Humanitarian Outpatient Pediatric Endeavor (HOPE): A Novel Specialist Ambulatory Health-Care Concept in Conflict Areas.

With the collapse of the medical system in Syria, Israel began providing Syrians with humanitarian aid, first to the war-injured and then general medical treatment. We developed a novel specialist ambulatory care concept to provide medical care for Syrian children. Children with their caregivers were transported by bus across the border from Syria to our medical center in Israel for day-stay outpatient-clinic advanced evaluation and treatment due to coordination between Syrian, Red Cross, and Israeli authorities, including Israeli Defense Forces. This retrospective field report includes 371 Syrian children treated as outpatients at Galilee Medical Center between January 2016 and September 2018. In our experience, this novel pediatric ambulatory care concept has been feasible, efficient, and successful in providing specialist care for children in a crisis region devoid of access to health care. We believe it can also serve adult patients and be implemented in other crises and disasters scenarios.

Point mutation revealed the resurgence of sub-genotype VII.2 Newcastle disease virus in Israel.

RESEARCH HIGHLIGHTSIn 2019, there was a resurgence of NDV from sub-genotype VII.2 in Israel, in an already endemic area of sub-genotype VII.1.A mismatch at the 3' end of the reverse primer caused a diagnostic failure of the NDV virulence differentiation rRT-PCR assay.The 2019 NDV sub-genotype VII.2 virus is genetically close to viruses from Jordan (2018) and Pakistan (2015-2016).

Utility of the Pediatric Bleeding Questionnaire in Predicting Posttonsillectomy Bleeding.

OBJECTIVE: Posttonsillectomy bleeding is a dreadful complication that may be life-threatening. Preoperative coagulation tests have not been shown to be effective in predicting this complication. The Pediatric Bleeding Questionnaire (PBQ) is a validated and sensitive tool in diagnosing children with abnormal hemostatic functions, and the objective of our study was to assess its utility as a preoperative screening tool for predicting posttonsillectomy bleeding. STUDY DESIGN: Prospective single-blinded cohort study. SETTING: Tertiary care hospital system. METHODS: All children scheduled for tonsil surgery between 2017 and 2019 in the Galilee Medical Center were included. The PBQ was completed by the caregivers prior to surgery, and all children underwent coagulation tests. Each PBQ item is scored on a scale of -1 to 4, and the total score per candidate is based on summation of all items. RESULTS: An overall 272 patients were included in the study with a mean age of 5.2 years; 57.7% were boys. The main finding was that in a multivariable model adjusted to age, a PBQ score of 2 is correlated with increased postoperative bleeding risk (odds ratio, 10.018 [95% CI, 1.20-82.74]; P = .046). The results of the PBQ demonstrated better predictive ability when compared with abnormal coagulation test results (odds ratio, 1.76 [95% CI, 0.63-4.80]; P = .279). Sex was not found to be significant (odds ratio, 1.45 [95% CI, 0.70-3.18]; P = .343). CONCLUSIONS: This study demonstrated that a PBQ score ≥2 has a higher yield for detecting children at risk for posttonsil surgery bleeding as compared with coagulation studies.

Conjunctivodacryocystorhinostomy (CDCR) success rates and complications in endoscopic vs non-endoscopic approaches: a systematic review.

BACKGROUND: Epiphora due to refractory bicanalicular obstructions is typically managed by conjunctivodacryocystorhinostomy (CDCR) with or without the assistance of nasal endoscopy. However, the evidence for its benefit is unclear. METHODS: A systematic review of the literature on the treatment of epiphora by CDCR was performed (March 1, 2018). All studies reporting original data on patients suffering from epiphora treated with CDCR surgery were included. Primary outcomes were success and satisfaction rates. Secondary outcomes were CDCR complications. A comparison was made between the results obtained in patients undergoing CDCR with vs without assistance of nasal endoscopy. RESULTS: Fifty-four studies representing information on 2555 CDCR procedures were included in the systematic review. All the studies are case series, most of them retrospective. Lester Jones tube (LJT) is the most commonly used in CDCR (66.7%). The overall success rate with all studies included (n = 2555) was 88.9%; 90.8% (n = 890) in CDCR with assistance of nasal endoscope and 87.7% (n = 1575) in the non-endoscopic approach. The overall "tube displacement" rate, the most common complication, was 24.5% (n = 2522), 20.8% (n = 1575) tube displacement in CDCR with assistance of nasal endoscope vs 26.7% (n = 1575) in the non-endoscopic approach. Only 3 studies (5.5%) used patient-reported outcome measures (PROMs) to evaluate epiphora improvement. Due to the low level of evidence and the high bias of the studies, a meta-analysis was not performed. CONCLUSION: Based on the data available in the literature, CDCR is considered an effective procedure for treating epiphora due to proximal obstruction. Controlled and qualitative studies are needed to clarify the significance of the endoscope's contribution to CDCR.

Nationwide Survey of Intratympanic Steroids for the Management of Sudden Sensorineural Hearing Loss.

BACKGROUND: The currently accepted treatment for idiopathic sudden sensorineural hearing loss (ISSHL) is systemic steroids as first-line and intratympanic steroids as salvage therapy. Intratympanic (IT) treatment is applied worldwide in many different ways with no universally accepted protocol. OBJECTIVES: To present the current disparity in ISSHL management and to discuss the necessity for establishing a common national protocol. METHODS: In 2014 we conducted a national survey by sending questionnaires on ISSHL management to otologists in every otolaryngology department in the country. RESULTS: The majority of otolaryngology departments (56%) admit patients with sudden sensorineural hearing. Almost two-thirds (61%) of departments recommend supplementary initial treatment in addition to systemic steroids. None of the medical centers offer intratympanic steroid treatment as primary therapy, but 94% offer this treatment as a salvage therapy. Fewer than half the medical centers (44%) consider the maximal period for intratympanic therapy to be 4 weeks since hearing loss appears. Almost half (48%) the departments use intratympanic steroids once every 5-7 days, usually in an ambulatory setting. Almost half (44%) the medical centers tend to use not more than four courses of IT steroids. In 44% of departments an audiogram is performed at the beginning and at the end of the intratympanic course. CONCLUSIONS: Our results demonstrate a variability among Israeli medical centers in many aspects of intratympanic treatment. We believe this reinforces the need for a comparative international study in order to establish a standard protocol.

Clinical criteria for CT scan evaluation of upper digestive tract fishbone.

OBJECTIVES: To establish clinical criteria for performing computed tomography scan for suspected upper digestive tract fishbone. METHODS: This is a prospective study of all adult patients referred to the otolaryngology emergency department at our medical center for suspected fishbone in the upper digestive tract after no fishbone was seen on physical examination. The patients were divided into two groups: 1) The first was a high clinical suspicion group, which included patients with at least one of the following criteria: drooling, accumulation of saliva in the sinus piriformis, fever, referral 24 hours after the ingestion with worsening/continuing symptoms, and readmission. These patients underwent nonenhanced CT scan (NECT) of the neck. 2) The second was a low clinical suspicion group, which included patients discharged with no NECT performed. These patients were followed at 1 week and 3 months. RESULTS: One hundred and fourteen patients were included in the study; the median age was 41 years. Half of the patients arrived at the emergency department within 7 hours. There were no false negatives. The negative predictive value and sensitivity were 100%. Positive predictive value and specificity were 28.5% and 65%, respectively. Referral to the emergency department 24 hours after the ingestion with continuing symptoms had the highest false positive rate. CONCLUSIONS: Our clinical criteria score for excluding foreign body fishbone in the upper aerodigestive tract was established. According to this score, a NECT can be spared in about 75% of all cases, thus reducing unnecessary ionizing radiation, stay at the emergency department, and costs with a very high NPV of almost 99%. LEVEL OF EVIDENCE: 4. Laryngoscope, 2467-2472, 2018.

Regulation of glial cyclooxygenase by bradykinin.

The aim of the present study was to investigate the short-term effect of bradykinin on the two cyclooxygenase species in neonatal rat glial cells. In spite of the fact that cyclooxygenase protein levels were not altered, an increase in cyclooxygenase activity was observed. Use of cyclooxygenase-1 inhibitors and paracetamol resulted in complete elimination of the bradykinin-induced prostaglandin E(2) synthesis and of cyclooxygenase enzyme activity. Cyclooxygenase-2 inhibitors only partially inhibited enzyme activity and prostaglandin production. Our data suggest that cyclooxygenase-1 is probably the major contributor to short-term modulation of glial prostaglandin E2 synthesis by bradykinin.

Kinins and neuroinflammation: dual effect on prostaglandin synthesis.

The role of kinins, well known as peripheral inflammatory mediators, in the modulation of brain inflammation is unclear. The present data show that bradykinin, a bradykinin B(2) receptor agonist, enhanced both basal and lipopolysaccharide-induced prostaglandin E(2) synthesis in rat neonatal glial cells in culture. By contrast, Lys-des-Arg(9)-bradykinin, which is a kinin breakdown product and a selective bradykinin B(1) receptor agonist, attenuated both basal and lipopolysaccharide-induced production of prostaglandin E(2) in glia. These results suggest a feedback regulatory mechanism of kinins on glial cells, in which prostaglandin synthesis is initially enhanced by bradykinin (B(2)) and eventually blocked by the effect of the kinin breakdown product, acting on bradykinin B(1) receptors.