Utility of Smartphone Telemedical Consultations for Peritonsillar Abscess Diagnosis and Triage.

Importance: Telemedicine is rapidly gaining traction as a way to reduce costs and connect patients with medical experts outside their local communities. Peritonsillar abscess (PTA) is a logical pathologic condition to evaluate for effectiveness of remote diagnosis given its prevalence and the paucity of on-site otolaryngologists at many institutions. Objective: To explore the potential of otolaryngology telemedical consultation in triaging and diagnosing patients with suspected PTA. Design, Setting, and Participants: A comparative effectiveness research study was conducted from January 1 to June 30, 2018, at 3 tertiary care hospitals among 31 consecutive patients aged 18 to 85 years for whom the otolaryngology department was consulted to assess for PTA. Statistical analysis was conducted from July 1 to September 30, 2018. Interventions: Telemedical evaluation of suspected PTA by 5 attending otolaryngologists blinded to patients' history aside from the chief report of odynophagia. Otolaryngologists rated each patient video on whether they believed the patient had a PTA and whether the case warranted prompt evaluation by an otolaryngologist. Predictions were compared with the criterion standard of drainage or negative needle aspiration. Otolaryngologists additionally assessed video quality. Main Outcomes and Measures: Rates of accurate diagnosis and triage of PTA based on otolaryngologists' review of oropharyngeal examinations recorded using standard smartphone cameras, as well as percentage of videos of oropharyngeal examinations using standard smartphone cameras deemed of sufficiently high quality for clinical decision-making. Results: A total of 31 patients (16 women [51.6%]; mean age, 31.9 years [range, 18-62 years]) were recruited, and 16 patients (51.6%) had a PTA. Comparing otolaryngologists' predictions with PTA status by the criterion standard, the prediction was consistent with that of the criterion standard 81% of the time averaged across otolaryngologists (mean diagnostic accuracy, 0.81). Similarly, the mean diagnostic accuracy was 0.83 when comparing the otolaryngologist's suggestion for a prompt in-person evaluation with actual PTA status by the criterion standard. Comparing patients who were deemed to require prompt otolaryngology evaluation and those with PTA by the criterion standard, mean sensitivity was 90%. Videos were rated as of sufficiently high quality to make a diagnosis in 154 of 155 videos (99.4%). Conclusions and Relevance: This study suggests that telemedical consultation is a viable, cost-conscious, efficient, and safe approach to PTA management. Despite having some difficulty diagnosing PTAs based on "history concerning for PTA" and oropharyngeal video alone, otolaryngologists are able to determine, with high sensitivity, which patients require prompt otolaryngology evaluation. The recording of consistently high-quality video using a standard smartphone camera is achievable without formal training.

The influence of vegetation and soil characteristics on active-layer thickness of permafrost soils in boreal forest.

Carbon release from thawing permafrost soils could significantly exacerbate global warming as the active-layer deepens, exposing more carbon to decay. Plant community and soil properties provide a major control on this by influencing the maximum depth of thaw each summer (active-layer thickness; ALT), but a quantitative understanding of the relative importance of plant and soil characteristics, and their interactions in determine ALTs, is currently lacking. To address this, we undertook an extensive survey of multiple vegetation and edaphic characteristics and ALTs across multiple plots in four field sites within boreal forest in the discontinuous permafrost zone (NWT, Canada). Our sites included mature black spruce, burned black spruce and paper birch, allowing us to determine vegetation and edaphic drivers that emerge as the most important and broadly applicable across these key vegetation and disturbance gradients, as well as providing insight into site-specific differences. Across sites, the most important vegetation characteristics limiting thaw (shallower ALTs) were tree leaf area index (LAI), moss layer thickness and understory LAI in that order. Thicker soil organic layers also reduced ALTs, though were less influential than moss thickness. Surface moisture (0-6 cm) promoted increased ALTs, whereas deeper soil moisture (11-16 cm) acted to modify the impact of the vegetation, in particular increasing the importance of understory or tree canopy shading in reducing thaw. These direct and indirect effects of moisture indicate that future changes in precipitation and evapotranspiration may have large influences on ALTs. Our work also suggests that forest fires cause greater ALTs by simultaneously decreasing multiple ecosystem characteristics which otherwise protect permafrost. Given that vegetation and edaphic characteristics have such clear and large influences on ALTs, our data provide a key benchmark against which to evaluate process models used to predict future impacts of climate warming on permafrost degradation and subsequent feedback to climate.

The Cleft Lip Nose: Primary and Secondary Treatment.

This article presents an overview of the cleft lip nasal deformity and its treatment. The complex pathologic changes to normal nasal anatomy are described, and treatment strategies for both unilateral and bilateral cleft lip patients are presented. The surgical technique for management of the cleft lip nasal deformity is discussed as it pertains to both primary and secondary correction.

Evaluation of surface sampling for Bacillus spores using commercially available cleaning robots.

Five commercially available domestic cleaning robots were evaluated on their effectiveness for sampling aerosol-deposited Bacillus atrophaeus spores on different indoor material surfaces. The five robots tested include three vacuum types (R1, R2, and R3), one wet wipe (R4), and one wet vacuum (R5). Tests were conducted on two different surface types (carpet and laminate) with 10(6) colony forming units of B. atrophaeus spores deposited per coupon (35.5 cm × 35.5 cm). Spores were deposited on the center surface (30.5 × 30.5 cm) of the coupon's total surface area (71.5 × 71.5 cm), and the surfaces were sampled with an individual robot in an isolation chamber. Chamber air was sampled using a biofilter sampler to determine the potential for resuspension of spores during sampling. Robot test results were compared to currently used surface sampling methods (vacuum sock for carpet and sponge wipe for laminate). The test results showed that the average sampling efficacies for R1, R2, and R3 on carpet were 26, 162, and 92% of vacuum sock sampling efficacy, respectively. On laminate, R1, R2, R3, R4, and R5 average sampling efficacies were 8, 11, 2, 62, and 32% of sponge wipe sampling efficacy, respectively. We conclude that some robotic cleaners were as efficacious as the currently used surface sampling methods for B. atrophaeus spores on these surfaces.

Localized delivery of chemotherapy to the cervix for radiosensitization.

OBJECTIVE: Chemoradiation is the mainstay of therapy for advanced cervical cancer, with the most effective treatment regimens involving combinations of radiosensitizing agents. However, administration of radiosensitizing chemotherapeutics concurrently with pelvic radiation is not without side effects. The aim of this study was to examine the utility of localized drug delivery as a means of improving drug targeting of radiosensitizing chemotherapeutics to the cervix while limiting systemic toxicities. METHODS: An initial proof-of-concept study was performed in 14 healthy women following local administration of diazepam utilizing a novel cervical delivery device (CerviPrep™). Uterine vein and peripheral blood samples were collected and diazepam was measured using a GC-MS method. In the follow-up study, gemcitabine was applied to the cervix in 17 women undergoing hysterectomy for various gynecological malignancies. Cervical tissue, uterine vein blood samples, and peripheral plasma were collected, and gemcitabine and its deaminated metabolite 2',2'-difluorodeoxyuridine (dFdU) were measured using HPLC-UV and LC/MS methods. RESULTS: Targeted delivery of diazepam to the cervix was consistent with parent drug detectable in the uterine vein of 13 of 14 women. In the second study, pharmacologically relevant concentrations of gemcitabine (0.01-6.6 nmol/g tissue) were detected in the cervical tissue of 11 of 16 available specimens with dFdU measureable in 15 samples (0.04-8.8 nmol/g tissue). Neither gemcitabine nor its metabolites were detected in the peripheral plasma of any subject. CONCLUSIONS: Localized drug delivery to the cervix is possible and may be useful in limiting toxicity associated with intravenous administration of chemotherapeutics for radiosensitization.

Challenges in the management of sphenoid inverted papilloma.

BACKGROUND: Inverted papilloma (IP) arising in the sphenoid sinus is extremely rare. Management of sphenoid sinus IP is especially challenging because of the paucity of sinonasal symptoms on presentation and the inherent surgical risks associated with the anatomic location of the sphenoid sinus. METHODS: We performed a retrospective review of medical records of all patients with IP arising within the sphenoid sinus. RESULTS: A total of five patients were identified. All patients were managed with endoscopic resection. The most common presenting symptom was headache (three patients). The mean follow-up period was 37.6 months (range, 10-79 months). Two patients with erosive skull base lesions adjacent to the internal carotid artery were managed with a staged endoscopic resection. Only one patient developed a recurrence after 38 months and underwent revision endoscopic resection. CONCLUSION: Endoscopic management of sphenoid IP allows maximal resection with minimal morbidity and facilitates endoscopic postoperative surveillance. Complete preoperative radiological assessment of tumor extent is essential. Preoperative medical therapy can help normalize inflamed mucosa and minimize intraoperative bleeding. For large erosive IP, surgical risks may be minimized by considering a staged resection and using computer-aided surgery.

Endoscopic and endoscope-assisted resections of inverted sinonasal papillomas.

OBJECTIVE: To evaluate the success of endoscopic and endoscope-assisted resection of inverted sinonasal papillomas and to assess the indications for adjunctive external procedures. STUDY DESIGN: Retrospective chart review. RESULTS: Fifty patients were treated surgically during the 10-year study period and had greater than 1 year of follow-up care. These patients had a recurrence rate of 14% (7/50) with a mean follow-up of 31.1 months. Of these 7 patients with recurrences, 3 were treated primarily at this institution, and 4 had been treated prior to referral. Recurrence was 11% (3/27) for primary resections and 17% (4/23) for secondary resections. Average time to recurrence was 11.7 months. Of the patients, 38% (19/50) had adjunctive external procedures either during the initial resection or for the management of recurrent disease. CONCLUSIONS: Endoscopic and endoscope-assisted resections of inverted papilloma are effective techniques for managing inverted papilloma. The intraoperative findings, most importantly the site(s) of tumor attachment, dictate whether an endoscopic procedure is sufficient to complete resect the inverted papilloma or whether an adjunctive external procedure is required. Appropriate patient selection and an aggressive surgical approach are necessary for the management of these neoplasms.

Bilateral squamous cell carcinoma of the external auditory canals.

OBJECTIVES: To report a case of bilateral squamous cell carcinoma of the external auditory canals and to present a management algorithm for this difficult clinical scenario. STUDY DESIGN: Case report and literature review. METHODS: The study comprises a case report of a 69-year-old man who initially presented with complaints of bilateral otorrhea, left-sided otalgia, and a left-sided hearing loss. Following attempted treatment of a presumed case of otitis externa, biopsy of both external auditory canals revealed squamous cell carcinoma. A computed tomography scan demonstrated marked abnormal soft tissue in the left external auditory canal with no bony erosion and thickening of the soft tissue in the right external auditory canal. RESULTS: The left-sided lesion required a lateral temporal bone resection, a partial superficial and deep-lobe parotidectomy, and postoperative irradiation. The right-sided lesion was more limited and was managed with a lateral temporal bone resection and tympanoplasty for hearing preservation. CONCLUSIONS: Bilateral squamous cell carcinoma of the external auditory canals is an extremely uncommon but aggressive malignancy that may present with symptoms similar to a case of otitis externa, and this can result in delays in proper diagnosis. Early recognition is essential because management and prognosis are determined by the extent of the lesion.

A novel multi-coaxial hollow fiber bioreactor for adherent cell types. Part 1: hydrodynamic studies.

A novel multi-coaxial bioreactor for three-dimensional cultures of adherent cell types, such as liver, is described. It is composed of four tubes of increasing diameter placed one inside the other, creating four spatially isolated compartments. Liver acinar structure and physiological parameters are mimicked by sandwiching cells in the space between the two innermost semi-permeable tubes, or hollows fibers, and creating a radial flow of media from an outer compartment (ECC), through the cell mass compartment, and to an inner compartment (ICC). The outermost compartment is created by gas-permeable tubing, and the housing is used to oxygenate the perfusion media to periportal levels in the ECC. Experiments were performed using distilled water to correlate the radial flow rate (Q(r)) with (1) the pressure drop (DeltaP) between the media compartments that sandwich the cell compartment and (2) the pressure in the cell compartment (P(c)). These results were compared with the theoretical profile calculated based on the hydraulic permeability of the two innermost fibers. Phase-contrast velocity-encoded magnetic resonance imaging was used to visualize directly the axial velocities inside the bioreactor and confirm the assumptions of laminar flow and zero axial velocity at the boundaries of each compartment in the bioreactor. Axial flow rates were calculated from the magnetic resonance imaging results and were similar to the measured axial flow rates for the previously described experiments.