92 Reshaping the Diagnostic Pathways for Investigation of Haematuria During and After The COVID-19 Pandemic: Diagnostic Accuracy of Strategies for Detection of Bladder Cancer from The IDENTIFY Cohort Study

Introduction

Diagnostic haematuria services have been reduced due to the COVID-19 pandemic, compromising patient care, and necessitating a more pragmatic pathway.

Method

The IDENTIFY study was an international, prospective, multicentre cohort study of over 11,000 patients referred to secondary care for investigation of haematuria. Using this data, we developed strategies using combinations of imaging and cytology as triage tests to maximise cancer detection within a pragmatic pathway.

Results

8112 patients (74·4%) received an ultrasound or a CT urogram, with or without cytology. 5737 (70·7%) patients had visible haematuria (VH) and 2375 (29·3%) had non-visible haematuria (NVH). Diagnostic test performance was used to determine optimal age cut-offs for four proposed strategies. We recommended proceeding directly to transurethral resection of bladder tumour for patients of any age with positive triage tests for cancer. Patients with negative triage tests under 35-years-old with VH, or under 50-years-old with NVH can safely be discharged without undergoing flexible cystoscopy. The remaining patients may undergo flexible cystoscopy, with a greater priority for older patients to capture high risk bladder cancer.

Conclusions

We suggest diagnostic strategies in patients with haematuria, which focus on detection of bladder cancer, whilst reducing the burden to healthcare services in a resource-limited setting.

DuMond Spectroscopy: A Technique for the Determination of Bone Density

DuMond spectroscopy is a new technique for the determination of bone mineral density. The instrument consists of an Americium-241 source mounted in an absorber post located on the surface of a sodium iodide detector. The analysis is based on the energy distribution of photons scattered by the tissue. Measurements made using a series of powdered bovine cortical bone and wax mixtures gave an R value of 0.991. Repeated measurements made on a series of calcaneus specimens gave a precision of 0.96%.

Validation of a Magnetic Resonance Imaging-based Auto-contouring Software Tool for Gross Tumour Delineation in Head and Neck Cancer Radiotherapy Planning

AIMS

To carry out statistical validation of a newly developed magnetic resonance imaging (MRI) auto-contouring software tool for gross tumour volume (GTV) delineation in head and neck tumours to assist in radiotherapy planning.

MATERIALS AND METHODS

Axial MRI baseline scans were obtained for 10 oropharyngeal and laryngeal cancer patients. GTV was present on 102 axial slices and auto-contoured using the modified fuzzy c-means clustering integrated with the level set method (FCLSM). Peer-reviewed (C-gold) manual contours were used as the reference standard to validate auto-contoured GTVs (C-auto) and mean manual contours (C-manual) from two expert clinicians (C1 and C2). Multiple geometric metrics, including the Dice similarity coefficient (DSC), were used for quantitative validation. A DSC≥0.7 was deemed acceptable. Inter- and intra-variabilities among the manual contours were also validated. The two-dimensional contours were then reconstructed in three dimensions for GTV volume calculation, comparison and three-dimensional visualisation.

RESULTS

The mean DSC between C-gold and C-auto was 0.79. The mean DSC between C-gold and C-manual was 0.79 and that between C1 and C2 was 0.80. The average time for GTV auto-contouring per patient was 8 min (range 6-13 min; mean 45 s per axial slice) compared with 15 min (range 6-23 min; mean 88 s per axial slice) for C1. The average volume concordance between C-gold and C-auto volumes was 86.51% compared with 74.16% between C-gold and C-manual. The average volume concordance between C1 and C2 volumes was 86.82%.

CONCLUSIONS

This newly designed MRI-based auto-contouring software tool shows initial acceptable results in GTV delineation of oropharyngeal and laryngeal tumours using FCLSM. This auto-contouring software tool may help reduce inter- and intra-variability and can assist clinical oncologists with time-consuming, complex radiotherapy planning.

Pragmatic detection of anxiety and depression in a prospective cohort of voice outpatient clinic attenders

OBJECTIVE

To evaluate diagnostic performance of the emotional domain of the VoiSS questionnaire compared with the Hospital Anxiety and Depression Scale (HADS).

DESIGN

Cross-sectional questionnaire study.

SETTING

Tertiary referral centre voice clinic.

PARTICIPANTS

210 consecutive voice clinic patients.

MAIN OUTCOME MEASURES

Screening with VoiSS and HADS questionnaires. Paired comparison, correlation, multinomial logistic regression and receiver-operating characteristic (ROC) curve analysis.

RESULTS

A total of 177 returned complete data sets. Ninety-six patients (54.2%) had functional dysphonia, and 81 (45.8%) had organic laryngeal disorders. Mean total VoiSS score = 39.7/120 (standard deviation (sd) 22.2). Mean emotional VoiSS subscale = 7.6/22 (sd 7.5). Mean HADS anxiety = 6.5/21 (sd 5.2) and depression mean = 7.1/21 (sd 4.8). There were 35 (20%) borderline anxiety and/or depression scores and 30 (17%) scores considered positive for 'caseness'. There was strong correlation between emotional VoiSS and HADS anxiety (Spearman's Rho = 0.68, P < 0.001) and HADS depression (Spearman's Rho = 0.62, P < 0.001). ROC curve analysis exhibited significant association between emotional VoiSS and HADS 'caseness' (area under curve = 0.88). In addition, functional dysphonia patients had lower mean VoiSS and HADS scores than patients with identifiable laryngeal abnormalities.

CONCLUSION

The VoiSS emotional subscale strongly correlates with HADS anxiety and depression scores and could be used as a measure of psychological distress. This could allow targeted psychological strategies, without additional psychometric questionnaires. Functional dysphonia has less association with psychological distress than certain organic laryngological disorders.

Insights into the life history and ecology of a large shortfin mako shark Isurus oxyrinchus captured in southern California

In June 2013, a record-breaking female Isurus oxyrinchus (total length 373 cm, mass 600 kg) was captured by rod and reel off Huntington Beach, California, where it was subsequently donated to research and provided a rare opportunity to collect the first data for a female I. oxyrinchus of this size. Counts of vertebral band pairs estimate the shark to have been c. 22 years old, depending upon assumptions of band-pair deposition rates, and the distended uteri and spent ovaries indicated that this shark had recently given birth. The stomach contained a c. 4 year-old female California sea lion Zalophus californianus that confirmed the high trophic position of this large I. oxyrinchus, which was corroborated with the high levels of measured contaminants and tissue isotope analyses.

Voice outcomes following endolaryngeal surgery; are we achieving our aims?

OBJECTIVE

To determine voice outcomes in endolaryngeal surgery.

METHODS

Prospective assessment of patients undergoing endolaryngeal surgery in one head and neck team in North Glasgow from 2007 to 2014. Each patient completed a VoiSS (the Voice Symptom Scale) questionnaire at pre-assessment and post-endolaryngeal surgery. Per-operatively, the aim of the procedure was recorded from a choice of seven options in addition to the clinical conditions and the procedure.

RESULTS

One thousand and sixty-six patient episodes were recorded. Thirty-two had incomplete data at pre-assessment and were excluded. Of the remainder, 703 (68%) had complete paired data sets. 'To improve voice' (n = 169, 24%) and 'to achieve a biopsy with no deterioration in voice' (n = 185, 26%) categories had significant outcomes in keeping with the operative aims.

CONCLUSION

This study demonstrated that it is possible to assess patient reported voice outcomes in universal heterogeneous endolaryngeal surgery cohort over a prolonged period. The voice outcomes were in keeping with the stated aims of the endolaryngeal surgical procedures.

Variation in practice: an analysis of Scottish Surgical Profiles ENT data

Background

Variation in otolaryngology intervention rates is reported in the Scottish Surgical Profiles Project. Tonsillectomy is one of the selected key indicator procedures. The variation in practice was discussed nationally at the Scottish Otolaryngology Society summer meetings in 2009 and 2010. NHS Grampian had a significantly higher tonsillectomy rate compared with other Scottish NHS boards.

Aims

To determine the accuracy of NHS Grampian data reported by the Information Service Division (ISD) and to record the appropriateness of listing of patients for tonsillectomy with reference to the Scottish Intercollegiate Guidelines Network (SIGN).

Methods

Retrospective review of case notes and surgical records of patients who had undergone tonsillectomy between March 2007 and March 2008 in NHS Grampian.

Results

Between March 2007 and March 2008, 509 tonsillectomy cases were performed in NHS Grampian. This corresponded to the data received from ISD. 87% of tonsillectomies performed were compliant with SIGN guidelines.

Conclusion

The Scottish otolaryngology clinicians have found the reporting of the intervention rates stimulating and challenging. Discussion of the surgical profile project regularly at national specialty meetings resulted in a preliminary detailed targeted audit of those who were persistent outliers for tonsillectomy. This refuted the presumed reasons for this variation, namely inaccurate figures from ISD and inappropriate listings by clinicians.

Investigating preference-performance relationships in aboveground-belowground life cycles: a laboratory and field study with the vine weevil (Otiorhynchus sulcatus)

The preference-performance hypothesis has principally considered insect herbivores with aboveground lifecycles, although the hypothesis could be equally relevant to insects with life stages occurring both aboveground and belowground. Moreover, most studies have focussed on either laboratory or field experiments, with little attempt to relate the two. In this study, the preference-performance hypothesis was examined in an aboveground-belowground context in the laboratory using the vine weevil (Otiorhynchus sulcatus (F.)) (Coleoptera: Curculionidae) and two cultivars of red raspberry (Rubus idaeus), Glen Rosa and Glen Ample. A two-year field study (2008-2009) was also undertaken to characterise the population dynamics of adult weevils on the two raspberry cultivars. Larval performance (abundance and mass) differed significantly between Glen Rosa and Glen Ample, with Glen Rosa resulting in 26% larger but 56% fewer larvae compared to Glen Ample. Larval abundances were significantly and positively correlated with root nitrogen and magnesium concentrations, but negatively correlated with root iron. However, concentrations of these minerals were not significantly different in the two cultivars. Adult weevils did not preferentially select either of the two cultivars for egg laying (laying 3.08 and 2.80 eggs per day on Glen Ample and Glen Rosa, respectively), suggesting that there was no strong preference-performance relationship between adult vine weevils and their belowground offspring. Field populations of adult vine weevils were significantly higher on Glen Ample than Glen Rosa, which may reflect the higher larval survival on Glen Ample observed in laboratory experiments.

Towards an understanding of the nature of resistance to Phytophthora root rot in red raspberry

A mapping population segregating for root rot resistance was screened under both field and glasshouse conditions over a number of seasons. Few correlations between field and glasshouse scores were significant. Final root rot scores were significantly negatively correlated with measures of root vigour. Two QTL associated with resistance were identified as were overlapping QTL for root vigour assessments. Markers significantly associated with the traits were used to identify BAC clones, which were subsequently sequenced to examine gene content. A number of genes were identified including those associated with stem cell identity, cell proliferation and elongation in the root zone, control of meristematic activity and organisation, cell signalling, stress response, sugar sensing and control of gene expression as well as a range of transcription factors including those known to be associated with defence. For marker-assisted breeding, the SSR marker Rub118b 110 bp allele from Latham was found in resistant germplasm but was not found in any of the susceptible germplasm tested.

The role of ENT surgeons in snoring assessment: some prospective preliminary evidence

OBJECTIVES

To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers.

DESIGN

Prospective analytical cohort study.

SETTING

Snoring clinic in Secondary Care Otolaryngology centre.

PARTICIPANTS

Ninety-three patients referred with disruptive snoring.

MAIN OUTCOME MEASURES

A structured history of upper aerodigestive tract symptoms was obtained by clinic interview. All patients underwent detailed ENT examination. Univariate analysis was undertaken on data collected.

RESULTS

The prevalence of oropharyngeal and laryngeal pathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routine flexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology.

CONCLUSION

The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness or pain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment.

Cervical lymphadenopathy resulting in a diagnosis of lymphoma

BACKGROUND AND AIMS

Currently there is no protocol in the west of Scotland for the investigation of a patient with a lymph node in the neck which might contain lymphoma. The aim of this audit was to examine the current management of these patients.

METHODS

Data were collected on 112 patients diagnosed as having lymphoma from a neck node biopsy within a 12 month period from 1st November 2004 to 31st October 2005. Biopsy data were collected in combination with the first point of consultation, investigations used to arrive at diagnosis and any associated complications.

RESULTS

Eighty seven percent of patients underwent excision biopsy with complications noted in 7%. Fine needle aspiration cytology (FNAC) was carried out in 60% of which 34% were ultrasound guided. Core biopsy was carried out in 17% of which 63% were ultrasound guided, Forty-five percent of patients were first referred to ear, nose and throat (ENT) surgery, 17% to general surgery, 14% to haematology, 13% to general medicine and 11% to other specialties.

CONCLUSION

This audit shows that there was a wide range of first points of consultation and diagnostic procedures used. It is recommended that there should be access for all patients with cervical lymphadenopathy to a weekly neck lump clinic with standardised protocols for lymphoma diagnosis. This should ensure that patients are diagnosed accurately and treated in a timely manner.

Towards the large-scale synthesis of carbon nanotubes in fluidised beds

Carbon nanotubes (CNTs) are a form of crystalline carbon with extraordinary properties, making them valuable in a broad range of applications. However, the lack of suitable large-scale manufacturing techniques, which we define as being of the order 10000 tonnes per annum, continues to inhibit their widespread use. Of the three established synthesis methods for CNTs: (i) chemical vapour deposition (CVD), (ii) laser ablation, and (iii) arc discharge, CVD techniques show the greatest promise for economically viable, large-scale synthesis. In particular, the fluidised bed CVD (FBCVD) technique, where the CVD reaction occurs within a fluidised bed of catalyst particles, has the potential to produce high quality CNTs, inexpensively, in large quantities. In this work we report on the development of a catalytic chemical vapour deposition process, using batch fluidised bed reactors, for the synthesis of straight and spiral carbon nanotubes at pilot scale (up to 1 kg/hr). We believe this to be the first report of the synthesis of spiral carbon nanotubes using fluidised bed CCVD. Iron, nickel and cobalt transition metal catalysts supported on non-porous alumina substrates were fluidised in a mixture of nitrogen, hydrogen and ethylene at temperatures between 550 and 800 degrees C for between 15 and 90 minutes. Nanotube yield was inferred from thermogravimetric analysis and the quality and size of the CNTs from transmission electron microscopy. Conflicting information in the literature about the influence of synthesis parameters on CNT properties suggests that further investigation is necessary to understand the synthesis process at a fundamental level, i.e., independent of reactor design and operation.

Helminth parasites of stellate sturgeon Acipenser stellatus Pallas, 1771 and Persian sturgeon Acipenser persicus Borodin, 1897 (Pisces: Acipenseridae) from the South-East Caspian Sea

A total of 182 specimens of two sturgeon species, stellate sturgeon Acipenser stellatus (N=112) and Persian sturgeon Acipenser persicus (N=70), from three coastal stations in the South-East Caspian Sea were examined for endohelminth parasites. Four helminth species were recorded: Cucullanus sphaerocephala (Nematoda: Cucullanidae) and Skrjabinopsolus semiarmatus (Digenea: Acanthocolpidae), found in both host species, and Leptorhynchoides plagicephalus (Acanthocephala: Rhadinorhynchidae) and Amphilina foliacea (Cestodaria: Amphilinidae), found only in A. stellatus. The most abundant parasites were C. sphaerocephala and S. semiarmatus in A. persicus and A. stellatus, respectively. Canonical discriminant analysis was applied for separating host species using parasite numbers data, Brillouin index of diversity, and species richness. By this means, 83% of the hosts were assigned to their correct a priori groups. The different feeding habits and habitat preferences of the two hosts are probably the major factors accounting for the difference in their parasite burdens.

A technique for the orientation of endoscopically resected laryngeal lesions

Endoscopic resection is a widely accepted method of treating early laryngeal malignancies. Accurate histological assessment of resected laryngeal specimens can be difficult due to their small size and potential damage and distortion caused by standard orientation and processing techniques. A new technique is described which employs dehydrated cucumber to mount laryngeal specimens for orientation and processing. This technique is quick, easy, cheap and reliable, allowing accurate histological assessment of potentially malignant lesions. Better orientating and processing of laryngeal specimens can optimise treatment decisions based on histological results.

Optimising outcome assessment of voice interventions, II: sensitivity to change of self-reported and observer-rated measures

Objectives:

A wide range of well validated instruments is now available to assess voice quality and voice-related quality of life, but comparative studies of the responsiveness to change of these measures are lacking. The aim of this study was to assess the responsiveness to change of a range of different measures, following voice therapy and surgery.

Design:

Longitudinal, cohort comparison study.

Setting:

Two UK voice clinics.

Participants:

One hundred and forty-four patients referred for treatment of benign voice disorders, 90 undergoing voice therapy and 54 undergoing laryngeal microsurgery.

Main outcome measures:

Three measures of self-reported voice quality (the vocal performance questionnaire, the voice handicap index and the voice symptom scale), plus the short form 36 (SF 36) general health status measure and the hospital anxiety and depression score. Perceptual, observer-rated analysis of voice quality was performed using the grade–roughness–breathiness–asthenia–strain scale. We compared the effect sizes (i.e. responsiveness to change) of the principal subscales of all measures before and after voice therapy or phonosurgery.

Results:

All three self-reported voice measures had large effect sizes following either voice therapy or surgery. Outcomes were similar in both treatment groups. The effect sizes for the observer-rated grade–roughness–breathiness–asthenia–strain scale scores were smaller, although still moderate. The roughness subscale in particular showed little change after therapy or surgery. Only small effects were observed in general health and mood measures.

Conclusion:

The results suggest that the use of a voice-specific questionnaire is essential for assessing the effectiveness of voice interventions. All three self-reported measures tested were capable of detecting change, and scores were highly correlated. On the basis of this evaluation of different measures' sensitivities to change, there is no strong evidence to favour either the vocal performance questionnaire, the voice handicap index or the voice symptom scale.

Teleconferencing in the management of head and neck cancer

Teleconferencing can be used as part of the integrated management of head and neck cancer. An audit of the participants' views would suggest that the meeting is used in the management of complex head and neck issues.

Optimising outcome assessment of voice interventions, I: reliability and validity of three self-reported scales

Background:

There is an increasing choice of voice outcome research tools, but good comparative data are lacking.

Objective:

To evaluate the reliability and validity of three voice-specific, self-reported scales.

Design:

Longitudinal, cohort comparison study.

Setting:

Two UK voice clinics: the Freeman Hospital, Newcastle upon Tyne, and the Glasgow Royal Infirmary.

Participants:

One hundred and eighty-one patients presenting with dysphonia.

Main outcome measures:

All patients completed the vocal performance questionnaire, the voice handicap index and the voice symptom scale. For comparison, each patient's voice was recorded and assessed perceptually using the grade–roughness–breathiness–aesthenia–strain scale. The reliability and validity of the three self-reported vocal performance measures were assessed in all subjects, while 50 completed the questionnaires again to assess repeatability.

Results:

The results of the 170 participants with completed data sets showed that all three questionnaires had high levels of internal consistency (Cronbach's alpha = 0.81–0.95) and repeatability (voice handicap index = 0.83; vocal performance questionnaire = 0.75; voice symptom scale = 0.63). Concurrent and criterion validity were also good, although, of the grade–roughness–breathiness–aesthenia–strain subscales, roughness was the least well correlated with the self-reported measures.

Conclusion:

The vocal performance questionnaire, the voice handicap index and the voice symptom scale are all reliable and valid instruments for measuring the patient-perceived impact of a voice disorder.