Heat Exposure and Cause-Specific Hospital Admissions in Spain: A Nationwide Cross-Sectional Study.

BACKGROUND: More frequent and intense exposure to extreme heat conditions poses a serious threat to public health. However, evidence on the association between heat and specific diagnoses of morbidity is still limited. We aimed to comprehensively assess the short-term association between cause-specific hospital admissions and high temperature, including the added effect of temperature variability and heat waves and the effect modification by humidity and air pollution. METHODS: We used data on cause-specific hospital admissions, weather (i.e., temperature and relative humidity), and air pollution [i.e., fine particulate matter with aerodynamic diameter ≤2.5µm (PM2.5), fine particulate matter with aerodynamic diameter ≤10µm (PM10), NO2, and ozone (O3)] for 48 provinces in mainland Spain and the Balearic Islands between 1 January 2006 and 31 December 2019. The statistical analysis was performed for the summer season (June-September) and consisted of two steps. We first applied quasi-Poisson generalized linear regression models in combination with distributed lag nonlinear models (DLNM) to estimate province-specific temperature-morbidity associations, which were then pooled through multilevel univariate/multivariate random-effect meta-analysis. RESULTS: High temperature had a generalized impact on cause-specific hospitalizations, while the added effect of temperature variability [i.e., diurnal temperature range (DTR)] and heat waves was limited to a reduced number of diagnoses. The strongest impact of heat was observed for metabolic disorders and obesity [relative risk (RR) = 1.978; 95% empirical confidence interval (eCI): 1.772, 2.208], followed by renal failure (1.777; 95% eCI: 1.629, 1.939), urinary tract infection (1.746; 95% eCI: 1.578, 1.933), sepsis (1.543; 95% eCI: 1.387, 1.718), urolithiasis (1.490; 95% eCI: 1.338, 1.658), and poisoning by drugs and nonmedicinal substances (1.470; 95% eCI: 1.298, 1.665). We also found differences by sex (depending on the diagnosis of hospitalization) and age (very young children and the elderly were more at risk). Humidity played a role in the association of heat with hospitalizations from acute bronchitis and bronchiolitis and diseases of the muscular system and connective tissue, which were higher in dry days. Moreover, heat-related effects were exacerbated on high pollution days for metabolic disorders and obesity (PM2.5) and diabetes (PM10, O3). DISCUSSION: Short-term exposure to heat was found to be associated with new diagnoses (e.g., metabolic diseases and obesity, blood diseases, acute bronchitis and bronchiolitis, muscular and connective tissue diseases, poisoning by drugs and nonmedicinal substances, complications of surgical and medical care, and symptoms, signs, and ill-defined conditions) and previously identified diagnoses of hospital admissions. The characterization of the vulnerability to heat can help improve clinical and public health practices to reduce the health risks posed by a warming planet. https://doi.org/10.1289/EHP13254.

Venous thromboembolism chemical prophylaxis after skull base surgery.

PURPOSE: There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis. METHODS: Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons. RESULTS: One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM. CONCLUSION: Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.

Reported Hearing Outcome Measures Following Stereotactic Radiosurgery for Vestibular Schwannoma: A Scoping Review.

Background Evidence on hearing outcome measures when assessing hearing preservation following stereotactic radiosurgery (SRS) for adults with vestibular schwannoma (VS) has not previously been collated in a structured review. Objective The objective of the present study was to perform a scoping review of the evidence regarding the choice of hearing outcomes and other methodological characteristics following SRS for adults with VS. Methods The protocol was registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses extension guidelines for scoping reviews. A systematic search of five online databases revealed 1,591 studies, 247 of which met the inclusion criteria. Results The majority of studies ( n = 213, 86%) were retrospective cohort or case series with the remainder ( n = 34, 14%) prospective cohort. Pure-tone audiometry and speech intelligibility were included in 222 (90%) and 158 (64%) studies, respectively, often summarized within a classification scheme and lacking procedural details. Fifty-nine (24%) studies included self-report measures. The median duration of follow-up, when reported, was 43 months (interquartile range: 29, 4-150). Conclusion Evidence on hearing disability after SRS for VS is based on low-quality studies which are inherently susceptible to bias. This review has highlighted an urgent need for a randomized controlled trial assessing hearing outcomes in patients with VS managed with radiosurgery or radiological observation. Similarly, consensus and coproduction of a core outcome set to determine relevant hearing and communication outcome domains is required. This will ensure that patient priorities, including communication abilities in the presence of background noise and reduced participation restrictions, are addressed.

Ambient temperature and risk of cardiovascular and respiratory adverse health outcomes: a nationwide cross-sectional study from Spain.

AIMS: We assessed the association of temperature and temperature variability with cause-specific emergency hospitalizations and mortality from cardiovascular and respiratory diseases in Spain, as well as the effect modification of this association by individual and contextual factors. METHODS AND RESULTS: We collected data on health (hospital admissions and mortality), weather (temperature and relative humidity), and relevant contextual indicators for 48 Spanish provinces during 2004-2019. The statistical analysis was separately performed for the summer (June-September) and winter (December-March) seasons. We first applied a generalized linear regression model with quasi-Poisson distribution to estimate daily province-specific temperature-health associations, and then we fitted multilevel multivariate meta-regression models to the evaluate effect modification of the contextual characteristics on heat- and cold-related risks. High temperature increased the risk of mortality across all cardiovascular and respiratory diseases, with the strongest effect for hypertension (relative risk (RR) at 99th temperature percentile vs. optimum temperature: 1.510 [95% empirical confidence interval {eCI} 1.251 to 1.821]), heart failure (1.528 [1.353 to 1.725]), and pneumonia (2.224 [1.685 to 2.936]). Heat also had an impact on all respiratory hospitalization causes (except asthma), with similar risks between pneumonia (1.288 [1.240 to 1.339]), acute bronchitis and bronchiolitis (1.307 [1.219 to 1.402]), and chronic obstructive pulmonary disease (1.260 [1.158 to 1.372]). We generally found significant risks related to low temperature for all cardiovascular and respiratory causes, with heart failure (RR at 1st temperature percentile vs. optimum temperature: 1.537 [1.329 to 1.779]) and chronic obstructive pulmonary disease (1.885 [1.646 to 2.159]) exhibiting the greatest risk for hospitalization, and acute myocardial infarction (1.860 [1.546 to 2.238]) and pneumonia (1.734 [1.219 to 2.468]) for mortality. Women and the elderly were more vulnerable to heat, while people with secondary education were less susceptible to cold compared to those not achieving this educational stage. Results from meta-regression showed that increasing heating access to the highest current provincial value (i.e. 95.6%) could reduce deaths due to cold by 59.5% (57.2 to 63.5). CONCLUSION: Exposure to low and high temperatures was associated with a greater risk of morbidity and mortality from multiple cardiovascular and respiratory conditions, and heating was the most effective societal adaptive measure to reduce cold-related mortality.

Exposure to low and high temperatures increases the risk of morbidity and mortality from several cardiovascular and respiratory diseases, especially among the elderly. Increasing access to heating could substantially reduce cold-related mortality burden.

Remeasuring the influence of ageing on heat-related mortality in Spain, 1980 to 2018.

Climate change and population ageing are converging challenges that are expected to significantly worsen the health impacts of high temperatures. We aimed to remeasure the implications of ageing for heat-related mortality by comparing time trends based on chronological age (number of years already lived) with those derived from the application of state-of-the-art demographic methodology which better captures the dynamics of evolving longevity: prospective age (number of years still to be lived). We conducted a nationwide time-series analysis of 13 regions in Spain over 1980-2018 using all-cause mortality microdata for people aged 65+ and annual life tables from the Spanish National Institute of Statistics, and daily mean temperatures from E-OBS. Based on confounder-adjusted quasi-Poisson regression with distributed lag non-linear models and multivariate meta-analysis in moving 15-year timeslices, we assessed sex-specific changes in absolute risk and impacts for heat-related mortality at extreme and moderate temperatures, for chronological and prospective age groups. In the conventional chronological age analysis, absolute risk fell over the study period (e.g. females, extreme heat: -54%; moderate heat: -23%); after accounting for rising longevity, the prospective age analysis, however, found a smaller decline in risk for extreme heat (-15%) and a rise for moderate heat (+46%). Additionally, while the chronological age analysis suggested a shift in mortality towards higher ages, the prospective age analysis showed that over the study period, people of largely the same (prospective) age were impacted. Further, the prospective age analysis revealed excess risk in females (compared to males) rose from 20% to 27% for extreme heat, and from 40% to 70% for moderate heat. Assessing the implications of ageing using a prospective age perspective showed the urgency of re-doubling risk reduction efforts, including accelerating healthy ageing programs that incorporate climate considerations. The age patterns of impacts suggested that such actions have the potential to mitigate ageing-related heat-health threats to generate climate change-ready, healthy societies.

Predicting recreational water quality and public health safety in urban estuaries using Bayesian Networks.

To support the reactivation of urban rivers and estuaries for bathing while ensuring public safety, it is critical to have access to real-time information on microbial water quality and associated health risks. Predictive modelling can provide this information, though challenges concerning the optimal size of training data, model transferability, and communication of uncertainty still need attention. Further, urban estuaries undergo distinctive hydrological variations requiring tailored modelling approaches. This study assessed the use of Bayesian Networks (BNs) for the prediction of enterococci exceedances and extrapolation of health risks at planned bathing sites in an urban estuary in Sydney, Australia. The transferability of network structures between sites was assessed. Models were validated using a novel application of the k-fold walk-forward validation procedure and further tested using independent compliance and event-based sampling datasets. Learning curves indicated the model's sensitivity reached a minimum performance threshold of 0.8 once training data included ≥ 400 observations. It was demonstrated that Semi-Naïve BN structures can be transferred while maintaining stable predictive performance. In all sites, salinity and solar exposure had the greatest influence on Posterior Probability Distributions (PPDs), when combined with antecedent rainfall. The BNs provided a novel and transparent framework to quantify and visualise enterococci, stormwater impact, health risks, and associated uncertainty under varying environmental conditions. This study has advanced the application of BNs in predicting recreational water quality and providing decision support in urban estuarine settings, proposed for bathing, where uncertainty is high.

Improved Recovery after Vestibular Schwannoma Excision with Intratympanic Gentamicin Prehabilitation.

OBJECTIVE: Translabyrinthine excision of a vestibular schwannoma is associated with acute vestibular failure. Preoperative intratympanic gentamicin (ITG) injections can improve objective balance function after surgery but its clinical benefits remain to be established. METHODS: Adult patients undergoing translabyrinthine removal of a vestibular schwannoma between January 2014 and February 2018 underwent preoperative vestibular function testing. Patients were divided in to 3 groups, those with vestibular function (VF) who received ITG injections, those with VF but did not receive ITG and those with no VF. Groups were compared according to degree of vertigo, length of stay, time to unassisted mobilization, and postoperative anti-emetic consumption. RESULTS: Forty six patients had ITG injections (Group 1), 7 had residual VF but refused treatment (Group 2), 21 had no VF (Group 3). Group 1 had a significant improvement in vertigo over time whereas groups 2 and 3 did not. There was a statistically significant 70% decrease in time to independent mobilization between Group 1 and other groups and a 19% decrease in length of stay in Group 1 compared to other groups although this did not reach statistical significance. Two patients had injection-related complications. Group 1 used less anti-emetics than other groups but this was not statistically significant. CONCLUSION: Preoperative intratympanic gentamicin injection with vestibular rehabilitation exercises is associated with less postoperative vertigo and earlier postoperative mobilization. There was reduced duration of hospitalization and decreased consumption of anti-emetic but not significantly so possibly because of low numbers of patients in the no treatment group. LEVEL OF EVIDENCE: 2 Laryngoscope, 2024.

Changes in audiovestibular handicap following treatment of vestibular schwannomas.

OBJECTIVE: This study aimed to assess degree of audiovestibular handicap in patients with vestibular schwannoma. METHODS: Audiovestibular handicap was assessed using the Hearing Handicap Inventory, Tinnitus Handicap Inventory and Dizziness Handicap Inventory. Patients completed questionnaires at presentation and at least one year following treatment with microsurgery, stereotactic radiosurgery or observation. Changes in audiovestibular handicap and factors affecting audiovestibular handicap were assessed. RESULTS: All handicap scores increased at follow up, but not significantly. The Tinnitus Handicap Inventory and Dizziness Handicap Inventory scores predicted tinnitus and dizziness respectively. The Hearing Handicap Inventory was not predictive of hearing loss. Age predicted Tinnitus Handicap Inventory score and microsurgery was associated with a deterioration in Dizziness Handicap Inventory score. CONCLUSION: Audiovestibular handicap is common in patients with vestibular schwannoma, with 75 per cent having some degree of handicap in at least one inventory. The overall burden of handicap was, however, low. The increased audiovestibular handicap over time was not statistically significant, irrespective of treatment modality.

Drivers of the time-varying heat-cold-mortality association in Spain: A longitudinal observational study.

BACKGROUND: A number of studies have reported reductions in mortality risk due to heat and cold over time. However, questions remain about the drivers of these adaptation processes to ambient temperatures. We aimed to analyse the demographic and socioeconomic drivers of the downward trends in vulnerability to heat- and cold-related mortality observed in Spain during recent decades (1980-2018). METHODS: We collected data on all-cause mortality, temperature and relevant contextual indicators for 48 provinces in mainland Spain and the Balearic Islands between Jan 1, 1980, and Dec 31, 2018. Fourteen contextual indicators were analysed representing ageing, isolation, urbanicity, heating, air conditioning (AC), house antiquity and ownership, education, life expectancy, macroeconomics, socioeconomics, and health investment. The statistical analysis was separately performed for the range of months mostly causing heat- (June-September) and cold- (October-May) related mortality. We first applied a quasi-Poisson generalised linear regression in combination with distributed lag non-linear models (DLNM) to estimate province-specific temperature-mortality associations for different periods, and then we fitted univariable and multivariable multilevel spatiotemporal meta-regression models to evaluate the effect modification of the contextual characteristics on heat- and cold-related mortality risks over time. FINDINGS: The average annual mean temperature has risen at an average rate of 0·36 °C per decade in Spain over 1980-2012, although the increase in temperature has been more pronounced in summer (0·40 °C per decade in June-September) than during the rest of the year (0·33 °C per decade). This warming has been observed, however, in parallel with a progressive reduction in the mortality risk associated to both hot and cold temperatures. We found independent associations for AC with heat-related mortality, and heating with cold-related mortality. AC was responsible for about 28·6% (31·5%) of the decrease in deaths due to heat (extreme heat) between 1989 and 1993 and 2009-2013, and heating for about 38·3% (50·8%) of the reductions in deaths due to cold (extreme cold) temperatures. Ageing (ie, proportion of population over 64 years) attenuated the decrease in cold-related mortality. INTERPRETATION: AC and heating are effective societal adaptive measures to heat and cold temperatures. This evidence holds important implications for climate change health adaptation policies, and for the projections of climate change impacts on human health.

Rationale for the Development of a Novel Clinical Grading Scale for Postoperative Facial Nerve Function: Results of a Multidisciplinary International Working Group.

OBJECTIVE: The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. STUDY DESIGN: Survey. SETTING: A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. RESULTS: House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. CONCLUSIONS: Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.

Model Choice for Quantitative Health Impact Assessment and Modelling: An Expert Consultation and Narrative Literature Review.

BACKGROUND: Health impact assessment (HIA) is a widely used process that aims to identify the health impacts, positive or negative, of a policy or intervention that is not necessarily placed in the health sector. Most HIAs are done prospectively and aim to forecast expected health impacts under assumed policy implementation. HIAs may quantitatively and/ or qualitatively assess health impacts, with this study focusing on the former. A variety of quantitative modelling methods exist that are used for forecasting health impacts, however, they differ in application area, data requirements, assumptions, risk modelling, complexities, limitations, strengths, and comprehensibility. We reviewed relevant models, so as to provide public health researchers with considerations for HIA model choice. METHODS: Based on an HIA expert consultation, combined with a narrative literature review, we identified the most relevant models that can be used for health impact forecasting. We narratively and comparatively reviewed the models, according to their fields of application, their configuration and purposes, counterfactual scenarios, underlying assumptions, health risk modelling, limitations and strengths. RESULTS: Seven relevant models for health impacts forecasting were identified, consisting of (i) comparative risk assessment (CRA), (ii) time series analysis (TSA), (iii) compartmental models (CMs), (iv) structural models (SMs), (v) agent-based models (ABMs), (vi) microsimulations (MS), and (vii) artificial intelligence (AI)/machine learning (ML). These models represent a variety in approaches and vary in the fields of HIA application, complexity and comprehensibility. We provide a set of criteria for HIA model choice. Researchers must consider that model input assumptions match the available data and parameter structures, the available resources, and that model outputs match the research question, meet expectations and are comprehensible to end-users. CONCLUSION: The reviewed models have specific characteristics, related to available data and parameter structures, computational implementation, interpretation and comprehensibility, which the researcher should critically consider before HIA model choice.

The Direct and Indirect Influences of Interrelated Regional-Level Sociodemographic Factors on Heat-Attributable Mortality in Europe: Insights for Adaptation Strategies.

BACKGROUND: Heat is a significant cause of mortality, but impact patterns are heterogenous. Previous studies assessing such heterogeneity focused exclusively on risk rather than heat-attributable mortality burdens and assume predictors are independent. OBJECTIVES: We assessed how four interrelated regional-level sociodemographic predictors-education, life expectancy, the ratio of older to younger people (aging index), and relative income-influence heterogeneity in heat-attributable mortality burdens in Europe and then derived insights into adaptation strategies. METHODS: We extracted four outcomes from a temperature-mortality study covering 16 European countries: the rate of increase in mortality risk at moderate and extreme temperatures (moderate and extreme slope, respectively), the minimum mortality temperature percentile (MMTP), and the underlying mortality rate. We used structural equation modeling with country-level random effects to quantify the direct and indirect influences of the predictors on the outcomes. RESULTS: Higher levels of education were directly associated with lower heat-related mortality at moderate and extreme temperatures via lower slopes and higher MMTPs. A one standard deviation increase in education was associated with a -0.46±0.14, -0.41±0.12, and 0.41±0.12 standard deviation (±standard error) change in the moderate slope, extreme slope, and MMTP, respectively. However, education had mixed indirect influences via associations with life expectancy, the aging index, and relative income. Higher life expectancy had mixed relations with heat-related mortality, being associated with higher risk at moderate temperatures (0.33±0.11 for the moderate slope; -0.19±0.097 for the MMTP) but lower underlying mortality rates (-0.72±0.097). A higher aging index was associated with higher burdens through higher risk at extreme temperatures (0.13±0.072 for the extreme slope) and higher underlying mortality rates (0.93±0.055). Relative income had relatively small, mixed influences. DISCUSSION: Our novel approach provided insights into actions for reducing the health impacts of heat. First, the results show the interrelations between possible vulnerability-generating mechanisms and suggest future research directions. Second, the findings point to the need for a dual approach to adaptation, with actions that explicitly target heat exposure reduction and actions focused explicitly on the root causes of vulnerability. For the latter, the climate crisis may be leveraged to accelerate ongoing general public health programs. https://doi.org/10.1289/EHP11766.

Surgery versus radiosurgery for vestibular schwannoma: Shared decision making in a multidisciplinary clinic.

Background: Our neurosurgical unit adopted a model of shared decision-making (SDM) based on multidisciplinary clinics for vestibular schwannoma (VS). A unique feature of this clinic is the interdisciplinary counseling process with a surgeon presenting the option of surgery, an oncologist radiosurgery or radiotherapy, and a specialist nurse advocating for the patient. Methods: This is a retrospective cohort study. All new patients seen in the combined VS clinic and referred from the skull base multidisciplinary team (MDT) from beginning of June 2013 to end of January 2019 were included. Descriptive statistics and frequency analysis were carried out for the full cohort. Results: Three hundred and fifty-four patients presenting with new or previously untreated VS were included in the analysis. In our cohort, roughly one-third of patients fall into each of the treatment strategies with slightly smaller numbers of patients undergoing surgery than watch, wait and rescan (WWR) ,and SRS (26.6% vs. 32.8% and 37.9%, respectively). Conclusion: In our experience, the combined surgery/oncology/specialist nurse clinic streamlines the patient experience for those with a VS suitable for either microsurgical or SRS/radiotherapy treatment. Decision-making in this population of patients is complex and when presented with all treatment options patients do not necessarily choose the least invasive option as a treatment. The unique feature of our clinic is the multidisciplinary counseling process with a specialist nurse advocating and guiding the patient. Treatment options are likely to become more rather than less complex in future years making combined clinics more valuable than ever in the SDM process.

The clinical, genetic, and immune landscape of meningioma in patients with NF2-schwannomatosis.

NF2-schwannomatosis is the most common genetic predisposition syndrome associated with meningioma. Meningioma in NF2-schwannomatosis is a major source of morbidity and mortality. This is due to accumulative tumor burden in patients with synchronous schwannomas and ependymomas, sometimes including complex collision tumors. Balancing the impact of multiple interventions against the natural history of various index tumors, and the ongoing risk of de novo tumors over an individual's lifetime makes decision-making complex. The management of any given individual meningioma is often different from a comparable sporadic tumor. There is typically a greater emphasis on conservative management and tolerating growth until a risk boundary is reached, whereby symptomatic deterioration or higher risk from anticipated future treatment is threatened. Management by high-volume multidisciplinary teams improves quality of life and life expectancy. Surgery remains the mainstay treatment for symptomatic and rapidly enlarging meningioma. Radiotherapy has an important role but carries a higher risk compared to its use in sporadic disease. Whilst bevacizumab is effective in NF2-associated schwannoma and cystic ependymoma, it has no value in the management of meningioma. In this review, we describe the natural history of the disease, underlying genetic, molecular, and immune microenvironment changes, current management paradigms, and potential therapeutic targets.

Changes in antimicrobial resistance in acute otitis media and otitis externa.

OBJECTIVES: Acute otitis media (AOM) and otitis externa (OE) are common ear infections which may warrant antibiotic therapy. For many infections, there is a rise in antimicrobial resistance, which is associated with treatment failure, morbidity, prolonged hospitalisation and mortality. This study aimed to identify longitudinal changes in microbiology and antimicrobial resistance in aural swabs taken from patients with AOM or OE. DESIGN: Retrospective observational analysis. SETTING: Aural samples processed at Manchester Medical Microbiology Partnership Laboratories between January 2008 and December 2018 were analysed to record organism isolated and antimicrobial sensitivity. PARTICIPANTS: Individual aural swabs from 7200 patients. MAIN OUTCOME MEASURES: Changes in the incidence of organisms and antimicrobial resistance between two time periods (2008-2012 and 2013-2018) were compared using the chi-squared test (alpha = 0.05). RESULTS: From 7200 swabs, 2879 (40%) were from children. The most frequently isolated organisms were Staphylococcus aureus (25%), Pseudomonas aeruginosa (24.4%), yeast (9.1%), mixed anaerobes (7.9%) and Haemophilus influenzae (6.1%). In children aged 0-4 years, H. influenzae had particularly high incidence (25%). Overall, the incidence of P. aeruginosa decreased significantly with time (p = 0.05). Isolates displaying resistance to one or more antimicrobial agents increased significantly in number in the second time period for P. aeruginosa (p = 0.04) and H. influenzae (p = 0.03). There was increased resistance to amoxicillin for P. aeruginosa (p = 0.01) and to erythromycin for H. influenzae (p < 0.01). CONCLUSION: Variations in type and frequency of organisms with increasing age likely result from differences in the preponderance of AOM compared to OE in children versus adults. We found increasing antimicrobial resistance for two organisms commonly isolated from AOM and OE infections, suggesting that aspects of current UK treatment practices and national recommendations may need to be revised.

Radiation treatment of benign tumors in NF2-related-schwannomatosis: A national study of 266 irradiated patients showing a significant increase in malignancy/malignant progression.

Background: Radiation treatment of benign tumors in tumor predisposition syndromes is controversial, but short-term studies from treatment centers suggest safety despite apparent radiation-associated malignancy being reported. We determined whether radiation treatment in NF2-related schwannomatosis patients is associated with increased rates of subsequent malignancy (M)/malignant progression (MP). Methods: All UK patients with NF2 were eligible if they had a clinical/molecular diagnosis. Cases were NF2 patients treated with radiation for benign tumors. Controls were matched for treatment location with surgical/medical treatments based on age and year of treatment. Prospective data collection began in 1990 with addition of retrospective cases in 1969. Kaplan-Meier analysis was performed for malignancy incidence and survival. Outcomes were central nervous system (CNS) M/MP (2cm annualized diameter growth) and survival from index tumor treatment. Results: In total, 1345 NF2 patients, 266 (133-Male) underwent radiation treatments between 1969 and 2021 with median first radiotherapy age of 32.9 (IQR = 22.4-46.0). Nine subsequent CNS malignancies/MPs were identified in cases with only 4 in 1079 untreated (P < .001). Lifetime and 20-year CNS M/MP was ~6% in all irradiated patients-(4.9% for vestibular schwannomas [VS] radiotherapy) versus <1% in the non-irradiated population (P < .001/.01). Controls were well matched for age at NF2 diagnosis and treatment (Males = 133%-50%) and had no M/MP in the CNS post-index tumor treatment (P = .0016). Thirty-year survival from index tumor treatment was 45.62% (95% CI = 34.0-56.5) for cases and 66.4% (57.3-74.0) for controls (P = .02), but was nonsignificantly worse for VS radiotherapy. Conclusion: NF2 patients should not be offered radiotherapy as first-line treatment of benign tumors and should be given a frank discussion of the potential 5% excess absolute risk of M/MP.

Cochlear Implantation in Sporadic Vestibular Schwannoma and Neurofibromatosis Type II.

Cochlear implantation offers significantly better hearing outcomes than auditory brainstem implantation in patients with vestibular schwannoma. Neither the primary treatment modality nor the cause of the tumor (neurofibromatosis type 2 related or sporadic) seems to have a significant effect on hearing outcome with cochlear implantation. Some uncertainty remains regarding long-term hearing outcomes; however, cochlear implantation in vestibular schwannoma serves to offer patients, with a functioning cochlear nerve, the probability of open set speech discrimination with a consequent positive impact on quality of life.