Impact of coronavirus disease 2019 on urgent referrals to secondary care otolaryngology: a prospective case series.

OBJECTIVE: As the novel coronavirus disease 2019 changed patient presentation, this study aimed to prospectively identify these changes in a single ENT centre. DESIGN: A seven-week prospective case series was conducted of urgently referred patients from primary care and accident and emergency department. RESULTS: There was a total of 133 referrals. Referral rates fell by 93 per cent over seven weeks, from a mean of 5.4 to 0.4 per day. Reductions were seen in referrals from both primary care (89 per cent) and the accident and emergency department (93 per cent). Presentations of otitis externa and epistaxis fell by 83 per cent, and presentations of glandular fever, tonsillitis and peritonsillar abscess fell by 67 per cent. CONCLUSION: Coronavirus disease 2019 has greatly reduced the number of referrals into secondary care ENT. The cause for this reduction is likely to be due to patients' increased perceived risk of the virus presence in a medical setting. The impact of this reduction is yet to be ascertained, but will likely result in a substantial increase in emergency pressures once the lockdown is lifted and the general public's perception of the coronavirus disease 2019 risk reduces.

Health and safety of the older worker.

BACKGROUND: In the UK, increasing numbers of paid employees are over 60 years with further increases expected as the state pension age rises. Some concern surrounds possible increased work-related illness and accidents for people working beyond the age of 60. AIMS: To identify the available evidence for health and safety risks of workers over age 60 years with respect to factors associated with injuries and accidents. METHODS: Databases searched included PUBMED, OSHUpdate, National Institute for Occupational Safety and Health (NIOSHTIC-2), SafetyLit, the UK The Health and Safety Executive (HSELINE) and the Canadian Centre for Occupational Health and Safety until December 2009. Inclusion criteria were workers aged over 60 years. Findings were grouped into occupational accidents and injuries and individual and workplace factors that may have influenced risk of injury to the over-60s. RESULTS: Very little direct evidence was found concerning safety practices and health risks of workers over age 60. Some safety risks were associated with specific physical declines such as age-related hearing loss. Overall, these workers had fewer accidents and injuries but these were more likely to be serious or fatal when they occurred. There was no strong evidence that work patterns, including shift work or overtime, affected safety. Protective, compensatory strategies or experience may maintain safe working practices. CONCLUSIONS: Implications for health and safety risks cannot be assessed without longitudinal research on workforces with substantial numbers of workers over age 60 in order to address the healthy worker effect.

Household chemicals, persistent wheezing and lung function: effect modification by atopy?

The aims of the present study were to assess the effects of maternal use of domestic chemicals during pregnancy on wheezing and lung function in children aged 30 months) wheezing in nonatopic children (adjusted odds ratio per z-score of CHCE (95% confidence interval) 1.41 (1.13-1.76), 1.43 (1.02-2.13) and 1.69 (1.19-2.41), respectively). Increasing CHCE score was associated with decrements in FEV(1) and FEF(25-75%). Higher domestic chemical exposure during pregnancy was associated with persistent wheeze and lung function abnormalities in nonatopic children. This may result from pre-natal developmental effects or post-natal irritant effects on the developing airway, but is unlikely to be mediated through increased hygiene in the home.

Pedicled genial osteotomy modification of the mandibular release access operation for access to the back of the tongue.

We report a modification of the operation of mandibular release or 'visor drop down'. It allows more accurate repositioning and more permanent fixation of the genioglossus, geniohyoid, and digastric muscles using a small anterior osteotomy. We hope that this more accurate and reliable repositioning will give improved outcomes in terms of speech, chewing, and swallowing.

Frequent use of chemical household products is associated with persistent wheezing in pre-school age children.

BACKGROUND: In the UK and other developed countries the prevalence of asthma symptoms has increased in recent years. This is likely to be the result of increased exposure to environmental factors. A study was undertaken to investigate the association between maternal use of chemical based products in the prenatal period and patterns of wheeze in early childhood. METHODS: In the population based Avon Longitudinal Study of Parents and Children (ALSPAC), the frequency of use of 11 chemical based domestic products was determined from questionnaires completed by women during pregnancy and a total chemical burden (TCB) score was derived. Four mutually exclusive wheezing patterns were defined for the period from birth to 42 months based on parental questionnaire responses (never wheezed, transient early wheeze, persistent wheeze, and late onset wheeze). Multinomial logistic regression models were used to assess the relationship between these wheezing outcomes and TCB exposure while accounting for numerous potential confounding variables. Complete data for analysis was available for 7019 of 13, 971 (50%) children. RESULTS: The mean (SD) TCB score was 9.4 (4.1), range 0-30. Increased use of domestic chemical based products was associated with persistent wheezing during early childhood (adjusted odds ratio (OR) per unit increase of TCB 1.06 (95% confidence interval (CI) 1.03 to 1.09)) but not with transient early wheeze or late onset wheeze. Children whose mothers had high TCB scores (>90th centile) were more than twice as likely to wheeze persistently throughout early childhood than children whose mothers had a low TCB score (<10th centile) (adjusted OR 2.3 (95% CI 1.2 to 4.4)). CONCLUSION: These findings suggest that frequent use of chemical based products in the prenatal period is associated with persistent wheezing in young children. Follow up of this cohort is underway to determine whether TCB is associated with wheezing, asthma, and atopy at later stages in childhood.

Clinical investigation of a true color scanning laser ophthalmoscope.

OBJECTIVE: To show true color scanning laser ophthalmoscope (SLO) images produced by simultaneously imaging the retina with red, green, and blue lasers. METHODS: Low-power red, green, and blue lasers were combined using fiber optics. By rapidly pulsing the lasers, each point on the fundus is illuminated by the 3 colors in quick succession, with the total power level being similar to that from a single laser. The reflected light is then decoded to extract the red, green, and blue color information and the true color fundus image is displayed live on a computer monitor. RESULTS: Comparison was made between the color SLO images from 5 patients and their digitized fundus photographs. The background fundus and retinal vasculature showed a similar appearance. The SLO gave better quality information in patients with ocular histoplasmosis, macular dystrophy, and optic disc drusen. By operating the color SLO in the indirect mode, macular edema could be clearly seen as lines and ridges surrounding the fovea. CONCLUSION: The color SLO offers all the advantages of the present commercially available monochromatic device, with the added advantage of true color representation of the fundus without increasing either imaging time or the level of exposure.

Delayed conception and active and passive smoking. The Avon Longitudinal Study of Pregnancy and Childhood Study Team.

OBJECTIVE: To determine whether passive as well as active smoking by women or smoking by men is associated with delayed conception, after adjustment for confounding factors. DESIGN: Population study of couples expecting a baby. Logistic regression was performed to identify factors associated with delayed conception. SETTING: The Avon Health Authority area, United Kingdom. PATIENT(S): All couples expected to deliver between April 1991 and December 1992. INTERVENTION(S): Questionnaires administered early in pregnancy. MAIN OUTCOME MEASURE(S): Time taken to conceive, categorized as <6 months, 6-11 months, 1-3 years, and >3 years. RESULT(S): After correction for confounding factors, delayed conception was statistically significantly associated with both active smoking by the woman (odds ratio [OR] 1.23 [95% CI 0.98-1.49] for > 6 months and 1.54 [95% CI 1.19-2.01] for >12 months) and her exposure to passive smoking (OR 1.17 [95% CI 1.02-1.37] and 1.14 [95% CI 0.92-1.42]) compared with women with no exposure to tobacco smoke (referent). Heavy smoking by men was independently associated with delayed conception. In active smokers, the effect increased with the number of cigarettes. CONCLUSION(S): Smoking by men and passive and active smoking by women are associated with delayed conception.

Increasing paternal age is associated with delayed conception in a large population of fertile couples: evidence for declining fecundity in older men. The ALSPAC Study Team (Avon Longitudinal Study of Pregnancy and Childhood).

The impact of male age on fecundity remains controversial. Here, a large population study was used to investigate the effect of paternal age on time to conception. All couples in the Avon Health district expecting a baby between 1 April 1991 and 31 December 1992 were eligible. Questionnaires completed by both the man and the woman at 18 weeks gestation covered specific fertility factors, e.g. parity, paternity, cohabitation and oral contraception; and non-specific factors, e.g. educational achievement, housing, cigarette smoking, alcohol consumption, obesity. Logistic regression was used to identify factors independently related to conception in < or =6 or < or =12 months. Of 8515 planned pregnancies, 74% were conceived in < or =6 months, 14% in the second 6 months and 12% after more than a year. Nine variables, including the age of the woman, were independently related to time to conception. After adjustment for these, the likelihood of conception within 6 or 12 months was lower in older men. Compared to men <25 years old, the adjusted odds ratios (95% confidence interval) for conception in < or =12 months were 0.62 (0.40, 0.98), 0.50 (0.31, 0.81) and 0.51 (0.31, 0.86) in men aged 30-34, 35-39 and > or =40 years respectively.

Chronic caloric restriction alters muscle membrane fatty acid content.

Chronic caloric restriction (CR) has been demonstrated to increase longevity in lower species and studies are ongoing to evaluate its effect in higher species. A consistent metabolic feature of CR is improved insulin sensitivity and lowered lifetime glycemia, yet the mechanism responsible is currently unknown. However, the membrane's physiochemical properties, as determined by phospholipid composition, have been related to insulin action in animal and human studies and CR has been reported to alter membrane lipid content. We evaluated muscle membrane fatty acid content in rodents randomized to CR versus control diets for up to 29 months. CR was observed to increase the membrane content of C22:6 (docosahexaenoate) and to decrease C18:2 content. The membrane lipid content was related to insulin levels but not to parameters assessing glycemic control. This study suggests that membrane lipids, in particular 22:6, may contribute to the variation in insulin sensitivity seen with age.

Diarrhoea and nitrogen oxides.

It is hypothesized that higher indoor nitrogen dioxide levels cause diarrhoea in infants and that this is the result of a direct action of oxides of nitrogen on the gut. This hypothesis is tested by reviewing the reported association between methaemoglobin and diarrhoea in children and two recent reports on indoor air and diarrhoea in infants. The collection of further empirical data is now needed. Studies which measure indoor levels of nitrogen dioxide could usefully collect data on infants symptoms that are not exclusively respiratory. Similarly, studies which are collecting diary information on children's health symptoms should consider collecting data on indoor air quality with respect to the oxides of nitrogen.

Increased nonenzymatically glycosylated proteins in the vitreous humor of diabetic animals.

One of the earliest pathologic changes of diabetes mellitus is increased nonenzymatic glycosylation (i.e., glycation) of proteins, which results in abnormal aggregation of collagen fibrils and production of superoxide radicals. These abnormalities may be responsible for the precocious senescence of connective tissue associated with the disease. We sought to determine whether glycation is increased in the vitreous humor of short-term diabetic cats (6 months' duration) and rabbits (2 months' duration), using a nitroblue tetrazolium colorimetric assay for fructosamine. Vitreous protein fructosamine concentration was significantly higher in diabetic cats and rabbits, compared with that in control (nondiabetic) animals. These results indicate that glycation is increased in the vitreous humor of short-term diabetic animals, and therefore may be one of the initial triggers for clinically apparent diabetic retinopathy.

Clinical validity of a self-test fructosamine in outpatient diabetic management.

BACKGROUND: Measurement of glycated hemoglobin and hemoglobin A1c (HbA1c) is now well established as the best means of measuring overall glucose control in managing diabetes. Other glycated serum protein assays reflecting recent glycemic control, e.g., glycated albumin and glycated protein (fructosamine), have also been validated in clinical studies. Regardless of the method, the expense and inconvenience of laboratory testing of blood samples may contribute to the well-documented underutilization of clinical glycated protein assessment. Accordingly, a rapid, inexpensive fingerstick test of fructosamine has been developed. This study cross-sectionally and prospectively assesses the clinical validity of fingerstick fructosamine versus laboratory determination. METHODS: Fifty-one subjects (18 control, 33 with diabetes) participated in a cross-sectional study and 20 subjects with type 2 diabetes participated in a prospective, 6-week study with clinical intervention consisting of glipizide gits or metformin in mono- and combination therapy. Subjects had weekly laboratory determination of serum fructosamine, glycated hemoglobin, and fasting glucose; fingerstick fructosamine was obtained at each clinic visit. RESULTS: Fingerstick fructosamine was shown to correlate highly to laboratory fructosamine (r = 0.80, p < 0.001) and glycated hemoglobin (r = 0.81, p < 0.001). In the clinical intervention study subjects, significant decreases in fasting glucose (p < 0.001), laboratory fructosamine (p < 0.001), and fingerstick fructosamine (p < 0.001) were noted compared to baseline. The subject's self-test fingerstick fructosamine mirrored laboratory testing of fructosamine in detection of changes in clinical glucose control. CONCLUSIONS: This study demonstrates that fingerstick fructosamine correlates well to laboratory assessment of fructosamine and glycated hemoglobin. The patient self-test fructosamine provides the same clinical information as laboratory assessment.

Influence of caloric restriction on the development of atherosclerosis in nonhuman primates: progress to date.

Caloric restriction (CR) has been observed to retard aging processes and extend the maximum life span in rodents. In an effort to evaluate the effect of this nutritional intervention on physiologic variables in higher species, several nonhuman primate trials are ongoing. In particular, a study evaluating the independent effect of CR on the extent of atherosclerosis was initiated in 1993 in 32 adult cynomolgus monkeys. Therefore, the trial was designed to achieve identical cholesterol intake after animals were randomized to a control group or a calorie-restricted group (30% reduction from baseline caloric intake). The animals were routinely evaluated for glycated proteins, plasma insulin and glucose levels, insulin sensitivity, and specific measures for abdominal fat distribution by CT scans over a 4-year interval. The results from 4 years of intervention demonstrate that CR improves cardiovascular risk factors (such as visceral fat accumulation) and improves insulin sensitivity. In contrast to other primate studies with normolipidemic animals, CR had no independent effects on plasma lipid levels and composition in the presence of equivalent amounts of dietary cholesterol intake. Preliminary analysis of atherosclerotic lesion extent in the abdominal aorta has failed to demonstrate differences between control animals and CR animals. Follow-up studies are being conducted to determine the effect of CR on atherosclerosis extent in coronary and carotid arteries.

Insulin resistance and fat patterning with aging: relationship to metabolic risk factors for cardiovascular disease.

Both insulin resistance and abdominal fat patterning are related to aging, and have been related to cardiovascular disease (CVD) risk factors such as dyslipidemia and hypertension. However, previous studies have not used direct methods to quantify the independent strength of the association of each of these two putative primary factors with metabolic outcomes. We quantified overall obesity by the body mass index (BMI) and used a previously validated magnetic resonance imaging (MRI) method to quantify abdominal fat in 63 healthy nondiabetic individuals aged 22 to 83 years. We also measured the glucose and insulin response to an oral glucose tolerance test and the insulin sensitivity ([SI] by modified minimal model analysis). Body fat patterning was evaluated by the waist to hip ratio (WHR) and by MRI, which allowed direct measurement of subcutaneous (SCF) and intraabdominal (IAF) fat depots at the umbilicus in these subjects. These independent parameters were related to risk factors for CVD (blood pressure, lipids, and lipoproteins) and to plasma concentrations of free fatty acids (FFAs). Measures of overall obesity (BMI), total fat [TF], and/or SCF measured at the abdomen by MRI), glucose/insulin metabolism and SI, and central fat patterning (WHR or IAF measured by MRI) were correlated with mean arterial pressure (MAP), triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C) levels in univariate analysis and after controlling for age and gender. An index of central fat patterning (WHR) added to the informativeness of the insulin area under the curve (IAUC) in explaining 24% of the variability in plasma TG concentration, but measures of overall obesity were not independently related. Both the BMI and TF contributed to the IAUC in explaining 32% to 34% of the variability in MAP, but central fat patterning was not independently related. No index of overall obesity, fat patterning, glucose/insulin metabolism, and/or SI, was independently related to the plasma concentration of HDL-C after controlling for any one of the other two. Direct measurement of glucose/insulin metabolism and SI, as well as fat patterning, provides information on their relative associations with CVD risk factors. The measures of glucose/insulin metabolism and SI were more consistently related to dyslipidemia and hypertension than were the overall obesity and fat patterning in this healthy population.

Birthweight of term infants and maternal occupation in a prospective cohort of pregnant women. The ALSPAC Study Team.

OBJECTIVE: To study the relation between birthweight of term infants and maternal occupation. METHODS: Information on job titles since the age of 16, and sociodemographic and other lifestyle factors were obtained by means of questionnaires as part of the Avon longitudinal study of pregnancy and childhood (ALSPAC), from a cohort of 14,000 pregnant women. The British 1990 standard occupational classification was used to code jobs within nine major job groups. RESULTS: For 9282 women who delivered term infants and reported a job for the relevant period, there was a significant difference in mean birthweight among the nine major job groups. A 148 g difference was found between the mean birthweight of infants born to women with professional occupations and those with plant and machine operative jobs. Multiple regression analysis adjusted for sex of infant, parity, maternal height, smoking, caffeine consumption, and race. After adjustment the maternal job was no longer significantly associated with birthweight. CONCLUSION: Despite the absence of a significant association between birthweight and job after adjustment, there were several findings which agreed with publications on maternal occupation and pregnancy outcome. The major job groups with the lowest birthweights included the following jobs; metal forming or welding, electric or electronic work, jobs in the textile trade, and assembling and working with equipment (mobile and stationary). The lack of an association may indicate that the study was of insufficient power to detect a small difference; it may indicate the presence of confounding variables that were not adjusted for or it may indicate that no association exists.

Elevation of homocysteine and excitatory amino acid neurotransmitters in the CSF of children who receive methotrexate for the treatment of cancer.

PURPOSE: Folate deficiency, either by diet or drug, increases plasma homocysteine (Hcy). Hcy damages cerebrovascular endothelium, and hyperhomocysteinemia is a risk factor for stroke. Hcy is metabolized to excitatory amino acid (EAA) neurotransmitters, such as homocysteic acid (HCA) and cysteine sulfinic acid (CSA), which may cause seizures and excitotoxic neuronal death. We postulated that excess Hcy and EAA neurotransmitters may partly mediate methotrexate (MTX)-associated neurotoxicity. PATIENTS AND METHODS: In this retrospective analysis, we used high-performance liquid chromatography (HPLC) to measure Hcy, HCA, and CSA in CSF from two groups of children: (1) a control group of patients with no MTX exposure, and (2) a treatment group of patients who had received MTX no more than 7 days before a scheduled lumbar puncture. RESULTS: The treatment group had a significantly (P = .0255) greater concentration of Hcy in CSF (0.814 micromol/L +/- 0.215 [mean +/- SEM], n = 23) than the control group (0.210 micromol/L +/- 0.028, n = 34). HCA and CSA were not detected in CSF from control patients (n = 29); however, MTX caused marked accumulation of CSF HCA (119.1 micromol/L +/- 32.0, n = 16) and CSA (28.4 micromol/L +/- 7.7, n = 16) in the treatment group. Patients with neurologic toxicity at the time of lumbar puncture had many of the highest concentrations of Hcy, HCA, and CSA. CONCLUSION: These data support our hypothesis that MTX-associated neurotoxicity may be mediated by Hcy and excitotoxic neurotransmitters.

An investigation of the effect of paternal occupation group at conception on birth weight and gestational age. ALSPAC Study Team of Pregnancy and Childhood.

The occupational histories of fathers were collected prospectively as part of the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC), and were used to investigate the association of paternal job title with a baby's birth weight and gestational age. The analysis cohort consisted of 4,795 singleton live-born babies whose fathers responded fully to questionnaire items regarding occupational history. Jobs were coded using the British Standard Occupational Codes and classified into nine major occupational groups. A 73-gram difference (95% CI: 0.16, 145.17) was found between the mean birth weight of full-term babies born of professional fathers (3,543 gm) and of fathers working in craft and related occupations (3,470 gm). This difference decreased and lost significance after controlling for sociodemographic variables. No difference was found in the mean birth weight of preterm babies, or in the rate of preterm delivery, when analyzed by paternal occupation at conception. Our results suggest that when important sociodemographic variables are known, the father's job title alone may not be a useful predictor of birth weight or preterm delivery.