Acoustic resonance therapy is safe and effective for the treatment of nasal congestion in rhinitis: A randomized sham-controlled trial

BACKGROUND

Acoustic resonance therapy (ART) is a novel vibrational treatment that delivers patient-specific resonant frequency acoustic energy to the sinonasal cavities. In a pilot study, ART was effective for the acute treatment of nasal congestion. We conducted a sham-controlled randomized trial to validate the efficacy of ART when administered daily for 2 weeks.

METHODS

A total of 52 adult patients were enrolled in a multi-center, randomized, double-blinded, sham-controlled, interventional study evaluating ART administered by a vibrational headband. Patients received either active treatment or a non-therapeutic sham treatment twice daily over 2 weeks. Clinical endpoints were the average change in nasal congestion sub-score of the Total Nasal Symptom Score (TNSS) and the average change in composite TNSS.

RESULTS

ART resulted in a significantly greater mean change in the nasal congestion sub-score compared to sham (-0.87 [95% confidence interval [CI] -1.11, -0.62] vs. -0.44 [95% CI -0.64, -0.23], p = 0.008). ART also resulted in a significantly greater reduction in the composite TNSS versus sham, (-2.85 [95% CI -3.85, -1.85], vs. -1.32 [95% CI -2.27, -0.36], p = 0.027). The response rate, determined by a nasal congestion sub-score minimal clinically important difference of 0.23, was 80.8% for ART and 46.2% for sham, with an adjusted risk ratio of 1.95 (95% CI 1.26, 3.02, p = 0.003) in favor of ART. Safety endpoints showed no adverse events.

CONCLUSION

ART is a safe and effective non-pharmacologic alternative for the treatment of nasal congestion.

Economic impact analysis of a minimally invasive temperature-controlled radiofrequency device versus nasal surgery for the treatment of nasal airway obstruction in the United States

Objective: To determine the economic impact of a minimally invasive temperature-controlled radiofrequency (TCRF) device for treating nasal airway obstruction (NAO).Methods: A budget impact model was developed for two scenarios: a reference scenario of functional rhinoplasty surgery with concomitant septoplasty and inferior turbinate reduction (ITR) performed in the hospital outpatient department where TCRF is not an available a treatment option and a new scenario consisting of in-office TCRF treatment of the nasal valve and ITR. A payor perspective was adopted with a hypothetical population plan size of one million members. Costs were estimated over a time horizon of 4 years. The eligible population included patients with severe/extreme NAO and nasal valve collapse (NVC) as the primary cause or significant contributor. Data inputs were sourced from targeted literature reviews. Uncertainty within the model structure and input parameters was assessed using one-way sensitivity analysis.Results: The introduction of a TCRF device resulted in population-level cost savings of $20,015,123 and per-responder average cost savings of $3,531 through a 4-year time horizon due to lower procedure costs and complication rates of the device relative to the surgical comparator. Results were robust when varying parameter values in sensitivity analyses, with cost savings being most sensitive to the prevalence of NAO and estimated response rates to functional rhinoplasty and TCRF.Conclusions: In patients with severe/extreme NAO, with NVC as the primary or major contributor, introducing TCRF with ITR as a treatment option demonstrates the potential for significant cost savings over functional rhinoplasty with septoplasty and ITR.

Cost-effectiveness Analysis of Inferior Turbinate Reduction and Immunotherapy in Allergic Rhinitis

BACKGROUND

Allergic rhinitis (AR) is a common condition that is frequently associated with atopic inferior turbinate hypertrophy (ITH) resulting in nasal obstruction. Current guidelines support the use of subcutaneous allergen immunotherapy (SCIT) when patients fail pharmacologic management. However, there is a lack of consensus regarding the role of inferior turbinate reduction (ITR), a treatment that we hypothesize is cost-effective compared with other available treatments.

METHODS

We conducted a cost-effectiveness analysis comparing the following treatment combinations over a 5-year time horizon for AR patients presenting with atopic nasal obstruction who fail initial pharmacotherapy: (1) continued pharmacotherapy alone, (2) allergy testing and SCIT, (3) allergy testing and SCIT and then ITR for SCIT nonresponders, and (4) ITR and then allergy testing and SCIT for ITR nonresponders. Results were reported as incremental cost-effectiveness ratios (ICERs).

RESULTS

For patients who fail initial pharmacotherapy, prioritizing ITR, either by microdebrider-assisting submucous resection or radiofrequency ablation, before SCIT was the most cost-effective strategy. Probabilistic sensitivity analysis demonstrated that prioritizing ITR before SCIT was the most cost-effective option in 95.4% of scenarios. ITR remained cost-effective even with the addition of concurrent septoplasty.

CONCLUSION

For many AR patients who present with nasal obstruction secondary to atopic inferior turbinate hypertrophy that is persistent despite pharmacotherapy, ITR is a cost-effective treatment that should be considered prior to immunotherapy.

LEVEL OF EVIDENCE

NA - Laryngoscope, 2023 Laryngoscope, 134:1572-1580, 2024.

The effect of PM2.5 on acute sinusitis: A population-based study

KEY POINTS

PM2.5 exposure is a risk factor for the development of acute sinusitis. PM2.5 exposure affects acute sinusitis in a dose response fashion.

Impact of dupilumab prescribing on utilization of medical and surgical therapies for chronic rhinosinusitis with nasal polyps

KEY POINTS

Increased dupilumab utilization coincided with decreased ESS in patients with CRSwNP between 2019 and 2021. One potential confounder was the concurrent COVID-19 pandemic, which may have negatively impacted surgery utilization rates.

Cost-effectiveness analysis of biologics for the treatment of chronic rhinosinusitis with nasal polyps in Canada

BACKGROUND

Dupilumab, omalizumab, and mepolizumab are the three biologics currently approved for use in CRSwNP in Canada. Despite evidence of efficacy, their cost-effectiveness, which is a key factor influencing prescribing patterns, has not yet been compared to each other.

METHODS

A cost-effectiveness model using quality-adjusted life years (QALYs) was constructed using a Decision Tree Markov analysis. A third-party healthcare payer perspective and a 10-year time horizon was used. A willingness-to-pay (WTP) threshold of 50,000 Canadian dollars (CAD) per QALY was used to determine cost-effectiveness. Dupilumab, omalizumab, and mepolizumab were each compared to each other.

RESULTS

Omalizumab was the most cost-effective biologic using current estimates of cost and efficacy in CRSwNP. Using omalizumab as a baseline, dupilumab had an ICER of $235,305/QALY. Mepolizumab was dominated by omalizumab and dupilumab at the current drug prices and estimates of efficacy. Sensitivity analyses determined that when increasing the WTP threshold to $150,000/QALY, dupilumab became cost-effective compared to omalizumab in 22.5% of simulation scenarios. Additionally, altering dosing frequency had a significant effect on cost-effectiveness.

CONCLUSION

When comparing the relative cost-effectiveness of biologics in recalcitrant CRSwNP, omalizumab currently appears to be the most cost-effective option. Future reductions in drug prices, adjustments to currently approved dosing regimens, better patient selection, and improvements in sinus surgery outcomes will challenge the current cost-effectiveness models and necessitate reassessment as treatments for CRSwNP continue to evolve.

Mobile health school screening and telemedicine referral to improve access to specialty care in rural Alaska: a cluster- randomised controlled trial

BACKGROUND

School-based programmes, including hearing screening, provide essential preventive services for rural children. However, minimal evidence on screening methodologies, loss to follow-up, and scarcity of specialists for subsequent care compound rural health disparities. We hypothesised telemedicine specialty referral would improve time to follow-up for school hearing screening compared with standard primary care referral.

METHODS

In this cluster-randomised controlled trial conducted in 15 rural Alaskan communities, USA, we randomised communities to telemedicine specialty referral (intervention) or standard primary care referral (control) for school hearing screening. All children (K-12; aged 4-21 years) enrolled in Bering Straight School District were eligible. Community randomisation occurred within four strata using location and school size. Participants were masked to group allocation until screening day, and assessors were masked throughout data collection. Screening occurred annually, and children who screened positive for possible hearing loss or ear disease were monitored for 9 months from the screening date for follow-up. Primary outcome was the time to follow-up after a positive hearing screen; analysis was by intention to treat. The trial was registered with ClinicalTrials.gov, NCT03309553.

FINDINGS

We recruited participants between Oct 10, 2017, and March 28, 2019. 15 communities were randomised: eight (750 children) to telemedicine referral and seven (731 children) to primary care referral. 790 (53·3%) of 1481 children screened positive in at least one study year: 391 (52∤1%) in the telemedicine referral communities and 399 (50∤4%) in the primary care referral communities. Of children referred, 268 (68·5%) in the telemedicine referral communities and 128 (32·1%) in primary care referral communities received follow-up within 9 months. Among children who received follow-up, mean time to follow-up was 41·5 days (SD 55·7) in the telemedicine referral communities and 92·0 days (75·8) in the primary care referral communities (adjusted event-time ratio 17·6 [95% CI 6·8-45·3] for all referred children). There were no adverse events.

INTERPRETATION

Telemedicine specialty referral significantly improved the time to follow-up after hearing screening in Alaska. Telemedicine might apply to other preventive school-based services to improve access to specialty care for rural children.

FUNDING

Patient-Centered Outcomes Research Institute.

Identifying barriers to care for complex airway disease and multidisciplinary solutions to optimize therapy in Canada

Background

Complex airway disease such as Chronic Rhinosinusitis with Asthma or Aspirin Exacerbated Respiratory Disease requires a multidisciplinary approach to management and treatment. Many centers in the USA have created collaborative multidisciplinary clinics to support the management of these patients; however, similar structures do not appear to exist in Canada.

Methods

This mixed methods study used a combination of structured interviews and a cross-sectional national survey. Interviewees included members of the Canadian Rhinology Working Group and survey participants were a combination of academic and community Rhinologists, Respirologists and Allergists. All participation was voluntary and selection criteria was based on their involvement in treating complex airway disease. Our objective was to identify the current state of diagnosis and treatment of complex airway patients in Canada between Rhinology, Respirology and Allergy and understand the barriers, challenges and propose solutions to establishing a multidisciplinary airway clinic in Canada.

Results

Four Rhinologists participated in qualitative interviews and a convenience sample of 42 specialists through our known network responded to our quantitative survey. From our survey, 54.8% believed multidisciplinary clinics were necessary in the management of complex airway disease, providing better outcomes and cost-savings (69%, 45.2%). Most specialties agreed that history, physical, pulmonary function and skin prick testing was important for diagnosis (92.9%, 92.9%, 88.1%). If clinicians were to participate in a multidisciplinary clinic, they would be willing to forego an average of 14.2% of their mean daily income for that clinic. The ideal clinic location was split between a neutral shared location vs. a Rhinology clinic space (38.1%, 45.2%).

Conclusions

Complex airway diseases are currently managed in subspecialty silos resulting in fragmented care. Our study highlights gaps in management, areas for improvement and support for establishing multidisciplinary complex airway disease clinics in Canada to better treat this population.

The prevalence of CFTR mutations in patients with chronic rhinosinusitis: A systematic review and meta-analysis

OBJECTIVES

Undetected cystic fibrosis transmembrane regulator (CFTR) mutations may predispose individuals to develop CRS independent of formal CF diagnosis. The objective of this study was to determine the prevalence of CFTR mutations among individuals with CRS.

DESIGN

A systematic search following PRISMA guidelines was performed. A meta-analysis was performed to calculate pooled estimates for the prevalence of any CFTR mutation and for the DF508 mutation.

SETTING AND PARTICIPANTS

The systematic search included all studies identifying adults diagnosed with CRS, with no limitation to region or publication date. Studies had to identify a sample of patients previously diagnosed with CRS but not with CF and reporting testing for the prevalence of CF or the CFTR gene mutation.

MAIN OUTCOME MEASURES

Prevalence of CFTR mutations among the general CRS population, with subgroup analysis of individuals with the dF508 mutation.

RESULTS AND CONCLUSIONS

The 6 included studies represented five countries: the United States, the UK, France, Poland and Finland. The pooled prevalence of CFTR mutations of any kind in CRS subjects without CF was 5.65% (RE 95% CI 2.99 - 10.41). The overall prevalence for the dF508 mutation was 4.22% (RE 95% CI 1.71 - 10.07). These estimates were significantly higher than the baseline estimated prevalence of CFTR carrier status of 3%-4% in the general population. However, the clinical relevance of the presence of CFTR mutations in CRS patients who have not been diagnosed with CF is currently unclear. Future studies should include sweat chloride testing as a measure of CFTR function.

Cost-effectiveness analysis comparing dupilumab and aspirin desensitization therapy for chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRSwNP) in the setting of aspirin-exacerbated respiratory disease (AERD) is a disease that is difficult to treat and prone to recurrence. Dupilumab is a promising treatment for these patients, but its cost-effectiveness has not yet been compared with aspirin (acetylsalicyclic acid, or ASA) desensitization, a known and effective treatment. We aimed to compare the cost-effectiveness of ASA desensitization with dupilumab therapy for the treatment of CRSwNP in AERD.

METHODS

Analyses of cost-effectiveness, as measured in quality-adjusted life years (QALYs), and cost-utility, as measured in number of required revision endoscopic sinus surgeries (ESSs), were conducted.

RESULTS

ASA desensitization after ESS was cost-effective and dominated appropriate medical management. Adding salvage dupilumab was also cost-effective (incremental cost-effectiveness ratio [ICER] $135,517.33), and upfront dupilumab therapy was not cost-effective in any scenario (ICER $273,181.32). The cost-utility analysis demonstrated that, over a 10-year period per patient, appropriate medical management after ESS cost $54,125.31 and resulted in 2.25 revision ESSs, ASA desensitization after ESS cost $53,775.15 and resulted in 2.02 revision ESSs, ASA desensitization with salvage dupilumab cost $121,176.25 and resulted in 1.68 revision ESSs, and upfront dupilumab cost $185,950.34 and resulted in 1.51 revision ESSs.

CONCLUSION

Dupilumab for the treatment of severe CRSwNP was found to be cost-effective as salvage therapy under the willingness-to-pay threshold of $150,000. Further analysis highlighted that the cost-effectiveness of dupilumab was most sensitive to drug price and expected gains in quality of life. This suggests that additional investigation into improving patient population selection and tailoring treatment algorithms may improve the cost-effectiveness of dupilumab in specific scenarios.

The effect of prior radiation on the success of ventral skull base reconstruction: A systematic review and meta-analysis

The incidence of cerebrospinal fluid leak after ventral skull base reconstruction is a primary outcome of interest to skull base surgeons. Exposure to pre-operative radiation may put patients at an increased risk of skull base reconstructive failure. A systematic search identified studies which included patients receiving ventral skull base reconstruction in the setting of pre-operative radiation. A meta-analysis using a random effects model was conducted to estimate an odds ratio of cerebrospinal fluid (CSF) leak in patients exposed to pre-operative radiation. A meta-analysis of 13 studies demonstrated that the odds ratio of CSF leak was 1.73 (95% CI 0.98-3.05). The majority of studies (77%) used vascularized tissue grafts for reconstruction. We identified an increased incidence of CSF leak among patients undergoing ventral skull base reconstruction after prior radiation therapy, although not of statistical significance. Skull base surgeons should exercise caution when planning reconstruction in this population.

SARS-CoV-2 in migrant worker dormitories: Geospatial epidemiology supporting outbreak management

Background

Migrant worker dormitories—residential complexes where 10–24 workers share living spaces—account for the majority of cases of SARS-CoV-2 infection in Singapore. To prevent overspill of transmission to the wider population, starting in early April 2020, residents were confined to their dormitories while measures were put in place to arrest the spread of infection. This descriptive study presents epidemiological data for a population of more than 60 000 migrant workers living in two barracks-style and four apartment-style dormitories located in western Singapore from April 3 to June 10, 2020.

Methods

Our report draws from data obtained over the first 50 days of outbreak management in order to describe SARS-CoV-2 transmission in high-density housing environments. Cumulative counts of SARS-CoV-2 cases and numbers of housing units affected were analyzed to report the harmonic means of harmonic means of doubling times and their 95% confidence intervals (CI).

Results

Multiple transmission peaks were identified involving at least 5467 cases of SARS-CoV-2 infection across six dormitories. Our geospatial heat maps gave an early indication of outbreak severity in affected buildings. We found that the number of cases of SARS-CoV-2 infection doubled every 1.56 days (95% CI 1.29–1.96) in barracks-style buildings. The corresponding doubling time for apartment-style buildings was 2.65 days (95% CI 2.01–3.87).

Conclusions

Geospatial epidemiology was useful in shaping outbreak management strategies in dormitories. Our results indicate that building design plays an integral role in transmission and should be considered in the prevention of future outbreaks.

How the World's Children Hear: A Narrative Review of School Hearing Screening Programs Globally

Objective

School hearing screening may mitigate the effects of childhood hearing loss through early identification and intervention. This study provides an overview of existing school hearing screening programs around the world, identifies gaps in the literature, and develops priorities for future research.

Data Sources

A structured search of the PubMed, Embase, and Cochrane Library databases.

Review Methods

A total of 65 articles were included according to predefined inclusion criteria. Parameters of interest included age groups screened, audiometric protocols, referral criteria, use of adjunct screening tests, rescreening procedures, hearing loss prevalence, screening test sensitivity and specificity, and loss to follow-up.

Conclusions

School hearing screening is mandated in few regions worldwide, and there is little accountability regarding whether testing is performed. Screening protocols differ in terms of screening tests included and thresholds used. The most common protocols included a mix of pure tone screening (0.5, 1, 2, and 4 kHz), otoscopy, and tympanometry. Estimates of region-specific disease prevalence were methodologically inaccurate, and rescreening was poorly addressed. Loss to follow-up was also a ubiquitous concern.

Implications for Practice

There is an urgent need for standardized school hearing screening protocol guidelines globally, which will facilitate more accurate studies of hearing loss prevalence and determination of screening test sensitivity and specificity. In turn, these steps will increase the robustness with which we can study the effects of screening and treatment interventions, and they will support the development of guidelines on the screening, diagnostic, and rehabilitation services needed to reduce the impact of childhood hearing loss.

Cost-effectiveness of School Hearing Screening Programs: A Scoping Review

Objective

School hearing screening is a public health intervention that can improve care for children who experience hearing loss that is not detected on or develops after newborn screening. However, implementation of school hearing screening is sporadic and supported by mixed evidence to its economic benefit. This scoping review provides a summary of all published cost-effectiveness studies regarding school hearing screening programs globally. At the time of this review, there were no previously published reviews of a similar nature.

Data Sources

A structured search was applied to 4 databases: PubMed (Medline), Embase, CINAHL, and Cochrane Library.

Review Methods

The database search was carried out by 2 independent researchers, and results were reported in accordance with the PRISMA-ScR checklist and the JBI methodology for scoping reviews. Studies that included a cost analysis of screening programs for school-aged children in the school environment were eligible for inclusion. Studies that involved evaluations of only neonatal or preschool programs were excluded.

Results

Four of the 5 studies that conducted a cost-effectiveness analysis reported that school hearing screening was cost-effective through the calculation of incremental cost-effectiveness ratios (ICERs) via either quality- or disability-adjusted life years. One study reported that a new school hearing screening program dominated the existing program; 2 studies reported ICERs ranging from 1079 to 4304 international dollars; and 1 study reported an ICER of £2445. One study reported that school-entry hearing screening was not cost-effective versus no screening.

Conclusion

The majority of studies concluded that school hearing screening was cost-effective. However, significant differences in methodology and region-specific estimates of model inputs limit the generalizability of these findings.

INNOVATIVE POLICIES AND TECHNOLOGIES TO INCREASE ACCESS TO HEARING AIDS FOR ADULTS

As the proportion of older adults in the world’s total population continues to grow, the deleterious downstream health economic outcomes of age-related hearing loss are steadily becoming more prevalent. While recent research has shown that age-related hearing loss is the single greatest modifiable risk factor for dementia, the rate of hearing aid use remains low in many countries across the globe. Reasons for poor uptake are multifactorial and likely involve a combination of factors, ranging from increasing costs of hearing aid technology to lack of widespread insurance coverage. This paper aims to first identify the current state of hearing aid access across the world using eight representative countries as examples. We then provide recommendations on how to facilitate greater access to hearing aids for consumers by addressing areas in regulation, technology, reimbursement, and workforce.

Access to adults' hearing aids: policies and technologies used in eight countries

As the proportion of older adults in the world’s total population continues to grow, the adverse health outcomes of age-related hearing loss are becoming increasingly recognized. While research has shown that age-related hearing loss is the single greatest modifiable risk factor for dementia, use of hearing aids remains low worldwide, even in many middle- and high-income countries. Reasons for poor uptake of hearing aids are likely to involve a combination of factors, ranging from increasing costs of hearing aid technology to a widespread lack of insurance coverage. This article aims to identify the current state of access to hearing aids, focusing on eight middle- and high-income countries. We discuss how to facilitate greater access to hearing aids for patients by addressing changes in how devices are regulated, technological advancements in hearing devices, the need to adjust reimbursement schemes and the importance of adaptation among the community workforce for hearing-care.

The importance of both CYP2C19 and CYP2B6 germline variations in cyclophosphamide pharmacokinetics and clinical outcomes

Cyclophosphamide is an alkylating agent used in the treatment of solid and haematological malignancies and as an immunosuppressive agent. As a prodrug, it is dependent on bioactivation to the active phosphoramide mustard metabolite to elicit its therapeutic effect. This focused review will highlight the evidence for the role of germline pharmacogenetic variation in both plasma pharmacokinetics and clinical outcomes. There is a substantial indication from 13 pharmacokinetic and 17 therapeutic outcome studies, in contexts as diverse as haematological malignancy, breast cancer, systemic lupus erythematosus and myeloablation, that pharmacogenetic variation in both CYP2C19 and CYP2B6 influence the bioactivation of cyclophosphamide. An additional role for pharmacogenetic variation in ALDH1A1 has also been reported. Future studies should comprehensively assess these 3 pharmacogenes and undertake appropriate statistical analysis of gene-gene interactions to confirm these findings and may allow personalised treatment regimens.

Subjective and objective vestibular changes that occur following paediatric cochlear implantation: systematic review and meta-analysis

Objective

Cochlear implantation can result in post-operative vestibular dysfunction of unknown clinical significance. The objective of this study was to characterize the presence, magnitude, and clinical significance of vestibular dysfunction that occurs after pediatric cochlear implantation.

Data sources

The databases Embase, Medline (OvidSP), and PubMed were used. Only articles published in English were included. Grey literature and unpublished sources were also reviewed.

Study selection

Articles published from 1980 until the present which documented pre-operative and post-operative vestibular testing on children under the age of 18 were used.

Data extraction

Parameters that were assessed included number of patients, pre- and post-operative vestibular-evoked myogenic potentials (VEMPs), head impulse testing (HIT), calorics, and posturography, timing of pre- and post-operative testing, symptomatology, and other demographic data such as etiology of the hearing loss.

Data synthesis

Ten articles were included. Relative risk values evaluating the effect of cochlear implantation on vestibular function were calculated for VEMPs and caloric testing due to the availability of published data. I² values were calculated and 95% confidence intervals were reported. Separate analyses were conducted for each individual study and a pooled analysis was conducted to yield an overall relative risk. Assessment on risk of bias in individual studies and overall was performed.

Conclusion

Pediatric cochlear implantation is associated with a statistically significant decrease in VEMP responses post-operatively (RR 1.8, p < 0.001, I² 91.86, 95%CI 1.57–2.02). Similar results are not seen in caloric testing. Insufficient data is available for analysis of HIT and posturography. Further studies are necessary to determine the effect of cochlear implantation on objective vestibular measures post-operatively and whether any changes seen are clinically relevant in this population.

The use of video glasses improved learning of tonsillectomy and adenoidectomy surgery: A randomized controlled trial

OBJECTIVE

One of the most common challenges in surgical education for trainees is gaining practical experience through observing procedures in the operating room. Due to the nature of some procedures, a narrow surgical view severely limits the learning experience. Video glasses are new devices that offer the potential to project the primary surgeon's exact view to learners in real-time, allowing for an enhanced operative learning experience.

STUDY DESIGN

Single center randomized prospective trial.

SETTING

Tertiary care pediatric hospital.

PARTICIPANTS

Using block randomization, medical students and surgical residents observed either a tonsillectomy or adenoidectomy, either directly at table-side or by real-time video feed from the surgeon's video glasses projected to a screen in the operating room, in random order. Participants then completed a survey comparing aspects of their learning experience viewing the procedure through the video feed in comparison to direct observation.

MAIN OUTCOME MEASURES

Evaluating the hypothesis that video glasses provided an improved overall learning experience and a realistic simulation of the open surgical procedures tested.

RESULTS

23 trainees participated in the study. Survey results demonstrated that the overall learning experience with the use of video glasses was significantly improved when compared to direct visualization (average Visual Analog Scale (VAS) score 82/100 vs. 64/100, p = 0.021). Video glasses were shown to be superior when comparing the view of the surgical field (83/100 vs. 54/100 on VAS, p < 0.001) and the ability to identify anatomical structures (79/100 vs. 56/100 on VAS, p = 0.001). The ease of following surgical steps with video glasses was also shown to be better than by direct visualization (81/100 vs. 69/100 on VAS, p = 0.039). All participants stated that video glasses closely simulated the learning environment of the real-life open procedure.

CONCLUSION

This study showed that the use of video glasses was beneficial for surgical education and a realistic tool for learners at varying levels of training. Video glasses may significantly improve the learning experience for procedures with a narrow field of view.

Myocardial perfusion/metabolism mismatch and ventricular arrhythmias in the chronic post infarction state

Aim: Ventricular arrhythmias have been shown to originate in the myocardial peri-infarct region due to irregular heterotopic conduction. Hypoperfused but viable myocardium is often localised in those areas and may be involved in the pathogenesis of arrhythmias. We tested the hypothesis that these myocardial perfusion/metabolism mismatches (MM) are significantly associated with ventricular arrhythmias in the chronic post infarction state. Patients, methods: 47 post infarction patients were included in the study. 33 suffered from ventricular arrhythmia whereas 14 did not. All patients underwent 99mTc tetrofosmin SPECT and 18F-FDG PET. A region-of-interest(ROI)-analysis was used to assess viable myocardium based on predefined MM-criteria. Univariate analyses as well as a logistic regression model for the multivariate analysis were carried out. Results: 94% of the arrhythmic patients displayed at least one MM-segment as compared to 64% of the non-arrhythmic patients. MMsegments and arrhythmia showed a statistically significant relation (p = 0.018). The logistic regression model predicted the occurrence or absence of arrhythmia in 85% of all cases. Multivariate analysis gave consistent results, after adjusting for symptomatic chronic heart failure (CHF), aneurysms and age. Conclusion: Our results support the hypothesis that hypoperfused but viable myocardium represents an arrhythmogenic substrate and is a relevant risk factor for developing ventricular arrhythmias following myocardial infarction. Therefore, the detection of MM-segments allows the identification of patients with a higher risk for future cardiac events.

Endoscopic ear surgery in Canada: a cross-sectional study

Background

Endoscopic ear surgery is an emerging technique with recent literature highlighting advantages over the traditional microscopic approach. This study aims to characterize the current status of endoscopic ear surgery in Canada and better understand the beliefs and concerns of the otolaryngology – head & neck surgery community regarding this technique.

Methods

A cross-sectional survey study of Canadian otolaryngologists was performed. Members of the Canadian Society of Otolaryngology were contacted though an online survey carried out in 2015.

Results

The majority of participants in this study (70 %) used an endoscope in their practice, with a large proportion utilizing the endoscope for cholesteatoma or tympanoplasty surgery. To date, 38 Canadian otolaryngologists (70 % of respondents) have used an endoscope for at least 1 surgical case, but only 6 (11 %) have performed more than 50 endoscopic cases. Of the otolaryngologists who use endoscopes regularly, the majority still use the microscope as their primary instrument and use the endoscope only as an adjunct during surgery. However, the general attitude surrounding endoscopes is positive; 81 % believe that endoscopes have a role to play in the future of ear surgery and 53 % indicated they were likely to use endoscopes in their future practice. Participants who were earlier in their practice or who had more exposure to endoscopic techniques in their career were more likely to have a positive stance towards endoscopic ear surgery (p < 0.05, p < 0.01, respectively). The main concern regarding endoscopic ear surgery was the technical challenge of one-handed surgery, while the primary perceived advantage was the reduced rates of residual or recurrent disease.

Conclusions

Endoscopic ear surgery is a new technique that is gaining momentum in Canada and there is enthusiasm for its incorporation into future practice. Further investment in training courses and guidance for those looking to start or advance the use of endoscopes in their practice will be vital in the years to come.

Electronic supplementary material

The online version of this article (doi:10.1186/s40463-016-0117-7) contains supplementary material, which is available to authorized users.

Expression and significance of ERβ and TrkB in endometriosis

OBJECTIVES

To study the potential pathogenesis of endometriosis (EMs) in an area of estrogen receptors (ERs) and tyrosine kinase receptor type B (TrkB) expressions in tissues from patients with EMs.

STUDY DESIGN

The authors examined the expressions of ERα, ERβ, TrkB, brain-derived neurotrophic factor (BDNF), and SGPL1 in tissues with EMs, using real-time PCR, western blot, and immunohistochemistry.

RESULTS

ERα and SGPL1 were mainly expressed in eutopic endometrium than that in ectopic endometrium of patients with ovarian endometriosis (p < 0.05), while ERβ, BDNF, and TrkB were adverse, mainly detected in ectopic endometrium of the same patients with EMs (p < 0.01 and p < 0.05 ) by real-time PCR and western blot. ERβ, ERα, TrkB, and SGPL1 proteins were mainly expressed in eutopic endometrium of proliferative phase with EMs than that in eutopic endometrium of secretory phase (p < 0.05 ). TrkB, BDNF, and SGPL1 were not found in endometrium of proliferative or secretory phase in control group.

CONCLUSIONS

ERβ expressed in cytoplasm may mediate pathogenesis of EMs.

Management of pediatric penile keloid

Keloids are abnormal scar tissue growths that extend beyond the original area of injury, occasionally occurring post-surgery. Risk factors for keloids include skin trauma, infection, prolonged wound healing and individuals of certain ethnicities. Keloid formation on the penis, however, is a rare occurrence even among circumcised males, and can produce both aesthetic and functional complications. We document the tenth patient in the literature, to our knowledge, to present with a keloid of the penis.

Imiquimod use in adolescents: off-label but effective

Genital warts are very common in the under-18 years old population, yet treatment with imiquimod is currently off-label. We looked at 50 cases of genital warts in patients aged under 18 years who had been treated with Imiquimod to see if this treatment was effective, and it was.

P4-11-19: Healthcare Resource Utilization among Breast Cancer Patients with Bone Metastases and Skeletal-Related Events: A Population-Based Cohort Study in Denmark (1997 - 2009)

Background

The healthcare resource utilization (HRU) of breast cancer patients who develop bone metastases and skeletal-related events (SREs) has not been well-characterized. Our objective was to describe the HRU associated with SREs in a large population-based cohort of Danish breast cancer patients with bone metastases and one or more SRE.

Methods: We identified women diagnosed with incident breast cancer from January 1, 1997 through December 31, 2006 using the Danish Cancer Registry. We followed this cohort of patients for development of subsequent bone metastases and SREs identified through the Danish National Registry of Patients through December 31, 2009. SREs were defined as pathologic fracture, spinal cord compression, and radiation or surgery to bone. Among patients with only one SRE, the HRU period, composed of all HRU occurring within a 90-day period after the SRE and within a two-week diagnostic period prior to the SRE, was assessed. For patients with multiple SREs (each one separated by less than 90 days), the HRU period, composed of all HRU occurring within a two-week diagnostic period prior to the first SRE up until 90 days after the last SRE, was described. Patients may have had multiple HRU periods if SREs were separated by more than 90 days. The HRU summarized included number of inpatient hospitalizations, length of hospitalization stay, outpatient physician visits, emergency room visits, and procedures.

Results: We identified 1,148 patients with bone metastases and SREs among 38,485 breast cancer patients. The mean age at breast cancer diagnosis for those who developed bone metastases and SREs was 59 years (SD, 13 years) and the majority (72%) of patients had multiple SREs during the first HRU period. Approximately 20% to 30% of patients with single and multiple SREs, respectively, died within the first HRU period. Overall, length of hospitalization was longest for patients with spinal cord compression followed by patients with pathologic fracture. In general, patients with multiple SREs had higher HRU compared to those with a single SRE in the first HRU period, particularly in length of hospitalization stay.

Conclusion: SREs secondary to bone metastases are serious events. In Denmark, high HRU was observed in all patients with SREs, but especially in those with multiple SREs, where increased lengths of hospitalization were observed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-11-19.

Ministry of Health clinical practice guidelines: bipolar disorder

The Ministry of Health (MOH) has published clinical practice guidelines on Bipolar Disorder to provide doctors and patients in Singapore with evidence-based guidance on the management of bipolar disorders. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Bipolar Disorder, for the information of readers of the Singapore Medical Journal. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http: //www.moh.gov.sg/content/moh_web/home/Publications/guidelines/clinical_practiceguidelines/2011/bipolar_disorder.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Mortality following bone metastasis and skeletal-related events among men with prostate cancer: a population-based analysis of US Medicare beneficiaries, 1999-2006

Information on the impact of bone metastasis and skeletal-related events (SREs) on mortality among prostate cancer patients is limited. Using the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database, we identified men aged 65 years or older diagnosed with prostate cancer between July 1 1999 and December 31 2005 and followed to determine deaths through December 31 2006. We classified subjects as having bone metastasis and SREs as indicated by Medicare claims. Using Cox regression, we estimated mortality hazards ratios (HR) among men with bone metastasis with or without SRE, compared with men without bone metastasis. Among 126,978 men with prostate cancer (median follow-up, 3.3 years), 9746 (7.7%) had bone metastasis at prostate cancer diagnosis (1.7%) or during follow-up (5.9%). SREs occurred in 4296 (44%) men with bone metastasis. HRs for risk of death were 6.6 (95% CI=6.4-6.9) and 10.2 (95% CI=9.8-10.7), respectively, for men with bone metastasis but no SRE and for men with bone metastasis plus SRE, compared with men without bone metastasis. Bone metastasis was associated with mortality among prostate cancer patients. This association appeared to be stronger for bone metastasis plus SRE than for bone metastasis without SRE.

Intratumor RNA interference of cell cycle genes slows down tumor progression

Small interfering RNAs (siRNAs) are emerging as promising therapeutic tools. However, the widespread clinical application of such molecules as modulators of gene expression is still dependent on several aspects that limit their bioavailability. One of the most promising strategies to overcome the barriers faced by gene silencing molecules involves the use of lipid-based nanoparticles (LNPs) and viral vectors, such as adenoviruses (Ads). The primary obstacle for translating gene silencing technology from an effective research tool into a feasible therapeutic strategy remains its efficient delivery to the targeted cell type in vivo. In this study, we tested the capability of LNPs and Ad to transduce and treat locally tumors in vivo. Efficient knockdown of a surrogate reporter (luciferase) and therapeutic target genes such as the kinesin spindle protein (KIF11) and polo-like kinase 1 were observed. Most importantly, this activity led to a cell cycle block as a consequence and slowed down tumor progression in tumor-bearing animals. Our data indicate that it is possible to achieve tumor transduction with si/short hairpin RNAs and further improve the delivery strategy that likely in the future will lead to the ideal non-viral particle for targeted cancer gene silencing.

Diabetes and genital warts: an unhappy coalition

Through clinical practice, it is often perceived that patients with diabetes are more likely to suffer from severe and recalcitrant warts. This study was set up to investigate if genital warts were more common in patients with diabetes and to determine if patients with diabetes and genital warts required more treatment than those without diabetes. Only female patients with diabetes and genital warts were investigated and were compared to the non-diabetic population. Results suggested that patients with diabetes had more extensive warts and recurrences. This study will hopefully further inform the debate surrounding preferential use of quadrivalent human papilloma virus (HPV) vaccine as opposed to bivalent HPV vaccine especially in the setting of a Diabetes Young Person's clinic.

Novel anti-inflammatory action of 5-aminoimidazole-4-carboxamide ribonucleoside with protective effect in dextran sulfate sodium-induced acute and chronic colitis

AMP-activated protein kinase (AMPK) is an important cellular energy sensor that is responsible for maintaining systemic and cellular energy balance. Its role in intestinal inflammation remains unclear. Recent studies indicate that AMPK activation initiated by 5-aminoimidazole-4-carboxamide ribonucleoside (AICAR) participates in modulating inflammatory responses. Inflammatory bowel disease (IBD) has been characterized by sustained intestinal mucosa inflammation, caused mainly by excessive macrophage activation and T helper type 1 (Th1) and Th17 immune responses. Thus, we sought to determine the effect of AICAR on inflammatory responses of murine models of IBD. Mice with acute or chronic colitis induced by dextran sulfate sodium (DSS) were treated with or without AICAR. Body weight and colon inflammation were evaluated, and production of proinflammatory cytokines in colon tissues was determined. Nuclear factor kappaB (NF-kappaB) activation in colon tissues was assayed, and Th1 and Th17 cell responses were also evaluated. By inducing AMPK activation, AICAR had a therapeutic effect in ameliorating acute and chronic DSS-induced murine colitis as shown by reduced body weight, loss and significant attenuation in clinical symptoms, and histological inflammation. Moreover, AICAR treatment inhibited NF-kappaB activation in macrophages, reduced levels of Th1- and Th17-type cytokines in colon tissues, and down-regulated Th1 and Th17 cell responses during the progress of acute and chronic experimental colitis. AICAR acts as a central inhibitor in immune responses of experimental colitis. Our data show that AICAR-initiated AMPK activation may represent a promising alternative to our current approaches to suppress intestinal inflammation in IBD.

Impact of an occupational health promotion program on subsequent illness and mortality experience

BACKGROUND

Integrating general health initiatives into established occupational health programs may be an effective way of contributing more broadly to employee health. Objective assessment of the success of such initiatives is needed, but is often difficult to carry out because of their voluntary nature.

METHODS

A cohort of 24,586 wage employees, 35+ years of age and with 15+ years of prior employment, was established to assess morbidity and mortality outcomes relative to participation in an ongoing health initiative instituted in 1983. Outcomes were evaluated for employees who attended the seminar program (attendees), those who had clearance examinations, but did not take part in the program (withdrawals), and non-participants.

RESULTS

At entry to follow-up, the prevalence of chronic illnesses including diabetes, obesity, and diseases of the circulatory system was lowest among non-participants and highest among withdrawals. During the follow-up period, the incidence of new disease conditions was similar between attendees and non-participants; however, overall mortality was significantly reduced among attendees after adjustment for explanatory factors including age, job grade, smoking history, alcohol intake, and body-mass-index (relative risk = 0.83; 95% confidence interval: 0.69-0.99) and was still marginally decreased when withdrawals were combined with attendees.

CONCLUSIONS

Although self-selection cannot be ruled out as a contributing factor to the reduction in mortality risk among attendees, our findings indicate that offering health promotion activities in the context of an existing occupational health program may benefit overall employee health.

The Incidence of Bone Metastases and Skeletal-Related Events in Breast Cancer Patients: A Population-Based Cohort Study in Denmark (1999 – 2007)

Background Breast cancer (BrCa) is the most commonly diagnosed cancer among women in the industrialized world. More than half of women presenting with metastatic BrCa develop bone metastases. Bone metastases increase the risk of skeletal-related events (SREs), defined as radiation to bone, pathologic fractures, spinal cord compression, bone surgery, or altered antineoplastic therapy to treat bone pain. Both bone metastases and SREs are associated with unfavorable prognosis and greatly affect quality of life. To date, the epidemiology of the subgroup of BrCa patients who develop bone metastases and/or SREs has not been well-characterized. Our objective was to estimate the one- and five-year incidence of bone metastases and SREs in a large population cohort of newly-diagnosed BrCa patients in Denmark (population ∼ 5.4 million inhabitants). Methods We identified women diagnosed with BrCa (International Classification of Diseases, 10th Revision (ICD-10) code C50.x.) from January 1, 1999 through December 31, 2007, with follow-up through April 2008. We retrieved this data from Denmark's National Registry of Patients (NRP), which includes records from all Danish hospitals. We also identified bone metastases (ICD-10 code C79.5) and recorded SREs. The Kaplan-Meier method was used to estimate time to bone metastases and time to first SRE. We also calculated 1- and 5-year incidence rates (IR) of bone metastases and first SRE in newly-diagnosed BrCa patients. Results We identified 35,941 BrCa patients from the NRP. The median age at diagnosis was 62 years (range, 18-104 years). A total of 1,494 (4%) patients developed bone metastases during follow-up, and of these, 712 developed an SRE. The distribution of SREs by type were 394 (55%) with radiation to the bone, 133 (19%) with pathological or osteoporotic fracture, 42 (6%) with bone surgery, and 143 (20%) with spinal cord compression. The 1-year IR of bone metastases was 13.7 [95% confidence interval (CI): 12.5-15.0] per 1000 person-years (P-Y). The 1-year IR of SREs among patients with bone metastases was 55 times that of the 1-year IR of bone metastases in BrCa patients at 759.2 (95% CI: 662.0-870.5) per 1000 P-Y. After five years of follow-up, the incidence curves plateaued at approximately 4% and 48% for bone metastases and SREs, respectively (Figures 1 and 2). Conclusions Among breast cancer patients with bone metastases, there was a strong tendency towards development of SREs within a year of bone metastases diagnosis; however, this phenomenon stabilized beyond 5 years of bone metastases diagnosis.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2051.

Data standards for minimum information collection for antibody therapy experiments

Research groups developing antibody therapies generate diverse data sets; the value of these sets would be compounded when shared or amalgamated. A complete amalgamation of diverse data sets requires data standards for information collection during experiments. We propose to define elements of the data standards in the form of common data elements (CDEs) in order to clarify each experiment's targets and data values. We have created a set of core information elements which we suggest should be collected from antibody therapy experiments. We propose these as a basis for community consultation with a view to defining a set of data standards which can be developed under the auspices of the Antibody Society.

Survival associated with bone metastases and skeletal-related events in breast cancer patients: A population-based cohort study in Denmark (1999 - 2007)

e22210

Background: Breast cancer (BrCa) is the most commonly diagnosed cancer for women in the industrialized world. Among women who present with metastatic BrCa, more than half will develop bone metastases. Bone metastases increase the risk for skeletal-related events (SREs) defined as radiation to bone, pathologic fractures, spinal cord compression, surgery to bone, or change in antineoplastic therapy to treat bone pain. These complications are associated with an unfavorable prognosis and have a major impact on patients' quality of life. However, data on survival of BrCa patients who experience SREs are lacking. We evaluated survival among BrCa patients without bone metastases, with bone metastases, and with both bone metastases and SREs. Methods: Using Denmark's National Registry of Patients (NRP) database, we conducted a retrospective cohort study in the North and Mid- Jutland Region. Patients with a diagnosis of BrCa from January 1, 1999 through December 31, 2007 were identified using the International Classification of Diseases, 10th Revision (ICD-10) codes C50.x. SREs after BrCa diagnosis were identified using the ICD-10 code C79.5. Cox proportional-hazards regression was used to estimate the mortality rate ratio (MRR), adjusting for age and comorbidity, to compare survival among three subgroups of BrCa patients: no bone metastases, bone metastases, and bone metastases with SREs. Results: We identified 9,474 BrCa patients from the NRP. Of these, 621 (7%) developed bone metastases and 267 (3%) developed both bone metastases and SREs during the study period. The 5-year mortality rates among BrCa patients without bone metastases, with bone metastases, and with bone metastases and SREs were 50.7 per 1,000 person-years (PYs), 469 per 1,000 PYs, and 712 per 1,000 PYs, respectively. Compared to BrCa patients without bone metastases, the adjusted MRRs among BrCa patients with bone metastases and patients with bone metastases and SREs were 11.6 [95% confidence interval (CI): 10.9 - 13.6] and 18.1 (95% CI: 15.5 - 21.0), respectively. Conclusions: Our results suggest that bone metastases and SREs have a major impact on the overall mortality of BrCa patients in Denmark.

[Table: see text]

Prevalence of early-stage prostate and estrogen receptor positive (ER+) breast cancer patients receiving primary androgen deprivation therapy (ADT) and aromatase inhibitors (AIs) in the United States (U.S.)

e22126

Background: AIs and ADT are used to prevent recurrence of breast and prostate cancers but have been shown to accelerate bone loss. We estimated the prevalence of early-stage ER+ breast and prostate cancer patients on hormone therapy in the U.S., as this is not well-described in the literature. Methods: Data from the Surveillance, Epidemiology, and End Results (SEER) Program, published literature, clinical practice, and a large claims database were used. We began with the American Cancer Society's estimated number of new breast and prostate cancer cases for the year 2008. We then assessed the number of patients with localized/regional disease and ER+ tumors and those receiving primary ADT (both chemical and surgical) or AI therapy by applying proportions from SEER, published literature, clinical practice, and the claims database. Using these incident case counts, we calculated the 5-year prevalence using appropriate cohort-specific survival rates to sum the number of new and surviving cases over a 5-year period. Results: The estimated 5-year prevalence of early-stage ER+ breast cancer for women aged ≥50 years in the U.S. was 607,411, of which 293,904 (48.4%) were on AI therapy based on the claims database. However, because this data source was limited to women aged <65 years, we also used estimates from clinical practice to capture AI use for women of all ages. Based on clinical practice, 402,637 (66.3%) to 460,156 (75.8%) of early-stage ER+ breast cancer patients were on AI therapy. For early-stage prostate cancer, the estimated 5-year prevalence for all ages was 1,024,238, of which 141,451 (13.8%) were on primary ADT. However, these figures may underestimate current usage of hormone therapies, as our data and the literature show increasing trends in ADT and AI use for early-stage disease. Conclusions: Based on a combination of population-based data and the published literature, approximately half of all early-stage ER+ breast cancer patients and a modest proportion of early-stage prostate cancer patients are on hormone therapy in the U.S.

[Table: see text]