Development and validation of a new grading scale for otitis media

Otoendoscopy in the era of narrow-band imaging: a pictorial review

PURPOSE

Otoendoscopy represents the initial non-invasive diagnostic cornerstone for external and middle ear disorders. Recently, new techniques of enhanced imaging such as narrow-band imaging (NBI) have been introduced but their role as a potential aid in otological practice remains unproven. In this pictorial review, we want to present the potential application of this endoscopic method, highlight its limitations, and give some hints regarding its future implementation.

METHODS

Representative cases of external and/or middle ear pathologies were selected to illustrate the role of NBI in this regard.

RESULTS

NBI may represent a useful aid in the otological work-up, in the differential diagnosis of ear tumor-like masses, and, possibly, in the prognosis of tympanic perforations. For other ear disorders, instead, this technique does not seem to add anything to the standard clinical practice.

CONCLUSIONS

NBI might prove useful in the assessment of selected external and middle ear disorders but its role must be prospectively validated.

Evaluation of digital otoscopy in pediatric patients: A prospective randomized controlled clinical trial

BACKGROUND

Acute otitis media is often misdiagnosed. Pediatric trainees learn otoscopy from supervisors who cannot concurrently view the eardrum. Digital, smartphone otoscopes show promise to improve the visibility and learning due to a concurrent view by trainees and supervisors. We aimed to determine whether use of digital otoscopes improved accuracy of the ear exams between medical trainees and their supervisors, compared to using traditional otoscopes. Secondarily, we evaluated whether the use of digital otoscopes reduced the number of repeat ear examinations by supervisors, changed the trainee's confidence in their exam findings, and led to differences in the rate of antibiotics prescribed.

METHODS

This study was a randomized controlled trial comparing use of a digital otoscope to a traditional otoscope, in a pediatric emergency department and primary care clinic in an academic tertiary care children's center. We used a modified validated image-based grading scale to compare accuracy of the ear exam between trainees and supervisors. Surveys documented modified OMgrade scores, frequency of supervisor exams, trainee confidence on a 5-point Likert scale, and antibiotic prescriptions. Inter-rater agreement of trainees and supervisors, the number of supervisor confirmatory examinations performed, trainee confidence, and antibiotic prescription rates were evaluated.

RESULTS

Amongst 188 children, 375 ears were examined by 85 trainees and 22 supervisors. The digital otoscope was utilized in 92 (48.9%) exams and 96 (51.1%) used the traditional otoscope. Accuracy of ear exam findings between trainees and supervisors improved by 11.2% (95% CI: 1.5, 21.8%, p = 0.033) using the Cellscope Oto (74.8%, 95% CI: 67.3, 82.1%) compared to the traditional otoscope (63.5%, 95% CI: 56.7, 70.4%). Fewer repeat supervisor exams were performed in the digital otoscope group (27.2%) vs. the traditional otoscope group (97.9%) (p < 0.001). There was no difference in mean trainee confidence in their examination (p = 0.955) or antibiotic prescription rates when using digital versus traditional otoscopes (p = 0.071).

CONCLUSIONS

Utilization of a digital otoscope resulted in increased accuracy of the ear exam between trainees and supervisors, and fewer total number of examinations performed on a given child. Compared to a traditional otoscope, a digital otoscope may be a more efficient and effective diagnostic tool.

Incidence and predictors of attrition among children attending antiretroviral follow-up in public hospitals, Southern Ethiopia, 2020: a retrospective study

BACKGROUND

It is a global challenge to enrol and retain paediatric patients in HIV/AIDS care. Attrition causes preventable transmission, stoppable morbidity and death, undesirable treatment outcomes, increased cost of care and drug resistance. Thus, this study intended to investigate the incidence and predictors of attrition among children receiving antiretroviral treatment (ART).

METHOD

A retrospective follow-up study was conducted among children <15 years who had ART follow-up in Gedeo public hospitals. After collection, data were entered into Epi-data V.4.6, then exported to and analysed using STATA V.14. Data were described using the Kaplan-Meier statistics, life table and general descriptive statistics. The analysis was computed using the Cox proportional hazard regression model. Covariates having <0.25 p values in the univariate analysis (such as developmental stage, nutritional status, haemoglobin level, adherence, etc) were fitted to multivariable analysis. Finally, statistical significance was declared at a p value of <0.05.

RESULTS

An overall 254 child charts were analysed. At the end of follow-up, attrition from ART care was 36.2% (92 of 254), of which 70 (76.1%) were lost to follow-up, and 22 (23.9%) children died. About 8145.33 child-months of observations were recorded with an incidence attrition rate of 11.3 per 1000 child-months (95% CI: 9.2 to 13.9), whereas the median survival time was 68.73 months. Decreased haemoglobin level (<10 g/dl) (adjusted HR (AHR)=3.1; 95% CI: 1.4 to 6.9), delayed developmental milestones (AHR=3.6; 95% CI: 1.2 to 10.7), underweight at baseline (AHR=5.9; 95% CI: 1.6 to 21.7), baseline CD4 count ≤200 (AHR=4.4; 95% CI: 1.6 to 12.2), and poor or fair ART adherence (AHR=3.5; 95% CI: 1.5 to 7.9) were significantly associated with attrition.

CONCLUSION AND RECOMMENDATION

Retention to ART care is challenging in the paediatrics population, with such a high attrition rate. Immune suppression, anaemia, underweight, delayed developmental milestones and ART non-adherence were independent predictors of attrition to ART care. Hence, it is crucial to detect and control the identified predictors promptly. Serious adherence support and strengthened nutritional provision with monitoring strategies are also essential.

Infectious Disease and Primary Care Research-What English General Practitioners Say They Need

BACKGROUND

Infections are one of the most common reasons for patients attending primary care. Antimicrobial resistance (AMR) is perhaps one of the biggest threats to modern medicine; data show that 81% of antibiotics in the UK are prescribed in primary care.

AIM

To identify where the perceived gaps in knowledge, skills, guidance and research around infections and antibiotic use lie from the general practitioner (GP) viewpoint.

DESIGN AND SETTING

An online questionnaire survey.

METHOD

The survey, based on questions asked of Royal College of General Practitioners (RCGP) members in 1999, and covering letter were electronically sent to GPs between May and August 2017 via various primary care dissemination routes.

RESULTS

Four hundred and twenty-eight GPs responded. Suspected Infection in the elderly, recurrent urinary tract infection (UTI), surveillance of AMR in the community, leg ulcers, persistent cough and cellulitis all fell into the top six conditions ranked in order of importance that require further research, evidence and guidance. Acute sore throat, otitis media and sinusitis were of lower importance than in 1999.

CONCLUSION

This survey will help the NHS, the UK National Institute for Health and Care Excellence (NICE) and researchers to prioritise for the development of guidance and research for chronic conditions highlighted for which there is little evidence base for diagnostic and management guidelines in primary care. In contrast, 20 years of investment into research, guidance and resources for acute respiratory infections have successfully reduced these as priority areas for GPs.

The "TIP algorithm" for the accurate diagnosis of pediatric otitis media

OBJECTIVES

The authors studied the correlation between the grading TIP which evaluates three otoendoscopic characteristics of the tympanic membrane (TM) (transparency, integrity and position) with the gold standard represented by the impedenzometry.

METHODS AND MATERIALS

Cross-sectional studies with independent and blind comparison with the gold standard diagnostic. The setting was primary care and ambulatory. 115 TMs were examined (57 right and 58 left) of 60 children (36 males and 24 females) and classified according to the TIP grading (transparency, integrity, position). Each patient underwent otoendoscopy to obtain TIP grading and subsequently to tympanometry, which was considered the gold standard for diagnosis. The Transparency is the condition in which at least one or more structures behind the TM are visible: promontory, incudo-malleolar and incudo-stapedial articulations. The Integrity is such when no holes in the TM are visible. The TM must be displayed up to the anulus. The position of the TM is evaluated according to the handle and the short apophysis of the malleus. The correlation between TIP grade and tympanometry was measured by the "Chi Square" test.

RESULTS

The method showed an average sensitivity and specificity of the three TIP parameters (TIP1 TIP2, TIP 4) versus tympanometry of 95.6% (I.C. 90.1-98.5); PPV and PPN 95.6 (I.C 90.3%-98.1%) Positive Likelihood Ratio 22,000 (I.C. 9.327 to 51.894) Negative Likelihood Ratio 0.045 0.019 to 0.107.

CONCLUSION

Grading TIP is a valid method for accurate diagnosis of pediatric otitis media and can predict the tympanometry result with high statistical significance.

Community-Based Accompaniment and the Impact of Distance for HIV Patients Newly Initiated on Antiretroviral Therapy: Early Outcomes and Clinic Visit Adherence in Rural Rwanda

Community-based accompaniment (CBA) has been associated with improved antiretroviral therapy (ART) patient outcomes in Rwanda. In contrast, distance has generally been associated with poor outcomes. However, impact of distance on outcomes under the CBA model is unknown. This retrospective cohort study included 537 adults initiated on ART in 2012 in two rural districts in Rwanda. The primary outcomes at 6 months after ART initiation included overall program status, missed a visit and missed three consecutive visits. The associations between cost surface distance (straight-line distance adjusted for surface features) and outcomes were assessed using logistic regression, controlling for potential confounders. Died/lost-to-follow-up and missed three consecutive visits were not associated with distance. Patients within 0-1 km cost surface distance were significantly more likely to miss a visit, potentially due to stigma of attending clinic within one's community. These results suggest that CBA may mediate the impact of long distances on outcomes.

Diagnostic accuracy of a general practitioner with video-otoscopy collected by a health care facilitator compared to traditional otoscopy

OBJECTIVE

Video-otoscopy is rapidly developing as a new method to diagnose common ear disease and can be performed by trained health care facilitators as well as by clinicians. This study aimed to compare remote asynchronous assessments of video-otoscopy with otoscopy performed by a general practitioner.

METHOD

Children, aged 2-16 years, attending a health center in Johannesburg, South Africa, were examined. An otologist performed otomicroscopy and a general practitioner performed otoscopy. Video-otoscopy was performed by a health care facilitator and video sequences were stored on a server for assessment by the same general practitioner 4 and 8 weeks later. At all examinations, a diagnosis was set and the tympanic membrane appearance was graded using the OMgrade-scale. The otologist's otomicroscopic diagnosis was set as reference standard to compare the accuracy of the two otoscopic methods.

RESULTS

Diagnostic agreement between otologist's otomicroscopic examination and the general practitioner's otoscopic examination was substantial (kappa 0.66). Agreement between onsite otomicroscopy and the general practitioners asynchronous video assessments were also substantial (kappa 0.70 and 0.80).

CONCLUSION

Video-otoscopy performed by a health care facilitator and assessed asynchronously by a general practitioner had similar or better accuracy compared to face-to-face otoscopy performed by a general practitioner.

Otitis media

Otitis media (OM) or middle ear inflammation is a spectrum of diseases, including acute otitis media (AOM), otitis media with effusion (OME; 'glue ear') and chronic suppurative otitis media (CSOM). OM is among the most common diseases in young children worldwide. Although OM may resolve spontaneously without complications, it can be associated with hearing loss and life-long sequelae. In developing countries, CSOM is a leading cause of hearing loss. OM can be of bacterial or viral origin; during 'colds', viruses can ascend through the Eustachian tube to the middle ear and pave the way for bacterial otopathogens that reside in the nasopharynx. Diagnosis depends on typical signs and symptoms, such as acute ear pain and bulging of the tympanic membrane (eardrum) for AOM and hearing loss for OME; diagnostic modalities include (pneumatic) otoscopy, tympanometry and audiometry. Symptomatic management of ear pain and fever is the mainstay of AOM treatment, reserving antibiotics for children with severe, persistent or recurrent infections. Management of OME largely consists of watchful waiting, with ventilation (tympanostomy) tubes primarily for children with chronic effusions and hearing loss, developmental delays or learning difficulties. The role of hearing aids to alleviate symptoms of hearing loss in the management of OME needs further study. Insertion of ventilation tubes and adenoidectomy are common operations for recurrent AOM to prevent recurrences, but their effectiveness is still debated. Despite reports of a decline in the incidence of OM over the past decade, attributed to the implementation of clinical guidelines that promote accurate diagnosis and judicious use of antibiotics and to pneumococcal conjugate vaccination, OM continues to be a leading cause for medical consultation, antibiotic prescription and surgery in high-income countries.

Remote evaluation of video-otoscopy recordings in an unselected pediatric population with an otitis media scale

BACKGROUND

A recently validated image-based grading scale for acute otitis media (OMGRADE) can be used to assess tympanic membrane (TM) status. The aim of this study was to evaluate the validity and reliability of this scale for remote assessments of TM status using video-otoscopy recordings in an unselected pediatric population.

METHOD

Children 2-16 years attending a South African primary health clinic were offered an ear examination by an otologist using otomicroscopy. An ear and hearing telehealth facilitator then made video-otoscopy recordings (9-33s) of the ears and uptakes were uploaded to a secure server for remote assessments in Sweden by an otologist and general practitioner at four- and eight-weeks post onsite assessment. TM appearance was judged according to the OMGRADE scale. Concordance between onsite otomicroscopy and asynchronous assessments of video-otoscopy recordings was calculated together with intra- and inter-rater agreements.

RESULTS

One hundred and eighty ears were included. Concordance of TM classifications using the OMGRADE scale was found to be substantial (weighted kappa range 0.66-0.79). Intra- and inter-rater agreement (test-retest) was found to be substantial to almost perfect (weighted kappa range 0.85-0.88 and 0.69-0.72, respectively).

CONCLUSION

The OMGRADE scale can be used to accurately assess the normal TM and secretory otitis media (SOM) remotely using video-otoscopy recordings in an unselected pediatric population.

Factors Determining Survival and Retention among HIV-Infected Children and Adolescents in a Community Home-Based Care and a Facility-Based Family-Centred Approach in Kampala, Uganda: A Cohort Study

We describe factors determining retention and survival among HIV-infected children and adolescents engaged in two health care delivery models in Kampala, Uganda: one is a community home-based care (CHBC) and the other is a facility-based family-centred approach (FBFCA). This retrospective cohort study reviewed records from children aged from 0 to 18 years engaged in the two models from 2003 to 2010 focussing on retention/loss to follow-up, mortality, use of antiretroviral therapy (ART), and clinical characteristics. Kaplan Meier survival curves with log rank tests were used to describe and compare retention and survival. Overall, 1,623 children were included, 90.0% (1460/1623) from the CHBC. Children completed an average of 4.2 years of follow-up (maximum 7.7 years). Median age was 53 (IQR: 11-109) months at enrolment. In the CHBC, retention differed significantly between patients on ART and those not (log-rank test, adjusted, P < 0.001). Comparing ART patients in both models, there was no significant difference in long-term survival (log-rank test, P = 0.308, adjusted, P = 0.489), while retention was higher in the CHBC: 94.8% versus 84.7% in the FBFCA (log-rank test, P < 0.001, adjusted P = 0.006). Irrespective of model of care, children receiving ART had better retention in care and survival.

Description of the cascade of care and factors associated with attrition before and after initiating antiretroviral therapy of HIV infected children in a cohort study in India

In low- and middle-income countries, the attrition across the continuum of care of HIV infected children is not well known. The aim of this study was to investigate predictors of mortality and loss to follow up (LTFU) in HIV infected children from a cohort study in India and to describe the cascade of care from HIV diagnosis to virological suppression after antiretroviral therapy (ART) initiation. Multivariable analysis was performed using competing risk regression. The cumulative incidence of attrition due to mortality or LTFU after five year of follow-up was 16% from entry into care to ART initiation and 24.9% after ART initiation. Of all children diagnosed with HIV, it was estimated that 91.9% entered into care, 77.2% were retained until ART initiation, 58% stayed in care after ART initiation, and 43.4% achieved virological suppression on ART. Approximately half of the attrition occurred before ART initiation, and the other half after starting ART. Belonging to socially disadvantaged communities and living >90 min from the hospital were associated with a higher risk of attrition. Being >10 years old and having higher 12-month risk of AIDS (calculated using the absolute CD4 lymphocyte count and the age) were associated with an increased risk of mortality. These findings indicate that we should consider placing more emphasis on promoting research and implementing interventions to improve the engagement of HIV infected children in pre-ART care. The results of this study can be used by HIV programmes to design interventions aimed at reducing the attrition across the continuum of care of HIV infected children in India.