Differences in Hearing Devices and Speech Therapy Utilization Between Children With Permanent Unilateral Versus Bilateral Hearing Loss

OBJECTIVES

In this study, we aimed to describe differences in diagnosis and both auditory and speech/language intervention utilization between children with permanent unilateral hearing loss as compared with bilateral hearing loss.

DESIGN

A retrospective cohort study was performed of children evaluated in a multidisciplinary hearing loss clinic at a tertiary care pediatric hospital. Children aged 0 to 18 years with either permanent unilateral or bilateral hearing loss were included.

RESULTS

One hundred fourteen children with unilateral hearing loss and 268 children with bilateral hearing loss were studied for a total of 382 children. There were no demographic differences between children with permanent unilateral versus bilateral hearing loss. Rates of newborn hearing screening and referred screening results were similar between those with unilateral and bilateral hearing loss. Despite similar rates of referred newborn hearing screening, those with bilateral hearing loss were diagnosed at a younger age (mean 3.6 years, SD 3.8 years) as compared with those with unilateral hearing loss (mean 5.0 years, SD 4.2 years). Children with unilateral hearing loss had similar severity of hearing loss in their poorer hearing ear as compared with children with bilateral hearing loss, yet they were significantly less likely to be fitted with hearing devices (53% versus 78%) or receive speech/language therapy (36% versus 54%) as compared with children with bilateral hearing loss. Multivariate analysis found that bilateral hearing loss and earlier age of hearing loss diagnosis were associated with hearing device use.

CONCLUSIONS

Early diagnosis and intervention for childhood hearing loss have a significant impact on a child's educational success and social relationships. However, little is known about differences in diagnosis and resource utilization between children with permanent unilateral hearing loss versus bilateral hearing loss. Children with unilateral hearing loss were diagnosed at a later age and were less likely to utilize hearing devices or speech/language therapy compared with those with bilateral hearing loss, despite having similar severity of hearing loss in the poorer hearing ear. There is a strong body of evidence that children with unilateral hearing loss have improved hearing outcomes with hearing devices, which suggests there is room for improvement in identifying unilateral hearing loss and providing adequate services to optimize educational success. However, speech therapy is generally implemented in response to language delays. Therefore, children with unilateral loss may have lower rates of language delays as compared with those with bilateral hearing loss, thereby explaining differences in speech therapy utilization.

Tumor resistance to anti-mesothelin CAR-T cells caused by binding to shed mesothelin is overcome by targeting a juxtamembrane epitope

Despite many clinical trials, CAR-T cells are not yet approved for human solid tumor therapy. One popular target is mesothelin (MSLN) which is highly expressed on the surface of about 30% of cancers including mesothelioma and cancers of the ovary, pancreas, and lung. MSLN is shed by proteases that cleave near the C terminus, leaving a short peptide attached to the cell. Most anti-MSLN antibodies bind to shed MSLN, which can prevent their binding to target cells. To overcome this limitation, we developed an antibody (15B6) that binds next to the membrane at the protease-sensitive region, does not bind to shed MSLN, and makes CAR-T cells that have much higher anti-tumor activity than a CAR-T that binds to shed MSLN. We have now humanized the Fv (h15B6), so the CAR-T can be used to treat patients and show that h15B6 CAR-T produces complete regressions in a hard-to-treat pancreatic cancer patient derived xenograft model, whereas CAR-T targeting a shed epitope (SS1) have no anti-tumor activity. In these pancreatic cancers, the h15B6 CAR-T replicates and replaces the cancer cells, whereas there are no CAR-T cells in the tumors receiving SS1 CAR-T. To determine the mechanism accounting for high activity, we used an OVCAR-8 intraperitoneal model to show that poorly active SS1-CAR-T cells are bound to shed MSLN, whereas highly active h15B6 CAR-T do not contain bound MSLN enabling them to bind to and kill cancer cells.

Nanobody-Based ImmunoPET for Hepatocellular Carcinoma

PURPOSE/OBJECTIVE(S)

HCC accounts for 75-90% of all primary liver cancers, the majority of which are treated with liver-directed therapy. Treatment response and recurrence are difficult to discern using conventional imaging with MR/CT. Tumor-selective PET imaging could help with clinical management in this setting. Here, we engineer HN3, a single-domain antibody (nanobody) specific to GPC3, a histopathologically-defining HCC marker, as an immunoPET agent. We compared both conventional and sortase-based site-specific modification methods for synthesizing HN3 immunoPET tracers.

MATERIALS/METHODS

Stochastic lysine conjugation with deferoxamine (DFO-NCS) was done to synthesize nHN3-DFO. ssHN3-DFO was engineered utilizing sortase-mediated conjugation of HN3 containing an LPETG C-terminal tag and a triglycine-DFO chelator. Biolayer interferometry (BLI) and radioligand saturation assays were done to determine binding affinity pre- and post-Zirconium-89 labeling. Following, PET/CT with a terminal 3-hour biodistribution was done in mice inoculated with isogenic A431 and A431-GPC3+ xenografts to determine conjugate specificity for GPC3. Finally, conjugates were evaluated in a HepG2 liver cancer model via ex vivo biodistribution studies and a comparative PET/CT study in mice bearing HepG2 tumors that were imaged with both [18F]FDG and 89Zr-ssHN3.

RESULTS

Both conjugates exhibited nanomolar binding affinity for GPC3 in vitro (11-30 nM for nHN3 and 10-15 nM for ssHN3). A431 and A431-GPC3+ PET/CT and biodistribution studies showed specificity to GPC3 by both probes, with more favorable tumor uptake by 89Zr-ssHN3 at 3 hours post-injection (14% IA/g vs. 7% IA/g for nHN3). Both tracers also displayed uptake in HepG2 (GPC3+) liver tumors, again with the site specifically conjugated probe having higher tumor accumulation and lower liver signal than the conventionally modified HN3 (7% IA/g vs. 5 % IA/g for tumor and 2% IA/g vs. 4% IA/g for liver at 1-hour post-injection). PET/CT studies in mice imaged with [18F]FDG and 89Zr-ssHN3 demonstrated more consistent tumor accumulation for the nanobody conjugate (4/4 mice had uptake by the tumor vs. 1/4 for FDG).

CONCLUSION

We successfully designed, synthesized, and characterized novel GPC3-selective nanobody PET probes that can image liver tumors in vivo. The site-specifically conjugated tracer showed more favorable biodistribution and pharmacokinetic properties, resulting in a much higher tumor: liver signal compared to 89Zr-nHN3. We also show the superiority of the 89Zr-ssHN3 imaging over conventional [18F]FDG, highlighting a clear advantage in using targeted tumor imaging for this cancer type. Successful translation of the site-specifically conjugated nanobody may ultimately aid in characterizing lesions following liver-directed therapy and allow for more comprehensive screening, early diagnosis, and post-treatment surveillance of HCC.

Comparison of United Kingdom and United States screening criteria for detecting retinopathy of prematurity in Hong Kong

INTRODUCTION

We examined whether the United Kingdom (UK) or the United States (US) screening criteria are more appropriate for retinopathy of prematurity (ROP) screening in Hong Kong, in terms of sensitivity for detecting type 1 ROP and the number of infants requiring screening.

METHODS

In this retrospective cohort study, we reviewed the medical records of all infants who underwent ROP screening from 2009 to 2018 at a tertiary hospital in Hong Kong. During this period, all infants born at gestational age (GA) ≤31 weeks and 6 days or birth weight (BW) <1501 g (ie, the UK screening criteria) underwent ROP screening. We determined the number of infants requiring screening and the number of type 1 ROP cases that would have been missed if the US screening criteria (GA ≤30 weeks & 0 days or BW ≤1500 g) had been used.

RESULTS

Overall, 796 infants were screened using the UK screening criteria. If the US screening criteria had been used, the number of infants requiring screening would have decreased by 21.1%; all type 1 ROP cases would have been detected (38/38, 100% sensitivity). Of the 168 infants who would not have been screened using the US screening criteria, only four of them (2.4%) had developed ROP (all maximum stage 1 only).

CONCLUSION

In our population, the use of the US screening criteria could reduce the number of infants screened without compromising sensitivity for the detection of type 1 ROP requiring treatment. We suggest narrowing the GA criterion for consistency with the US screening criteria during ROP screening in Hong Kong.

Improved responsiveness to change in joint space width over 24-month follow-up: comparison of 3D JSW on weight-bearing CT vs 2D JSW on radiographs in the MOST study

OBJECTIVE

Radiographic joint space width (JSW) has been a standard for measuring knee osteoarthritis (OA) structural change. Limitations in the responsiveness of this approach might be overcome by instead measuring 3D JSW on weight-bearing CT (WBCT). This study compared the responsiveness of 3D JSW measurements using WBCT with the responsiveness of radiographic 2D JSW.

DESIGN

Standing, fixed-flexion knee radiographs (XR) and WBCT were acquired ancillary to the 144- and 168-month Multicenter Osteoarthritis Study visits. Tibiofemoral JSW was measured on both XR and WBCT. Responsiveness to change was defined by the standardized response mean (SRM) for change in JSW (1) at predetermined mediolateral locations (JSWx) on both modalities and (2) in the following subregions measured on WBCT images: central medial and lateral femur (CMF/CLF) and tibia (CMT/CLT), and anterior and posterior tibia (AMT/ALT, PMT/MLT).

RESULTS

Baseline and 24-month follow-up JSWx measurements were completed for 265 participants (58.1% women). Responsiveness of 3D JSWx for medial tibiofemoral compartment on coronal WBCT (SRM range: -0.18, -0.24) exceeded that for 2D JSWx (-0.10, -0.16). Responsiveness of 3D JSW subregional mean (-0.06, -0.36) and maximal (-1.14, -1.75) CMF and CMT and maximal CLF/CLT 3D JSW changes were statistically significantly greater in comparison with respective medial and lateral 2D JSWx (P ≤ 0.002).

CONCLUSIONS

Subregional 3D JSW on WBCT is substantially more responsive to 24-month changes in tibiofemoral joint structure compared to radiographic measurements. Use of subregional 3D JSW on WBCT could enable improved detection of OA structural progression over a 24-month duration in comparison with measurements made on XR.

Predictors of successful natural sleep MRI for sensorineural hearing loss in infants

OBJECTIVES

Cochlear implantation (CI) in children with sensorineural hearing loss (SNHL) before 12 months of age (mo) improves language outcomes. MRI is important to assess CI candidacy. Anesthesia before 3 years old may increase risk of neurocognitive delay. Natural sleep MRI (NS-MRI) is an emerging technique to avoid anesthesia in infants, but relies on successful sleep for adequate imaging. Our multidisciplinary team hypothesized the following predictors of successful NS-MRI for CI evaluation: age, distance travelled, comorbidities, primary language, insurance type, HL characteristics, time and duration of MRI.

METHODS

We performed retrospective review of children 0-12mo who attempted NS-MRI. The NS-MRI was successful if imaging was sufficient for definitive clinical management per the managing otolaryngologist.

RESULTS

Among 26 patients (29 scans), the median age was 3.2mo (range: 1.2-6.8mo), distance travelled was 16.3 miles (range: 0.9 to 365 miles), 12 (46%) children had medical comorbidities. 8 (31%) had public insurance. 10 (38%) had bilateral HL. 52% (15/29) of scans were successful. Patients with comorbidities had significantly lower odds of successful NS-MRI (OR 0.09; 95% CI 0.01-0.54). Success was not associated with age, distance travelled, insurance type, primary language, HL characteristics, time or duration of MRI on univariable analysis. All 11 children who failed NS-MRI underwent hearing-aid fitting and/or imaging with sedation and CI as clinically indicated before 12mo.

CONCLUSION

NS-MRI was successful in 52% of infants, regardless of age, demographics, HL or MRI characteristics. Unsuccessful NS-MRI did not result in delayed intervention. NS-MRI is an effective consideration for a broad range of infants with SNHL.

Impact of Sociodemographic Disparities on Language Outcomes After Cochlear Implantation in a Diverse Pediatric Cohort

OBJECTIVE

We examined how sociodemographic and audiologic factors affect receptive and expressive language outcomes in children with cochlear implantation.

STUDY DESIGN

Retrospective cohort study.

SETTING

A hearing loss (HL) clinic at a tertiary center.

METHODS

Sociodemographic variables, HL characteristics, age at implantation, and receptive language scores (Preschool Language Scale and the Clinical Evaluation of Language Fundamentals) were collected from patients with congenital HL who received their first implant by 4 years old after January 1, 2007. t Tests, linear regression, Mann-Whitney, Cohen's d, and mediation analysis were used for descriptive statistics and hypothesis testing.

RESULTS

Among 79 patients, 42 (53%) were females, 44 (56%) under-represented minorities, and 56 (71%) had public insurance. At least 1 year after implantation, the median receptive language score was 69 (range 50-117). Females (p = .005), having private insurance (p = .00001), having a Cochlear Implant Profile score below 4 (p = .0001), and receiving their implant at or before 12 months of age (p = .0009) were significantly associated with improved receptive language outcomes. Insurance type had a significant effect on receptive language outcomes, independent from age at first implantation (total effect: coef = -13.00, p = .02; direct effect: coef = -12.26, p = .03; indirect effect: coef = -0.75, p = .47). Sociodemographic variables had large effect sizes, with the Cochlear Implant Profile score having the largest effect size (d = 1.3).

CONCLUSION

Sociodemographic factors have a large impact on receptive language outcomes. Public insurance is associated with worse receptive language, not mediated by later age at implantation, suggesting that other factors primarily impact language outcomes in publicly insured children with cochlear implants.

Food industry shaping of the principles of scientific integrity

Background

There is evidence that food industry actors try to shape science on nutrition and physical activity. But they are also involved in the influence of scientific integrity principles. Our research objective was to study the extent of that involvement, with a case study of ILSI as a key actor in that space.

Methods

We conducted a qualitative document analysis, triangulating data from an existing scoping review, publicly available information, internal industry documents, and existing freedom of information requests.

Results

Food companies have joined forces through ILSI to shape the development of scientific integrity principles. These activities started in 2007, in direct response to the growing criticism of the food industry's funding of research. ILSI first built a niche literature on conflicts of interest (COI) in food science and nutrition at the individual and study levels. Because the literature was scarce on that topic, these publications were used and cited in ILSI's and others' further work on COI, scientific integrity, and PPP, beyond the fields of nutrition and food science. In the past few years, ILSI started to shape the very principles of scientific integrity then and to propose that government agencies, professional associations, non-for-profits, and others, adopt these principles. In the process, ILSI built a reputation in the scientific integrity space. ILSI's work on scientific integrity ignores the risks of accepting corporate funding and fails to provide guidelines to protect from these risks.

Conclusions

The activities developed by ILSI on scientific integrity principles are part of a broader set of political practices of corporations to influence public health policy, research, and practice. It is important to learn about and counter these practices as they risk shaping scientific standards to suit corporate interests rather than public health ones.

Key messages

ILSI, a group funded by corporations, shaped the very principles of scientific integrity. ILSI built a reputation in the scientific integrity space.

1512 A Service Evaluation of Transoral Laser Resection Procedures for Oral Cancer and Dysplasia

Aim

The use of the diode laser is a frequently employed treatment modality in primary surgical excision, especially for early oral cancer. This is due to advantages offered in precision of excision, and potential reduced post-operative pain compared to other excision methods. Additionally, haemostasis can often be obtained simultaneous to excision. Despite frequent use of laser excision for oral cancer/dysplasia, there is limited information on the incidence of postoperative complications.

Method

Data was collected retrospectively by review of electronic healthcare records for a 5-year period (Jan 2015-Jan 2020) for patients who underwent transoral laser excision of oral dysplasia in a major UK teaching hospital. The number of short (&lt;30 days) and longer-term complications was evaluated and categorised using the Clavien-Dindo classification.

Results

A total 260 patients received diode laser resection for oral cancer/dysplasia in this period. Approximately one third of patients had the diagnosis of SCC and 52% of patients were treated on a day case basis. Approximately one third of patients experienced postoperative complications.; including positive or close resection margins (16%), bleeding (8%), superficial infection (6%) and significant postoperative pain (2%). A total of 16% of patients required further treatment in theatre (Clavien-Dindo IIIb).

Conclusions

The use of lasers for excision of oral tumours and dysplastic lesions is a frequently employed modality, offering advantages to the operating surgeon (improved haemostasis, excellent manoeuvrability) and patients (reduced pain and scarring). Complications are largely predictable in nature, but the surgical team should be aware of potential issues to ensure safe, effective patient care.

Access Challenge Index: A Novel Disparity Measure Predictive of Language Outcomes in Children Who Are Deaf/Hard of Hearing

OBJECTIVE

To evaluate the effect of demographic disparities on language outcomes in a diverse group of children who are deaf or hard of hearing.

STUDY DESIGN

Retrospective cohort study.

SETTING

UCSF Benioff Children's Hospital (a tertiary care center).

METHODS

Forty-four patients aged <18 years were identified with sensorineural hearing loss managed with a behind-the-ear hearing aid or cochlear implant. Demographic and clinical data were extracted from the medical record. The primary outcome measure was the Preschool Language Scales-5 at least 6 months after intervention. Predictors of language outcome were assessed: hearing level at the time of hearing intervention, cochlear implant status, age of identification and intervention, travel time to site of hearing care, home language, race/ethnicity, insurance type, and Access Challenge Index-a novel measure of educational environment and family support based on the Child Cochlear Implant Profile. Multivariate and univariate analysis assessed predictors for association with intervention and receptive, expressive, and total language scores.

RESULTS

Overall 82% of patients had cochlear implants. The median age at hearing intervention was 12 months. The sample was 59% female, 52% non-White, and 61% publicly insured, and 20% had a non-English primary home language. Accounting for multiple demographic and clinical predictors, a high Access Challenge Index score was independently associated with longer time to intervention (P = .01) and poorer language outcomes (P < .001).

CONCLUSION

Access Challenge Index-a novel comprehensive measure of educational and family environment-is a strong independent predictor of language outcomes in children who are deaf or hard of hearing.

Prevalence of lower limb venous disease in surgeons: a case study and results of a survey by the BAOMS Reconstruction Surgical Subspecialty Interest Group

We report a case of venous leg ulceration in a reconstructive oral and maxillofacial surgeon. An online survey was created by the British Association of Oral and Maxillofacial Surgeons (BAOMS) Reconstruction Surgical Subspecialty Interest Group (SSIG), primarily to target head and neck surgeons, to investigate the perceived risk and occurrence of venous leg disease. Two respondents had received treatment for lower limb venous disease thus compromising their ability to work, while 13 had symptoms of early venous disease. Our study shows an interesting area of concern for occupational health in surgeons, particularly in those carrying out long operations, as will be the case for members of the Reconstruction SSIG.

Investigating Risk Factors for Falls among Community-Dwelling Older Adults According to WHO's Risk Factor Model for Falls

OBJECTIVES

The World Health Organization developed the Risk Factor Model for Falls to describe fall risks in a comprehensive manner. However, there was a lack of study adopting such framework in quantifying falls risk from different factors in a single model. Therefore, this study examined the risk factors from four domains in the Risk Factor Model for Falls among older adults.

DESIGN

Secondary data analysis of 10-year assessment records of the Minimum Data Set-Home Care instrument.

SETTING

Hong Kong.

PARTICIPANTS

89,100 community-dwelling adults aged 65 and over who first applied for publicly funded long-term care services from 2005 to 2014.

MEASUREMENTS

The Minimum Data Set-Home Care instrument was used to ascertain older adults' care needs and match them with appropriate services. Additionally, meteorological records from the same period were extracted from the Hong Kong Observatory. The logistic regression model was used to examine risk factors and their associations with falls.

RESULTS

In total 70 factors were included in the analysis, of which 37 were significantly associated with falls. Behavioral risk factors generally had greater odds ratios of falling, as compared with biological, socioeconomic, and environmental factors. Out of all significant factors, functional status, alcohol drinking, and locomotion outdoors had the largest odds ratios of falling.

CONCLUSION

Behavioral risk factors for falls are of remarkable influence yet are modifiable among older adults. Hence, falls prevention programs may need to prioritize addressing these factors.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Noisy Preprocessing Facilitates a Photonic Realization of Device-Independent Quantum Key Distribution

Device-independent quantum key distribution provides security even when the equipment used to communicate over the quantum channel is largely uncharacterized. An experimental demonstration of device-independent quantum key distribution is however challenging. A central obstacle in photonic implementations is that the global detection efficiency, i.e., the probability that the signals sent over the quantum channel are successfully received, must be above a certain threshold. We here propose a method to significantly relax this threshold, while maintaining provable device-independent security. This is achieved with a protocol that adds artificial noise, which cannot be known or controlled by an adversary, to the initial measurement data (the raw key). Focusing on a realistic photonic setup using a source based on spontaneous parametric down conversion, we give explicit bounds on the minimal required global detection efficiency.

Referral indications and prevalence of sleep abnormalities in children with early onset scoliosis

This study describes the utility of overnight sleep studies in children with early onset scoliosis (EOS). Children with EOS have diminished respiratory reserve which is associated with abnormal breathing and sleep quality in children. Currently, there are no criteria for referral of these children to evaluate breathing during sleep or data on the use of sleep treatments as part of their supportive care. A review of the 159 patients with EOS who were followed at a single institution from 2003 to 2016 identified 68 who underwent overnight polysomnograms (PSGs). Sixty-five of 68 (96%) had elevated apnea-hypopnea index (AHI) and a majority (56%) were prescribed nighttime respiratory support. A majority of young children (< 5 years) with PSG were referred for a history of snoring, apnea, or restless sleep; all 30 had abnormal PSGs. Twenty-seven (90%) had nighttime hypoxemia (nadir oxygen saturation values < 92%). Eighteen (60%) were referred to otolaryngology, of whom 11 (37%) subsequently underwent tonsil and/or adenoid removal. In older children (≥ 5 years), those referred for PSGs had more severe restrictive chest wall disease [lower forced vital capacity (FVC) values] than those who were not sent for PSG. Correlation between FVC and apnea-hypopnea index, however, was not significant. Pre-operative coronal curve magnitude did not strongly correlate with nadir SaO₂ or AHI in either age group. These results suggest that sleep studies are underutilized in the management of children with EOS. Inadequate and poor-quality sleep adversely affects growth, behavior, and cognitive function in children. This study suggests that screening for sleep abnormalities should be incorporated into assessment and treatment of more patients with EOS.

ICES: Data, Discovery, Better Health

ICES was founded in 1992 to study the health care system and promote effective, efficient and equitable health care. Over 27 years later, the goal remains largely unchanged, though the institute has grown in size and impact. Created as an independent not-for-profit research institute and given what was, at the time, unprecedented access to administrative health data records for the population of Ontario, ICES’ initial focus was to better understand the delivery of hospital services and translate its findings into better health care and policy. From modest beginnings with a handful of researchers located in a few hospital offices, ICES has grown to encompass a community of almost 500 scientists and staff across a network of seven physical sites in Ontario. The original focus on hospital-based services has expanded significantly and now includes research and analysis of community-based health services, health policy, Indigenous health, social determinants of health, and data science.

Polymicrobial Outbreak of Intermittent Peritoneal Dialysis Peritonitis during External Wall Renovation at a Dialysis Center

Objective

To investigate an outbreak of peritonitis in intermittent peritoneal dialysis (IPD) patients.

Design

An outbreak investigation was performed to identify the etiology of the polymicrobial outbreak, and a retrospective case-control study was conducted to assess the risk factors for development of peritonitis.

Setting

Renal dialysis center.

Patients

Ten episodes of peritonitis occurred in 8 of 61 patients over a 6-month period in which 669 IPD procedures were analyzed.

Interventions

Field visit to renal dialysis center to examine the entire IPD procedure, inspect the hospital environment, and perform air bacterial count.

Main Outcome Measures

The environmental factors and risk factors contributing to the polymicrobial peritonitis outbreak in IPD patients. The incidence of IPD peritonitis was determined before and after interventions.

Results

The causative organisms included Acinetobacter baumanii ( 6 ), Stenotrophomonas maltophilia ( 2 ), Pseudomonas aeruginosa ( 1 ), Candida albicans ( 1 ), C. tropicalis ( 1 ), Enterococcus ( 3 ), and Enterobacteriaceae ( 2 ). Four episodes of peritonitis involved infection by more than one organism. Air sampling of the environment detected a median of 110 colony forming units of bacteria per cubic meter of air, 10% of which were found to be Acinetobacter baumanii. The source of this polymicrobial outbreak was attributed to the bamboo scaffolding structure covering the external wall of the hospital during renovation. A retrospective case-control study indicated that the absence of the flush-before-fill step was a risk factor for development of peritonitis.

Conclusion

In addition to invasive aspergillosis in transplant or oncology patients, Acinetobacter peritonitis in dialysis patients should be considered another microbial cause of outbreak associated with hospital renovation.

Right Upper Lobe Collapse Secondary to an Anomalous Bronchus after Endotracheal Intubation for Routine Surgery

Perioperative hypoxaemia is a common but serious problem with well recognised causes. However, an anomalous bronchus causing lobar collapse as a cause is seldom mentioned. A healthy young male patient was anaesthetised for a knee operation. He required reintubation immediately postoperatively for hypoxia. He was found to have right upper lobe collapse. Fibreoptic examination of the trachea demonstrated an anomalous bronchus as the cause. Intra-operatively, the endotracheal tube had been inserted too deeply and the bronchial orifice had been obstructed by the tip. It took several hours for the lung to re-expand. Greater awareness of this potential complication is needed.

Sleep disturbance and symptom burden in sarcoidosis

INTRODUCTION

Sarcoidosis is a systemic inflammatory disease associated with myriad symptoms, including fatigue. It can affect physiological processes like sleep, leading to poor sleep quality and excessive daytime sleepiness. We hypothesized that sarcoidosis patients would report more severe sleep disturbance than healthy controls and that relationships would be found with sleep disturbance and the severity of other symptoms.

METHODS

We enrolled 84 sarcoidosis patients and 30 healthy controls and recorded demographic and clinical characteristics. Self-report measures were used to assess sleep disturbance, psychosocial symptoms, and quality of life at enrollment and longitudinally. Relationships between different self-report outcomes were analyzed using correlation statistics.

RESULTS

Using the General Sleep Disturbance Scale, 54% of sarcoidosis patients reported frequent and occasional sleep disturbance compared to only 17% of healthy controls (p < 0.0001). This significant increase in sleep disturbance found in sarcoidosis patients strongly correlated with multiple psychosocial symptoms, including fatigue, depression, and cognitive dysfunction, and negatively impacted quality of life (p < 0.01). Traditional measures of sarcoidosis disease severity or activity were not associated with sleep disturbance. Sleep disturbance scores remained stable at follow-up (mean time between first and last administration of questionnaire was 17.3 months) in 56 of the sarcoidosis patients.

CONCLUSIONS

Sarcoidosis patients experienced significant sleep disturbance that correlated with higher levels of fatigue, depression, and cognitive dysfunction, and poorer quality of life. These associations were present regardless of disease severity or activity and result in decrements in quality of life and mental health.

Intestinally-restricted Janus Kinase inhibition: a potential approach to maximize the therapeutic index in inflammatory bowel disease therapy

Background

An unmet need remains for safe and effective treatments to induce and maintain remission in inflammatory bowel disease (IBD) patients. The Janus kinase (JAK) inhibitor, tofacitinib, has demonstrated robust efficacy in ulcerative colitis patients although, like other systemic immunosuppressants, there may be safety concerns associated with its use. This preclinical study evaluated whether modulating intestinal inflammation via local JAK inhibition can provide efficacy without systemic immunosuppression.

Methods

The influence of tofacitinib, dosed orally or intracecally, on oxazolone-induced colitis, oxazolone or interferon-γ (IFNγ)-induced elevation of colonic phosphorylated signal transducer and activator of transcription1 (pSTAT1) levels, and basal splenic natural killer (NK) cell counts was investigated in mice.

Results

Tofacitinib, dosed orally or intracecally, inhibited, with similar efficacy, oxazolone-induced colitis, represented by improvements in the disease activity index and its sub-scores (body weight, stool consistency and blood content). Intracecal dosing of tofacitinib resulted in a higher colon:plasma drug exposure ratio compared to oral dosing. At equieffective oral and intracecal doses, colonic levels of tofacitinib were similar, while the plasma levels for the latter were markedly lower, consistent with a lack of effect on splenic NK cell counts. Tofacitinib, dosed orally, intracecally, or applied to the colonic lumen in vitro, produced dose-dependent, and maximal inhibition of oxazolone or IFNγ-induced STAT1 phosphorylation in the colon.

Conclusions

Localized colonic JAK inhibition, by intracecal delivery of tofacitinib, provides colonic target engagement and efficacy in a mouse colitis model at doses which do not impact splenic NK cell counts. Intestinal targeting of JAK may permit separation of local anti-inflammatory activity from systemic immunosuppression, and thus provide a larger therapeutic index compared to systemic JAK inhibitors.

Clinical and Biological Insights from the University of California San Francisco Prospective and Longitudinal Cohort

INTRODUCTION

Sarcoidosis is a systemic inflammatory disease characterized by non-necrotizing granulomas in involved organs, most commonly the lung. Description of patient characteristics in the Western United States is limited. Furthermore, blood-based measures that relate to clinical sarcoidosis phenotypes are lacking. We present an analysis of a prospective, longitudinal sarcoidosis cohort at a Northern Californian academic medical center.

METHODS

We enrolled 126 sarcoidosis subjects and 64 healthy controls and recorded baseline demographic and clinical characteristics. We used regression models to identify factors independently associated with pulmonary physiology. We tested whether blood transcript levels at study entry could relate to longitudinal changes in pulmonary physiology.

RESULTS

White, non-Hispanics composed ~70% of subjects. Hispanics and Blacks had a diagnostic biopsy at an age ~7 years younger than whites. Obstructive, but not restrictive, physiology characterized Scadding Stage IV patients. Subjects reporting use of immunosuppression had worse FEV1%p, FVC%p, and DLCO%p compared to subjects never treated, regardless of Scadding stage. We defined sarcoidosis disease activity by a drop in pulmonary function over 36 months and found that subjects meeting this definition had significant repression of blood gene transcripts related to T cell receptor signaling pathways, referred to as the "TCR factor."

CONCLUSION

Obstructive pulmonary physiology defined Stage IV patients which were mostly white, non-Hispanics. Genes comprising the composite gene expression score, TCR factor, may represent a blood-derived measure of T-cell activity and an indirect measure of active sarcoidosis inflammation. Validation of this measure could translate into individualized treatment for sarcoidosis patients.

Effects of Oxaliplatin, Carboplatin, and Cisplatin Across Treatment on High-Frequency Objective and Subjective Auditory Measures in Adults

Platinum chemotherapies are often ototoxic, initially affecting the basal end of the cochlea. Thus, monitoring high-frequency auditory function is advised to reveal early damage. Objective measures of high-frequency auditory function are repeatable over time, but the sensitivity of these measures for monitoring patients receiving platinum derivatives have not been established. We monitored 13 patients across oxaliplatin, carboplatin, or cisplatin treatment using the highest frequencies with responses for each individual. Behavioral thresholds and distortion product otoacoustic emission (DPOAE) gross frequency (f2=16–2 kHz) and concentrated frequency (1/48 octave steps at the highest frequency with a present DPOAE) sweeps were monitored. DPOAE results indicated changes during treatment within individuals using absolute change criteria, as well as statistically significant differences across trial when analyzing group data. Changes varied depending on the drug administered. Behavioral thresholds changed less often than DPOAE measures and when changes were noted, they initially occurred at the highest frequencies monitored. Often, DPOAE changes occurred at frequencies which conventional equipment could not monitor (>8 kHz). Additionally, some changes were characterized by DPOAE level enhancements at conventional frequencies (<8 kHz), while levels at higher frequencies were reduced. Overall, objective high-frequency measures were sensitive to auditory changes in adults undergoing platinum chemotherapy treatment.

Do daily ward interviews improve measurement of hospital quality and safety indicators? A prospective observational study

RATIONALE, AIMS AND OBJECTIVES

The aim of this study was to determine if the addition of daily ward interview data improves the capture of hospital quality and safety indicators compared with incident reporting systems alone. An additional aim was to determine the potential characteristics influencing under-reporting of hospital quality and safety indicators in incident reporting systems.

METHODS

A prospective, observational study was performed at two tertiary metropolitan public hospitals. Research assistants from allied health backgrounds met daily with the nurse in charge of the ward and discussed the occurrence of any falls, pressure injuries and rapid response medical team calls. Data were collected from four general medical wards, four surgical wards, an orthopaedic, neurosciences, plastics, respiratory, renal, sub-acute and acute medical assessment unit.

RESULTS

An estimated total of 303 falls, 221 pressure injuries and 884 rapid response medical team calls occurred between 15 wards across two hospitals, over a period of 6 months. Hospital incident reporting systems underestimated falls by 30.0%, pressure injuries by 59.3% and rapid response medical team calls by 17.0%. The use of ward interview data collection in addition to hospital incident reporting systems improved data capture of falls by 23.8% (n = 72), pressure injuries by 21.7% (n = 48) and rapid response medical team calls by 12.7% (n = 112). Falls events were significantly less likely to be reported if they occurred on a Monday (P = 0.04) and pressure injuries significantly more likely to be reported if they occurred on a Wednesday (P = 0.01).

CONCLUSIONS

Hospital quality and safety indicators (falls, pressure injuries and rapid response medical team calls) were under-reported in incident reporting systems, with variability in under-reporting between wards and the day of event occurrence. The use of ward interview data collection in addition to hospital incident reporting systems improved reporting of hospital quality and safety indicators.

What are the Needs of Students? An Experience from a District Based Health Promoting Schools Project in Hong Kong

A district based needs assessment as conducted over the past year to uderstand the health problems and the health education needs of the students in Tai Po district, Hong ong. 6879 primary one to primary six students from eighteen rimary schools, participating in a district based Health Promoting Schools Project in Hong Kong, were invited to complete a self-administrated questionnaire which was partly adapted from the Centre for Diseases and Control (CDC)'s Youth Risk Behaviour Surveillance Survey. The results presented a holistic picture of the health and needs of primary students with respect to their general health status, mental health, body weight and dietary behaviour, exercise, preventive health care, tobacco use, alcohol and other drug use, school environment and school health education. It provides baseline information for the project to prioritize the problems and strategically plan health promotion 'programmes with reference to the concept of Health Promoting Schools by the World Health Organization.

The future of regional anesthesia education: lessons learned from the surgical specialty

PURPOSE

Application of ultrasound in regional anesthesia has now become the standard of care and its use has shown to reduce complications. Nevertheless, gaining expertise in ultrasound-guided regional anesthesia requires the acquisition of new cognitive and technical skills. In addition, due to a reduction in resident working hours and enforcement of labour laws and directives across various states and countries, trainees perform and witness fewer procedures. Together, these issues create challenges in the teaching and learning of ultrasound-guided regional anesthesia in the time-based model of learning.

PRINCIPAL FINDINGS

The challenges of teaching ultrasound-guided regional anesthesia are similar to those experienced by our surgical counterparts with the advent of minimally invasive surgery. In order to overcome these challenges, our surgical colleagues used theories of surgical skills training, simulation, and the concept of deliberate practice and feedback to shift the paradigm of learning from experience-based to competency-based learning.

CONCLUSION

In this narrative review, we describe the theory behind the evolution of surgical skills training. We also outline how we can apply these learning theories and simulation models to a competency-based curriculum for training in ultrasound-guided regional anesthesia.