Effectiveness, perceptions and environmental benefits of remote consultation for adults referred with recurrent tonsillitis

INTRODUCTION

We evaluate remote consultation for adult patients referred with recurrent sore throat, measuring the effectiveness of the consultation, satisfaction and environmental impact.

METHODS

Eligible patients were invited to telephone clinics, undertaking a satisfaction survey after consultation, focusing on perceived convenience, satisfaction, cost and travel arrangements (used to calculate potential environmental benefit). Provider opinion was also captured.

RESULTS

Forty-eight of 60 patients attended, with 38 (63%) eligible for inclusion. Thirty-six of these 38 patients (95%) had a definitive outcome of tonsillectomy (27/38) or discharge (9/38). Thirty-three of the 38 patients (87%) responded to the survey and reported high satisfaction in all arms of questioning (mean Likert ranking = 4.7/5). A mean of 3.76 hours of missed work and 5.17kg carbon dioxide emission equivalents were saved per patient. Provider responses were positive towards ongoing remote consultation use.

CONCLUSIONS

Telephone consultation for adult patients considered for tonsillectomy is convenient to patients in terms of cost and time, reduces environmental harm and is associated with high patient and provider satisfaction.

Access to ear and hearing care services in Cambodia: a qualitative enquiry into experiences of key informants

OBJECTIVE

In Cambodia, little is known about the state of ear and hearing care, or the roles providers or key stakeholders play in delivering services.

METHOD

This was an exploratory study using semi-structured qualitative interviews and a questionnaire addressed to key stakeholders to explore their perceptions and experiences in providing services to people suffering from ear disease or hearing loss in Cambodia.

RESULTS

Several challenges were described including a lack of hearing services to meet the demand, especially outside Phnom Penh in primary care and aural rehabilitation. Supply-side challenges include a shortage of trained professionals, facilities and resources, poor co-ordination between providers, unclear referral pathways, and long wait times.

CONCLUSION

Now is an opportune time to build on the positive trend in providing integrated care for non-communicable diseases in Cambodia, through the integration of effective ear and hearing care into primary care and strengthening the package of activities delivered at government facilities.

Disparities in access to ear and hearing care in Cambodia: a mixed methods study on patient experiences

OBJECTIVE

Chronic suppurative otitis media is a major global disease disproportionately affecting low- and middle-income countries, but few studies have explored access to care for those with ear and hearing disorders.

METHOD

In a tertiary hospital in Cambodia providing specialist ear services, a mixed method study was undertaken. This study had three arms: (1) quantitative analysis of patients undergoing ear surgery, (2) a questionnaire survey and (3) semi-structured in-depth interviews.

RESULTS

Patients presented with advanced middle-ear disease and associated hearing loss at rates that are amongst the highest per capita levels globally. Patients reported several structural, financial and socio-cultural barriers to treatment. This study showed a significant burden of ear disease in Cambodia, which reflects a delay in receiving timely and effective treatment.

CONCLUSION

This study highlights the opportunity to integrate effective ear and hearing care into primary care service provision, strengthening the package of activities delivered at government facilities.

Outcomes of remote versus face-to-face ear, nose and throat outpatient consultation on patient pathways

INTRODUCTION

Remote consultation has potential benefits in increasing patient pathway efficiency and has been found to reduce costs and carbon emissions. Previous studies of remote consultation in ear, nose and throat (ENT) practice have reported mixed results and used relatively small sample sizes. The aim of this article is to study the impact of remote telephone consultation on ENT clinic outcomes and pathway efficiency, compared with in-person review, within new and follow-up patient cohorts and subspeciality, where previous studies demonstrate mixed and inconclusive results.

METHODS

This was a comparison of remote clinic appointment outcomes over a 2-month period from a single ENT referral centre (426) with an equivalent data set of face-to-face clinic appointments over a similar time frame (1,533). Statistical analysis included chi-squared test for clinic outcomes and two-sample t-squared test for mean hand-off between both cohorts (p < 0.05).

RESULTS

For new referrals, remote consultation was associated with statistically significantly greater rates of follow-up (p < 0.00001), investigation (p = 0.00251) and hand-off (p < 0.00013) than patients seen face-to-face - particularly where presenting with head and neck symptoms. For follow-up patients, remote consultation had similar rates of investigation (p = 0.11071) or further follow-up (p = 0.08) and mean hand-off (p < 0.11764) to those seen face-to-face.

CONCLUSIONS

Remote consultation in ENT could become the norm for follow-up patients, but should be used with caution in the initial consultation of new patients.

Effectiveness of an online module: climate-change and sustainability in clinical practice

BACKGROUND

Climate change has significant implications for health, yet healthcare provision itself contributes significant greenhouse gas emission. Medical students need to be prepared to address impacts of the changing environment and fulfil a key role in climate mitigation. Here we evaluate the effectiveness of an online module on climate-change and sustainability in clinical practice designed to achieve learning objectives adapted from previously established sustainable healthcare priority learning outcomes.

METHODS

A multi-media, online module was developed, and 3^rd and 4^th year medical students at Brighton and Sussex Medical School were invited to enrol. Students completed pre- and post-module questionnaires consisting of Likert scale and white space answer questions. Quantitative and qualitative analysis of responses was performed.

RESULTS

Forty students enrolled and 33 students completed the module (83% completion rate). There was a significant increase in reported understanding of key concepts related to climate change and sustainability in clinical practice (p < 0.001), with proportion of students indicating good or excellent understanding increasing from between 2 - 21% students to between 91 - 97% students. The majority (97%) of students completed the module within 90 min. All students reported the module was relevant to their training. Thematic analysis of white space responses found students commonly reported they wanted access to more resources related to health and healthcare sustainability, as well as further guidance on how to make practical steps towards reducing the environmental impact within a clinical setting.

CONCLUSION

This is the first study to evaluate learner outcomes of an online module in the field of sustainable health and healthcare. Our results suggest that completion of the module was associated with significant improvement in self-assessed knowledge of key concepts in climate health and sustainability. We hope this approach is followed elsewhere to prepare healthcare staff for impacts of climate change and to support improving the environmental sustainability of healthcare delivery.

TRIAL REGISTRATION

Study registered with Brighton and Sussex Medical School Research Governance and Ethics Committee (BSMS RGEC). Reference: ER/BSMS3576/8, Date: 4/3/2020.

A survey of UK and Irish surgeons' attitudes, behaviours and barriers to change for environmental sustainability

INTRODUCTION

Surgery is a major contributor to the large environmental impact of healthcare, demanding urgent attention. To date there are no data on the attitudes and behaviours of surgeons towards climate change, or perceived barriers towards sustainable practice.

METHODS

We invited surgeons and surgical trainees in the UK and Ireland to participate in an online survey (developed in accordance with the CHERRIES checklist) conducted between June and November 2020 and disseminated via the Royal College of Surgeons of England, Edinburgh and Ireland, the Association of Surgeons in Training and through local communication.

RESULTS

We received 130 responses, across 14 surgical specialties. The majority of respondents (122/130; 94%) were concerned about the threat of climate change. Most respondents had instigated more sustainable practices in their personal lives (113/130; 87%) and, to a lesser extent, at work (73/130; 56%). Surgeons were willing to make changes to their clinical practice (107/130; 82%), but the main perceived barrier to improving sustainability was a lack of leadership (92/130; 70%). Surgeons welcomed greater leadership and guidance from national bodies (118/130; 91%) and more monitoring and regulation (113/130; 87%).

CONCLUSIONS

The surgeons who responded to our survey are concerned about climate change and willing to engage in efforts to transition to more sustainable practice, but would welcome greater support, guidance and leadership.

A cross-sectional evaluation of the validity of a smartphone otoscopy device in screening for ear disease in Nepal

OBJECTIVES

Hearing loss is a neglected international health problem. The greatest burden of ear disease is in low-income countries where there is also a lack of resources. In this context, screening for otological disease may be worthwhile. Cupris© has developed an otoscopy device that offers the possibility of low-cost mass screening in remote communities. We evaluated the validity of this device in diagnosing ear disease and in determining whether referral to an ENT centre is warranted.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinic, Nepal.

PARTICIPANTS

All adults and children were invited to take part over a 2-day period. The Cupris© device was used to record participants otological history and examination. Stored history and images were assessed in the United Kingdom by a Consultant-grade ENT Surgeon, who provided a diagnosis and decided whether referral to an ENT centre was warranted. After screening with the Cupris© device, participants were immediately assessed by a UK trained ENT Consultant Surgeon using a standard otoscope ("standard assessment"). A diagnosis was recorded for each participant and a decision was made as to whether referral to an ENT centre was warranted.

OUTCOMES

Concordance in primary diagnosis (analysed per ear) and concordance in the decision to refer (analysed per patient). Cohen's kappa coefficient for inter-rater agreement in diagnosis.

RESULTS

Fifty-six patients agreed to participate. In four patients, the quality of video recorded precluded a diagnosis or management plan. These patients were excluded from subsequent analysis, leaving 52 patients for analysis. The same diagnosis was reached for 99 of 104 ears when comparing the Cupris© device to standard assessment (95% concordance), with Cohen's kappa coefficient of 0.89. The decision as to whether a patient should be referred to an ENT centre for further assessment was the same for all 52 participants when comparing the Cupris© device to standard assessment.

CONCLUSIONS

When compared to standard assessment, the Cupris© device is a valid tool for the diagnosis of ear disease and decision for onward referral. It shows considerable promise for use by trained non-medical workers, as a low-cost and portable tool to screen for ear disease in remote settings, particularly in low- and middle-income countries.

A review of simulation platforms in surgery of the temporal bone

BACKGROUND

Surgery of the temporal bone is a high-risk activity in an anatomically complex area. Simulation enables rehearsal of such surgery. The traditional simulation platform is the cadaveric temporal bone, but in recent years other simulation platforms have been created, including plastic and virtual reality platforms.

OBJECTIVE OF REVIEW

To undertake a review of simulation platforms for temporal bone surgery, specifically assessing their educational value in terms of validity and in enabling transition to surgery.

TYPE OF REVIEW

Systematic qualitative review.

SEARCH STRATEGY

Search of the Pubmed, CINAHL, BEI and ERIC databases.

EVALUATION METHOD

Assessment of reported outcomes in terms of educational value.

RESULTS

A total of 49 articles were included, covering cadaveric, animal, plastic and virtual simulation platforms. Cadaveric simulation is highly rated as an educational tool, but there may be a ceiling effect on educational outcomes after drilling 8-10 temporal bones. Animal models show significant anatomical variation from man. Plastic temporal bone models offer much potential, but at present lack sufficient anatomical or haptic validity. Similarly, virtual reality platforms lack sufficient anatomical or haptic validity, but with technological improvements they are advancing rapidly.

CONCLUSIONS

At present, cadaveric simulation remains the best platform for training in temporal bone surgery. Technological advances enabling improved materials or modelling mean that in the future plastic or virtual platforms may become comparable to cadaveric platforms, and also offer additional functionality including patient-specific simulation from CT data.

Nasal polyps do not contain olfactory structures

BACKGROUND

Nasal polyposis can lead to olfactory dysfunction, either due to physical obstruction of the olfactory cleft or physiological disruption of the olfactory neuroepithelium. Where medical therapy has failed to relieve symptoms of nasal polyposis, surgical excision can be considered. However, removal of polyps medial to the middle turbinate is controversial: some believe this will relieve physical obstruction to odourants, others state that removal here risks excising olfactory neuroepithelium.

METHODS

We stained 25 nasal polypectomy samples from the area medial to the middle turbinate with olfactory marker protein.

RESULTS

We confirmed that our staining method worked on normal olfactory tissue. However, no positive staining of nasal polyps was demonstrated.

CONCLUSION

We conclude that nasal polyps medial to the middle turbinate do not contain olfactory neurons, and surgical excision is not contraindicated.

Nurse-led adult ENT pre-operative assessment

Pre-operative assessment in some ENT departments is now nurse-led rather than doctor-led. Appropriately trained nursing staff can perform medical aspects of pre-operative assessment to the same or a better standard than a doctor. Almost all patients are satisfied with a nurse-led pre-operative assessment, and in some cases they prefer it.

Adult ENT day surgery: a case for expansion of services

Day case surgery is acknowledged to have many advantages over inpatient surgery, including greater efficiency, reduced risk of infection, reduced waiting lists and lower costs. 1 Although in the past two decades day surgery has experienced a gradual expansion of services in the UK, the 2001 Audit Commission report on day surgery showed that there was still far more potential for expansion 2 and the Department of Health launched the 'day surgery strategy' in January 2002 with the specific aim of increasing and improving day surgery in the NHS.

Cervico-thoracic teratoma masquerading as lymphatic malformation

A case is presented of a nine-month-old male infant who presented acutely with an anterior neck and mediastinum mass compressing the trachea. Radiological assessment by ultrasound, magnetic resonance imaging and computed tomography suggested the nature of the mass to be a lymphatic malformation (cystic hygroma). The excised specimen was revealed as a mature teratoma. The inability to distinguish between lymphatic malformation and teratoma on multi-imaging modalities confers a risk of mismanaging these lesions with the use of sclerotherapy; surgical excision is the necessary treatment. The potential consequences are discussed.

Alendronate-induced chemical laryngitis

Alendronate is a bisphosphonate used in treating osteoporosis. Its recognized side-effects include oesophageal irritation and ulceration. The authors describe a case of laryngitis induced by transient contact of this medication with the laryngeal mucosa. Successful management of this case is also detailed.