Cochlear implant eligibility in an adult hearing aid population: a multi-perspective service evaluation of a patient referral pathway at a British district general hospital.

OBJECTIVES: To quantify patient eligibility for cochlear implantation following National Institute for Health and Care Excellence 2019 guidelines (TA566) over five years at our institution, and identify factors influencing patients' decisions surrounding cochlear implantation referral. METHODS: A multi-perspective service evaluation was conducted at a district general hospital, comprising cochlear implantation eligible patients. The main outcome measures were: eligibility numbers for 2014-2019, comparing application of TA566 versus 2009 (TA166) guidelines; and patient interview transcripts and questionnaires. RESULTS: There was a 259 per cent average increase in cochlear implantation eligibility from 2014 to 2019. Most patients' thresholds were 80 dB HL or more at 3 kHz and 4 kHz. There are several cochlear implantation barriers, including patient-centred issues (e.g. health-related anxieties, implantation misperceptions) and external barriers (difficulty getting to regional implant centres). Motivating factors for cochlear implantation include improved quality of life and access to local cochlear implantation services. CONCLUSION: The TA566 guidelines have increased cochlear implantation eligibility, putting pressure on cochlear implantation centres and referring hospitals. Current referral systems have external and patient-centred implantation barriers. British cochlear implantation delivery may need rethinking to meet increasing populational demands and improve accessibility for those most vulnerable to these barriers.

Validation of a new ENT emergencies course for first-on-call doctors.

BACKGROUND: First-on-call ENT cover is often provided by junior doctors with limited ENT experience; yet, they may have to manage life-threatening emergencies. An intensive 1-day simulation course was developed to teach required skills to junior doctors. METHODS: A prospective, single-blinded design was used. Thirty-seven participants rated their confidence before the course, immediately following the course and after a two-month interval. Blinded assessors scored participant performance in two video-recorded simulated scenarios before and after the course. RESULTS: Participant self-rated confidence was increased in the end-of-course survey (score of 27.5 vs 53.0; p < 0.0001), and this was maintained two to four months after the course (score of 50.5; p < 0.0001). Patient assessment and management in video-recorded emergency scenarios was significantly improved following course completion (score of 9.75 vs 18.75; p = 0.0093). CONCLUSION: This course represents an effective method of teaching ENT emergency management to junior doctors. ENT induction programmes benefit from the incorporation of a simulation component.

The time to and determinants of first fractures in boys with Duchenne muscular dystrophy.

Boys with vertebral fractures (VF) identified through routine spine radiographs had milder, less symptomatic, and fewer VF compared to those diagnosed with VF following consultation for back pain. Spontaneous (i.e., medication-unassisted) reshaping of fractured vertebral bodies was absent. Long bone fractures were present even before Duchenne muscular dystrophy (DMD) diagnosis in some boys. INTRODUCTION: The objective of the study was to determine the time to and characteristics of first fractures in Duchenne muscular dystrophy. METHODS: This study was a retrospective longitudinal study of 30 boys with DMD <18 years. Boys were classified into four groups according to their first fracture: those with VF identified on routine lateral spine radiographs, those with VF diagnosed following consultation for back pain, those with long bone fractures, and those without fractures. RESULTS: Compared to boys diagnosed with VF as their initial fracture following consultation for back pain, those with VF surveillance radiographs had shorter durations of glucocorticoid (GC) therapy at the time of VF diagnosis (median 1.6 versus 5.3 years, p < 0.01), higher areal (mean ± standard deviation -1.4 ± 0.7 versus -3.1 ± 0.8, p = 0.01), and volumetric (-0.3 ± 0.5 versus -2.6 ± 0.8, p < 0.01) lumbar spine bone mineral density Z-scores, as well as fewer VF (median 1.4 versus 5.2 per person, p < 0.01) and a lower median spinal deformity index (median 1.5 versus 9.5, p < 0.01). Vertebral body reshaping following VF was not observed. Ten boys sustained a long bone fracture as their first fracture at a mean age of 8.9 ± 4.0 years; four of these boys later sustained a total of 27 incident VF. CONCLUSIONS: Routine lateral spine radiographs led to detection of VF in their earlier stages, vertebral body reshaping following VF was absent, and VF were frequent after the first long bone fracture. These results support the inclusion of a lateral spine radiograph starting at the time of GC initiation as part of routine bone health monitoring in DMD.

A break-even analysis of major ear surgery.

OBJECTIVES: To determine variables which affect cost and profit for major ear surgery and perform a break-even analysis. DESIGN: Retrospective financial analysis. SETTING: UK teaching hospital. PARTICIPANTS: Patients who underwent major ear surgery under general anaesthesia performed by the senior author in main theatre over a 2-year period between dates of 07 September 2010 and 07 September 2012. MAIN OUTCOME MEASURES: Income, cost and profit for each major ear patient spell. Variables that affect major ear surgery profitability. RESULTS: Seventy-six patients met inclusion criteria. Wide variation in earnings, with a median net loss of £-1345.50 was observed. Income was relatively uniform across all patient spells; however, theatre time of major ear surgery at a cost of £953.24 per hour varied between patients and was the main determinant of cost and profit for the patient spell. Bivariate linear regression of earnings on theatre time identified 94% of variation in earnings was due to variation in theatre time (r = -0.969; P < 0.0001) and derived a break-even time for major ear surgery of 110.6 min. Theatre time was dependent on complexity of procedure and number of OPCS4 procedures performed, with a significant increase in theatre time when three or more procedures were performed during major ear surgery (P = 0.015). CONCLUSION: For major ear surgery to either break-even or return a profit, total theatre time should not exceed 110 min and 36 s.

Evidence-based management of otitis media: a 5S model approach.

OBJECTIVE: The 5S model proposes five hierarchical levels (systems, summaries, synopses, syntheses and studies) of pre-appraised evidence to guide evidence-based practice. This review aimed to identify and summarise pre-appraised evidence at the highest available 5S level for the management of different subsets of otitis media: acute otitis media, otitis media with effusion, chronic suppurative otitis media and cholesteatoma in both adults and children. METHOD: Data sources were pre-appraised evidence resources. Evidence freely available from sources at the highest available level of the 5S model were summarised for this review. RESULTS: System level evidence exists for acute otitis media and otitis media with effusion. Summary level evidence exists for recurrent acute otitis media and medical management of chronic suppurative otitis media. There is an absence of randomised controlled trials to prove the efficacy of surgical management of chronic suppurative otitis media and cholesteatoma. CONCLUSION: Until randomised controlled trial data are generated, consensus publications on the surgical management of chronic suppurative otitis media and cholesteatoma should be used to guide best practice.

Intratympanic gentamicin treatment for unilateral Ménière's disease: long-term follow up of a proven regime.

OBJECTIVE: To determine the long-term efficacy of a fixed-dose intratympanic gentamicin treatment regime in controlling unilateral Ménière's disease. METHODS: Pfleiderer (1998) published two-year follow-up results for a series of 16 patients treated with a 4-day, 12-dose intratympanic gentamicin regime for unilateral Ménière's disease that was refractory to medical treatment. In 2010, a long-term telephone follow up (mean 17 years and 3 months) of this same cohort was conducted to determine long-term vertigo control. Of the 16 patients, 13 were eligible for the long-term follow up. RESULTS: At 2 years' follow up, all 16 patients experienced substantial control of vertigo, with complete control achieved in 87 per cent of cases. At the long-term follow up, 9 of the 13 eligible patients were contactable, and all reported complete control of vertigo. CONCLUSION: Fixed-dose intratympanic gentamicin controlled symptomatic unilateral Ménière's disease in both the short and long term.

Caliper measurement to improve clinical assessment of palpable neck lumps.

INTRODUCTION: One-stop neck lump clinics with ultrasonography and cytopathology support are an expensive and finite resource. Consequently, many neck lump patients are assessed in general ear, nose and throat or head and neck clinics. Optimal clinical assessment of neck lump size is important to guide investigation, monitor change and provisionally stage nodal disease. The aims of this study were to investigate whether caliper measurement is more accurate than clinical palpation in assessing neck lump size and whether caliper measurement of neck lump size correlates closely with accurate ultrasonography measurement. METHODS: A prospective study was carried out involving 50 patients with clinically palpable neck lumps presenting to the one-stop neck lump clinic. Long and short axis neck lump dimensions were estimated first by clinical palpation and second by caliper measurement. Estimations were compared with accurate ultrasonography measurement. RESULTS: The mean combined long and short axis measurement deviation from accurate ultrasonography measurement was smaller for caliper measurement (7.80 mm) than for clinical palpation (12.38 mm) (p <0.01). There was no significant difference observed between combined axis ultrasonography and combined axis caliper measurement of neck lumps (p = 0.462). CONCLUSIONS: Caliper measurement is more accurate than clinical palpation in estimating the size of clinically palpable neck lumps. The use of calipers to measure the skin surface dimensions of palpable neck lumps is statistically comparable to accurate ultrasonography measurement.

Myringoplasty: impact of perforation size on closure and audiological improvement.

OBJECTIVES: To investigate the impact of perforation size and other variables on the success of myringoplasty, and also to determine audiological gain following successful closure of tympanic membrane perforations of various sizes. STUDY DESIGN: Retrospective analysis of 130 case notes. MAIN OUTCOME MEASURES: (1) Successful closure of tympanic membrane following myringoplasty, in relation to recorded variables (i.e. perforation size, grade of surgeon, surgical technique, graft material, previous myringoplasty and smoking history). (2) Mean, four-frequency, air conduction audiometric gain following successful myringoplasty for various, pre-operatively categorised tympanic membrane perforation sizes. RESULTS AND CONCLUSION: The collective myringoplasty success rate was 80.8 per cent (105/130); for successful patients, the mean air conduction audiometric gain was -6.8 dB (t = 5.29, p < 0.0001). Neither perforation size nor any other assessed variable was a statistically significant determinant factor for successful myringoplasty. Air conduction audiometric gains following successful myringoplasty were directly correlated with pre-operative perforation size (-4.0 dB for 0-20 per cent perforations, -5.0 dB for 21-40 per cent, -9.1 dB for 41-60 per cent, -10.8 dB for 61-80 per cent and -13.3 dB for 81-100 per cent).

Impact of polymorphisms in WFS1 on prediabetic phenotypes in a population-based sample of middle-aged people with normal and abnormal glucose regulation.

AIM/HYPOTHESIS: Recently, variants in WFS1 have been shown to be associated with type 2 diabetes. We aimed to examine metabolic risk phenotypes of WFS1 variants in glucose-tolerant people and in individuals with abnormal glucose regulation. METHODS: The type 2 diabetes-associated WFS1 variant rs734312 (His611Arg) was studied in the population-based Inter99 cohort involving 4,568 glucose-tolerant individuals and 1,471 individuals with treatment-naive abnormal glucose regulation, and in an additional 3,733 treated type 2 diabetes patients. RESULTS: The WFS1 rs734312 showed a borderline significant association with type 2 diabetes with directions and relative risks consistent with previous reports. In individuals with abnormal glucose regulation, the diabetogenic risk A allele of rs734312 was associated in an allele-dependent manner with a decrease in insulinogenic index (p = 0.025) and decreased 30-min serum insulin levels (p = 0.047) after an oral glucose load. In glucose-tolerant individuals the same allele was associated with increased fasting serum insulin concentration (p = 0.019) and homeostasis model assessment of insulin resistance (HOMA-IR; p = 0.026). To study the complex interaction of WFS1 rs734312 on insulin release and insulin resistance we introduced Hotelling's T (2) test. Assuming bivariate normal distribution, we constructed standard error ellipses of the insulinogenic index and HOMA-IR when stratified according to glucose tolerance status around the means of each WFS1 rs734312 genotype level. The interaction term between individuals with normal glucose tolerance and abnormal glucose regulation on the insulinogenic index and HOMA-IR was significantly associated with the traits (p = 0.0017). CONCLUSIONS/INTERPRETATION: Type 2 diabetes-associated risk alleles of WFS1 are associated with estimates of a decreased pancreatic beta cell function among middle-aged individuals with abnormal glucose regulation.

Improving correspondence to general practitioners regarding patients attending the ENT emergency clinic: a regional general practitioner survey and audit.

INTRODUCTION: The ENT emergency clinic provides an important out-patient service; however, often, no correspondence is sent to the general practitioner. AIM: To conduct a general practitioner questionnaire audit in order to assess whether a standardised, computerised clinic letter template could improve communication between the ENT emergency clinic and patients' general practitioners. STANDARD: All ENT emergency clinic patients should have a summary letter sent to their general practitioner. METHODS: One hundred general practitioner questionnaires were enclosed with the first 100 ENT emergency clinic template letters sent to patients' general practitioners. RESULTS: Seventy-two general practitioners responded (72 per cent). Of these respondents, only 7 per cent had previously received regular correspondence from the ENT emergency clinic before the introduction of the computerised letter template. Following its implementation, such a letter was sent to 100 per cent of the clinic patients' general practitioners. Ninety-seven per cent of the general practitioners valued the template letter, with a mean satisfaction score of 8.4 on a 10-point scale. Eighty-six per cent of the general practitioners stated that they would not prefer a dictated letter. CONCLUSION: The introduction of a simple, computerised clinic letter template improves communication with ENT emergency clinic patients' general practitioners.

How we do it: diagrammatic recording of tympanomastoid procedures.

Accurate documentation of the operative findings of tympanomastoid procedures is essential for effective patient management and to satisfy the growing demands of clinical audit. Due to the three-dimensional complexity of the middle ear, it is difficult to represent graphically. Consequently, most surgeons only describe subjectively their operative, otological findings. We present for the first time a simple middle ear template which provides an objective tool to improve the recording of tympanomastoid procedures.

Did Ludwig's angina kill Ludwig?

Wilhelm Frederick von Ludwig first described in 1836 a potentially fatal, rapidly spreading soft tissue infection of the neck and floor of the mouth. The condition was later named 'Ludwig's angina', a term which persists in medicine to this day. A gold medallist at 19 and professor at 25, Ludwig also served as president of the Württemberg Medical Association and chief physician to the royal family. His outstanding contribution to medicine was rewarded with the title Excellence upon retiring in 1855. Ludwig died at the age of 75, ironically, days after developing an inflammation of the neck. Could it be that Ludwig died of his own condition? This article combines a biography of Wilhelm Frederick von Ludwig with an overview of his eponymous condition and its management.

Optimizing training opportunities for otolaryngology senior house officers: an audit.

Implementation of the European Working Time Directive and the Modernising Medical Careers initiative will mean junior surgeons must be trained in fewer hours over a shorter period. For this reason, junior surgeon training opportunities must be optimized. We undertook a departmental audit to identify where opportunities to train senior house officers (SHOs) in theatre were being lost, so that appropriate timetable changes could be made in order to optimize exposure to suitable surgical cases. During the first audit cycle, the SHOs followed their existing timetable and theatre attendance was monitored prospectively over a two-week period. Only 30 per cent of theatre sessions were attended and case participation was only 27 per cent. Simple timetable changes were made to maximize SHO theatre attendance, and a second prospective two-week audit was undertaken. The new rota yielded 46 per cent theatre attendance and 48 per cent case participation.

Mice conditionally lacking the Wolfram gene in pancreatic islet beta cells exhibit diabetes as a result of enhanced endoplasmic reticulum stress and apoptosis.

AIMS/HYPOTHESIS: Wolfram syndrome is an autosomal recessive disorder characterised by childhood diabetes mellitus, optic atrophy and severe neurodegeneration, resulting in premature death. The aim of this study was to investigate the mechanisms responsible for the phenotype of carbohydrate intolerance and loss of pancreatic beta cells in this disorder. MATERIALS AND METHODS: To study the role of the Wolfram gene (Wfs1) in beta cells, we developed a mouse model with conditional deletion of Wfs1 in beta cells by crossing floxed Wfs1 exon 8 animals with mice expressing Cre recombinase under the control of a rat insulin promoter (RIP2-Cre). Complementary experiments using RNA interference of Wfs1 expression were performed in mouse insulinoma (MIN6) cell lines (WfsKD). RESULTS: Male knockout mice (betaWfs(-/-)) began developing variable and progressive glucose intolerance and concomitant insulin deficiency, compared with littermate controls, by 12 weeks of age. Analysis of islets from betaWfs(-/-) mice revealed a reduction in beta cell mass, enhanced apoptosis, elevation of a marker of endoplasmic reticulum stress (immunoglobulin heavy chain-binding protein [BiP]), and dilated endoplasmic reticulum with decreased secretory granules by electron microscopy. WfsKD cell lines had significantly increased apoptosis and elevated expression of the genes encoding BiP and C/EBP-homologous protein (CHOP), two markers of endoplasmic reticulum stress. CONCLUSIONS/INTERPRETATION: These results indicate that (1) lack of expression of Wfs1 in beta cells was sufficient to result in the diabetes mellitus phenotype; (2) beta cell death occurred by an accelerated process of apoptosis; and (3) lack of Wfs1 was associated with dilated endoplasmic reticulum and increased markers of endoplasmic reticulum stress, which appears to be a significant contributor to the reduction in beta cell survival.

Typology of diatom communities and the influence of hydro-ecoregions: a study on the French hydrosystem scale.

By comparing diatom communities in natural and disturbed sites, indicators for different types and levels of anthropogenic disturbance can be found. As a first step, this study aims to describe the different natural and disturbed community types found throughout the French hydrosystem. 836 diatom samples were analysed with an unsupervised neural network, the self-organising-map, a well accepted method for community ordination. 11 different communities were identified, 5 corresponding to non-impacted or slightly impacted conditions and representing the diatom natural variability of our dataset. These 5 communities corresponded to 5 different hydro-ecoregions, i.e. 5 river types with similar geological context and range in altitude. The 6 other communities were typical of rivers under anthropogenic pressure. The influence of natural conditions within the hydro-ecoregions was overwhelmed by the nature and the intensity of the pollution at the sampling stations. This work was done in the context of the application and enforcement of the Water Framework Directive.