Clinical utility of smartphone applications for sleep physicians.

PURPOSE: To review various smartphone applications (apps) for sleep architecture and screening of obstructive sleep apnea (OSA) and to outline their utility for sleep physicians. METHODS: Mobile application stores (Google Play and Apple iOS App Store) were searched for sleep analysis applications (apps) that are targeted for consumer use. Apps were identified by two independent investigators for apps published through July 2022. App information including parameters obtained for sleep analysis were extracted from each app. RESULTS: The search identified 50 apps that reported sufficient outcome measures to be considered for assessment. Half of the apps tracked sleep with phone-only technology, while 19 utilized sleep and fitness trackers, three utilized sleep-only wearable devices, and three utilized nearable devices. Seven apps provided data useful for tracking users for signs and symptoms of obstructive sleep apnea. CONCLUSION: There are a variety of sleep analysis apps available on the market to consumers currently. Though the sleep analysis of these apps may not be validated, sleep physicians should be aware of these apps to improve understanding and education of their patients.

Hyperbaric oxygen therapy in malignant otitis externa: A systematic review of the literature.

OBJECTIVE: To review the role of adjuvant hyperbaric oxygen therapy (HBOT) in the treatment of malignant otitis externa (MOE). DATA SOURCES: PubMed, Scopus, Web of Science, Science Direct, and Cochrane Library were searched for the following concepts: "hyperbaric oxygen" and "malignant or necrotizing otitis externa." METHODS: Studies were included if they contained (1) patients with reported evidence of MOE, (2) employment of adjuvant HBOT, (3) details on patients' medical condition, and (4) documented survival outcomes. Extracted information included patient demographics, underlying medical conditions, infectious etiology, signs and symptoms, medical and surgical treatments, duration of medical treatment, mean follow up time, HBOT setting, number of HBOT sessions, complications, survival rate, and all-cause mortality. RESULTS: A total of 16 studies comprising 58 patients (mean age 68.0 years) were included. Diabetes was present in 94.7% of cases and Pseudomonas spp (64.3%) was the most common infectious agent. Cranial nerve VII was involved in 55.2% of cases. Overall, the disease cure rate with adjuvant HBOT was 91.4% and all-cause mortality was 8.6%. Among those who had cranial nerve VII involvement, 72.0% had return of function and 93.8% of them survived. CONCLUSION: HBOT may be an effective treatment option for refractory or advanced MOE but its efficacy remains unproven due to lack of strong scientific evidence. However, its therapeutic value should not be underestimated given good results and few adverse events reported in this study.

Treatment of Vestibular Migraine: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the efficacy of the various therapies used for the prevention of vestibular migraine (VM). METHODS: Primary studies were identified though PubMed, Scopus, PsycINFO, and Cochrane Library by two independent investigators for articles published through April 2019. The search identified randomized comparison or observational studies pertaining to vestibular migraine treatment. Meta-analysis was performed on pre- and posttreatment Dizziness Handicap Inventory, vertigo frequency, and percentage of perceived improvement. RESULTS: Literature search identified 13 studies that reported sufficient outcome measures to be included in the analysis. Patients with VM had a mean age of 43.3 years with female-to-male gender ratio of 2.1:1. Classes of therapeutic agents included antiepileptic drugs, calcium channel blockers, tricyclic antidepressants, ß-blockers, serotonin and norepinephrine reuptake inhibitors, and vestibular rehabilitation. All treatment options that were analyzed demonstrated improvement in all of the outcome parameters, but due to significant heterogeneity and lack of standardized reporting on outcomes, establishment of preferred treatment modality could not be determined. CONCLUSIONS: Various treatment modalities have been evaluated for preventative treatment of VM. Physician familiarity, patient comorbidities, and the side-effect profiles of various interventions likely influence the selection of intervention. Future randomized controlled trials with restrictive inclusion criteria and generalizable standardized outcome measures will allow for more robust meta-analyses and for more evidence-based treatment of vestibular migraines. Laryngoscope, 131:186-194, 2021.

The Prevalence of Olfactory Dysfunction in the General Population: A Systematic Review and Meta-analysis.

BACKGROUND: Olfactory dysfunction (OD) is common and has been reported as an early indicator of COVID-19. However, the reported prevalence of OD in the general population varies widely depending upon the metric used to assess olfaction.Methodology/Principal: To perform a systematic review and meta-analysis of the prevalence of OD in the healthy general population, review the various assessment metrics used, and compare pooled OD prevalence rates. RESULTS: A total of 175,073 subjects were identified (mean age 63.5 years, range 18 to 101) with an overall OD prevalence of 22.2% (95% CI 14.8-30.6). OD prevalence was significantly greater using objective olfactory assessments, compared to subjective measures (28.8%, CI 20.3-38.2 versus 9.5%, CI 6.1-13.5, p < 0.001). The prevalence of OD was greater using expanded identification tests (>8 items) compared to brief test with ≤8 items (30.3%, CI 16.2-46.5 versus 21.2%, CI 12.3-31.8). Prevalence was higher in studies with a mean age greater than 55 years compared to those with a mean age of 55 years or less (34.5%, CI 23.4-46.5 versus 7.5%, CI 2.6-14.5, p < 0.001). CONCLUSIONS: The reported prevalence of OD in the general population depends on the testing method and population age. OD prevalence was greater in studies using objective tests, expanded identification tests, and in those with older subjects.

Sebaceous Carcinoma of the Eyelid: A Systematic Review and Meta-Analysis.

BACKGROUND: Sebaceous carcinoma (SC) of the eyelid is a rare, aggressive malignancy associated with high rates of recurrence, metastasis, and tumor-related mortality. OBJECTIVE: Provide a collective analysis of clinical presentations, management techniques, and outcomes, and compare outcomes of common treatment methods. METHODS AND MATERIALS: Observational studies reporting management and outcomes of SC of the eyelid were included. Patient and clinical data were extracted, and meta-analysis of proportions was performed. RESULTS: One thousand three hundred thirty-three subjects were included with a mean age of 65.2 years and 803 (60.2%) women. Of 647 initial diagnoses reported, 277 (42.8%) were correct, and the mean diagnostic delay was 14.7 months (range 8.5-34.8). The tumor location was reported in 1,246 subjects and involved the upper eyelid in 780 (62.6%), lower eyelid in 409 (32.8%), and 57 (4.8%) involved both. Overall rates of recurrence, metastasis, and tumor-related mortality were 15.9%, 12.1%, and 6.2%, respectively. There were no statistically significant differences in wide local excision (WLE) versus Mohs micrographic surgery (MMS) outcomes. CONCLUSION: Sebaceous carcinoma of the eyelid is more common in women, on the upper eyelid, and is frequently misdiagnosed initially. Rate of recurrence, metastasis, and tumor-related mortality were similar in subjects managed with WLE versus MMS.

Presentation and management of type 1 laryngeal clefts: A systematic review and meta-analysis.

OBJECTIVE: To evaluate outcomes of injection laryngoplasty (IL) and endoscopic surgical repair for the treatment of type 1 laryngeal clefts (LC1) and to determine the most common presentations of LC1. METHODS: Primary studies were searched for in PubMed, Scopus, OVID, and Cochrane Library using search terms laryngeal cleft and laryngotracheoesophageal cleft for articles published from database inception through August 2019. The search identified all articles pertaining to the symptomatology and management of LC1. Meta-analysis was performed on presenting symptoms and improvement of clinical symptoms and swallow function. RESULTS: Twenty-four studies, comprising 713 patients with a mean age of 33.7 months (range 0-168 months), were included. The most common presenting symptoms were aspiration (80%, CI [55%-96%]), dysphagia (61%, CI [47%-74%]), and choking (57%, CI [37%-76%]). Gastroesophageal reflux disease (GERD) was the most common comorbidity (68%, CI [51%-83%]) and premature birth comprised 27% [21%-32%] of the patients. Overall, 38% of patients received IL as a primary therapy. Prior to injection, 91% [87%-94%] of patients aspirated on swallow evaluations, and 62% [55%-68%] aspirated post-injection. At an average follow-up time of 6.8 months, 90% [70%-100%] of parents reported symptom improvement. An additional 54% of patients underwent endoscopic surgical repair as primary treatment. The rate of aspiration decreased from 73% [43%-94%] to 28% [13%-46%] after repair. At a mean follow-up of 14.2 months, 80% [67%-91%] reported symptom improvement. CONCLUSION: A high level of clinical suspicion is necessary to detect LC1 since its most common presenting symptoms overlap with other diseases commonly found in this patient population. Both IL and formal surgical repair were effective in managing LC1.

Necrotizing Otitis Externa: A Systematic Review and Analysis of Changing Trends.

OBJECTIVE: To assess for changes in trends of the disease process, management, and outcomes of necrotizing otitis externa (NOE) over the last decade. DATA SOURCES: Articles in English, published between January 2011 and June 2019, were searched in PubMed, Scopus, Web of Science, ScienceDirect, and the Cochrane Database. STUDY SELECTION: Inclusion criteria: 1) reported evidence of NOE, 2) details on patient demographic and underlying medical disorder, 3) details on treatments, 4) documented outcomes, and 5) greater than 10 cases. DATA EXTRACTION: Study demographics, underlying conditions, infectious etiology, treatments, signs and symptoms, and outcomes. DATA SYNTHESIS: Ten studies, totalling 284 patients with a mean age of 67.8 years, were included. The time period of collected patient data ranged from 2000 to 2018. Temporal subgroup analysis was conducted before and after 2009. Cure rate was lower in the post-2009 group (76.0 versus 94.1%, p < 0.01) while disease-specific mortality remained stable. Increases in proportions of diabetes and culture negative results (p < 0.01) were also observed in this latter group. Rate of extensive surgery and the use of ciprofloxacin decreased (p < 0.01), while the use of ceftazidime increased in the post-2009 group (p < 0.01). CONCLUSION: A decrease in cure rate of NOE patients was observed in the setting of an increase in prevalence of diabetes. Various antipseudomonal agents are being used and an increase in culture negative results is seen.

Transcutaneous Electrical Nerve Stimulation for Treatment of Tinnitus: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with tinnitus. DATA SOURCES: PubMed, Scopus, Web of Science, and Cochrane Library were searched for the following concepts: "Transcutaneous Electric Nerve Stimulation" and "Tinnitus." STUDY SELECTION: Inclusion: 1) double- or single-blinded randomized controlled trials; 2) double- or single-blinded randomized comparison trials; 3) prospective or retrospective observational studies; and 4) case series. Exclusion: Non-English studies, nonhuman studies, case reports (n ≤ 5), and review articles. DATA EXTRACTION: Tinnitus Handicap Inventory (THI), the Visual Analog Scale (VAS), and perceived tinnitus suppression after treatment. Additional data collected included tinnitus laterality, duration of symptoms, location of electrode placement, time to follow-up, etiology of tinnitus, and treatment side effects. DATA SYNTHESIS: The literature search yielded 2941 unique articles. After reviewing 118 full-text articles, 17 studies reporting on 1,215 patients were included for final analysis. Four studies provided data available for meta-analysis of pre- and posttreatment THI and VAS (Cochrane Review Manager). TENS showed significant overall reduction on THI (-7.55 [-10.93 to -4.18], p < 0.0001) and VAS (-0.65 [-0.99 to -0.30], p < 0.0002). Subjective improvement of tinnitus was pooled across 13 studies using meta-analysis of proportions (MedCalc). Tinnitus suppression occurred in 40.0% [28.9-51.7%] patients. Among those who responded, 22.2% [12.2-29.7%] experienced complete suppression and 10.2% [0.2-31.9%] experienced persistent improvement at 3 months. CONCLUSIONS: TENS represents a safe and feasible treatment option for tinnitus and might be a worthy consideration among the spectrum of interventions developed for tinnitus.

Transcutaneous Electrical Stimulation Therapy in Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the treatment efficacy of transcutaneous electrical nerve stimulation (TENS) in patients with obstructive sleep apnea (OSA). DATA SOURCES: Primary studies were identified though PubMed, Scopus, OVID, and Cochrane Library. REVIEW METHODS: Systematic review was conducted by querying databases for articles published through July 2019. The search identified randomized controlled trial, randomized comparison, or observational studies pertaining to TENS treatment for OSA. Meta-analysis was performed on pre- and posttreatment apnea-hypopnea index (AHI), mean oxygen saturation (SaO2), lowest oxygen saturation (LSAT), and arousal index (AI). RESULTS: Literature search identified 10 studies that reported sufficient outcome measures to be considered for analysis. A total of 198 patients were identified with a mean age of 50.9 years with a male to female ratio of 1.6:1. Average body mass index (BMI) of the cohort was 29.8 kg/m2. Treatment with TENS demonstrated reduction in AHI by 12.9 points (95% confidence interval, -22.3 to -3.43; P = .008). The mean differences in SaO2, LSAT, and AI did not reach statistical significance. CONCLUSION: The TENS treatment of upper airway dilator muscles resulted in reduction of AHI in patients with OSA. However, its effects on SaO2, LSAT, and AI were equivocal. Its impact on patients' quality of life could not be assessed due to heterogeneity in outcome measures. Future randomized controlled trials with generalizable standardized outcome measures are needed to assess the efficacy and compliance of TENS.

Transoral Robotic Surgery versus Plasma Ablation for Tongue Base Reduction in Obstructive Sleep Apnea: Meta-analysis.

OBJECTIVES: To compare the effectiveness of transoral robotic surgery (TORS) versus plasma ablation (PA) in tongue base reduction surgery for obstructive sleep apnea (OSA). DATA SOURCES: PubMed, Scopus, Cochrane Library, OVID. REVIEW METHODS: Keywords searched included OSA, tongue base surgery, TORS, and coblation. Outcomes included pre- to postoperative apnea-hypopnea index, Epworth Sleepiness Scale (ESS), and lowest oxygen saturation. Additional outcomes included surgical success rate, postoperative bleeding, operative time, and length of stay. RESULTS: A total of 690 unique articles were identified, of which 60 underwent full-text review. Twenty-six articles were included in final analysis, comprising 18 studies on TORS (834 patients) and 11 studies on PA (294 patients). Mean differences of apnea-hypopnea index, ESS, and lowest oxygen saturation for TORS were -23.92, -7.6, and 5.83% (all P < .01). Corresponding values for PA were -22.07, -4.14, and 5.48% (all P < .00001). TORS had greater ESS reduction than PA (P = .02). Follow-up duration was shorter in TORS than PA (mean ± SD: 4.2 ± 2.6 vs 4.6 ± 1.4 months, P = .0482). Surgical success rates in TORS and PA were similar (57.6% vs 60.3%, P = .4474). Postoperative bleeding occurred less frequently in TORS versus PA (3.3% vs 7.5%, P = .0103). Operative time was longer for TORS than PA (77.9 ± 16.4 minutes vs 44.0 ± 12.9 minutes, P < .0001). Length of stay was similar between TORS and PA (3.9 ± 1.6 days vs 3.9 ± 2.5 days, P = .9047). CONCLUSION: Tongue base reduction with TORS or PA each effectively treats OSA and provides comparable results. The choice between techniques might depend on patient factors, availability of technology, and associated costs.

Continuous infusion versus intermittent bolus injection of propofol during endoscopic retrograde cholangiopancreatography.

BACKGROUND/AIMS: It is unclear whether continuous infusion or intermittent bolus injection of propofol is better for achieving adequate sedation in endoscopic retrograde cholangiopancreatography (ERCP). We aimed to compare the efficacy and safety of continuous infusion and intermittent bolus injection of propofol during therapeutic ERCP. METHODS: In this prospective study, we randomly assigned 232 patients undergoing therapeutic ERCP to either continuous infusion (CI group, n = 113) or intermittent bolus injection (BI group, n = 119) of propofol. The primary outcome was the quality of sedation as assessed by the endoscopist. Other sedation-related parameters included sedation induction time, total dose of propofol, recovery time, involuntary patient movement, and adverse events. RESULTS: Overall satisfaction with sedation by the endoscopist and monitoring nurse were significantly higher in the CI group than the BI group (mean satisfaction score, 9.66 vs. 8.0 and 9.47 vs. 7.96, respectively, p < 0.01 for both). However, patients in the CI group had a significantly longer sedation induction time (5.28 minutes vs. 4.34 minutes, p < 0.01) and received a higher dose of propofol than patients in the BI group (4.22 mg/kg vs. 2.08 mg/kg, p < 0.01). There was no significant difference in adverse events between the two groups. CONCLUSION: Continuous infusion of propofol during therapeutic ERCP had the advantage over intermittent bolus injection of maintaining a constant level of sedation without increasing adverse events. However, it was associated with an increased total dose of propofol and prolonged sedation induction time.

Endonasal endoscopic surgery for pediatric anterior cranial fossa encephaloceles: A systematic review.

BACKGROUND: Endoscopic endonasal skull base surgery (ESBS) is a well-established management strategy for anterior cranial fossa (ACF) encephaloceles in adults. However, its application to the pediatric population has not been evaluated in large-scale studies. This study systematically reviews the safety of ESBS for pediatric ACF encephaloceles. METHODS: Articles reporting on pediatric patients undergoing purely ESBS for encephaloceles were reviewed from three databases (PubMed, Scopus, and Cochrane Library). Main outcomes were post-operative cerebrospinal fluid (CSF) leak and other surgical complications. RESULTS: Twenty-three articles provided data on 110 eligible patients with a mean age of 4.3 years (range birth - 18 years). Intraoperative CSF leaks occurred in 18.5% of children while post-operative CSF leaks developed in 6.0% of cases. Rates of meningitis and hydrocephalus were each 3.7%. Other complications included alar collapse, nasal stenosis, transient diabetes insipidus, pneumonia, and neurologic injury, collectively occurring in 7.0% of cases. The rate of death was 4.8%. The average duration of follow-up was 25.3 months. Encephaloceles recurred in 5.2% of patients. CONCLUSIONS: ESBS for pediatric ACF encephaloceles provides a relatively favorable risk-benefit profile, with a low rate of post-operative CSF leak, other surgical complications, and disease recurrence.

Risk of Clostridium difficile Infection with the Use of a Proton Pump Inhibitor for Stress Ulcer Prophylaxis in Critically Ill Patients.

BACKGROUND/AIMS: Proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) are commonly prescribed for stress ulcer prophylaxis (SUP) in critically ill patients. Several studies have suggested that the use of PPIs is a potential risk factor for Clostridium difficile infection (CDI). We compared the incidences of CDI in the PPI group and H2RA group for SUP in critically ill patients. METHODS: From August 2005 to July 2012, the incidences of CDI were retrospectively analyzed in patients who were admitted directly to intensive care units and stayed for more than 3 days. SUP-related CDI was defined as a CDI diagnosed during the SUP period. Patient clinical data were analyzed to identify potential risk factors for SUP-related CDI. RESULTS: Of the 1,005 patients enrolled (444 patients received PPI and 561 received H2RA), 38 (3.8%) were diagnosed with SUP-related CDI. The incidence of SUP-related CDI was considerably higher in patients who received PPI than in those who received H2RA (6.7% vs 1.8%). PPI use for SUP (odds ratio [OR], 3.3; confidence interval [CI], 1.5 to 7.1; p=0.003) and diabetes mellitus (OR, 2.3; CI, 1.2 to 4.7; p=0.019) were independent risk factors for SUP-related CDI. CONCLUSIONS: PPI therapy is associated with a higher risk of SUP-related CDI than H2RA therapy in critically ill patients.

A case of chronic myeloid leukemia with features of essential thrombocythemia in peripheral blood and bone marrow.

Chronic myeloid leukemia (CML) is a myeloproliferative neoplasm characterized by overproduction of myeloid white blood cells. Philadelphia chromosome is an essential finding for CML diagnosis. Generally, a clinical diagnosis of essential thrombocythemia (ET) can be established from isolated marked thrombocytosis in peripheral blood. However, Philadelphia chromosome-positivity or bcr/abl rearrangement with isolated thrombocytosis should be diagnosed as CML, not ET, according to World Health Organization diagnostic criteria. Therefore, CML should not be excluded before confirming the presence of the Philadelphia chromosome or bcr/abl rearrangement in cases of isolated thrombocytosis in peripheral blood. We report a case of CML with clinical features of ET in a patient successfully treated with imatinib.