Setting the top 10 research priorities to improve the health of people with Type 2 diabetes: a Diabetes UK-James Lind Alliance Priority Setting Partnership.

AIMS: To describe processes and outcomes of a priority setting partnership to identify the 'top 10 research priorities' in Type 2 diabetes, involving people living with the condition, their carers, and healthcare professionals. METHODS: We followed the four-step James Lind Alliance Priority Setting Partnership process which involved: gathering uncertainties using a questionnaire survey distributed to 70 000 people living with Type 2 diabetes and their carers, and healthcare professionals; organizing the uncertainties; interim priority setting by resampling of participants with a second survey; and final priority setting in an independent group of participants, using the nominal group technique. At each step the steering group closely monitored and guided the process. RESULTS: In the first survey, 8227 uncertainties were proposed by 2587 participants, of whom 18% were from black, Asian and minority ethnic groups. Uncertainties were formatted and collated into 114 indicative questions. A total of 1506 people contributed to a second survey, generating a shortlist of 24 questions equally weighted to the contributions of people living with diabetes and their carers and those of healthcare professionals. In the final step the 'top 10 research priorities' were selected, including questions on cure and reversal, risk identification and prevention, and self-management approaches in Type 2 diabetes. CONCLUSION: Systematic and transparent methodology was used to identify research priorities in a large and genuine partnership of people with lived and professional experience of Type 2 diabetes. The top 10 questions represent consensus areas of research priority to guide future research, deliver responsive and strategic allocation of research resources, and improve the future health and well-being of people living with, and at risk of, Type 2 diabetes.

Tranexamic acid - a useful drug in ENT surgery?

BACKGROUND: Tranexamic acid is a synthetic antifibrinolytic drug. It has been widely available for over 40 years, but only recently has it started to be used routinely in many surgical disciplines. For ENT surgeons, epistaxis and post-tonsillectomy bleeding contribute a significant proportion of the morbidity and emergency workload in a general ENT department. Published evidence indicates a potentially helpful role for tranexamic acid in managing epistaxis. RESULTS AND CONCLUSION: To date, the benefits of tranexamic acid as a prophylactic treatment to reduce the rate and severity of post-tonsillectomy bleeding are less certain. Two recently published pilot studies looking at primary haemorrhage in children and secondary haemorrhage in adults following tonsillectomy suggest that further large, randomised trials should explore the efficacy of tranexamic acid in routine ENT surgery. There are potential reductions in patient morbidity and cost savings if tranexamic acid is found to be efficacious in larger trials.

Perioperative tranexamic acid in day-case paediatric tonsillectomy.

INTRODUCTION: Tranexamic acid has been used for many years to minimise blood loss during surgery and, more recently, to reduce morbidity after major trauma. While small studies have confirmed reduction in blood loss during tonsillectomy with its use, the rate of primary haemorrhage following tonsillectomy has not been reported. In the UK, less than 50% of children having a tonsillectomy are managed as day cases, partly because of concerns about bleeding during the initial 24 hours following surgery. METHODS: A retrospective review of clinical records between January 2007 and January 2013 produced 476 children between the ages of 3 and 16 years who underwent Coblation™ tonsillectomy, with or without adenoidectomy and/or insertion of ventilation tubes. All children were ASA (American Society of Anesthesiologists) grade 1 or 2 and anaesthetised using a standard day surgery protocol. Following induction of anaesthesia, all received intravenous tranexamic acid at a dose of 10-15 mg/kg. RESULTS: Two children (0.4%) had minor bleeding within two hours of surgery. Both returned to theatre for haemostasis and were discharged home later the same day with no further complications. The expected rate for primary haemorrhage in the UK using this technique for tonsillectomy is 1%. CONCLUSIONS: Perioperative tranexamic acid in a single, parenteral dose might reduce the incidence of primary haemorrhage following paediatric tonsillectomy, facilitating discharge on the day of surgery. The results from this observational study indicate a potential benefit and need for a large, prospective, multicentre, randomised controlled trial.

Post-operative nausea and vomiting following paediatric day-case tonsillectomy: audit of the Epsom protocol.

OBJECTIVE: To audit a protocol for elective, day-case, paediatric ENT surgery, previously reported as enabling an overall post-operative nausea and vomiting rate of 2 per cent and a discharge rate of 100 per cent on the day of surgery. METHOD: The audit included 91 children (45 boys and 46 girls) aged three to 14 years. Forty-seven children underwent tonsillectomy, 36 adenotonsillectomy and eight tonsillectomy with postnasal space examination; indications included recurrent tonsillitis, tonsillitis and nasal block, upper airway obstruction, and a combination of upper airway obstruction and recurrent tonsillitis. RESULTS: No post-operative nausea or vomiting was recorded in any of the children on the day of surgery, and no discharges were delayed. The reactionary haemorrhage rate was 1 per cent and the secondary haemorrhage rate 3.3 per cent. CONCLUSION: These findings have implications for the safe same-day discharge of children following tonsillectomy.

Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party.

During 2008, ENT-UK received a number of professional enquiries from colleagues about the management of children with upper airway obstruction and uncomplicated obstructive sleep apnoea (OSA). These children with sleep-related breathing disorders (SRBDs) are usually referred to paediatricians and ENT surgeons. In some district general hospitals, (DGHs) where paediatric intensive care (PICU) facilities to ventilate children were not available, paediatrician and anaesthetist colleagues were expressing concern about children with a clinical diagnosis of OSA having routine tonsillectomy, with or without adenoidectomy. As BAPO President, I was asked by the ENT-UK President, Professor Richard Ramsden, to investigate the issues and rapidly develop a working consensus statement to support safe but local treatment of these children. The Royal Colleges of Anaesthetists and Paediatrics and Child Health and the Association of Paediatric Anaesthetists nominated expert members from both secondary and tertiary care to contribute and develop a consensus statement based on the limited evidence base available. Our terms of reference were to produce a statement that was brief, with a limited number of references, to inform decision-making at the present time. With patient safety as the first priority, the working party wished to support practice that facilitated referral to a tertiary centre of those children who could be expected, on clinical assessment alone, potentially to require PICU facilities. In contrast, the majority of children who could be safely managed in a secondary care setting should be managed closer to home in a DGH. BAPO, ENT-UK, APA, RCS-CSF and RCoA have endorsed the consensus statement; the RCPCH has no mechanism for endorsing consensus statements, but the RCPCH Clinical Effectiveness Committee reviewed the statement, concluding it was a 'concise, accurate and helpful document'. The consensus statement is an interim working tool, based on level-five evidence. It is intended as the starting point to catalyze further development towards a fully structured, evidence-based guideline; to this end, feedback and comment are welcomed. This and the constructive feedback from APA and RCPCH will be incorporated into a future guideline proposal.

Paediatric tonsillectomy: parental experience and outcomes.

OBJECTIVE: To evaluate parental experience, satisfaction and outcomes following their child's tonsillectomy surgery. DESIGN: Structured postal questionnaire sent to the parents or guardians of 77 sequential children undergoing elective day-case tonsillectomy. SUBJECTS: Seventy-seven children with a mean age of 6.25 years (range three to 17 years) undergoing day-case tonsillectomy predominantly for recurrent acute tonsillitis, upper airway obstruction or a combination of these symptoms; 63.6 per cent of the parents or guardians of these children responded to the questionnaire. RESULTS: There was overall satisfaction with the operation, and positive health outcomes. CONCLUSIONS: Despite the current public health agenda to limit access to routine high volume operations such as childhood tonsillectomy on economic grounds, the users of this service rated the outcomes and benefits of the procedure highly.

Adenoidectomy: does it work?

Adenoidectomy is a common, routine paediatric operation for which the evidence base for effectiveness is lacking. While there is a broad evidence base of variable quality for other common children's ENT operations, most published data including adenoidectomy is combined with the effect of combined tonsillectomy or grommet surgery. For the common indications for adenoidectomy, does it work?

Copying clinic letters to patients: a survey of patient attitudes.

Guidance from the Department of Health, published in 2000, stated that, 'as a matter of right', communications between clinicians would be copied to patients. In further guidance, the department indicated that, from April 2004, patients would receive copies of correspondence exchanged between healthcare professionals. There has been little research on this issue, and the few existing publications have come from the hospital psychiatric clinic setting. We examined the attitudes of 100 patients attending an ENT clinic as well as those of 100 parents of children attending a paediatric ENT clinic in a general hospital out-patient setting. At the end of consultations, patients or parents were invited to take part in the survey by completing a short questionnaire. Forty-three per cent of the adult patients and 44 per cent of the parents requested a copy of the clinic letter. These people were followed up by a telephone survey, three weeks after the copy of the clinic letter to the general practitioner was posted to the patient or parent. Eighty-one per cent of the patients and 77 per cent of the parents were successfully contacted for the follow-up telephone survey. Sixty per cent of the adults and 77 per cent of the parents reported that the copy of the clinic letter was helpful. There were no differences in responses between the adult patient and paediatric patient groups. In this study, less than half of both groups requested a copy of the ENT clinic letter to their general practitioner. To follow Department of Health guidance and copy the letter without patient consent is arguably contradictory to best practice and also to the concept of patient choice. There are significant financial implications in adopting the departmental guidance. We propose patients should be offered a copy of their clinic letter on request.

Do surgeons wish to become doctors?

OBJECTIVES: To gauge opinion among otolaryngologists about their wish to retain the title Mr, Miss, Ms or Mrs or to adopt the title of doctor. DESIGN: An e-mail questionnaire sent to all members of ENT-UK (The British Association of Otolaryngologists-Head and Neck Surgeons), who had registered an e-mail address with the ENT-UK secretariat. SETTING: The specialty group of otolaryngologists in the UK. PARTICIPANTS: 723 recipients of e-mails, who were members or fellows of a surgical Royal College and, by convention in the UK, entitled to adopt the title Mr, Miss, Ms or Mrs. RESULTS: 304 recipients of the e-mail questionnaire responded. 39% were not aware of any proposals to change the convention, addressing surgeons as 'doctor' in the future. Overall, 61.8% were in favour of retaining the current convention and retaining the title Mr or a female equivalent. Applying the null hypothesis that most surgeons would not like to change a title, the chi(2) test produced a highly significant P value of 0.0002. Of female respondents, however, only 43% supported retention of the current convention. Using Fisher's exact test to compare female and male respondents, the two-sided P value was highly significant at 0.006, with female respondents favouring the title of doctor. CONCLUSIONS: A large proportion of ENT surgeons in the UK responded to the questionnaire. They were unaware of proposals to change the current convention of address for surgeons. A significant number of those responding were in favour of retaining the current convention. The small proportion of female respondents indicated a preference for being addressed as 'doctor'.

Multi-element survey of wild edible fungi and blackberries in the UK.

A survey of 12 metals including lead (Pb), copper (Cu), cadmium (Cd), mercury (Hg), arsenic (As) and platinum (Pt) was carried out using ICP-MS in 34 samples of wild fungi and 48 samples of wild blackberries collected from sites across the UK. On a fresh weight basis (mg/kg) levels of Pb were in the range 0.003-5.990, Cu 0.596-34.800, Cd<0.001-19.6, Hg<0.001-4.150, As 0.001-0.972 and Pt (microg/kg) 0.006-0.200, with higher concentrations found in fungi than in blackberries. The results of the survey showed that the concentrations of the metals were consistent with previous studies, where available. Concentrations in wild fungi of Pt, tin (Sn), and titanium (Ti) were significantly higher at urban sites than at rural sites. Urban blackberries had significantly higher levels of Pb, Ti, and Cd than rural ones, but lower levels of manganese (Mn). Pb, Ti and Sn concentrations were significantly higher in blackberries sampled near main roads rather than in rural areas.

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy.

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.