Objectives: To measure morbidity and mortality rates following insertion of gastrostomy tubes in head and neck cancer patients. To determine evidence for any relationship between gastrostomy insertion technique and complication rates. Design: A prospective cohort study and qualitative systematic review. Setting: Multi-cancer networks in the South West of England, Hampshire and the Isle of White. Participants: One hundred and seventy-two patients with head and neck cancer undergoing gastrostomy tube insertion between 2004 and 2005. Percutaneous endoscopic gastrostomy (PEG) was performed in 121 patients. Fifty-one patients had radiologically inserted gastrostomy (RIG). Twenty-seven studies reporting outcomes following 2353 gastrostomy procedures for head and neck cancer. Main outcome measures: Post-procedure mortality, major and minor complications. Results: In the present series, mortality rates were 1.0% (1 ⁄ 121) for PEG and 3.9% (2 ⁄ 51) for RIG. Overall major complication rates following PEG and RIG were 3.3% (4 ⁄ 121) and 15.6% (9 ⁄ 51) respectively. In our systematic review and meta-analysis of 2379 head and neck cancer patients, we observed fatality rates of 2.2% (95% CI 0.014-0.034) following PEG and 1.8% (95% CI 0.010-0.032) following RIG. Furthermore, major complication rates following PEG were 7.4% (95% CI 5.9-9.3%) and 8.9% (95% CI 7.0-11.2%) after RIG. Conclusions: Procedure related mortality rates following gastrostomy in head and neck cancer patients are higher than those in mixed patient populations. Major complication rates following RIG in head and neck cancer patients are greater than those following PEG. Major complications following PEG in patients with head and neck cancer appear no worse than in mixed pathology groups. We have identified that RIG is associated with increased morbidity and mortality in patients who are ineligible for PEG. The serious nature of the complications associated with gastrostomy particularly in patients with head and neck cancer requires careful consideration by the referring physician.The optimum technique for gastrostomy placement in patients with head and neck cancer remains controversial.1-4 Examination of the literature relating to complication and success rates of gastrostomy is made difficult by patient and pathology diversity and modifications of insertion technique. In 1995, Wollman et al.5 reported a metaanalysis investigating outcomes of 5752 patients following radiologic, endoscopic and surgical gastrostomy for all types of pathology. The authors concluded that radiologically inserted gastrostomies (RIG) were slightly more successful than percutaneous endoscopic gastrostomy (PEG) (99.2% versus 95.7%) and also safer, with statistically significant lower rates of major complications (5.9% versus 9.4%). Cancer comprised only 24-29% of the study populations and interpretation of the results in the context of head and neck cancer practice remains exigent. In this study, we examine outcomes following gastrostomy tube insertion in 172 consecutive patients trea...

A good nursing handover process is a crucial part of providing quality nursing care in a modern healthcare environment. The conservation of patient data during the handover process is vital to ensure good continuity of care and safe practice. Any errors or omissions made during the handover process may have dangerous consequences. The authors observed the handover of 12 simulated patients over five consecutive handover cycles between nurses. Three handover styles were used and the amount of data loss was recorded for each style. A purely verbal handover style resulted in the loss of all data after three cycles. A note-taking style (the traditional style used in most hospital wards) resulted in only 31% of data being transferred correctly after five cycles. When a typed sheet was included with the verbal handover, data loss was minimal. Current handover methods may result in significant loss of important data that may impact on patient care. The authors recommend that prior to handover, a formal handover sheet be constructed that can be transferred as part of the handover process.

Ann R Coll Surg Engl 2007; 89: 298-300 298Medical handover is 'the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis'.1 The implementation of the New Deal and the European Working Time Directive has meant that junior doctors are increasingly working in shifts and that handover of clinical information is taking place more frequently. There is reduced continuity of care with patients often being looked after by more than one group of doctors on any given day.3 In many instances, doctors have no day-to-day contact with patients for whom they are responsible in the outof-hours period.2 There are many published examples of cases where poor communication between doctors has had serious consequences for patients; 3 for these reasons, it is now well recognised that accurate handover of clinical information is of great importance to patient safety. 1There are currently many different handover methods being used in clinical practice. 4 Often, a verbal handover is conducted, either by telephone or in person, where the recipient of the handover may or may not take notes to refer to over the course of his shift. Some groups arrange for a handover book or folder to be used so that teams can leave messages about patients of particular concern. In this case, there may be no verbal contact at all. Increasingly, more formal pre-prepared handover sheets are being used which contain information about all of the patients belonging to that particular team.5 This can be typed on a computer and printed out for the on-call doctor for his reference. However, this process inevitably takes more time and effort.Despite this variation in clinical practice, there is very little prospective experimental evidence in the literature investigating optimal methods of handover. The British Medical Association, in conjunction with the General Medical Council, NHS Modernisation agency, National Patient Safety Agency and the Junior Doctors Committee have recently published guidelines 4 for safe handover, but these are based largely on expert opinion. We designed a study to assess the differences in information retention for different handover styles. The styles examined included a purely verbal style, a verbal with note-taking style and a handover using a pre-prepared sheet.

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A postal survey of 500 general practitioners (GPs) in south-west England was undertaken to evaluate the levels of undergraduate and postgraduate otolaryngology training and/or experience received by GPs in that area. Most GPs had received two weeks of undergraduate training in ENT, which had involved no formal assessment. Three-quarters of GPs considered this inadequate. A quarter of GPs had completed a hospital post in ENT prior to entering general practice, most of which lasted three months. Sixty-one per cent of GPs had received some formal postgraduate training in ENT, in the form of courses, lectures or hospital training sessions. Almost half of the GPs considered this inadequate. Seventy-five per cent of GPs stated they would like further training in ENT. Subjective estimates of referral rates to hospital ENT specialist clinics varied considerably. This study illustrates the variability and level of dissatisfaction regarding ENT training amongst GPs at both undergraduate and postgraduate levels.

The round window region is a critical area of the middle ear; the aim of this paper is to describe its anatomy from an endoscopic perspective, emphasizing some structures, the knowledge of which could have important implications during surgery, as well as to evaluate what involvement cholesteatoma may have with these structures. Retrospective review of video recordings of endoscopic ear surgeries and retrospective database review were conducted in Tertiary university referral center. Videos from endoscopic middle ear procedures carried out between June 2010 and September 2012 and stored in a shared database were reviewed retrospectively. Surgeries in which an endoscopic magnification of the round window region and the inferior retrotympanum area was performed intraoperatively were included in the study. Involvement by cholesteatoma of those regions was also documented based on information obtained from the surgical database. Conformation of the tegmen of the round window niche may influence the surgical view of round window membrane. A structure connecting the round window area to the petrous apex, named the subcochlear canaliculus, is described. Cholesteatoma can invade the round window areas in some patients. Endoscopic approaches can guarantee a very detailed view and allow the exploration of the round window region. Exact anatomical knowledge of this region can have important advantages during surgery, since some pathology can invade inside cavities or tunnels otherwise not seen by instrumentation that produces a straight-line view (e.g. microscope).

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