Vertical-flow constructed wetlands as a sustainable on-site greywater treatment process for the decrease of micropollutant concentration in urban wastewater and integration to households' water services.

Micropollutant removal from effluent of conventional wastewater treatment has recently become one of the most discussed topics in the design and operation of wastewater treatment plants (WWTPs). This is due to the need to add a post-treatment step to the conventional processes to comply with stricter quality standards for effluents as outlined in the revised Urban Wastewater Treatment Directive (UWWTD). The adoption of on-site or decentralized greywater (GW) treatment in sustainable buildings using vertical-flow constructed wetlands (VFCWs) is a promising direction. It represents an interesting alternative for the removal of micropollutants at the source of pollution, such as personal care products (PCPs) and some pharmaceuticals which are mainly present in this wastewater fraction. Additionally, the treated greywater could be used in households' water services which do not require potable water quality, thus saving drinking water. In this context, this work compares the results of micropollutant removal from projects using VFCWs as a polishing step of WWTPs effluent, as a centralized solution, to the results from a decentralized GW treatment. The results show that VFCWs can remove the investigated micropollutants (Diclofenac and DEET) with an efficiency of >90 %, in both centralized and decentralized treatments. The admixture biochar from plant residues and from cellulose-toilet paper proved to be a promising substitute for the mineral zeolite when mixed with sand to remove PCPs from GW and, therefore, a circular economy concept can be applied to this technology.

Biochar from recovered cellulose as new admixture in constructed wetlands for micropollutant removal: A circular approach.

This study aimed to evaluate the suitability of biochar produced by pyrolysis from recovered wastewater cellulose and activated biologically as an admixture in Constructed Wetlands (CWs) when applied as a post-treatment step to remove micropollutants (MPs) from municipal wastewater effluent. Two planted vertical flow mesocosm CWs with cellulose-based admixtures of different origins (plant residue and recovered toilet paper) were fed with a municipal wastewater effluent representative for rural catchments. The results showed an average MPs elimination of 89.1 % for the activated biochar produced from recovered cellulose when 15 relevant compounds are considered and a reduction of the risk from compounds cocktail below the maximum acceptable level having diclofenac, carbamazepine, PFOS, ciprofloxacin and clarithromycin as main risk drivers (Risk Quotient > 1). The implementation of a circular approach to reduce MPs was finally conducted for the Blies catchment (Saarland region in Germany) characterized by low population density and small, sensitive water bodies. This approach demonstrates the feasibility of combining cellulose recovery with a fine sieve in large wastewater treatment plants (WWTPs) and providing biochar produced from recovered cellulose as an admixture to small WWTP where CW is an affordable solution for MP mitigation.

Can ChatGPT outperform a neurosurgical trainee? A prospective comparative study.

PURPOSE: This study aimed to compare the performance of ChatGPT, a large language model (LLM), with human neurosurgical applicants in a neurosurgical national selection interview, to assess the potential of artificial intelligence (AI) and LLMs in healthcare and provide insights into their integration into the field. METHODS: In a prospective comparative study, a set of neurosurgical national selection-style interview questions were asked to eight human participants and ChatGPT in an online interview. All participants were doctors currently practicing in the UK who had applied for a neurosurgical National Training Number. Interviews were recorded, anonymised, and scored by three neurosurgical consultants with experience as interviewers for national selection. Answers provided by ChatGPT were used as a template for a virtual interview. Interview transcripts were subsequently scored by neurosurgical consultants using criteria utilised in real national selection interviews. Overall interview score and subdomain scores were compared between human participants and ChatGPT. RESULTS: For overall score, ChatGPT fell behind six human competitors and did not achieve a mean score higher than any individuals who achieved training positions. Several factors, including factual inaccuracies and deviations from expected structure and style may have contributed to ChatGPT's underperformance. CONCLUSIONS: LLMs such as ChatGPT have huge potential for integration in healthcare. However, this study emphasises the need for further development to address limitations and challenges. While LLMs have not surpassed human performance yet, collaboration between humans and AI systems holds promise for the future of healthcare.

Fate of glyphosate and its metabolite AminoMethylPhosponic acid (AMPA) from point source through wastewater sludge and advanced treatment.

The fate of glyphosate and its metabolite AminoMethylPhosponic acid (AMPA) was followed at the catchment of the Sûre river, mainly characterized by small population density and small and medium-sized wastewater treatment plants (WWTPs). A high concentration of AMPA was found in water samples collected in inlet from different wastewater streams, the industry being the main contributor, while glyphosate resulted mainly in domestic origin. The two molecules were also monitored in the anaerobic digestion as in the supernatant produced after centrifugation (reject water). A total of 0.0713 and 2.24 g/d of glyphosate and AMPA respectively were regularly returned to the activated sludge tank (AST) indicating a 20% impact of the sludge management line on the global wastewater mass balance. Finally, the use of Constructed Wetlands (CWs) in Vertical Flow (VF) configuration was tested as a suitable technology to retain both glyphosate and AMPA (90 and up to 50% elimination respectively) and minimize their discharge into surface water.

Systematic review and meta-analysis of predictive factors for spontaneous regression in lumbar disc herniation.

OBJECTIVE: Relatively little evidence exists on predictive factors for the spontaneous regression of lumbar disc herniation (LDH), although it is a well-documented phenomenon. Therefore, current care is not optimized to identify those who would benefit from early surgery versus those who could avoid surgical risks and pursue nonsurgical therapy. In this study, the authors aimed to analyze and summarize all literature to date on predictive factors for spontaneous LDH regression as well as suggest future research strategies to aid in the decision-making for this cohort. METHODS: A literature search was conducted of the Cochrane, Embase, and MEDLINE databases for articles that described LDH in terms of the North American Spine Society task force definitions: bulging, protruded, extruded, and sequestered disc morphologies. All articles described a nonsurgical primary symptomatic LDH cohort with at least two MR images to assess regression. Those with concomitant spinal disease were excluded. The primary outcome was to assess the probability of disc regression for each disc morphology, with a secondary analysis for any other predictive factors identified. The authors synthesized their results with the only previous review (examining articles published before March 2014) to comprehensively describe the literature. A qualitative analysis of the wider literature was also performed for those studies with differing definitions of LDH but meeting all remaining inclusion criteria. RESULTS: Sixteen articles describing 360 cases of LDH were identified. Participants tended to be younger and male and presented with radiculopathy and L4-5 or L5-S1 LDH. The mean time to follow-up imaging was 11.5 months. The probabilities of spontaneous regression with bulging, protruded, extruded, and sequestered discs were 13.3%, 52.5%, 70.4%, and 93.0%, respectively (χ2 = 126.01, p < 0.001). Extruded and sequestered discs were also significantly more likely to completely regress than smaller morphologies. Other predictors of regression were larger baseline herniation volume (1260.16 vs 1006.71 mm3, p < 0.002), transligamentous herniation (χ2 = 13.321, p < 0.001), and higher Komori types (χ2 = 14.5132, p < 0.001). The authors also found similar trends in qualitative data as well as confirmed that symptom improvement was associated with disc regression. CONCLUSIONS: This study shows further evidence of the influence of disc morphology on predicting LDH regression as well as provides the first meta-analysis of data indicating additional predictive factors. Further investigation of predictive factors for early (< 6 months) LDH regression is suggested to optimize clinical use.

Optimising trajectory planning for stereotactic brain tumour biopsy using artificial intelligence: a systematic review of the literature.

PURPOSE: Despite advances in technology, stereotactic brain tumour biopsy remains challenging due to the risk of injury to critical structures. Indeed, choosing the correct trajectory remains essential to patient safety. Artificial intelligence can be used to perform automated trajectory planning. We present a systematic review of automated trajectory planning algorithms for stereotactic brain tumour biopsies. METHODS: A PRISMA adherent systematic review was conducted. Databases were searched using keyword combinations of 'artificial intelligence', 'trajectory planning' and 'brain tumours'. Studies reporting applications of artificial intelligence (AI) to trajectory planning for brain tumour biopsy were included. RESULTS: All eight studies were in the earliest stage of the IDEAL-D development framework. Trajectory plans were compared through a variety of surrogate markers of safety, of which the minimum distance to blood vessels was the most common. Five studies compared manual to automated planning strategies and favoured automation in all cases. However, this comes with a significant risk of bias. CONCLUSIONS: This systematic review reveals the need for IDEAL-D Stage 1 research into automated trajectory planning for brain tumour biopsy. Future studies should establish the congruence between expected risk of algorithms and the ground truth through comparisons to real world outcomes.

Operation of a pilot-scale lipid accumulation technology employing parameters to select Microthrix parvicella for biodiesel production from wastewater.

Wastewater treatment plants (WWTPs) may play a crucial role in shifting to a zero-emission future by becoming more sustainable and contributing to the circular economy (CE). Recovered lipids from urban sewage can serve as a raw material for biofuel production contributing to a waste reduction, mitigation of natural resources depletion and reinforcing security and energy independence. A novel, pilot-scale lipid accumulation technology (LAT) employing parameters to select M. parvicella for the biofuel/biodiesel production was implemented on a side stream of an urban WWTP. The LAT proved its concept as the average amount of extracted lipids accumulated in the bioreactors was three-fold higher when compared to the lipids existing in activated sludge. The average transesterification of extracted lipids to biodiesel resulted in a 1.6 % yield, meaning that from 1 kg of dried sludge, 16 g of biodiesel could be formed. The biodiesel produced complies with European standard specifications (EN14214).

Assessing the impact of micropollutant mitigation measures using vertical flow constructed wetlands for municipal wastewater catchments in the greater region: a reference case for rural areas.

The present research aims at giving an approach to the issue of surface water contamination due to micropollutants in rural areas. The catchment of the Sûre river was selected as a reference case for the Greater Region, characterized mainly by settlements with low population density, small water bodies and small- to medium-sized wastewater treatment plants (WWTPs). For these WWTPs, conventional technical solutions for micropollutant elimination are not suitable; therefore, an adapted mitigation strategy is needed to prevent the impact of micropollutants, especially during the dry season. As a suitable alternative to more intensive technologies, Constructed Wetlands (CW) in Vertical Flow (VF) configuration have been successfully tested over a 1-year period and the elimination rate of 27 micropollutants was quantified. Emission reduction by VF was then considered in a static mass balance model that calculates the longitudinal concentration profile for the entire river catchment. The EmiSûre approach, which focuses on river quality (concentrations of pollutants) instead of emitted loads, effectively allowed simulation of adopted measures a priori and resulted in efficient support for decision-makers with WWTP upgrade scenarios.

Characterization of unconventional sand-based substrates for adsorption of micropollutants in nature-based systems.

The focus of this study is the characterization of unconventional sand-based substrates used in our previous project EmiSûre, (Interreg Greater Region (German federal states Rhineland-Palatinate and Saarland, the Grand Duchy of Luxembourg, regions Wallonia and Lorraine from Belgium and France, respectively), 2017-2021). The project aimed to develop and test alternative, nature-based technologies for the elimination of micropollutants (MPs) from municipal wastewater. For the characterization, two approaches were chosen. In the first approach, adsorption kinetics with a single compound allowed a perception of the adsorption capacity of the studied substrates compared to conventional substrates (granular activated carbons). This knowledge was completed by the second approach: an implementation of the studied substrates in packed-bed columns, which treated a mixture of 27 MPs in tap water for 10 months. Additionally, all three substrates (bentonite sand, sand with 15% activated biochar and sand with 15% zeolite) were characterized for physical and chemical properties, and the microbial potential of the activated and non-activated biochar was examined. From the studies, it is clear that the sand with an admixture of activated biochar is the most efficient sorbent in terms of single compound adsorption in batch (dye) and adsorption of 27 MPs on packed-bed columns. In contrast to the two other substrates, it shows long-term stable removal efficiencies. In the packed-bed columns, 18 out of 27 compounds were removed on average with high efficiency (80-99%), which is impressive, if we consider the variety of the compounds examined (pharmaceuticals, herbicides, pesticides, etc.) and their removal in conventional treatments. Additionally, adsorption models were created for the experimental data of all compounds adsorbed on the substrate with an admixture of activated biochar resulting in the best fit with the combined Langmuir-Freundlich model. These satisfying results suggest the application of the sand-based substrate with an admixture of activated biochar for further research and possibly upscale installations with the aim to offer and prove a reasonable and efficient alternative for MPs elimination from municipal wastewater.

Behaviour of 27 selected emerging contaminants in vertical flow constructed wetlands as post-treatment for municipal wastewater.

Six substrates (i.e. sand enriched with activated or non-activated biochar or zeolite in different ratios) were tested in Vertical Flow Constructed Wetlands (VFCWs) planted with Phragmites australis and Iris pseudacorus for the removal of 27 emerging contaminants from municipal wastewater. The laboratory investigation under controlled conditions (spiked constant concentrations in synthetic wastewater) lasted 357 days and proved VFCWs being able to provide excellent effluent quality in terms of both macro - and micropollutant elimination. Because overall removal efficiencies exceeded 90% in most of the cases, significant differences among the substrates were not detectable. For compounds with medium elimination (i.e. AMPA) the type of substrate seemed to play a strong role and the maximum amount of active ingredient adsorbed per amount of substrate has been quantified (i.e. 0.77 µg of AMPA per g of 30% biochar mixed with sand). Three of the most promising substrates from laboratory where thus selected to be tested under real conditions (fluctuation in concentration, variable temperature). As result, VFCWs with 15% activated biochar mixed with sand proved to be effective in the removal of 18 emerging contaminants and complying with national discharge standards for 4 selected compounds.

Prehospital triage of trauma patients before and after implementation of a regional triage guideline.

INTRODUCTION: Severely injured trauma patients have a considerable mortality rate. One way to reduce the mortality is to ensure optimal triage. The American College of Surgeons Committee on Trauma has since 1986 made guidelines for the triage of trauma patients. These guidelines formed the basis, when the capital region of Denmark implemented a regional trauma triage guideline on February 15th 2016. It is uncertain how the implementation of the regional trauma triage guideline has influenced the triage of trauma patients. The aim of this study was to investigate the changes in admission pattern of trauma patients in the entire region after the implementation of the regional trauma triage guideline. We hypothesized that there would be a reduction in the proportion of trauma patients admitted to the trauma center after the implementation of the regional trauma triage guideline. PATIENTS AND METHODS: In this observational cohort study with one-year follow-up, we used a national patient registry in Denmark. We identified trauma patients three years before and three years after the implementation of a new regional trauma triage guideline. The primary outcome was the proportion of trauma patients triaged to the regional trauma center. Secondary outcomes were: 30-day and one-year mortality, overtriage, and undertriage. RESULTS: We found a significant reduction in the proportion of trauma patients triaged to the trauma center from 2115/5951 (35.5%) to 1970/5857 (33.6%), after the implementation of the regional trauma triage guideline, the difference being 1.9% (95% CI: 0.19 to 3.6%); P = 0.03. Further, a significant reduction of overtriage from 15.4% to 9.5% (difference 5.9% with 95% CI of 3.8 to 7.9%) was found. No significant changes in undertriage, 30-day or one-year mortality were found (1.07% vs 0.97%, 4.3% vs 4.5%, and 15.7% vs 16.6% respectively). CONCLUSION: A significant decrease in the proportion of trauma patients admitted to the trauma center was found after implementation of a new regional trauma triage guideline. A reduction was seen in overtriage, but no changes were found in undertriage and both short-term and long-term mortality remained unchanged.

Identifying metabolic alterations in newly diagnosed small cell lung cancer patients.

BACKGROUND: Small cell lung cancer (SCLC) is a malignant disease with poor prognosis. At the time of diagnosis most patients are already in a metastatic stage. Current diagnosis is based on imaging, histopathology, and immunohistochemistry, but no blood-based biomarkers have yet proven to be clinically successful for diagnosis and screening. The precise mechanisms of SCLC are not fully understood, however, several genetic mutations, protein and metabolic aberrations have been described. We aim at identifying metabolite alterations related to SCLC and to expand our knowledge relating to this aggressive cancer. METHODS: A total of 30 serum samples of patients with SCLC, collected at the time of diagnosis, and 25 samples of healthy controls were included in this study. The samples were analyzed with nuclear magnetic resonance spectroscopy. Multivariate, univariate and pathways analyses were performed. RESULTS: Several metabolites were identified to be altered in the pre-treatment serum samples of small-cell lung cancer patients compared to healthy individuals. Metabolites involved in tricarboxylic acid cycle (succinate: fold change (FC) = 2.4, p = 0.068), lipid metabolism (LDL triglyceride: FC = 1.3, p = 0.001; LDL-1 triglyceride: FC = 1.3, p = 0.012; LDL-2 triglyceride: FC = 1.4, p = 0.009; LDL-6 triglyceride: FC = 1.5, p < 0.001; LDL-4 cholesterol: FC = 0.5, p = 0.007; HDL-3 free cholesterol: FC = 0.7, p = 0.002; HDL-4 cholesterol FC = 0.8, p < 0.001; HDL-4 apolipoprotein-A1: FC = 0.8, p = 0.005; HDL-4 apolipoprotein-A2: FC ≥ 0.7, p ≤ 0.001), amino acids (glutamic acid: FC = 1.7, p < 0.001; glutamine: FC = 0.9, p = 0.007, leucine: FC = 0.8, p < 0.001; isoleucine: FC = 0.8, p = 0.016; valine: FC = 0.9, p = 0.032; lysine: FC = 0.8, p = 0.004; methionine: FC = 0.8, p < 0.001; tyrosine: FC = 0.7, p = 0.002; creatine: FC = 0.9, p = 0.030), and ketone body metabolism (3-hydroxybutyric acid FC = 2.5, p < 0.001; acetone FC = 1.6, p < 0.001), among other, were found deranged in SCLC. CONCLUSIONS: This study provides novel insight into the metabolic disturbances in pre-treatment SCLC patients, expanding our molecular understanding of this malignant disease.

Removal of 27 micropollutants by selected wetland macrophytes in hydroponic conditions.

In this work, the primary focus is given on a mixture of 27 micropollutants (pharmaceuticals, pesticides, herbicides, fungicides and others) and its removal from aqueous solution by phytoremediation. Phytoremediation belongs to technologies, which are contributing on removal of micropollutants from wastewater in constructed wetlands. Constructed wetlands can be used as an additional step for elimination of micropollutants from municipal medium-sized wastewater treatment plants. To our knowledge, such a broad variety of micropollutants was never targeted for removal by phytoremediation before. In this work, we carry out experiments with 3 emergent macrophytes: Phragmites australis, Iris pseudacorus and Lythrum salicaria in hydroponic conditions. The selected plants are exposed to mixture of micropollutants in concentrations 1-14 mg/l for a time period of 30 days. The highest affinity for phytoremediation is detected at groups of fluorosurfactants (removal rate up to 30%), beta-blockers (removal rate up to 50%) and antibiotics (removal rate up to 90%). The leading capability for micropollutant uptake is detected at Lythrum salicaria, where 25 out of 27 compounds are removed with more than 20% efficiency. The results demonstrate well usefulness of this technology e.g. in an additional treatment step, because the mentioned groups of micropollutants are removed with comparable or even higher effectivity, than it is in case of conventional wastewater treatment plants.

Management of Ambulatory Anesthesia in Older Adults.

The number of older patients is increasing globally. Combined with the growing number of ambulatory surgeries, many older patients will undergo ambulatory surgery in the future. The ambulatory setting offers many advantages: early mobilization, higher patient satisfaction, lower costs, and a low incidence of several complications such as infections and thromboembolic events. Moreover, cognitive recovery seems to be enhanced compared with in-hospital surgery, and both frail patients and patients with dementia can benefit from ambulatory surgery. This review provides suggestions for managing perioperative anesthesia for older patients in the ambulatory setting. Not all older patients are eligible for ambulatory surgery, and clinicians must be aware of risk factors for complications, especially frailty. Most anesthesia techniques and agents can be used in the ambulatory setting, but short-acting agents are preferred to ensure fast recovery. Both regional and general anesthesia are useful, but clinicians must be familiar with the physiological changes and specific implications in the older population. The older patients are more sensitive to anesthetic agents, meaning that a lower dose is needed to obtain the desired effect. However, they exhibit huge variation in pharmacodynamics and pharmacokinetics. Prolonged onset time may lead to overdosing and extended recovery. After surgery, effective pain management with opioid minimization is essential to ensure rapid recovery.

Climate change in healthcare: Exploring the potential role of inhaler prescribing.

Climate change has been described as the biggest global health threat of the 21st century. As a result, governments around the world are committing to legislative change in order to reduce greenhouse gas emissions (GHGEs). The healthcare sector makes a significant contribution to GHGEs and in line with national legislation in the UK, the NHS has recently committed to achieving net zero emissions by 2050. The management of asthma and COPD largely depends on the prescribing of medications that are delivered through inhalers. In the UK, the use of pressurized metered dose inhalers (pMDIs), which rely on hydrofluorocarbon (HFC) propellants accounts for 3.5% of the NHS's total carbon footprint. In contrast, dry powder inhalers (DPIs) have a much lower carbon footprint due to the absence of a HFC propellant. Here we review evidence of the impact of inhaler choices across four domains: environmental impact, clinical effectiveness, cost effectiveness and patient preferences. We find that as well as a lower global-warming potential, DPIs have additional benefits over pMDIs in other domains and should be considered first line where clinically appropriate.

Does the size of rewards influence performance in cognitively demanding tasks?

Classic micro-economic and psychology theories propose different implications of monetary incentives on performance. Empirical studies in sports settings show that athletes generally perform worse when the stakes are higher, while a range of lab studies involving cognitively demanding tasks have led to diverging results, supporting positive, negative and null-effects of higher (vs. lower) stakes. In order to further investigate this issue, we present a pre-registered, randomized, controlled trial of 149 participants solving both anagrams and math addition tasks. We do not find a statistically significant effect of the size of the reward on neither performance, self-reported effort nor intrinsic motivation. We propose that future studies should contrast the potential impact of rewards on different kinds of task, e.g. compare tasks that solely require cognitive effort vs. tasks that require motor skills, as in sports.

New Validated Method for Measuring Fat Graft Retention in the Breast with MRI.

In this study, we present a new method for measuring fat graft volume retention in the breast based on magnetic resonance imaging scans and a validation study to assess its accuracy and precision. The method was validated by 4 observers using the magnetic resonance imaging scans of 14 patients undergoing breast augmentation with fat grafting. The method was translated into software and was used to measure the change in breast volume from a preoperative scan to a postoperative scan recorded within 3 hours after the surgery, which was compared with the injected fat graft volume. The new method measured the injected fat graft volumes with an average systematic overestimation of 6.3% (SD, 10.5). The median interobserver variation was <7%. We propose that this new method can be a good alternative to previous techniques for clinical research purposes. The software can be made available upon request free of charge for use on the MeVisLab platform.

The current gold standard breast volumetry technique seems to overestimate fat graft volume retention in the breast: A validation study.

BACKGROUND: MRI is generally considered as the gold standard for measuring breast volume because of its high accuracy of the modality. Many techniques used to measure total breast volume have been validated, but none of these techniques have been validated for their ability to measure the volume retention of fat grafts in the breast. In this study, the authors investigated the accuracy of the most common MRI technique used to measure fat graft retention in the breast by measuring the volume changes after breast augmentation. METHODS: Patients undergoing breast augmentation with either breast implants or fat grafting underwent MRI scans before and after surgery. Blinded observers measured the change in breast volume from the MRI scans. The difference between the measured change in breast volume and the volume of the breast augmentation was used to determine the accuracy of the MRI technique. RESULTS: Twenty-eight patients with a total of 56 breasts were included. In total, 168 measurements of change in breast volume were performed by the observers. The MRI measurements of change in breast volume overestimated the true volumes of the breast augmentations by an average of 50.8%, and only 8 of the 168 individual measurements had measurement errors below 50 mL. CONCLUSION: The MRI technique, which is considered as the gold standard for the quantification of fat graft volume retention, was associated with a significant measurement error. These findings have potential implications for the interpretation of previously published results of studies based on this technique.

Machine learning for energy cost modelling in wastewater treatment plants.

Understanding the energy cost structure of wastewater treatment plants is a relevant topic for plant managers due to the high energy costs and significant saving potentials. Currently, energy cost models are generally generated using logarithmic, exponential or linear functions that could produce not accurate results when the relationship between variables is highly complex and non-linear. In order to overcome this issue, this paper proposes a new methodology based on machine-learning algorithms that perform better with complex datasets. In this paper, machine learning was used to generate high-performing energy cost models for wastewater treatment plants, using a database of 317 wastewater treatment plants located in north-west Europe. The most important variables in energy cost modelling were identified and for the first time, the energy price was used as model parameter and its importance evaluated.

Acute external otitis as debut of acute myeloid leukemia - A case and review of the literature.

Acute leukemia is a well known childhood cancer. The relation between leukemia and otological symptoms has long been established but is highly rare as a debut symptom of leukemia. External otitis is a common condition affecting many children, and most cases are successively treated with topical medicine. Here we present a child with acute external otitis later shown to be the debut symptom of acute myeloid leukemia, to our knowledge the first specific case described. We have reviewed the literature to find red flags for suspicion of severe disease in case of acute external otitis.