A document by Hammoda Abu-Odah, written on Authorea.

Background, aims and objectives: With ageing global populations, hospitals need to adapt to ensure high quality hospital care for older inpatients. Older person friendly hospital (OPFH) principles and practices to improve care for older people are recognised, but many remain poorly implemented in practice. The aim of this study was to understand barriers and enablers to achieving OPFH from the perspective of key informants within an academic health system. Methods: Interpretive phenonomenological study, using open-ended interviews conducted by a single researcher with experienced clinicians, managers, academics and consumers who had peer-recognised interest in care of older people. Initial coding was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Coding and charting was cross checked by three researchers, and themes validated by an expert reference group. Reporting was guided by COREQ guidelines. Results: Twenty interviews were completed (8 clinicians, 7 academics, 4 clinical managers, 1 consumer). Key elements of OPFH were: older people and their families are recognized and respected; skilled compassionate staff work in effective teams; and care models and environments support older people across the system. Valuing care of older people underpinned three other key enablers: empowering local leadership, investing in implementation and monitoring, and training and supporting a skilled workforce. Conclusions: Progress towards OPFH will require genuine partnerships between clinicians, consumers, health system managers, policy makers and academic organisations, and reframing the value of caring for older people in hospital.

Rationale, aims, and objectives: The coronavirus pandemic has disrupted normal activities across the world, from economy to socialization, and claiming hundreds of thousands of lives. The activities in radiopharmacy laboratories across the globe have been affected significantly. This survey was conducted to assess the effect of COVID-19 on radiopharmacy and activities going on in the laboratories around the world. This was meant to undertake a preliminary record of the continuing survey. Methods: A three-sectioned questionnaire with 12 questions was distributed to the professional working on radiopharmacy laboratories. The sections included demographic information, the effect of the pandemic on the regular operation on a radiopharmacy, and the measures taken to prevent the spread of the virus among the laboratory staff. Random sampling approach was used to select 100 respondents, including staff and radiochemists, across different parts of the world. Results: The survey demonstrated that the pandemic hugely impacted activities in a radiopharmacy laboratory. 98% of the respondents reported major disruptions in the normal schedule in the laboratory. Even though some laboratories continued working normally, strict measures were put in place to prevent the spread of the virus among the staff. In many radiopharmacy laboratories, diagnostic procedures and tests quantitatively decreased. The survey reported positron emission radiopharmaceutical fluorodeoxyglucose F-18 (F18-FDG) as the frequently organ imaging radiopharmaceutical during the pandemic. Conclusions: The survey showed that COVID-19 has negatively impacted activities in a radiopharmacy laboratory, consequently affecting research activities.

Rationale, aims and objectives: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is an important uncommon complication. Due to its complexity, its prevention requires a multidisciplinary approach, involving physicians and dental clinicians. This study aimed to assess the knowledge level of physicians prescribing bisphosphonates in Tehran about dental considerations in such patients and prevention and treatment of BRONJ in 2019. Methods: This descriptive, cross-sectional study evaluated 100 physicians (rheumatologists, endocrinologists, oncologists, and orthopedists) practicing in Tehran. A questionnaire comprising of a demographic section, and knowledge questions regarding dental considerations in patients taking bisphosphonates was administered among the physicians. The frequency of qualitative variables such as gender, type of specialty, and physicians’ responses to each question was calculated, and the knowledge scores were analyzed separately based on the type of specialty of physicians using one-way ANOVA followed by the Tukey’s test for pairwise comparisons. The effect of different variables on knowledge score was analyzed by simple regression. Results: The mean knowledge score of physicians was 5.19±1.78 (range 2-8). The mean knowledge score of oncologists was significantly higher than that of endocrinologists (5.88 versus 4.52, P=0.03). No other significant differences were noted. Work experience (P=0.04), age (P=0.02), orthopedics specialty (P=0.05) and oncology specialty (P=0.006) had significant effects on the knowledge score. Type of practice (P=0.75), gender (P=0.32), and rheumatology specialty (P=0.07) had no significant effect on the knowledge score. Conclusion: Considering acquiring about 50% of the total score, physicians seem to have limited knowledge about dental considerations in patients taking bisphosphonates. Attempts must be made to enhance their knowledge by the continuing education programs or revising the curricula.

Objective: Sentinel lymph node biopsy (SLNB) seems as efficient as selective neck dissection (SND) for the treatment of occult metastases in T1-T2cN0 oral squamous cell carcinoma (SCC). The aim of our study was to assess and compare the cost of these two surgical procedures. Patients and methods: This retrospective cost analysis includes consecutive patients treated between 2012 and 2017 in two French hospitals either by SLNB or SND. Hospital cost (hospital stay for initial surgery and re-hospitalizations over a period of 60 days after the initial surgery), the length of hospital stay for the initial surgery and the perioperative management were described and compared between the two techniques. The propensity score regression adjustment method was used to address selection bias. Results: Ninety-four patients underwent SLNB procedure and seventy-seven patients underwent SND. The length of hospital stay for initial surgery was lower in SLNB group: 5.8 days (SD: 3.8) versus 9.2 days (SD: 5) in the SND group. Hospital costs were lower in SLNB group: \euro7 489 (standard deviation: \euro3 691) versus \euro8 886 (standard deviation: \euro4 381) but this difference was not significant after propensity score regression adjustment. The rate of complication, the delay of full oral feeding and postoperative drainage were lower in SLNB group. Conclusion: SLNB in T1-T2cN0 oral SCC is less invasive than SND with fewer complications, a shorter length of hospital stay and favorable perioperative management. This study shows that this technique could be also less expensive than SND.

Rationale, aims and objectives Healthcare services play a vital role in identifying and responding to family violence. There is a growing expectation and requirement that hospital staff have an understanding of family violence and have the skills to identify and manage disclosure. While health services have historically implemented training programs to improve the clinical skillset, it is unclear how effective these training programs have been at improving the response to family violence. This study aims to evaluate the effectiveness of a multi-faceted family violence training program on clinician self-reported knowledge, confidence and skills. Method Clinical staff including allied health, emergency department nursing and care co-ordinators underwent comprehensive family violence training. Training included aspects of a clinical champion’s model, Common Risk Assessment Framework Level 3 training, monthly clinical supervision, quarterly network meetings, additional training opportunities and secondary consultations if/as needed. Effectiveness was measured using a modified version of the Assisting Patient/Clients Experiencing Family Violence: Royal Melbourne Hospital Clinician Survey at pre-training, post-training and two further follow up time points. Results Of the 45 clinicians who participated in the family safety training, 41 completed the evaluation survey at least once, with varying numbers of survey completion across the other 3 time-points. Statistically significant and sustained improvements were found in levels of self-reported family violence knowledge, confidence and frequency of screening. Conclusion In-depth, multi-faceted training can result in significant and sustained improvements in clinician self-rated knowledge and awareness of how to identify and respond to family violence. Change in clinical practice was further observed in clinicians’ self-reported screening for family violence. Findings from this study suggest that a multi-faceted approach to training hospital staff may increase translation of knowledge into clinical practice.

Introduction: Although the association between necrotizing otitis externa (NOE) and diabetes mellitus (DM) is well known, there is little knowledge in regards to the effects of DM and glycemic control (preadmission and during hospitalization) on the outcome of NOE. The aim of the study was to determine the effects of DM duration and preadmission glycemic control, and in-hospital glycemic control on NOE severity. Methods: A retrospective case series analysis, including all patients between the years 1990-2018 hospitalized due to NOE were included in the study. Data collected included NOE disease characteristics, duration of DM, DM associated comorbidities, glycated hemoglobin (HbA1c), urine micro-albumin and in-hospital blood glucose measurements. Disease severity was defined based on duration of hospitalization (above or below 20 days) and need for surgery. Results: Eighty nine patients were included in the study. Eighty three patients (94.3%) had DM. Preadmission HbA1c was 8.13% (5.8%-12.6%). Forty nine patients (65.5%) had mean blood glucose of ≥140mg\dL and 26 patients (34.5%) had ≤ 140mg/dL. DM duration was 157.88 months among NOE patients who required surgery, and 127.6 months among patients who were treated conservatively (p-value 0.25). HbA1c in patients hospitalized < 20 days was 7.6%, and 8.7% among NOE hospitalized ≥ 20 days (p-value 0.027). Seven patients with mean blood glucose of ≤140mg\dL had Pseudomonas Aeruginosa (PA-NOE) (26.7%), in comparison to 25 patients (51.0%) with mean blood glucose measurement of ≥140mg\dL (p=0.045). Conclusions: HbA1c levels at admission are associated with longer hospitalization duration among NOE patients. High mean blood glucose during hospitalization was associated with a higher likelihood for a PA infection, however it had no effect on disease outcome.

Objective: To determine the number of academic papers which have been submitted and published by ENT specialty trainees at each level of higher surgical training. Design: A cross-sectional survey was designed and validated according to the ‘Good Practice in Conduct of and Reporting of Survey Research’ checklist. Settings: Voluntary completion of a web-based questionnaire which was distributed to participants between 11 May – 22 June 2020. Participants: All ENT higher surgical trainees (ST3-ST8 level) in the UK. Main outcomes measured: The number of submitted and published articles by each higher surgical trainee. Comparisons were made between deaneries, training grades and trainees who had achieved a higher degree. Trainees in academic training pathways and those in less than full-time training were analysed separately. Results: One hundred fifty-three ENT speciality trainees across the UK took part in the survey, giving a national response rate of 46.5%. There was a slight male preponderance in the respondents, with 85 males and 68 females completing the survey. Across all years of training, the mean number of first author publications was three and for non-first author publications the mean number was two. For trainees at ST8 level, these numbers were nine and five, respectively. Trainees undertaking a PhD programme produced a mean number of nine first author publications – 5.31 more than the rest (p < 0.0001). Those in academic training pathways achieved 3.48 more publications compared to those who were not (p = 0.092). Trainees with additional undergraduate degrees and those in less than full-time training had an overall lower number of first author publications compared to the general cohort. Conclusions: ENT specialty trainees achieve a higher average number of academic publications than is currently required in order to successfully obtain a Certificate of Completion of Training (CCT). This is particularly the case for trainees in an academic training programme and those with a higher degree. It is the authors’ hope that the data from this study will help in informing and guiding junior trainees, educational supervisors and training programme directors when considering the level of research engagement required for gaining a CCT.

Background: The health care delivery model in the United States does not work; it perpetuates unequal access to care, favors treatment over prevention, and contributes to persistent health disparities and lack of insurance. The historical lack of support in the United States for primary health care, universal health coverage, population health, addressing the social determinants of health, and community empowerment, creates opportunities for community health scientists to develop innovative solutions for addressing community health needs. Methods: We developed a model community health science approach combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action. Results: From 2000-2020, we established partnerships with community organizations to reduce the risk of chronic disease in vulnerable minority communities. Our programs have provided structured community health science training for hundreds of physicians and other health care workers in training. Conclusion: As the U.S. begins to seek solutions to chronic health disparities and health inequities, community health science provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest error that U.S. health care systems could make in trying to better address population health and the social determinants of health, would be ignoring the important community initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for reducing health disparities. This has been the greatest lesson we have learned during the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

Abstract Background: The relation between health investment and research has been portrayed previously in several medical fields, showing a positive relation between economic resources and academic yield. Purpose: To assess the relations between various economic and bibliometric parameters in otolaryngology - head and neck surgery (ORL-HNS) of the OECD countries. Methods: Data regarding bibliometric parameters in ORL-HNS; number of publications, citations, citations per document and H index, between the years 1996 and 2019, were gathered from the Scimago Journal and Country Rank source. These data were then analysed in several breakdowns – seldom county, regional and language comparisons, in order to assess variations in ORL-HNS scholar activity. Economic data regarding each OECD country; GDP per capita, total health expenditure as percent of the GDP and GERD as percent of the GDP were gathered from the OECD and World Bank websites. The correlation between economic and bibliometric indicators was analysed. Results: Among 209,949 documents analysed, a strong correlation was found between H index and health expenditure (r=0.734, p=0.000), and a moderate connection was found between H index and both GDP per capita (r=0.459, p=0.005) and GERD as percent of GDP (r=0.579, p=0.000). Health expenditure showed the strongest correlations to bibliometric parameters. Nonetheless, most data showed some degree of positive correlations between economics and scholar productivity. Conclusion: This study emphasizes the positive relation between scholar productivity and economic indicators, mostly health expenditure, in the OECD countries in the field of ORL-HNS, implying the importance of health investment to ORL-HNS research.

Background: The SARS-CoV-2 was first reported in December 2019 in Wuhan, China and has been declared a pandemic in March 2020. COVID-19 has caused unprecedented and lasting biopsychosocial effects worldwide. All healthcare professionals have faced life threatening risks by attending their daily jobs. The daily emergence of advice and guidelines was necessary to ensure the safety of patients and staff. To this effect, all elective services came to a halt to preserve hospitals’ capacity for dealing with the sickest. This retrospective, descriptive review aims to assess the volume and timing of the advice released specifically relevant to the UK Otolaryngologist. Methods: The search included online advice published in English by international, national and ENT-specific organisations between the 1st of January to the 31st of May. The date, title, source, type of advice and link to the advice was recorded in Excel. The resources were analysed per week of publication. A separate search for peer-reviewed publications was conducted using PubMed Central and Cochrane databases. Findings: 175 covid-19 related guidance’s were identified. 52/175 (29.7%) articles were published by international organisations. 56/175 (32%) were produced by national organisations and 67/175 (38.28%) were produced by ENT specific organisations. The peak guidance production took place in the third and fourth week of March (16/03/2020- 29/03/2020) with 72/175 publications. Of these, 27/72 came from the international category, 17/72 from national bodies and 28/72 from ENT-specific organisations. 13,863 total publications relating to COVID-19 were found using PubMed and Cochrane search strategies; 76% were relevant to ENT surgeons. Conclusion: The challenges faced by the Otolaryngologist relate to the unprecedented, sudden and daily changes to clinical practice. Multiple bodies interpreted the guidance giving an opportunity for confusion and delays in treatments for patients. Implementing a system with clear lines of communication and dissemination of information will improve our response in future pandemic events whilst maintaining a commercial awareness to better use the human and financial resources of an already financially-restricted NHS.

• COVID 19 patients with severe respiratory failure may require prolonged mechanical ventilation. Placement of a tracheostomy tube often becomes necessary for such patients. • The steps of tracheostomy procedure and post tracheostomy care of these patients can be classified as aerosol generating. • We performed percutaneous dilation tracheostomy in three clinically challenging COVID-19 patients in our ICU. • We developed guidelines aiming to minimise aerosolisation during and after the tracheostomy procedure to safeguard healthcare workers. Percutaneous tracheostomy was performed by a team of three experienced anaesthetists and an ICU nurse. • The decision of surgical or percutaneous tracheostomy should be dependent on the experience of the tracheostomy performer, health-care worker safety, resource availability, and patient-centred care. We believe our modified strategic approach for PCDT offers an extra level of safety to healthcare workers.

• Telephone consultations are effective in mild epistaxis and nasal trauma • Telephone follow-ups can save hospital attendances particularly in peritonsillar abscess and certain cases of otitis externa • Otitis externa and foreign bodies tend to require face-to-face consultations • Otitis externa was the most common reason for semi-urgent ENT consultation whilst social restrictions were in place

• Respirators are currently recommended for use for any aerosol generating procedure • Verbal communication is impeded by the use of respirators • The authors have trialled a simple throat mic speaker system • The system improves both volume and clarity of speech • The authors recommend this, or similar systems to improve communication in theatre

Objectives: To evaluate the safety of intratympanic and intravenous dexamethasone administration for the treatment of sudden sensorineural hearing loss(SSNHL) and hearing improvement at low, mid and high frequencies. Methods: SSNHL patients were randomly divided into two groups within 72 hours after onset and received 24 days of dexamethasone therapy.The group A patients only received intravenous dexamethasone once every other day.Patients in group B received 12 days intravenous dexamethasome and six injection of intratympanic dexamethasome from the 13th day to 24th day like in Group A.Side effects and hearing recovery were compared. Results: The discomfort of intratympanic injection were mild and transient, no tympanic membrane perforation and otitis media, whereas the systemic adverse effects increased cumulatively over the course of intratympanic dexamethasone treatment in group A.The systemic side effects were more serious in group B than in group A. On day 7 (D7),the average 3-frequency PTA (250, 500, and 1000 Hz) was 34.10±9.14 dBHL in group A and 25.70±6.88 dBHL in group B(P<0.05). Hearing recovery was better in group A than group B,but there are the same long-term efficacy at the 90-day follow-up.Group A had slightly better high-frequency hearing recovery than group B, but this difference was not statistically significant. There were no significant differences in the total effective rate of hearing improvement. Conclusions: Early intratympanic dexamethasone intervention led to the rapid recovery of hearing loss, with a good remedial effect on hearing at low-mid frequencies. Intratympanic dexamethasone was safer than intravenous dexamethasone for SSNHL, and high-frequency hearing recovery may have been better with intratympanic dexamethasone, but the difference was not statistically significant. Therefore, it is necessary to make individualized treatment decisions according to the patient’s condition.

Key points 1- We report otitis media in eight patients with coronavirus disease-2019 (COVID-19) and no background history of otologic problems. 2- Otitis media was the first manifestation of COVID-19 in the majority of patients in this case series. 3- Effusion in the middle ear was present in six patients, three patients had typical signs of acute otitis media, with one patient having tympanic membrane perforation. 4- Hearing loss was present in majority of patients, with conductive and mild sensory-neural loss at high frequency as the underlying mechanisms. 5- Our findings suggest that otitis media should be considered a possible manifestation of COVID-19 during the current pandemic.

Objective: To assess the cost-effectiveness of induction of labour (IOL) with outpatient balloon catheter cervical priming versus inpatient prostaglandin (PG) vaginal gel or tape. Design: Economic evaluation alongside a multi-centre, randomized controlled trial. Setting: Eight Australian maternity hospitals. Population: A total of n=448 women with a live singleton pregnancy, cephalic presentation, at or beyond 37+0 weeks gestation, undergoing IOL for low-risk indications between September 2015 and October 2018. Methods: An economic decision tree model was designed from a health services perspective. Sensitivity and subgroup analyses were performed to test the robustness of model outcomes. Main Outcome Measures: We estimated resource use from time of IOL to discharge of mother and infant, collected data on health outcomes (using EQ-5D-3L questionnaire) and reported cost per quality-adjusted life year (QALY) gained, incremental cost-effect ratio (ICER) and net monetary benefit (NMB). Results: Deterministic analysis showed lower mean costs (AUD $7,294 versus AUD $7,585) in the outpatient-balloon (n=205) compared to the inpatient-PG group (n=243), with better health outcomes (0.75 vs 0.74 QALYs gained) and overall higher NMB ($30,054 vs $29,338). In probabilistic analyses outpatient-balloon IOL was cost-effective in 55.3% of all simulations and 59.1% for women with favourable cervix (modified Bishop score >3) and 64.5% for nulliparous women. Conclusions: Outpatient-balloon IOL might be cost-saving compared to inpatient IOL with PG and is most likely to be cost-effective for nulliparous women. Funding: There was no external funding source for this study. Keywords: Decision analysis, labor induced, cost-effectiveness, prostaglandin, balloon ripening, randomised controlled trial

Objectives This study aimed to define the clinical features of anosmia, a symptom observed in patients with coronavirus disease 2019 (COVID-19). Methods The presence of olfactory symptoms, such as loss of smell, in COVID-19 patients and their relationship with the disease process were evaluated. Results A total of 217 patients with COVID-19 were evaluated, of which 135 patients were interviewed via phone calls. The patients were divided into four subgroups: group 1 had only olfactory complaints (isolated, sudden-onset loss of smell); group 2 had isolated, sudden-onset loss of smell, followed by typical COVID-19 complaints; group 3 initially had typical COVID-19 complaints, but gradually developed olfactory complaints; and group 4 had no olfactory complaints. In total, 59.3% of the patients had olfactory complaints. In groups 1–3, the odor scores after the disease were significantly lower than those before the disease; this decrease was more evident in groups 1 and 2 than in group 3 (p = 0.003, p = 0.000, and p = 0.014, respectively). Groups 1 and 2 had a greater loss of smell than group 3 (7.8 ± 2.1 in groups 1 and 2 vs. 6.2 ± 2.6 in group 3; p = 0.01). The odor scores completely returned to the pre-disease values in 51.2% of patients with olfactory dysfunction (41 patients); the mean duration of loss of smell was 7.1 ± 2.4 days. Conclusion Timely detection of anosmia is important in patients with COVID-19 in order to help control the spread of this highly contagious disease.

Rationale, aims and objectives There is a high prevalence of upper limb impairment following a stroke in both the acute and chronic phases of recovery. Evidence suggests that patients do not receive recommended amounts of task specific practice. Robotics provide a potential solution to address this gap but clinical adoption is low. Studies have found that adoption of technology is largely determined by perceived ease of use and perceived usefulness. The aim of this study was to utilise the extended technology acceptance model (TAM2) as a framework to identify factors influencing clinician adoption of a robotic device into clinical practice. Methods Mixed methods study including survey data and focus group discussions across two health services. Participants were allied health professionals whose primary caseload is rehabilitation of the neurologically impaired upper limb. TAM2 surveys were collected pre/post exposure to and use of a robotic device for a period of 3-months. Focus groups were conducted at conclusion of the 3-month period of using the robotic device. Results A total of 34 rehabilitation clinicians completed the pre/post TAM2 surveys. Results indicate that following exposure to the robotic device, there was a statistically significant change in perceived usefulness and perceived ease of use. Two focus groups with 12 participants revealed that lack of experience and protected time to learn how to use such devices were strong moderators of perceived behavioural control. Conclusion This study found that perceived usefulness and perceived ease of use can be moderated through experience. Clinicians reported a need for embedded technological support during the introductory phase of a robotic device in order to acquire the skills for safe and effective use. However, embedded support is rarely offered, suggesting there is a discordance between current implementation of robotic devices into practice and the learning needs of rehabilitation clinicians.

Objective: To quantify the incidence, risk and associated factors that contribute to the development of Surgical Site Infection (SSI) in emergency Caesarean Section (CS). Design: A retrospective case-control study. Setting: An acute District General Hospital in England. Sample: 206 patients (101 SSI patients and 105 non-SSI patients) who had emergency CS between January-December 2017. Methods: Grade of surgeon, smoking status, pre-operative vaginal swab, diabetes status, age, body mass index (BMI), membrane rupture to delivery interval and length of surgery were recorded. Risk factors significantly associated with SSI were identified using simple and multiple logistic regression procedures. Results: BMI (kg/m2) was significantly associated with SSI occurrence and age (odds ratio (OR) 1.17; 95% confidence interval (CI) 1.11 to 1.24; p<0.001). Substantive non-significant associations were recorded between SSI, patient age and vaginal swab. Conclusion: This study identified BMI as the only significant risk factor from a range of patient-level factors for the development of an SSI in emergency CS, possibly due to the impact of excessive adipose tissue on the body’s immune system and reduced effectiveness of antibiotics. The importance of appropriate wound management including frequent wound cleaning, appropriate dressings and dressing change and education is highlighted. Improved guidelines and strategies for managing at-risk patients would enable clinicians to manage emergency CS patients better and reduce the risk of SSI development. Diabetes status, patient age and pre-op vaginal swab were not significantly associated with SSI in emergency CS. Future research on larger samples should be conducted to validate these findings.

Introduction: The objective was to compare transoral robotic surgery (TORS) vs. non-TORS tongue resection procedures performed for obstructive sleep apnea from 2010-14 using a national database, focusing on patient characteristics, performance of concurrent procedures, operative time, length of hospital stay, and postoperative complications Methods: A cohort of adults undergoing TORS and non-TORS tongue resection procedures was identified in the Nationwide Inpatient Sample, a publicly-available national administrative database incorporating a stratified sample of hospital discharge records. Outcomes were annual case volumes, prolonged (≥3 days) hospital stay, and complications for TORS and non-TORS tongue resection procedures. Statistical analyses examined potential associations between the use of TORS and prolonged hospital stay and complications, with adjustment for the performance of concurrent procedures and specific patient and hospital characteristics. Results: From 2010-14, 5185 hospital discharges included tongue resection surgery to treat obstructive sleep apnea. There was a gradual decline in overall volumes, with the proportion of TORS use showing an initial increase, followed by a decrease. TORS patients were less likely to undergo concurrent nasal surgery (14% vs. 45%, p<0.01), but there was no association between the use of TORS and concurrent palate/oropharyngeal or other hypopharyngeal surgery. TORS use was associated with patient age, payor, and certain hospital characteristics. TORS use was associated with an increased risk of prolonged hospital stay (33% vs. 25%, p=0.045) and pulmonary complications (8.4% vs. 6.0%, p=0.04) but not total complications (7.7% vs. 7.4%, p=0.2). Conclusion: This study provides insight into TORS use in tongue resection surgery for obstructive sleep apnea during this period of early TORS adoption.

The global pandemic of new Coronavirus disease (COVID-19) is a grave threat to both physical and mental health. We must be mindful of the consequences of psychological effects that caused by COVID-19 in healthy population and people with psychiatric problems (Asmundson et al., 2020). In many countries, health anxiety was reported, which is characterized by catastrophic interpretations of bodily sensations and physical changes, which generates dysfunctional beliefs about health and illness, may lead to different clinical symptoms and disorders. Recently, the outpatient department of Xiangya, Changsha, received a couple of patients with tinnitus when onset is related to stress or anxiety due to COVID-19 pandemic. We report a case of tinnitus in a patient with anxiety and insomnia related to COVID-19 and recover rapidly after psychiatric intervention and therapy.

OBJECTIVES: To audit quality of intrapartum care and birth outcomes before and after a restriction in the number of women admitted in childbirth. This restriction policy was implemented as number of births vastly exceeded the pre-dimensioned capacity. DESIGN: A retrospective, comparative criterion-based audit. SETTING: Taiz Houbane Maternal and Child Health Hospital, Yemen. POPULATION: All women giving birth in a high-volume month (August 2017; n=1034) and a low-volume month (November 2017; n=436). METHOD: Criterion-based audit of case files was conducted for all caesarean sections (n=108 and n=82) and for 250 randomly selected vaginal births in each month. Birth outcomes were assessed for all women and newborns. MAIN OUTCOME MEASURES: Prevalence of sub-optimal quality of intrapartum care and adverse birth outcomes (stillbirths, intra-facility newborn deaths, and Apgar score <7). RESULTS: Background characteristics of women were comparable between the months. Rates of labour inductions and caesarean sections increased significantly in the low-volume month (14% vs. 22% (relative risk (RR) 0.62, 95% confidence interval (CI) 0.45-0.87) and 11% vs. 19% (RR 0.55, 95% CI 0.42-0.71), respectively). No other care or birth outcome indicators were significantly different. Structural and human resources remained constant throughout, despite differences in patient volume. CONCLUSIONS: Assumptions regarding quality of care in periods of high demand may be misguiding - resilience to maintain quality of care was strong. We recommend health actors to closely monitor changes in quality of care when implementing resource changes - to enable safe care at birth for as many women as possible. FUNDING: Médecins Sans Frontières

Introduction: Litigation against the National Health Service (NHS) in England is rising, costing £2.4 billion in 2018/19. The aim of this study was to determine the incidence and characteristics of otolaryngology clinical negligence claims in England. Methods: A retrospective review was undertaken of all clinical negligence claims in England held by NHS Resolution relating to otolaryngology between April 2013 and April 2018. Analysis was performed using information for cause, patient injury and claim cost. Where claim information was adequately detailed, the authors categorised claims by subspecialty, diagnosis and operation. Results: A total of 727 claims were identified with an estimated potential cost of £108 million. From these, 463 were closed claims. Including open claim reserves, the mean cost of a claim was £148,923. Head and neck surgery was the subspecialty with the highest number of claims (n=313, 43%) and highest cost (£51.5 million) followed by otology (n=171, £24.5 million) and rhinology (n=171, £13.6 million). Over half of claims were associated with an operation (n=429, 59%) where mastoid surgery (n=46) and endoscopic sinus surgery (n=46) were equally associated with the greatest number of claims. The most frequent reasons for litigation included failure or delay to diagnose (n=178, 25%) failure or delay to treat (n=136, 19%), intra-operative complications (n=130, 18%) and failure of the consent process (n=107, 15%). Discussion: Clinical negligence claims in otolaryngology are related to several different components of patient management and is not limited to post-operative complications. This study highlights the importance of robust pathways in outpatient diagnostics and the consenting process, especially in the high-risk speciality of head and neck surgery, in order to deliver better patient care and reduce the impact of litigation.