Matthew E. Smith

Ami - The chemist's amanuensis

The Ami project was a six month Rapid Innovation project sponsored by JISC to explore the Virtual Research Environment space. The project brainstormed with chemists and decided to investigate ways to facilitate monitoring and collection of experimental data.A frequently encountered use-case was identified of how the chemist reaches the end of an experiment, but finds an unexpected result. The ability to replay events can significantly help make sense of how things progressed. The project therefore concentrated on collecting a variety of dimensions of ancillary data - data that would not normally be collected due to practicality constraints. There were three main areas of investigation: 1) Development of a monitoring tool using infrared and ultrasonic sensors; 2) Time-lapse motion video capture (for example, videoing 5 seconds in every 60); and 3) Activity-driven video monitoring of the fume cupboard environs.The Ami client application was developed to control these separate logging functions. The application builds up a timeline of the events in the experiment and around the fume cupboard. The videos and data logs can then be reviewed after the experiment in order to help the chemist determine the exact timings and conditions used.The project experimented with ways in which a Microsoft Kinect could be used in a laboratory setting. Investigations suggest that it would not be an ideal device for controlling a mouse, but it shows promise for usages such as manipulating virtual molecules.

Can trainees design and deliver a national audit of epistaxis management? A pilot of a secure web-based audit tool and research trainee collaboratives

OBJECTIVE To investigate the feasibility of a national audit of epistaxis management led and delivered by a multi-region trainee collaborative using a web-based interface to capture patient data. METHODS Six trainee collaboratives across England nominated one site each and worked together to carry out this pilot. An encrypted data capture tool was adapted and installed within the infrastructure of a university secure server. Site-lead feedback was assessed through questionnaires. RESULTS Sixty-three patients with epistaxis were admitted over a two-week period. Site leads reported an average of 5 minutes to complete questionnaires and described the tool as easy to use. Data quality was high, with little missing data. Site-lead feedback showed high satisfaction ratings for the project (mean, 4.83 out of 5). CONCLUSION This pilot showed that trainee collaboratives can work together to deliver an audit using an encrypted data capture tool cost-effectively, whilst maintaining the highest levels of data quality.

Validation of a new ENT emergencies course for first-on-call doctors

BACKGROUND First-on-call ENT cover is often provided by junior doctors with limited ENT experience; yet, they may have to manage life-threatening emergencies. An intensive 1-day simulation course was developed to teach required skills to junior doctors. METHODS A prospective, single-blinded design was used. Thirty-seven participants rated their confidence before the course, immediately following the course and after a two-month interval. Blinded assessors scored participant performance in two video-recorded simulated scenarios before and after the course. RESULTS Participant self-rated confidence was increased in the end-of-course survey (score of 27.5 vs 53.0; p < 0.0001), and this was maintained two to four months after the course (score of 50.5; p < 0.0001). Patient assessment and management in video-recorded emergency scenarios was significantly improved following course completion (score of 9.75 vs 18.75; p = 0.0093). CONCLUSION This course represents an effective method of teaching ENT emergency management to junior doctors. ENT induction programmes benefit from the incorporation of a simulation component.

Congenital pulmonary malformations associated with esophageal duplication and teratoma: prenatal to postnatal management.

A unique case is reported of bronchopulmonary foregut malformation with associated benign teratoma. Antenatal Doppler ultrasound scan findings and postnatal management are described. We discuss the appropriate radiologic investigations and the necessity for surgical intervention. The possible embryogenesis is hypothesized.

Tests of Eustachian Tube Function: the Effect of Testing Technique on Tube Opening in Healthy Ears

OBJECTIVE There is no agreement on the best clinical test for Eustachian tube (ET) dysfunction. Numerous tests have been developed to detect ET opening, and all require a patient to perform a Valsalva, Toynbee or sniff maneuver, or to swallow on demand. We aimed to characterize existing tests of ET function in healthy ears, and identify the optimal method and patient maneuver for each test. Our own normative data is presented alongside published comparisons. STUDY DESIGN Diagnostic test cohort study. SETTING Tertiary referral center. PATIENTS Seventy-five healthy ears from 42 volunteers. INTERVENTIONS Six tests of ET function, each performed using multiple different patient maneuvers. MAIN OUTCOME MEASURE Detected ET opening rate for each test-maneuver combination. RESULTS The highest detected opening rates were: Sonotubometry 94%; nine-step test inflation/deflation 93/94%; continuous impedance 88%, patient-reported opening 79%; observed tympanic membrane movement 78%; and Tubo-tympano-aerodynamic-graphy 76%. Valsalva maneuvers were most effective at opening the ET. Toynbee and swallow maneuvers were more effective when performed without water, when compared to with water. For Valsalva and sniff maneuvers, there was significant correlation between the peak nasopharyngeal pressure generated and the ET opening rate. CONCLUSION Based on ET opening detection rates, we recommend the use of dry swallows with sonotubometry and the nine-step test. When testing patient-reported opening and observed membrane movement, and when performing Tubo-tympano-aerodynamic-graphy and impedance tests, we recommend the use of Valsalva maneuvers. Further studies are required to explore the association between the test technique and results in ears with ET dysfunction.

Middle Ear Pressure Changes during Balloon Eustachian Tuboplasty.

Objective Balloon eustachian tuboplasty (BET) has entered clinical use as a treatment for eustachian tube dysfunction. Some surgeons perform myringotomy prior to BET due to concerns that the increase in middle ear (ME) pressure caused by BET may cause otic barotrauma. We investigated the ME pressure changes occurring during BET in cadavers. Study design Human cadaver investigation of a surgical technique Setting Laboratory study at a tertiary referral center. Subjects and Methods ME pressures were recorded from fresh-frozen cadavers, and BET was performed with the Bielefeld balloon catheter inflated to 10 bar. Peak ME pressures were recorded during catheter insertion, inflation, deflation, and removal. A second pressure measurement was taken 15 seconds after each stage to assess the residual pressures. All BET procedures were repeated at least once. Where transmastoid recordings were made, BET was repeated, measuring pressure via a myringotomy to ensure equivalence. Results Data from 25 procedures in 13 ears (9 heads) were analyzed. A consistent pattern of ME pressure change was observed in all cases. Positive pressures occurred on insertion (maximum, 26 daPa) and inflation (maximum, 99 daPa) and negative pressures on deflation (maximum, –46 daPa) and removal (maximum, –42 daPa). There were no significant pressure differences between first and second procedures, except at 15 seconds after insertion (P = .04). Conclusion In adult cadaveric specimens, BET induces ME pressures within the normal physiologic range. On this basis, routine myringotomy prior to BET in adults is not necessary.

The repeatability of tests of eustachian tube function in healthy ears

Many objective tests of eustachian tube (ET) function have been devised for clinical and research use but they have not been directly compared or characterized. As a first step to identifying tests to incorporate into an outcome set for ET dysfunction, we assessed repeatability of a panel of eight of these tests in healthy ears.

Surgical and interventional radiological management of adult epistaxis: systematic review

BACKGROUND There is variation regarding the use of surgery and interventional radiological techniques in the management of epistaxis. This review evaluates the effectiveness of surgical artery ligation compared to direct treatments (nasal packing, cautery), and that of embolisation compared to direct treatments and surgery. METHOD A systematic review of the literature was performed using a standardised published methodology and custom database search strategy. RESULTS Thirty-seven studies were identified relating to surgery, and 34 articles relating to interventional radiology. For patients with refractory epistaxis, endoscopic sphenopalatine artery ligation had the most favourable adverse effect profile and success rate compared to other forms of surgical artery ligation. Endoscopic sphenopalatine artery ligation and embolisation had similar success rates (73-100 per cent and 75-92 per cent, respectively), although embolisation was associated with more serious adverse effects (risk of stroke, 1.1-1.5 per cent). No articles directly compared the two techniques. CONCLUSION Trials comparing endoscopic sphenopalatine artery ligation to embolisation are required to better evaluate the clinical and economic effects of intervention in epistaxis.

Tuboimpedance: A New Test of Eustachian Tube Function:

Objective Eustachian tube (ET) dysfunction is most frequently caused by a failure of the ET to adequately open; however, there is currently no reliable method of assessing this. Tubomanometry has recently shown good interindividual repeatability as a measure of ET function by measuring middle ear pressure after the application of regulated nasopharyngeal pressures during swallowing. We present the first reports of a novel test: middle ear impedance measurements during standard nasopharyngeal pressure application (tuboimpedance). We assess repeatability in healthy ears and any advantages over tubomanometry. Study Design Exploratory cohort diagnosis study. Setting Tertiary referral center. Subjects Twenty screened, healthy ears (10 volunteers). Methods Tubomanometry and tuboimpedance tests were performed while individuals swallowed with applied nasopharyngeal pressures of 20, 30, 40, and 50 mbar. Eustachian tube opening detection rate and test repeatability (measured by intraclass correlation coefficient [ICC]) for immediate and delayed repeats at each pressure were compared. Results ET opening was detected more frequently using tuboimpedance, with a 100% detection rate using a nasopharyngeal pressure of 30 mbar or more, compared to 88% to 96% with tubomanometry. Detection of ET opening at 20 mbar was possible with tuboimpedance. Repeatability of both tests was mostly strong (ICC >0.7) for both immediate and delayed repeats. Repeatability for the tubomanometry R value was only fair to moderate. Conclusion Tuboimpedance may provide a repeatable measure of ET opening that is easier to perform due to lower nasopharyngeal pressures required and fewer issues with poor ear-probe sealing. Further assessment in patients with different forms of ET dysfunction is required.

Intranasal packs and haemostatic agents for the management of adult epistaxis: Systematic review

BACKGROUND The mainstay of management of epistaxis refractory to first aid and cautery is intranasal packing. This review aimed to identify evidence surrounding nasal pack use. METHOD A systematic review of the literature was performed using standardised methodology. RESULTS Twenty-seven eligible articles were identified relating to non-dissolvable packs and nine to dissolvable packs. Nasal packing appears to be more effective when applied by trained professionals. For non-dissolvable packs, the re-bleed rates for Rapid Rhino and Merocel were similar, but were higher with bismuth iodoform paraffin paste packing. Rapid Rhino packs were the most tolerated non-dissolvable packs. Evidence indicates that 96 per cent of re-bleeding occurs within the first 4 hours after nasal pack removal. Limited evidence suggests that dissolvable packs are effective and well tolerated by patients. There was a lack of evidence relating to: the duration of pack use, the economic effects of pack choice and the appropriate care setting for non-dissolvable packs. CONCLUSION Rapid Rhino packs are the best tolerated, with efficacy equivalent to nasal tampons. FloSeal is easy to use, causes less discomfort and may be superior to Merocel in anterior epistaxis cases. There is no strong evidence to support prophylactic antibiotic use.