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.

Outcomes in patients ≥ 80 years with a diagnosis of a hepatopancreaticobiliary (HPB) malignancy.

Older patients are underrepresented in oncological clinical trials. The incidence of hepatopancreaticobiliary (HPB) malignancies is higher in older patients, but data on outcomes are lacking. This study assessed patient outcomes in those < 80 and ≥ 80 years with a HPB malignancy seen at a tertiary referral centre, The Christie NHS Foundation Trust. Data on patients with a HPB malignancy were collected retrospectively between 2012 and 2017 via on-line case-note review. Survival was calculated using the Kaplan-Meier method and prognostic factors using log-rank analysis. Of 1421 patients, 10% were ≥ 80 years. Of patients < 80 and ≥ 80 years, 56% and 57% had pancreas cancer, 39% and 36% biliary tract cancer, and 5% and 7% had hepatocellular carcinoma, respectively. Amongst patients ≥ 80 years, 75% had an Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2. Patients ≥ 80 years had higher rates of comorbidity; 28% received systemic anti-cancer therapy (SACT), compared with 62% of patients < 80 years. Best supportive care (BSC) was instituted in 44% of older patients, compared with 13% in those < 80 years. Of patients ≥ 80 years who received SACT, 82% received monotherapy. Median overall survival (OS) for patients receiving palliative SACT was 10.07 months (95% CI 8.89-11.08) and 10.10 months (95% CI 6.30-12.30) in patients < 80 and ≥ 80 years, respectively, p 0.41; ECOG PS (p < 0.001) was prognostic for OS in older patients but Adult Comorbidity Evaluation-27 comorbidity score (p = 0.07, when comparing groups of ACE score ≤ 1 and > 1) was not. Baseline factors were similar in both age cohorts, but more comorbidities were present in older patients. Older patients were less likely to receive SACT, but when they did, they had an equivalent benefit in OS to younger patients.

Current and Emerging Treatments for Postsurgical Cleft Lip Scarring: Effectiveness and Mechanisms.

Cleft lip with or without cleft palate is the most common congenital malformation of the head and the third-most common birth defect. Surgical repair of the lip is the only treatment and is usually performed during the first year of life. Hypertrophic scar (HTS) formation is a frequent postoperative complication that impairs soft tissue form, function, or movement. Multiple lip revision operations are often required throughout childhood, attempting to optimize aesthetics and function. The mechanisms guiding HTS formation are multifactorial and complex. HTS is the result of dysregulated wound healing, where excessive collagen and extracellular matrix proteins are deposited within the wound area, resulting in persistent inflammation and resultant fibrosis. Many studies support the contribution of dysregulated, exaggerated inflammation in scar formation. Fibrosis and scarring result from chronic inflammation that interrupts tissue remodeling in normal wound healing. Failure of active resolution of inflammation pathways has been implicated. The management of HTS has been challenging for clinicians, since current therapies are minimally effective. Emerging evidence that specialized proresolving mediators of inflammation accelerate wound healing by preventing chronic inflammation and allowing natural uninterrupted tissue remodeling suggests new therapeutic opportunities in the prevention and management of HTS.

Management of hyperosmolar hyperglycaemic state in adults with diabetes.

Hyperglycaemic hyperosmolar state (HHS) is a medical emergency, which differs from diabetic ketoacidosis (DKA) and requires a different approach. The present article summarizes the recent guidance on HHS that has been produced by the Joint British Diabetes Societies for Inpatient Care, available in full at http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_HHS_Adults.pdf. HHS has a higher mortality rate than DKA and may be complicated by myocardial infarction, stroke, seizures, cerebral oedema and central pontine myelinolysis and there is some evidence that rapid changes in osmolality during treatment may be the precipitant of central pontine myelinolysis. Whilst DKA presents within hours of onset, HHS comes on over many days, and the dehydration and metabolic disturbances are more extreme. The key points in these HHS guidelines include: (1) monitoring of the response to treatment: (i) measure or calculate the serum osmolality regularly to monitor the response to treatment and (ii) aim to reduce osmolality by 3-8 mOsm/kg/h; (2) fluid and insulin administration: (i) use i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration, (ii) fluid replacement alone will cause a fall in blood glucose (BG) level, (iii) withhold insulin until the BG level is no longer falling with i.v. fluids alone (unless ketonaemic), (iv) an initial rise in sodium level is expected and is not itself an indication for hypotonic fluids and (v) early use of insulin (before fluids) may be detrimental; and (3) delivery of care: (i) The diabetes specialist team should be involved as soon as possible and (ii) patients should be nursed in areas where staff are experienced in the management of HHS.

Abnormal liver function tests in patients with Type 1 diabetes mellitus: prevalence, clinical correlations and underlying pathologies.

AIMS: To determine the prevalence of elevated alanine transaminase (ALT) in a large cohort of patients with Type 1 diabetes and to examine the clinical correlations and causes. Methods Patients with Type 1 diabetes mellitus were prospectively recruited and ALT, glycated haemoglobin and lipid profile were measured. Patients with Type 2 diabetes mellitus were recruited as a comparison group. PATIENTS: with abnormal ALT were investigated for underlying causes. Prevalence of abnormal ALT was analysed at three separate cut-offs and multivariable analysis used to identify independent risk factors. RESULTS: Nine hundred and eleven with Type 1 diabetes and 963 with Type 2 diabetes were included. The prevalence of elevated ALT was dependent on the cut-off value: > 30 IU/l in males and > 19 IU/l in females, > 50 and > 63 IU/l was 34.5, 4.3 and 1.9%, respectively, in Type 1 diabetes and 51.4, 8.2 and 3.7%, respectively, in Type 2 diabetes. In Type 1 diabetes an elevated ALT was associated with worse glycaemic control, age > 55 years and elevated triglycerides. Investigation of these patients revealed a cause in 43.6% of patients, predominantly non-alcoholic fatty liver disease (NAFLD). CONCLUSIONS: Elevated ALT is not uncommon in Type 1 diabetes and is associated with NAFLD-related risk factors. Patients with Type 1 diabetes and elevated ALT should be investigated as significant abnormalities may be found which are amenable to interventions.

Audiometric outcomes of tympanoplasty with hydroxylapatite prosthesis: consultant versus trainees.

OBJECTIVE: To assess and compare the audiometric outcomes and surgical complication rates of tympanoplasty with hydroxylapatite (HA) prostheses performed by a single consultant and advanced trainees. STUDY DESIGN: A retrospective case review was undertaken. SETTING: Tertiary referral center. PATIENTS: One hundred eighteen cases of primary and revision tympanoplasty were included in the study performed during a 6-year period. INTERVENTION: Tympanoplasty with HA prosthesis. MAIN OUTCOME MEASURES: Preoperative and postoperative audiometric data were compared for both the consultant and trainee groups. Details of the surgical procedure and operative complications were also recorded. RESULTS: Fifty-eight procedures were performed by the consultant and 60 operations were performed by trainees. The average improvement in air-bone gap (ABG) for consultants was 14.8 dB, with a 95% confidence interval (10.4, 19.2) (paired t test; test statistic: t=6.80, 57 df, p<0.01), whereas for trainees, the average improvement in ABG was 7.8 dB, with a 95% confidence interval (4.1, 11.6) (paired t test; test statistic: t=4.19, 59 df, p<0.01). The difference of 7.0 dB in mean ABG between the 2 groups was significant (two-sample t test; test statistic: t=2.44, 116 df, p=0.02). There was no significant difference in the surgical procedure or in the number of revision operations performed by the consultant or trainees. Surgical complication rates were comparable for the two groups. CONCLUSION: In this series, the consultant achieved a significantly better closure in ABG than trainees for tympanoplasty with HA prostheses.

The Australian Vascular Quality of Life Index (AUSVIQUOL): an improved clinical quality of life tool for peripheral vascular disease.

OBJECTIVES: To validate the Australian Vascular Quality of Life Index (AUSVIQUOL) as a quality of life (QOL) tool appropriate for peripheral vascular disease patients in the clinical setting. DESIGN: Cross-sectional study. MATERIALS: The study group consisted of 71 patients with vascular claudication of varying severity attending a tertiary hospital outpatient department. METHODS: The results of the AUSVIQUOL and Medical Outcomes Short Form Health Survey (SF-36) were compared through factor and regression analyses. A group of 12 patients was then reassessed to compare the reliability and internal consistency of the two indices. RESULTS: The AUSVIQUOL took less time to complete than the SF-36 (3.27 v 10.79 min; p<0.0001) and fewer patients found the questions confusing (2% v 26%). The AUSVIQUOL was easier to administer and had a higher level of patient acceptance than the SF-36. The regression analysis showed that for each of the domains in the AUSVIQUOL there was a significant correlation with measures in the SF-36 (adjusted R-squared 0.420, 0.480 and 0.331). The AUSVIQUOL demonstrated a good level of internal consistency when compared to the SF-36 (Cronbach's alpha 0.8702 vs 0.6307). CONCLUSION: In comparison with the SF-36, the AUSVIQUOL is an improved tool for the QOL assessment of patients with peripheral vascular disease in the clinical setting.

Implications of hyperglycaemia and ethnicity in patients with acute coronary syndromes in New Zealand.

BACKGROUND: Admission blood glucose (ABG) is an independent predictor of death in patients with acute ST elevation myocardial infarction (STEMI). In New Zealand, mortality following myocardial infarction is disproportionally higher in Maori. Little information, however, exists concerning the predictive value of ABG in non-ST elevation acute coronary syndromes (NSTEACS) events or indeed if similar ethnic differences exist in outcome in this patient population. AIM: To assess the predictive value of ABG and ethnicity in individuals admitted with acute coronary syndromes (ACS) on mortality. METHODS: A retrospective analysis of hospital discharge diagnosis of all ACS between 1 January 1999 and 31 December 2002 at Waikato hospital, Hamilton, New Zealand. The primary outcome was all-cause mortality. RESULTS: There were 4408 episodes of ACS with 1091 (25%) due to STEMI. There were 806 (18%) deaths. The presence of diabetes mellitus (DM) or an elevated ABG, in the absence of a history of DM, was associated with poor patient outcome. Early mortality is seen in individuals presenting with STEMI. People in the highest glucose category were older, more likely to be Maori, had a higher percentage of people with diabetes and remained in hospital longer, regardless of ACS type, than those in the lowest glucose category. Diabetes was more common in Maori (33%) than in Europeans (17.5%); p < 0.001. Significant risk factors for mortality were age, gender, diabetes, ethnicity, glucose and STEMI. For each mmol/l increase in glucose there is a 4.3% increase risk of dying. Adjusting for age and gender, Maori have a much higher mortality than Europeans (RR 2.12; p < 0.00001) regardless of ACS type (STEMI or NSTEACS). CONCLUSIONS: Our study confirms the higher mortality following ACS, of Maori compared to New Zealanders of European origin. A raised ABG is a marker of this increased risk in all patients with ACS.

Effect of hormone replacement therapy on cardiovascular risk factors in postmenopausal women with diabetes.

BACKGROUND: Hormone replacement therapy (HRT) in postmenopausal women improves menopausal symptoms, decreases the incidence of osteoporotic fracture, but the effects on cardiovascular risk factors remain controversial. AIM: To test the hypothesis that HRT may have beneficial effects on the cardiovascular risk profile in postmenopausal women with diabetes. METHODS: One hundred and fifty postmenopausal patients with type 1 (T1DM) and type 2 diabetes (T2DM) were randomized to receive HRT (Kliofem) or placebo for 12 months. We monitored the effects on cardiovascular risk factors, including lipid profile, glycaemic control, blood pressure and body weight. RESULTS: Mean low-density lipoprotein (LDL) cholesterol was associated with a nonsignificant decrease [-0.14 mmol/l (CI=-0.44, 0.17) (p=0.37)] in the Kliofem-treated group. Total cholesterol fell by 0.42 mmol/l (CI=-0.78, -0.05) (p=0.027). High-density lipoprotein (HDL) cholesterol was reduced by a mean of 0.07 mmol/l compared to a mean rise of 0.12 mmol/l on placebo. There were apparent differences in the treatment effects between T1DM and T2DM. There was no change in triglycerides or apoprotein B and no effect on glycaemic control, blood pressure or menopausal symptom scores. In the Kliofem group, BMI fell by 0.66 kg/m2 compared to an increase of 0.14 kg/m2 for placebo patients (p=0.046). CONCLUSIONS: Although the long-term effects of HRT in women with or without diabetes appear to suggest that some types of HRT either confer no cardiovascular protection or may increase risk, the impact of Kliofem diabetic women on cardiovascular risk factors is probably neutral.

Metabolic and cardiovascular effects of very-low-calorie diet therapy in obese patients with Type 2 diabetes in secondary failure: outcomes after 1 year.

AIMS: To evaluate the short-term and 1-year outcomes of an intensive very-low-calorie diet (VLCD) on metabolic and cardiovascular variables in obese patients with Type 2 diabetes (T2DM) and symptomatic hyperglycaemia despite combination oral anti-diabetic therapy +/- insulin, and to assess patient acceptability and the feasibility of administering VLCD treatment to this subgroup of patients in a routine practice setting. METHODS: Forty obese patients with T2DM (22 M, mean age 52 years, body mass index (BMI) 40 kg/m2, duration of T2DM 6.1 years) and symptomatic hyperglycaemia despite combination oral therapy (n = 26) or insulin + metformin (n = 14) received 8 weeks of VLCD therapy (750 kcal/day) followed by standard diet and exercise advice at 2-3-month intervals up to 1 year. Insulin was discontinued at the start of the VLCD, and anti-diabetic therapy was adjusted individually throughout the study, including (re)commencement of insulin as required. RESULTS: Immediate improvements in symptoms and early weight loss reinforced good compliance and patient satisfaction. After 8 weeks of VLCD, body weight and BMI had fallen significantly: 119 +/- 19-107 +/- 18 kg and 40.6-36.6 kg/m2, respectively, with favourable reductions in serum total cholesterol (5.9-4.9 mm), blood pressure (10/6 mmHg) and fructosamine (386 +/- 73-346 +/- 49 microm) (equates to an HbA1c reduction of approximately 1%). Sustained improvements were evident after 1 year, with minimal weight regain, e.g. mean body weight 109 +/- 18 kg and BMI 37 +/- 4 kg/m2. Glycaemic control tended to deteriorate after 1 year. CONCLUSIONS: The absence of a control group is a major limitation, but the results indicate that 8 weeks of VLCD treatment may be effective and well tolerated in symptomatic obese patients with T2DM in secondary failure, producing sustained cardiovascular and metabolic improvements after 1 year. VLCD therapy is a treatment option that deserves greater consideration in this difficult-to-treat patient population.

Improvements in total mortality and lipid levels after acute myocardial infarction in an English health district (1995-1999).

OBJECTIVES: To quantify changes in 30 day and one year mortality among patients with acute myocardial infarction in southern Derbyshire (population 560 000) in each of five consecutive years (1995-1999) before the publication of the National Service Framework for coronary heart disease, and to assess the proportion of one year survivors in whom serum lipids were measured and were below target values. DESIGN: All hospital admissions coded on the patient administration system (PAS) as "AMI" (ICD codes I-21, I-22, and I-23) and with a creatine kinase measurement in the pathology database were identified over a five year period (n = 4912). All deaths in the district are automatically notified to the PAS. Total mortality after acute myocardial infarction (30 days and one year) and lipid levels were analysed by year of admission, age group (35-74 years v > or = 75 years), and sex using unconditional logistic regression analysis. SETTING: An acute hospitals trust and pathology laboratory, as sole service providers for a catchment population of 560 000. RESULTS: The number of admissions for acute myocardial infarction was similar in each of the five years (n = 4912, 62% male, 63% < 75 years old). Overall, among patients aged 35-74 years there were 396 deaths (13%) at 30 days and 585 (19%) at one year; mortality was higher in women (1.28-fold at 30 days, p = 0.02) and in subjects aged 75 years or more (3.26-fold at 30 days, p < 0.0001). There was a progressive reduction in 30 day mortality of 9%/year over the five year period (95% confidence interval, 4% to 13%, p = 0.012). The proportion of one year survivors (35-74 years) in whom serum lipids were measured at least once increased from 74% in 1995 to 88% in 1999; of these, 27% of men and 23% of women had a total serum cholesterol of < 5 mmol/l in 1995, increasing to 65% and 74%, respectively, in 1998 and 1999 (p < 0.0001). CONCLUSIONS: In the five year period 1995-1999, there was a significant year on year decline in 30 day and one year mortality after admission for acute myocardial infarction, and progressively more patients achieved cholesterol levels below 5 mmol/l. Men were more likely than women to have their lipids measured after myocardial infarction. Mortality at one year was 1.32-fold higher among women than among men.

Post-cricoid web associated with Rubinstein-Taybi syndrome.

A case of dysphagia due to a post-cricoid web in a seven-year-old boy with Rubinstein-Taybi syndrome is presented. The main features of this syndrome are summarized with particular reference to dysphagia and with previous cases of post-cricoid webs in children reviewed.

Cost of endovascular versus open surgical repair of abdominal aortic aneurysms.

BACKGROUND: Endovascular repair of abdominal aortic aneurysms (AAA) is a new minimally invasive method of aneurysm exclusion that has been adopted with increasing enthusiasm, and with acceptable clinical results. It is important, however, to assess new health-care technologies in terms of their economic as well as their clinical impact. The aim of the present study was to compare the total treatment costs for endovascular (EVR) and open surgical repair (OSR) for AAA. METHODS: A retrospective review of patient hospital and outpatient records for 62 patients undergoing either EVR (n = 31) or OSR (n = 31) was carried out between June 1996 and October 1999. Resource utilization was determined by a combination of patient clinical and financial accounting data. Costs were determined for preoperative assessment, inpatient hospital stay, cost of readmissions and follow up, and predicted lifetime follow-up costs. RESULTS: The two groups were well matched, with no significant difference with respect to age, gender, maximum aneurysm diameter or comorbid factors. Endovascular treatment resulted in a shorter intensive care unit (ICU) and hospital stay (mean: 0.07 vs 2.9 days, P < 0.001; mean: 6.0 vs 13.4 days, P < 0.001; respectively) and fewer postoperative complications (P = 0.003). The cost of hospitalization was less for EVR ($7614 vs $15092, P < 0.001), but this was offset by the more costly vascular prosthesis ($10284 vs $686). Costs were higher for the EVR group for preoperative assessment ($2328 vs $1540, P < 0.001) and follow up ($1284 vs $70, P < 0.001). Lifelong follow up could be expected to cost an additional $4120 per patient after EVR. Total lifetime treatment costs including costs associated with readmission for procedure-related complications were higher for EVR ($26909 vs $17650). CONCLUSION: Treatment costs for endovascular repair are higher than conventional surgical repair due to the cost of the vascular prosthesis and the greater requirement for radiological imaging studies.

The influence of MRI on treatment decisions regarding knee injuries.

This study evaluated whether the information gained from magnetic resonance imaging (MRI) of the knee would provide information that was useful in the treatment algorithm. Three orthopedic surgeons completed a questionnaire immediately after the initial evaluation of a patient with a knee injury and for whom an MRI also was ordered by that surgeon. The questionnaire asked the surgeons' what their proposed clinical diagnoses and treatment plans would be if MRI was not available. Eighty-five patients were included in the study. Initial treatment recommendation was altered for 18 patients (21%) solely because of the MRI results. The physicians and MRI were most accurate for anterior cruciate ligament (ACL) tears followed by medial meniscus tears, and lateral meniscus tears, and significantly behind in accuracy for patellofemoral chondral pathology. These diagnoses were more frequently missed in the face of acute ACL pathology for the clinician and MRI. In 19 cases in which the surgeon was confident of ACL insufficiency, in only 1 (5%) case did the MRI scan provide useful information. In 19 cases in which an ACL reconstruction was performed, the decision to proceed with the reconstruction was hastened in 3 patients because of the MRI results. These results indicate that the use of MRI for decision making in acute ACL tears is not of much benefit unless the diagnosis of ACL insufficiency is in question. Magnetic resonance imaging is more useful for the decision-making process when the pathology involves the menisci or chondral surfaces. In this study, MRI of the knee beneficially altered the treatment plan of the orthopedist in 18% of the patients and resulted in the prolongation of symptoms in 4% of patients.

Expression of an engineered form of recombinant procollagen in mouse milk.

We have examined the suitability of the mouse mammary gland for expression of novel recombinant procollagens that can be used for biomedical applications. We generated transgenic mouse lines containing cDNA constructs encoding recombinant procollagen, along with the alpha and beta subunits of prolyl 4-hydroxylase, an enzyme that modifies the collagen into a form that is stable at body temperature. The lines expressed relatively high levels (50-200 micrograms/ml) of recombinant procollagen in milk. As engineered, the recombinant procollagen was shortened and consisted of a pro alpha 2(I) chain capable of forming a triple-helical homotrimer not normally found in nature. Analysis of the product demonstrated that (1) the pro alpha chains formed disulphide-linked trimers, (2) the trimers contained a thermostable triple-helical domain, (3) the N-propeptides were aligned correctly, and (4) the expressed procollagen was not proteolytically processed to collagen in milk.