Update on fracture risk assessment in osteoporosis.

PURPOSE OF REVIEW: The assessment of fracture risk is playing an ever-increasing role in osteoporosis clinical management and informing international guidelines for osteoporosis. FRAX, a fracture risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used since 2008. In this review, we recap the development and limitations of intervention thresholds and the role of absolute fracture risk. RECENT FINDINGS: There is an increasing awareness of disparities and inequities in the setting of intervention thresholds in osteoporosis. The limitations of the simple use of prior fracture or the DXA-derived BMD T -score threshold are increasingly being discussed; one solution is to use fracture risk or probabilities in the setting of such thresholds. This approach also permits more objective assessment of high and very high fracture risk to enable physicians to make choices not just about the need to treat but what agents to use in individual patients. SUMMARY: Like all clinical tools, FRAX has limitations that need to be considered, but the use of fracture risk in deciding who to treat, when to treat and what agent to use is a mechanism to target treatment equitably to those at an increased risk of fracture.

Performance of a multigene genomic classifier and clinical parameters in predicting malignancy in a Southeast Asian cohort of patients with cytologically indeterminate thyroid nodules.

BACKGROUND: Most thyroid nodules are benign. It is important to determine the likelihood of malignancy in such nodules to avoid unnecessary surgery. The primary objective of this study was to characterize the genetic landscape and the performance of a multigene genomic classifier in fine-needle aspiration (FNA) biopsies of cytologically indeterminate thyroid nodules in a Southeast Asian cohort. The secondary objective was to assess the predictive contribution of clinical characteristics to thyroid malignancy. METHODS: This prospective, multicenter, blinded study included 132 patients with 134 nodules. Molecular testing (MT) with ThyroSeq v3 was performed on clinical or ex-vivo FNA samples. Centralized pathology review also was performed. RESULTS: Of 134 nodules, consisting of 61% Bethesda category III, 20% category IV, and 19% category V cytology, and 56% were histologically malignant. ThyroSeq yielded negative results in 37.3% of all FNA samples and in 42% of Bethesda category III-IV cytology nodules. Most positive samples had RAS-like (41.7%), followed by BRAF-like (22.6%), and high-risk (17.9%) alterations. Compared with North American patients, the authors observed a higher proportion of RAS-like mutations, specifically NRAS, in Bethesda categories III and IV and more BRAF-like mutations in Bethesda category III. The test had sensitivity, specificity, negative predictive value, and positive predictive value of 89.6%, 73.7%, 84.0%, and 82.1%, respectively. The risk of malignancy was predicted by positive MT and high-suspicion ultrasound characteristics according to American Thyroid Association criteria. CONCLUSIONS: Even in the current Southeast Asian cohort with nodules that had a high pretest cancer probability, MT could lead to potential avoidance of diagnostic surgery in 42% of patients with Bethesda category III-IV nodules. MT positivity was a stronger predictor of malignancy than clinical parameters.

Multi-breed genomic predictions and functional variants for fertility of tropical bulls.

Worldwide, most beef breeding herds are naturally mated. As such, the ability to identify and select fertile bulls is critically important for both productivity and genetic improvement. Here, we collected ten fertility-related phenotypes for 6,063 bulls from six tropically adapted breeds. Phenotypes were comprised of four bull conformation traits and six traits directly related to the quality of the bull's semen. We also generated high-density DNA genotypes for all the animals. In total, 680,758 single nucleotide polymorphism (SNP) genotypes were analyzed. The genomic correlation of the same trait observed in different breeds was positive for scrotal circumference and sheath score on most breed comparisons, but close to zero for the percentage of normal sperm, suggesting a divergent genetic background for this trait. We confirmed the importance of a breed being present in the reference population to the generation of accurate genomic estimated breeding values (GEBV) in an across-breed validation scenario. Average GEBV accuracies varied from 0.19 to 0.44 when the breed was not included in the reference population. The range improved to 0.28 to 0.59 when the breed was in the reference population. Variants associated with the gene HDAC4, six genes from the spermatogenesis-associated (SPATA) family of proteins, and 29 transcription factors were identified as candidate genes. Collectively these results enable very early in-life selection for bull fertility traits, supporting genetic improvement strategies currently taking place within tropical beef production systems. This study also improves our understanding of the molecular basis of male fertility in mammals.

Utility of multi-omics data to inform genomic prediction of heifer fertility traits.

Biologically informed single nucleotide polymorphisms (SNPs) impact genomic prediction accuracy of the target traits. Our previous genomics, proteomics, and transcriptomics work identified candidate genes related to puberty and fertility in Brahman heifers. We aimed to test this biological information for capturing heritability and predicting heifer fertility traits in another breed i.e., Tropical Composite. The SNP from the identified genes including 10 kilobases (kb) region on either side were selected as biologically informed SNP set. The SNP from the rest of the Bos taurus genes including 10-kb region on either side were selected as biologically uninformed SNP set. Bovine high-density (HD) complete SNP set (628,323 SNP) was used as a control. Two populations-Tropical Composites (N = 1331) and Brahman (N = 2310)-had records for three traits: pregnancy after first mating season (PREG1, binary), first conception score (FCS, score 1 to 3), and rebreeding score (REB, score 1 to 3.5). Using the best linear unbiased prediction method, effectiveness of each SNP set to predict the traits was tested in two scenarios: a 5-fold cross-validation within Tropical Composites using biological information from Brahman studies, and application of prediction equations from one breed to the other. The accuracy of prediction was calculated as the correlation between genomic estimated breeding values and adjusted phenotypes. Results show that biologically informed SNP set estimated heritabilities not significantly better than the control HD complete SNP set in Tropical Composites; however, it captured all the observed genetic variance in PREG1 and FCS when modeled together with the biologically uninformed SNP set. In 5-fold cross-validation within Tropical Composites, the biologically informed SNP set performed marginally better (statistically insignificant) in terms of prediction accuracies (PREG1: 0.20, FCS: 0.13, and REB: 0.12) as compared to HD complete SNP set (PREG1: 0.17, FCS: 0.10, and REB: 0.11), and biologically uninformed SNP set (PREG1: 0.16, FCS: 0.10, and REB: 0.11). Across-breed use of prediction equations still remained a challenge: accuracies by all SNP sets dropped to around zero for all traits. The performance of biologically informed SNP was not significantly better than other sets in Tropical Composites. However, results indicate that biological information obtained from Brahman was successful to predict the fertility traits in Tropical Composite population.

Prior biological information can be helpful in the genomic prediction of the traits. Previous multi-omics studies by our group identified genes relevant to puberty and fertility in Brahman cattle, a beef breed in northern Australia. We used this biological information in the genomic prediction of three heifer fertility traits, measured in another beef cattle breed: Tropical Composites. The three traits were: pregnancy status after the first mating season (PREG1), first conception score (FCS), and rebreeding score (REB). To test if prior biological information could capture genetic variation in the traits and improve genomic predictions, we compared the results obtained using three subsets of genetic information (i.e., subsets of DNA variants). The first subset contained only variants deemed biologically relevant (as per previous multi-omics studies). The second subset contained only variants considered biologically irrelevant. The third subset had all the variants contained in the commercial DNA assay known as the bovine high-density chip, intended as a practical control. The results indicate that multi-omics data was informative across breed scenario and can be useful in informing genomic predictions of traits of interest.

Personalised Dosing Using the CURATE.AI Algorithm: Protocol for a Feasibility Study in Patients with Hypertension and Type II Diabetes Mellitus.

Chronic diseases typically require long-term management through healthy lifestyle practices and pharmacological intervention. Although efficacious treatments exist, disease control is often sub-optimal leading to chronic disease-related sequela. Poor disease control can partially be explained by the 'one size fits all' pharmacological approach. Precision medicine aims to tailor treatments to the individual. CURATE.AI is a dosing optimisation platform that considers individual factors to improve the precision of drug therapies. CURATE.AI has been validated in other therapeutic areas, such as cancer, but has yet to be applied in chronic disease care. We will evaluate the CURATE.AI system through a single-arm feasibility study (n = 20 hypertensives and n = 20 type II diabetics). Dosing decisions will be based on CURATE.AI recommendations. We will prospectively collect clinical and qualitative data and report on the clinical effect, implementation challenges, and acceptability of using CURATE.AI. In addition, we will explore how to enhance the algorithm further using retrospective patient data. For example, the inclusion of other variables, the simultaneous optimisation of multiple drugs, and the incorporation of other artificial intelligence algorithms. Overall, this project aims to understand the feasibility of using CURATE.AI in clinical practice. Barriers and enablers to CURATE.AI will be identified to inform the system's future development.

The Impact of Frailty, Falls and Cognition on Osteoporosis Management in the Oldest Old.

Data and clinical guidelines on the management of osteoporosis in nonagenarians are lacking. The aim of this study was to assess the characteristics of osteoporosis management and identify any gaps or trends in a cohort of nonagenarians who were newly diagnosed with osteoporosis during an inpatient admission. A retrospective analysis of nonagenarians admitted to the medicine department of a tertiary hospital who were newly diagnosed with osteoporosis based on extracted ICD-10 codes. Baseline demographics, frailty based on the clinical frailty scale, comorbidities, initiation, compliance and adverse effects on osteoporosis medication were analysed. Mean age of the study group was 93.0 ± 2.5 years. There was a high prevalence of frailty (71.7%), cognitive impairment (34.2%) and recurrent falls (30.0%). 82.5% were started on osteoporosis treatment with denosumab (43.4%) being the most prescribed, followed by alendronate (41.4%). Cognitive impairment and male gender were associated with less likelihood of being on osteoporosis treatment on multivariate analysis. Having a previous fracture was associated with a higher likelihood of being on osteoporosis treatment. There was a discontinuation rate of 49.5% with a mean time to discontinuation of 26.3 ± 22.9 months. There was a high rate of osteoporosis treatment in nonagenarians with osteoporosis. The presence of previous fractures was associated with initiation of osteoporosis medications, whereas frailty and falls had no impact on treatment decisions. Cognitive impairment and males were associated with a lower rate of initiation of osteoporosis medication.

Meta-Analysis of Heifer Traits Identified Reproductive Pathways in Bos indicus Cattle.

Fertility traits measured early in life define the reproductive potential of heifers. Knowledge of genetics and biology can help devise genomic selection methods to improve heifer fertility. In this study, we used ~2400 Brahman cattle to perform GWAS and multi-trait meta-analysis to determine genomic regions associated with heifer fertility. Heifer traits measured were pregnancy at first mating opportunity (PREG1, a binary trait), first conception score (FCS, score 1 to 3) and rebreeding score (REB, score 1 to 3.5). The heritability estimates were 0.17 (0.03) for PREG1, 0.11 (0.05) for FCS and 0.28 (0.05) for REB. The three traits were highly genetically correlated (0.75-0.83) as expected. Meta-analysis was performed using SNP effects estimated for each of the three traits, adjusted for standard error. We identified 1359 significant SNPs (p-value < 9.9 × 10-6 at FDR < 0.0001) in the multi-trait meta-analysis. Genomic regions of 0.5 Mb around each significant SNP from the meta-analysis were annotated to create a list of 2560 positional candidate genes. The most significant SNP was in the vicinity of a genomic region on chromosome 8, encompassing the genes SLC44A1, FSD1L, FKTN, TAL2 and TMEM38B. The genomic region in humans that contains homologs of these genes is associated with age at puberty in girls. Top significant SNPs pointed to additional fertility-related genes, again within a 0.5 Mb region, including ESR2, ITPR1, GNG2, RGS9BP, ANKRD27, TDRD12, GRM1, MTHFD1, PTGDR and NTNG1. Functional pathway enrichment analysis resulted in many positional candidate genes relating to known fertility pathways, including GnRH signaling, estrogen signaling, progesterone mediated oocyte maturation, cAMP signaling, calcium signaling, glutamatergic signaling, focal adhesion, PI3K-AKT signaling and ovarian steroidogenesis pathway. The comparison of results from this study with previous transcriptomics and proteomics studies on puberty of the same cattle breed (Brahman) but in a different population identified 392 genes in common from which some genes-BRAF, GABRA2, GABR1B, GAD1, FSHR, CNGA3, PDE10A, SNAP25, ESR2, GRIA2, ORAI1, EGFR, CHRNA5, VDAC2, ACVR2B, ORAI3, CYP11A1, GRIN2A, ATP2B3, CAMK2A, PLA2G, CAMK2D and MAPK3-are also part of the above-mentioned pathways. The biological functions of the positional candidate genes and their annotation to known pathways allowed integrating the results into a bigger picture of molecular mechanisms related to puberty in the hypothalamus-pituitary-ovarian axis. A reasonable number of genes, common between previous puberty studies and this study on early reproductive traits, corroborates the proposed molecular mechanisms. This study identified the polymorphism associated with early reproductive traits, and candidate genes that provided a visualization of the proposed mechanisms, coordinating the hypothalamic, pituitary, and ovarian functions for reproductive performance in Brahman cattle.

Assessment of renal fibrosis and anti-fibrotic agents using a novel diagnostic and stain-free second-harmonic generation platform.

Current histological measurement techniques for interstitial collagen, the basis of interstitial fibrosis, are semi-quantitative at best and only provide a ratio of collagen levels within tissues. The Genesis200 imaging system and supplemental image analysis software, FibroIndex from HistoIndex, is a novel, automated platform that uses second-harmonic generation (SHG) for imaging and characterization of interstitial collagen deposition and additional characteristics, in the absence of any staining. However, its ability to quantify renal fibrosis requires investigation. This study compared SHG imaging of renal fibrosis in mice with unilateral ureteric obstruction (UUO), to that of Masson's trichrome staining (MTS) and immunohistochemistry (IHC) of collagen I. Additionally, the platform generated data on collagen morphology and distribution patterns. While all three methods determined that UUO-injured mice underwent significantly increased renal fibrosis after 7 days, the HistoIndex platform additionally determined that UUO-injured mice had a significantly increased collagen-to-tissue cross reticulation ratio (all P < .001 vs sham group). Furthermore, in UUO-injured mice treated with the relaxin family peptide receptor-1 agonists, relaxin (0.5 mg/kg/day) or B7-33 (0.25 mg/kg/day), or angiotensin converting enzyme-inhibitor, perindopril (1 mg/kg/day) over the 7-day period, only the HistoIndex platform determined that the drug-induced prevention of renal fibrosis correlated with significantly reduced collagen fiber thickness and collagen-to-tissue cross reticulation ratio, but increased collagen fiber counts. Relaxin or B7-33 treatment also increased renal matrix metalloproteinase-2 and reduced tissue inhibitor of metalloproteinase-1 levels (all P < .01 vs UUO alone). This study demonstrated the diagnostic value of the HistoIndex platform over currently used staining techniques.

Short-Term Interferential Transabdominal Electrical Stimulation Did Not Change Oral-Rectal Transit Time in Piglets.

BACKGROUND: Transcutaneous electrical stimulation (TES) using interferential current (IFC) is a new therapeutic treatment for constipation. Clinical studies show that TES-IFC for 3-6 months improves colonic transit, but it is not clear if short-term stimulation affects transit or the effect requires longer to develop. The aim of this study was to determine if TES-IFC for only four days affects oral-rectal transit time in healthy pigs. METHODS: Twenty-two 4-5-week old large white female piglets had transit studies during week 4 and week 5 by placing a capsule containing 18 radiopaque plastic markers in the esophagus under anesthetic followed by x-rays at 6, 30, 54, and 78 hours. Animals were randomly assigned to active or control groups. The active group received TES for 30 min daily for four days. Interferential current was applied through four electrodes (4 × 4 cm), with two para-spinal just below the last rib and two on the belly at the same level. Stimulation was at 4000 Hz and 4080-4160 Hz with currents crossing through the abdominal cavity. RESULTS: Whole bowel transit times ranged from 7.7 to 72.2 hours, stomach transit from <1 to 63 hours, and bowel with rectum transit time from 5 to 53 hours. Transit times were the same for the control (median 28.4 hours) and TES-IFC (23.0 hours) groups in the prestimulation and stimulation weeks (control 23.0, TES-IFC 19.8 hours) with no change within or between groups. CONCLUSION: Four days of half-hour TES-IFC daily in healthy 5-week-old piglets did not change oral-rectal transit time.

Time to lung aeration during a sustained inflation at birth is influenced by gestation in lambs.

BackgroundCurrent sustained lung inflation (SI) approaches use uniform pressures and durations. We hypothesized that gestational-age-related mechanical and developmental differences would affect the time required to achieve optimal lung aeration, and resultant lung volumes, during SI delivery at birth in lambs.Methods49 lambs, in five cohorts between 118 and 139 days of gestation (term 142 d), received a standardized 40 cmH2O SI, which was delivered until 10 s after lung volume stability (optimal aeration) was visualized on real-time electrical impedance tomography (EIT), or to a maximum duration of 180 s. Time to stable lung aeration (Tstable) within the whole lung, gravity-dependent, and non-gravity-dependent regions, was determined from EIT recordings.ResultsTstable was inversely related to gestation (P<0.0001, Kruskal-Wallis test), with the median (range) being 229 (85,306) s and 72 (50,162) s in the 118-d and 139-d cohorts, respectively. Lung volume at Tstable increased with gestation from a mean (SD) of 20 (17) ml/kg at 118 d to 56 (13) ml/kg at 139 d (P=0.002, one-way ANOVA). There were no gravity-dependent regional differences in Tstable or aeration.ConclusionsThe trajectory of aeration during an SI at birth is influenced by gestational age in lambs. An understanding of this may assist in developing SI protocols that optimize lung aeration for all infants.

QSAR classification of metabolic activation of chemicals into covalently reactive species.

Metabolic activation of chemicals into covalently reactive species might lead to toxicological consequences such as tissue necrosis, carcinogenicity, teratogenicity, or immune-mediated toxicities. Early prediction of this undesirable outcome can help in selecting candidates with increased chance of success, thus, reducing attrition at all stages of drug development. The ensemble modelling of mixed features was used for the development of a model to classify the metabolic activation of chemicals into covalently reactive species. The effects of the quality of base classifiers and performance measure for sorting were examined. An ensemble model of 13 naive Bayes classifiers was built from a diverse set of 1,479 compounds. The ensemble model was validated internally with five-fold cross validation and it has achieved sensitivity of 67.4% and specificity of 93.4% when tested on the training set. The final ensemble model was made available for public use.

Head and neck injuries in adult victims of intimate-partner violence.

OBJECTIVE: to quantify head and neck injuries in known adult victims of intimate-partner violence (IPV). DESIGN: retrospective chart review. SETTING: sexual assault and domestic violence program in a southeastern Ontario hospital. METHODS: all subjects over the age of 16 years consenting for evaluation by a domestic violence nurse from August 2004 until February 2009 were eligible for inclusion. Subjects for which no physical injury was documented were excluded. Data were extracted from body maps and surveys completed by a specially trained domestic violence nurse. Demographic data, mechanisms of injury, relationship to the assailant, and a history of IPV from the same assailant were collected from the survey. The type and anatomic location of the injury were collected from body maps. Injuries were categorized into six larger categories for analysis according to general anatomic area and multiplicity of areas involved. MAIN OUTCOME MEASURE: anatomic location of the injury. RESULTS: one hundred eight visits were eligible for inclusion in the study. Data on 657 injuries were recorded. The frequency of any head and neck injury was significantly greater than no head and neck injury (p < .001). In subjects experiencing multiple areas of injury, head and neck injuries were significantly more common than not (p < .001). In subjects experiencing only one area of injury, head and neck injuries were more common than lower extremity injuries alone (p = .003) and trunk injuries alone (p = .033) but not significantly more common than upper extremity injuries (p = .102). CONCLUSIONS: head and neck injuries are more common than not in known adult victims of IPV.

Lifetime intimate partner violence exposure, attitudes and comfort among Canadian health professions students.

BACKGROUND: Intimate partner violence (IPV) is a widespread public health problem and training of health professions students has become common. Understanding students' prior knowledge, attitudes and personal exposure to IPV will aid educators in designing more effective curriculum. As interprofessional educational efforts proliferate, understanding differences across disciplines will be critical. FINDINGS: Students in the schools of Medicine, Nursing and Rehabilitation at a university in Ontario attend an annual daylong interprofessional IPV training. To measure perceived role and comfort with IPV and prior personal exposure, we administered a brief Likert scale survey to a convenience sample of students over three years. 552 students completed the survey; the overall response rate was 73%. The majority (82%) agreed that it was their role to intervene in cases of IPV; however Rehabilitation students expressed lower overall comfort levels than did their peers in other schools (p < .0001). Gender, age and prior training on the subject were not significant predictors of comfort. Seven percent reported lifetime IPV and one-fifth had witnessed IPV, but these exposures did not predict comfort in adjusted logistic regression models. CONCLUSION: While the majority of professional students believe it is their role to address IPV in clinical practice, comfort level varied significantly by field of study. More than one fifth of the students reported some personal exposure to IPV. However this did not impact their level of comfort in addressing this issue. Educators need to take students' preexisting attitudes and personal exposure into account when planning curriculum initiatives in this area.

Acute otitis media in children with tympanostomy tubes.

OBJECTIVE: To review evidence regarding antibiotic treatment of acute otitis media in children with tympanostomy tubes and to discuss antibiotic resistance and ototoxicity. QUALITY OF EVIDENCE: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched for relevant articles. Articles providing level I evidence(randomized controlled trials) for treatment were used. Key words used in the search included otitis media(MeSH), middle ear ventilation (MeSH), tympanostomy tubes, and otorrhea. MAIN MESSAGE: Tympanostomy tube insertion is a common procedure; acute otitis media is a frequent sequela. Treatment options include systemic or topical antibiotics with or without corticosteroids. The development of bacterial resistance to antibiotics and ototoxicity related to treatment are important considerations. There have been well-conducted randomized controlled trials of topical versus systemic antibiotic agents. Combined with proper ear cleaning and tragal pumping, topical fluoroquinolone agents offer the most effective treatment. CONCLUSION: Current evidence suggests that a topical fluoroquinolone, with or without a corticosteroid, is the treatment of choice for acute otitis media with tympanostomy tubes.

Noise-induced hearing loss in snorers and their bed partners.

OBJECTIVE: As habitual snoring affects a large percentage of the population and is associated with various medical and social complications, we examined whether loud snoring is also associated with noise-induced hearing loss for the snorers and/or their bed partners. PATIENT SELECTION: Healthy adults between the ages of 35 and 55 years with subjective symptoms of severe snoring were screened to exclude those with a past history of noise exposure (e.g., factory workers, army personnel), use of ototoxic medications, and previously diagnosed hearing disorder. MAIN OUTCOME MEASURES: Behavioural audiograms and otoacoustic emission testing were used to evaluate the subjects' hearing. RESULTS: Although all of the snorers did not demonstrate consistent hearing loss patterns, all four bed partners of snorers in our study demonstrated a unilateral high-frequency pattern of hearing loss consistent with noise-induced hearing loss. Furthermore, the affected ear in every case was the one that was claimed to be chronically exposed to snoring noise. CONCLUSIONS: The findings suggest that there may be a relationship between snoring and noise-induced hearing loss in the bed partners of chronic snorers. Further investigation of this association may enable the population at risk to identify early hearing loss in order that appropriate management of noise exposure and snoring can be recommended, including preventive measures and medical and surgical therapies.

Cost comparison of auditory brainstem response versus magnetic resonance imaging screening of acoustic neuroma.

The cost-effectiveness of current diagnostic approaches employed in patients with suspected acoustic neuroma was evaluated. Currently, patients with signs and symptoms suggestive of acoustic neuroma, such as sudden unilateral hearing loss and/or tinnitus, undergo auditory brainstem response (ABR) screening tests to rule out this condition. If the ABR is normal, acoustic neuroma can be ruled out. However, if the ABR is abnormal, magnetic resonance imaging (MRI) or computed tomography is necessary to confirm the diagnosis. When one considers the total costs of this screening approach, one can ask whether straight MRI screening of all of these patients would be a more cost-effective approach to diagnosing this condition. A retrospective chart review of patient records obtained from the acoustic diagnostics laboratory at Hotel Dieu Hospital, Kingston, Ontario, was performed. A database of patients who have undergone ABR testing over the past 2 years was compiled and analyzed to assess how many of them went on to receive MRI. The total costs (based on Ontario Health Insurance Plan [OHIP] fee schedule rates) of this approach were compared with the estimated costs of straight MRI screening performed on the same patient population. By making such an analysis, decisions regarding the most cost-effective approach to screening for acoustic neuroma can be objectively assessed.

Infection control for the otolaryngologist in the era of severe acute respiratory syndrome.

OBJECTIVES: Severe acute respiratory syndrome (SARS) has affected more than 8400 persons in 28 countries, with more than 800 deaths. The current SARS outbreak, especially in North American health care centers, has motivated a re-evaluation of infection control practices in the hospital and clinic environment. These considerations are particularly important to otolaryngology, in which examination and diagnostic procedures often bring the otolaryngologist in close--if not direct--contact with the patient's upper airway, mucosa, and secretions. The otolaryngologist is at increased risk of contracting a respiratory pathogen. METHOD: A joint effort by the Department of Otolaryngology at Queen's University and the Infection Control Services of the Hotel Dieu Hospital, Kingston, Ontario, was carried out to develop specific infection control guidelines for the otolaryngologists using strategies from the Centers for Disease Control and Prevention in the United States and the Laboratory Center for Disease Control, Health Canada. RESULTS: A set of specific recommendations was developed for the otolaryngologists to augment current infection control, including diligent use of personal protective equipment with every patient encounter. Moreover, this equipment should be removed according to specific protocol, to avoid contamination of self, others, and surroundings. Finally, a number of practice modifications are being adopted as prudent precautionary measures. CONCLUSION: It is essential to adhere to these recommendations in order to protect the health and safety of clinicians, colleagues, and patients.