The oral health of adults with learning disabilities: A secondary analysis of the Adult Dental Health Survey 2009

OBJECTIVES

Adults who have learning disabilities are a vulnerable group, little is known about their oral health and how this affects their quality of life. The aims of this secondary analysis of data from the 2009 Adult Dental Health Survey (ADHS) were to describe the oral health status of adults with learning disabilities, determine if severity of learning disability is associated with oral health and identify some of the methodological complexities of working with this population. The survey yields the most recent representative data on the oral health of adults with learning disabilities in England and importantly, contains information about oral health related quality of life (OHRQoL).

BASIC RESEARCH DESIGN

Secondary analysis of data from a supplemental survey of adults with learning disabilities collected alongside the 2009 ADHS.

PARTICIPANTS

607 participants with a diagnosed learning disability aged 18 years and over.

RESULTS

Adults with learning disabilities had similar levels of active dental caries, fewer natural teeth, and fewer fillings than comparable participants from the general population. Self-reported oral and general health were worse for adults with learning disabilities than the general population. Possible associations between the severity of learning disability and the numbers of decayed, missing or filled teeth were identified. However, large amounts of missing data limited the analysis.

CONCLUSIONS

There are important questions relating to the accessibility of existing self-reported oral health questionnaires and the reliability of proxy-reported questions about OHRQoL that should be addressed to give a fuller picture of the oral health of adults with learning disabilities.

The characteristics and predictors of mortality in periprosthetic fractures around the knee

Aims

Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality.

Methods

Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality.

Results

Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation.

Conclusion

The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

Dynamic mechanisms of exercise to improve body satisfaction: Perceived or actual fat loss?

We examined the dynamic mechanisms of aerobic training (AT) and strength training (ST) to improve body satisfaction. Sixty-six participants were randomised to either the AT or ST condition and completed an 8-week intervention. Participants completed 3 weekly, 30-minute sessions of moderate intensity AT (65-75% VO2 max) or ST (65-75% 1-RM). The energy consumption of each session was approximately equivalent under both conditions. Body satisfaction, body composition, perceived fitness and exercise self-efficacy were measured at baseline and biweekly during the intervention. Exercise improved individuals' body satisfaction (p < .05). When the energy expenditures of AT and ST were equal, there was no difference in body satisfaction improvement. There were dynamic mechanisms underlying the effects of exercise on body satisfaction. Specifically, perceived fitness influenced body satisfaction improvements during the early stages of the exercise program, while changes in body composition influenced body satisfaction toward the end of the exercise program. There were sex differences in the mechanisms underlying body satisfaction. For women, perceived fat was more important in the early intervention period; for men, actual body fat was more valuable in the late intervention period. An effective strategy to improve body satisfaction is to initially target perceived fitness before focusing on changing body composition.

Paradigm shift towards emergency cholecystectomy: one site experience of the Chole-QuiC process

INTRODUCTION

Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

METHODS

This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes.

RESULTS

Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p=0.042) and for operation times within 7 days (OR 0.32; p=0.037), with worse outcomes in BMI ≥35 (OR 3.32; p=0.005) and operation time >7 days (OR 3.11; p=0.037).

CONCLUSION

A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study

INTRODUCTION

Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip.

METHODS

Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality.

RESULTS

A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality.

CONCLUSION

The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

EGS P05 Surgical Same Day Emergency Care at a District General Hospital - Our Experience

Background

Surgical Same day emergency care (SDEC) is a new service started at a medium sized district general hospital (DGH) since November 2021. The surgical SDEC service is divided into Theatre (ambulatory theatres) and non-theatre (Hot Clinic) pathways aiming at improving patient experience, and reducing length of stay (LOS), by introducing a pathway through which patients are assessed, diagnosed, and initiated treatment and discharge on the same day for common emergency surgical conditions of gallstone disease, appendectomy, painful hernia, and abscesses. The service delivery planned with the existing facilities leading to structured fewer admissions, increased diagnostics, coordinating the patient flow with preop assessments, day case theatre utilisation and post-operative criteria led discharge. The Surgical SDEC is now established, and we continue to audit to benchmark success, recommend improvement and for quality assurance.

Methods

It's a prospective data collection of patients admitted under general surgery with the above common surgical emergency presentations over 6 months period since the start of the service in November 2021. The inclusion criteria were stable patients of ASA grade 1 and 2, BMI less than 40 kg/m2, and with social support. The unstable patients, ASA 3 or more and without social support were excluded. The postoperative follow up was arranged with virtual ward, clinics and in the event a post-surgery hot clinic review.

Results

From 15th November 2021 to 27th May 2022, 192 surgical operations were carried out. 130 Laparoscopic cholecystectomies, 22 hernia repairs, 13 diagnostic laparoscopies, and 27 abscesses incision and drainage. There were 77 male patients and 115 female patients with age ranging from 20 to 88 years old. About 70% of the patients were successfully discharged on the same day with a readmission rate of 3.6%. The cholecystectomy patients had a mean waiting time of 3.2 days and almost all cases were done within a week of admission. All the other cases including appendectomy were performed either the same day or the following day.

Conclusions

Surgical Same Day Emergency Care service proved to be a step forward for improving patient care. It allows the same day diagnostics and treatment, and reduces the length of stay, prevents readmissions, improves the quality of care, and helps recovery following the impacts of the pandemic. Finally, it has a significant financial benefit by decreasing readmissions, and it also utilisation of hospital beds more desired cases.

Molecular transistors as substitutes for quantum information applications

Applications of quantum information science (QIS) generally rely on the generation and manipulation of qubits. Still, there are ways to envision a device with a continuous readout, but without the entangled states. This concise perspective includes a discussion on an alternative to the qubit, namely the solid-state version of the Mach-Zehnder interferometer, in which the local moments and spin polarization replace light polarization. In this context, we provide some insights into the mathematics that dictates the fundamental working principles of quantum information processes that involve molecular systems with large magnetic anisotropy. Transistors based on such systems lead to the possibility of fabricating logic gates that do not require entangled states. Furthermore, some novel approaches, worthy of some consideration, exist to address the issues pertaining to the scalability of quantum devices, but face the challenge of finding the suitable materials for desired functionality that resemble what is sought from QIS devices.

64 The Impact of Inadequate Pain Control Following Chest Trauma on The Incidence of Hospital Acquired Pneumonia and Hospital Admission Length

Introduction

The National Audit Office (2010) report estimated there was 20,000 cases of major trauma per year in England; of which 5,400 died and many others sustaining permanent disability. Blunt chest wall injuries are associated with high levels of morbidity and mortality, and we aimed to investigate the impact of poor pain control in patient outcomes.

Method

Compliance with trust guidelines was assessed via a retrospective audit of all chest trauma patients between October 2019-20.

Results

28 chest trauma patients identified (M:F 15:13) with ages ranging from 47-94 yrs old (average age 73). Chest trauma was associated with high levels of morbidity (32%) and mortality (7%). 39% patients were found to have inadequate pain control. Only 17% patients eligible for regional anaesthetic blocks were performed within 24hrs. 33% patients developed hospital acquired pneumonias (HAP), of which 44% had received inadequate pain control. Average admission length of patients with a HAP was 15 days compared to 5 days without. 85% patients experienced either delayed or no assessment by specialist teams (i.e., physiotherapy, pain team).

Conclusions

Chest trauma patients often receive inadequate pain control and delayed specialist team input resulting in increased frequency of HAPs, admission length and morbidity/mortality.

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

1678 Impact of anemia in exercise stress echocardiography: effects on exercise capacity and stress testing safety

Funding Acknowledgements

None

Background/Purpose:

Anemia is a common condition in patients with cardiovascular disease. The effect of anemia in exercise stress testing has not been evaluated in a large cohort of patients.

Methods

We performed a retrospective review of patients undergoing exercise stress echocardiography over a 10 year period who had blood hemoglobin assessed within 48 hours of stress testing. World Health Organization cutoffs were used in defining the degree of anemia. The effect of anemia on exercise capacity and stress testing safety outcomes was assessed.

Results

In 15,652 patients, 90.3% were non-anemic, 7.6% mildly anemic, 2.1% moderately anemic, and 0.1% severely anemic. The incidence of serious supraventricular or ventricular arrhythmias and need to transfer to the hospital was low (0.1%) and did not correlate to anemia severity (p = 0.25). There was an increased incidence of non-sustained SVT or atrial fibrillation with moderate anemia and increased incidence of hypotension with stress testing with mild and moderate anemia. There was a significant reduction in duration of exercise (p &lt; 0.001) and METS (p &lt; 0.001) achieved with worsening anemia.

Conclusion

Our study demonstrates that exercise stress testing is safe in patients with mild and moderate anemia, albeit with reduced exercise capacity. Low numbers of severely anemic patients despite a large study population limit generalizability of these results in this group.

Exercise Capacity Severe Anemia (N = 9) Moderate Anemia (N = 332) Mild Anemia (N = 1183) Non-anemic (N = 14128) P value Resting heart rate 81 ± 13 # 79 ± 14 # 72 ± 14 74 ± 13 &lt;0.001* Peak heart rate 148 ± 22 139 ± 24 # 138 ± 23 # 147 ±22 &lt;0.001* Exercise duration 5.3 ± 2.5 # 6.3 ± 2.1 # 7.2 ± 2.5 # 8.6 ± 2.7 &lt;0.001* METS 6.3 ± 2.5 # 7.1 ± 2.2 # 8.0 ± 2.5 # 9.5 ± 2.7 &lt;0.001* Safety Hypotension with stress 0 (0%) 31 (9.4%) # 94 (8.0%) # 437 (3.1%) &lt;0.001* Mild supraventricular arrhythmia 1 (11.1%) 15 (4.5%) # 20 (1.7%) # 237 (2.3%) 0.04* Severe supraventricular arrhythmia 0 (0%) 0 (0%) 0 (0%) 7 (0.1%) 0.99 Mild ventricular arrhythmia 0 (0%) 20 (6.0%) 74 (6.3%) 756 (5.4%) 0.94 Moderate ventricular arrhythmia 0 (0%) 3 (0.9%) 13 (1.1%) 182 (1.3%) 0.78 Severe ventricular arrhythmia 0 (0%) 1 (0.3%) 2 (0.2%) 1 (0.0%) 0.02 Transfer to hospital 0 (0%) 2 (0.6%) 1 (0.1%) 9 (0.1%) 0.29 Any severe arrhythmia or hospitalization 0 (0%) 2 (0.6%) 3 (0.3%) 17 (0.1%) 0.25 # Multi-comparison adjusted P-value &lt;0.05 compared to non-anemic when group P &lt; 0.05

A review of training in neuropsychiatry

The boundary between neurology and psychiatry has never been sharply defined. It remains the case that a number of conditions (e.g. epilepsy, head-injury sequelae, dementia, and conversion hysteria) are seen by both neurologists and psychiatrists (Reynolds & Trimble, 1989). Few neurologists would dispute that there may be a marked psychiatric element to the presentation of multiple sclerosis, and it has long been noticed that even unmedicated chronic schizophrenic patients sometimes exhibit abnormalities of movement and so-called “soft” neurological signs such as dysgraphia and clumsiness (Lishman, 1988). These and other conditions may all on occasion present to the neuropsychiatrist.

The quality and diagnostic value of open narratives in verbal autopsy: a mixed-methods analysis of partnered interviews from Malawi

BACKGROUND

Verbal autopsy (VA), the process of interviewing a deceased's family or caregiver about signs and symptoms leading up to death, employs tools that ask a series of closed questions and can include an open narrative where respondents give an unprompted account of events preceding death. The extent to which an individual interviewer, who generally does not interpret the data, affects the quality of this data, and therefore the assigned cause of death, is poorly documented. We aimed to examine inter-interviewer reliability of open narrative and closed question data gathered during VA interviews.

METHODS

During the introduction of VA data collection, as part of a larger study in Mchinji district, Malawi, we conducted partner interviews whereby two interviewers independently recorded open narrative and closed questions during the same interview. Closed questions were collected using a smartphone application (mobile-InterVA) and open narratives using pen and paper. We used mixed methods of analysis to evaluate the differences between recorded responses to open narratives and closed questions, causes of death assigned, and additional information gathered by open narrative.

RESULTS

Eighteen partner interviews were conducted, with complete data for 11 pairs. Comparing closed questions between interviewers, the median number of differences was 1 (IQR: 0.5-3.5) of an average 65 answered; mean inter-interviewer concordance was 92% (IQR: 92-99%). Discrepancies in open narratives were summarized in five categories: demographics, history and care-seeking, diagnoses and symptoms, treatment and cultural. Most discrepancies were seen in the reporting of diagnoses and symptoms (e.g., malaria diagnosis); only one pair demonstrated no clear differences. The average number of clinical symptoms reported was 9 in open narratives and 20 in the closed questions. Open narratives contained additional information on health seeking and social issues surrounding deaths, which closed questions did not gather.

CONCLUSIONS

The information gleaned during open narratives was subject to inter-interviewer variability and contained a limited number of symptom indicators, suggesting that their use for assigning cause of death is questionable. However, they contained rich information on care-seeking, healthcare provision and social factors in the lead-up to death, which may be a valuable source of information for promoting accountable health services.

Are we seeing the effects of public awareness campaigns? A 10-year analysis of Breslow thickness at presentation of malignant melanoma in the South West of England

INTRODUCTION

The last 20 years has seen a marked improvement in skin cancer awareness campaigns. We sought to establish whether this has affected the presenting Breslow thickness of malignant melanoma in the South West.

METHOD

This is a retrospective study looking at the first presentation of melanomas from 2003 to 2011. Data was accessed using the local online melanoma database.

RESULTS

A total of 2001 new melanomas presented from 2003 to 2012 (Male:Female = 1:1.062). The average yearly number of melanomas was 200.1 (range = 138-312). The mean age was 62.5 years (range 12-99). Data was analysed using a Chi² test. For 0-1 mm melanomas, there is a significant difference in the observed versus expected values over the 10 years (p = 0.0018). There is an increasing proportion of 0-1 mm (thin) melanomas presenting year on year, with a positive linear trend. This is very statistically significant (p < 0.0001). The 1-2 mm melanomas are decreasing in proportion with a negative linear trend (p = 0.0013). The 2-4 mm are also decreasing in proportion (p = 0.0253). There is no significant change in the thick >4 mm melanomas (p = 0.1456).

CONCLUSION

The proportion of thin 0-1 mm melanomas presenting in South West England has significantly increased from 2003 to 2012. There is no significant change in the thick >4 mm melanomas. This may be a result of increased public awareness due to effective public health campaigns which has significant prognostic and financial implications.

Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study

BACKGROUND

Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death in people with chronic refractory epilepsy. Very rarely, SUDEP occurs in epilepsy monitoring units, providing highly informative data for its still elusive pathophysiology. The MORTEMUS study expanded these data through comprehensive evaluation of cardiorespiratory arrests encountered in epilepsy monitoring units worldwide.

METHODS

Between Jan 1, 2008, and Dec 29, 2009, we did a systematic retrospective survey of epilepsy monitoring units located in Europe, Israel, Australia, and New Zealand, to retrieve data for all cardiorespiratory arrests recorded in these units and estimate their incidence. Epilepsy monitoring units from other regions were invited to report similar cases to further explore the mechanisms. An expert panel reviewed data, including video electroencephalogram (VEEG) and electrocardiogram material at the time of cardiorespiratory arrests whenever available.

FINDINGS

147 (92%) of 160 units responded to the survey. 29 cardiorespiratory arrests, including 16 SUDEP (14 at night), nine near SUDEP, and four deaths from other causes, were reported. Cardiorespiratory data, available for ten cases of SUDEP, showed a consistent and previously unrecognised pattern whereby rapid breathing (18-50 breaths per min) developed after secondary generalised tonic-clonic seizure, followed within 3 min by transient or terminal cardiorespiratory dysfunction. Where transient, this dysfunction later recurred with terminal apnoea occurring within 11 min of the end of the seizure, followed by cardiac arrest. SUDEP incidence in adult epilepsy monitoring units was 5·1 (95% CI 2·6-9·2) per 1000 patient-years, with a risk of 1·2 (0·6-2·1) per 10,000 VEEG monitorings, probably aggravated by suboptimum supervision and possibly by antiepileptic drug withdrawal.

INTERPRETATION

SUDEP in epilepsy monitoring units primarily follows an early postictal, centrally mediated, severe alteration of respiratory and cardiac function induced by generalised tonic-clonic seizure, leading to immediate death or a short period of partly restored cardiorespiratory function followed by terminal apnoea then cardiac arrest. Improved supervision is warranted in epilepsy monitoring units, in particular during night time.

FUNDING

Commission of European Affairs of the International League Against Epilepsy.

United Kingdom Myeloma Forum (UKMF) position statement on the use of bendamustine in myeloma

Bendamustine is a unique bifunctional alkylating agent with promising activity in myeloma. Despite the increasing number of studies demonstrating its efficacy in both the upfront and relapse settings, including patients with renal insufficiency, the optimal use of bendamustine, in terms of dosage, schedule and combination with other agents, has yet to be defined. It is currently licensed for use as frontline treatment with prednisolone for patients with myeloma who are unsuitable for transplantation and who are contraindicated for thalidomide and bortezomib. Studies in relapsed/refractory patients are currently ongoing with other combinations. Given the increasing data to date, the UK Myeloma Forum believes that bendamustine with steroids alone or in combination with a novel agent could be considered for patients with multiply relapsed myeloma. This document provides guidance for the use of bendamustine for patients with myeloma until the results of definitive studies are available.

Retrospective Study of Esophageal Food Bolus Impaction

Objective: Establish the recurrence rate of food bolus impaction (FBI) and identify demographic/pathological features associated with food bolus obstruction recurrence.

Method: Retrospective case note review of patients (greater than or equal to 16 years) admitted to the hospital with FBI between 2002 and 2007. Patient demographics, co-morbidities, interventions, radiological investigations, and results were recorded. Statistical analysis was performed using SPSS 13.

Results: A total of 99 patients fulfilled the inclusion criteria (65 males and 34 females; median ages 59 and 71.5 years), IQR 47-74, and 53-81 years respectively). A total of 22 patients died between first presentation with FBI and the time of this study being conducted (mean follow up 34 months ±17). A total of two patients had recurrences but died before this study. For all other patients without recurrences the mean follow-up was 68 months ±20. Logistic regression demonstrated that only hiatus hernia demonstrated a statistical significance in its association with FBI recurrence (OR 4.77 95% CI 1.15-19.82, P = .032). All other variables were not statistically significant.

Conclusion: The recurrence rate of food bolus impaction of the esophagus was 9%. Hiatus hernia was the only esophageal pathology associated with recurrence of food bolus impaction.

Does Academic Output Affect Mortality Rates in NHS Trusts?

Objective: It has been claimed that institutions engaging in academic activities provide better care. The aim of this study was to establish whether there is an association between academic output and mortality rates for NHS Trusts (NT).

Method: Standardized mortality rates for 2010 were obtained from www.drfosterhealth.co.uk . MEDLINE was queried to establish the number of citations credited to NT from 2006 to 2010. Admissions for NT for 2009-2010 were obtained from www.hesonline.nhs.uk . The number of citations per admission was calculated and used as an indicator of academic output.

Results: Spearman rank analysis was performed to identify any correlation between citations per admission and the inverse of 4 types of mortality rates: high risk conditions r = 0.20 ( P = .01); low risk conditions r = -0.06 ( P = .46); deaths after surgery r = 0.193 ( P = .019); overall mortality 0.291 ( P < .01).

Conclusion: The results of this preliminary study demonstrate a statistically significant correlation between academic output and mortality rates. However, it should be noted that the correlation coefficients are small, but the findings of this study encourage further debate.

Interobserver Reliability of the “Clockface” Method of Describing the Site and Size of Tympanic Membrane Perforations

Objective: Analyze the interobserver reliability of a “clockface” method for describing the site and size of tympanic membrane perforations.

Method: Six junior doctors (ENT experience 0-3 months) and 6 ENT surgeons (ENT experience 4-26 years) were asked to estimate the position, percentage size, and “clockface” position of perforations in 30 images of tympanic membrane perforations. Four juniors repeated the exercise 2 weeks later to investigate test-retest reliability.

Results: Results were analyzed using intraclass correlation coefficients (95% confidence interval in brackets). With junior raters, perforation size percentage estimate gave 0.85 (0.77-0.92), clockhand method site of perforation (CM1) gave 0.91 (0.87-0.94), and clockhand method size of perforation (CM2) gave 0.82 (0.73-0.90). With ENT surgeons, perforation size percentage estimate gave 0.85 (0.77-0.92), CM1 gave 0.96 (0.94-0.99), and CM2 gave 0.88 (0.78-0.94). With all raters, perforation size percentage estimate gave 0.86 (0.78-0.92), CM1 gave 0.93 (0.90-0.95), and CM2 gave 0.84 (0.76-0.91). In test-retest reliability, using Pearson correlation coefficients, perforation size percentage estimate gave 0.94 ( P < .001), CM1 gave 0.91( P < .001), and CM2 gave 0.92( P < .001).

Conclusion: The clockface method allows quick, detailed, and reliable recording of site and size of perforation at the time of clinical assessment. This may also become a valuable research and audit tool.

Negative BOLD in the Lateral Geniculate Nucleus: Neuronal Implications and Cortico-Thalamic Feedback

Previous research has demonstrated a sustained negative BOLD response (NBR) that is negatively correlated with the spatio-temporal properties of a visual stimulus. Whilst it has been suggested that the NBR surrounding the positive BOLD response (PBR) may reflect blood-stealing, evidence indicates that the extensive NBR distal to the PBR is a manifestation of neuronal suppression. This study aimed to evaluate NBR in the lateral geniculate nucleus (LGN), and to explore the source of the NBR. fMRI data were obtained from six subjects, while they viewed a grating stimulus. The NBR was identified in the LGN ipsilateral to the stimulus. The results also verified the NBR in V1 ipsilateral to the stimulus and revealed the PBR in bilateral V5. It was concluded that the NBR can be found in the LGN, and is most likely driven by feedback from ipsilateral V1. The finding that the stimulus that stimulates the LGN in one hemisphere can cause extensive suppression in the LGN of the opposite hemisphere rejects the notion that the effect is purely a blood-stealing effect as the two LGN have different blood supplies. The results, together with previous research, indicate that the NBR may reflect neuronal suppression.