne during manufacture of the UK acellular anthrax vaccine.

AIM: To analyse the growth of Bacillus anthracis during simulations of the UK anthrax vaccine manufacturing process. METHODS AND RESULTS: Simulated vaccine production runs were performed using the toxigenic, acapsulate Sterne 34F(2) strain of B. anthracis in semi-defined medium. After rising during the logarithmic growth phase, the pH of the culture starts to fall at about 18 h from pH 8.7 to reach <7.6 at 26 h, coincident with consumption of glucose and optimal production of protective antigen (PA; 7.89 g ml(-1), SD 1.0) and lethal factor (LF; 1.85 g ml(-1), SD 0.29). No increased breakdown of toxin antigens was seen over the 26-32 h period. When glucose was exhausted, amino acids (principally serine) were utilized as an alternative carbon source. Sporulation was not observed during the 32 h. CONCLUSIONS: PA and LF, the principal constituents in the UK anthrax vaccine, undergo little degradation during vaccine fermentation. The vaccine manufacturing process is robust and reproducible. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first detailed analysis of the manufacturing process used for the UK acellular anthrax vaccine; insight gained into the process will support continued and safe vaccine manufacture.

Inhaled corticosteroids for non-specific chronic cough in children.

BACKGROUND: Cough in isolation of other clinical features is known as non-specific cough, which has been defined as non-productive cough in the absence of identifiable respiratory disease or any known aetiology. In children with non-specific cough the possibility of asthma being the underlying disorder is often raised (so called cough variant asthma). The proponents of cough variant asthma suggest a therapeutic trial of medications usually used to treat asthma. OBJECTIVES: To determine the efficacy of inhaled corticosteroids in non-specific cough in children over the age of two years. SEARCH STRATEGY: Searches were conducted on Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Searches were current as of March 2004. SELECTION CRITERIA: All randomised (randomised and quasi-randomised) controlled clinical trials in which an inhaled corticosteroid (beclomethasone (BDP), fluticasone (FP), triamcinalone (TAA) or any other corticosteroid) were given for cough in children over two years of age were included. Two review authors independently assessed articles for inclusion and methodological quality. DATA COLLECTION AND ANALYSIS: Data from trials was extracted by both review authors and entered into the Cochrane Collaboration software program RevMan Analyses 1.0.2. MAIN RESULTS: Two trials met the inclusion criteria (123 participants). One compared inhaled beclomethasone dipropionate (400 micrograms per day) with placebo and the other compared fluticasone propionate (2 mg per day for 3 days followed by 1 mg per day for 11 days) with placebo. Both studies used metered dose inhalers via a spacer. With the lower dose of inhaled corticosteroid there was no significant difference between the beclomethasone and placebo groups. With the higher dose there was a significant improvement in nocturnal cough frequency after two weeks in children presenting with persistent nocturnal cough. However, a significant but smaller improvement was also seen with placebo. AUTHORS' CONCLUSIONS: In one study beclomethasone dipropionate (400 micrograms per day) was no different from placebo in reducing the frequency of cough measured objectively or scored subjectively. There might be a small improvement with very high-dose inhaled corticosteroid but the clinical impact of this is unlikely to beneficial.

Inhaled beta2-agonists for treating non-specific chronic cough in children.

BACKGROUND: The pathophysiology of so called 'cough variant asthma' has not received a great deal of research interest and opinion lies divided as to whether it is really asthma or not. The proponents of cough variant asthma suggest a therapeutic trial of medications usually used to treat asthma OBJECTIVES: To determine the effectiveness of inhaled ss2 agonists in non-specific chronic cough in children over the age of 2 years. SEARCH STRATEGY: The Cochrane Airways Group database (including MEDLINE, EMBASE and CINAHL) and the Cochrane Controlled Trials Register (CCRT) were searched. Additional searching included hand searching of medical journals through the Cochrane Collaboration, references, references of references listed in primary sources and personal communication with authors. In addition "Grey literature" including theses, internal reports, non-peer reviewed journals were sought. SELECTION CRITERIA: All randomised (randomised and quasi-randomised) controlled clinical trials in which inhaled ss2 agonists were given for chronic cough in children over 2 years of age were included. Two reviewers independently assessed articles for inclusion and methodological quality. DATA COLLECTION AND ANALYSIS: Data for trials of salbutamol versus placebo were extracted by both reviewers and entered into the Cochrane Collaboration software program Review Manager, version 4.2 MAIN RESULTS: In children presenting with isolated chronic cough there was no significant difference between salbutamol treated group and placebo group. AUTHORS' CONCLUSIONS: Salbutamol was no different from placebo in reducing the frequency of cough measured objectively or scored subjectively.

Surgical versus non-surgical interventions for vocal cord nodules.

BACKGROUND: Vocal cord nodules are bilateral swellings of the mid-portion of the membranous vocal folds. They are of variable size and are characterised histologically by thickening of the epithelium with a variable degree of inflammatory action in the underlying superficial lamina propria. They characteristically produce hoarseness. Treatment of vocal cord nodules aims to eliminate or reduce this hoarseness. OBJECTIVES: To assess the effectiveness of surgery versus non-surgical interventions for vocal cord nodules. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (CCTR) and Medline (1966-2000), Embase (1974-2000), Biological Abstracts (1970-2000), Biological Abstracts RRM (Reports, Reviews and Meetings) on CD-ROM (1989-2000) and review articles. SELECTION CRITERIA: Randomised and quasi-randomised trials comparing any surgical intervention for vocal cord nodules with non-surgical treatment or no treatment. DATA COLLECTION AND ANALYSIS: No suitable trials were identified. MAIN RESULTS: No studies fulfilled the inclusion criteria. REVIEWER'S CONCLUSIONS: There is a need for high quality randomised controlled trials to evaluate the effectiveness of surgical and non-surgical treatment of vocal cord nodules.

The effect of nasal patency on the clearance of radiolabeled saline in healthy volunteers.

PURPOSE: The objective of this study was to investigate the effect of nasal cavity patency on the penetration, deposition, and clearance of an aqueous isotonic saline solution. METHODS: The study was carried out as a single center, open, randomized, 2-way cross-over in healthy volunteers. Nasal patency was assessed using misting patterns on a cold metal surface at the beginning and end of study. 100 microl of technetium-99m radiolabeled saline solution was introduced into either the most or least patent nasal cavity using a purpose designed spray device. The distribution and residence time of the radiolabel was followed for 2 hours using gamma scintigraphy. RESULTS: The mean times to 50% clearance were 34+/-7 and 28+/-12 minutes (+/- s.d.) for the side view of the least and most patent nasal cavity respectively. Total clearance of the radiolabelled saline from the nose was not affected by patency. Between 7 and 35% of the radiolabelled saline solution remained in the nasal cavity at the end of imaging. Using endoscopy to track the clearance of an aqueous solution of food dye using the same delivery procedure, identified this region as hair in the nasal vestibule. The dye was seen to dry in this region along with the mucus. CONCLUSIONS: Nasal patency affects the initial, but not total clearance of solutions, however, the remaining solution may not be available for drug delivery.

Larynx synchronised stroboscopy--a new tool for outcome measures in the voice clinic.

Direct vocal fold synchronised stroboscopy is a new technique for obtaining useful images of pathological voice, with reduced requirements for both vocal fold cycle regularity and the duration of sustained phonation. Precise synchronisation of the firing of the stroboscope from the Laryngograph waveform, and the capture of images and waveforms into a computer, allows inspection of short periods of phonation (less than one second) as a continuous replay of the images. Replay can be continued indefinitely, automatically repeating the short period of image capture, eliminating the need to rewind a video-tape repetitively. This in turn avoids the need for the lengthy phonation otherwise required when clinical examination is based on the use of conventional live or video-taped stroboscopy. Since the LxStrobe system is based on digital processing, archiving and retrieval of images is much enhanced. A demonstration of the system, called the LxStrobe, is available on the world-wide-web at www.laryngograph.com.

The role of the Davis graft technique in the treatment of chronic post-mastoidectomy otorrhoea.

The effect of grafting mastoid cavities with small Davis cutaneous pinch grafts was assessed in 15 patients. Following revision of the cavity and Davis pinch grafting the resultant cavity was completely dry in 13 patients (87%) over a period ranging from 1 to 30 months with a mean of 7.3 months, with five becoming dry within 1 month. Patient satisfaction with respect to reduction in discharge and smell was excellent (87%). We believe that the Davis graft technique has a beneficial role in persistent post-mastoidectomy otorrhoea especially when previous standard revision techniques have failed.

Angioedema secondary to angiotensin-converting enzyme inhibitors.

Angioedema secondary to angiotensin-converting enzyme (ACE) inhibitors is rare, but it is a side effect which is likely to be seen more frequently because of the increased use of these drugs to treat cardiac failure and hypertension. Presentation is variable and the diagnosis may go unrecognized for many months or years. The cases reported illustrate problems both in the diagnosis and management of this life-threatening condition.

Lingual haematoma following treatment with streptokinase and heparin; anaesthetic management.

A 79-year-old man with a diagnosis of myocardial infarction treated with streptokinase and heparin developed a large lingual haematoma, precipitating dysphagia and upper airway obstruction. Spontaneous haemorrhage into the tongue is a previously unreported but serious complication of thrombolytic therapy. Tracheal intubation was performed under local anaesthesia.

Massive epistaxis following sphenoid sinus exploration.

Internal carotid artery trauma is a rare but potentially disastrous complication of surgery to the sphenoid sinus and pituitary gland. Emergency and elective procedures to establish haemostasis are discussed.

Jugular bulb phlebectasia.

Phlebectasia of the internal jugular vein (IJV) is a rare venous anomaly that usually presents in young children as a soft cystic swelling in the neck and represents a pathologically enlarged vein. We present a case of jugular bulb phlebectasia in a 4-year-old boy. He presented with a blue pulsatile swelling arising from the floor of the left middle ear cleft. The venous phase of digital subtraction vertebral arteriography (DSVA) and computerised axial tomography (CT) with contrast confirmed a diagnosis of phlebectasia of the lateral sinus and proximal part of the left IJV, with a complete bony defect in the floor of the middle ear. The child did not have any neck symptoms or signs. No active treatment was required. To our knowledge, this is the first case of jugular bulb phlebectasia presenting in the middle ear.

A comparative study of calcium sodium alginate (Kaltostat) and bismuth tribromophenate (Xeroform) packing in the management of epistaxis.

A prospective study was undertaken to compare the efficacy of calcium sodium alginate fibre (Kaltostat) to petrolatum gauze impregnated with bismuth tribromophenate (Xeroform) for the control of epistaxes that require hospital admission. Forty patients presenting with severe epistaxis requring hospital admission were treated with either Kaltostat or Xeroform nasal packs. Allocation to either treatment group was made randomly. The composition of each group in terms of age, sex distribution, aetiology of epistaxis and severity of bleed was not significantly different. There was no significant difference in the efficacy or patient acceptability of either therapeutic agent. It is concluded that calcium sodium alginate fibre should be considered as an acceptable alternative to traditional gauze packing.

Verrucous carcinoma of the maxillary antrum.

Verrucous carcinoma is a rare variant of squamous cell carcinoma which occurs most frequently in the oral cavity and larynx. In this article we describe a patient with verrucous carcinoma of the maxillary antrum, and present a review of the literature.

Solitary keratoacanthoma of the nasal vestibule.

Keratoacanthomas are lesions which rarely present to Otorhinolaryngologists; however they must be considered in the differential diagnosis of any rapidly growing lesion in the head and neck. We report a case of a keratoacanthoma of the nasal vestibule which caused clinical and histopathological difficulties in diagnosis. Keratoacanthomas and the treatment options are discussed.