A validation study of the 30-day questionnaire in the national Norwegian Tonsil Surgery Register: can we trust the data reported by the patients?

PURPOSE: The aim of this study was to validate the Patient Reported Outcome Measure (PROM) in the Norwegian Tonsil Surgery Register (NTSR) and to examine whether any improvements to the questionnaire could be useful. METHODS: This is a prospective, descriptive study. NTSR collects data from patients who undergo tonsil surgery and the intention of the register is to improve the quality of treatment and to contribute to research. The patients answers questions about admission due to postoperative haemorrhage, infection and pain 30 days after surgery. 305 patients were contacted on phone 1-2 weeks after answering the questionnaires electronically (ePROM) and asked the same questions. 180 of 305 patients we contacted had some kind of complications after surgery. They were asked additional questions to search for possible points for improvement of the questionnaire. RESULTS: When comparing the results on the ePROM with the answers on phone, we found that 12 out of 14 variables achieve almost perfect agreement (AC1 ≥ 0.81). Two variables are categorized to be substantial agreement (AC1 = 0.61-0.80). The additional questions showed us that the questionnaire can be improved with more detailed information regarding the severity of the postoperative haemorrhage and the need of better treatment against postoperative pain. CONCLUSION: This study shows that the information from the 30-day ePROM has high reliability. The questions were understood as they were intended, and the answers reflect what the patients had of complications. Some changes can be done to improve the questionnaire and to open up for more research around the tonsillectomy procedure.

Reducing post-tonsillectomy haemorrhage: a multicentre quality improvement programme incorporating video-based cold technique instruction.

OBJECTIVE: Data from the Norwegian Tonsil Surgery Register (NTSR) showed large differences between the hospitals in Norway in the readmission rate due to post-tonsillectomy haemorrhage (rrPTH; range, 0%-25%; national average, 8%). Because of these large variations in the rrPTH, we conducted a quality improvement project involving hospitals with good and bad readmission rates. METHODS: Seven hospitals with readmission rates greater than 10% and four with rates lower than 5% participated in this project. We recorded videos of ear, nose and throat surgeons from the hospitals with low readmission rates when they performed extracapsular tonsillectomy, and these videos of cold dissection tonsillectomy were used as teaching material for examples of good surgical skills for the other hospitals. After a 2-day workshop, all participants from the hospitals went back to their institutions and prepared local plans to improve their results. We used the Plan-Do-Study-Act model. The primary outcome variable was the patient-reported rrPTH in the NTSR. As secondary goal, we aimed to identify aspects of the tonsillectomy procedure that could help achieve a lower rrPTH. RESULTS: The participating hospitals reduced their rrPTH from 18% at baseline (2017/2018) to 7% in 2020. Six of seven hospitals changed their dissection technique significantly to more use of cold dissection. CONCLUSION: By learning cold dissection tonsillectomy from surgeons with low rrPTH, it seems possible to decrease the rates of bleeding complications after tonsillectomy. A combination of videos as a teaching tool, new treatment plans, and focus on quality and improvement may effectively improve surgical results. The videos can show details that are difficult to convey in the literature. Quality registers can be used to identify areas requiring improvement and evaluate the effects of changes in practice.

Salmon Erythrocytes Sequester Active Virus Particles in Infectious Salmon Anaemia.

Infectious salmon anaemia virus (ISAV) binds circulating Atlantic salmon erythrocytes, but the relevance of this interaction for the course of infection and development of disease remains unclear. We here characterise ISAV-erythrocyte interactions in experimentally infected Atlantic salmon and show that ISAV-binding to erythrocytes is common and precedes the development of disease. Viral RNA and infective particles were enriched in the cellular fraction of blood. While erythrocyte-associated ISAV remained infectious, erythrocytes dose-dependently limited the infection of cultured cells. Surprisingly, immunostaining of blood smears revealed expression of ISAV proteins in a small fraction of erythrocytes in one of the examined trials, confirming that ISAV can be internalised in this cell type and engage the cellular machinery in transcription and translation. However, viral protein expression in erythrocytes was rare and not required for development of disease and mortality. Furthermore, active transcription of ISAV mRNA was higher in tissues than in blood, supporting the assumption that ISAV replication predominantly takes place in endothelial cells. In conclusion, Atlantic salmon erythrocytes bind ISAV and sequester infective virus particles during infection, but do not appear to significantly contribute to ISAV replication. We discuss the implications of our findings for infection dynamics and pathogenesis of infectious salmon anaemia.

Establishment and Characterization of a Novel Gill Cell Line, LG-1, from Atlantic Lumpfish (Cyclopterus lumpus L.).

The use of lumpfish (Cyclopterus lumpus) as a cleaner fish to fight sea lice infestation in farmed Atlantic salmon has become increasingly common. Still, tools to increase our knowledge about lumpfish biology are lacking. Here, we successfully established and characterized the first Lumpfish Gill cell line (LG-1). LG-1 are adherent, homogenous and have a flat, stretched-out and almost transparent appearance. Transmission electron microscopy revealed cellular protrusions and desmosome-like structures that, together with their ability to generate a transcellular epithelial/endothelial resistance, suggest an epithelial or endothelial cell type. Furthermore, the cells exert Cytochrome P450 1A activity. LG-1 supported the propagation of several viruses that may lead to severe infectious diseases with high mortalities in fish farming, including viral hemorrhagic septicemia virus (VHSV) and infectious hematopoietic necrosis virus (IHNV). Altogether, our data indicate that the LG-1 cell line originates from an epithelial or endothelial cell type and will be a valuable in vitro research tool to study gill cell function as well as host-pathogen interactions in lumpfish.

Mucosal and Systemic Immune Responses to Salmon Gill Poxvirus Infection in Atlantic Salmon Are Modulated Upon Hydrocortisone Injection.

Salmon Gill Poxvirus Disease (SGPVD) has emerged as a cause of acute mortality in Atlantic salmon (Salmo salar L.) presmolts in Norwegian aquaculture. The clinical phase of the disease is associated with apoptotic cell death in the gill epithelium causing acute respiratory distress, followed by proliferative changes in the regenerating gill in the period after the disease outbreak. In an experimental SGPV challenge trial published in 2020, acute disease was only seen in fish injected with hydrocortisone 24 h prior to infection. SGPV-mediated mortality in the hydrocortisone-injected group was associated with more extensive gill pathology and higher SGPV levels compared to the group infected with SGPV only. In this study based on the same trial, SGPV gene expression and the innate and adaptive antiviral immune response was monitored in gills and spleen in the presence and absence of hydrocortisone. Whereas most SGPV genes were induced from day 3 along with the interferon-regulated innate immune response in gills, the putative SGPV virulence genes of the B22R family were expressed already one day after SGPV exposure, indicating a potential role as early markers of SGPV infection. In gills of the hydrocortisone-injected fish infected with SGPV, MX expression was delayed until day 10, and then expression skyrocketed along with the viral peak, gill pathology and mortality occurring from day 14. A similar expression pattern was observed for Interferon gamma (IFNγ) and granzyme A (GzmA) in the gills, indicating a role of acute cytotoxic cell activity in SGPVD. Duplex in situ hybridization demonstrated effects of hydrocortisone on the number and localization of GzmA-containing cells, and colocalization with SGPV infected cells in the gill. SGPV was generally not detected in spleen, and gill infection did not induce any corresponding systemic immune activity in the absence of stress hormone injection. However, in fish injected with hydrocortisone, IFNγ and GzmA gene expression was induced in spleen in the days prior to acute mortality. These data indicate that suppressed mucosal immune response in the gills and the late triggered systemic immune response in the spleen following hormonal stress induction may be the key to the onset of clinical SGPVD.

Piscine Orthoreovirus (PRV)-3, but Not PRV-2, Cross-Protects against PRV-1 and Heart and Skeletal Muscle Inflammation in Atlantic Salmon.

Heart and skeletal muscle inflammation (HSMI), caused by infection with Piscine orthoreovirus-1 (PRV-1), is a common disease in farmed Atlantic salmon (Salmo salar). Both an inactivated whole virus vaccine and a DNA vaccine have previously been tested experimentally against HSMI and demonstrated to give partial but not full protection. To understand the mechanisms involved in protection against HSMI and evaluate the potential of live attenuated vaccine strategies, we set up a cross-protection experiment using PRV genotypes not associated with disease development in Atlantic salmon. The three known genotypes of PRV differ in their preference of salmonid host species. The main target species for PRV-1 is Atlantic salmon. Coho salmon (Oncorhynchus kisutch) is the target species for PRV-2, where the infection may induce erythrocytic inclusion body syndrome (EIBS). PRV-3 is associated with heart pathology and anemia in rainbow trout, but brown trout (S. trutta) is the likely natural main host species. Here, we tested if primary infection with PRV-2 or PRV-3 in Atlantic salmon could induce protection against secondary PRV-1 infection, in comparison with an adjuvanted, inactivated PRV-1 vaccine. Viral kinetics, production of cross-reactive antibodies, and protection against HSMI were studied. PRV-3, and to a low extent PRV-2, induced antibodies cross-reacting with the PRV-1 σ1 protein, whereas no specific antibodies were detected after vaccination with inactivated PRV-1. Ten weeks after immunization, the fish were challenged through cohabitation with PRV-1-infected shedder fish. A primary PRV-3 infection completely blocked PRV-1 infection, while PRV-2 only reduced PRV-1 infection levels and the severity of HSMI pathology in a few individuals. This study indicates that infection with non-pathogenic, replicating PRV could be a future strategy to protect farmed salmon from HSMI.

Multi-agent in situ hybridization confirms Ca. Branchiomonas cysticola as a major contributor in complex gill disease in Atlantic salmon.

Gill diseases may cause high mortalities in farmed Atlantic salmon. In seawater reared fish co-infections involving the epitheliocystis associated bacterium Ca. Branchiomonas cysticola, the microsporidian Desmozoon lepeophtherii, the causative agent of amoebic gill disease Paramoeba perurans and salmon gill poxvirus are common and histopathological lesions may be complex. Here, we report detection of these agents utilising multiplex real-time PCR and link the presence of agents to histopathologically visible gill lesions by in situ hybridisation (ISH) utilising RNAscope®. We show that Ca. Branchiomonas cysticola infections may remain undetected if diagnostic investigations are restricted to histopathology alone. Further, positive in situ labelling of Ca. Branchiomonas cysticola was observed within epitheliocysts, but also in small foci within areas of inflammation and necrosis in which histologically detectable epitheliocysts were not visible. In situ labelling of D. lepeophtherii corresponded well with tissue distribution patterns previously associated with this microsporidian. Salmon gill poxvirus was associated with apoptotic gill epithelial cells, while Ca. Piscichlamydia salmonis could not be associated with pathological changes. The multiplex real-time PCRs utilised were rapid and sensitive diagnostic tools and the results corresponded well with ISH. This study shows that the agents involved in complex gill disease can be linked to lesions using ISH and suggests that Ca. B. cysticola plays a crucial role in the development of gill disease in the farming of salmon in Norway.

First record of experimentally induced salmon gill poxvirus disease (SGPVD) in Atlantic salmon (Salmo salar L.).

Salmon gill poxvirus (SGPV) infection is a common denominator in many cases of complex gill disease in the Norwegian salmon farming industry and may, as a single agent infection, result in salmon poxvirus disease (SGPVD). Experiences from the field suggest that stress may be a decisive factor for the induction of SGPVD. Here we investigated the effect of stress hormone treatment on SGPV kinetics and disease development. In our experiment, Atlantic salmon were divided into four groups. Two groups of fish received an intraperitoneal injection of hydrocortisone dissolved in a fatty vehicle, whereas fish in the other two groups received a sham injection of the vehicle. After 24 h, one group with hydrocortisone injection and one with sham injection were exposed to dead SGPV-infected fish. Plasma cortisol level, virus kinetics, virus localization, and pathological gill were monitored for 4 weeks post-exposure. Hydrocortisone injected fish displayed higher plasma cortisol and SGPV loads than non-hydrocortisone treated fish. Signs of SGPVD and ensuing mortality appeared only in fish exposed to the virus and injected with hydrocortisone around 2 weeks post-exposure. No clinical signs of disease or mortality were recorded in the other groups. Further, gill histopathology in diseased fish correlated well with SGPV load, with the infection apparently confined to gill epithelial cells. The current findings suggest elevated plasma cortisol being a prerequisite for the development of SGPVD and recommend minimization of stressful farming activities, particularly if SGPV infection has been previously identified.

Quality of life and symptoms before and after nasal septoplasty compared with healthy individuals.

BACKGROUND: The goal of this study is to compare quality of life (Qol) and symptoms in 91 patients with a deviated nasal septum preoperatively and postoperatively with a control group of 93 healthy individuals. METHODS: All patients reported Qol on Sino-Nasal-Outcome-Test-20 (SNOT-20) and symptoms on visual analogue scale (VAS) preoperatively and 6 months after surgery and the results were compared with the controls. RESULTS: Mean SNOT-20 score improved from 1.8(SD0.9) preoperatively to 0.9(SD0.8) postoperatively (p < 0.000) but did not reach the same level as the controls 0.4(SD0.5). Septum surgery leads to a significant symptom improvement for all symptoms investigated (p < 0.000) on VAS. The patients reached the same level as the healthy controls in 6 of 11 symptoms (headache, facial pain, sneezing, trouble with rhinosinusitis, cough and snoring) but the patients group had significantly more trouble with nasal blockage (VAS 29 vs 9), change in sense of smell (VAS 12 vs5), nasal discharge (VAS 22 vs 11), oral breathing (VAS 23 vs 13) and reduced general health (VAS 12 vs 5) also postoperatively (p < 0.01). Sub analyses showed that allergic patients reported a VAS score of 36 (SD30) for nasal blockage and 17 (SD22) for facial pressure postoperatively versus 23(SD22) and 6(SD13) in non-allergic patients (p < 0.03 and p < 0.01). Patients with obstructive sleep apnea syndrome (OSAS) reported more trouble with snoring on VAS postoperatively than other patients, 42(SD28) versus 20(SD23) (p < 0.002). CONCLUSION: Septoplasty leads to a highly significant improvement in Qol and symptoms. The patients do not reach the same level of Qol as healthy controls. All symptoms are reported as mild on VAS postoperatively. Allergic patients tend to report more nasal blockage and facial pressure postoperatively than other patients and a focus on medical treatment should be kept also postoperatively. Patients with obstructive sleep apnea report more trouble with snoring postoperatively and alterative treatment options for snoring may be considered in these patients.