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This study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery.
Methods
A retrospective single-institution cohort study was performed. Patients underwent endoscopic tympanoplasty between May 2013 and April 2019 performed by the senior surgeon or a trainee surgeon under direct supervision from the senior surgeon. Following data collection, statistical analysis compared success rates between early (learning curve) surgical procedures and later (experienced) tympanoplasties.
Results
In total, 157 patients (86 male, 71 female), with a mean age of 41.6 years, were included. The patients were followed up for an average of 43.2 weeks. The overall primary closure rate was 90.0 per cent.
Conclusion
This study demonstrates an early learning curve for endoscopic ear surgery that improves with surgical experience. Adoption of the endoscopic technique did not impair the success rates of tympanoplasty.
Blunt neck trauma can cause serious morbidity and mortality rates of up to 40 per cent, but there is a paucity of literature on the topic.
Method
A retrospective case note review was performed for all blunt neck trauma cases managed at the Queen Elizabeth Hospital Birmingham between 1st January 2011 and 31st December 2017.
Results
Seventeen cases were managed, with no mortality and limited morbidity. Most patients were male (70.6 per cent) and road traffic accidents were the most common cause of injury (41.2 per cent). The median age of patients was 40.6 years (range, 21.5–70.3 years). Multidetector computed tomography angiography of the neck was performed in 9 patients (52.9 per cent) with ‘hot’ reports made by on-duty radiology staff matching consultant reports in all but 1 case. Six patients underwent operative exploration yielding a negative exploration rate of 33.3 per cent. Imaging reports matched operative findings in 3 cases (60 per cent).
Conclusion
Blunt neck trauma is uncommon but usually presents in polytrauma. Imaging has inaccuracies when compared with operative findings, regardless of radiological experience.
Patients with advanced otosclerosis can present with hearing thresholds eligible for cochlear implantation. This study sought to address whether stapes surgery in this patient group provides a clinically significant audiological benefit.
Objectives:
To assess pre- and post-operative hearing outcomes of patients with advanced otosclerosis, and to determine what proportion of these patients required further surgery including cochlear implantation.
Methods:
Between 2002 and 2015, 252 patients underwent primary stapes surgery at our institution. Twenty-eight ears in 25 patients were deemed to have advanced otosclerosis, as defined by pure audiometry thresholds over 80 dB. The patients’ records were analysed to determine audiological improvement following stapes surgery, and assess whether any further surgery was required.
Results:
The audiological outcome for most patients who underwent primary stapes surgery was good. A minority of patients (7 per cent) required revision surgery. Patients who underwent cochlear implantation after stapes surgery (10 per cent) also demonstrated a good audiological outcome.
Conclusion:
Stapes surgery is a suitable treatment option for patients with advanced otosclerosis, and should be considered mandatory, before offering cochlear implantation, for those with a demonstrable conductive component to their hearing loss. A small group of patients get little benefit from surgery and subsequently a cochlear implant should be considered.
To summarise published research investigating maximal temperatures associated with endoscopes used in otology. Possible thermal issues surrounding the use of endoscopes in middle-ear surgery are discussed, and recommendations regarding the safest ways to use endoscopes in endoscopic ear surgery are made.
Methods:
A non-systematic review of the relevant literature was conducted, with descriptive analysis and presentation of the results.
Results:
There are currently no reports of any temperature-related deleterious effects in patients having undergone endoscopic ear surgery. There is debate regarding heat issues in endoscopic ear surgery, with a limited body of work documenting potential negative impacts of middle-ear heat exposure from endoscopes. The diameter of endoscope, type of light source used, distance from endoscope tip and duration of exposure are highlighted potential factors for high temperatures in endoscopic ear surgery.
Conclusion:
There is a trend towards endoscopes being used routinely in ear surgery. Simple practice points are recommended to minimise potential thermal risks.
Maladaptive cognitive biases such as negative attributional style and hopelessness have been implicated in the development and maintenance of depression. According to the hopelessness theory of depression, hopelessness mediates the association between attributional style and depression. The aetiological processes underpinning this influential theory remain unknown. The current study investigated genetic and environmental influences on hopelessness and its concurrent and longitudinal associations with attributional style and depression across adolescence and emerging adulthood. Furthermore, given high co-morbidity between depression and anxiety, the study investigated whether these maladaptive cognitions constitute transdiagnostic cognitive content common to both internalizing symptoms.
Method
A total of 2619 twins/siblings reported attributional style (mean age 15 and 17 years), hopelessness (mean age 17 years), and depression and anxiety symptoms (mean age 17 and 20 years).
Results
Partial correlations revealed that attributional style and hopelessness were uniquely associated with depression but not anxiety symptoms. Hopelessness partially mediated the relationship between attributional style and depression. Hopelessness was moderately heritable (A = 0.37, 95% confidence interval 0.28–0.47), with remaining variance accounted for by non-shared environmental influences. Independent pathway models indicated that a set of common genetic influences largely accounted for the association between attributional style, hopelessness and depression symptoms, both concurrently and across development.
Conclusions
The results provide novel evidence that associations between attributional style, hopelessness and depression symptoms are largely due to shared genetic liability, suggesting developmentally stable biological pathways underpinning the hopelessness theory of depression. Both attributional style and hopelessness constituted unique cognitive content in depression. The results inform molecular genetics research and cognitive treatment approaches.
Litigation in surgery is increasing and liabilities are becoming unsustainable. This study aimed to analyse trends in claims, and identify areas for potential risk reduction, improved patient safety and a reduction in the number, and cost, of future claims.
Methods:
Ten years of retrospective data on claims in otorhinolaryngology (2003–2013) were obtained from the National Health Service Litigation Authority via a Freedom of Information request. Data were re-entered into a spreadsheet and coded for analysis.
Results:
A total of 1031 claims were identified; of these, 604 were successful and 427 were unsuccessful. Successful claims cost a total of £41 000 000 (mean, £68 000). The most common areas for successful claims were: failure or delay in diagnosis (137 cases), intra-operative problems (116 cases), failure or delay in treatment (66 cases), failure to warn – informed consent issue (54 cases), and inappropriate treatment (47 cases).
Conclusion:
Over half of the claims in ENT relate to the five most common areas of liability. Recent policy changes by the National Health Service Litigation Authority, over the level of information divulged, limits our learning from claims.
The Atacama Large Millimeter/submillimeter Array (ALMA) was used to obtain measurements of spatially and spectrally resolved CH3OH emission from comet C/2012 K1 (PanSTARRS) on 28-29 June 2014. Detection of 12-14 emission lines of CH3OH on each day permitted the derivation of spatially-resolved rotational temperature profiles (averaged along the line of sight), for the innermost 5000 km of the coma. On each day, the CH3OH distribution was centrally peaked and approximately consistent with spherically symmetric, uniform outflow. The azimuthally-averaged CH3OH rotational temperature (Trot) as a function of sky-projected nucleocentric distance (ρ), fell by about 40 K between ρ= 0 and 2500 km on 28 June, whereas on 29 June, Trot fell by about 50 K between ρ =0 km and 1500 km. A remarkable (~50 K) rise in Trot at ρ = 1500-2500 km on 29 June was not present on 28 June. The observed variations in CH3OH rotational temperature are interpreted primarily as a result of variations in the coma kinetic temperature due to adiabatic cooling, and heating through Solar irradiation, but collisional and radiative non-LTE excitation processes also play a role.
The loading of bone-anchored hearing system sound processors usually occurs two to three months after surgical implant. This study examined a new bone-anchored hearing system coupling mechanism that permits loading at two weeks post-implantation without compromising osseointegration.
Methods:
Twenty implants were implanted into 15 patients. The interval between operation and time of processor loading was recorded, along with the cause of any delay and any late complications.
Results:
Two patients were fitted with implants at seven and nine weeks. The delay was a result of administrative errors; the patients reported no skin problems. Of the remaining 17 implants, 8 processors were fitted at 2 weeks, 1 at 3 weeks, 4 at 4 weeks, 3 at 7 weeks and 1 at 8 weeks. For those nine implants fitted later than two weeks, the delay was because of incomplete skin healing.
Conclusion:
The Oticon Medical Xpress system allowed processor loading at two weeks post-operatively, providing skin healing was adequate. Early loading occurred in approximately half of the patients. All patients were fitted within the two to three months traditionally allowed. Prolonged skin healing time was the main reason for the delayed fitting of sound processors.
The use of benzodiazepines has been advised against in older people, but prevalence rates remain high.
Aims
To review the evidence for interventions aimed at reducing benzodiazepine use in older people.
Method
We conducted a systematic review, assessment of risk of bias and meta-analyses of randomised controlled trials of benzodiazepine withdrawal and prescribing interventions.
Results
Ten withdrawal and eight prescribing studies met the inclusion criteria. At post-intervention, significantly higher odds of not using benzodiazepines were found with supervised withdrawal with psychotherapy (odds ratio (OR) = 5.06, 95% CI 2.68–9.57, P<0.00001) and withdrawal with prescribing interventions (OR = 1.43, 95% CI 1.02–2.02, P=0.04) in comparison with the control interventions treatment as usual (TAU), education placebo, withdrawal with or without drug placebo, or psychotherapy alone. Significantly higher odds of not using benzodiazepines were also found for multifaceted prescribing interventions (OR = 1.37, 95% CI 1.10–1.72,P = 0.006) in comparison with control interventions (TAU and prescribing placebo).
Conclusions
Supervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.
Quantitative sampling schemes for estimating within-tree populations of attacking Dendroctonus frontalis Zimmerman were investigated. Accuracy and precision of five small sample procedures were affected by the number and location of the sample heights, the number of sample disks per sample height, and the techniques used for calculating infested surface area and average insect density. Best small sample estimates were obtained from samples near the middle of the infested bole. Unbiased, minimum variance combinatorials were derived. High precision estimates were obtained only by sampling the infested bole at frequent intervals.
Within-tree larval and progeny adult populations of Dendroctonus frontalis Zimm. attacking loblolly pine, Pinus taeda L., were investigated in order to define the distribution of larvae within sample units (100 cm2 disks of bark) and to describe the functional relationship of both larvae and progeny adults to the infested portion of the tree bole.
Larvae and progeny adults were sampled over the infested bole of the 50 trees. Two separate measures of progeny adults were obtained. The first measure was taken just prior to emergence from the tree and the second measure was obtained by rearing the insect until emergence from the sample disks was completed.
Larvae were found to be uniformly distributed within the total disk. The functional relationship of the larvae and the two measures of progeny adults to the normalized height on the infested bole was described by the two parameter nonlinear model y = Ax(1−x)eBx.
Highest larval density along the infested portion of the tree bole occurred just below the center and tapered abruptly towards the base and gradually towards the top of the tree. The density of progeny adults on the other hand was greatest just above the center portion of the infested bole and tapered abruptly towards the top and gradually towards the base of the tree. Both measures of progeny adults produced curves of virtually the same shape. However, the density of progeny adults was substantially less in the samples which were reared indicating that mortality agents continued to act on the population until emergence from the tree.
Population data collected from 132 trees during a 3-year period were used to simulate spots of K trees (1≤ k ≤ 50) infested by the attacking adult stage of Dendroctonus frontalis Zimmerman. The total number of beetles on the K trees was then estimated by sampling k trees (1≤ k ≤ 10). The k trees were chosen at random and by selecting those of largest diameter and largest infested area. Within-tree populations were estimated at two levels of precision and within-spot populations were then estimated by scaling the sum of the k within-tree estimates according to the proportion of the tree numbers, tree diameters, or infested phloem areas included in the sample. The various combinations of tree selection, within-tree precision, and scaling produced 10 procedures which were evaluated for bias, precision, and cost as estimators of within-spot populations. Bias was calculated as the mean of the proportional errors in estimating the true numbers, and the standard deviation of the proportional errors was used as a measure of precision.
The procedures in which trees were randomly selected provided unbiased estimates of the within-spot populations. Selecting the largest trees tended to overestimate the true number with the bias diminishing to zero as k → K. However, separate analyses of trees sampled on the same date within actual spots showed no reason to reject the hypothesis of no difference in beetle density (insects/diameter and insects/area) between the largest and smallest trees.
When k = K = 1, the precision of all within-spot estimators was equivalent to the precision of the within-tree estimate. For larger k = K, the precision improved approximately as √(K). No attempt was made to derive functional relationships of precision for k < K. For each procedure, precision improved as k → K. Sampling the k trees at two sample heights (3.5 and 6.5 m, 4–100 cm2 disks/height) was more precise than single level sampling (4 disks at 5 m), but equally precise estimates could be obtained by single level sampling of just one or two additional trees in the spot. Random selection of the k trees with scaling by the number of infested trees was the least precise of the estimating procedures; scaling by diameter and by infested surface area increased the precision. Best precision was obtained by selecting the k trees of greatest infested phloem area, but selecting the largest diameter trees was nearly as precise. The least costly procedure for obtaining a desired level of precision consists of selecting the k trees of largest diameter and extracting 4 disks/tree at 5 m.
The process of resource utilization by Dendroctonus frontalis Zimmerman attacking loblolly pine, Pinus taeda L., was investigated. The quantitative relationship of attacking parent adult D. frontalis as a function of the normalized infested bole height is described by the model y = Ax(1−x)eBx. Greatest attack density occurs at the mid-bole of the tree and tapers toward the top and bottom. Gallery length (and hence eggs)/100 cm2 was independent of attack density. The relationship between gallery length (or eggs) per parent adult and parent adult density is described by the exponential decay curve y = AeBx, indicating that gallery length and egg population density are controlled by a density dependent compensatory feedback process operating instantaneously. Further support for the mechanism was obtained by analyzing the gallery length per parent adult at different locations on the infested bole. The relationship is described by the model y = [AeBx]/[x(1−x)] and indicates that gallery construction and egg population per attacking beetle increase in the upper and basal portion of the bole. The result is a uniform amount of food and space per individual of the developing population.
The within-sample distributions of gallery length (GL) and egg (E) density as well as their functional relationships to the infested bole were studied in an epidemic population of the southern pine beetle in southeast Texas.
A least-squares linear regression analysis through the origin showed an average of 1.59 eggs per centimeter of gallery. GL accounted for 81% of the variation in E and thus is useful for estimating egg numbers. The density of attacking adults is unsatisfactory for predicting E.
GL and E are uniformly distributed within but not among the 100-cm2 sample disks at a given height. The functional relationship of both variables to the infested bole is adequately described by the model y = (A+Bx)exp(Cln(x−x2)), where y = GL or E per 100 cm2, x = the normalized height on the infested bole, and A, B, and C are parameters to be estimated for each set of data.
Within-tree models of Dendroctonus frontalis generation survival from attacking adults to emerging adults and survivorship from eggs to emergence were developed for five regions of the infested tree bole of Pinus taeda L. The generation survival model (GS) describes the number of D. frontalis/attacking adult as a function of time at a specific height. The form of the model is
YGS = 1.0 + C(1–e–20.0X)eA(1.0–X)B + ɛ.
The survival model (S) describes the number of D. frontalis/100 eggs as a function of time at a specific height. The form of this model is
YS = CeA(1.0–X)B + ɛ.
The generation survival model indicated that the rate of survival was primarily a function of generation development time, rather than position on the infested tree bole. The rates also varied in different sections of the tree depending on the initial egg/attacking adult population of D. frontalis. The emergence/attack ratios for the tree sections were slightly greater at the top and bottom than in the middle of the infested bole.
The survivorship curves, based on an initial cohort of 100 eggs, were similar for the various sections of the tree bole. Again, the rate of population change was primarily a function of developmental time, rather than position on the tree. The curves for the various tree sections were essentially the same.
The combined action of the various biotic and abiotic mortality agents acting in the different sections of the tree resulted in essentially uniform survivorship throughout the infested portion of the tree bole.
(1) To assess hypersensitivity to bismuth iodoform paraffin paste impregnated ribbon gauze following its use in packing canal wall down mastoidectomy cavities; (2) to determine if isolation of the skin and mucosa from the pack, using thin Silastic sheeting and Cortisporin ointment, reduces hypersensitivity reactions, compared with a previous series; and (3) to review the literature and to determine if bismuth iodoform paraffin paste hypersensitivity precludes the consumption of seafood (due to its high iodine content).
Materials and methods:
All patients undergoing canal wall down mastoidectomy with intra-operative bismuth iodoform paraffin paste packing between 1985 and 2009 were identified and reviewed.
Results:
Of 587 patients identified, the overall bismuth iodoform paraffin paste reaction rate was 1 per cent. All reactions were in patients undergoing revision mastoidectomy procedures, giving a reaction rate for revision procedures of 2.4 per cent.
Conclusion:
Reactions are an uncommon event following post-operative mastoid cavity packing using bismuth iodoform paraffin paste. Reaction rates may be lowered by preparing the cavity with Silastic sheeting and Cortisporin ointment prior to packing, thus isolating the skin and mucosal surfaces. Development of such a reaction does not preclude the consumption of seafood.
Background: Regular physical activity is generally associated with psychological well-being, although there are relatively few prospective studies in older adults. We investigated habitual physical activity as a risk factor for de novo depressive and anxiety disorders in older men and women from the general population.
Methods: In this nested case-control study, subjects aged 60 years or more were identified from randomly selected cohorts being followed prospectively in the Geelong Osteoporosis Study. Cases were individuals with incident depressive or anxiety disorders, diagnosed using the Structured Clinical Interview for DSM-IV-TR (SCID-I/NP); controls had no history of these disorders. Habitual physical activity, measured using a validated questionnaire, and other exposures were documented at baseline, approximately four years prior to psychiatric interviews. Those with depressive or anxiety disorders that pre-dated baseline were excluded.
Results: Of 547 eligible subjects, 14 developed de novo depressive or anxiety disorders and were classified as cases; 533 controls remained free of disease. Physical activity was protective against the likelihood of depressive and anxiety disorders; OR = 0.55 (95% CI 0.32–0.94), p = 0.03; each standard deviation increase in the transformed physical activity score was associated with an approximate halving in the likelihood of developing depressive or anxiety disorders. Leisure-time physical activity contributed substantially to the overall physical activity score. Age, gender, smoking, alcohol consumption, weight and socioeconomic status did not substantially confound the association.
Conclusion: This study provides evidence consistent with the notion that higher levels of habitual physical activity are protective against the subsequent risk of development of de novo depressive and anxiety disorders.
This paper presents evidence for the involvement of herring gulls (Larus argentatus) as vectors in the recent outbreaks of Salmonella montevideo in sheep and cattle in Scotland and suggests that the transfer can take place over considerable distances. The breeding area in Scotland of herring gulls which overwinter in N.E. England is remarkably similar to the geographical distribution of the outbreaks. This pattern, together with the feeding behaviour of herring gulls on farmland, the presence of S. montevideo in herring gulls just before their departure from the wintering area and the timing of the return just before the peak of outbreaks are all circumstantial evidence implicating this gull in the outbreaks. The rapid return of these gulls to their breeding areas means that S. montevideo can be transported long distances in one day and raises the possibility that the original source of S. montevideo could have been in N. E. England rather than in Scotland.