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This study aimed to assess whether increasing operative experience results in better surgical outcomes in endoscopic middle-ear surgery.
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.
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.
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.
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.
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).
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.
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.
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.
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.
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.
A non-systematic review of the relevant literature was conducted, with descriptive analysis and presentation of the 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.
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.
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).
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.
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.
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.
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).
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.
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.
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.
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.
To review the evidence for interventions aimed at reducing benzodiazepine
use in older people.
We conducted a systematic review, assessment of risk of bias and
meta-analyses of randomised controlled trials of benzodiazepine
withdrawal and prescribing interventions.
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).
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.
(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.
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.
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.
The proportion of salmonella carriers among town-nesting herring gulls increased significantly from 2·1% in 1975–6 to 8·4% in 1979. The range of serotypes carried by herring gulls was similar to that causing infection in man, and it is likely that the gulls ingest these serotypes when feeding at untreated sewage outfalls on the coast. This is supported by the proportion of salmonella carriers being higher among first-year birds (9·7%) than among older birds (2·0%), as it is known that higher proportions of immature herring gulls feed on the coast. Herring gulls carrying salmonellas appeared healthy at the time of capture and at a later date it was assumed that they were not themselves infected. However, their habit of congregating in large numbers on reservoirs and rubbish tips and also at resting sites on farmland often far from feeding and roosting areas, multiplies thejpollution problem and increases the potential health hazard for both man and farm stock. Herring gulls feed at a variety of sites and fly many miles from food source to food source and from feeding areas to the roost. Thus, even within the same day, there is the possibility of the transfer of salmonellas over a much wider area than previously considered.
Between November 1990 and February 1991 101 gull faecal samples, collected in central Scotland, and 50 cloacal lavages, from gulls captured at two refuse tips near Durham, England were examined for the presence of Cryptosporidium sp. oocysts. Five of 101 (c 5%) of faecal samples and 11 of 50 (22%) of cloacal lavages contained oocysts, of which 64% and 83%, respectively were considered viable when examined with propidium iodide and 4′-6-diamidino-2-phenylindole. Since there is insufficient evidence to ascribe these oocysts to a recognized species they are therefore referred to as Cryptosporidium sp. oocysts. There were significant differences in the occurrence of oocysts between gulls captured at the different refuse tips (P < 0.01), but no significant difference between the distribution of oocysts in two species of gull, Larus argentatus (Herring Gull) and L. ridibundus (Black-head Gull). The differences may be explained by different food sources and feeding habits. The contribution of gulls to environmental contamination with Cryptosporidium sp. oocysts is probably generally small, but may be more significant when large numbers roost on surface waters.
In 1990 we reported that milk bottles pecked by jackdaws and magpies were a probable source of human Campylobacter infection. During April to June 1990 an extended study of Campylobacter infections was carried out in the Gateshead area. Prior to the study a health education programme was undertaken in an attempt to reduce human infection. Fifty-nine cases of human infection were recorded and 52 were interviewed. Thirty were entered into a case control study which demonstrated a very strong association between consumption of pecked milk and human Campylobacter infection (X2 = 12·6, P < 0·0004). It was estimated that between 500 and 1000 jackdaws (Corvus monedula) were present in the area where milk bottles were pecked and 63 isolates of Campylobacter were made from the bill and cloaca. Target bottles were put out in the early mornings and Campylobacters were isolated from 12 of 123 pecked bottles. Typing of the Campylobacters revealed a wide distribution of strains amongst birds, pecked milk and human infections. The health education programme had only limited success.
Detailed investigations of strain generation and relaxation in Si films grown on thin Si0.78Ge0.22 virtual substrates using Raman spectroscopy are presented. Good virtual substrate relaxation (>90%) is achieved by incorporating C during the initial growth stage. The robustness of the strained layers to relaxation is studied following high temperature rapid thermal annealing typical of CMOS processing (800-1050 °C). The impact of strained layer thickness on thermal stability is also investigated. Strain in layers below the critical thickness did not relax following any thermal treatments. However for layers above the critical thickness the annealing temperature at which the onset of strain relaxation occurred appeared to decrease with increasing layer thickness. Strain in Si layers grown on thin and thick virtual substrates having identical Ge composition and epilayer thickness has been compared. Relaxation through the introduction of defects has been assessed through preferential defect etching in order to verify the trends observed. Raman signals have been analysed by calibrated deconvolution and curve-fitting of the spectra peaks. Raman spectroscopy has also been used to study epitaxial layer thickness and the impact of Ge out-diffusion during processing. Improved device performance and reduced self-heating effects are demonstrated in thin virtual substrate devices when fabricated using strained layers below the critical thickness. The results suggest that thin virtual substrates offer great promise for enhancing the performance of a wide range of strained Si devices.
New photometry of main-sequence debris discs has been carried out at 850 and 450/μm; the derived SEDs indicate that the dust can lie in either thin rings or radially-extended discs, as seen directly in the few nearby objects which are resolvable. All such objects are consistent with a long wavelength opacity index β of 1.0±0.2 - similar to T Tauri stars, but significantly lower than embedded objects.
Sheep were domesticated in the Near East around 10 000 years ago and spread into Western Europe from there (J. Clutton-Brock 1981). Sheep similar to Soays had reached the Orkneys by 4000 bc and the sheep population of St Kilda may have originated around that date. In many aspects of their anatomy and physiology, they appear to be intermediate between contemporary domestic sheep and wild sheep (Boyd and Jewell 1974; Jewell 1986).
To understand the unusual dynamics of Soay sheep and their consequences for selection and adaptation, it is important to know something of their history as well as of the human inhabitants of St Kilda. The first two sections of this chapter describe the islands of St Kilda (section 2.2) and their history (section 2.3). Subsequent sections describe the appearance and anatomy of Soay sheep (section 2.4), their feeding ecology (section 2.5) and their reproductive system (section 2.6). Since variation in fecundity and neonatal survival affect the growth rate of the population, we describe the factors affecting the early development of lambs (section 2.7) as well as the factors affecting winter survival in juveniles and yearlings (section 2.8). Finally section 2.9 reviews the costs of reproduction and other factors affecting mortality in adults.
The islands of St Kilda
The four main islands of the St Kilda archipelago lie 160 km to the north-west of the Scottish mainland (Fig. 1.1).