A cluster-randomized trial of client and provider directed financial interventions to align incentives with appropriate case management in private medicine retailers: results of the TESTsmART Trial in Lagos, Nigeria.

Malaria remains a major health priority in Nigeria. Among children with fever who seek care, less than a quarter gets tested for malaria, leading to inappropriate use of the recommended treatment for malaria; Artemether Combination Therapies (ACT). Here we test an innovative strategy to target ACT subsidies to clients seeking care in Nigeria's private retail health sector who have a confirmed malaria diagnosis. We supported point-of-care malaria testing (mRDTs) in 48 Private Medicine Retailers (PMRs) in the city of Lagos, Nigeria and randomized them to two study arms; a control arm offering subsidized mRDT testing for USD $0.66, and an intervention arm where, in addition to access to subsidized testing as in the control arm, clients who received a positive mRDT at the PMR were eligible for a free (fully subsidized) first-line ACT and PMRs received USD $0.2 for every mRDT performed. Our primary outcome was the proportion of ACTs dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients who were tested at the PMR and adherence to diagnostic test results. Overall, 23% of clients chose to test at the PMR. Test results seemed to inform treatment decisions and resulted in enhanced targeting of ACTs to confirmed malaria cases with only 26% of test-negative clients purchasing an ACT compared to 58% of untested clients. However, the intervention did not offer further improvements, compared to the control arm, in testing rates or dispensing of ACTs to test-positive clients. We found that ACT subsidies were not passed on to clients testing positive in the intervention arm. We conclude that RDTs could reduce ACT overconsumption in Nigeria's private retail health sector, but PMR-oriented incentive structures are difficult to implement and may need to be complemented with interventions targeting clients of PMRs to increase test uptake and adherence. Clinical Trials Registration Number: NCT04428307.

Diagnostic role of video-assisted thoracoscopy in the management of indeterminate pleural effusion.

Background: The management of pleural effusion usually involves the drainage of the effusion, identification, and treatment of the underlying cause (s). Studies have shown that the initial diagnostic techniques do not give conclusive diagnosis in some cases of pleural effusion. This group of patients described as patients with indeterminate or undiagnosed pleural effusion constitutes a significant proportion of patients with pleural effusion in clinical practice. In this study, we examined the role of video-assisted thoracoscopy (VAT) in the diagnostic work-up of these patients. Aim: To determine the diagnostic outcome of VAT in the management of indeterminate pleural effusion in our center. Patients and Methods: Consecutive patients who presented with pleural effusions and who met the inclusion criteria had video-assisted thoracoscopy for diagnostic purposes. Outcome measures including the diagnostic yield, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAT in patients with indeterminate pleural effusion, duration of the procedure, duration of hospitalization after the procedure, and complications for all the patients were documented and analyzed. Results: Of the 22 patients with indeterminate pleural effusion, conclusive diagnosis was obtained in 18 (81.8%) with a sensitivity of 91.7% [95% confidence interval (CI); 61.5-99.8%], specificity of 100% (95% CI; 69.1-100%), PPV of 100% (95% CI; 0-100%), and NPV of 90.9% (95% CI; 60.5-98.5%) for malignancy and a sensitivity of 78% (95% CI; 40-97%), a specificity of 100% (95% CI; 75.3-100%), PPV of 100% (95% CI; 0-100%), and NPV of 86.7% (95% CI; 65.7-95.7%) for tuberculosis. Conclusion: Our results show that video-assisted thoracoscopy plays a useful role in our center in obtaining diagnosis in patients with indeterminate pleural effusion.

Socio-demographic characteristics of children and young adults with varied asthma control- does it make a difference?

Background: The socioeconomic status and caregiver perception of asthma as a disease, the availability of specialty care and medication adherence have major influence on outcome of asthma control in children with asthma. The control of asthma therefore depends on the optimizing the interplay of these factors taking into consideration the regional and racial variations. Objective: The objective of this study was to evaluate the association between socio-demographic factors and asthma control outcome in children with asthma. Materials and Methods: This was a cross-sectional study involving 66 consecutively enrolled participants with asthma whose economic burden for asthma was assessed in a previous study. Based on the number of registered children attending the clinic, a minimum sample size of 66 calculated for this study was obtained.The participants were consenting children and young adults between the ages of 1 and 20 years. Using standard methods, data on socio-economic status, personal and family demographics, including household number, mothers' educational attainments and employment status; and asthma control were collected and analyzed. Asthma control was assessed using Asthma control test (ACT) and guided by the original developers scoring, participants were grouped into well controlled, partly controlled and uncontrolled. The Chi-square test was used to test for association between participants' socio-demographic characteristics (age, socioeconomic status, mothers' education and employment, and number of children in the household) and asthma control status at 5% level of significance. Results: Of all study participants, 34 (51.55%) were male, with mean age (SD) of 11.6 (4.8) years. The mean (SD) age at initial asthma diagnosis was 6.2 (4.6) years. The majority 49(76.5%) of the mothers had tertiary education. Study participants belonging to the poorest; very poor; poor; and least poor socio-economic cadres were, 16 (24.2%); 17 (25.8%); 17 (25.8%); and 16 (24.2%) respectively. Asthma control classification showed that, 26 (39.4%); 31 (47%) and 9 (13.6%) participants had well controlled asthma, partially controlled asthma and uncontrolled asthma respectively. The factors like age, socioeconomic status, mothers 'educational level, employment status and number of children in the household did not show any statistically significant association with the asthma control status of participants. Conclusions: Asthma control outcome remains multifactorial as participants' socio-demographic characteristics did not impact on the level of control of asthma, among participants in the south eastern parts of Nigeria, despite being in a LMIC. A larger study is recommended to further explore this.

Paediatric Bonebridge: bilateral simultaneous asymmetrical implantation.

BACKGROUND: The Bonebridge is an active transcutaneous bone conduction implant recommended as a surgical option for adults and children (aged 5-18 years). Successful implantation of the Bonebridge is often restricted by an insufficient amount of temporal bone to house the transducer in the paediatric patient. METHOD AND RESULTS: In this unique paediatric case, bilateral Bonebridge devices were implanted simultaneously in the right sinodural angle and the left middle cranial fossa. CONCLUSION: The simultaneous implantation of bilateral Bonebridge devices was well tolerated in this paediatric patient, with significant improvement in her hearing. The middle cranial fossa is a viable option for housing the transducer.

Comparison of sprinting vs non-sprinting to wean nasal continuous positive airway pressure off in very preterm infants.

OBJECTIVE: Though nasal continuous positive airway pressure (NCPAP) is commonly used for non-invasive neonatal respiratory support, the optimal method of weaning NCPAP is not established. In this prospective, two-center randomized control trial we hypothesize that gradually increasing spontaneous breathing time off NCPAP increases successful weaning from NCPAP in infants born <31 weeks gestational age. STUDY DESIGN: Infants were randomized to one of the two NCPAP weaning protocols, a sprinting, that is, gradually increasing spontaneous breathing time off CPAP, protocol vs a non-sprinting (weaning pressure down) protocol. RESULT: Eighty-six infants were enrolled in one of the two study groups. Thirty-one infants (77%) in the sprinting group and 30 (75%) in the non-sprinting group were successfully weaned off NCPAP at the first attempt (P>0.05). It took 1.3 (1 to 1.75) (median (IQR)) attempts and 7 (7 to 7) days to wean NCPAP off in the sprinting group vs 1.3 (1 to 1.75) attempts and 7 (7 to 10) days in the non-sprinting group (P>0.05). Additionally, no differences in the secondary outcomes of bronchopulmonary dysplasia, severe retinopathy of prematurity (⩾stage 3), periventricular leukomalacia and length of stay were noted between the two groups. CONCLUSION: Weaning NCPAP via sprinting or non-sprinting protocol is comparable, not only for successful weaning but also for the occurrence of common neonatal morbidities that impact the long-term outcome in premature infants (ClinicalTrials.gov number, NCT02819050).

Labyrinthine sequestration secondary to auditory implantation: report of two cases and review of the literature.

BACKGROUND: Auditory implantation into the inner ear is increasingly performed for a variety of indications. Infective complications are rare, but when they occur they can have devastating consequences. CASE REPORTS: This paper reports two cases where vestibular sequestration of the bony labyrinth developed following implantation into the middle ear. CONCLUSION: To the authors' knowledge, these are the first reported cases where vestibular sequestration has resulted from auditory implant surgery. This paper outlines the radiological changes characteristic of this pathology. It also describes the surgical and conservative treatment options for this condition, challenging the previously accepted belief that affected patients always require aggressive surgical intervention.

Nasal dermoids in children: a proposal for a new classification based on 103 cases at Great Ormond Street Hospital.

OBJECTIVES: Nasal dermoids are rare developmental anomalies seen in children. This study reports the largest case series of 103 patients seen in a quaternary specialist unit over a 10-year period. We report the surgical and radiological findings and propose a new classification system, which clearly describes the extent of the lesions, thus allowing better surgical planning. METHODS: A retrospective review of case notes was conducted. Data collection included demographics, initial presentation, site of lesion, pre-operative CT and MRI imaging, surgical procedure, intraoperative findings (including depth of lesion), complications and recurrence. Surgical findings were correlated with radiological findings. RESULTS: A total of 103 patients were included in the study. The mean age at presentation was 29 months. 89% of children presented with a naso-glabellar or columellar lesion and 11% had a medial canthal lesion. All the patients underwent preoperative imaging and were treated with surgical excision. 58 children had superficial lesions, 45 had subcutaneous tracts extending to varying depths. Of these, 38 had intraosseous extension into the frontonasal bones, eight extended intracranially but remained extradural and two had intradural extension. There was good correlation between radiological and surgical findings. The superficial lesions were locally excised. The lesions with intraosseous tracts were removed via open rhinoplasty and the frontonasal bones drilled for access. Intracranial extension was approached either via a bicoronal flap and frontal craniotomy or the less invasive anterior small window craniotomy. CONCLUSIONS: This report describes the largest published cases series of nasal dermoids. The cases demonstrate the presenting features and the variable extent of the lesions. The new proposed classification; superficial, intraosseous, intracranial extradural and intracranial intradural, allows precise surgical planning. In the presence of intracranial extension, the low morbidity technique of using a brow incision and small window anterior craniotomy avoids the more invasive and commonly used bicoronal flap and frontal craniotomy.

Difficult airway in a child with severe dystonia.

OBJECTIVE: To describe the management of a 15-year-old girl with repeated life-threatening complications of her tracheostomy secondary to muscle dystonia and thoracolumbocervical lordosis. METHOD: This paper reports a retrospective case review. RESULTS: Regular microlaryngoscopy and bronchoscopy, treatment with systemic steroids and a soft tracheostomy tube, in addition to better control of the dystonia, resulted in control of the patient's airway. This minimised tracheal inflammation and granulation tissue formation. CONCLUSION: The need for a tracheostomy in patients with thoracolumbocervical lordosis and severe dystonia should be considered only after all other options of airway management have been explored. Every attempt should be made to minimise tracheal trauma caused by excessive movement of a tracheostomy tube.

Basilar membrane velocity in a cochlea with a modified organ of Corti.

Many cochlear models assign zero longitudinal coupling in the cochlea. Although this is consistent with the transverse basilar membrane (BM) fibers, the cochlear partition contains cellular longitudinal coupling. In cochlear models, longitudinal coupling diminishes passive BM tuning; however, it has recently been employed in theories of active mechanics to enhance tuning. Our goal in this study was to probe passive longitudinal coupling by comparing BM responses in damaged cochleae with passive responses in normal cochleae. The cochleae of gerbils were damaged with intratympanic neomycin followed by a waiting period to ensure that all of the cells of the partition were missing or severely disrupted. We then measured BM motion and examined the cochleae histologically. In comparison with passive responses in normal cochleae, we observed a downward shift in characteristic frequency, an expected consequence of reduced stiffness from cellular damage. However, we did not observe enhanced passive tuning in the damaged cochleae, as would be expected if longitudinal coupling were substantially greater in the normal cochleae. Thus, we conclude that cell-based longitudinal coupling is not large enough to influence passive cochlear mechanics. This finding constrains theories of active mechanics.

Dysphonia secondary to traumatic avulsion of the vocal fold in infants.

OBJECTIVE: Airway compromise due to paediatric intubation injuries is well documented; however, intubation injuries may also cause severe voice disorders. We report our experience and review the world literature on the voice effects of traumatic paediatric intubation. CASE SERIES: We report five cases of children referred to Great Ormond Street Hospital for Children who suffered traumatic avulsion of the vocal fold at the time of, or secondary to, endotracheal intubation. All children had significant dysphonia and underwent specialist voice therapy. CONCLUSIONS: The mechanisms of injury, risk factors and management of the condition are discussed. Children suffering traumatic intubation require follow up throughout childhood and beyond puberty as their vocal needs and abilities change. At the time of writing, none of the reported patients had yet undergone reconstructive or medialisation surgery. However, regular specialist voice therapy evaluation is recommended for such patients, with consideration of phonosurgical techniques including injection laryngoplasty or thyroplasty.

Prospective, comparative, cohort study comparing the rhinogram, Sino-Nasal Outcome Test-20 and Heath-Related Quality of Life questionnaire.

BACKGROUND: Many outcome measures exist for rhinosinusitis. However, few are used in the clinical setting due to their long completion times. OBJECTIVE: To assess the validity, reliability and responsiveness of the rhinogram, compared with two validated rhinosinusitis outcome measures: the Sino-Nasal Outcome Test-20 and the Heath-Related Quality of Life questionnaire. METHODS: Fifty-one patients were entered into a prospective, comparative, cohort study using all three outcome measures one week pre-operatively and three months post-operatively. Outcome scores were then correlated using non-parametric Spearman's rank correlation and chi-square testing for the diagnostic criteria of all three outcome measures. RESULTS: Statistically significant correlations were found between all three outcome measures for all symptom scores, individually as well as combined (p < 0.01 for all calculations). Comparison of the diagnostic accuracy of the rhinogram, compared with the Sino-Nasal Outcome Test-20 and the Heath-Related Quality of Life questionnaire, showed statistical significance (p < 0.05; chi-square test). CONCLUSION: The rhinogram is a reliable, valid and responsive rhinosinusitis outcome measure which can assist patient diagnosis and management in the clinical setting. Due to its quick completion time, this outcome measure could be used in rhinology out-patient clinics.

Laser inferior turbinectomy under local anaesthetic: a well tolerated out-patient procedure.

The suitability of performing laser inferior turbinectomy under local anaesthesia in an out-patient setting was assessed, regarding its effectiveness and patients' toleration of the procedure. Prospective data collection was undertaken from 129 patients undergoing laser inferior turbinectomy over four years. Patients were assessed, pre-operatively, operatively and at two weeks and three months post-operatively, for pain, complications and symptoms, using the sino-nasal assessment questionnaire. All patients had hypertrophied inferior turbinates. Ninety-eight patients complained of nasal obstruction and 67 had the procedure as part of treatment for snoring. One hundred and twenty-one of the patients had treatment to both inferior turbinates. There were no cases of intra-operative haemorrhage. The average pre-operative sino-nasal assessment questionnaire score was 18.22, which improved to 10.68 at the three month post-operative assessment (p<0.001). Five patients had significant intra-operative pain. This study shows that laser inferior turbinectomy under local anaesthesia is well tolerated and that good results can be achieved when performing the procedure in the out-patient department.

Chaperones in ENT out-patients; the patients' perspective.

Chaperones are used in order to avoid misunderstandings that can lead to false accusations. Consultations and examinations may be a minefield especially if the doctors are accused of sexual misconduct. The allegations may have irreparable effects on their reputation and may lead to removal from the medical register and to criminal charges being brought. We present the results of a questionnaire from 85 patients, exploring patient experience in ENT out-patients particularly with respect to examination of the ear under the microscope. This procedure necessitates close contact between the patient and doctor for several minutes and there may be inadvertent contact with intimate areas on the patient. Up to 30 per cent of patients expressed a preference for a chaperone during the ENT consultation. There was noticeably a greater proportion of men than women patients stating a preference for a chaperone during the consultation. Interestingly, there was a strong positive correlation between the presence of friends/relatives and the preference for a chaperone. Patients should be given the freedom to choose for or against the presence of a chaperone in clinic consultations. The most commonly predicted scenario requiring a chaperone is with the male doctor and female patient. This study shows that based on patient feedback, this scenario, although common is not the exclusive area in which chaperones should be used.

The in-vitro antimicrobial activities of some medicinal plants from Cameroon.

The antimicrobial activities of 10 plant species (Voacanga africana, Crepis cameroonica, Plagiostyles africana, Crotalaria retusa, Mammea africana, Lophira lanceolata, Ochna afzelii, Ouratea elongata, Ou. flava and Ou. sulcata), each of which is currently used in the traditional medicine of Cameroon, were investigated in vitro. The activities of a methanol extract of each plant were tested, in disc-diffusion assays, against 37 reference or laboratory strains of seven species of microorganism (Staphylococcus aureus, S. epidermidis, Enterococcus hirae, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Candida albicans). The minimal inhibitory concentrations of each extract were then estimated, against each of the more susceptible microorganisms (i.e. those giving an inhibition zone measuring at least 9 mm in diameter in the disc-diffusion assays), by agar dilution. Although, in the disc-diffusion assays, each of the 10 methanol extracts investigated displayed some degree of antimicrobial activity against at least one species of microorganism, no activity against the Gram-negative bacteria (Es. coli, K. pneumoniae and Ps. aeruginosa) was observed. The extract with the greatest antimicrobial activity was that of Pl. africana (Euphorbiaceae).

The midfacial degloving approach to sinonasal tumours in children.

The midfacial degloving approach was originally described by Denker and Kahler in 1926 but has been little used in the paediatric population. The procedure allows access to benign and malignant lesions of the sinonasal region with the avoidance of an external scar. The advantages and application of this technique are presented in 9 paediatric patients, ranging from 3 months to 15 years of age with a mean follow-up of 7 months. Eight children had benign pathology. There were two juvenile angiofibromas, two nasal gliomas, one ossifying fibroma, one fibroma, one fibrous dysplasia and one benign myofibroblastic proliferation. One child had malignant disease in the form of recurrent embryonal rhabdomyosarcoma. All had excellent cosmetic results and no complications were encountered during follow-up.

Epistaxis: are temperature and seasonal variations true factors in incidence?

OBJECTIVE: To investigate the previously documented inverse association between ambient temperature and presentation rates for patients with epistaxis and seasonal variation of emergency presentation rates for patients with epistaxis. STUDY DESIGN: A retrospective analysis of all consecutive emergency patients with epistaxis presenting to hospital from the community over a five-year period, 1997-2002 (1830 days), including those who required admission to hospital with epistaxis over the same period. Patients in whom there was a clear aetiology for the epistaxis (traumatic, recurrent, iatrogenic, coagulopathic and hypertensive) were excluded. SETTING: A tertiary referral centre in south-west London serving a population in excess of 2.8 million. METHOD: A retrospective analysis of all patients presenting or admitted to St George's Hospital with epistaxis over a five-year period. Daily ambient temperature readings from London Heathrow airport were recorded for the same period. Presentations were correlated with monthly temperature variations and the month itself. Statistical analysis with Pearson's correlation coefficient was performed. RESULTS: 1373 patients with epistaxis presented to our department, of whom 386 (28.1 per cent) were admitted to hospital. No correlation is seen between ambient temperature and presentation rate for patients with epistaxis. No seasonal preponderance is noted for presentation rate (Pearson r = 0.160, p = 0.221) in this series. CONCLUSION: To our knowledge, this is the largest study to date examining ambient temperature association and epistaxis, and the first to investigate presentation rate in place of admission rate. We feel that the exclusion of all patients with epistaxis not admitted to hospital introduces a bias. In this series, there is no correlation between ambient temperature, seasonal preponderance, presentation rate or admission rate for patients with epistaxis. This is contrary to previously reported findings. We do not support the view that there is a relationship between epistaxis and temperature or seasonal variation. This contradicts the current belief that incidence of epistaxis displays seasonality, and has implications for the allocation of resources for healthcare provision within ENT departments.

Advice given to patients with epistaxis by A&E doctors.

This study was devised to determine the proportion of patients with epistaxis seen in accident and emergency (A&E) departments and discharged with verbal/written advice, and to examine if this information affects re-attendance rates. A questionnaire was given to all A&E doctors probing their current practice regarding advice given to patients with epistaxis on discharge. The information was complemented with a case note audit of patients with epistaxis seen and discharged by A&E doctors over a 2 month period, which assessed the content and format of advice given and the number of re-attendances. The standard used stated that all patients discharged from A&E should be given both verbal and written advice regarding the prevention and management of further bleeds. The A&E doctors were then invited to a presentation on the management of epistaxis and the appropriate advice to give patients on discharge. Written advice leaflets on the prevention and management of further bleeds were placed in the A&E department and were accessible to doctors and patients. Case notes were re-audited over the following 2 month period. Verbal and written advice increased from 19% to 61% and 2% to 54% respectively. The number of re-attenders who had previously only seen A&E doctors was reduced from 11 (17%) in the first half to 5 (8%) in the second half of the cycle, representing a 9% reduction. We conclude that the provision of adequate verbal and written advice to patients with epistaxis may have an important role in the prevention of further bleeds and subsequent re-attendance to A&E departments.