The 'take-5 theatre brief': Group mindfulness practice for operating theatre teams

BACKGROUND

A surgical team works in a high-performance environment and is exposed to stress. Mindfulness practice is evidenced to reduce symptoms of stress, as well as burnout, which is high amongst health workers. The operating theatre is unique, with many job-roles, needs and time-critical tasks. It is plausible that group mindfulness may benefit the surgical team. This evaluates the take-5 theatre brief, consisting of a 'check-in' and short breathwork, when used by two surgical teams as part of the regular theatre team brief.

APPROACH

The take-5 theatre brief was evaluated using domains of acceptability and implementation. Data were collected at two district general hospitals in the United Kingdom using 5-point Likert scales hosted on electronic surveys Thematic analysis was performed of participant voice notes, strategic meeting notes and transcripts of interviews between key informants.

EVALUATION

There were 17 participants. Ten were from site A (59%), with the remainder being from site B (41%) and covered a range of roles within the theatre team. Participants found the take-5 theatre brief helpful (median Likert 5) and felt that it would benefit themselves (median Likert 5) as well as the team (median Likert 5) and that it fitted into the day easily (median Likert 4). There was a high demand, no financial investment was required and overall it was easy to implement; however, it became challenged in theatre lists that were late to start.

IMPLICATION

The take-5 theatre brief is an acceptable initiative for these two operating theatre teams.

Trends in neck of femur fracture incidence in EU15+ Countries from 1990-2017

BACKGROUND

Neck of femur fractures (NOFF) pose significant socio-economic costs to society with a high degree of morbidity and mortality. Its incidence rate has been collated within the Global Burden of Disease (GBD) database; however, to date, no comparison across countries has been reported.

METHODS

NOFF age-standardised incidence rates (ASIR) per 100,000 population were extracted from the GBD database for European Union (EU) 15+ countries over the period 1990 to 2017. Joinpoint regression analysis of the data identified trends in ASIR and associated estimated annual percentage changes (EAPC). These were analysed by specified timeframe, country and gender.

RESULTS

Of the 19 EU15+ countries, 11 (58%) had overall increases in NOFF ASIRs in 2017 compared to 1990. The median ASIRs were 240/100,000 and 322/100,000 for males and females, respectively, in 1990. By 2017, this had increased to 259/100,000 and 325/100,000, respectively. Females consistently had relatively higher NOFF ASIRs with a median gender fracture gap of 62/100,000 in 2017. Males had a higher percentage change in increasing ASIRs, with a smaller percentage change in decreasing ASIRs for all included countries. The highest national ASIRs was observed in Australia, followed by Finland and Belgium. Conversely the Mediterranean countries demonstrated the lowest ASIRs, closely followed by the USA.

CONCLUSION

Despite significant advances in primary and secondary hip fracture prevention strategies over the 28-year study period, significant increases in NOFF ASIRs among most EU15+ countries were observed, especially with respect to gender.

Tackling Thyroid Cancer in Europe—The Challenges and Opportunities

Thyroid cancer (TC) is the most common malignancy of the endocrine system that affects the thyroid gland. It is usually treatable and, in most cases, curable. The central issues are how to improve knowledge on TC, to accurately identify cases at an early stage that can benefit from effective intervention, optimise therapy, and reduce the risk of overdiagnosis and unnecessary treatment. Questions remain about management, about treating all patients in referral centres, and about which treatment should be proposed to any individual patient and how this can be optimised. The European Alliance for Personalised Medicine (EAPM) hosted an expert panel discussion to elucidate some of the challenges, and to identify possible steps towards effective responses at the EU and member state level, particularly in the context of the opportunities in the European Union’s evolving initiatives—notably its Beating Cancer Plan, its Cancer Mission, and its research funding programmes. Recommendations emerging from the panel focus on improved infrastructure and funding, and on promoting multi-stakeholder collaboration between national and European initiatives to complement, support, and mutually reinforce efforts to improve patient care.

12 Trends in Neck of Femur Fracture Incidence in EU15+ Countries From 1990–2017

Background

Neck of femur fractures (NOFF) pose significant socio-economic costs to society with a high degree of morbidity and mortality. Its incidence rate has been collated within the Global Burden of Disease (GBD) database; however, to date, no comparison across countries has been reported.

Method

NOFF age-standardised incidence rates (ASIR) per 100,000 population were extracted from the GBD database for European Union (EU) 15+ countries over the period 1990 to 2017. Joinpoint regression analysis of the data identified trends in ASIR and associated estimated annual percentage changes (EAPC). These were analysed by specified timeframe, country, and gender.

Results

Of the 19 EU15+ countries, 11 (58%) had overall increases in NOFF ASIRs in 2017 compared to 1990. The median ASIRs were 240/100,000 and 322/100,000 for males and females, respectively, in 1990. By 2017, this had increased to 259/100,000 and 325/100,000, respectively. Females consistently had relatively higher NOFF ASIRs with a median gender fracture gap of 62/100,000 in 2017. Males had a higher percentage change in increasing ASIRs, with a smaller percentage change in decreasing ASIRs for all included countries. The highest national ASIRs was observed in Australia, followed by Finland and Belgium. Conversely the Mediterranean countries demonstrated the lowest ASIRs, closely followed by the USA.

Conclusions

Despite significant advances in primary and secondary hip fracture prevention strategies over the 28-year study period, significant increases in NOFF ASIRs among most EU15+ countries were observed, especially with respect to gender.

A Comparison of the Burden of Thyroid Cancer Among the European Union 15+ Countries, 1990-2019: Estimates From the Global Burden of Disease Study

Importance

The global incidence of thyroid cancer has been increasing rapidly, and this increase has had an attendant burden on health systems. However, it is unclear how the burden of this disease differs among the pre-2004 countries of the European Union (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, and the UK), US, Australia, Canada, and Norway (EU15+).

Objective

To assess the trends in mortality, incidence, and disability-adjusted life-years (DALYs) associated with thyroid cancer between 1990 and 2019 in EU15+ nations. Data analysis was conducted from July 11 to October 11, 2021.

Design, Setting, and Participants

Observational cross-sectional analysis of the incidence of thyroid cancer was conducted using data obtained from the Global Burden of Disease Study database. Nineteen countries of the EU15+ were included.

Exposures

Thyroid cancer.

Main Outcomes and Measures

Age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs) and DALYs were extracted for individual EU15+ countries per sex for each of the years from 1990 to 2019, and mortality-to-incidence indexes were computed. Joinpoint regression analysis was used to describe the trends.

Results

Thirteen of 19 countries (68%) showed an average annual percentage change increase in ASIR across the study period (range, 0.2%-2.5%). Joinpoint regression analysis revealed largely plateauing ASIR trends in recent years across most EU15+ nations since 1990. Between 2011 and 2019, the estimated annual percentage change in the US was 0. Australia, Denmark, and the US were the only countries with increasing ASMR trends with positive average annual percentage changes: Australia, 0.6 (95% CI, 0.2-1.0); Denmark, 1.0 (95% CI, 0.8-1.3); and US, 0.4 (95% CI, 0.4-0.5); the remaining 16 countries showed negative trends (range, -0.2 to -2.1). Disability-adjusted life-years decreased in all EU15+ countries except Australia, Denmark, and the US.

Conclusions and Relevance

This cross-sectional analysis found that overall, the burden of thyroid cancer across EU15+ countries appears to be decreasing, evidenced by plateauing incidence rates and reductions in mortality and DALYs over the 30-year study period. However, the US and Australia appear to have increasing ASMR and DALY trends. Ongoing observation is required to monitor how changes in international clinical practice guidelines affect thyroid cancer DALYs and mortality.

A systematic-review of endotracheal stenting in patients with locally advanced thyroid cancer

OBJECTIVE

Locally aggressive thyroid cancer can result in airway obstruction secondary to tracheal compression or vocal cord palsy. A tracheal stent provides an alternative to surgical resection, tracheostomy or conservative management in patients with compressive symptoms. This systematic review synthesises the current evidence associated with tracheal stenting in locally advanced thyroid cancer.

DESIGN, SETTING AND PARTICIPANTS

We conducted a systematic review of tracheal stenting in locally advanced thyroid cancers. We searched MEDLINE, Embase and Web of Science for studies until September 22nd 2020. Inclusion criteria were studies involving patients who had received tracheal stents to treat laryngo-tracheal stenosis secondary to locally advanced thyroid cancer. Single case reports or single cases were not included.

MAIN OUTCOME MEASURES

We assessed studies for data on the performance of tracheal stenting; defined as symptomatic relief, spirometry data, complication rates and mortality. We also extracted data pertaining to the use of different types of stent.

RESULTS

We identified 8 full-text articles from 325 titles found in our search. These were all single-centre retrospective studies that lacked homogeneity of thyroid cancer histotypes. The number of patients in each study ranged from 4 to 35 patients. Stenting improved performance status (2 of 2 studies), symptoms (5 of 5 studies) and spirometry (2 of 3 studies). The most common complications were tracheal granulation, tumor overgrowth, stent migration and sputum retention.

CONCLUSION

There is a lack of evidence in the literature of tracheal stents in locally advanced Thyroid cancer. However, the evidence available suggests tracheal stenting may be a useful treatment adjunct in advanced thyroid cancer causing symptomatic airway obstruction.

Coblation debulking of a paediatric laryngeal plexiform neurofibroma: a pragmatic response to a rare tumour

Laryngeal neurofibroma is a rare but important differential diagnosis in a patient presenting with stridor. In paediatric patients, these lesions present a management conundrum: complete surgical resection is the established treatment of choice, but an aggressive approach can be detrimental to developing anatomy. We report the case of a plexiform neurofibroma affecting the right hemilarynx of a 3-year-old boy. Endoscopy revealed a large tumour, involving the right aryepiglottic fold and extending into the piriform sinus, ventricle and the false cord. Given the patient’s young age and the challenging tumour location, the lesion was debulked, rather than resected, using coblation (low-temperature plasma radiofrequency ablation). At 30 months follow-up, the neurofibroma has mildly increased in size—in line with expectations that these lesions exhibit slow growth throughout childhood—but there are no significant respiratory symptoms and there is no functional impairment.

A high-definition, low cost endoscope to video record head and neck surgery- our experience

Head and neck surgery is a challenging speciality to video-record due to its open, small and sometimes deep operative field. Consequently current commercial technologies yield a high financial cost. This study explores how a low-cost, commercially available endoscope, called a borescope, may be used to overcome these challenges. It was hypothesised that due to its size, versatility and low-cost, it may be an accessible tool to circumnavigate the pitfalls of previously trialled recording devices. We report two cases in which a borescope was used intra-operatively. We found that the borescope can capture images suitable for teaching and training purposes but not when mounted as a headcam. As such the borescope is unable to provide a surgeons point of view.

Unilateral nasal obstruction: a rare presentation of acute myeloid leukaemia

Myeloid sarcoma, and, with it, Acute Myeloid Leukaemia (AML), is a rare but important differential diagnosis in the consideration of unilateral nasal blockage. These lesions are often misdiagnosed as lymphoma or poorly differentiated carcinoma. We report the case of a patient with unilateral nasal blockage who underwent Endoscopic Sinus Surgery and biopsy. Histology revealed myeloid sarcoma and she was diagnosed with AML. Genetic testing could not be fully undertaken as the biopsy samples were preserved in formalin, which can degrade the quality of the DNA required for the more sensitive fms-like tyrosine kinase 3-internal tandem duplication (FLT3 ITD) test. Given that these levels have a significant impact on treatment decisions, a further biopsy, preserved in saline, was required. This case exemplifies the need for Ear, Nose and Throat clinicians to have a high index of suspicion for this lesion, and a working knowledge of the testing requirements for samples taken.

A comparison of the burden of thyroid cancer amongst European Union 15+ countries, 1990-2017: Estimates from the Global Burden of Disease Study

e18048

Background: The global incidence of thyroid cancer has been increasing rapidly and this has an attendant burden on health-systems. The Global Cancer Observatory reported an estimate of 567,233 new cases of thyroid cancer and 41,071 deaths in 2018. The objective of this study is to observe the trends in mortality, incidence and disability-adjusted life years (DALYs) from thyroid cancer between 1990-2017 in European Union (EU) 15+ nations. Methods: We extracted thyroid cancer mortality data from the Global Burden of Disease Study database based on the International Classification of Diseases versions 10 and 9. Age-standardised incidence rates (ASIR), age-standardised mortality rates (ASMR) and disability-adjusted life years (DALYs) were extracted for individual EU15+ countries per sex for each of the years 1990-2017, inclusive, and mortality-to-incidence indices (MII) were computed. Joinpoint regression analysis was used to describe trends. Results: Between 1990 and 2017, thyroid cancer ASIRs increased in all EU15+ countries for males, and in 15/19 countries for females. We identify ASIR to have plateaued in the majority of nations in the time period covered by the most recent trends. 16/19 countries observed decreasing ASMRs. Australia showed the highest increasing trends in both males (+19.2%) and females (+7.5%). The greatest decreases were seen in Belgium (-63.3%) for females and Austria for males (-34.9%). For both sexes, the MIIs decreased in all EU15+ countries. The smallest reductions were observed in the US (-22.4%) and Denmark (-22.4%) for males, and the US (-30.6%) for females. Variable directions of trends in DALYs were observed. Increasing DALYs for both genders were observed in the US and Australia. In 2017, highest ASIR was seen in Luxembourg for males (5.89/100,000) and Italy for females (8.81/100,000), highest ASMR was seen in Luxembourg for males (0.69/100,000) and females (0.53/100,000), highest MII was observed in Portugal for males (2.60/100,000) and in Finland for females (0.10/100,000) and, highest DALY was observed in Luxembourg for males (17.77/100,000) and Greece for females (16.69/100,000). Conclusions: Overall, we report EU15+ countries to be managing the burden of thyroid cancer, as evidenced by plateauing incidence rates and reductions in mortality and DALYs over the 28-year study period. However, some EU15+ countries, including the United States, demonstrate unfavorable ASMR and DALY trends. Ongoing vigilance is required to ensure changes in clinical practice and risk factor prevalence do not negatively impact on DALYs and mortality.

35 Comparative Performance of Prediction Model, Non-Expert and Tele-Diagnosis of Common External and Middle Ear Disease Using A Patient Cohort from Cambodia That Included One Hundred and Thirty-Eight Ears

Introduction

Globally 6% of the population suffers from disabling hearing loss and the majority resides in low- and middle-income countries, but diagnosis and treatment are hampered by poor availability of expert diagnosis. We compared the utility of tele-diagnosis, non-expert diagnosis, and prediction model diagnosis as a screening tool for common external and middle ear disorders.

Method

We recruited consecutive adult and paediatric patients presenting with ear or hearing symptoms to ENT outpatients at Children’s Surgical Centre, Cambodia. Each participant underwent sequential symptomatic and otoscopic assessment by a non-specialist and an ENT specialist. The non-specialist captured data using a novel automated symptom questionnaire loaded onto a smartphone otoscope. An ENT specialist in the UK subsequently reviewed these data.

Results

138 ears were recruited. The prediction model performed poorly, but absence of otorrhoea was found to reliably exclude a diagnosis of chronic suppurative otitis media (negative predictive value=0.99). Both on-site non-expert and expert tele-diagnosis had high diagnostic specificity (90-99% and 86-99%), but low sensitivity (<43% and 32-100%).

Conclusions

We report the first study to directly compare approaches for non-specialist diagnosis of disorders of the middle/external ear, which shows suboptimal but comparable performance using an automated questionnaire, on site non-expert diagnosis, or remote expert diagnosis

36 A Randomised Trial to Compare How Undergraduates Diagnose Common Ear Pathology Using A Smartphone Otoscope and Standard Otoscope in A Simulated Setting

Introduction

Competent otoscopy is a key otolaryngology skill for a broad range of medical careers, yet undergraduate’s confidence to perform otoscopy is reported as low. This study aimed to evaluate whether a smartphone-otoscope could enhance medical undergraduates recognition of common ear pathology.

Method

52 medical students were randomised into a standard group (traditional otoscope) and an intervention group (smartphone-otoscope). Following a short didactic presentation, participants were asked to diagnose four simulated pathologies. Force response items and 5-point Likert scales loaded on an electronic platform recorded their diagnosis and their perceptions towards the otoscope.

Results

The smartphone-group (n = 20) had higher overall rates of correct diagnosis compared to control (n = 22) (84% vs 39%, p = <0.001). Only the grommet station did not show a significant improvement between the two groups (100% vs 91%, p = 0.49). 90% (n = 20) of participants felt the smartphone-otoscope was preferential for their learning. The same number expressed they want to use it in future learning. The remainder were indifferent.

Conclusions

The smart-phone otoscope enabled learners to better observe and recognise middle ear pathology. This popular learning tool has the potential to accelerate the learning curve of otoscopy and therefore improve the proficiency of future doctors at recognising middle ear diseases.

A Near-Peer Teaching Module to Supplement Current Undergraduate Teaching in ENT Surgery

BACKGROUND

Near-peer teaching (NPT) has been successfully used in other medical specialties but not in ear, nose and throat surgery (ENT). Historically, undergraduates receive limited ENT exposure and subsequently report low confidence in ENT competencies. This has been a posited cause of high referral rates to the specialty. This study aimed to see if NPT could be implemented as an adjunct to traditional ENT teaching.

ACTIVITY

Learners received a short NPT module that was focused on clinical ENT. Pre- and post-module questionnaires collected data on students' confidence and knowledge.

RESULTS AND DISCUSSION

One hundred twenty-five undergraduate learners received the intervention. There was a significant percentage increase in both confidence (24.2%, p = < 0.001) and knowledge (35.9%, p = < 0.001) of learners. In a supervised setting, NPT could be a valuable adjunct to traditional undergraduate ENT education.

Understanding the role of Foundation doctors through a self-reported time-mapping pilot study

INTRODUCTION

There is a reduction in Foundation trainee applications to speciality training and this is attributed to an administrative job role, with subsequent fears of burnout. This pilot study presents the findings of a real-time self-reporting tool to map a group of Foundation doctors' elective activities. Self-reporting is efficient, low cost to run and allows for repeated measures and scalability. It aimed to example how a time-map could be used by departments to address any work imbalances and improve both well-being and future workforce planning.

METHOD

Foundation doctors', at a busy District General Hospital, were asked to contemporaneously report their work activities over an 'elective' day. Outcomes measures included the mean duration per task and the time of day these were performed.

RESULTS

Nine Foundation doctors' returned 26 timesheet days. Foundation doctors' time was split between direct patient tasks (18.2%, 106.8 min per day), indirect patient tasks (72.9%, 428.6 min per day) and personal or non-patient activities. Indirect tasks were the most frequent reason for Foundation doctors leaving late. No clinical experience was recorded at all and only an average of 4% (23.4 min per day) of a Foundation doctors' time was spent in theatre.

CONCLUSIONS

This particular cohort performed a high proportion of indirect tasks. These have been associated with burnout. Time-mapping is a low-cost, acceptable and seemingly scalable way to elucidate a clearer understanding of the type of activities Foundation doctors may perform. This methodology could be used to modernise the traditional Foundation doctor job description.

Multicentre collaborative cohort study of the use of Kirschner wires for the management of supracondylar fractures in children

PURPOSE

Supracondylar fractures of the humerus cause significant morbidity in children. Nerve damage and loss of fracture reduction are common recognised complications in patients with this injury. Uncertainty surrounds the optimal Kirschner wire configuration and diameter for closed reduction and pinning of these fractures. This study describes current practice and examined the association between wire configuration or diameter and outcomes (clinical and radiological) in the operative management of paediatric supracondylar fractures.

METHODS

Children presenting with Gartland II or III supracondylar fractures at five hospitals in south-west England were eligible for inclusion. Collaborators scrutinised paper and electronic case notes. Outcome measures were maintenance of reduction and iatrogenic nerve injury.

RESULTS

Altogether 209 patients were eligible for inclusion: 15.7% had a documented neurological deficit at presentation; 3.9% who were neurologically intact at presentation sustained a new deficit caused by treatment and 13.4% experienced a clinically significant loss of reduction following fixation. Maintenance of reduction was significantly better in patients treated specifically with crossed ×3 Kirschner wire configuration compared to all other configurations. The incidence of iatrogenic nerve injury was not significantly different between groups treated with different wire configurations.

CONCLUSION

We present a large multicentre cohort study showing that crossed ×3 Kirschner wires are associated with better maintenance of reduction than crossed ×2 or lateral entry wires. Greater numbers would be required to properly investigate nerve injury relating to operative management of supracondylar fractures. We found significant variations in practice and compliance with the British Orthopaedic Association Standard for Trauma (BOAST) 11 guidelines.