Tranexamic acid in sinus and nasal surgery: an up-to-date meta-analysis.

OBJECTIVE: There are gaps within current meta-analyses looking at the effects of tranexamic acid on sino-nasal surgery. This study aimed to update and summarise all current available evidence on the use of tranexamic acid in sino-nasal surgery. METHOD: A literature search was performed using four medical databases, Cochrane Library, Embase, Medline and PubMed. Data analysis was performed using dedicated meta-analysis software Review Manager (Revman). RESULTS: Thirteen studies were included in the meta-analysis. The amount of blood loss and duration of surgery in tranexamic acid groups was statistically lower than placebo for both sinus and nasal surgery. Tranexamic acid improves the surgical field quality in sinus surgery but worsens the field in nasal surgery. Topical or intravenous administration of tranexamic acid in sinus surgery reduces blood loss, duration of surgery and improves the quality of the surgical field. CONCLUSION: This study suggests that the use of tranexamic acid in sinus surgery reduces blood loss, decreases surgical duration and improves surgical field quality.

A change in clinical practice for aural foreign bodies - what we learnt from the coronavirus disease 2019 pandemic.

OBJECTIVE: This case series, conducted during the coronavirus disease 2019 pandemic, investigates the impact of leaving aural foreign bodies in situ for a prolonged period of time, including the risk of complications and success rates of subsequent removal attempts. METHOD: A retrospective study of aural foreign body referrals over a six-month period was carried out. RESULTS: Thirty-four patients with 35 foreign bodies were identified (6 organic and 29 inorganic). The duration of foreign bodies left in situ ranged from 1 to 78 days. Four patients suffered from traumatic removal upon initial attempts. First attempts made by non-ENT specialists (68.8 per cent) all failed and were associated with a high risk of trauma (36.4 per cent). CONCLUSION: Because of the coronavirus disease 2019 pandemic, this is the first case series to specifically investigate the relationship between the duration of aural foreign bodies left in situ and the risk of complications. Our data suggest that prolonged duration does not increase the incidence of complications.

Feasibility of magnetic resonance guided radiotherapy for the treatment of bladder cancer.

Whole bladder magnetic resonance image-guided radiotherapy using the 1.5 Telsa MR-linac is feasible. Full online adaptive planning workflow based on the anatomy seen at each fraction was performed. This was delivered within 45 min. Intra-fraction bladder filling did not compromise target coverage. Patients reported acceptable tolerance of treatment.

Injuries during transition periods across the year in pre-professional and professional ballet and contemporary dancers: A systematic review and meta-analysis.

OBJECTIVE: To consider the association of injuries with transition periods in the dance year, i.e., when dancers return at the start of the year, and when they transition from rehearsal to performance periods. METHODS: Six electronic databases were searched to November 2019. All English language peer-reviewed studies, of any study design investigating ballet and contemporary pre-professional and professional dance populations were included. Only those studies reporting on the timing of injury were included. RESULTS: Fifteen cohort and two case-series studies were included. A meta-analysis of seven studies revealed the rate of injuries to be significantly higher for the second and third months (1.52; 95% confidence interval [CI]:1.11-2.08; 1.26; 95%CI:1.07-1.48 respectively) after the return to dance. Two further studies report more injuries up to Week 13 of the year. One study showed an increase in injured dancers at three and four weeks after transition from rehearsals to a performance season. Four studies show an increase in injuries at performance times. CONCLUSIONS: Meta-analyses of seven studies shows the second and third months after returning to dance have a significantly higher rate of injuries. More research is needed to quantify training loads in dance. Practitioners should be cognisant of the higher injury rates during periods of transition and consider modifying load, as it is a potential contributing factor.

A dedicated high-quality service for the management of patients with an inherited risk of colorectal cancer.

AIM: To demonstrate the quality improvement associated with the implementation of a specialist family history of bowel cancer service in secondary care. METHOD: The following outcomes were assessed: (1) adherence to the British Society of Gastroenterology (BSG) guidelines for colonoscopic surveillance of individuals with a family history of colorectal cancer (CRC); (2) adherence to the revised Bethesda criteria for the identification of CRC patients with suspected Lynch syndrome; (3) identification of inherited syndromes with increased CRC risk; and (4) colonoscopic adenoma detection rate. Data were collected for a 21-month period before and after the establishment of this service for all patients who underwent colonoscopic surveillance for a family history of CRC and all patients newly diagnosed with CRC. Analyses compared the number of colonoscopies performed that were not indicated by BSG guidelines, the average number of years early that patients were screened, the adenoma detection rate and the rate of tumour testing for mismatch repair genes before and after the implementation of the service. RESULTS: Following the establishment of the service there was a reduction in the number of colonoscopies not indicated by BSG guidelines (39.6% before and 5.8% after, P < 0.001, chi-square test) and surveillance colonoscopy took place at a more appropriate age (10.6 years too early before and 5.9 years early after, P = 0.01, t-test). There was an increased adenoma detection rate (17% before and 31.9% after, P < 0.01, chi-square test) and increased tumour MMR testing (3.4% before and 91.8% after, P < 0.01, chi-square test). CONCLUSION: The introduction of a family history of bowel cancer service results in improved patient care through improved adherence to guidelines for colonoscopic surveillance and increased cancer detection rates.

High Performance Bi-2212 Round Wires Made with Recent Powders.

Multifilamentary Bi2Sr2CaCu2Ox (Bi-2212) wire made by the powder-in-tube technique is the only high temperature superconductor made in the round shape preferred by magnet builders. The critical current density (J C ) of Bi-2212 round wire was improved significantly by the development of overpressure heat treatment in the past few years. Bi-2212 wire is commercially available in multiple architectures and kilometer-long pieces and a very promising conductor for very high field NMR and accelerator magnets. We studied the effects of precursor powder and heat treatment conditions on the superconducting properties and microstructure of recent Bi-2212 wires. Short samples of recent wire with optimized overpressure processing showed J C (4.2 K, 15 T) = 6640 A/mm2 and J C (4.2 K, 30 T) = 4670 A/mm2, which correspond to engineering critical current densities J E (4.2 K, 15 T) = 1320 A/mm2 and J E (4.2 K, 30 T) = 930 A/mm2.

Magnetic resonance imaging sequence evaluation of an MR Linac system; early clinical experience.

OBJECTIVES: To systematically identify the preferred magnetic resonance imaging (MRI) sequences following volunteer imaging on a 1.5 Tesla (T) MR-Linear Accelerator (MR Linac) for future protocol development. METHODS: Non-patient volunteers were recruited to a Research and Ethics committee approved prospective MR-only imaging study on a 1.5T MR Linac system. Volunteers attended 1-3 imaging sessions that included a combination of mDixon, T1w, T2w sequences using 2-dimensional (2D) and 3-dimensional (3D) acquisitions. Each sequence was acquired over 2-7 minutes and reviewed by a panel of 3 observers to evaluate image quality using a visual grading analysis based on a 4-point Likert scale. Sequences were acquired and modified iteratively until deemed fit for purpose (online image matching or re-planning) and all observers agreed they were suitable in 3 volunteers. RESULTS: 26 volunteers underwent 31 imaging sessions of six general anatomical regions. Images were acquired in one or two of six general anatomical regions: male pelvis (n = 9), female pelvis (n = 4), chestwall/breast (n = 5), lung/oesophagus (n = 5), abdomen (n = 3) and head and neck (n = 5). Images were acquired using a pre-defined exam-card that on average, included six sequences (range 2-10), with a maximum scan time of approximately one hour. The majority of observers preferred T2-weighted sequences. The thorax teams were the only groups to prefer T1-weighted imaging. CONCLUSIONS: An iterative process identified sequence agreement in all anatomical regions. These sequences will now be evaluated in patient volunteers. ADVANCES IN KNOWLEDGE: This manuscript is the first publication sharing the results of the first systematic selection of MRI sequences for use in on-board MRI-guided radiotherapy by end-users (therapeutic radiographers and clinical oncologists) in healthy volunteers.

Adaptive Radiotherapy Enabled by MRI Guidance.

Adaptive radiotherapy (ART) strategies systematically monitor variations in target and neighbouring structures to inform treatment-plan modification during radiotherapy. This is necessary because a single plan designed before treatment is insufficient to capture the actual dose delivered to the target and adjacent critical structures during the course of radiotherapy. Magnetic resonance imaging (MRI) provides superior soft-tissue image contrast over current standard X-ray-based technologies without additional radiation exposure. With integrated MRI and radiotherapy platforms permitting motion monitoring during treatment delivery, it is possible that adaption can be informed by real-time anatomical imaging. This allows greater treatment accuracy in terms of dose delivered to target with smaller, individualised treatment margins. The use of functional MRI sequences would permit ART to be informed by imaging biomarkers, so allowing both personalised geometric and biological adaption. In this review, we discuss ART solutions enabled by MRI guidance and its potential gains for our patients across tumour types.

Impact of previous hepatitis B infection on the clinical outcomes from chronic hepatitis C? A population-level analysis.

Chronic coinfection with hepatitis C virus (HCV) and hepatitis B virus (HBV) is associated with adverse liver outcomes. The clinical impact of previous HBV infection on liver disease in HCV infection is unknown. We aimed at determining any association of previous HBV infection with liver outcomes using antibodies to the hepatitis B core antigen (HBcAb) positivity as a marker of exposure. The Scottish Hepatitis C Clinical Database containing data for all patients attending HCV clinics in participating health boards was linked to the HBV diagnostic registry and mortality data from Information Services Division, Scotland. Survival analyses with competing risks were constructed for time from the first appointment to decompensated cirrhosis, hepatocellular carcinoma (HCC) and liver-related mortality. Records of 8513 chronic HCV patients were included in the analyses (87 HBcAb positive and HBV surface antigen [HBsAg] positive, 1577 HBcAb positive and HBsAg negative, and 6849 HBcAb negative). Multivariate cause-specific proportional hazards models showed previous HBV infection (HBcAb positive and HBsAg negative) significantly increased the risks of decompensated cirrhosis (hazard ratio [HR]: 1.29, 95% CI: 1.01-1.65) and HCC (HR: 1.64, 95% CI: 1.09-2.49), but not liver-related death (HR: 1.02, 95% CI: 0.80-1.30). This is the largest study to date showing an association between previous HBV infection and certain adverse liver outcomes in HCV infection. Our analyses add significantly to evidence which suggests that HBV infection adversely affects liver health despite apparent clearance. This has important implications for HBV vaccination policy and indications for prioritization of HCV therapy.

A bioluminescent Pseudomonas aeruginosa wound model reveals increased mortality of type 1 diabetic mice to biofilm infection.

OBJECTIVE: To examine how bacterial biofilms, as contributing factors in the delayed closure of chronic wounds in patients with diabetes, affect the healing process. METHOD: We used daily microscopic imaging and the IVIS Spectrum in vivo imaging system to monitor biofilm infections of bioluminescent Pseudomonas aeruginosa and evaluate healing in non-diabetic and streptozotocin-induced diabetic mice. RESULTS: Our studies determined that diabetes alone did not affect the rate of healing of full-depth murine back wounds compared with non-diabetic mice. The application of mature biofilms to the wounds significantly decreased the rate of healing compared with non-infected wounds for both non-diabetic as well as diabetic mice. Diabetic mice were also more severely affected by biofilms displaying elevated pus production, higher mortality rates and statistically significant increase in wound depth, granulation/fibrosis and biofilm presence. Introduction of a mutant Pseudomonas aeruginosa capable of producing high concentrations of cyclic di-GMP did not result in increased persistence in either diabetic or non-diabetic animals compared with the wild type strain. CONCLUSION: Understanding the interplay between diabetes and biofilms may lead to novel treatments and better clinical management of chronic wounds.

Does the EarPopper(®) device improve hearing outcomes in children with persistent otitis media with effusion? A randomised single-blinded controlled trial.

OBJECTIVE: To provide an independent evaluation of the efficacy and safety of the EarPopper(®) in improving hearing outcomes in children with otitis media with effusion (OME) and reducing the ventilation tube insertion rate. STUDY DESIGN: Randomised single-blinded controlled trial. SETTING: The Ear Nose and Throat Department of a district general hospital (Heatherwood and Wexham Park). PARTICIPANTS AND METHODS: Twenty-nine children aged between 4 and 11 years diagnosed with persistent OME lasting at least 3 months with an average hearing of 25 dBHL or worse in the better ear were randomised to a treatment or control group for 7 weeks using random computer-generated codes. Syndromic children, children with developmental delay, previous grommets and cleft palate were excluded. The audiologists were blinded at the final post-treatment audiogram. RESULTS: After the seven-week period, the mean improvement in air conduction across all frequencies was 10.9 dBHL in the treatment group (P < 0.001) and 3.6 dBHL in the control group (P = 0.201). At every frequency, the treatment group had larger improvements in air conduction, the largest being at 4 kHz where the mean air conduction in both ears improved by 14.8 dBHL. Compliance with the EarPopper(®) was over 90%, the only side-effect reported being discomfort in the ears immediately after use which resolved and did not affect compliance. The ventilation tube insertion rate was 53.3% in the treatment group and 78.6% in the control group. Median follow-up time for all patients is 47.7 months. CONCLUSION: Our study shows that the EarPopper(®) is a safe, effective treatment option for children with hearing loss from persistent OME, and it reduces the rate of ventilation tube insertion. More studies with larger sample sizes are required to support our findings.

Why are Children Still Being Infected with HIV? Impact of an Integrated Public Health and Clinical Practice Intervention on Mother-to-Child HIV Transmission in Las Vegas, Nevada, 2007-2012.

BACKGROUND: During a 9 months period, September 2005 through June 2006, Nevada documented six cases of pediatric HIV acquired through mother-to-child transmission. Subsequently, a community-based approach to the care of women and children living with or exposed to HIV was implemented. SUBJECTS AND METHODS: A detailed review of mother-infant pairs where HIV transmission occurred was performed to identify missed opportunities for prevention of mother-to-child HIV transmission. An intervention program was developed and implemented using the six-step process. Data were collected prospectively over a 6 years period (2007-2012) and were evaluated for six core outcomes measures: (1) adequacy of prenatal care (2) HIV diagnoses of expectant mothers prior to delivery (3) appropriate use of antiretroviral (ARV) therapy before delivery (4) appropriate use of cesarean section for delivery (5) adequacy of zidovudine prophylaxis to newborn (6) HIV transmission rate. RESULTS: Twenty-six infants were born to HIV-infected mothers from July 2005 to June 2006 with 6 documented infections. One hundred and five infants were born to HIV infected mothers from January 2007 to December 2012. Postimplementation, adequacy of prenatal care increased from 58% (15/26) to 85% (89/105); appropriate use of ARV therapy before delivery increased from 73% (19/26) to 86% (90/105); cesarean section as the method for delivery increased from 62% (16/26) to 74% (78/105); adequacy of zidovudine prophylaxis to newborn increased from 54% (14/26) to 87% (91/105). HIV transmission rate dropped from 23% (6/26) to 0%. CONCLUSION: Integrating public health and clinical services in the care of HIV-infected pregnant women and exposed infants leads to better coordination of care and improved quality of care.

Scaling of geochemical reaction rates via advective solute transport.

Transport in porous media is quite complex, and still yields occasional surprises. In geological porous media, the rate at which chemical reactions (e.g., weathering and dissolution) occur is found to diminish by orders of magnitude with increasing time or distance. The temporal rates of laboratory experiments and field observations differ, and extrapolating from laboratory experiments (in months) to field rates (in millions of years) can lead to order-of-magnitude errors. The reactions are transport-limited, but characterizing them using standard solute transport expressions can yield results in agreement with experiment only if spurious assumptions and parameters are introduced. We previously developed a theory of non-reactive solute transport based on applying critical path analysis to the cluster statistics of percolation. The fractal structure of the clusters can be used to generate solute distributions in both time and space. Solute velocities calculated from the temporal evolution of that distribution have the same time dependence as reaction-rate scaling in a wide range of field studies and laboratory experiments, covering some 10 decades in time. The present theory thus both explains a wide range of experiments, and also predicts changes in the scaling behavior in individual systems with increasing time and/or length scales. No other theory captures these variations in scaling by invoking a single physical mechanism. Because the successfully predicted chemical reactions include known results for silicate weathering rates, our theory provides a framework for understanding changes in the global carbon cycle, including its effects on extinctions, climate change, soil production, and denudation rates. It further provides a basis for understanding the fundamental time scales of hydrology and shallow geochemistry, as well as the basis of industrial agriculture.

Sexual dimorphism of human vallate papillae: an in vivo study of normative morphology.

The perimeters of vallate papillae (VP) house approximately half of the taste buds on the human tongue. However, little information exists regarding perimeter measurements of VP. Likewise, great diversity exists among reports of the number of VP and diameter of VP, in general. The research presents an analysis of the perimeters, counts, and diameters of VP in vivo. Endoscopic examination was performed on 79 individuals (40 females, 39 males) between 18 and 26 years of age. A total of 583 VP were counted, 565 of which were able to be measured. Data revealed a statistically significant difference between male and female VP count (t(75.6) = 4.5; p = 0.00003). Females had, on average, 2.22 more VP than males. Males were found to have larger mean VP diameter per person and mean VP perimeter per person than females (t(58.9) = -2.4; p = 0.021 and t(59.3) = -2.4; p = 0.019, respectively). The report demonstrates that VP are sexually dimorphic at the gross anatomical level.

Knowledge and awareness of personal sickle cell genotype among parents of children with sickle cell disease in southeast Nigeria.

Sickle cell trait (SCT; HbAS), the heterozygous state for the sickle cell allele of the beta globin gene, is carried by as many as 100 million individuals worldwide. Nigeria has the highest prevalence of SCT, impacting an estimated 25 % of adult population. This study was designed to assess timing of awareness, knowledge of SCT status and preferred method of education among parents of children with sickle cell disease (SCD). We conducted a cross-sectional survey of parents of children with SCD from June 2013-March 2014. Participants completed a 20-item questionnaire to assess (1) awareness of personal sickle cell genotype, (2) timing of awareness of personal sickle cell genotype, and (3) knowledge of SCT. One hundred and fifty-five participants completed the survey. Seventy-eight percent were females, and 87 % (135/155) were aware of their own sickle cell genotype. Timing of awareness varied as follows: following birth of a child with sickle cell disease (45 %); during marriage (21.5 %); school admission (9.6 %); during pregnancy (9.6 %); and other times (14 %). Approximately 35.5 % of participants thought that sickle cell trait was a mild form of sickle cell disease. Radio (43.9 %), informational community meetings (27.7 %), and television (21.9 %) were identified by participants as the most effective method of increasing sickle cell trait awareness. Innovative approaches are needed to increase the proportion of individuals who are aware of their own sickle cell genotype prior to having a child with sickle cell anemia in line with the Healthy People 2020 objective.

Immunoglobulin G4 related chronic sclerosing sialadenitis.

BACKGROUND: ENT surgeons may be the first specialists to encounter and diagnose patients with salivary gland disease. A new entity involving the salivary glands has recently been described of which ENT surgeons need to be aware: immunoglobulin G4 related chronic sclerosing sialadenitis. METHOD: A literature search of Medline, Embase and Cochrane Library databases was performed, using the search terms 'IgG4', 'hyperIgG4 syndrome' and 'IgG4 related chronic sclerosing sialadenitis'. RESULTS: Knowledge concerning immunoglobulin G4 related chronic sclerosing sialadenitis is rapidly increasing. This new entity is part of a fibro-inflammatory corticosteroid-responsive systemic disease (immunoglobulin G4 related disease) and has been described in almost every organ. Biopsy of the submandibular gland can be diagnostic. However, the diagnosis can easily be overlooked if: clinical suspicion is not high, one is unaware of the classical morphology and/or immunoglobulin G4 staining is not performed. This paper presents a summary of the current understanding of the disease and its management. CONCLUSION: ENT surgeons should be aware of this new disease entity. Patients with systemic disease should be managed under a multidisciplinary team, with input from clinicians who have an interest in such diseases (such as gastroenterologists and rheumatologists), and input from histopathologists and radiologists.

Randomized controlled trial of asthma risk with paracetamol use in infancy--a feasibility study.

BACKGROUND: There is non-experimental evidence that paracetamol (acetaminophen) use may increase the risk of developing asthma. However, numerous methodological issues need to be resolved before undertaking a randomized controlled trial to investigate this hypothesis. OBJECTIVE: To establish the feasibility of a randomized controlled trial of liberal paracetamol as usually given by parents/guardians vs. a comparator (restricted paracetamol in accordance with WHO guidelines, ibuprofen or placebo), and childhood asthma risk. METHODS: Questionnaires were completed by parents/guardians of infants admitted to Wellington Hospital with bronchiolitis to assess views about comparator treatments. Subsequently, infants of parents/guardians who provided informed consent were randomized to restricted or liberal paracetamol use for 3 months with paracetamol use recorded. RESULTS: Of 120 eligible participants, 72 (60%) parents/guardians completed the questionnaire. Ibuprofen, restricted paracetamol and placebo were acceptable to 42 (58%), 29 (40%) and 9 (12%) parents/guardians, respectively. 36 (30%) infants were randomized to restricted or liberal paracetamol. Paracetamol use was greater for the liberal vs. restricted group for reported [Hodges-Lehmann estimator of difference 0.94 mg/kg/day (95% CI 0.2-3.52), P = 0.02] and measured use [Hodges-Lehmann estimator of difference 2.11 mg/kg/day (95% CI 0.9-4.18), P = 0.004]. The median reported and measured use of paracetamol was 2.0-fold and 3.5-fold greater in the liberal vs. restricted group. CONCLUSIONS AND CLINICAL RELEVANCE: Although separation in paracetamol dosing is likely to be achieved with a liberal vs. restricted paracetamol regime, ibuprofen is the preferred comparator treatment in the proposed RCT of paracetamol use and risk of asthma in childhood.

Quality and age of shallow groundwater in the Bakken Formation production area, Williston Basin, Montana and North Dakota.

The quality and age of shallow groundwater in the Bakken Formation production area were characterized using data from 30 randomly distributed domestic wells screened in the upper Fort Union Formation. Comparison of inorganic and organic chemical concentrations to health based drinking-water standards, correlation analysis of concentrations with oil and gas well locations, and isotopic data give no indication that energy-development activities affected groundwater quality. It is important, however, to consider these results in the context of groundwater age. Most samples were recharged before the early 1950s and had 14C ages ranging from <1000 to >30,000 years. Thus, domestic wells may not be as well suited for detecting contamination associated with recent surface spills as shallower wells screened near the water table. Old groundwater could be contaminated directly by recent subsurface leaks from imperfectly cemented oil and gas wells, but horizontal groundwater velocities calculated from 14C ages imply that the contaminants would still be less than 0.5 km from their source. For the wells sampled in this study, the median distance to the nearest oil and gas well was 4.6 km. Because of the slow velocities, a long-term commitment to groundwater monitoring in the upper Fort Union Formation is needed to assess the effects of energy development on groundwater quality. In conjunction with that effort, monitoring could be done closer to energy-development activities to increase the likelihood of early detection of groundwater contamination if it did occur.