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IntroductionThe COVID-19 pandemic has catalysed the need to implement the National Health Service Long-Term Plan to deliver more care in the community and to reduce face-to-face hospital appointments by up to 33%. This study aimed to assess the feasibility of a remote otology service from triage through to delivery.MethodsNew adult otology referrals at a tertiary ear, nose and throat (ENT) hospital aged between 18 and 70 with hearing loss or tinnitus were included. Patients attended an audiology-led community clinic where they underwent a focused history, audiometric testing, and a smartphone-based application and otoscope (Tympa System) was used to capture still and video images of their eardrums. The information was reviewed by ENT clinicians using a remote review platform with a subset of patients subsequently undergoing an in-person review to measure concordance between the two assessments.Results58 patients participated. 75% of patients had their pathways shortened by one hospital visit with 65% avoiding any hospital attendances. 24% required an additional face-to-face appointment due to incomplete views of the tympanic membrane or need for additional examinations. Electronic validation by a blinded consultant otologist demonstrated a diagnosis concordance of 95%, and concordance between remote-review and in-person consultations in the 12 patients who agreed to attend for an in-person review was 83.3%. 98% of patients were satisfied with the pathway.ConclusionThis pilot service is feasible, safe and non-inferior to the traditional outpatient model in the included patient group. There is potential for the development of a community audiology-led service or use for general practioner advice and guidance.

A previously fit and well 48-year-old woman presented to her emergency department with a 4-day history of sore throat. Over the past 24 hours her symptoms had progressed rapidly with associated fevers, and she had become unable to tolerate liquids or food. She had no significant medical history

Objective Cancer has been reported to trigger symptoms of post-traumatic stress disorder (PTSD) in a substantial proportion of individuals. Despite the significant burden associated with these symptoms, there are as yet no therapeutic guidelines. This systematic review aims to evaluate the effectiveness of interventions for cancer-related post-traumatic stress in order to provide an evidence base for developing appropriate clinical practice. Methods Databases searched until April 2018 included Psych INFO, EMBASE, Medline, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). No restrictions to study design were applied. Participants aged 18 years or older who received their cancer diagnosis in adulthood and had symptoms of cancer-related PTSD were included. Because of significant clinical heterogeneity, a meta-analysis was not performed. Results Of 508 unique titles, eight studies met study inclusion criteria: five randomised controlled trials (RCTs), one before-and-after study, one case series, and one case study. Interventions were predominately psychological and were administered to patients with a range of cancer types. Eye movement desensitisation and reprocessing and cognitive behavioural therapy-based interventions were associated with reduced symptomatology; however, overall the methodological quality of studies had limitations. Conclusions At present, there is only weak evidence available for the effectiveness of psychological interventions in reducing symptoms of cancer-related PTSD. The majority of interventions were administered to all cancer patients regardless of whether they showed pretreatment levels of post-traumatic stress. Future studies would be better targeted towards patients with a diagnosis of cancer and who have significant levels of cancer-related post-traumatic symptoms. Higher quality trials are also needed before treatment recommendations can be made.

Obstructive sleep apnea (OSA) is a common, underdiagnosed condition that is associated with significant morbidity and mortality in the perioperative setting. Increasing evidence suggests that the utility of preoperative screening tools may go beyond identification of OSA, to the prediction of perioperative complications. The primary objective of this study was to systematically review the literature on all studies assessing whether high risk scores on the STOP-Bang questionnaire, American Society of Anesthesiologists (ASA) checklist, and the Berlin Questionnaire (BQ) are associated with higher rates of postoperative complications.A systematic review of English language records was performed using Medline, EMBASE, and PsychInfo with additional studies identified by manual search through reference lists. Only studies that evaluated the ability of the STOP-Bang, the BQ, and ASA checklist to predict postoperative complications in adults were included.Twelve studies were included in the final review. Eight studies looked at STOP-Bang, 3 at the Berlin Questionnaire, and 2 at the ASA Checklist. Significant differences across study characteristics prevented a meta-analysis and the studies were evaluated qualitatively.The ASA checklist, Berlin Questionnaire, and STOP-Bang questionnaire may be able to risk stratify patients for perioperative and postoperative complications. Further research is required, with a particular focus on specific surgery types and adjustment of potentially confounding factors in the analysis.

In the last five years, IDH1 mutations in human malignancies have significantly shaped the diagnosis and management of cancer patients. Ongoing intense research efforts continue to alter our un- derstanding of the role of the IDH1 mutation in tumor formation. Currently, evidence suggests the IDH1 mutation to be an early event in tumorigenesis with multiple downstream oncogenic con- sequences including maintenance of a hypermethylator phenotype, alterations in HIF signalling, and disruption of collagen maturation contributing to a cancer-promoting extracellular matrix. The most recent reports elucidating these mechanisms is described in this review with an emphasis on the pathogenesis of the IDH1 mutation in glioma. Conflicting findings from various studies are discussed, in order to highlight areas warranting further research. Finally, the latest progress in developing novel therapies against the IDH1 mutation is presented, including recent findings from ongoing phase 1 clinical trials and the exciting prospect of vaccine immunotherapy targeting the IDH1 mutant protein.

The past 20 years have brought several important advances in the management of multiple sclerosis (MS). Magnetic resonance imaging (MRI) has given us a window into this disease and has transformed the diagnostic process, allowing it to be made much earlier. It has also been established that immunomodulation can prevent demyelinating events in relapsing remitting MS (RRMS). These developments impact on primary care because there is increasing evidence that early diagnosis and treatment of MS may delay, or even prevent the previously inevitable disability.1 At the other end of the spectrum, people with MS with disability are increasingly being managed in the community away from secondary care. The National Institute for Health and Care Excellence (NICE) has recently published an updated guideline for MS patient care. This article highlights the new developments and NICE guidance. MS is the most common cause of non-traumatic neurological disability in young adults with a prevalence of around 1 in 1000 and evidence that the incidence is increasing.2 It is a chronic, progressive, demyelinating condition of the central nervous system (CNS) that typically presents during the ages of 20–40 years, occurring twice as frequently in females as in males. Typically, a large GP practice will have between 10–20 patients with MS.3 Despite the highly heterogeneous course, a number of distinct subtypes have been identified. The most common is the relapsing remitting form (RRMS), which accounts for 80–90% of all cases. This is characterised by demyelinating events where there is loss-of-function, inter-spaced by periods of partial or complete recovery. After 10 years around 50% of those with RRMS will go onto develop secondary progressive MS (SPMS) with fewer relapses but a progressive worsening of disability. Around 10% of patients with MS have a progressive decline in disability …