Pediatric tympanostomy tube assessment via deep learning.

PURPOSE: Tympanostomy tube (TT) placement is the most frequently performed ambulatory surgery in children under 15. After the procedure it is recommended that patients follow up regularly for "tube checks" until TT extrusion. Such visits incur direct and indirect costs to families in the form of days off from work, copays, and travel expenses. This pilot study aims to compare the efficacy of tympanic membrane (TM) evaluation by an artificial intelligence algorithm with that of clinical staff for determining presence or absence of a tympanostomy tube within the TM. METHODS: Using a digital otoscope, we performed a prospective study in children (ages 10 months-10 years) with a history of TTs who were being seen for follow up in a pediatric otolaryngology clinic. A smartphone otoscope was used by study personnel who were not physicians to take ear exam images, then through conventional otoscopic exam, ears were assessed by a clinician for tubes being in place or tubes having extruded from the TM. We trained and tested a deep learning (artificial intelligence) algorithm to assess the images and compared that with the clinician's assessment. RESULTS: A total of 123 images were obtained from 28 subjects. The algorithm classified images as TM with or without tube in place. Overall classification accuracy was 97.7 %. Recall and precision were 100 % and 96 %, respectively, for TM without a tube present, and 95 % and 100 %, respectively, for TM with a tube in place. DISCUSSION: This is a promising deep learning algorithm for classifying ear tube presence in the TM utilizing images obtained in awake children using an over-the-counter otoscope available to the lay population. We are continuing enrollment, with the goal of building an algorithm to assess tube patency and extrusion.

Clinician-rated quality of video otoscopy recordings and still images for the asynchronous assessment of middle-ear disease.

INTRODUCTION: Video otoscopy plays an important role in improving access to ear health services. This study investigated the clinician-rated quality of video otoscopy recordings and still images, and compared their suitability for asynchronous diagnosis of middle-ear disease. METHODS: Two hundred and eighty video otoscopy image-recording pairs were collected from 150 children (aged six months to 15 years) by an ear, nose, and throat (ENT) specialist, audiologists, and trained research assistants, and independently rated by an audiologist and ENT surgeon. On a five-point scale, clinicians rated the cerumen amount, field of view, quality, focus, light, and gave an overall rating, and asked whether they could make an accurate diagnosis for both still images and recordings. RESULTS: More video otoscopy recordings were rated as 'good' or 'excellent' compared to still images across all domains. The mean difference between the two otoscopic procedures ratings was significant across almost all domains (p < 0.05), except 'cerumen amount'. The suitability to make a diagnosis significantly improved when using recordings (p<0.05). Younger participant age was found to have a significant, negative impact on the ratings across all domains (p < 0.03). The role of the tester conducting video otoscopy did not have a significant impact on the ratings. DISCUSSION: Video otoscopy recordings were found to provide clearer views of the tympanic membrane and increase the ability to make diagnoses, compared to still images, for both audiologists and ENT surgeons. Research assistants with limited practice were able to obtain video otoscopy images and recordings that were comparable to the ones obtained by clinicians.

Comparative validity of three simulation platforms for objective assessment of otoscopy skills.

OBJECTIVES: To assess the face, construct and content validity of three different platforms for otoscopy skills assessment, using a traditional otoscope with manikin, digital otoscope (Tympahealth) with manikin, and traditional otoscope with a low-cost model ear (SimEar). DESIGN: Prospective mixed methods study. SETTING: Tertiary hospital. PARTICIPANTS: Postgraduate trainees and expert assessors. MAIN OUTCOME MEASURES: Face and Content validity based on expert assessor ranking on each model and their feedback from semi-structured interviews. Construct validity based on Objective Structured Clinical Examination scores. RESULTS: Each platform differed in face, construct and content validity scores, with no one platform consistently outperforming others. Three main themes were identified during thematic analysis of expert assessor interviews: ability to assess what is seen, anatomical reality, and ease of use. The low-cost model showed greatest potential, where modification to include a silicone ear could lead to high validity with marginal increase in cost. CONCLUSION: Several modalities for assessing otoscopy skills exist, each with advantages and disadvantages. Modifications to a low-cost model, for use with either a traditional or digital otoscope, could prove to be the best model.

Artificial intelligence to diagnose ear disease using otoscopic image analysis: a review.

AI relates broadly to the science of developing computer systems to imitate human intelligence, thus allowing for the automation of tasks that would otherwise necessitate human cognition. Such technology has increasingly demonstrated capacity to outperform humans for functions relating to image recognition. Given the current lack of cost-effective confirmatory testing, accurate diagnosis and subsequent management depend on visual detection of characteristic findings during otoscope examination. The aim of this manuscript is to perform a comprehensive literature review and evaluate the potential application of artificial intelligence for the diagnosis of ear disease from otoscopic image analysis.

[Mobile solutions in hearing assessment]. / Mobil'nye resheniya v otsenke slukha.

PURPOSE OF THE STUDY: To evaluate the effectiveness of the application of the web application "Automated system of primary hearing assessment" created by us for the diagnosis of hearing impairment in different age groups. MATERIAL AND METHODS: With the help of this web application, 712 patients were examined in 3 age groups: group 1 - patients aged 18 to 44 years, 196 people (average age 25.6±2.7 years), group 2 - patients aged 45 to 59 years, 265 people (mean age 46.3±3.6 years), 3rd group - patients 60 years old and older, 251 people (mean age 75.4±1.1 years). RESULTS: It was revealed that 61.8% of patients had risk factors for the development of hearing loss. In the 1st age group, one risk factor for hearing loss prevailed, in the 2nd and 3rd groups, up to 5-9 factors were simultaneously combined. Clinically significant hearing loss was found in 24.3% of patients. Hearing studies at frequencies of 10 and 12 kHz revealed latent hearing loss in 31.3% of patients, 57% of them had risk factors for the development of hearing loss. Comparative analysis in the groups showed that hearing impairment at high frequencies was found in 47.4% of patients in older age groups and in 15.8% of young people. The possibility of performing otoscopy images made it possible to identify changes in the tympanic membrane in 17.1% of patients, to give a correct conclusion about the state of their hearing and to propose an algorithm for further examination. It was found that the sensitivity of the study in the web application was 98%, the specificity - 99.9%. FINDINGS: The use of the web application allows assessing the risk factors for the development of hearing loss, identifying patients with latent hearing loss, objectifying the study with otoscopy images, and remotely obtaining a conclusion about the state of hearing from a specialist doctor.

Population-based otoscopic and audiometric assessment of a birth cohort recruited for a pneumococcal vaccine trial 15-18 years earlier: a protocol.

INTRODUCTION: A cohort of 12 000 children in the Philippines who had enrolled in a 2000-2004 (current ages 16 to 20 years) Phase 3 11-valent pneumococcal conjugate vaccine for the prevention of radiographically confirmed pneumonia are now being asked to participate in a separate study (expected completion date September 2021) to assess the cohort's current long-term audiometric and otologic status. This new study would allow assessments of the utility of the pneumococcal vaccine in conferring its protective effects on the long-term sequelae of otitis media (OM), if any. Lack of trained local healthcare providers in otolaryngology/audiology and testing equipment in Bohol, Philippines, necessitates the development of a distinct methodology that would lead to meaningful data analysis. METHODS AND ANALYSIS: Reliable data collection and transfer are achieved by a US otolaryngologist/audiologist team training local nurses on all procedures in a didactic and hands-on process. An assortment of portable otolaryngologic and audiologic equipment suitable for field testing has been acquired, including an operating otoscope (Welch-Allyn), a video-otoscope (JedMed), a tympanometer with distortion product otoacoustic emission measurements (Path Sentiero) and a screening audiometer (HearScreen). Data will then be uploaded to a Research Electronic Data Capture database in the USA.Tympanometric and audiologic data will be codified through separate conventional algorithms. A team of paediatric otolaryngology advanced practice providers (APPs) have been trained and validated in interpreting video otoscopy. The protocol for classification of diagnostic outcome variables based on video otoscopy and tympanometry has been developed and is being used by APPs to evaluate all otoscopy data. ETHICS AND DISSEMINATION: The study was approved by the Research Institute of Tropical Medicine, Alabang, Manila, Philippines, and the institutional review board and the Colorado Multiple Institutional Review Board of the University of Colorado School of Medicine, Aurora, Colorado, USA.Research results will be made available to children and their caregivers with abnormal audiologic outcomes, the funders and other researchers. TRIAL REGISTRATION NUMBER: ISRCTN 62323832; Post-results.

A systematic review of remote otological assessment using video-otoscopy over the past 10 years: reliability and applications.

PURPOSE: This systematic review describes and evaluates the current literature on remote otological assessment using video-otoscopy with regards to reliability and potential applications. METHODS: Systematic review was conducted in accordance with the PRISMA statement. There was heterogeneity of included studies, so a descriptive analysis was undertaken. RESULTS: Seventeen studies were included for analysis conducted across a variety of healthcare settings. Overall, there was a trend towards acquisition of adequate images for diagnosis by non-otolaryngology-specialist facilitators with reasonable agreement between asynchronous images and controls; however, there was significant variation between the studies. CONCLUSION: Remote otological assessment using video-otoscopy shows potential as a safe and effective method for detecting the presence of ear disease in a wide range of healthcare settings. Barriers to the acquisition of adequate images include the presence of obstructing cerumen, and strategies to deal with this should be considered. Further work is required to evaluate endoscope-based systems to assess whether they will allow the acquisition of higher quality images.

Comprehensive Community Screening of Otological Patients by Trained Technicians Using a Telemedicine Device: An Efficient and Cost-Effective Way to Triage Patients With Ear Diseases.

OBJECTIVE: To emphasize the benefits of tele-otology in community screening of patients with ear diseases. METHODS: A retrospective study of all patients screened and treated under the Shruti tele-otology program between 2013 and 2019 was conducted. It involved screening, diagnosis, medical management, surgical intervention, and rehabilitation using hearing aid. The study focused on underprivileged and underserved community of rural and urban slums across 12 states of India. The study was conducted using a telemedicine device called ENTraview, that is, a camera-enabled android phone integrated with an otoscope and audiometry screening. RESULT: A total of 810 746 people were screened, and incidence of various ear diseases was recorded. Ear problems were found in 265 615 (33%) patients, of which 151 067 (57%) had impacted wax, 46 792(18%) had chronic suppurative otitis media, 27 875 (10%) had diminished hearing, 12 729 (5%) had acute otitis media and acute suppurative otitis media (ASOM), and 27 152 (10%) had problems of foreign body, otomycosis, and so on. Of the total 265 615 referred patients, 20 986 (8%) reported for treatment and received treatment at a significantly reduced cost through Shruti program partners. The conversion rate of nonsurgical and surgical procedure was also compared, and it was found that, while 9% of the patients opted for nonsurgical treatment, only 3% opted for surgery in the intervention group giving a significant P value of .00001. CONCLUSION: The potential for telemedicine to reduce inequalities in health care is immense but remains underutilized. Shruti has largely been able to bridge this gap as it is an innovative, fast, and effective programs that address the ear ailment in the community.

Field test of the Rapid Assessment of Hearing Loss survey protocol in Ntcheu district, Malawi.

Objective: (1) To test the feasibility of the Rapid Assessment of Hearing Loss (RAHL) survey protocol in Malawi (Ntcheu); (2) To estimate the prevalence and probable causes of hearing loss (adults 50+).Design: Cross-sectional population-based survey.Study sample: Clusters (n = 38) were selected using probability-proportionate-to-size-sampling. Within each cluster, 30 people aged 50+ were selected using compact-segment-sampling. All participants completed smartphone-based audiometry (hearTest). Prevalence was estimated using WHO definitions (PTA of thresholds 0.5, 1, 2, 4 kHz in the better ear of >25 dB HL (any) and >40 dB HL (≥moderate)). Otoscopy and questionnaire were used to assess probable causes. Participants with hearing loss and/or ear disease were asked about care-seeking and barriers.Results: Four teams completed the survey in 24 days. 1080 of 1153 (93.7%) participants were examined. The median time to complete the protocol was 24 min/participant. Prevalence of hearing loss was 35.9% (95% CI = 31.6-40.2) (any level); and 10.0% (95% CI = 7.9-12.5) (≥moderate). The majority was classified as probable sensorineural. Nearly one third of people (30.9%) needed diagnostic audiology services and possible hearing aid fitting. Hearing aid coverage was <1%. Lack of perceived need was a key barrier.Conclusion: The RAHL is simple, fast and provides information about the magnitude and probable causes of hearing loss to plan services.

Development and Evaluation of an Objective Tympanic Membrane Visualization Assessment Technique.

OBJECTIVES: To introduce an inexpensive method for objectively evaluating otoscopic visualization of the tympanic membrane wherein learners match what they visualize in standardized patients to tympanic membrane photographs. METHODS: Two standardized patients had photographs taken of their tympanic membranes using a commercially-available digital otoscope. First- and third-year medical students were asked to perform an otoscopic examination on each patient using a conventional handheld otoscope and to match what they saw with the correct tympanic membrane image among distractor photographs belonging to other patients. The ability of students to match the standardized patients' tympanic membrane to the correct photographs was assessed before and after a didactic training session. These measurements were compared between the two cohort groups for construct validity. RESULTS: Fifty-one first-year medical students (with no previous otoscopy experience) and 44 third-year medical students (with otoscopy experience from completing pediatric and family medicine clinical clerkships) were recruited to voluntarily participate in this study. At baseline, a larger percentage of third-year students correctly matched both tympanic membranes compared to first-year students (27% vs 8%, P < .01). After otoscopy training, correct matching of both tympanic membranes significantly improved among both first-year students (8-31%, P < .01) and third-year students (27-54%, P < .01). CONCLUSION: The use of tympanic membrane photographs from standardized patients provides a novel technique for objectively assessing proficiency in otoscopic visualization of the middle ear. The concept is low cost, uses live patients, and can be easily implemented in pre-clinical instruction and beyond.

Development and Validation of an Assessment Tool for Technical Skills in Handheld Otoscopy.

OBJECTIVE: Handheld otoscopy requires both technical and diagnostic skills, and is often reported to be insufficient after medical training. We aimed to develop and gather validity evidence for an assessment tool for handheld otoscopy using contemporary medical educational standards. STUDY DESIGN: Educational study. SETTING: University/teaching hospital. SUBJECTS AND METHODS: A structured Delphi methodology was used to develop the assessment tool: nine key opinion leaders (otologists) in undergraduate training of otoscopy iteratively achieved consensus on the content. Next, validity evidence was gathered by the videotaped assessment of two handheld otoscopy performances of 15 medical students (novices) and 11 specialists in otorhinolaryngology using two raters. Standard setting (pass/fail criteria) was explored using the contrasting groups and Angoff methods. RESULTS: The developed Copenhagen Assessment Tool of Handheld Otoscopy Skills (CATHOS) consists 10 items rated using a 5-point Likert scale with descriptive anchors. Validity evidence was collected and structured according to Messick's framework: for example the CATHOS had excellent discriminative validity (mean difference in performance between novices and experts 20.4 out of 50 points, P < .001); and high internal consistency (Cronbach's alpha = 0.94). Finally, a pass/fail score was established at 30 points for medical students and 42 points for specialists in ORL. CONCLUSION: We have developed and gathered validity evidence for an assessment tool of technical skills of handheld otoscopy and set standards of performance. Standardized assessment allows for individualized learning to the level of proficiency and could be implemented in under- and postgraduate handheld otoscopy training curricula, and is also useful in evaluating training interventions. LEVEL OF EVIDENCE: NA.

Reference ranges and stability of auditory and vestibular measures in a comprehensive assessment battery for traumatic brain injury.

BACKGROUND: Audiology clinics have many tools available to evaluate auditory and vestibular complaints. However, many tools lack established normative ranges across the life span. We conducted this study to establish reference ranges across the life span for audiology/vestibular measures commonly used to evaluate patients with traumatic brain injury. MATERIALS AND METHODS: In this repeated measures study, 75 adults, ages 18-65 years, without a history of traumatic brain injury, underwent robust auditory/vestibular evaluations three times over six months, including rotational chair, videonystagmography, computerized dynamic posturography, vestibular evoked myogenic potentials, and retinal fundoscopy. RESULTS: Age effect was notable for transient evoked otoacoustic emissions, pure-tone audiometry, auditory brainstem response, auditory middle latency response, and auditory-steady state response at 4000 hertz (Hz). Older participants (50-65 years) were more likely to have delayed latency horizontal saccades, positional nystagmus, slowed lower-extremity motor control responses, and delayed latency ocular vestibular evoked myogenic potentials. Low to mid-frequency horizontal (0.003-4 Hz) and mid-frequency vertical (1-3 Hz) vestibulo-ocular reflex, otolith-mediated reflexes, dynamic visual acuity and balance measures were generally not influenced by age. Females had larger static subjective visual testing offset angles, longer cervical vestibular evoked myogenic potential P1 latency, faster velocity horizontal saccades, and quicker motor control latency for large backward translations than age-matched males. CONCLUSION: These reference ranges can be used to discern impairment within the auditory and vestibular pathway following traumatic brain injury in young to middle-aged adults. ID: TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT01925963.

Large-scale otoscopic and audiometric population assessment: A pilot study.

OBJECTIVE: Large-scale otoscopic and audiometric assessment of populations is difficult due to logistic impracticalities, particularly in low- and middle-income countries (LMIC). We report a novel assessment methodology based on training local field workers, advances in audiometric testing equipment and cloud-based technology. METHODS: Prospective observational study in Bohol, Philippines. A U.S. otolaryngologist/audiologist team trained 5 local nurses on all procedures in a didactic and hands-on process. An operating otoscope (Welch-AllynR) was used to clear cerumen and view the tympanic membrane, images of which were recorded using a video otoscope (JedMedR). Subjects underwent tympanometry and distortion product otoacoustic emission (DPOAE) (Path SentieroR), and underwent screening audiometry using noise cancelling headphones and a handheld Android device (HearScreenR). Sound-booth audiometry was reserved for failed subjects. Data were uploaded to a REDCap database. Teenage children previously enrolled in a 2000-2004 Phase 3 pneumococcal conjugate vaccine trial, were the subjects of the trainees. RESULTS: During 4 days of training, 47 Filipino children (M/F = 28/19; mean/median age = 14.6/14.6 years) were the subjects of the trainee nurses. After the training, all nurses could perform all procedures independently. Otoscopic findings by ears included: normal (N = 77), otitis media with effusion (N = 2), myringosclerosis (N = 5), healed perforation (N = 6), perforation (N = 2) and retraction pocket/cholesteatoma (N = 2). Abnormal audiometric findings included: tympanogram (N = 4), DPOAE (N = 4) and screening audiometry (N = 0). CONCLUSION: Training of local nurses has been shown to be robust and this methodology overcomes challenges of distant large-scale population otologic/audiometric assessment.

Optical assessment of the in vivo tympanic membrane status using a handheld optical coherence tomography-based otoscope.

OBJECTIVE: Conventional otoscopes and oto-endoscopes, which are used to examine the tympanic membrane (TM), do not provide tomographic information. Optical coherence tomography (OCT) non-invasively reveals the depth-resolved internal microstructure of the TM with very high spatial resolution. We designed this study to examine the TMs with middle ear diseases using a handheld otoscope employing 860 nm spectral domain (SD)-OCT, combined with video camera and to demonstrate the clinical applicability of this system. DESIGN: A total of 120 patients with otologic symptoms were enrolled. TM images were obtained using the handheld OCT-based otoscope (860 nm central wave length, 15 µm axial resolution, 15 µm lateral resolution, and 7 mm scanning range using relay lens). Both OCT and oto-endoscope images were compared according to the clinical characteristics such as perforation, retraction, and postoperative healing process. RESULTS: The objective grade about the thickness of perforation margins and the accurate information about the extent of TM retraction that was not distinguishable by oto-endoscopic exam could be identified using this system. The postoperative healing process of TMs could be also followed using the OCT device. CONCLUSION: These analyses from the surgeon-oriented perspective suggest another useful application of the handheld OCT device.

Teaching the pediatric ear exam and diagnosis of Acute Otitis Media: a teaching and assessment model in three groups.

BACKGROUND: The serious consequences of inaccurate diagnosis of acute otitis media have led to a call for greater education to develop proficient pediatric otoscopy skills. Despite the clinical and educational needs, peer-reviewed standardized curricula with validated assessment instruments remain limited. This study evaluated a pediatric otoscopy curriculum incorporated into the Pediatric medical student clerkship with use of outcome measures that included assessment of skills with real patients. The objective was to determine whether students who received the intervention would demonstrate significant gains in pediatric otoscopy skills when compared with students with only routine immersion learning exposure. METHODS: During their Pediatric clerkship, an intervention group (IG) of 100 medical students received routine instruction and a curriculum intervention. A non-intervention group (NIG) of 30 students received only routine instruction. Outcome measures included written tests and assessment of skills with real patients. A retention group (RG) consisted of 79 students in the IG who completed a written test at the end of medical school. Paired t-tests were used to compare differences in pre-intervention, post-intervention, and retention scores for the IG, NIG, and RG, while analysis of covariance tests were used to compare differences in scores between the IG and NIG. RESULTS: Pre-intervention scores were similar for the IG and NIG for the written test (mean/SD of 12.9/2.9 for IG and 12.9/1.8 for NIG, p = 0.78) and skills checklist (mean/SD of 11.1/4.4 for IG and 10.9/4.0 for NIG, p = 0.88). The IG had significantly higher post-intervention scores than the NIG for the written test (mean/SD of 22.6/1.7 for IG and 13.9/2.5 for NIG, p < 0.001) and skills checklist (mean/SD of 19.2/3.4 for IG and 11.0/3.8 for NIG, p < 0.001). The IG also had significantly higher gain in scores than the NIG for the written test (mean/SD +9.6/2.8 for IG and +1.0/2.3 for NIG, p < 0.001) and skills checklist (mean/SD of +8.1/4.8 for IG and +0.1/4.5 for NIG, p < 0.001). For the RG, there was a significant decrease (p < 0.001) from the post-intervention scores to retention scores (mean/SD of -7.4/2.7) but a significant increase (p < 0.001) from the pre-intervention score to retention score (mean + 2.6/3.3). CONCLUSIONS: Medical students who received a formal curriculum intervention demonstrated significant gains in pediatric otoscopy skills when compared with students with only routine immersion learning exposure. However, learning gains diminished over time, emphasizing the need for continued practice opportunities to reinforce students' skills. Our study provides a formal curriculum to meet identified educational gaps in the important topic of pediatric otoscopy and offers a model for teaching of other clinical skills using rigorous outcome measures including assessment of skills in real patients.

Intra- and inter-rater reliability of the modified ENT assessment score (ENTAS 2) in granulomatosis with polyangiitis: a prospective randomised trial.

OBJECTIVES: Ears nose and throat (ENT) involvement is found on a substantial proportion of patients with granulomatosis with polyangiitis (GPA). Structured, reliable ENT assessment is essential in the management of GPA patients. It is the aim of this study to determine the repeatability (intra-rater reliability) and reproducibility (inter-rater reliability) of the ENT Assessment Score (ENTAS 2). METHODS: The ENTAS 2 built the fundament of the prospective randomized trial. Anamnestic, video endoscopic and diagnostic data of 47 patients were used. A single assessor reference was created. GPA/ENT activity and damage were evaluated by three physicians at two time points (T1/T2). GPA/ENT activity was evaluated in dichotomy (yes/no) and grading (none/mild/moderate/high) and GPA/ ENT damage in dichotomy. RESULTS: ENTAS 2 activity evaluations intra-rater reliability was 80.7% (κ=0.56) in dichotomy and 72.8% (κ=0.41) in grading. ENTAS 2 damage evaluations showed 87.8% (κ=0.74) intra-rater reliability. ENTAS 2 activity inter-rater reliability at T1 was 62.2% (κ=0.43) in dichotomy and 51.1% (κ=0.29) in grading, at T2 it was 68.2% (κ=0.48) in dichotomy and 55.32% (κ=0.33) in grading. Inter-rater reliability of ENTAS 2 damage evaluation was 84.4% (κ=0.79) at T1 and 72.5% (κ=0.64) at T2. CONCLUSIONS: ENTAS 2 intra-rater reliability was high in dichotomous and graded GPA/ENT activity and damage evaluations. Inter-rater reliability was high in dichotomous activity and damage evaluations, but low in graded activity evaluations. The data demonstrate that the ENTAS 2 is a reliable score-system considering GPA/ENT activity and damage evaluations.

Assessment of afoxolaner efficacy against Otodectes cynotis infestations of dogs.

BACKGROUND: The efficacy of a single 2.5 mg/kg dose of afoxolaner (NexGard®, Merial) against induced Otodectes cynotis infestations was assessed in eight afoxolaner-treated dogs, compared to eight untreated dogs. METHODS: After O. cynotis infestations were established and confirmed by otoscopic assessments in 16 dogs, all of the dogs were included in the study and allocated to two separate treatment groups. The first group of eight ear mite-infested dogs remained untreated, while afoxolaner was administered orally to the second group of dogs at the minimum recommended dose once on Day 0. Otoscopic assessments performed on all dogs (Days -7, -2, 14 and 28) confirmed the presence or absence of live mites throughout the study. No serious adverse events were recorded throughout the study, and no adverse events were likely related to the administration of NexGard. RESULTS: By Day 28, seven out of eight untreated dogs were still infested with ear mites, while only two out of eight afoxolaner-treated dogs were infested, with one and four ear mites, respectively. On Day 28, the reductions of mite counts in the afoxolaner-treated group versus those of the control dogs were 98.5% based on geometric means, and 99.4% based on arithmetic means. Significantly fewer (P < 0.05) live mites were present in the afoxolaner-treated group than the untreated group on Day 28. CONCLUSION: The results of this study demonstrated that a single oral administration of afoxolaner at the minimum recommended dose is highly effective (>98%) in treating dogs with induced O. cynotis infestations.

Assessment of the light intensity of otoscopes utilized in teaching hospitals / Avaliação da intensidade da luz dos otoscópios em hospitais-escola

ABSTRACT INTRODUCTION: To attain an accurate otoscopic diagnosis, a functioning device with adequate capacity must be used. OBJECTIVE: Evaluate the light intensity of otoscopes, comparing it utilizing the batteries present at the moment of calibration and after new batteries were supplied. METHODS: Cross-sectional study of a historical cohort, which assessed 38 otoscopes, measuring the light intensity with the batteries present at the moment of assessment compared to the intensity with new batteries, as well as charge of the test batteries and the new batteries. RESULTS: The mean of the sum of new batteries' charge was 3.19 V, and of the test batteries was 2.70 V, representing a decrease of 18.02% in charge. The mean luminosity with the new batteries was 366.89 lumens, whereas in the test batteries it was 188.32 lumens, representing a decrease of 83.75% in the light intensity. Student's t-test was applied for data comparison, showing a statistical difference between the light intensity with the original batteries and the new batteries (p = 0.0001; CI = 0.95). CONCLUSION: There was a statistically significant difference between the proportions of light intensity in the otoscopes. A small variation in battery charge results in a great variation in light.

RESUMO Introdução: Para a realização de um diagnóstico otoscópico preciso deve-se utilizar um aparelho funcionando com uma capacidade adequada. Objetivo: Avaliar a intensidade luminosa dos otoscópios comparando a intensidade da luz comas pilhas encontradas no momento da aferição e com pilhas novas. Método: Estudo de coorte histórica com corte transversal, onde foram analisados 38 otoscópios, sendo realizada a aferição da qualidade luminosa com a pilha utilizada e comparado com uma pilha nova, e a aferição da carga das pilhas novas e em utilização no momento do exame. Resultados: A média da soma das cargas das pilhas novas foi de 3,19 V, e a das pilhas testes foi de 2,70 V, representando decréscimo de 18,02% na carga das pilhas. A média da luminosidade comas pilhas novas foi de 366.89 lúmens, e com a pilha teste foi de 188.32 lúmens, representando decréscimo de 83,75% na intensidade luminosa. Foi aplicado o teste T para comparação entre os dados, onde percebe-se diferença estatística entre a intensidade luminosa com pilhas testes e novas (p = 0,0000; IC = 0,95). Conclusão: Houve diferença estatisticamente significativa entre a proporção de intensidade da luz dos otoscópios. Uma pequena variação da pilha proporciona uma grande variação na luz.

Assessment of the light intensity of otoscopes utilized in teaching hospitals.

INTRODUCTION: To attain an accurate otoscopic diagnosis, a functioning device with adequate capacity must be used. OBJECTIVE: Evaluate the light intensity of otoscopes, comparing it utilizing the batteries present at the moment of calibration and after new batteries were supplied. METHODS: Cross-sectional study of a historical cohort, which assessed 38 otoscopes, measuring the light intensity with the batteries present at the moment of assessment compared to the intensity with new batteries, as well as charge of the test batteries and the new batteries. RESULTS: The mean of the sum of new batteries' charge was 3.19V, and of the test batteries was 2.70V, representing a decrease of 18.02% in charge. The mean luminosity with the new batteries was 366.89lumens, whereas in the test batteries it was 188.32lumens, representing a decrease of 83.75% in the light intensity. Student's t-test was applied for data comparison, showing a statistical difference between the light intensity with the original batteries and the new batteries (p=0.0001; CI=0.95). CONCLUSION: There was a statistically significant difference between the proportions of light intensity in the otoscopes. A small variation in battery charge results in a great variation in light.

The effect and acceptability of tympanometry and pneumatic otoscopy in general practitioner diagnosis and management of childhood ear disease.

BACKGROUND: Tympanometry and pneumatic otoscopy are recommended for diagnosis of otitis media, but are not frequently used by general practitioners (GPs). We examined how, after targeted short training, GP diagnosis and management of childhood ear disease was changed by the addition of these techniques to non-pneumatic otoscopy. We further explored factors influencing the uptake of these techniques. METHODS: Between 2011 and 2012, we used a crossover experimental design to determine associations between tympanometry and pneumatic otoscopy and the GP diagnosis and management of ear disease in children aged 6 months to 6 years. GPs recorded a diagnosis and management plan after examining ears using non-pneumatic otoscopy, and another after using either tympanometry or pneumatic otoscopy. We compared diagnosis, prescription of oral antibiotics and planned GP follow-up at these two steps between the tympanometry and pneumatic otoscopy groups. We interviewed participants about their views regarding these techniques and analysed these data thematically. RESULTS: Thirteen GPs recorded 694 ear examinations on 347 children: 347 examinations with non-pneumatic otoscopy; then 196 using tympanometry; and 151 using pneumatic otoscopy. Tympanometry was more likely to be associated with changes in diagnosis (χ (2) = 28.64, df 1, p < 0.001) and planned GP follow-up (χ (2) = 9.24, df 1, p < 0.01) than pneumatic otoscopy. Change in oral antibiotic prescription was no different between the two techniques. GPs preferred tympanometry to pneumatic otoscopy, but cost was a barrier to ongoing use. Pneumatic otoscopy was considered the more difficult skill. GPs were not convinced that the increased detection of middle ear effusion afforded by tympanometry and pneumatic otoscopy resulted in benefit to general practice patients. CONCLUSION: Tympanometry was more likely than pneumatic otoscopy to change GP diagnoses and follow-up plans of childhood ear disease. Tympanometry may require less training than pneumatic otoscopy. GPs preferred tympanometry due to ease of use and interpretation; however, perceived high cost inhibited their intent to use it in the future. Training, cost and perceived lack of patient benefit are barriers to the use of tympanometry and pneumatic otoscopy in general practice.