Biomedical subjects
A Drake-Lee
Publications and source records attributed to A Drake-Lee.
Structured education and the changes in ENT training: background to recent changes in training.
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Day case tonsillectomy: what is the risk and where is the economic benefit?
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Social conditions and paediatric day case tonsillectomy.
OBJECTIVE: To develop a simple method for assessing the proportion of children referred to hospital for tonsillectomy in different areas likely to be suitable for day case treatment based on their medical and social characteristics. METHODS: Four patient suitability criteria were selected based on previous experience of successful day case surgery and a literature review of the prevalence of contraindications and postoperative complications, as follows: medical contraindications (at least American Society of Anesthetists grade ASA2 to be eligible); home circumstances (no telephone, no car and single parent households were ineligible); distance from the hospital (more than 10 miles resulted in ineligibility); and likelihood of postoperative complications. Data relating to the social criteria were collected prospectively from 500 children under 12 years of age reviewed in the outpatient department and under the care of one of the authors. In addition, the electoral ward UPA8 (Jarman 8) deprivation score relevant to each child was recorded and the sample was divided into quintiles according to mean UPA8 scores. In each quintile, the percentage of children with the appropriate social criteria for day case tonsillectomy was calculated. The relationship between deprivation score and social criteria for day case tonsillectomy was determined using logistic regression. RESULTS: The proportion of children deemed socially suitable for day surgery fell continuously from 95% in the least deprived quintile to 55% in the most deprived group (proportion passing the social criteria for suitability = -1.5035 + 0.0298UPA8). Using these findings and those from the literature review on the nature and prevalence of contraindications and postoperative complications, a simple formula for realistic day case tonsillectomy targets was specified as A x B x C x D x 100%, where A is the proportion of children with no additional medical problems, B is the proportion passing the social suitability criteria, C is the proportion living within 10 miles and D is the proportion with no postoperative complications. Values for A and D would be derived from local audits. CONCLUSIONS: The formula can be used by purchasers and hospital managers to set differential day case targets for hospitals related to the characteristics of their patients referred for tonsillectomy. In principle, a similar approach could be applicable to other procedures and other age groups.
A prospective study of the length of stay of 150 children following tonsillectomy and/or adenoidectomy.
This is a prospective study of the length of stay in 150 children who underwent adenoidectomy, tonsillectomy and adenotonsillectomy with and without grommets. Seventeen children were unsuitable for same-day discharge because of coexisting medical conditions and 39 because of social factors, which meant that 94 children were potentially suitable for same-day discharge. All patients received a standardized surgical and anaesthetic technique. Twenty-eight of the 94 children were kept in for postoperative complications thus 66 (70%) were treated as day cases. Haemorrhage occurred in one (1%); nausea and vomiting prevented discharge of 11 cases; and a further seven were kept overnight since the children were reluctant to eat and drink. Pain control was a problem with nine children (two had nausea and vomiting as well). Two patients had other complications. These results are compared to those found in the literature. Children who have adenoidectomy without tonsillectomy are more suitable for day surgery (P < 0.001). Because of the high risk of minor complications, the authors recommend that children who have tonsillectomy as part of the procedure should be treated from inpatient beds even when discharged on the same day.
Mast cell ultrastructure in the inferior turbinate and stroma of nasal polyps.
Fourteen unselected adult patients with nasal polyps had ultrastructural examination of mast cells from matching biopsies of the polyp and inferior turbinate. Between three and 10 blocks were examined for each patient in both tissues and every mast cell that had a nucleus was photographed for study. Fifty-three mast cells were found within the stroma of nasal polyps and 54 in the submucosa of the inferior turbinate biopsies. The number of granules ranged between 13 and 167 (mean 60) for polyps and 18 and 148 (mean 61) in the inferior turbinate. The mast cells appeared essentially normal in the inferior turbinate of four patients. The degree of degranulation of the mast cells was calculated as in previous studies and then averaged for both the polyp and the inferior turbinate of each patient. There was greater degranulation in the nasal polyp compared to inferior turbinate (p = 0.03). These results were compared with mast cell degranulation found in the normal nose and in the inferior turbinate of patients with perennial allergic rhinitis which we previously published. The inferior turbinates in these patients were more degranulated than the normal nose (p = 0.0001) but were similar to that found in patients with perennial allergic rhinitis. This suggested that some degree of degranulation may occur throughout the nose in two thirds of the patients with nasal polyps which supports the theory that mast cell reactions are not limited to the polyps in a proportion of patients.
Suitability of children for ENT day case procedures.
This prospective study evaluates the suitability of 500 children under 12 years of age using both medical and social criteria, to determine the proportion of children suitable for increasing the scope of ENT operations performed as day cases. Co-existing medical conditions that could interfere with both surgery and anaesthesia were found in 39 (8%). A combination of adverse social and domestic conditions, including the number of adults and children resident, number of bedrooms and individuals sleeping in the child's bedroom, the number of cars, and the presence of a telephone, were present in 171 (34%) of children's homes and were almost exclusively found in National Health Service (NHS) patients. Private patients, 31 (6%) were more suitable for day surgery. Guidelines need to be followed to minimize the risk if the number of procedures is increased, if more patients were treated privately, the proportionate number of patients requiring in patient care would rise in the National Health Service (NHS).
In vitro effects of diazepam on human ciliary function.
This study demonstrated the in vitro effect of diazepam on human ciliary beat frequency (CBF) from fifteen normal subjects using brush cytology. Tube A contained culture medium, tube B the diluent that diazepam intravenous injectate was carried in and culture medium (controls). Tube C, D and E contained, 0.4 mg/l, 4.0 mg/l and 40.0 mg/l of diazepam in culture medium respectively. The mean effective diazepam concentration in plasma is 0.4 mg/l. CBF was measured photometrically. The most vigorous cilia were measured in 5 areas taking 10 readings on each sample, 30 minutes and 1 hour after mixing. Standard deviation (SD) and confidence limits were calculated along with significance testing (p < 0.05) using the paired t-test and ANOVA. The mean of the CBF of tubes A and B were 13.44 (SD 2.65) and 13.67 (SD 2.48). There was a reduction of the CBF with increasing concentrations of diazepam at 30 minutes, 11.32 (SD 2.14), 10.29 (SD 1.58) and 4.14 (SD 1.57) tubes C. D and E respectively. There was a significant lowering in CBF of 17% (p < 0.01) of diazepam at the mean effective plasma level (tube C) when compared against the controls. CBF decreased over time and at 1 hour was 10.57 (SD, 1.36), 9.02 (SD, 1.39) and 3.58 (SD, 1.31) tubes C, D and E respectively. A proposed mechanism of altered intracellular calcium flux via the action diazepam on GABA receptors is described.
Levels of substance P and IgE decapeptide in nasal polyp fluid and matching sera: a preliminary study.
Sixteen unselected patients with nasal polyps had the levels of substance P and IgE decapeptide measured by ELISA in the oedema fluids and their matched sera. All 16 samples had low levels of substance P in their sera and had high level of substance P in eight samples of nasal polyp oedema. There was a considerable variation in the values of IgE decapeptide found in the sera but 14 polyp oedema fluids had high levels of IgE decapeptide. This study supports the idea that there is a linkage between the cellular and neurovascular responses. High levels of IgE decapeptide suggest that mast cell reactions occur in the majority of cases and that IgE may be implicated in the process of mast cell degranulation.
Mass in the post nasal space and acquired immune deficiency syndrome.
We report a case of previously undiagnosed acquired immunodeficiency syndrome (AIDS) who had a mass in the post-nasal space causing almost complete nasal obstruction. Histology showed both respiratory and squamous epithelium covering an active chronic inflammatory infiltrate. Lymphoma, Kaposi's sarcoma and infiltrative fungal sinusitis were excluded. There was no evidence of the common viruses associated with lesions in AIDS. Unlike adenoid hypertrophy, the lesion was an exuberant growth with an additional chronic inflammatory reaction due to ulceration of the surface epithelium.
Magical numbers and the treatment of nasal polyps.
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Wound management in ear, nose and throat surgery.
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Mast cell ultrastructure in the adenoids of children with and without secretory otitis media.
This study was designed to compare the differences in morphology of the mast cells from the adenoid in children with otitis media with effusion (OME) and those from children with recurrent tonsillitis. Tissue for electron microscopy was prepared in the standard manner and between three and 10 blocks were examined for each child. All the mast cells with nuclei were photographed and the condition of the granules noted. The number of electron dense granules in each cell was assessed on a scale between zero and 10. Sixteen unselected children with OME were compared with 19 children with recurrent tonsillitis. There were no obvious differences in the degree of degranulation between the two groups although there was more vacuolation than previously described in the normal nose but less than in those patients with perennial allergic rhinitis. Allergy and mast cell reactions do not seem to predispose to OME. It was concluded that the adenoids are not the ideal tissue in which to study normal mast cells.
Treatment of allergy.
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Nasal polyps in identical twins.
Nasal polyps are multifactorial in aetiology but are associated with respiratory diseases, particularly late onset asthma. Several members of a family may be affected with nasal polyps but there is little evidence for a genetic basis for this. Some evidence to support a genetic predisposition comes from the development of polyps in identical twins.
Severe angioneurotic oedema causing acute airway obstruction.
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Pitfalls in the assessment of dysphagia by fibreoptic oesophagogastroscopy.
We present a paper to highlight that the investigation of dysphagia by the standard methods of barium swallow and the now routinely used fibreoptic oesophagogastroscope may miss or inadequately assess pharyngeal and hypopharyngeal causes of dysphagia and to remind that if such a cause is suspected then rigid endoscopy is required to assess or exclude the pathology.