Panel 1: Epidemiology and global health, including child development, sequelae and complications.

OBJECTIVE: To summarise the published research evidence on the epidemiology of otitis media, including the risk factors and sequelae associated with this condition. DATA SOURCES: Medline (PubMed), Embase, and the Cochrane Library covering the period from 2019 to June 1st, 2023. REVIEW METHODS: We conducted a broad search strategy using otitis [Medical Subject Heading] combined with text words to identify relevant articles on the prevalence, incidence, risk factors, complications, and sequelae for acute otitis media, otitis media with effusion, and chronic suppurative otitis media. At least one review author independently screened titles and abstracts of the retrieved records for each condition to determine whether the research study was eligible for inclusion. Any discrepancies were resolved by reviewing the full text followed by discussion with a second review author. Studies with more than 100 participants were prioritised. RESULTS: Over 2,000 papers on otitis media (OM) have been published since 2019. Our review has highlighted around 100 of these publications. While the amount of otitis media research on the Medline database published each year has not increased, there has been an increase in epidemiological studies using routinely collected data and systematic review methodology. Most of the large incidence studies have addressed acute otitis media (AOM) in children. Several studies have described a decrease in incidence of AOM after the introduction of conjugate PCV vaccines. Similarly, a decrease was noted when rates of coronavirus disease of 2019 (COVID-19) were high and there were major public health efforts to reduce the spread of infection. There have been new studies on OM in adults and OM prevalence in a broader range of countries and population subgroups. CONCLUSION: Overall, the rates of severe and/or suppurative OM appeared to be decreasing. However, there is substantial heterogeneity between populations. While better use of available data is informative, it can be difficult to predict rates of severe disease without accurate examination findings. Most memorably, the COVID-19 pandemic had an enormous impact on the research and clinical services for otitis media for most of the period under review. IMPLICATIONS FOR PRACTICE: The use of routinely collected data for epidemiological studies will lead to greater variability in the definitions and diagnostic criteria used. The impact of new vaccines will continue to be important. Some of the lessons learned during the COVID-19 pandemic concerning behaviours that reduce spread of respiratory viruses can hopefully be used to decrease the burden of otitis media in the future. There are still many countries in the world where the burden of otitis media is not well described. In countries where otitis media has been studied over many years, new potential risk factors continue to be identified. In addition, a better understanding of the disease in specific subgroups has been achieved.

INdigenous Systems and Policies Improved and Reimagined for Ear and hearing care (INSPIRE): a multi-method study protocol.

INTRODUCTION: Otitis media (middle ear disease) severity and chronicity among Aboriginal and Torres Strait Islander people, as well as gaps in socioeconomic outcomes related to hearing loss, indicates a breakdown in the current ear and hearing care system. The ear and hearing care system spans multiple sectors due to long-term impacts of otitis media and hearing loss in health, education and employment, necessitating a multi-disciplinary cross-sectorial approach to ear and hearing care. Public policies shape the current ear and hearing care system and here it is argued that a critical public policy analysis across different sectors is needed, with strong Aboriginal and Torres Strait Islander leadership and guidance. The current study aims to establish consensus-based ear and hearing care policy solutions for Aboriginal and Torres Strait Islander people in Australia. METHODS AND ANALYSIS: This multi-method study will be guided by a Brains Trust with strong Aboriginal and Torres Strait Islander leadership. Public policies in hearing health, social services, and education will be scoped to identify policy gaps, using the World Health Organization framework. Qualitative data will be collected through a culturally specific process of yarning circles to identify policy challenges and/or limitations in enabling accessible ear and hearing care programs/services for Aboriginal and Torres Strait Islander people, using dimensions of Morestin's public policy appraisal tool as an interview guide for stakeholders. Themes from the yarning circles will be used to inform an expert Delphi process to establish consensus-based policy solutions for optimising the ear and hearing care system for Aboriginal and Torres Strait Islander people. ETHICS AND DISSEMINATION: This study has approval from the Australian Institute of Aboriginal and Torres Strait Islander Studies Ethics Committee. Study findings will be disseminated to community through Brains Trust members and study participants, as well as through publications in peer-reviewed journals and research forum presentations.

The views of parents and carers on managing acute otitis media in urban Aboriginal and Torres Strait Islander children: a qualitative study.

OBJECTIVES: To explore the views of parents and carers regarding the management of acute otitis media in urban Aboriginal and Torres Strait Islander children who are at low risk of complications living in urban communities. STUDY DESIGN: Qualitative study; semi-structured interviews and short telephone survey. SETTING, PARTICIPANTS: Interviews: purposive sample of parents and carers of urban Aboriginal and Torres Strait Islander children (18 months - 16 years old) screened in Aboriginal medical services in Queensland, New South Wales, and Canberra for the WATCH study, a randomised controlled trial that compared immediate antibiotic therapy with watchful waiting for Aboriginal and Torres Strait Islander children with acute otitis media. SURVEY: parents and carers recruited for the WATCH trial who had completed week two WATCH surveys. RESULTS: We interviewed twenty-two parents and carers, including ten who had declined participation in or whose children were ineligible for the WATCH trial. Some interviewees preferred antibiotics for managing acute otitis media, others preferred watchful waiting, expressing concerns about side effects and reduced efficacy with overuse of antibiotics. Factors that influenced this preference included the severity, duration, and recurrence of infection, and knowledge about management gained during the trial and from personal and often multigenerational experience of ear disease. Participants highlighted the importance of shared decision making by parents and carers and their doctors. Parents and carers of 165 of 262 WATCH participants completed telephone surveys (63%); 81 were undecided about whether antibiotics should always be used for treating acute otitis media. Open-ended responses indicated that antibiotic use should be determined by clinical need, support for general practitioners' decisions, and the view that some general practitioners prescribed antibiotics too often. CONCLUSIONS: Parents and carers are key partners in managing acute otitis media in urban Aboriginal and Torres Strait Islander children. Our findings support shared decision making informed by the experience of parents and carers, which could also lead to reduced antibiotic use for managing acute otitis media.

Examining relationships between parent-reported factors and recurring ear symptoms among Aboriginal and Torres Strait Islander children.

ISSUE ADDRESSED: Aboriginal and Torres Strait Islander child ear health is complex and multiple. We examined relationships between parent-reported sociodemographic, child health, health service access factors and ear symptoms among Aboriginal and Torres Strait Islander children aged 3 to 7 years. METHODS: The Longitudinal Study of Indigenous Children is a large child cohort study with annual parent-reported data collection. Generalised linear mixed model analyses examined Wave 1 (1309 children 0-5 years; 2008) predictors of being free of parent-reported ear symptoms in both Waves 2 and 3. RESULTS: A total of 1030 (78.7%) had no reported ear symptoms in either Wave 2 or 3. In the fully adjusted model, children who had been hospitalised in the past year (aOR = 2.16; 95% CI 1.19-3.93) and those with no ear symptoms (aOR = 2.94; 95% CI, 1.59-5.46) at Wave 1 had higher odds of no ear symptoms in both the subsequent waves. There were also relationships between parent main source of income-government pension or allowance as well as parents who reported no history of their own ear symptoms and higher odds of no ear symptoms in Waves 2 and 3 after partial adjustment for sociodemographic factors. CONCLUSION: These findings suggest relationships between different sociodemographic and health factors and parent-reported ear symptoms among Aboriginal and Torres Strait Islander children that warrant further investigation. So what? Children with parent-reported ear symptoms during the early years need holistic support to prevent future ear symptoms that impact health, social and educational life trajectories.

An Opportunity to See the Heart Defect Physically: Medical Student Experiences of Technology-Enhanced Learning with 3D Printed Models of Congenital Heart Disease.

Three-dimensional (3D) printing is increasingly used in medical education and paediatric cardiology. A technology-enhanced learning (TEL) module was designed to accompany 3D printed models of congenital heart disease (CHD) to aid in the teaching of medical students. There are few studies evaluating the attitudes and perceptions of medical students regarding their experience of learning about CHD using 3D printing. This study aimed to explore senior medical students' experiences in learning about paediatric cardiology through a workshop involving 3D printed models of CHD supported by TEL in the form of online case-based learning. A mixed-methods evaluation was undertaken involving a post-workshop questionnaire (n = 94 students), and focus groups (n = 16 students). Focus group and free-text questionnaire responses underwent thematic analysis. Questionnaire responses demonstrated widespread user satisfaction; 91 (97%) students agreed that the workshop was a valuable experience. The highest-level satisfaction was for the physical 3D printed models, the clinical case-based learning, and opportunity for peer collaboration. Thematic analysis identified five key themes: a variable experience of prior learning, interplay between physical and online models, flexible and novel workshop structure, workshop supported the learning outcomes, and future opportunities for learning using 3D printing. A key novel finding was that students indicated the module increased their confidence to teach others about CHD and recommended expansion to other parts of the curriculum. 3D printed models of CHD are a valuable learning resource and contribute to the richness and enjoyment of medical student learning, with widespread satisfaction. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01840-w.

Ear health and hearing in urban Aboriginal children.

OBJECTIVE: Evaluate ear health and hearing among urban Aboriginal children and quantify relationships with child, family and social factors. METHODS: Baseline questionnaire and ear health examinations from 1430 children with diagnoses (0.5-18 years) attending Aboriginal Health Services enrolled in SEARCH. Ear health outcomes were Otitis Media (OM), and hearing loss (three-frequency average hearing loss >20dB) diagnosed using pneumatic otoscopy, tympanometry, and audiometry. RESULTS: Half the children 0.5-3 years had OM (51.5%, 136/264). One third 0.5-18 years (30.4%; 435/1430) had OM, including 1.8% (26/1430) with perforation (0.8% chronic suppurative OM, 0.6% dry perforation and 0.4% acute OM with perforation). One quarter 0.5-18 years (25.7%; 279/1087) had hearing loss; 12.4% unilateral, 13.2% bilateral (70.6% with bilateral loss had concurrent OM). OM was associated with: younger age (0.5-<3 years versus 6-18 years) age-sex-site; adjusted prevalence ratio (aPR)=2.64, 95%, 2.18-3.19); attending childcare/preschool (aPR=1.24, 95%CI, 1.04-1.49); foster care (aPR=1.40, 95%CI, 1.10-1.79); previous ear infection/s (aPR=1.68, 95%CI, 1.42-1.98); and ≥2 people/bedroom (aPR=1.66, 95%CI, 1.24-2.21). Hearing impairment was associated with younger age (0.5-<6 years vs. ≥6 years aPR=1.89, 95%CI, 1.40-2.55) and previous ear infection (aPR=1.87, 95%CI, 1.31-2.68). CONCLUSIONS: Half the urban Aboriginal children in this cohort had OM and two-thirds with hearing impairment had OM. IMPLICATIONS FOR PUBLIC HEALTH: Findings highlight importance of early detection and support for ear health, particularly in pre-school-aged children with risk factors.

Ear and hearing care programs for First Nations children: a scoping review.

BACKGROUND: Ear and hearing care programs are critical to early detection and management of otitis media (or middle ear disease). Otitis media and associated hearing loss disproportionately impacts First Nations children. This affects speech and language development, social and cognitive development and, in turn, education and life outcomes. This scoping review aimed to better understand how ear and hearing care programs for First Nations children in high-income colonial-settler countries aimed to reduce the burden of otitis media and increase equitable access to care. Specifically, the review aimed to chart program strategies, map the focus of each program against 4 parts of a care pathway (prevention, detection, diagnosis/management, rehabilitation), and to identify the factors that indicated the longer-term sustainability and success of programs. METHOD: A database search was conducted in March 2021 using Medline, Embase, Global Health, APA PsycInfo, CINAHL, Web of Science Core Collection, Scopus, and Academic Search Premier. Programs were eligible or inclusion if they had either been developed or run at any time between January 2010 to March 2021. Search terms encompassed terms such as First Nations children, ear and hearing care, and health programs, initiatives, campaigns, and services. RESULTS: Twenty-seven articles met the criteria to be included in the review and described a total of twenty-one ear and hearing care programs. Programs employed strategies to: (i) connect patients to specialist services, (ii) improve cultural safety of services, and (iii) increase access to ear and hearing care services. However, program evaluation measures were limited to outputs or the evaluation of service-level outcome, rather than patient-based outcomes. Factors which contributed to program sustainability included funding and community involvement although these were limited in many cases. CONCLUSION: The result of this study highlighted that programs primarily operate at two points along the care pathway-detection and diagnosis/management, presumably where the greatest need lies. Targeted strategies were used to address these, some which were limited in their approach. The success of many programs are evaluated as outputs, and many programs rely on funding sources which can potentially limit longer-term sustainability. Finally, the involvement of First Nations people and communities typically only occurred during implementation rather than across the development of the program. Future programs should be embedded within a connected system of care and tied to existing policies and funding streams to ensure long term viability. Programs should be governed and evaluated by First Nations communities to further ensure programs are sustainable and are designed to meet community needs.

Acute otitis media symptoms and symptom scales in research with Aboriginal and Torres Strait Islander children.

BACKGROUND: Aboriginal and Torres Strait Islander children experience a high burden of otitis media. We collected data on symptoms associated with acute otitis media (AOM) in a clinical trial involving children receiving primary care at urban Aboriginal Medical Services. Two scales were employed to monitor symptoms over time: the AOM-Severity of Symptoms scale (AOM-SOS) and the AOM-Faces Scale (AOM-FS). This study took place at a mid-point of the un-blinded trial. METHODS: We examined symptoms at enrolment and day 7, and compared the scales for trends, and bivariate correlation (Spearman's rho) over 14 days. Responsiveness of the scales to clinical change was determined by Friedman's test of trend in two subgroups stratified by day 7 AOM status. We interviewed parents/carers and research officers regarding their experience of the scales and analysed data thematically. RESULTS: Data derived from 224 children (18 months to 16 years; median 3.6 years). Common symptoms associated with AOM at baseline were runny nose (40%), cough (38%) and irritability (36%). More than one third had no or minimal symptoms at baseline according to AOM-SOS (1-2/10) and AOM-FS scores (1-2/7). The scales performed similarly, and were moderately correlated, at all study points. Although scores decreased from day 0 to 14, trends and mean scores were the same whether AOM was persistent or resolved at day 7. Users preferred the simplicity of the AOM-FS but encountered challenges when interpreting it. CONCLUSION: We found minimally symptomatic AOM was common among Aboriginal and Torres Strait Islander children in urban settings. The AOM-SOS and AOM-FS functioned similarly. However, it is likely the scales measured concurrent symptoms related to upper respiratory tract infections, given they did not differentiate children with persistent or resolved AOM based on stringent diagnostic criteria. This appears to limit the research and clinical value of the scales in monitoring AOM treatment among Aboriginal and Torres Strait Islander children.

Parent Perspectives of Ear Health and the Relationship with Children's Speech and Language in the Longitudinal Study of Indigenous Children.

Health and well-being are holistic concepts that are perceived to be inseparable for Aboriginal and Torres Strait Islander peoples. We examined relationships between parent-reported ear symptoms for 787 Indigenous children at two time points (age 2-3 years, age 4-5 years) and two parent-reported speech and language outcomes one year later (age 5-6 years). Most parents (80.2%) reported no concern about their child's expressive language and (93.8%) receptive language. Binary logistic regression models examined ear health as a predictor of children's expressive and receptive speech and language adjusting for sociodemographic and health covariates. For children without parent-reported ear symptoms, there were lower odds of parental concern about expressive speech and language (aOR = 0.45; 95% CI 0.21-0.99) and receptive language (aOR = 0.24; 95% CI 0.09-0.62). Parents were less likely to have concerns about the child's expressive speech and language if their child was female, lived in urban or regional areas, had excellent or very good global health, or had no disability when aged 2-5 years. Since parent-reported ear health and speech and language concerns were related, Aboriginal and Torres Strait Islander children could benefit from culturally safe, strength-based, and family-centered integrated speech, language, and ear health services.

'Every Human Interaction Requires a Bit of Give and Take': Medical Students' Approaches to Pursuing Feedback in the Clinical Setting.

PhenomenonStudents, alongside teachers, play a key role in feedback. Student behavior in feedback processes may impact feedback outcomes. Student feedback behavior includes recognizing, seeking, evaluating, and utilizing feedback. Student feedback behavior is influenced by numerous student attributes and environmental factors. ApproachWe aimed to explore influences on medical student feedback behavior during clinical attachments. We adopted a subjective inductive qualitative approach. We conducted 7 focus groups with 46 medical students undertaking pediatric hospital-based attachments. We based our discussion framework on existing characterizations of student feedback behavior and the educational alliance model with its focus on the relationship between learners and teachers, and the active role played by both. During initial data analysis, we identified that our results exhibited aspects of Bandura's model of Triadic Reciprocal Causation within Social Cognitive Theory. In line with our subjective inductive approach, we adopted Triadic Reciprocal Causation at this point for further analysis and interpretation. This allowed us to conceptualize the emerging interactions between influences on feedback behavior. Findings We identified three key determinants of student feedback behavior: Environmental influences, Student attributes and Relationships between teachers and students. Environmental influences encompassed factors external to the student, including Teacher attributes and behaviors and The clinical learning context. Through the lens of Triadic Reciprocal Causation, the interrelationships between the determinants of feedback behavior gave rise to five key themes: Interactions between student feedback behavior and environmental influences of the clinical learning context, Interactions between student feedback behavior and environmental influences of teacher attributes and behaviors, Interactions between student attributes and student feedback behavior, Interactions between student attributes and environmental influences of teacher attributes and behaviors, and Relationships and the determinants of student feedback behavior. Insights: We apply the Triadic Reciprocal Causation model of Social Cognitive Theory to understand the influences on student feedback behavior and the interactions between them. We extend the model by situating relationships between students and teachers as a central factor. Future interventions to facilitate students' role in feedback will need to address student attributes, environmental factors, and student-teacher relationships, appreciating the codependent nature of these influences.

Offshore detention: cross-sectional analysis of the health of children and young people seeking asylum in Australia.

OBJECTIVE: To describe the health and well-being of children and young people (CYP) seeking asylum subjected to Australia's immigration policy of indefinite mandatory detention on Nauru. DESIGN: Cross-sectional analysis of a cohort of CYP seeking asylum. SETTING: Australian paediatric clinicians from 10 health services completed detailed health assessments around the time of transfer from Nauru, mostly to Australia. PARTICIPANTS: Sixty-two CYP who were ≤18 years on entry into offshore immigration detention on Nauru between 2013 and 2019. Mean age at health assessment was 9 years. MAIN MEASURES: Health outcomes were categorised as physical, mental or neurodevelopmental concerns/conditions. Risk and protective factor data were collected using the adverse childhood experiences and refugee-specific adverse childhood experiences tools. RESULTS: Over half of the CYP (n=32, 52%) were held on Nauru for ≥4 years. The vast majority of CYP had physical health (n=55, 89%) and mental health (n=49, 79%) concerns including self-harm or suicidal ideation/attempt (n=28, 45%). Mental health concerns were more likely in CYP who were school-aged (p=0.001), had been held on Nauru for ≥1 year (p=0.01); originated from the Eastern Mediterranean region (p<0.05); witnessed trauma (p<0.05) or had exposure to ≥4 refugee-specific adverse childhood experiences (p<0.05). Neurodevelopmental concerns were seen in eight children (13%). CONCLUSIONS: This study highlights the almost universal physical and mental health difficulties in a sample of CYP who experienced forced migration and were subjected to Australia's offshore immigration detention policy. Immigration detention in recipient countries, a known adverse childhood experience, may contribute to or exacerbate harmful outcomes in CYP seeking asylum.

Utility of 3D Printed Models Versus Cadaveric Pathology for Learning: Challenging Stated Preferences.

Introduction: 3D printing has recently emerged as an alternative to cadaveric models in medical education. A growing body of research supports the use of 3D printing in this context and details the beneficial educational outcomes. Prevailing studies rely on participants' stated preferences, but little is known about actual student preferences. Methods: A mixed methods approach, consisting of structured observation and computer vision, was used to investigate medical students' preferences and handling patterns when using 3D printed versus cadaveric models in a cardiac pathology practical skills workshop. Participants were presented with cadaveric samples and 3D printed replicas of congenital heart deformities. Results: Analysis with computer vision found that students held cadaveric hearts for longer than 3D printed models (7.71 vs. 6.73 h), but this was not significant when comparing across the four workshops. Structured observation found that student preferences changed over the workshop, shifting from 3D printed to cadaveric over time. Interactions with the heart models (e.g., pipecleaners) were comparable. Conclusion: We found that students had a slight preference for cadaveric hearts over 3D printed hearts. Notably, our study contrasts with other studies that report student preferences for 3D printed learning materials. Given the relative equivalence of the models, there is opportunity to leverage 3D printed learning materials (which are not scarce, unlike cadaveric materials) to provide equitable educational opportunities (e.g., in rural settings, where access to cadaveric hearts is less likely).

Pediatric empyema: Are ultrasound characteristics at the time of intervention predictive of reintervention?

BACKGROUND: Parapneumonic effusions and empyema are the most frequent complication of pediatric pneumonia. Interventions include chest drain and fibrinolytics (CDF) or thoracoscopic surgery. CDF is considered less invasive, and more cost-effective though with higher rates of reintervention. We hypothesized that sonographic pleural fluid characteristics could identify cases at increased risk of reintervention following primary CDF. METHODS: A retrospective cohort of complicated pneumonia managed with primary CDF (2011-2018). Cases were reviewed using ultrasound criteria to describe pleural fluid. We analyzed the correlation between ultrasound findings and reintervention. RESULTS: We report 129 cases with a median age of 3.8 years and 44% female. A repeat intervention occurred for 24/129 (19%) cases. The interobserver reliability was moderate for the number of septations (κ 0.72, 95% CI [confidence interval]: 0.62-0.81), weak for the size of the largest locule (κ 0.55, 95% CI: 0.44-0.67), and minimal for the level of echogenicity (κ 0.24, 95% CI: 0.11-0.37), pleural thickening (κ 0.29, 95% CI: 0.17-0.42), maximum effusion depth (κ 0.37, 95% CI: 0.22-0.51), and radiologist's risk for reintervention (κ 0.34, 95% CI: 0.18-0.5). A repeat intervention was not associated with any objective sonographic variable. CONCLUSION: We report no association between ultrasound characteristics and repeat intervention for complicated pneumonia following primary CDF treatment. There was minimal interobserver agreement in reporting ultrasound characteristics despite more objective criteria. Clinicians rely on ultrasound findings to support decisions around intervention in pediatric empyema. This study does not support relying on ultrasound to estimate the likelihood of reintervention.

INFLATE: a protocol for a randomised controlled trial comparing nasal balloon autoinflation to no nasal balloon autoinflation for otitis media with effusion in Aboriginal and Torres Strait Islander children.

BACKGROUND: Otitis media with effusion (OME) is common and occurs at disproportionately higher rates among Indigenous children. Left untreated, OME can negatively affect language, development, learning, and health and wellbeing throughout the life-course. Currently, OME care includes observation for 3 months followed by consideration of surgical ventilation tube insertion. The use of a non-invasive, low-cost nasal balloon autoinflation device has been found beneficial in other populations but has not been investigated among Aboriginal and Torres Strait Islander children. METHODS/DESIGN: This multi-centre, open-label, randomised controlled trial will determine the effectiveness of nasal balloon autoinflation compared to no nasal balloon autoinflation, for the treatment of OME among Aboriginal and Torres Strait Islander children in Australia. Children aged 3-16 years with unilateral or bilateral OME are being recruited from Aboriginal Health Services and the community. The primary outcome is the proportion of children showing tympanometric improvement of OME at 1 month. Improvement is defined as a change from bilateral type B tympanograms to at least one type A or C1 tympanogram, or from unilateral type B tympanogram to type A or C1 tympanogram in the index ear, without deterioration (type A or C1 to type C2, C3, or B tympanogram) in the contralateral ear. A sample size of 340 children (170 in each group) at 1 month will detect an absolute difference of 15% between groups with 80% power at 5% significance. Anticipating a 15% loss to follow-up, 400 children will be randomised. The primary analysis will be by intention to treat. Secondary outcomes include tympanometric changes at 3 and 6 months, hearing at 3 months, ear health-related quality of life (OMQ-14), and cost-effectiveness. A process evaluation including perspectives of parents or carers, health care providers, and researchers on trial implementation will also be undertaken. DISCUSSION: INFLATE will answer the important clinical question of whether nasal balloon autoinflation is an effective and acceptable treatment for Aboriginal and Torres Strait Islander children with OME. INFLATE will help fill the evidence gap for safe, low-cost, accessible OME therapies. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12617001652369 . Registered on 22 December 2017. The Australia New Zealand Clinical Trials Registry is a primary registry of the WHO ICTRP network and includes all items from the WHO Trial Registration data set. Retrospective registration.

Artificial intelligence to classify ear disease from otoscopy: A systematic review and meta-analysis.

OBJECTIVES: To summarise the accuracy of artificial intelligence (AI) computer vision algorithms to classify ear disease from otoscopy. DESIGN: Systematic review and meta-analysis. METHODS: Using the PRISMA guidelines, nine online databases were searched for articles that used AI computer vision algorithms developed from various methods (convolutional neural networks, artificial neural networks, support vector machines, decision trees and k-nearest neighbours) to classify otoscopic images. Diagnostic classes of interest: normal tympanic membrane, acute otitis media (AOM), otitis media with effusion (OME), chronic otitis media (COM) with or without perforation, cholesteatoma and canal obstruction. MAIN OUTCOME MEASURES: Accuracy to correctly classify otoscopic images compared to otolaryngologists (ground truth). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool was used to assess the quality of methodology and risk of bias. RESULTS: Thirty-nine articles were included. Algorithms achieved 90.7% (95%CI: 90.1-91.3%) accuracy to difference between normal or abnormal otoscopy images in 14 studies. The most common multiclassification algorithm (3 or more diagnostic classes) achieved 97.6% (95%CI: 97.3-97.9%) accuracy to differentiate between normal, AOM and OME in three studies. AI algorithms outperformed human assessors to classify otoscopy images achieving 93.4% (95%CI: 90.5-96.4%) versus 73.2% (95%CI: 67.9-78.5%) accuracy in three studies. Convolutional neural networks achieved the highest accuracy compared to other classification methods. CONCLUSION: AI can classify ear disease from otoscopy. A concerted effort is required to establish a comprehensive and reliable otoscopy database for algorithm training. An AI-supported otoscopy system may assist health care workers, trainees and primary care practitioners with less otology experience identify ear disease.

An Artificial Intelligence Computer-vision Algorithm to Triage Otoscopic Images From Australian Aboriginal and Torres Strait Islander Children.

OBJECTIVE: To develop an artificial intelligence image classification algorithm to triage otoscopic images from rural and remote Australian Aboriginal and Torres Strait Islander children. STUDY DESIGN: Retrospective observational study. SETTING: Tertiary referral center. PATIENTS: Rural and remote Aboriginal and Torres Strait Islander children who underwent tele-otology ear health screening in the Northern Territory, Australia between 2010 and 2018. INTERVENTIONS: Otoscopic images were labeled by otolaryngologists to classify the ground truth. Deep and transfer learning methods were used to develop an image classification algorithm. MAIN OUTCOME MEASURES: Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, area under the curve (AUC) of the resultant algorithm compared with the ground truth. RESULTS: Six thousand five hundred twenty seven images were used (5927 images for training and 600 for testing). The algorithm achieved an accuracy of 99.3% for acute otitis media, 96.3% for chronic otitis media, 77.8% for otitis media with effusion (OME), and 98.2% to classify wax/obstructed canal. To differentiate between multiple diagnoses, the algorithm achieved 74.4 to 92.8% accuracy and an AUC of 0.963 to 0.997. The most common incorrect classification pattern was OME misclassified as normal tympanic membranes. CONCLUSIONS: The paucity of access to tertiary otolaryngology care for rural and remote Aboriginal and Torres Strait Islander communities may contribute to an under-identification of ear disease. Computer vision image classification algorithms can accurately classify ear disease from otoscopic images of Indigenous Australian children. In the future, a validated algorithm may integrate with existing telemedicine initiatives to support effective triage and facilitate early treatment and referral.

The socioemotional challenges and consequences for caregivers of Aboriginal and Torres Strait Islander children with otitis media: A qualitative study.

INTRODUCTION: Living with ear disease can have extensive impacts on physical, emotional and social well-being. This study explored otitis media (OM) and its management from the perspective of caregivers of Aboriginal and Torres Strait Islander children. METHODS: Semi-structured interviews were conducted from 2015 to 2020 with caregivers of Aboriginal and Torres Strait Islander children with OM. Thematic analysis of transcripts was undertaken using a constructivist grounded theory approach through the leadership and the cultural lens of an Aboriginal community-based researcher. RESULTS: Caregivers described OM as having profound impacts on their child's physical, developmental, and emotional well-being, with long waits for specialist treatment contributing to extra strain on families. Children's well-being suffered when OM was mistaken for poor behaviour and children were punished, with caregivers subsequently experiencing strong feelings of guilt. Concerns were conveyed about the social implications of having a sick child. The variable nature of OM symptoms meant that caregivers had to monitor closely for sequelae and advocate for appropriate treatment. Success in navigating the diagnosis and treatment of OM can be strongly impacted by the relationship between caregivers and health professionals and the perceived access to respectful, collaborative and informative healthcare. CONCLUSION: OM may have substantial social and emotional consequences for children and their caregivers. A holistic understanding of the way in which OM impacts multiple facets of health and well-being, as well as recognition of challenges in accessing proper care and treatment, will aid families managing OM and its sequelae. PATIENT OR PUBLIC CONTRIBUTION: Governing boards, managers, staff and community members from five Australian Aboriginal Medical Services were involved in the approval, management and conduct of this study and the wider clinical trials. The caregivers of Aboriginal and Torres Strait Islander patients at these services informed the interview study and guided its purpose.

Paediatric pneumonia: deriving a model to identify severe disease.

BACKGROUND: Community-acquired pneumonia (CAP) is a leading cause of childhood hospitalisation. Limited data exist on factors predicting severe disease with no paediatric-specific predictive tools. METHODS: Retrospective cohort (2011-2016) of hospitalised CAP cases. We analysed clinical variables collected at hospital presentation against outcomes. Stratified outcomes were mild (hospitalised), moderate (invasive drainage procedure, intensive care) or severe (mechanical ventilation, vasopressors, death). RESULTS: We report 3330 CAP cases, median age 2.0 years (IQR 1-5 years), with 2950 (88.5%) mild, 305 (9.2%) moderate and 75 (2.3%) severe outcomes. Moderate-severe outcomes were associated with hypoxia (SaO2 <90%; OR 6.6, 95% CI 5.1 to 8.5), increased work of breathing (severe vs normal OR 5.8, 95% CI 4.2 to 8.0), comorbidities (4+ comorbidities vs nil; OR 8.8, 95% CI 5.5 to 14) and being indigenous (OR 4.7, 95% CI 2.6 to 8.4). Febrile children were less likely than afebrile children to have moderate-severe outcomes (OR 0.57 95% CI 0.44 to 0.74). The full model receiver operating characteristic (ROC) area under the curve (AUC) was 0.78. Sensitivity analyses showed similar results with clinical or radiological CAP definitions. We derived a clinical tool to stratify low, intermediate or high likelihood of severe disease (AUC 0.72). High scores (≥5) had nearly eight times higher odds of moderate-severe disease than those with a low (≤1) score (OR 7.7 95% CI 5.6 to 10.5). CONCLUSIONS: A clinical risk prediction tool is needed for child CAP. We have identified risk factors and derived a simple clinical tool using clinical variables at hospital presentation to determine a child's risk of invasive or intensive care treatment with an ROC AUC comparable with adult pneumonia tools.

Randomised clinical trial research within Aboriginal and Torres Strait Islander primary health services: a qualitative study.

OBJECTIVE: To better understand how to undertake valuable, ethical and sustainable randomised controlled clinical trial (RCT) research within Aboriginal and Torres Strait Islander primary health services. DESIGN: In a qualitative approach, we utilised data collected between 2013 and 2020 during the planning and implementation of two RCTs. The data comprised agreed records of research meetings, and semistructured interviews with clinical trial stakeholders. The stakeholders were parents/carers of child participants, and site-based research officers, healthcare providers and community advisory groups. Our thematic analysis was informed by constructivist grounded theory. SETTING: The RCTs investigated the management of otitis media in Aboriginal and Torres Strait Islander children, with the first RCT commencing recruitment in 2014 and the second in 2017. They took place in Aboriginal Medical Services (AMSs), large primary health services for Aboriginal and Torres Strait Islander people, based in urban and regional communities across two Australian states and one territory. RESULTS: We analysed data from 56 meetings and 67 interviews, generating themes on making research valuable and undertaking ethical and sustainable RCTs. Aboriginal and Torres Strait Islander leadership, and support of AMSs in their service delivery function were critical. The broad benefits of the trials were considered important to sustainability, including workforce development, enhanced ear healthcare and multidirectional research capacity building. Participants emphasised the long-term responsibility of research teams to deliver benefits to AMSs and communities regardless of RCT outcomes, and to focus on relationships, reciprocity and creating positive experiences of research. CONCLUSION: We identify principles and strategies to assist in undertaking ethical and sustainable RCTs within Aboriginal and Torres Strait Islander primary health services. Maintaining relationships with AMSs and focusing on mutual workforce development and capacity building creates opportunities for long-term benefits so that health research and RCTs work for Aboriginal and Torres Strait Islander peoples, services, communities and researchers. TRIAL REGISTRATION NUMBER: ACTRN12613001068752 (Pre-results); ACTRN12617001652369 (Pre-results).

Otitis media guidelines for Australian Aboriginal and Torres Strait Islander children: summary of recommendations.

INTRODUCTION: The 2001 Recommendations for clinical care guidelines on the management of otitis media in Aboriginal and Torres Islander populations were revised in 2010. This 2020 update by the Centre of Research Excellence in Ear and Hearing Health of Aboriginal and Torres Strait Islander Children used for the first time the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. MAIN RECOMMENDATIONS: We performed systematic reviews of evidence across prevention, diagnosis, prognosis and management. We report ten algorithms to guide diagnosis and clinical management of all forms of otitis media. The guidelines include 14 prevention and 37 treatment strategies addressing 191 questions. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES: A GRADE approach is used. Targeted recommendations for both high and low risk children. New tympanostomy tube otorrhoea section. New Priority 5 for health services: annual and catch-up ear health checks for at-risk children. Antibiotics are strongly recommended for persistent otitis media with effusion in high risk children. Azithromycin is strongly recommended for acute otitis media where adherence is difficult or there is no access to refrigeration. Concurrent audiology and surgical referrals are recommended where delays are likely. Surgical referral is recommended for chronic suppurative otitis media at the time of diagnosis. The use of autoinflation devices is recommended for some children with persistent otitis media with effusion. Definitions for mild (21-30 dB) and moderate (> 30 dB) hearing impairment have been updated. New "OMapp" enables free fast access to the guidelines, plus images, animations, and multiple Aboriginal and Torres Strait Islander language audio translations to aid communication with families.