Learning needs of junior doctors in otolaryngology: a qualitative study.

OBJECTIVES: There is concern that junior doctors are not prepared for their post-graduate attachments in ENT. The aims of this study were to capture the learning priorities of those in the ENT first on-call role and facilitate further educational opportunities to address these needs. METHOD: Semi-structured interviews were undertaken to explore the learning needs of junior doctors with seven junior and two senior ENT clinicians. RESULTS: The thematic analysis generated three themes: the role of the ENT Junior; the perceived, expressed and prescribed learning needs; and attitudes towards future learning. These themes explored the misalignment between undergraduate training and post-graduate expectations, the lack of competence in ENT practical skills and the need for focused ENT training prior to commencing on-call shifts. CONCLUSION: All interviewees identified the need for greater experience in practical interventional skills prior to their ENT attachments and expressed interest towards a standardised, bootcamp-style induction with simulated emergency experience.

Mental health and life satisfaction among those advised to shield during the COVID-19 pandemic in the UK: a secondary analysis of the Understanding Society longitudinal study.

Introduction: During the COVID-19 pandemic in the UK, those considered most vulnerable to adverse outcomes from infection were designated "clinically extremely vulnerable" and advised to "shield." This involved prolonged confinement at home with strict limits on face-to-face contact, beyond national restrictions. Shielding ended in September 2021 and was considered likely to have harmed mental health and wellbeing. As the UK moved toward a new phase of "living with COVID-19" the mental health and wellbeing experiences of those advised to shield may have diverged from the general population. Methods: This study is a secondary analysis of nine "COVID-19 Survey" waves of Understanding Society, a longitudinal study of UK participants covering April 2020 to September 2021 alongside pre-pandemic baseline data. The prevalence of clinically significant psychological distress (General Health Questionnaire 12) and low life satisfaction were examined at each wave for participants with longitudinal responses across all waves, stratified by receipt of shielding guidance (Received n = 410, Not received n = 6,878). Mixed effects regression modeling examined associations between shielding guidance receipt and mental health and life satisfaction when adjusting for potential confounders including age and sex, pre-pandemic mental health/life satisfaction, and loneliness. Results: Those who received shielding guidance were more likely to experience poor mental health and low life satisfaction during the pandemic. However, this largely reflected differences in pre-pandemic baselines. Variation between waves broadly coincided with the changing burden of COVID-19 and associated restrictions, with similar patterns regardless of shielding guidance receipt. Regression modeling combining data across all waves indicated that receipt of shielding guidance did not independently predict adverse outcomes. However, poor pre-pandemic mental health and low life satisfaction, and frequent loneliness, as well as demographic factors including sex and age, consistently predicted adverse pandemic mental health and wellbeing. Discussion: While those who received shielding guidance did on average experience poorer mental health and life satisfaction during the pandemic, this study suggests this largely reflects existing inequalities. Drawing on data throughout the shielding program, it addresses an existing evidence gap. These findings reinforce the importance of addressing existing mental health inequalities in the recovery from the current pandemic and for future preparedness.

The impact of COVID-19 on head and neck cancer patients: A review of speech valve complications and patient experience during the COVID-19 pandemic in the UK.

PURPOSE: Surgical voice restoration (SVR) is associated with improved patient quality of life following laryngectomy. This study aims to determine the impact of the COVID-19 pandemic on patients with SVR and analyse the complications in this cohort of patients. METHOD: A retrospective review of all patients with SVR at a single tertiary ear, nose, and throat (ENT) unit in the UK for 12 months during the COVID-19 pandemic, with comparison to the preceding 12 months. A survey was also administered to assess patients' experiences during the pandemic. RESULT: Thirty-six patients were included in this study. During the pandemic period, 19.5% (n = 7) patients had significant complications, with five patients needing surgery to restore speech. In the 12 months pre-pandemic, 13.5% (n = 5) had significant complications, although none required surgery to restore speech. Six patients (19.4%) felt these complications were avoidable in normal circumstances. Further, 30.5% (n = 11) of patients reported a delay in seeking medical attention due to concerns about their vulnerability to COVID-19. CONCLUSION: The COVID-19 pandemic has had an impact on many patients with SVR. This has resulted in a large proportion of patients experiencing delayed care, a loss of voice, a need for further surgical intervention, and negative impacts on their quality of life.

Subglottic stenosis masquerading as asthma in a young adult: an overlooked and delayed diagnosis.

An otherwise fit young woman presented with a 10-year history of non-progressive wheeze and 'noisy breathing'. She had previously been diagnosed with teenage-onset asthma but had been unresponsive to inhaled corticosteroids and bronchodilators. A dysfunctional breathing disorder had been considered a possible diagnosis by several general practitioners, and there were no features to suggest systemic conditions. The patient had undergone an otherwise apparently uncomplicated intubation general anaesthetic for a gastroenterological investigation 13 years earlier. An outpatient flexible endoscopic examination of the upper aerodigestive tract demonstrated an isolated subglottic stenosis which was characterised by cross-sectional imaging. Microlaryngoscopy confirmed a smooth subglottic stenosis which was dilated using a minimally invasive balloon dilatation technique to good clinical effect.

A possible home for a bizarre Carboniferous animal: is Typhloesus a pelagic gastropod?

By contrast to many previously enigmatic Palaeozoic fossils, the Carboniferous metazoan Typhloesus has defied phylogenetic placement. Here, we document new features, including possible phosphatized muscle tissues and a hitherto unrecognized feeding apparatus with two sets of ca 20 spinose teeth whose closest similarities appear to lie with the molluscan radula. The ribbon-like structure, located well behind the mouth area and deep into the anterior part of the body, is interpreted as being in an inverted proboscis configuration. Gut contents, mostly conodonts, in the midgut area demonstrate that Typhloesus was an active predator. This animal was capable of propelling itself in the water column using its flexible body and a prominent posterior fin. The affinity of Typhloesus as a pelagic mollusc remains problematic but may lie more closely with the gastropods. Heteropod gastropods share with Typhloesus an active predatory lifestyle and have a comparable general body organization, albeit they possess characteristic aragonitic shells and their origins in the Jurassic post-date Typhloesus. Typhloesus may represent an independent radiation of Mid-Palaeozoic pelagic gastropods.

Sweet Shop Sialagogues: A Sour Solution to Sialolithiasis.

Historically, boiled sweets have been recommended by ear, nose, and throat surgeons for their sialagogue effect in patients with sialolithiasis. This study presents an in vivo analysis of boiled sweets and solutions to determine sialagogue superiority. Six high-street boiled sweets (lemon sherbets, rhubarb sweets, mint humbugs, Werther's Original® (August Storck, Germany), Fox's Glacier Fruits® (Fox's Confectionery, Braunstone, Leicester, United Kingdom), and Chupa Chups® lollipops (Perfetti Van Melle, Breda, Netherlands)) and two solutions (malt vinegar and lemon juice) were compared to two controls (no sweet and inert plastic) in two healthy participants. Malt vinegar and lemon juice produced the highest salivary flow. The best-performing boiled sweets were Chupa Chups lollipops and lemon sherbet. Substances with the highest concentrations of citric or lactic acid were the best sialagogues. This pilot study provides a proof of concept for further investigation in this cohort of patients.

Rationalising requests for preoperative sleep studies and postoperative HDU beds: a quality improvement project in paediatric ENT patients undergoing elective surgery.

BACKGROUND: Sleep disordered breathing represents a spectrum of upper airway obstruction including snoring, increased respiratory effort and obstructive sleep apnoea. An increasing demand for paediatric preoperative sleep studies and postoperative high dependency unit (HDU) beds was having a significant impact on service delivery at this ear, nose and throat (ENT) unit. METHODS: Retrospective and prospective review of all paediatric sleep study requests over a 30-month period in a single tertiary ENT department. Data were collected on indication for and result of sleep study, patient outcome, operative details and HDU bed occupancy. During the study period, a 'Sleep Study' proforma was introduced which incorporated the 'I'm Sleepy Score' (ISS) and ENT-UK national guidelines. RESULTS: Retrospective review included 198 sleep studies, of which 62% (n=118) showed no evidence of obstructive sleep apnoea (OSA). There was little consistency in patients' sleep study results and need for monitoring on HDU following adenotonsillectomy. Prospective review following intervention included 60 patients, of which 62% (n=37) showed evidence of OSA. The mean ISS in this cohort was 4.7. Only those with moderate-to-severe OSA or with relevant risk factors underwent overnight HDU observation. The number of sleep study requests fell by >50%; from 11 per month to 5 per month. The total HDU bed occupancy was reduced by 50% following intervention (from n=18 to n=9). CONCLUSION: The use of the ISS and incorporation of ENTUK's recommendations has reduced the number of negative sleep studies being requested and has rationalised the number of paediatric HDU bed requests being made. This has helped provide a prudent elective paediatric ENT service in this unit with corresponding cost benefits.

Keeping it human: Pandemic era psychiatry teaching.

BACKGROUND: Mental health is an important global issue, and doctors in training need a grounding in the principles of psychiatry. Undergraduate clinical placements in psychiatry can develop core knowledge and skills as well as challenging stigma towards mental illness. The onset of the coronavirus pandemic saw disruption to undergraduate clinical placements. In a U.K. medical school, th e authors were tasked with transforming a 6-week clinical placement in psychiatry into a primarily online course. APPROACH: A 4-week online course was developed in preparation for a condensed clinical placement. A range of resources were drawn upon to address key learning objectives and to engage students in broader thinking about mental health. These included videos and blogs describing personal experiences of mental illness, as well as interviews with prominent psychiatrists. Peer- and tutor-led sessions complemented these self-directed elements and reduced social isolation. EVALUATION: Sixty-seven students undertook the course, supported by eight consultant tutors. The content and structure of the course were highly rated; however, students indicated that peer group activities could benefit from further development. Students felt prepared for clinical placements and performed equally well in summative written examinations. Feedback indicated the development of positive attitudes towards mental health and illness. IMPLICATIONS: This course demonstrates how, even when clinical contact is challenged, a strong focus can be maintained on social elements of learning and patients' experiences of mental illness. This approach provides opportunities to develop essential knowledge and skills alongside broader attitudinal learning that may have a de-stigmatising effect.

Attend anywhere clinic: A virtual outpatient clinic experience in otolaryngology during the COVID-19 pandemic.

INTRODUCTION: Numerous technological advances have been made during the COVID-19 pandemic. There has been a growing body of evidence highlighting the value of virtual consultations as an adjunct to physical appointments. This study presents the virtual clinic experiences of one ENT department in the UK. METHODS: Retrospective review of all virtual consultations undertaken at a single ENT department during the COVID-19 pandemic. RESULTS: A total of 556 virtual consultations took place during the study period across all ENT sub-specialties. Of which 27% of patients were converted to face-to-face follow-up and over 30% were discharged following a virtual consultation. Out of 333 video consultation, 31% were converted to telephone due to patient preference or technological difficulties. CONCLUSION: This study highlights the benefits and lessons learnt from implementing a virtual clinic system in ENT. The authors recommend the introduction of video consultation as a useful adjunct to face-to-face appointments during the COVID-19 pandemic and beyond. LEVEL OF EVIDENCE: 4.

Lessons learnt from the first 200 unselected consecutive cases of laparoscopic exploration of common bile duct stones at a district general hospital.

BACKGROUND: The management of choledocholithiasis evolves with diagnostic imaging and therapeutic technology, facilitating a laparoscopic approach. We review our first 200 cases of laparoscopic exploration of the common bile duct, highlighting challenges and lessons learnt. METHODS: We retrospectively studied the first 200 cases of laparoscopic cholecystectomy with common bile duct exploration between 2006 and 2019. The database contains demographics, clinicopathological characteristics, diagnostic modalities, operative techniques, duration and outcomes. RESULTS: We compared two approaches: transcystic vs. transcholedochal in our 200 cases. Choledocholithiasis was suspected preoperatively in 163 patients. 21 cases found no stones. Of the remainder, 111/179 cases were completed via the transcystic route and the remaining were completed transcholedochally (68/179); 25% of the transcholedochal cases were converted from a transcystic approach. CBD diameter for transcystic route was 8.2 vs. 11.0 mm for transcholedochal. Total clearance rate was 84%. Retained or recurrent stones were noted in 7 patients. Length of stay was 5.8 days, 3.5 days in the transcystic route vs. 9.4 days after transcholedochal clearance. Eight patients required re-operation for bleeding or bile leak. No mortalities were recorded in this cohort, but 2 cases (1%) developed a subsequent CBD stricture. CONCLUSION: Concomitant laparoscopic common bile duct clearance with cholecystectomy is feasible, safe and effective in a district general hospital, despite constraints of time and resources. The transcystic route has a lower complication rate and shorter hospital stay, and hence our preference of this route for all cases. Advancements in stone management technology will allow wider adoption of this technique, benefitting more patients.

Effectiveness of a multi-session combined near-peer and faculty-led surgical skills course on self-perceived ability to perform basic surgical skills.

BACKGROUND: Newly qualified UK doctors report feeling unprepared to perform basic practical procedures. The Royal College of Surgeons of England (RCSEng) responded to this concern by developing a national surgical curriculum, however, a national survey of UK medical schools identified that surgical skills teaching is inconsistent throughout the UK.Peer assisted teaching sessions are delivered by senior students to junior peers and have been demonstrated to be effective in a number of settings. We aimed to develop a peer-led surgical skills course for medical students and assess its efficacy in teaching surgical skills. METHODS: Combined near-peer and faculty-led teaching sessions were delivered to medical students (N = 14). We assessed for confidence in these skills using pre- and post-course Likert scale questionnaires to determine self-perceived benefit. RESULTS: Overall, student confidence in all skills improved by +1.254 (p < 0.0001). Individually, confidence in every skill increased significantly, including continuous suturing, knot tying and excision and closure, which improved by +1.45 (p < 0.001), +1.22 (p < 0.05) and +1.59 (p < 0.0001), respectively. DISCUSSION: This study demonstrates that teaching provided through near-peer faculty improves medical student confidence in basic surgical skills. A similar course design could be implemented in other UK medical schools to improve the surgical skills of newly graduated doctors.

Lateral nasal wall abscess following manipulation of fractured nasal bones.

Nasal fracture accounts for over 50% of facial fractures and is a frequent presentation to ear, nose and throat emergency clinics. Optimal management of nasal injuries with deformity is by manipulation under anaesthetic and should be offered when appropriate. A healthy 27-year-old woman presented with a lateral nasal wall mass with purulent discharge 1 month following manipulation. CT imaging revealed a mass arising from fragments of the nasal bone, consistent with an abscess. Bone fragments and purulent material were initially debrided, with a subsequent formal excision of a persistent granuloma performed with an excellent cosmetic outcome. This appears to be the first description of a granuloma resulting from a closed reduction-manipulation of a nasal fracture.

Sclerite-bearing annelids from the lower Cambrian of South China.

Cambrian annelids are strikingly diverse and reveal important details of annelid character acquisition. Their contribution, however, to a wider understanding of the evolution of the trochozoans (encompassing the annelids as well as such groups as the brachiopods and molluscs) remains limited. Thus the early annelids had been linked to a variety of cataphract Cambrian metazoans, notably Wiwaxia and the halkieriids, but recent work assigns such fossils to stem-group molluscs. Here we report two new annelids from the Lower Cambrian Chengjiang Lagerstätte, South China. Ipoliknus avitus n. gen., n. sp. is biramous with neurochaetae and notochaetae, but significantly also bears dorsal spinose sclerites and dorso-lateral dentate sclerites. Adelochaeta sinensis n. gen., n. sp. is unique amongst Cambrian polychaetes in possessing the rod-like supports of the parapodia known as aciculae. This supports phylogenetic placement of Adelochaeta as sister to some more derived aciculate Palaeozoic taxa, but in contrast Ipoliknus is recovered as the most basal of the stem-group annelids. Sclerites and chaetae of I. avitus are interpreted respectively as the remnants and derivatives of a once more extensive cataphract covering that was a characteristic of more primitive trochozoans. The two sets of chaetae (noto- and neurochaetae) and two sets of sclerites (spinose and dentate) suggest that in a pre-annelid an earlier and more complete scleritome may have consisted of four zones of sclerites. Other cataphract taxa from the Lower Palaeozoic show a variety of scleritome configurations but establishing direct links with such basal annelids as Ipoliknus at present must remain conjectural.

The story of life: critical insights from evolutionary biology.

The notion that humans, in all their complexity, are merely an evolutionary accident, an insignificant speck in a boundless cosmos, is deeply unsatisfying for most nonscientists and fails to resonate with their life experience. What, then, can evolutionary biology ultimately tell us about the meaning of our lives? In conversation with Steve Paulson, executive producer and host of To the Best of Our Knowledge, paleoanthropologists Melanie Lee Chang and Ian Tattersall, and paleontologist Simon Conway Morris share their insights on these competing concepts and explain how meaning and purpose can be gleaned from the remarkable story of life itself.

Middle Ear Pressures in Wind Instrument Musicians.

OBJECTIVES: This study aimed to assess if playing wind instruments leads to a measurable increase in middle ear pressure during note generation and to provide evidence to clinicians to advise musicians undergoing middle ear surgery. STUDY DESIGN: An observational cohort study of 40 volunteers in 7 different wind instrument categories underwent tympanometry at rest and during note production. SETTING: Community. PATIENTS: Recreational musicians aged over 18 years recruited from the student body attending Birmingham University, UK. INTERVENTION: None. MAIN OUTCOME MEASURES: Tympanometry is used as a noninvasive measure of middle ear pressure. The pressure at which peak compliance occurred was taken as an indirect measure of middle ear pressure. The data produced at rest and during note production was statistically analysed with paired t testing and significance set at a p value less than 0.01. RESULTS: Overall a statistically significant increase in middle ear pressure change of 0.63 mm Hg (p = 0.0001) during note production was identified. Musicians playing the oboe and trumpet demonstrate the largest increase in middle ear pressure of 1.46 mm Hg (p = 0.0053) and 0.78 mm Hg (p = 0.0005) respectively. CONCLUSION: The data provided by this study gives evidence for the first time that playing wind instruments does increase middle ear pressure. Although the clinical significance of this is yet to be determined the authors would advise that musicians who undergo otological procedures should refrain from playing their instruments until full recovery has been achieved as advised by their clinician following direct microscopic review.

Head and Neck Anatomy: Effect of Focussed Near-Peer Teaching on Anatomical Confidence in Undergraduate Medical Students.

OBJECTIVES: To assess the effect of near-peer head and neck anatomy teaching on undergraduates and to quantify the benefit from a focussed teaching course. Near-peer teaching involves colleagues within close seniority and age proximity teaching one another on a specified topic. DESIGN: Small group teaching sessions were delivered to medical students on 3 key areas of ENT anatomy. Participants were given a precourse and postcourse questionnaire to determine the benefit attained from the course. SETTING: An undergraduate anatomy course taking place at the University of Birmingham Medical School. PARTICIPANTS: A total of 30 medical students: 15 preclinical (years 1-2) and 15 clinical (years 3-5) medical students participated from a single institution. RESULTS: A total of 71% of students expressed inadequate teaching of head and neck anatomy in undergraduate curriculum. All students (n = 30) expressed benefit from the course, however the patterns of learning differed: preclinical students showed a significant improvement in both their ability to name anatomical structures and their application (p < 0.05). CONCLUSIONS: Near-peer learning provides benefit to all medical undergraduates in the context of teaching anatomy which may make it a valuable teaching tool for the future of medical education.

Medical Students Teaching Medical Students Surgical Skills: The Benefits of Peer-Assisted Learning.

OBJECTIVE: Teaching surgical skills is a labor intensive process, requiring a high tutor to student ratio for optimal success, and teaching for undergraduate students by consultant surgeons is not always feasible. A surgical skills course was developed, with the aim of assessing the effectiveness of undergraduate surgical peer-assisted learning. DESIGN: Five surgical skills courses were conducted looking at eight domains in surgery, led by foundation year doctors and senior medical students, with a tutor to student ratio of 1:4. Precourse and postcourse questionnaires (Likert scales 0-10) were completed. Mean scores were compared precourse and postcourse. SETTING: Surgical skills courses took place within clinical skills rooms in the Queen Elizabeth Hospital Birmingham (UK). PARTICIPANTS: Seventy students (59 medical, 2 dental, and 9 physician associate students) from a range of academic institutions across the UK completed the course. RESULTS: There was an overall increase in mean scores across all eight domains. Mean improvement score precourse and postcourse in WHO surgical safety checklist (+3.94), scrubbing (+2.99), gowning/gloving (+3.34), knot tying (+5.53), interrupted sutures (+5.89), continuous sutures (+6.53), vertical mattress sutures (+6.46), and local anesthesia (+3.73). CONCLUSIONS: Peer-assisted learning is an effective and feasible method for teaching surgical skills in a controlled environment, subsequently improving confidence among healthcare undergraduates. Such teaching may provide the basis for feasibly mass-producing surgical skills courses for healthcare students.

Nutrient-dependent growth underpinned the Ediacaran transition to large body size.

Macroscale rangeomorph fossils, with characteristic branching fronds, appear (571 Myr ago) after the Gaskiers glaciation (580 Myr ago). However, biological mechanisms of size growth and potential connections to ocean geochemistry were untested. Using micro-computerized tomography and photographic measurements, alongside mathematical and computer models, we demonstrate that growth of rangeomorph branch internodes declined as their relative surface area decreased. This suggests that frond size and shape were directly responsive to nutrient uptake.

Meiofaunal deuterostomes from the basal Cambrian of Shaanxi (China).

Deuterostomes include the group we belong to (vertebrates) as well as an array of disparate forms that include echinoderms, hemichordates and more problematic groups such as vetulicolians and vetulocystids. The Cambrian fossil record is well-populated with representative examples, but possible intermediates are controversial and the nature of the original deuterostome remains idealized. Here we report millimetric fossils, Saccorhytus coronarius nov. gen., nov. sp., from an Orsten-like Lagerstätte from the earliest Cambrian period of South China, which stratigraphically are amongst the earliest of deuterostomes. The bag-like body bears a prominent mouth and associated folds, and behind them up to four conical openings on either side of the body as well as possible sensory structures. An anus may have been absent, and correspondingly the lateral openings probably served to expel water and waste material. This new form has similarities to both the vetulicolians and vetulocystids and collectively these findings suggest that a key step in deuterostome evolution was the development of lateral openings that subsequently were co-opted as pharyngeal gills. Depending on its exact phylogenetic position, the meiofaunal habit of Saccorhytus may help to explain the major gap between divergence times seen in the fossil record and estimates based on molecular clocks.