Pilot evaluation of a virtual training program for child injury prevention

Unintentional injuries are a leading cause of child death. The present study evaluated the effectiveness of a behavioral injury prevention program for children aged 3-18 years and their caregivers. To accommodate families during the Coronavirus-19 pandemic, training was modified to be delivered virtually. Forty-one children aged 3-18 years and 14 parents/caregivers of children aged 3-5 years attended one of several 4-hour online injury prevention training sessions directed toward residents of Washington state. Training was targeted to three different developmental stages (ages 3-5, 6-12 and 13-18 years). Study outcomes included knowledge about injury prevention strategies, perceived vulnerability for injury, self-efficacy to engage in safety behaviors and behavioral intentions to be safe. Following training, participants showed improved self-efficacy to stay safe, excellent knowledge about the learned material and increased behavioral intention to engage safely. There was minimal change in perceived vulnerability to injury among children; caregivers of young children felt their children were somewhat less vulnerable to injury following the training. Almost all participants said they would recommend the program to others. Results suggest that a virtual behavioral training program delivered remotely is feasible and may be effective to create behavior change and reduce child injury risk. Given its scalability and reach, such programs are recommended for further study, refinement and, if demonstrated effective in larger-scale controlled trials, dissemination to address the leading cause of child mortality in the United States, unintentional injury.

P-787 Factors associated with live birth rate (LBR) and multiple live birth rate (mLBR): UK vs France registries

Study question

Do the associations between age, previous attempts, frozen and day-5 transfers relative to LBR and mLBR differ between national registries (UK vs France)?

Summary answer

Both registries agree age negatively correlates with LBR and mLBR; disagree on effects of frozen transfers, previous attempts and day-5 transfers on LBR and mLBR.

What is known already

Due to the high risks of multiple pregnancy, the focus of ART success was shifted from having a high number of live birth rate (LBR) to one full-term, healthy baby and a low multiple live birth rate (mLBR). Elective single embryo transfer (eSET) has been an effective strategy for reducing the risk of mLBR but in most guidelines, it is recommended for young patients (<35 years) only. There is extensive evidence from large-scale studies characterising how factors, seen in eSET policies, affect LBR. However, only a few studies focus on mLBR.

Study design, size, duration

A retrospective analysis of two national registry datasets, HFEA (UK) (N = 442042; 2014-2018) and ABM (France) (N = 305142; 2014-2018), evaluating how age (<35 yrs, 35-37 yrs, 38-40 yrs, >41 yrs), fresh/frozen embryo transfer (ET), previous attempts (0, 1, 2, 3, 4, 5 attempts), and embryo stage (day-5 or day-3 transfers) impact LBR and mLBR following eSET (control group) and multiple embryo transfer (MET) (treatment group).

Participants/materials, setting, methods

Statistical analyses of the datasets were conducted using adjusted two-sided odds ratios from chi-squared tests with 95% confidence intervals (α = 0.05) with Bonferroni correction.

Main results and the role of chance

Two registries agreed on the negative correlation between age and LBR (HFEA: eSET OR:1.00-0.79-0.73-0.57, p < 0.001; MET OR:1.00-0.85-0.74-0.55, p < 0.001; ABM: eSET OR:1.00-0.75-0.71-0.52, p < 0.001; MET OR:1.00-0.80-0.69-0.50, p < 0.001) and mLBR following MET (HFEA OR:1.00-0.79-0.70-0.71, p < 0.001; ABM OR:1.00-0.74-0.74-0.59, p < 0.001). mLBR following eSET remained constant with increasing age in both datasets (HFEA OR:1.00-0.91-0.92-1.34, NS; ABM OR:1.00-0.87-1.02-1.13, NS). LBR was significantly higher for fresh vs frozen eSET in both datasets (HFEA OR:1.36, p < 0.001; ABM OR:1.83, p < 0.001). However, HFEA showed no significant difference in LBR between fresh and frozen MET (OR:0.98, NS), whereas LBR in fresh MET was significantly higher in ABM (OR:1.28, p < 0.001). There was disagreement on fresh vs frozen ET mLBR (HFEA: eSET OR:1.10, NS; MET OR:0.97, NS; ABM: eSET OR:0.81, p < 0.05; MET OR:1.36, p < 0.001). Registry results differed regarding the impact of previous attempts on LBR and mLBR.Day-5 ETs had significantly higher LBR compared to day-3 (HFEA eSET OR:1.29, p < 0.001; MET OR:1.37, p < 0.001; ABM: eSET OR:1.50, p < 0.001; MET OR:1.35, p < 0.001). mLBR was significantly higher following day-5 MET (HFEA OR:1.59, p < 0.001; ABM OR:1.27, p < 0.001) but only significantly higher following eSET in the French registry (HFEA OR:0.64, NS; ABM OR:1.40, p < 0.01).

Limitations, reasons for caution

Limitations included selection bias due to the retrospective design of the study, as a result, the populations include predominantly caucasian, European populations. The conclusions drawn relate to the practices from particular countries, so it is important to evaluate multiple, more diverse datasets.

Wider implications of the findings

It is encouraging that both registries agreed on the effects of age, whilst remaining factors were not generalizable and require further assessment. This study demonstrated that even large, national registries contain inherent biases and policymakers should not draw policies based on one dataset, especially when prospective trial is not feasible.

Trial registration number

N/A

P–165 Using Artificial Intelligence to Classify Embryo Shape: An International Perspective

Study question

Is a pre-trained machine learning algorithm able to accurately detect cellular arrangement in 4-cell embryos from a different continent?

Summary answer

Artificial Intelligence (AI) analysis of 4-cell embryo classification is transferable across clinics globally with 79% accuracy.

What is known already

Previous studies observing four-cell human embryo configurations have demonstrated that non-tetrahedral embryos (embryos in which cells make contact with fewer than 3 other cells) are associated with compromised blastulation and implantation potential. Previous research by this study group has indicated the efficacy of AI models in classification of tetrahedral and non-tetrahedral embryos with 87% accuracy, with a database comprising 2 clinics both from the same country (Brazil). This study aims to evaluate the transferability and robustness of this model on blind test data from a different country (France).

Study design, size, duration

The study was a retrospective cohort analysis in which 909 4-cell embryo images (“tetrahedral”, n = 749; “non-tetrahedral”, n = 160) were collected from 3 clinics (2 Brazilian, 1 French). All embryos were captured at the central focal plane using Embryoscope™ time-lapse incubators. The training data consisted solely of embryo images captured in Brazil (586 tetrahedral; 87 non-tetrahedral) and the test data consisted exclusively of embryo images captured in France (163 tetrahedral; 72 non-tetrahedral).

Participants/materials, setting, methods

The embryo images were labelled as either “tetrahedral” or “non-tetrahedral” at their respective clinics. Annotations were then validated by three operators. A ResNet–50 neural network model pretrained on ImageNet was fine-tuned on the training dataset to predict the correct annotation for each image. We used the cross entropy loss function and the RMSprop optimiser (lr = 1e–5). Simple data augmentations (flips and rotations) were used during the training process to help counteract class imbalances.

Main results and the role of chance

Our model was capable of classifying embryos in the blind French test set with 79% accuracy when trained with the Brazilian data. The model had sensitivity of 91% and 51% for tetrahedral and non-tetrahedral embryos respectively; precision was 81% and 73%; F1 score was 86% and 60%; and AUC was 0.61 and 0.64. This represents a 10% decrease in accuracy compared to when the model both trained and tested on different data from the same clinics.

Limitations, reasons for caution

Although strict inclusion and exclusion criteria were used, inter-operator variability may affect the pre-processing stage of the algorithm. Moreover, as only one focal plane was used, ambiguous cases were interpoloated and further annotated. Analysing embryos at multiple focal planes may prove crucial in improving the accuracy of the model.

Wider implications of the findings: Though the use of machine learning models in the analysis of embryo imagery has grown in recent years, there has been concern over their robustness and transferability. While previous results have demonstrated the utility of locally-trained models, our results highlight the potential for models to be implemented across different clinics.

Trial registration number

Not applicable

P–378 Using a machine learning tool (72% accuracy with 64% PPV) to predict multiple live birth when transferring multiple embryos, based on embryo specific data

Study question

Can Machine Learning predict multiple pregnancy based on data specific to the embryos and the patient?

Summary answer

Embryo data are useful in determining which embryos are likely to lead to multiple pregnancy. Patient age has low predictive value compared to embryo data.

What is known already

Our previous assessment of the HFEA data demonstrated that single embryo transfer (SET) in the UK occurred in a minority (45%) of fresh cycles, with a marginal increase in live birth rate (LBR) in some patient cohorts in favor of multiple embryo transfer (MET). Current policies on determining number of embryos for transfer tend to be generic and do not account for detailed embryology data. Generic policies may compromise LBR for some patients that would benefit from MET. Artificial Intelligence has the potential to assist in this decision process.

Study design, size, duration

Retrospective cohort analysis from 2013 to 2020 of 193 cycles with 386 embryos used in double ETs on day 5 at POMA fertility clinic with positive live birth outcome. ML model, xgboost, was trained to predict multiple live birth (N = 54) versus single live birth (N = 139). Detailed embryology data from day 1 to day 5 were used as input.

Participants/materials, setting, methods

Input of the machine learning model included patient age and 18 morphological parameters collected on days 1, 2, 3 and 5 (symmetry, number of cells, blastocyst status, fragmentation, ICM and troph grades) from the two transferred embryos. An xgboost algorithm was trained on 80% of the data (n = 154) and tested on 20% of blind data (n = 39).

Main results and the role of chance

Xgboost machine learning algorithm predicted multiple live birth on the blind dataset with an accuracy of 72%, with an AUC of 0.60, showing better results than random. PPV (true prediction of multiple births) was 64% and NPV (true prediction of single birth) was 75%.

The following parameters ranked high in the predictive power of the machine learning (in order of predictive power): blastocyst status on day 5 of both embryos, symmetry on day 3, number of cells on day 2, scores on day 2 and 3. Limitations, reasons for caution: The dataset was derived from a single clinic with manual annotations and may not be transferable to other clinics. The risk of bias is important as the model was trained only àon embryos that were transferred and led to at least one birth

Wider implications of the findings: A tool to help identify which patients are at increased risk of MP with MET would be clinically useful to help patients and clinical team make the best personalised decision for a specific embryo, finding the balance between maximising success rate whilst minimising multiple pregnancy rate and its associated risks.

Trial registration number

Not applicable

No stone unturned: Nodule Net, an intervention to reduce loss to follow-up of lung nodules

OBJECTIVE

Inadequate lung nodule surveillance leads to diagnostic delays. We implemented a retrospective intervention program, Nodule Net, to improve surveillance in our hospital.

METHODS

9,224 Chest computed tomography (CT) scans between January 1, 2015 and December 31, 2016 were manually reviewed for lung nodules. For patients without follow-up, charts were reviewed to assess follow-up. If follow-up appeared indicated, the clinician or patient was contacted, and follow-up was tracked.

RESULTS

Lung nodules were identified on 5,101 (55%) of 9,224 scans. Follow-up was potentially indicated and not completed in 1,385 (27%). 183 (13%) were excluded after imaging review. 1,202 received outreach. Of the 801 (66%) with a provider in our system, 225 (27%) returned for follow-up. Nodules were stable in 199 (88%), new or growing in 23 (11%), resolved in 3 (1%), and stage 1 lung cancer in 2 (1%). 90 (11%) had follow-up outside our system and 431 (51%) had no follow-up due to a clinical contraindication. 55 (7%) have imaging pending and 14 (2%) are awaiting pulmonary evaluation. Of the 302 (25%) patients with providers outside our system, 121 (40%) had followed-up elsewhere. 146 (48%) had no follow-up due to a clinical reason. 35 (12%) providers did not respond to outreach.

CONCLUSIONS

We identified 1,202 patients with lung nodules who needed follow-up over a two-year period. Compliance was more successful with providers within our hospital system. We recommend robust surveillance for patients to ensure follow-up is completed and clinical contraindications are well documented.

British Society for Immunology/United Kingdom Primary Immunodeficiency Network consensus statement on managing non-infectious complications of common variable immunodeficiency disorders

Common variable immunodeficiency (CVID) represents a heterogeneous group of rare disorders. There is considerable morbidity and mortality as a result of non-infectious complications, and this presents clinicians with management challenges. Clinical guidelines to support the management of CVID are urgently required. The UK Primary Immunodeficiency Network and the British Society for Immunology funded a joint project to address this. A modified Delphi Survey was conducted for the assessment, diagnosis and treatment of the non-infectious blood, respiratory, gut and liver complications of CVID. A steering group of 10 consultant immunologists and one nurse specialist developed and reviewed the survey statements and agreed the final recommendations. In total, 22 recommendations and three areas for research were developed.

Randomized controlled trial assessing two commercial weight loss programs in adults with overweight or obesity

Objective

Lifestyle interventions remain the cornerstone for obesity treatment. Commercial programs offer one weight loss approach, yet the efficacy of few such programs have been rigorously investigated. The purpose of this study was to evaluate the efficacy of two commercial weight-loss programs, both utilizing pre-portioned meal replacements (MRs) and different levels of behavioural support, compared to a self-directed control diet in adults with overweight and obesity.

Methods

In this 16-week study, participants were randomized to the low-calorie OPTAVIA® 5&1 Plan® with telephone coaching (OPT), the reduced-calorie Medifast® 4&2&1 self-guided plan (MED), or a self-directed, reduced-calorie control diet. Differences in weight, body composition (DXA) and body circumferences, all measured monthly, were assessed by analysis of covariance with sex and baseline measures as covariates.

Results

Of 198 participants randomized (80.8% female, BMI 34.2 kg/m², 45.7 years), 92.3% completed the study. The OPT and MED groups had significantly greater reductions in body weight (-5.7% and - 5.0%, respectively, p < 0.0001), fat and abdominal fat mass (p < 0.0001) and waist and hip circumferences (p ≤ 0.003) than control at 16 weeks. Weight change was correlated with MR usage and completion of coaching support calls.

Conclusions

Both structured commercial programs were more efficacious than a self-directed, reduced-calorie diet for weight loss and other anthropometric measures. Evidence-based commercial programs can be an important tool to help adults with overweight and obesity lose clinically relevant amounts of weight.

Section for Residents and Fellows-in-Training Leaders: Where Are They Now?

The purpose of this study was to examine the experiences of prior governing council (GC) members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) and assess the impact of early Academy involvement. A survey was conducted via email on all prior AAO-HNS SRF GC members. The AAO-HNS SRF has elected 52 GC members since its 2003 inception. Each member served an average of 1.5 year-long terms. The mean time since completion of training is 4.1 years. A subspecialty fellowship was pursued in 86%. Fifty-seven percent practice in academic settings, with 3 members advancing to subspecialty division director within their department. More than half (58%) have served on an AAO-HNS committee, and most are frequent attendees of the annual meeting. All prior members felt involvement in the SRF GC was beneficial, enabling them to gain leadership skills and deeper understanding of the specialty.

Section for Residents and Fellows Leaders: Where Are They Now?

Objectives:

1) Look at the experiences of prior governing council (GC) members of the American Academy of Otolaryngology (AAO) Section for Residents and Fellows (SRF), and 2) assess the impact of early Academy involvement.

Methods:

Survey of all prior members of the AAO SRF GC.

Results:

The AAO-SRF has elected 52 GC members since its 2003 inception. Ten members are currently in training, and no data were obtained for 3. The remaining 38 prior GC members were analyzed. Each member served an average of 1.5 years (terms ranged 1 - 3 years). The mean time since completion of training to present is 4.1 years (range 0 - 10 years). A subspecialty fellowship was pursued in 86%, with 92% matching into their fellowship field of choice. Fifty-seven percent practice in an academic setting, with 3 members advancing to a subspecialty division director within their department. All prior GC members are current AAO members. Over half (59%) have served on an AAO committee, and most are frequent attendees of the annual meeting. When asked, “What did being on the SRF GC do for you?”, the most common responses included understanding the importance of the AAO and involvement in it, networking, and leadership experience.

Conclusions:

All prior SRF GC members felt involvement in the SRF GC was a beneficial experience, enabling them to gain leadership skills and a deeper understanding of the inner-workings of our specialty. Most prior SRF GC members have pursued fellowship training and remain involved in the Academy.

Section for residents and fellows-in-training survey results

OBJECTIVES

(1) To present data from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Section for Residents and Fellows-in-Training (SRF) annual survey from 2002 to 2011. (2) To compare and analyze trends in resident demographics, residency experiences, and post-training career choices.

STUDY DESIGN

Review of cross-sectional survey data.

SETTING

Residents and Fellows registered as Members-in-Training through AAO-HNS.

METHODS

A review of data from surveys distributed between 2002 and 2011 was conducted. Respondent demographic data including age, postgraduate year, gender, and geographic distribution were analyzed. Responses about training experiences, fellowship selection, debt burden, and post-training practice choice were studied in order to elicit trends.

RESULTS

Respondents have consistently rated otolaryngology, anesthesia, and trauma/critical care as the most important intern rotations for otolaryngology residents. Each year, approximately 70% of respondents have reported interest in pursuing a fellowship. Pediatric otolaryngology fellowship is now the most popular fellowship among respondents. There has been a recent increase in the percentage of respondents who are interested in pursuing a career in academics. Location, family, and lifestyle have consistently been the most important factors in determining choice of practice. Respondents have reported increasing levels of educational debt.

CONCLUSION

The AAO-HNS SRF survey collects important data regarding resident/fellow training. Several factors limit the generalizability of these results. Despite its limitations, these unique data provide valuable information for continual evaluation and improvement of physician training in the specialty.

Section for Residents and Fellows-in-Training Survey Results

Objective: 1) To present data from the Section for Residents and Fellows-in-Training (SRF) annual survey from 2002-2011. 2) To compare and analyze trends in resident demographics and posttraining career choices.

Method: We conducted a retrospective review of data from surveys distributed between 2002 and 2011. Respondent demographic data including age, postgraduate year, gender, and geographic distribution were analyzed. Responses about training experiences, fellowship selection, debt burden, and posttraining practice choice were studied in order to elicit trends.

Results: Respondents have consistently rated otolaryngology, anesthesia, and trauma/critical care as the most important intern rotations for otolaryngology residents. Each year, approximately 70% of respondents have reported interest in pursuing a fellowship. Pediatric otolaryngology fellowship is now the most popular fellowship among respondents. There has been a recent increase in the percentage of respondents who are interested in pursuing a career in academics. Location, family, and lifestyle have consistently been the most important factors in determining choice of practice. Respondents have reported increasing levels of educational debt over the 10 years of the survey.

Conclusion: The AAO-HNS SRF survey is an opportunity to collect important data regarding resident/fellow training. Several factors limit the generalizability of these results. Despite its limitations, these unique data provide valuable information for continual evaluation and improvement of physician training in the specialty.

Effect of continuous positive airway pressure on C-reactive protein levels in sleep apnea: a meta-analysis

OBJECTIVE

Evaluate the effects of continuous positive airway pressure (CPAP) on C-reactive protein (CRP) levels, reported either as a primary or secondary end point among patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) based on a meta-analysis of published studies.

DATA SOURCES

English-language searches of PubMed, Ovid, and the Cochrane databases were completed. Reference sections of identified studies were also examined for additional relevant articles to review.

REVIEW METHODS

Studies of adult patients with OSAHS who reported pre- and post-CPAP treatment CRP were reviewed and analyzed. Two independent reviewers extracted data from 10 peer-reviewed studies, which were combined using a random effects meta-analysis model.

RESULTS

The CPAP treatment was found to lead to a significant reduction in CRP levels (17.8%, P = .002). This corresponds to an effect size of -0.485 (-0.731, -0.240). Sensitivity analysis was done to determine the impact of study design. Both case-control studies and case-series studies yielded a significant effect. Sensitivity analysis also yielded a significant effect for studies with average body mass index <30, studies where CPAP was employed over automatic positive airway pressure, and studies treating patients ≤ 3 months. Analysis of publication bias, however, revealed a likelihood of "missing" studies.

CONCLUSION

Although there is a significant lack of high-quality studies addressing this question, this analysis suggests that treatment with CPAP leads to a statistically significant reduction in CRP levels. However, the mean pre- and posttreatment CRP levels observed are considered "high risk" for cardiovascular morbidity. The clinical significance of this finding as it relates to cardiovascular risk reduction and the relationship between CRP and OSAHS requires further study.

Modified Adenotonsillectomy to Improve Cure Rates for Pediatric Obstructive Sleep Apnea

Objective

To compare the efficacy of adenotonsillectomy (T&A) with and without pharyngoplasty (tonsillar pillar closure) in the treatment of pediatric obstructive sleep apnea-hypopnea syndrome (OSAHS).

Study Design

Randomized single-blind controlled study.

Setting

Tertiary care center.

Subjects and Methods

Sixty pediatric patients with a clinical diagnosis of OSAHS presenting between January 2009 and December 2010 were enrolled and randomized to undergo either standard T&A (n = 30) or T&A with pharyngoplasty (n = 30). Surgical cure was defined as apnea-hypopnea index (AHI) <5 plus OSA-18 health-related quality-of-life (HRQL) score <60. Other outcomes included postsurgical AHI and minimum oxygen saturation (SpO2) improvement, changes in OSA-18 scores at 1 month, and postsurgical days to resume normal diet and activity.

Results

Three patients from each group did not undergo surgery. Of the 54 patients treated, 8 from the pharyngoplasty group and 2 from the standard group were lost to follow-up. Intention-to-treat analysis revealed no difference in cure rate between groups (standard 60%, pharyngoplasty 56.6%, P = .793). Limiting analysis to those patients with complete data, a higher, but not significantly increased, cure rate with pharyngoplasty was noted (72% vs 89.5%, P = .155). Greater OSA-18 improvement ( P = .036) and greater (although nonsignificant) AHI improvement and earlier return to normal function were noted with pharyngoplasty.

Conclusion

The addition of pharyngoplasty to traditional adenotonsillectomy did not significantly improve OSAHS cure rates as measured by sleep testing and HRQL, although a nonsignificant increase in cure rate was observed in those who completed the study protocol. An unexpectedly high rate of patient dropout rendered the study statistically underpowered and therefore inconclusive.

Compliance and efficacy of titratable thermoplastic versus custom mandibular advancement devices

OBJECTIVE

To share our experiences treating patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) with titratable thermoplastic (TPD) and custom-made mandibular advancement devices (MAD) and to compare these devices in terms of objective improvement and cure and treatment success (improvement/cure plus adherence at 6 months).

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Patients with OSAHS who failed or refused both continuous positive airway pressure (CPAP) and surgery had a titratable oral appliance fitted. Patients were offered an office-fitted TPD or a custom-made dentist-fitted device. Assessment included pretreatment and appliance-titration polysomnography (PSG). Improvement was defined as ≥ 50% apnea-hypopnea index (AHI) reduction plus posttreatment AHI <20, and cure was defined as AHI <5. Patients were contacted at 1 and 6 months regarding treatment adherence.

RESULTS

A total of 180 patients (123 TPD, 57 custom) with complete PSG data were reviewed. Improvement/cure were significantly better with the custom device overall (91.2%/71.9% vs 77.2%/52.0%, P = .024/.012). Adherence data at 1 and 6 months were obtained from 128/180 and 119/180 patients, respectively. Using an intention-to-treat analysis, those lost to follow-up were considered nonadherent. Adherence at 1/6 months was 64.9%/50.9% for custom versus 53.7%/32.5% for TPD (P = .156/.018), yielding treatment success rates (with initial improvement/cure) of 49.1%/40.4% for custom versus 27.6%/17.1% for TPD (P = .005/<.001) at 6 months.

CONCLUSION

Custom-fit devices achieve higher rates of objective improvement and cure of OSAHS than TPD at the time of titration-PSG. TPDs have a high acceptance rate, low cost, and reasonable initial improvement and cure rates of 77.2% and 52.0%, respectively, but significantly poorer 6-month compliance.

The Value of Routine pH Monitoring in the Diagnosis and Treatment of Laryngopharyngeal Reflux

Objective. To assess the need for pH testing in diagnosing laryngopharyngeal reflux (LPR).

Study Design. Case series with planned data collection.

Setting. Tertiary care center.

Subjects and Methods. On the basis of symptoms and/or abnormal endoscopic findings, more than 500 patients underwent 24-hour pharyngeal pH testing at a single center (using the Dx-pH probe) between January 2009 and June 2011. A total of 163 patients not on proton-pump inhibitors at the time of study and with complete data available for analysis (pH results, body mass index, smoking status, pretest reflux symptom index) were divided into 2 groups by positive (n = 70) and negative (n = 93) Ryan Score. The Reflux Symptom Index (RSI) was compared between groups and assessed overall against Ryan Score parameters at different pH thresholds. The diagnostic utility of an RSI ≥ 13 for prediction of Ryan Score was assessed.

Results. No significant difference in RSI was seen between Ryan-positive (17.50 ± 11.47) and Ryan-negative (14.95 ± 11.43) patients ( P = .161). Overall, RSI correlated poorly with percentage time spent below pH thresholds 6.5, 6.0, 5.5, and 5.0 and upright and supine Ryan parameters at these thresholds (as determined by linear regression analysis). The sensitivity, specificity, positive predictive value, and negative predictive value of RSI ≥ 13 for Ryan positivity were 55.7%, 47.3%, 44.3%, and 58.7%, respectively.

Conclusion. Our findings show that in our population of otolaryngology patients, the diagnosis of LPR cannot be reliably made on the basis of symptoms alone. Diagnosis, and in particular treatment decisions, should ideally be made on the basis of a combination of symptoms, signs, and confirmatory testing.

The value of routine pH monitoring in the diagnosis and treatment of laryngopharyngeal reflux

OBJECTIVE

To assess the need for pH testing in diagnosing laryngopharyngeal reflux (LPR).

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

On the basis of symptoms and/or abnormal endoscopic findings, more than 500 patients underwent 24-hour pharyngeal pH testing at a single center (using the Dx-pH probe) between January 2009 and June 2011. A total of 163 patients not on proton-pump inhibitors at the time of study and with complete data available for analysis (pH results, body mass index, smoking status, pretest reflux symptom index) were divided into 2 groups by positive (n = 70) and negative (n = 93) Ryan Score. The Reflux Symptom Index (RSI) was compared between groups and assessed overall against Ryan Score parameters at different pH thresholds. The diagnostic utility of an RSI ≥ 13 for prediction of Ryan Score was assessed.

RESULTS

No significant difference in RSI was seen between Ryan-positive (17.50 ± 11.47) and Ryan-negative (14.95 ± 11.43) patients (P = .161). Overall, RSI correlated poorly with percentage time spent below pH thresholds 6.5, 6.0, 5.5, and 5.0 and upright and supine Ryan parameters at these thresholds (as determined by linear regression analysis). The sensitivity, specificity, positive predictive value, and negative predictive value of RSI ≥ 13 for Ryan positivity were 55.7%, 47.3%, 44.3%, and 58.7%, respectively.

CONCLUSION

Our findings show that in our population of otolaryngology patients, the diagnosis of LPR cannot be reliably made on the basis of symptoms alone. Diagnosis, and in particular treatment decisions, should ideally be made on the basis of a combination of symptoms, signs, and confirmatory testing.

Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome

OBJECTIVE

In previous reports of transoral robotic surgery (TORS) for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS), patients underwent routine tracheotomy. We aim to assess the feasibility of performing robotically assisted partial glossectomy without tracheotomy and to assess efficacy by comparing OSAHS outcomes with those of established techniques.

STUDY DESIGN

Historical cohort study with planned data collection.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Forty consecutive patients underwent TORS for OSAHS between October 2010 and June 2011 and were followed up with regard to complications, morbidity, and subjective and objective outcomes. Data from 27 of these patients who underwent concomitant z-palatoplasty with 6-month follow-up were compared with those of 2 matched cohorts of patients, who underwent either radiofrequency (radiofrequency base-of-tongue reduction [RFBOT]) or coblation (submucosal minimally invasive lingual excision [SMILE]) reduction of the tongue base and z-palatoplasty.

RESULTS

No major bleeding or airway complications were observed. Postoperative pain and length of admission were similar between groups. All groups saw Epworth score and snore score improvement. Patients undergoing robot-assisted surgery took longer than their SMILE and RFBOT counterparts to tolerate normal diet and longer than RFBOT patients to resume normal activity. Apnea hypopnea index (AHI) reduction averaged 60.5% ± 24.9% for TORS versus 37.0% ± 51.6% (P = .042) and 32.0% ± 43.3% (P = .012) for SMILE and RFBOT, respectively. Only the robotic group achieved statistically significant improvement in minimum oxygen saturation. Surgical cure rate for TORS (66.7%) was significant compared with RFBOT (20.8%, P = .001) but not compared with SMILE (45.5%, P = .135).

CONCLUSION

Robotically assisted partial glossectomy feasibly can be performed without the need for tracheotomy. This technique resulted in greater AHI reduction but increased morbidity compared with the other techniques studied.

Reduction of CRP after CPAP Treatment of OSA: A Systematic Review and Meta-Analysis of the Literature

Objective: 1) Determine the effect of continuous positive airway pressure (CPAP) on C-reactive protein (CRP) levels in patients with obstructive sleep apnea (OSA). 2) Demonstrate the effect of CPAP on general health status using CRP as a marker for cardiovascular health.

Method: A computerized search was conducted using PubMed, Ovid, and the Cochrane database. A systematic review was preformed to identify studies that included CRP levels in adult patients (age >18 years) with OSA pre- and post-CPAP treatment.

Results: Initial search results identified 136 articles of which 64 articles then underwent second-stage review. Ten studies met the inclusion criteria and a meta-analysis was performed to determine the overall change in CRP levels. Meta-analysis included 325 subjects (mean sample size of 32.5 patients) with mean BMI of 33.12. The mean CRP level in patients with OSA decreased from 0.43 ± 0.39 mg/dL to 0.35 ± 0.346 mg/dL following CPAP treatment (p = 0.002).

Conclusion: In patients with OSA, CRP levels significantly decrease after CPAP therapy. Therefore, using CRP as a marker systemic inflammation, CPAP reduction of CRP levels may benefit patients’ cardiovascular health in addition to controlling OSA symptoms.

Treatment of Pediatric Obstructive Sleep Apnea beyond Tonsillectomy and Adenoidectomy

Objective: 1) Compare the efficacy of adenotonsillectomy with pharyngoplasty vs adenotonsillectomy alone in the treatment of pediatric OSAHS. 2) Compare the morbidity of adenotonsillectomy with pharyngoplasty vs adenotonsillectomy alone.

Method: Randomized single-blind controlled study of 60 pediatric patients treated between January 2009 to January 2010 at a tertiary care center. Patients were randomized into 2 groups: adenotonsillectomy alone (group I) and adenotonsillectomy with pharyngoplasty (group II). Endpoints included: pre- and postsurgical AHI, number of cures, pain levels, and change in OSA-18.

Results: Sixty patients were enrolled and 52 patients completed the study (group I n = 27, group II n = 25). The mean age, BMI, and baseline AHI did not differ significantly between the two groups. The change in AHI from pre- to postsurgery was not found to be significant between the 2 groups ( P = .337). No significant differences were found in the number of cures ( P = .709). There was no significant difference between groups for OSA-18 score ( P = .478). Pain outcomes measured on postoperative days 1 to 7 using VAS did not reveal a significant difference in pain levels.

Conclusion: With short-term follow-up, the addition of pillar closure to traditional adenotonsillectomy did not significantly improve sleep parameters as measured by polysomnogram or in quality of life as measured using the OSA-18. It is unknown if pharyngoplasty will have long-term benefits in preventing progression of OSA.

Symptoms of Laryngopharyngeal Reflux: Is It Really Reflux?

Objective: 1) Report the accuracy of subjective Reflux Symptom Index scores (RSI) and objective Reflux Finding Scores (RFS) in identifying patients with laryngopharyngeal reflux (LPR) using ambulatory pH monitoring as confirmation. 2) Present clinical recommendations for the use of subjective and objective tools in the diagnosis of LPR.

Method: Retrospective chart review of 300 adult outpatients from January 3, 2009 to December 30, 2010 in a tertiary care setting. Patients with a diagnosis of LPR based on abnormal RSI and positive findings on laryngeal endoscopic examination using RFS were tested for confirmation with a 24-hour oropharyngeal pH study using the Restech Dx-pH system.

Results: Among 300 consecutive patients with an RSI score >5, 58.6% were confirmed to have reflux after undergoing 24-hour oropharyngeal pH-monitoring. Of these 300 patients, 146 had an RFS score >5. Among patients with a RSI >5 and a RFS 5 and RFS>5 the positive predictive value (PPV) increased to 71.9% (105 of 146). Therefore, when combined, an RSI>5 and RFS>5 yields significantly higher PPV than RSI alone.

Conclusion: Patients with clinical signs and symptoms of LPR based on RSI alone do not demonstrate significant positive predictive value when confirmed with oropharyngeal pH testing, but predictive value is increased greatly when RSI and RSF are combined.

Thermoplastic Mandibular Advancement Devices for the Treatment of OSAHS

Objective: 1) Report our experience with custom-made and thermoplastic mandibular advancement devices (MADs). 2) Compare the cost, efficacy, and compliance of thermoplastic mandibular advancement devices vs custom made MADs.

Method: Retrospective review of 287 consecutive adult outpatients treated between July 2009 and August 2010. Compliance was assessed using chart review and phone interviews after 1 and 6 months. Endpoints included: 1. Efficacy measured by post-MAD AHI.

Results: The percentage of patients achieving AHI reduction criteria for efficacy was 70.3% and 72.2% for thermoplastic vs custom-made devices ( P = .204). Compliance more than 4 hours a night for 70% of nights within the first month after receiving MAD was 88.2% for thermoplastic vs 64.3% for custom-made ( P < .001). At 6 months compliance was 47.4% for thermoplastic devices vs 61.1% for custom devices ( P = .01). The average cost for the thermoplastic devices was $150 vs $1450 for the custom-made devices.

Conclusion: Thermoplastic devices resulted in slightly better compliance rate compared with the custom-made devices during the first month after prescription, but reversed at 6 months. Thermoplastic devices have the advantage of significantly lower cost, higher initial acceptance, and comparable efficacy, whereas custom-made devices result in higher long-term compliance.

Robotic Glossectomy for the Treatment of Obstructive Sleep Apnea/Hypopnea Syndrome

Objective: 1) Present the safety, morbidity, and efficacy of robotic midline glossectomy (RG) for the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in the first series of patients undergoing this procedure without tracheotomy. 2) Compare the efficacy of robotic midline glossectomy (RG) vs coblation and radiofrequency base-of-tongue (RFBOT) MG.

Method: Retrospective review of patients treated between January 2009 and December 2010 at a tertiary care center. Efficacy and morbidity of 40 RG patients was compared with a matched cohort of 40 patients who underwent traditional MG. Outcome variables included: postoperative pain, narcotic use, postoperative reduction of AHI, disposable costs, and complications.

Results: Twenty patients with severe disease treated with ZPP+RG were compared with 20 patients with ZPP + Coblation. The mean AHI of patients undergoing RG decreased from 55.1 (SD 28.7) preoperative to 25.9 (SD 9.9) postoperative which was significantly greater than the AHI reduction for ( P < .05). Twenty patients with moderate disease treated with palatal stiffening + RG were compared with 20 patients with RFBOT + palatal stiffening. Pain outcomes measured on postoperative days 0-5 using the Faces Visual Analogue Scale (VAS) resulted in no statistical difference between RG and coblation whereas RG vs RFBOT showed higher pain levels for RG.

Conclusion: This is the first recorded series of robotic MG performed without the need for tracheotomy. Results demonstrated an excellent safety profile with no significant complications. Although morbidity vs standard hypopharyngeal treatments is significant, robotic glossectomy allows for more aggressive tissue removal vs coblation and RFBOT thereby significantly improving efficacy.

De novo SCN1A mutations in migrating partial seizures of infancy

OBJECTIVE

To determine the genetic etiology of the severe early infantile onset syndrome of malignant migrating partial seizures of infancy (MPSI).

METHODS

Fifteen unrelated children with MPSI were screened for mutations in genes associated with infantile epileptic encephalopathies: SCN1A, CDKL5, STXBP1, PCDH19, and POLG. Microarray studies were performed to identify copy number variations.

RESULTS

One patient had a de novo SCN1A missense mutation p.R862G that affects the voltage sensor segment of SCN1A. A second patient had a de novo 11.06 Mb deletion of chromosome 2q24.2q31.1 encompassing more than 40 genes that included SCN1A. Screening of CDKL5 (13/15 patients), STXBP1 (13/15), PCDH19 (9/11 females), and the 3 common European mutations of POLG (11/15) was negative. Pathogenic copy number variations were not detected in 11/12 cases.

CONCLUSION

Epilepsies associated with SCN1A mutations range in severity from febrile seizures to severe epileptic encephalopathies including Dravet syndrome and severe infantile multifocal epilepsy. MPSI is now the most severe SCN1A phenotype described to date. While not a common cause of MPSI, SCN1A screening should now be considered in patients with this devastating epileptic encephalopathy.

Impact of nasal obstruction on obstructive sleep apnea

OBJECTIVES

The purpose of this study was to investigate the relationship between nasal obstruction and sleep-disordered breathing. The effect of postoperative nasal packing on sleep parameters was compared between patients with mild obstructive sleep apnea (OSA) and those with moderate/severe OSA.

STUDY DESIGN

A prospective, nonrandomized controlled study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Participants were recruited among adult patients with a history of snoring scheduled to undergo nasal surgery from November 2009 to February 2010. All subjects underwent polysomnogram (PSG) testing within 30 days prior to surgery. Patients underwent nasal surgery and received postoperative nasal packing, and a PSG was repeated on the first postoperative night with nasal packing in place. Outcome measures included a change in respiratory disturbance index (RDI), minimum oxygen saturation, oxygen desaturation index (ODI), and duration of snoring.

RESULTS

Forty-nine patients were included in the study. Patients were stratified into 2 groups: those with RDI ≥15 (n = 23) and those with RDI <15 (n = 26). Nasal packing was found to significantly increase RDI (5.2 ± 4.0 vs 10.4 ± 10.0; P = .0001), duration of snoring (86.5% ± 13.1% vs 79.3% ± 15.3%; P = .008), and ODI (7.6 ± 7.1 vs 9.9 ± 7.4; P = .001) in patients with mild OSA but not in patients with moderate/severe OSA. Mean minimum arterial oxygen saturation was unchanged in both groups.

CONCLUSION

Postoperative nasal packing aggravated measures of OSA in patients with mild OSA but not in patients with moderate/severe OSA.

Impact of pH monitoring on laryngopharyngeal reflux treatment: improved compliance and symptom resolution

OBJECTIVES

Treatment of laryngopharyngeal reflux (LPR) often suffers from poor patient compliance and hence poor symptom improvement. The aim of this study was to determine whether 24-hour oropharyngeal pH monitoring was associated with higher rates of treatment compliance and symptom improvement compared with empirical treatment for LPR.

STUDY DESIGN

Retrospective, case-control study.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Charts were reviewed from 170 consecutive adult patients diagnosed with LPR from January 2008 to March 2010. After clinical diagnosis, all patients were offered the option of empiric treatment with a proton pump inhibitor versus treatment based on a 24-hour oropharyngeal pH study using the Dx-pH system (Restech, San Diego, California). Treatment compliance and pretreatment and posttreatment reflux symptom index (RSI) scores were compared for the 2 groups. Only consecutive patients with complete data were included.

RESULTS

One-hundred and seventy patients were included in 2 groups. Group I consisted of 73 patients who underwent pH monitoring. Group II consisted of 70 patients treated empirically. Compliance with medication therapy (68.5% vs 50.0%, P = .019) and lifestyle modification (82.2 vs 25.7%, P = .0001) were greater among patients in group I. Symptom improvement was greater among patients in group I following treatment compared with patients in group II, with a significantly greater reduction in RSI (36.6% vs 24.4%, P = .023).

CONCLUSION

Among our patient population, treatment of LPR based on pH monitoring resulted in greater compliance, as well as greater symptom improvement, compared with empirical therapy alone.

Effective approaches to persuading pregnant women to quit smoking: A meta-analysis of intervention evaluation studies

OBJECTIVES

The study aimed to: (1) assess the effectiveness of prenatal smoking cessation interventions, (2) clarify whether the psychological changes targeted by interventions are related to their effectiveness, (3) identify specific intervention components associated with greater effectiveness, and (4) establish whether aspects of evaluation methodology are associated with a greater effectiveness.

DESIGN

Differences in proportions of women quitting and odds ratios were calculated for the intervention and control groups. Interventions were categorized in relation to the main intervention target (i.e. cognitive preparation versus increased threat perception), use of follow-up contact, use of individual cessation counselling and other characteristics. Methodological approaches to evaluation were also categorized.

METHODS

A systematic literature review generated 36 controlled evaluations, including one unpublished study. A meta-analysis was used to relate study classifications to effectiveness. This involved univariate analyses and a multivariate model of the relationship between observed univariate effects.

RESULTS

A weighted mean odds ratio of 1.93 indicated a good overall effectiveness. Cognitive preparation interventions achieved higher quit rates (6.5%) compared to interventions focusing on threat perception (2.2%). However, this effect was not maintained in the multivariate analysis.

CONCLUSION

Interventions should employ follow-up, but further research is required to assess the impact of one-to-one counselling. Clarification of the psychological change processes underlying the observed effectiveness of these interventions is required. Future research should seek to identify the active ingredients and cognitive mediators of successful interventions.

Co-induction of anaesthesia with 0.75 mg kg propofol followed by sevoflurane: a randomized trial in the elderly with cardiovascular risk factors

BACKGROUND

The induction of general anaesthesia is associated with the greatest cardiovascular changes in elderly patients. Induction can be performed either intravenously or with gaseous induction. Sevoflurane has advantages over propofol for induction of anaesthesia in the elderly, since the lower reduction in mean arterial pressure with sevoflurane is both statistically and clinically significant. This prospective randomized controlled trial investigated the cardiovascular benefits of co-induction of anaesthesia with 0.75 mg kg(-1) propofol and 8% sevoflurane, when compared with 8% sevoflurane alone in patients requiring surgery for fractured neck of femur.

METHOD

In total, 38 patients aged 75 or over were allocated into the two groups, receiving either 0.75 mg kg(-1) of propofol followed by 8% sevoflurane or 8% sevoflurane alone. Vital signs were recorded until successful insertion of a laryngeal mask. Induction times, induction events and patient satisfaction scores were also recorded.

RESULTS

Results showed that there were no differences in the cardiovascular parameters between the two groups. Induction times were faster in the propofol and sevoflurane group (62 vs. 81 s; P = 0.028). The postoperative questionnaire showed that the majority of patients in both groups were satisfied with the induction process.

CONCLUSIONS

We concluded that 0.75 mg kg(-1) of propofol followed by sevoflurane induction is an acceptable alternative to sevoflurane induction. It is associated with similar haemodynamic variables, faster induction times and is very well tolerated.

In vivo regulation of p21 by the Kruppel-like factor 6 tumor-suppressor gene in mouse liver and human hepatocellular carcinoma

Kruppel-like factor (KLF) 6 is a tumor-suppressor gene functionally inactivated by loss of heterozygosity, somatic mutation and/or alternative splicing that generates a dominant-negative splice form, KLF6-SV1. Wild-type KLF6 (wtKLF6) expression is decreased in many human malignancies, which correlates with reduced patient survival. Additionally, loss of the KLF6 locus in the absence of somatic mutation in the remaining allele occurs in a number of human cancers, raising the possibility that haploinsufficiency of the KLF6 gene alone contributes to cellular growth dysregulation and tumorigenesis. Our earlier studies identified the cyclin-dependent kinase inhibitor p21 as a transcriptional target of the KLF6 gene in cultured cells, but not in vivo. To address this issue, we have generated two genetic mouse models to define the in vivo role of KLF6 in regulating cell proliferation and p21 expression. Transgenic overexpression of KLF6 in the liver resulted in a runted phenotype with decreased body and liver size, with evidence of decreased hepatocyte proliferation, increased p21 and reduced proliferating cell nuclear antigen expression. In contrast, mice with targeted deletion of one KLF6 allele (KLF6+/-) display increased liver mass with reduced p21 expression, compared to wild type littermates. Moreover, in primary hepatocellular carcinoma samples, there is a significant correlation between wtKLF6 and p21 mRNA expression. Combined, these data suggest that haploinsufficiency of the KLF6 gene may regulate cellular proliferation in vivo through decreased transcriptional activation of the cyclin-dependent kinase inhibitor p21.

New multifunctional prosthetic arm and hand systems

We are building a new hand with 18 DOF which has all its actuators inside the body of the hand. This hand is in a form suitable for the 50% women but has the strength capabilities of a 50% male.

Practice parameter: diagnostic assessment of the child with status epilepticus (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society

OBJECTIVE

To review evidence on the assessment of the child with status epilepticus (SE).

METHODS

Relevant literature were reviewed, abstracted, and classified. When data were missing, a minimum diagnostic yield was calculated. Recommendations were based on a four-tiered scheme of evidence classification.

RESULTS

Laboratory studies (Na(++) or other electrolytes, Ca(++), glucose) were abnormal in approximately 6% and are generally ordered as routine practice. When blood or spinal fluid cultures were done on these children, blood cultures were abnormal in at least 2.5% and a CNS infection was found in at least 12.8%. When antiepileptic drug (AED) levels were ordered in known epileptic children already taking AEDs, the levels were low in 32%. A total of 3.6% of children had evidence of ingestion. When studies for inborn errors of metabolism were done, an abnormality was found in 4.2%. Epileptiform abnormalities occurred in 43% of EEGs of children with SE and helped determine the nature and location of precipitating electroconvulsive events (8% generalized, 16% focal, and 19% both). Abnormalities on neuroimaging studies that may explain the etiology of SE were found in at least 8% of children.

RECOMMENDATIONS

Although common clinical practice is that blood cultures and lumbar puncture are obtained if there is a clinical suspicion of a systemic or CNS infection, there are insufficient data to support or refute recommendations as to whether blood cultures or lumbar puncture should be done on a routine basis in children in whom there is no clinical suspicion of a systemic or CNS infection (Level U). AED levels should be considered when a child with treated epilepsy develops SE (Level B). Toxicology studies and metabolic studies for inborn errors of metabolism may be considered in children with SE when there are clinical indicators for concern or when the initial evaluation reveals no etiology (Level C). An EEG may be considered in a child with SE as it may be helpful in determining whether there are focal or generalized epileptiform abnormalities that may guide further testing for the etiology of SE, when there is a suspicion of pseudostatus epilepticus (nonepileptic SE), or nonconvulsive SE, and may guide treatment (Level C). Neuroimaging may be considered after the child with SE has been stabilized if there are clinical indications or if the etiology is unknown (Level C). There is insufficient evidence to support or refute routine neuroimaging in a child presenting with SE (Level U).