Diagnostic criteria and core outcome set development for necrotising otitis externa: the COSNOE Delphi consensus study.

OBJECTIVE: Evidence for necrotising otitis externa (NOE) diagnosis and management is limited, and outcome reporting is heterogeneous. International best practice guidelines were used to develop consensus diagnostic criteria and a core outcome set (COS). METHODS: The study was pre-registered on the Core Outcome Measures in Effectiveness Trials (COMET) database. Systematic literature review identified candidate items. Patient-centred items were identified via a qualitative study. Items and their definitions were refined by multidisciplinary stakeholders in a two-round Delphi exercise and subsequent consensus meeting. RESULTS: The final COS incorporates 36 items within 12 themes: Signs and symptoms; Pain; Advanced Disease Indicators; Complications; Survival; Antibiotic regimes and side effects; Patient comorbidities; Non-antibiotic treatments; Patient compliance; Duration and cessation of treatment; Relapse and readmission; Multidisciplinary team management.Consensus diagnostic criteria include 12 items within 6 themes: Signs and symptoms (oedema, otorrhoea, granulation); Pain (otalgia, nocturnal otalgia); Investigations (microbiology [does not have to be positive], histology [malignancy excluded], positive CT and MRI); Persistent symptoms despite local and/or systemic treatment for at least two weeks; At least one risk factor for impaired immune response; Indicators of advanced disease (not obligatory but mut be reported when present at diagnosis). Stakeholders were unanimous that there is no role for secondary, graded, or optional diagnostic items. The consensus meeting identified themes for future research. CONCLUSION: The adoption of consensus-defined diagnostic criteria and COS facilitates standardised research reporting and robust data synthesis. Inclusion of patient and professional perspectives ensures best practice stakeholder engagement.

Experiences of Motivational Interviewing in Virtual Health-care Visits for Adults With Type 2 Diabetes Mellitus: A Qualitative Analysis.

OBJECTIVES: The purpose of this qualitative study is to identify barriers minimizing the effectiveness of motivational interviewing during virtual clinic encounters for individuals with type 2 diabetes based on the capability, opportunity, motivation, and behaviour (COM-B) model. METHODS: One-on-one semistructured interviews were conducted from March to June 2023, with 17 adults with type 2 diabetes (64.7% female; median age 69 years, range 47 to 83 years) followed at St. Michael's Hospital (Toronto, Canada). Themes from transcribed interviews were identified through descriptive analysis using a grounded theory approach. RESULTS: The following main themes were identified: 1) face-to-face appointments strengthen provider-patient rapport and collaboration; 2) virtual encounters reduce patient accountability and hinder health-seeking behaviour; and 3) individuals with physical disabilities and/or low technological proficiency experience decreased provider accessibility. Protective factors that can mitigate these negative impacts include establishing rapport during in-person appointments before transitioning to virtual appointments and incorporating a video component during virtual encounters. CONCLUSIONS: Several barriers of virtual appointments currently limit the effectiveness of motivational interviewing for individuals with type 2 diabetes and make it difficult to provide person-centred care, especially by phone. However, there are protective factors that help to maintain healthy lifestyle behaviours, even after transitioning to virtual settings, and are areas for optimization moving forward.

Remote assessments for bone conduction hearing devices during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic had resulted in the suspension of many routine audiology services due to the risk of cross-infections in closed spaces. This has driven the need for exploring alternatives to conventional face-to-face consultations in the hospital outpatient setting. The aim of this study was to determine the efficacy of remote consultations and assessments for patients on the waiting list for consideration of bone conduction hearing devices (BCHDs), and whether this type of consultation could continue beyond the COVID-19 era. METHODS: This was a prospective cross-sectional study in a tertiary Neuro-otology Department. All new patients on the waiting list for assessment for BCHD as of 1 March 2020 were included. Patients' case notes were reviewed. All underwent a telephone consultation with an implant audiologist. If the patient wanted to go ahead with the remote trial, a BCHD sound processor on a headband would be mailed out and the patient would then have to use the device for two weeks and return the device after with their diary. RESULTS: There were 49 patients. The mean age was 55 (range 27-88, SD 16.3). Four did not proceed with the trial. All patients returned their devices to the department. Majority of patients (95.6%, n = 43), completed their diary. 75.6% wanted to proceed with surgery. All patients proceeding with surgery were happy with the remote assessment and would recommend this for the future. CONCLUSION: It is possible to satisfactorily assess appropriately screened patients for BCHDs remotely with a structured approach and explanation of process and expectations. It might be possible to consider this type of consultation as an option for assessing potential candidates for BCHDs beyond the COVID-19 era to reduce the number of hospital visits for patients.

Mortality in patients with cardiogenic shock supported with VA ECMO: A systematic review and meta-analysis evaluating the impact of etiology on 29,289 patients.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is associated with variable outcomes. In this meta-analysis, we evaluated the mortality after VA ECMO across multiple etiologies of cardiogenic shock (CS). METHODS: In June 2019, we performed a systematic search selecting observational studies with ≥10 adult patients reporting on short-term mortality (30-day or mortality at discharge) after initiation of VA ECMO by CS etiology published after 2009. We performed meta-analyses using random effect models and used metaregression to evaluate mortality across CS etiology. RESULTS: We included 306 studies (29,289 patients): 25 studies on after heart transplantation (HTx) (771 patients), 13 on myocarditis (906 patients), 33 on decompensated heart failure (HF) (3,567 patients), 64 on after cardiotomy shock (8,231 patients), 10 on pulmonary embolism (PE) (221 patients), 80 on acute myocardial infarction (AMI) (7,774 patients), and 113 on after cardiac arrest [CA] (7,814 patients). With moderate certainty on effect estimates, we observed significantly different mortality estimates for various etiologies (p < 0.001), which is not explained by differences in age and sex across studies: 35% (95% CI: 29-42) for after HTx, 40% (95% CI: 33-46) for myocarditis, 53% (95% CI: 46-59) for HF, 52% (95% CI: 38-66) for PE, 59% (95% CI: 56-63) for cardiotomy, 60% (95% CI: 57-64) for AMI, 64% (95% CI: 59-69) for post‒in-hospital CA, and 76% (95% CI: 69-82) for post-out‒of-hospital CA. Univariable metaregression showed that variation in mortality estimates within etiology group was partially explained by population age, proportion of females, left ventricle venting, and CA. CONCLUSIONS: Using an overall estimate of mortality for patients with CS requiring VA ECMO is inadequate given the differential outcomes by etiology. To further refine patient selection and management to improve outcomes, additional studies evaluating patient characteristics impacting outcomes by specific CS etiology are needed.

Re-approximated: a Medical Student's Reflection on the Surgical Approach to Cancer Treatment.

Medical school clerkship offers third year medical students multiple opportunities to acquire clinical experience through real patient interactions and integration into the healthcare teams of different specialities. As part of the general surgery rotation, medical students are invited to scrub in to assist with surgeries-a chance to simultaneously gain medical knowledge while developing technical skills. They learn that there is a possibility of inflicting harm to the patient at every step of any surgery; from making the first skin incision to tying up the final suture, the importance of staying alert is emphasized until the patient is transferred out of the operating room in stable condition. However, the obligation of a physician to do no harm extends beyond the surgery. In this reflection, a third year medical student discusses her experience during an hours-long Whipple procedure. She reflects on the impact of a cancer diagnosis on a patient's identity and narrative and comments on the necessity of maintaining a balance between offering medical guidance to patients and offering the space for them to express their unique illness experience.

Lasers in Rhinology-An Update.

OBJECTIVES: A wide and evolving range of lasers and their applications often makes it difficult for a busy surgeon to choose the ideal laser for a specific indication. With this in mind, this article aims to summarize the most recent literature concerning laser application in rhinology. METHODS: A literature search from 2000 to 2020 using the PubMed database was employed. Keywords used included "laser," "rhinology," "endonasal endoscopic surgery," "hereditary haemorrhagic telangiectasia," "rhinitis," "refractory rhinitis," "Inferior turbinate hypertrophy," "dacryocystorhinostomy," "septoplasty," "cartilage reshaping" and "choanal atresia." The most up to date studies published for each rhinology condition that could potentially be treated with laser surgery was included. RESULTS: Rhinological conditions appropriate for laser applications are discussed. We identified articles related to a number of applications including hereditary hemorrhagic telangiectasia, rhinitis, turbinate surgery, dacryocystorhinostomy, septoplasty, choanal atresia, and sphenopalatine artery ligation, paying attention to the outcomes of the studies and their limitations. CONCLUSIONS: There is currently no one-size-fits-all laser and therefore being up to date on the latest clinical application results can help the clinician decide which are the best treatments to offer their patients.

Resting Heart Rate as an Important Predictor of Mortality and Morbidity in Ambulatory Patients With Heart Failure: A Systematic Review and Meta-Analysis.

BACKGROUND: Resting heart rate is a risk factor of adverse heart failure outcomes; however, studies have shown controversial results. This meta-analysis evaluates the association of resting heart rate with mortality and hospitalization and identifies factors influencing its effect. METHODS AND RESULTS: We systematically searched electronic databases in February 2019 for studies published in 2005 or before that evaluated the resting heart rate as a primary predictor or covariate of multivariable models of mortality and/or hospitalization in adult ambulatory patients with heart failure. Random effects inverse variance meta-analyses were performed to calculate pooled hazard ratios. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess evidence quality. Sixty-two studies on 163,445 patients proved eligible. Median population heart rate was 74 bpm (interquartile range 72-76 bpm). A 10-bpm increase was significantly associated with increased risk of all-cause mortality (hazard ratio 1.10, 95% confidence interval 1.08-1.13, high quality). Overall, subgroup analyses related to patient characteristics showed no changes to the effect estimate; however, there was a strongly positive interaction with age showing increasing risk of all-cause mortality per 10 bpm increase in heart rate. CONCLUSIONS: High-quality evidence demonstrates increasing resting heart rate is a significant predictor of all-cause mortality in ambulatory patients with heart failure on optimal medical therapy, with consistent effect across most patient factors and an increased risk trending with older age.

Lasers in Cholesteatoma Surgery: A Systematic Review.

OBJECTIVES: The mainstay of cholesteatoma treatment is surgical and requires the removal of all squamous epithelium from the underlying normal structure. The application of laser technology in middle ear and mastoid surgery has shown promise in achieving both disease eradication and hearing preservation. This systematic review aims to include studies that have assessed the application of laser to the treatment of cholesteatoma and to review its outcomes in terms of disease eradication as well as hearing results. METHOD: Two independent researchers conducted a systematic review of the literature on MEDLINE and Cochrane library, according to PRISMA guidance. RESULT: The search resulted in 12 papers, reporting on 536 participants that fulfilled the inclusion criteria. The hearing results did not show that using laser surgery improved hearing in cholesteatoma surgery, but neither has the use of laser shown to deteriorate hearing. With regards to the prevention of residual/recurrent cholesteatoma, the current literature reports a residual/recurrent rate of 0% to 33%. The complication rate of facial palsy is 0.6%. CONCLUSION: While there is certainly a role for future studies especially randomised large-cohort prospective comparative studies, the current literature suggests that laser may have a role in prevention or minimizing of residual cholesteatoma and generally have a safe hearing outcome profile.

Surgical and audiological outcomes of a fully implantable middle ear implant: early results from a retrospective multicentre study.

PURPOSE: This paper reports the surgical and audiological outcomes of a large series of patients who received a fully implantable middle ear implant (MEI): carina (Cochlear, Australia). METHODS: This is a multicentre retrospective study involving three tertiary referral centres. Patient data were collected for the first 42 consecutive patients who were fitted with the MEI between 2014 and 2019 (Sheffield from February 2017 to January 2019; São Paulo from April 2015 to September 2017; Porto from December 2014 to May 2017). The main outcome measures included surgical results, free field speech testing with speech recognition thresholds (SRT) and audiological gain. RESULTS: There was one major complication due to infection resulting in a brain abscess and explantation of the device. Three other patients had minor skin infections; no other complications were reported. Results show a functional gain of 19.5 dB (p < 0.05) with the MEI versus unaided condition. SRT improved from 57.4 dB to 44.6 dB with the MEI (p < 0.05). CONCLUSIONS: This fully implanable active MEI offers a reliable option for patients with moderate-to-severe sensorineural or mixed hearing losses especially for those do not tolerate or cannot use conventional hearing aids. It provides significant improvement in hearing as shown in the audiological outcomes. The surgery is relatively straightforward but there is a steep learning curve. The devices are well tolerated by all patients.

First United Kingdom experience of the novel Osia active transcutaneous piezoelectric bone conduction implant.

PURPOSE: Bone conduction hearing devices are widely used and indicated in cases of conductive, mixed or single-sided deafness where the conventional hearing aids are not indicated or tolerated. This prospective study aims to investigate the surgical and hearing outcomes of a novel active piezoelectric transcutaneous bone conduction device (t-BCD). METHODS: Prospective data were collected from the first 10 patients who underwent implantation with the t-BCD Osia (Cochlear, Australia) (between Dec 2018 and March 2019) in a tertiary referral centre. The main outcome measures include: surgical outcome, free field speech testing with speech recognition thresholds, audiological gain and patient-reported outcomes including the 'Glasgow Benefit Inventory' (GBI) and the 'Client Oriented Scale of Improvement (COSI). RESULTS: The mean length of surgery was 70.6 min (range 50-87, SD = 9.5). Mean skin thickness measured was 5.6 mm (range 4-8, SD = 1.1). There were two post-operative wound infections which settled conservatively. One required revision surgery to thin skin. The average gain in hearing with the implant was + 39.4 dB. Pre-implantation mean unaided SRT was 38.1 dB (SD = 7.8) and the post-implantation mean-aided SRT was 22.7 dB (SD = 4.6) (p = 0.000078). There was improvement in COSI domains. The mean Glasgow disability score dropped from 52% pre-implantation to 20% post-implantation (p = 0.001). CONCLUSIONS: This new active t-BCHD provides excellent audiological gain and improvement in speech recognition. Patient-reported outcomes have also been very positive. The surgery was straightforward with no major surgical complications reported. Further studies will be required to examine long-term outcomes in larger number of patients.

Surfer's exostosis in a child who does not surf.

Surfer's exostoses are more commonly seen in adults who frequently participate in aquatic activities with repeated exposed to cold water and wind. However, this entity has not been previously reported in the pediatric population. Most patients can be managed conservatively, particularly considering that surgical removal of external auditory canal exostosis can be challenging.

Bridging the Gap between Gut Microbial Dysbiosis and Cardiovascular Diseases.

The human gut is heavily colonized by a community of microbiota, primarily bacteria, that exists in a symbiotic relationship with the host and plays a critical role in maintaining host homeostasis. The consumption of a high-fat (HF) diet has been shown to induce gut dysbiosis and reduce intestinal integrity. Recent studies have revealed that dysbiosis contributes to the progression of cardiovascular diseases (CVDs) by promoting two major CVD risk factors-atherosclerosis and hypertension. Imbalances in host-microbial interaction impair homeostatic mechanisms that regulate health and can activate multiple pathways leading to CVD risk factor progression. Dysbiosis has been implicated in the development of atherosclerosis through metabolism-independent and metabolite-dependent pathways. This review will illustrate how these pathways contribute to the various stages of atherosclerotic plaque progression. In addition, dysbiosis can promote hypertension through vascular fibrosis and an alteration of vascular tone. As CVD is the number one cause of death globally, investigating the gut microbiota as a locus of intervention presents a novel and clinically relevant avenue for future research, with vast therapeutic potential.

Higher atypical enteropathogenic Escherichia coli (a-EPEC) bacterial loads in children with diarrhea are associated with PCR detection of the EHEC factor for adherence 1/lymphocyte inhibitory factor A (efa1/lifa) gene.

BACKGROUND: Typical enteropathogenic Escherichia coli (t-EPEC) are known to cause diarrhea in children but it is uncertain whether atypical EPEC (a-EPEC) do, since a-EPEC lack the bundle-forming pilus (bfp) gene that encodes a key adherence factor in t-EPEC. In culture-based studies of a-EPEC, the presence of another adherence factor, called EHEC factor for adherence/lymphocyte activation inhibitor (efa1/lifA), was strongly associated with diarrhea. Since a-EPEC culture is not feasible in clinical laboratories, we designed an efa1/lifA quantitative PCR assay and examined whether the presence of efa1/lifA was associated with higher a-EPEC bacterial loads in pediatric diarrheal stool samples. METHODS: Fecal samples from children with diarrhea were tested by qPCR for EPEC (presence of eae gene) and for shiga toxin genes to exclude enterohemorrhagic E. coli, which also contain the eae gene. EPEC containing samples were then tested for the bundle-forming pilus gene found in t-EPEC and efa1/lifA. The eae gene quantity in efa1/lifA-positive and negative samples was compared. RESULTS: Thirty-nine of 320 (12%) fecal samples tested positive for EPEC and 38/39 (97%) contained a-EPEC. The efa1/lifA gene was detected in 16/38 (42%) a-EPEC samples. The median eae concentration for efa1/lifA positive samples was significantly higher than for efa1/lifA negative samples (median 16,745 vs. 1183 copies/µL, respectively, p = 0.006). CONCLUSIONS: Atypical enteropathogenic E. coli-positive diarrheal stool samples containing the efa1/lifA gene had significantly higher bacterial loads than samples lacking this gene. This supports the idea that efa1/lifA contributes to diarrheal pathogenesis and suggests that, in EPEC-positive samples, efa/lifA may be a useful additional molecular biomarker.

Chronic ischaemic colitis in a 48 year old man: an unusual presentation.

Ischaemic colitis typically presents with an acute abdominal pain and distension with bloody diarrhoea. However, this can vary and the condition is frequently missed or misdiagnosed, especially if the patient presents with chronic symptoms. Herein, we report a case of chronic presentation of ischaemic colitis in a 48-year-old man with a history of myocardial infarction. This report highlights the importance of having ischaemic colitis as a differential diagnosis whenever a patient with a history of arteriosclerosis presents with atypical chronic abdominal pain.