Otitis externa: what is the problem with getting it right? A mixed-methods study in primary and secondary care.

OBJECTIVE: Otitis externa accounts for 1.1-1.3 per cent of patient presentations in primary care and 25 per cent of urgent referrals to ENT. This study aimed to explore otitis externa clinical decision-making at the primary-secondary care interface, otitis externa prevalence and recent trends in antimicrobial resistance in otitis externa related bacterial isolates and ototopical prescribing. METHOD: This is a mixed-methods study drawing on data from primary and secondary care and open National Health Service sources. RESULTS: A total of 101 general practitioner survey respondents reported frequently prescribing oral antibiotics for otitis externa. General practitioner consultations for otitis externa increased 25 per cent over 15 years. General practitioner ototopical preparations cost the National Health Service £7 410 440 in 2006 and £11 325 241 in 2016. A total of 162 consecutive hospital otitis externa-related bacterial isolates yielded 128 pseudomonas species, with 18 that were resistant to gentamicin and 7 that were resistant to ciprofloxacin. Ten guidelines reviewed showed systematic inconsistencies. CONCLUSION: General practitioners reported regularly prescribing oral antibiotics for otitis externa. Antimicrobial drug resistance is common in otitis externa. The available guidance is suboptimal.

Acute mastoiditis in children: contemporary opportunities and challenges.

BACKGROUND: Mastoiditis is the most common intra-temporal complication of acute otitis media. Despite potentially lethal sequelae, optimal management remains poorly defined. METHOD: A retrospective case review was conducted of children diagnosed with mastoiditis at a tertiary referral centre, in North East England, between 2010 and 2017. RESULTS: Fifty-one cases were identified, 49 without cholesteatoma. Median patient age was 42 months (2 months to 18 years) and median hospital stay was 4 days (range, 0-27 days). There was no incidence trend over time. Imaging was conducted in 15 out of 49 cases. Surgery was performed in 29 out of 49 cases, most commonly mastoidectomy with (9 out of 29) or without (9 out of 29) grommets. Complications included sigmoid sinus thrombosis (3 out of 49) and extradural abscess (2 out of 51), amongst others; no fatalities occurred. CONCLUSION: A detailed contemporary description of paediatric mastoiditis presentation and management is presented. The findings broadly mirror those published by other UK centres, but suggest a higher rate of identified disease complications and surgical interventions.

Radiology of acute mastoiditis and its complications: a pictorial review and interpretation checklist.

BACKGROUND: Mastoiditis is an otological emergency, and cross-sectional imaging has a role in the diagnosis of complications and surgical planning. Advances in imaging technology are becoming increasingly sophisticated and, by the same token, the ability to accurately interpret findings is essential. METHODS: This paper reviews common and rare complications of mastoiditis using case-led examples. A radiologist-derived systematic checklist is proposed, to assist the ENT surgeon with interpreting cross-sectional imaging in emergency mastoiditis cases when the opinion of a head and neck radiologist may be difficult to obtain. RESULTS: A 16-point checklist (the 'mastoid 16') was used on a case-led basis to review the radiological features of both common and rare complications of mastoiditis; this is complemented with imaging examples. CONCLUSION: Acute mastoiditis has a range of serious complications that may be amenable to treatment, once diagnosed using appropriate imaging. The proposed checklist provides a systematic approach to identifying complications of mastoiditis.

Going where other methods cannot: A systematic mapping review of 25 years of qualitative research in Otolaryngology.

OBJECTIVE: To map the use of qualitative methods within otolaryngology, providing examples and identifying gaps in the literature. DESIGN: Systematic mapping review of journal-based literature from 1990 to 2015 using Medline, Embase, PsycINFO and CENTRAL. Included studies were categorised according to clinical subspecialty, research aims and qualitative approach. RESULTS: Of 4,061 identified articles, 388 were deemed relevant to qualitative research in ENT. The number of qualitative publications has risen markedly over the last 25 years (r = 0.802), particularly since 2010. The most commonly used method was semi-structured interviews 62.1% (241/388). Head and neck cancer (41.8% (162/388)) and otology (40.2% (156/388)) publish more qualitative research than rhinology (7.0% (27/388)) and laryngology (6.7% (26/388)). CONCLUSIONS: Qualitative research in otolaryngology has increased over time, but laryngology and rhinology remain under-represented. Most studies use interviews, underutilising the strengths of other qualitative methods. There is considerable scope for further application of qualitative methods in otolaryngology.

Minimal methylation classifier (MIMIC): A novel method for derivation and rapid diagnostic detection of disease-associated DNA methylation signatures.

Rapid and reliable detection of disease-associated DNA methylation patterns has major potential to advance molecular diagnostics and underpin research investigations. We describe the development and validation of minimal methylation classifier (MIMIC), combining CpG signature design from genome-wide datasets, multiplex-PCR and detection by single-base extension and MALDI-TOF mass spectrometry, in a novel method to assess multi-locus DNA methylation profiles within routine clinically-applicable assays. We illustrate the application of MIMIC to successfully identify the methylation-dependent diagnostic molecular subgroups of medulloblastoma (the most common malignant childhood brain tumour), using scant/low-quality samples remaining from the most recently completed pan-European medulloblastoma clinical trial, refractory to analysis by conventional genome-wide DNA methylation analysis. Using this approach, we identify critical DNA methylation patterns from previously inaccessible cohorts, and reveal novel survival differences between the medulloblastoma disease subgroups with significant potential for clinical exploitation.

Bile acids: a potential role in the pathogenesis of pharyngeal malignancy.

OBJECTIVE: Gastro-oesophageal reflux disease is thought to be a risk factor for head and neck malignancies. Bile acids are one of the principle components of gastric refluxate and have previously been implicated in the development of oesophageal and bowel malignancies. There is clear evidence that bile acids reflux into the laryngopharynx. Despite this, the carcinogenic properties of bile acids in this area are yet to be fully identified. We therefore investigated the potential role of bile acids in pharyngeal malignancy, through the highly conserved process of epithelial-mesenchymal transition (EMT). EMT occurs in invasion and metastasis and is a central process in the development of epithelial carcinoma. DESIGN: Translational research study. METHODS: Human hypopharyngeal squamous carcinoma FaDu cells were challenged with primary (cholic or chenodeoxycholic) and secondary (deoxycholic or lithocholic) bile acids. EMT-relevant proteins TGF-ß1 and MMP-9 were measured in the cell culture supernates at 48 h via ELISA. Cell viability was confirmed >95% via CellTiter-Blue assay. RESULTS: Significantly greater concentrations of TGF-ß1 were measured in the culture supernates of cells treated with cholic acid, deoxycholic acid and chenodeoxycholic acid. MMP-9 levels were increased in deoxycholic acid and lithocolic acid stimulations when compared to control (P < 0.05). CONCLUSION: This is the first demonstration that bile acids induce TGF-ß1 and MMP-9 in pharyngeal cells. TGF-ß1 is considered a master switch for EMT, while MMP-9 is a part of the EMT proteome which degrades basement membranes. This implies a potential role for bile acids in pharyngeal carcinogenesis through the mechanism of EMT and suggests potential novel therapeutic targets.

Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE.

INTRODUCTION: Routine cognitive screening for in-patients aged ≥75 years is recommended, but there is uncertainty around how this should be operationalised. We therefore determined the feasibility and reliability of the Abbreviated mental test score (AMTS/10) and its relationship to subjective memory complaint, Montreal Cognitive Assessment (MoCA/30) and informant report in unselected older admissions. METHODS: Consecutive acute general medicine patients aged ≥75 years admitted over 10 weeks (March-May 2013) had AMTS and a question regarding subjective memory complaint (if no known dementia/delirium). At ≥72 h, the 30-point Montreal Cognitive Assessment (MoCA) and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) were done. Cognitive impairment was defined as AMTS < 9 or MoCA < 26 (mild impairment) and MoCA < 20 (moderate/severe impairment) or IQCODE ≥ 3.6. RESULTS: Among 264 patients (mean age/SD = 84.3/5.6 years, 117 (44%) male), 228 (86%) were testable with AMTS. 49/50 (98%) testable patients with dementia/delirium had low AMTS compared with 79/199 (44%) of those without (P < 0.001). Subjective memory complaint agreed poorly with objective cognitive deficit (39% denying a memory problem had AMTS < 9 (kappa = 0.134, P = 0.086)) as did informant report (kappa = 0.18, P = 0.15). In contrast, correlation between AMTS and MoCA was strong (R2 = 0.59, P < 0.001) with good agreement between AMTS < 9 and MoCA < 20 (kappa = 0.50, P < 0.01), although 85% of patients with normal AMTS had MoCA < 26. CONCLUSIONS: The AMTS was feasible and valid in older acute medicine patients agreeing well with the MoCA albeit with a ceiling effect. Objective cognitive deficits were prevalent in patients without known dementia or delirium but were not reliably identified by subjective cognitive complaint or informant report.

Pulsed ultrasound modulated optical tomography utilizing the harmonic response of lock-in detection.

Ultrasound modulated optical tomography (USMOT) can image the optical properties of a scattering medium at a spatial resolution approaching that of ultrasound (US). A lock-in parallel speckle detection technique is proposed to detect pulsed US modulated light using a multipixel detector. The frequency components of the pass band match those of the US pulse train and provide efficient detection. The modulation depth is extracted by taking the difference between a pair of speckle patterns modulated by a pair of phase-inversed US bursts. Modification to pulse inversion mode enables the second harmonic US modulation due to nonlinear US propagation to be detected.

Diversity in destinations, routes and timing of small adult and sub-adult striped bass Morone saxatilis on their southward autumn migration.

Almost three-quarters of the 46 young adult and sub-adult striped bass Morone saxatilis that were acoustically tagged in Plum Island Estuary, Massachusetts, U.S.A., in the summer of 2006 were detected in one or more southern coastal arrays during their autumn migration. On the basis of the trajectories along which these M. saxatilis moved from feeding to overwintering areas, three migratory groups emerged. After leaving Plum Island Estuary, about half of the fish were detected only in a mid-latitude array, Long Island Sound. The other half of the tagged fish were detected during autumn and winter in a more southern array, the Delaware Estuary. This latter group of fish may have used two routes. Some travelled to the Delaware Estuary through Long Island Sound while other fish may have taken a second, more direct, coastal route that did not include Long Island Sound. Consequently, a seemingly homogeneous group of fish tagged at the same time in the same non-natal feeding location exhibited a diversity of southward movement patterns that could affect population-level processes. These three groups that differed in overwintering location and migration route could be movement contingents with migratory connectivity.

Longitudinal acoustic properties of poly(lactic acid) and poly(lactic-co-glycolic acid).

Acoustics offers rich possibilities for characterizing and monitoring the biopolymer structures being employed in the field of biomedical engineering. Here we explore the rudimentary acoustic properties of two common biodegradable polymers: poly(lactic acid) and poly(lactic-co-glycolic acid). A pulse-echo technique is developed to reveal the bulk speed of sound, acoustic impedance and acoustic attenuation of small samples of the polymer across a pertinent temperature range of 0-70 °C. The glass transition appears markedly as both a discontinuity in the first derivative of the speed of sound and a sharp increase in the acoustic attenuation. We further extend our analysis to consider the role of ethanol, whose presence is observed to dramatically modify the acoustic properties and reduce the glass transition temperature of the polymers. Our results highlight the sensitivity of acoustic properties to a range of bulk properties, including visco-elasticity, molecular weight, co-polymer ratio, crystallinity and the presence of plasticizers.

Medically assisted hydration for palliative care patients.

BACKGROUND: Many palliative care patients have reduced oral intake during their illness. The management of this can include the provision of medically assisted hydration with the aim of prolonging the length of life of a patient, improving their quality of life, or both. OBJECTIVES: To determine the effect of medically assisted hydration in palliative care patients on their quality and length of life. SEARCH STRATEGY: Studies were identified from searching CENTRAL, MEDLINE (1966 to 2008), EMBASE (1980 to 2008), CINAHL, CANCERLIT, Caresearch, Dissertation abstracts, SCIENCE CITATION INDEX and the reference lists of all eligible studies, key textbooks, and previous systematic reviews. The date of the latest search was February 2008. SELECTION CRITERIA: All relevant randomised controlled trials (RCTs) or prospective controlled studies of medically assisted hydration in palliative care patients. DATA COLLECTION AND ANALYSIS: Five relevant studies were identified. These included two RCTs (93 participants), and three prospective controlled trials (360 participants). These were assessed independently by two review authors for quality and validity. The small number of studies and the heterogeneity of the data meant that a quantitative analysis was not possible, so a description of the main findings was included only. MAIN RESULTS: One study found that sedation and myoclonus (involuntary contractions of muscles) were improved more in the intervention group (28 - hydration, 23 - placebo). Another study found that dehydration was significantly higher in the non-hydration group, but that some fluid retention symptoms (pleural effusion, peripheral oedema and ascites) were significantly higher in the hydration group (59 - hydration group, 167 - non -hydration group). The other three studies did not show significant differences in outcomes between the two groups. AUTHORS' CONCLUSIONS: There are insufficient good quality studies to make any recommendations for practice with regard to the use of medically assisted hydration in palliative care patients.

Clinical effectiveness and soft tissue compatibility of a temporary restorative material.

OBJECTIVE: The purpose of this six-week study was to evaluate in vivo the effectiveness of Systemp.inlay as a temporary restorative material. METHOD: Subjects with the proper indication for a class II restoration were entered into the study. Twenty-three subjects and twenty-nine temporary restorations were evaluated at time of placement, three and six weeks. Two faculty members were calibrated to evaluate the material. Following the six-week trial, the temporary restorative material was removed and the test teeth were restored with a definitive restorative material. RESULTS: The temporary restorative material provided mechanical and anticariogenic protection of tooth structure while preventing dental sensitivity and patient discomfort. It promoted soft tissue health as evidenced by the enhanced plaque and gingival indices found associated with the temporarily restored teeth. Its ease of placement and removal makes it an attractive alternative for the dental practitioner. The change in color of the material over the six-week duration of the study may limit its use to posterior teeth and to lingual/palatal surfaces of anterior teeth. CONCLUSION: Ease of placement and removal and retention of the temporary restorative material were extremely good. Marginal and surface integrity of the material was maintained and no or minimal sensitivity was reported throughout the study. The material did not promote the accumulation of plaque nor result in gingival inflammation. The color change noted was not of clinical importance. Therefore, this temporary restorative material was demonstrated to be clinically effective in Class II cavity preparations.

A post-genomic view of the mitochondrion in malaria parasites.

Mitochondria in Plasmodium parasites have many characteristics that distinguish them from mammalian mitochondria. Selective targeting of malaria parasite mitochondrial physiology has been exploited in successful antimalarial chemotherapy. At present, our understanding of the functions served by the parasite mitochondrion is somewhat limited, but the availability of the genomic sequences makes it possible to develop a framework of possible mitochondrial functions by providing information on genes encoding mitochondrially targeted proteins. This review aims to provide an overview of mitochondrial physiology in this post-genomic era. Although in many cases direct experimental proof for their mitochondrial functions may not be available at present, descriptions of these potential mitochondrial proteins can provide a basis for experimental approaches.

Investigation of vacuum pumping on the dose response of the MAGAS normoxic polymer gel dosimeter.

The effect of vacuum pumping on the dose response of the MAGAS polymer gel dosimeter has been investigated. A delay of several days post-manufacture before irradiation was previously necessary due to the slow oxygen scavenging of ascorbic acid. The MAGAS polymer gel dosimeter was vacuum pumped before gelation to remove dissolved oxygen. The MAGAS polymer gel dosimeter was poured into glass screw-top vials, which were irradiated at various times, post-manufacture to a range of doses. Magnetic resonance imaging techniques were used to determine the R2-dose response and R2-dose sensitivity of the MAGAS polymer gel. The results were compared with a control batch of MAGAS polymer gel that was not vacuum pumped. It was shown that vacuum pumping on the MAGAS polymer gel solution immediately prior to sealing in glass screw-top vials initially increases the R2-dose response and R2-dose sensitivity of the dosimeter. An increase in the R2-dose response and R2-dose sensitivity was observed with increasing time between manufacture and irradiation. Over the range of post-manufacture irradiation times investigated, the greatest R2-dose response and R2-dose sensitivity occurred at 96 hours.

A basic study of some normoxic polymer gel dosimeters.

Polymer gel dosimeters offer a wide range of potential applications in the three-dimensional verification of complex dose distribution such as in intensity-modulated radiotherapy (IMRT). Until now, however, polymer gel dosimeters have not been widely used in the clinic. One of the reasons is that they are difficult to manufacture. As the polymerization in polymer gels is inhibited by oxygen, all free oxygen has to be removed from the gels. For several years this was achieved by bubbling nitrogen through the gel solutions and by filling the phantoms in a glove box that is perfused with nitrogen. Recently another gel formulation was proposed in which oxygen is bound in a metallo-organic complex thus removing the problem of oxygen inhibition. The proposed gel consists of methacrylic acid, gelatin, ascorbic acid, hydroquinone and copper(II)sulphate and is given the acronym MAGIC gel dosimeter. These gels are fabricated under normal atmospheric conditions and are therefore called 'normoxic' gel dosimeters. In this study, a chemical analysis on the MAGIC gel was performed. The composition of the gel was varied and its radiation response was evaluated. The role of different chemicals and the reaction kinetics are discussed. It was found that ascorbic acid alone was able to bind the oxygen and can thus be used as an anti-oxidant in a polymer gel dosimeter. It was also found that the anti-oxidants N-acetyl-cysteine and tetrakis(hydroxymethyl)phosphonium were effective in scavenging the oxygen. However, the rate of oxygen scavenging is dependent on the anti-oxidant and its concentration with tetrakis(hydroxymethyl)phosphonium being the most reactive anti-oxidants. Potentiometric oxygen measurements in solution provide an easy way to get a first impression on the rate of oxygen scavenging. It is shown that cupper(II)sulphate operates as a catalyst in the oxidation of ascorbic acid. We, therefore, propose some new normoxic gel formulations that have a less complicated chemical formulation than the MAGIC gel.

Clinical evaluation of an automatic flossing device vs. manual flossing.

The aim of this study was to compare the effectiveness of an automatic flossing device to manual flossing. A total of seventy adult subjects (20 males and 50 females) were stratified into two groups balanced for age, sex, modified gingival index (MGI), plaque index (PI) and bleeding sites (Eastman Bleeding Index) using screening data. One group was randomly assigned the automatic power flosser and the other group was assigned manual dental floss. The subjects were instructed to brush their teeth twice a day (in the morning and before bedtime) for 30 seconds using the provided manual toothbrush and toothpaste. They were also to use their assigned dental floss or automatic power flosser once in the morning following toothbrushing. There was no significant difference between manual flossing and automatic flossing with respect to the MGI and the BI. There was, however, a significant difference at day 15 in the PI; however, this difference was only 0.73%. There was no significant difference in the PI at day 30 between the two techniques. The statistically significant difference noted in the interproximal PI at both day 15 and day 30 was less than 2%. Since the differences in plaque scores between the groups were so small, there was no apparent impact on gingival health since both flossers resulted in similar health benefits. Since there was a marked preference for the automatic flosser, patient compliance with the automatic flossing device may be better than with manual floss. Therefore, overall gingival health may benefit from this device.