A visiting otolaryngology team in northern Ontario - demographics, clinical presentation and barriers to access

CONTEXT

Approximately 20% of Canadians reside in rural or remote communities where access to medical specialties such as otolaryngology remains challenging due to long wait times and distance to services. The purpose of this study was to characterize patient demographics, common clinical diagnoses, and barriers to accessing otolaryngology services, in a remote Northern Ontario setting. A secondary objective was to describe a care model that provides multi-subspecialty otolaryngology services to a remote community.

ISSUE

A team of academic otolaryngologists provided annual (2020-2021) subspecialty services in otology, neurotology, rhinology, head and neck oncology, and pediatrics to a remote hospital with admitting, general anesthesia and surgical resources. Data regarding patient demographics, otolaryngology-related diagnosis, wait times and distance travelled were recorded. Data were obtained for 276 patients treated in the clinic. The median age was 47 years (range 0-85 years). The most common otolaryngological conditions were hearing loss (n=62) and nasal obstruction (n=34). Nearly 30% of patients traveled further than 150 km to access care, and 62% waited 3-6 months for a consultation.

LESSONS LEARNED

This is the first study to characterize the demographics and range of otolaryngological disorders encountered in a remote Northern Ontario setting. The results have identified specific otolaryngology needs and barriers to access to care. The data can be used to guide healthcare providers and administrators on resource allocation to optimize the delivery of otolaryngology services.

Automated Detection, Segmentation, and Tracking of Brain Metastases in Repeated Courses of Stereotactic Radiosurgery Using Integrated Artificial Intelligence

PURPOSE/OBJECTIVE(S)

Salvage stereotactic radiosurgery (SRS) for distant brain metastases has been demonstrated as a safe and effective approach for intracranial recurrences after initial SRS. However, accurate tumor detection and segmentation among responding tumors within the irradiated parenchyma can be challenging. The requirement for the registration and reference to the previous course of SRS is very time-consuming and suffers significant inter and intra-reader variability. Artificial intelligence (AI)-assisted system has been proven to improve the accuracy and efficiency in the clinical flow of de-novo SRS. We hypothesize that an integrated AI system can facilitate an automated tumor contouring process for repeated SRS.

MATERIALS/METHODS

Three patients who underwent their third course of SRS to brain metastases were selected for the pioneering works. They have had two sessions of SRS with a mean lesion number of 4 and 3.7, respectively. VBrain, an FDA-approved brain tumor management AI platform, was used to co-registered serial MR scans and automatically identify, track, and contour brain metastases for each course of SRS. The AI also indicated new lesions and treated lesions for each course. Three radiation oncologists experienced in brain SRS contoured the gross tumor volumes (GTVs) of the third course of SRS in two reader modes (assisted then unassisted) with a memory washout period of one week between each section. The segmentation ground truth was established through consensus among the three experts. Lesion-wise sensitivity, contouring accuracy, and consuming time were compared between the two contouring modes.

RESULTS

In each patient, there were 15, 11, and 9 metastases, with a median diameter of 4.72 (95% CI: 4.05, 6.91) mm. The mean lesion-wise sensitivity was 96.96±2.47% with AI assistance and 76.90 ± 7.10% without assistance. There were two false-positive lesions in the assisted read, resulting in a low average false-positive rate of 0.67 per patient, while no false positive for the unassisted mode. AI assistance improved contouring accuracy. The median Dice similarity coefficient (DSC) was 0.71 (95% CI: 0.55, 0.87) for assisted contouring and 0.65 (95% CI: 0.46, 0.85) for unassisted contouring. We also use average Hausdorff distance (HD) to measure segmentation results. The mean HD was 0.72± 0.13 mm versus 0.73±0.08 mm for the two contouring modes (p = 0.02) Furthermore, the median contouring time per case was significantly shorter with AI assistance than without assistance (20.8 minutes vs. 29.8 minutes; p < 0.001), corresponding to a 43.2% time-saving.

CONCLUSION

Our results suggest that the integration of an AI-based system into repeated brain SRS can significantly improve the accuracy and efficiency of tumor detection and segmentation. This approach has the potential to streamline the treatment planning process for salvage SRS.

Content Validity of a High-Fidelity Surgical Middle Ear Simulator: A Randomized Prospective International Multicenter Trial

OBJECTIVE

After demonstration of face validity of a surgical middle ear simulator (SMS) previously, we assessed the content validity of the simulator with otolaryngology residents.

STUDY DESIGN

Multicenter randomized prospective international study.

SETTING

Four academic institutions.

METHODS

Novice participants were randomized into control, low-fidelity (LF), and high-fidelity (HF) groups. Control and LF produced 2 recordings from 2 attempts, and HF produced 4 recordings from 10 attempts, with trials 1, 4, 7, and 10 used for scoring. Three blinded experts graded videos of the simulated stapedectomy operation using an objective skills assessment test format consisting of global and stapedotomy-specific scales.

RESULTS

A total of 152 recordings from 61 participants were included. Baseline characteristics did not differ significantly between groups. Depending on the step of the operation, inter-rater reliability ranged from 24 to 90%. For LF and HF, years of training was significantly associated with improved scores in certain objective skills assessment test subparts. HF outperformed the control group on stapes and global scores ( p < 0.05). The HF group demonstrated improvement in global score over trials, but plateaued after four trials. Scores varied greatly for participants from different institutions in certain operative steps, such as transecting incudostapedial joints, likely due to differences in instrumentation and time elapsed since manufacture.

CONCLUSION

Practice with SMS led to better performance in both global and stapes-specific scores. Further studies are needed to examine construct validity and to create otology-appropriate grading systems. Variables like instrumentation and decline in flexibility of the simulator after 12 months greatly affect performance on the simulator.

Gene mutations as a non-invasive measure of adult cochlear implant performance: Variable outcomes in patients with select TMPRSS3 mutations

BACKGROUND

The cochlear implant (CI) has proven to be a successful treatment for patients with severe-to-profound sensorineural hearing loss, however outcome variance exists. We sought to evaluate particular mutations discovered in previously established sensory and neural partition genes and compare post-operative CI outcomes.

MATERIALS AND METHODS

Utilizing a prospective cohort study design, blood samples collected from adult patients with non-syndromic hearing loss undergoing CI were tested for 54 genes of interest with high-throughput sequencing. Patients were categorized as having a pathogenic variant in the sensory partition, pathogenic variant in the neural partition, pathogenic variant in both sensory and neural partition, or with no variant identified. Speech perception performance was assessed pre- and 12 months post-operatively. Performance measures were compared to genetic mutation and variant status utilizing a Wilcoxon rank sum test, with P<0.05 considered statistically significant.

RESULTS

Thirty-six cochlear implant patients underwent genetic testing and speech understanding measurements. Of the 54 genes that were interrogated, three patients (8.3%) demonstrated a pathogenic mutation in the neural partition (within TMPRSS3 genes), one patient (2.8%) demonstrated a pathogenic mutation in the sensory partition (within the POU4F3 genes). In addition, 3 patients (8.3%) had an isolated neural partition variance of unknown significance (VUS), 5 patients (13.9%) had an isolated sensory partition VUS, 1 patient (2.8%) had a variant in both neural and sensory partition, and 23 patients (63.9%) had no mutation or variant identified. There was no statistically significant difference in speech perception scores between patients with sensory or neural partition pathogenic mutations or VUS. Variable performance was found within patients with TMPRSS3 gene mutations.

CONCLUSION

The impact of genetic mutations on post-operative outcomes in CI patients was heterogenous. Future research and dissemination of mutations and subsequent CI performance is warranted to elucidate exact mutations within target genes providing the best non-invasive prognostic capability.

Pilot Study of Optical Topographic Imaging Based Neuronavigation for Mastoidectomy

BACKGROUND

Mastoidectomy involves drilling the temporal bone while avoiding the facial nerve, semicircular canals, sigmoid sinus, and tegmen. Optical topographic imaging (OTI) is a novel registration technique that allows rapid registration with minimal navigational error. To date, no studies have examined the use of OTI in skull-base procedures.

METHODS

In this cadaveric study, 8 mastoidectomies were performed in 2 groups-4 free-hand (FH) and 4 OTI-assisted mastoidectomies. Registration accuracy for OTI navigation was quantified with root mean square (RMS) and target registration error (TRE). Procedural time, percent of mastoid resected, and the proximity of the mastoidectomy cavity to critical structures were determined.

RESULTS

The average RMS and TRE associated with OTI-based registration were 1.44 mm (±0.83 mm) and 2.17 mm (±0.89 mm), respectively. The volume removed, expressed as a percentage of the total mastoid volume, was 37.5% (±10.2%) versus 31.2% (±2.3%), P = 0.31, for FH and OTI-assisted mastoidectomy. There were no statistically significant differences between FH and OTI-assisted mastoidectomies with respect to proximity to critical structures or procedural time.

CONCLUSIONS

This work is the first examining the application of OTI neuronavigation in lateral skull-base procedures. This pilot study revealed the RMS and TRE for OTI-based navigation in the lateral skull base are 1.44 mm (±0.83 mm) and 2.17 mm (±0.89 mm), respectively. This pilot study demonstrates that an OTI-based system is sufficiently accurate and may address barriers to widespread adoption of navigation for lateral skull-base procedures.

Training prediction models for individual risk assessment of postoperative complications after surgery for colorectal cancer

BACKGROUND

The occurrence of postoperative complications and anastomotic leakage are major drivers of mortality in the immediate phase after colorectal cancer surgery. We trained prediction models for calculating patients' individual risk of complications based only on preoperatively available data in a multidisciplinary team setting. Knowing prior to surgery the probability of developing a complication could aid in improving informed decision-making by surgeon and patient and individualize surgical treatment trajectories.

METHODS

All patients over 18 years of age undergoing any resection for colorectal cancer between January 1, 2014 and December 31, 2019 from the nationwide Danish Colorectal Cancer Group database were included. Data from the database were converted into Observational Medical Outcomes Partnership Common Data Model maintained by the Observation Health Data Science and Informatics initiative. Multiple machine learning models were trained to predict postoperative complications of Clavien-Dindo grade ≥ 3B and anastomotic leakage within 30 days after surgery.

RESULTS

Between 2014 and 2019, 23,907 patients underwent resection for colorectal cancer in Denmark. A Clavien-Dindo complication grade ≥ 3B occurred in 2,958 patients (12.4%). Of 17,190 patients that received an anastomosis, 929 experienced anastomotic leakage (5.4%). Among the compared machine learning models, Lasso Logistic Regression performed best. The predictive model for complications had an area under the receiver operating characteristic curve (AUROC) of 0.704 (95%CI 0.683-0.724) and an AUROC of 0.690 (95%CI 0.655-0.724) for anastomotic leakage.

CONCLUSIONS

The prediction of postoperative complications based only on preoperative variables using a national quality assurance colorectal cancer database shows promise for calculating patient's individual risk. Future work will focus on assessing the value of adding laboratory parameters and drug exposure as candidate predictors. Furthermore, we plan to assess the external validity of our proposed model.

Overprescription of opioid analgesia is common following ambulatory Otolaryngology—Head and Neck surgery procedures: A multicenter study

Background

The rise in the use of prescription opioids for postoperative analgesia within surgery has mirrored an increased trend of opioid‐related morbidity within Canada and the United States. This study prospectively studied daily pain levels and medication requirements postoperatively in patients undergoing elective Otolaryngology—Head and Neck surgery procedures.

Methods

Patients were asked to prospectively document their pain level and medication use daily for 7 days postoperatively. A final survey was used to quantify unused medication left at home and clarify each patient's disposal plan. We included patients undergoing elective outpatient or short stay surgeries from three tertiary care centers in Toronto, Ontario from September 2016 to September 2017. Previous opioids users or patients suffering from chronic pain were excluded.

Results

A final cohort of 56 eligible adult patients were included in the study. The most common procedures were thyroidectomy (n = 19), endoscopic sinus surgery (n = 10), tympanoplasty/ossiculoplasty (n = 7), and cochlear implant (n = 5). Most patients received a prescription for acetaminophen/codeine (n = 29, 51.8%) or acetaminophen/oxycodone (n = 22, 39.3%) and used on average 29% of their initial prescription. Patients most commonly opted to keep their unused narcotics at home (n = 23, 41%). A total of 710 tablets of narcotics were overprescribed in our study population, 351 of which were kept in patients' home for future use.

Conclusion

There is a clear tendency to overestimate postoperative pain resulting in significant overprescription of opioids among Otolaryngologists.

Surgeons tend to overestimate post‐operative opioid analgesic requirements, leading to over‐prescription.

Less than half of the 56 participants in this study used non‐opioid analgesia during their post‐operative course, indicating a lack of counselling.

Most commonly, patients elected to keep unused opioids at home for future use – a known risk factor for opioid diversion.

Local magnetic delivery of adeno-associated virus AAV2(quad Y-F)-mediated BDNF gene therapy restores hearing after noise injury

Moderate noise exposure may cause acute loss of cochlear synapses without affecting the cochlear hair cells and hearing threshold; thus, it remains "hidden" to standard clinical tests. This cochlear synaptopathy is one of the main pathologies of noise-induced hearing loss (NIHL). There is no effective treatment for NIHL, mainly because of the lack of a proper drug-delivery technique. We hypothesized that local magnetic delivery of gene therapy into the inner ear could be beneficial for NIHL. In this study, we used superparamagnetic iron oxide nanoparticles (SPIONs) and a recombinant adeno-associated virus (AAV) vector (AAV2(quad Y-F)) to deliver brain-derived neurotrophic factor (BDNF) gene therapy into the rat inner ear via minimally invasive magnetic targeting. We found that the magnetic targeting effectively accumulates and distributes the SPION-tagged AAV2(quad Y-F)-BDNF vector into the inner ear. We also found that AAV2(quad Y-F) efficiently transfects cochlear hair cells and enhances BDNF gene expression. Enhanced BDNF gene expression substantially recovers noise-induced BDNF gene downregulation, auditory brainstem response (ABR) wave I amplitude reduction, and synapse loss. These results suggest that magnetic targeting of AAV2(quad Y-F)-mediated BDNF gene therapy could reverse cochlear synaptopathy after NIHL.

Perspective review on applications of optics in skull base surgery

The use of optic technology in skull base surgeries has the potential to revolutionize the field of medicine, particularly neurosurgery and neurology. Here, we briefly present the past, present, and future of skull-base surgery, with an emphasis on the applications of optical topography techniques. We discuss optical topography techniques such as functional near-infrared spectroscopy, optical diffusion tomography, and optical topographical imaging. Optical topography techniques are particularly advantageous when combined with other imaging methods. For instance, optical topography can be combined with techniques such as functional magnetic resonance imaging (fMRI) to combine the temporal resolution of optical topography with the spatial resolution of fMRI. Multimodal approaches will be critical to advance brain-related research as well as medicine. Structured light imaging techniques are also writing the future of 3-dimensional imaging. In short, optical topography can allow for non-invasive, high-resolution imaging that will provide real-time visualizations of the brain that are ideal for neurosurgery. From the limitations of traditional skull base surgeries to the newest developments in optical neuroimaging, here we will discuss the potential applications of optics in skull base procedures.

Neural correlates of visual stimulus encoding and verbal working memory differ between cochlear implant users and normal-hearing controls

A common concern for individuals with severe‐to‐profound hearing loss fitted with cochlear implants (CIs) is difficulty following conversations in noisy environments. Recent work has suggested that these difficulties are related to individual differences in brain function, including verbal working memory and the degree of cross‐modal reorganization of auditory areas for visual processing. However, the neural basis for these relationships is not fully understood. Here, we investigated neural correlates of visual verbal working memory and sensory plasticity in 14 CI users and age‐matched normal‐hearing (NH) controls. While we recorded the high‐density electroencephalogram (EEG), participants completed a modified Sternberg visual working memory task where sets of letters and numbers were presented visually and then recalled at a later time. Results suggested that CI users had comparable behavioural working memory performance compared with NH. However, CI users had more pronounced neural activity during visual stimulus encoding, including stronger visual‐evoked activity in auditory and visual cortices, larger modulations of neural oscillations and increased frontotemporal connectivity. In contrast, during memory retention of the characters, CI users had descriptively weaker neural oscillations and significantly lower frontotemporal connectivity. We interpret the differences in neural correlates of visual stimulus processing in CI users through the lens of cross‐modal and intramodal plasticity.

Cortical alpha oscillations in cochlear implant users reflect subjective listening effort during speech-in-noise perception

Listening to speech in noise is effortful for individuals with hearing loss, even if they have received a hearing prosthesis such as a hearing aid or cochlear implant (CI). At present, little is known about the neural functions that support listening effort. One form of neural activity that has been suggested to reflect listening effort is the power of 8–12 Hz (alpha) oscillations measured by electroencephalography (EEG). Alpha power in two cortical regions has been associated with effortful listening—left inferior frontal gyrus (IFG), and parietal cortex—but these relationships have not been examined in the same listeners. Further, there are few studies available investigating neural correlates of effort in the individuals with cochlear implants. Here we tested 16 CI users in a novel effort-focused speech-in-noise listening paradigm, and confirm a relationship between alpha power and self-reported effort ratings in parietal regions, but not left IFG. The parietal relationship was not linear but quadratic, with alpha power comparatively lower when effort ratings were at the top and bottom of the effort scale, and higher when effort ratings were in the middle of the scale. Results are discussed in terms of cognitive systems that are engaged in difficult listening situations, and the implication for clinical translation.

Patient Perspectives on Removing Adult Tonsillectomy and Septoplasty from the Government Health Insurance Plan in a Publicly Funded Health Care System

In several publicly funded health care systems, including Ontario, Canada, adult tonsillectomies and septoplasties have been suggested to be removed or “delisted” from the government health insurance plan. Thus, the objective of this study was to explore patient perspectives regarding out of pocket (OOP) payment for these procedures. An anonymous survey was administered to patients consented to undergo a tonsillectomy or septoplasty at a community otolaryngology—head and neck surgery (OHNS) practice. The survey asked patients if they would pay the projected cost for their surgery OOP and the maximum amount of time they would wait for their surgery. The survey also contained questions on socioeconomic status and disease severity. Seventy-one patients were included. Overall, 21% of patients were willing to pay OOP for their surgery. Forty-nine percent of patients reported that the maximum amount of time they would be willing to wait for their surgery was 2 to 6 months. There was no significant correlation found between any of the demographic variables or disease severity and willingness to pay OOP for these surgeries. In this study, a small percentage of patients who met the clinical indications for a tonsillectomy or a septoplasty would pay for their surgery in the event that it was not covered by the government health insurance plan. These surgeries are common operations and delisting them could potentially decrease the provision of these services and have a significant impact on Canadian OHNS practices.

Management of sudden sensorineural hearing loss among primary care physicians in Canada: a survey study

BACKGROUND

Sudden Sensorineural Hearing Loss (SSNHL) is a medical emergency requiring immediate attention as delayed treatment can lead to permanent and devastating consequences. Primary care physicians are likely the first to be presented with SSNHL and therefore have the crucial role of recognizing it and initiating timely and appropriate management. The aim of this study was to gain insight into the current knowledge and practice trends pertaining to the diagnosis and management of SSNHL among family physicians in Canada.

METHODS

An 18-question survey targeting Canadian family physicians was marketed through two, physician-only discussion groups on the social media platform Facebook. Responses were collected between August 1st and December 22nd 2019 then aggregated and quantified.

RESULTS

52 family physicians submitted responses. 94.2% (n = 49) reported that in their practice, unilateral SSNHL warrants urgent referral to otolaryngology and 84.6% (n = 44) reported that unilateral sudden-onset hearing loss warrants urgent referral for audiological testing. 73.1% of participants (n = 38) reported that they would attempt to differentiate between conductive and sensorineural hearing loss if presented with unilateral, acute or sudden-onset hearing loss. 61.5% (n = 32) would rely on tuning fork tests to inform management decisions, as compared to 94.2% (n = 49) relying on case history and 88.5% (n = 46) on otoscopy. 76.9% (n = 40) would prescribe corticosteroids if presented with confirmed, unilateral SSNHL.

CONCLUSION

The majority of family physicians in the study would make appropriate referral and treatment decisions in the management of SSNHL, understanding it is a medical emergency. Tuning fork tests are under-utilized for informing management decisions compared to other means of differentiating conductive and sensorineural hearing loss. Further research is needed to understand why some family physicians do not prescribe corticosteroids for treatment of SSNHL, which may then identify any gaps in knowledge or inform improvements in clinical protocol.

Noise in Otolaryngology - Head and Neck Surgery operating rooms: a systematic review

OBJECTIVE

Noise in operating rooms (OR) can have negative effects on both patients and surgical care workers. Noise can also impact surgical performance, team communication, and patient outcomes. Such implications of noise have been studied in orthopedics, neurosurgery, and urology. High noise levels have also been demonstrated in Otolaryngology-Head and Neck Surgery (OHNS) procedures. Despite this, no previous study has amalgamated the data on noise across all OHNS ORs to determine how much noise is present during OHNS surgeries. This study aims to review all the literature on noise associated with OHNS ORs and procedures.

METHODS

Ovid Medline, EMBASE Classic, Pubmed, SCOPUS and Cochrane databases were searched following PRISMA guidelines. Data was collected on noise measurement location and surgery type. Descriptive results and statistical analysis were completed using Stata.

RESULTS

This search identified 2914 articles. Final inclusion consisted of 22 studies. The majority of articles analyzed noise level exposures during mastoid surgery (18/22, 82%). The maximum noise level across all OHNS ORs and OHNS cadaver studies were 95.5 a-weighted decibels (dBA) and 106.6 c-weighted decibels (dBC), respectively (P = 0.2068). The mean noise level across all studies was significantly higher in OHNS cadaver labs (96.9 dBA) compared to OHNS ORs (70.1 dBA) (P = 0.0038). When analyzed together, the mean noise levels were 84.9 dBA.

CONCLUSIONS

This systematic review demonstrates that noise exposure in OHNS surgery exceeds safety thresholds. Further research is needed to understand how noise may affect team communication, surgical performance and patient outcomes in OHNS ORs.

Pharmacologic and surgical therapies for patients with Meniere's disease: A systematic review and network meta-analysis

BACKGROUND

Meniere's disease (MD) is a chronic condition of the inner ear consisting of symptoms that include vertigo attacks, fluctuating sensorineural hearing loss, tinnitus and aural fullness. Despite availability of various interventions, there is uncertainty surrounding their relative efficacy, thus making it difficult to select the appropriate treatments for MD. The objective of this systematic review was to assess the relative effects of the available pharmacologic and surgical interventions in patients with MD with regard to vertigo and other key patient outcomes based on data from randomized clinical trials (RCTs).

METHODS

Our published protocol registered with PROSPERO (CRD42019119129) provides details on eligibility criteria and methods. We searched various databases including MEDLINE, Embase and the Cochrane Library from inception to December 10th, 2018. Screening at citation and full-text levels and risk of bias assessment were performed by two independent reviewers in duplicate, with discrepancies resolved by consensus or third-party adjudication. Bayesian network meta-analyses (NMA) were performed for hearing change and vertigo control outcomes, along with pairwise meta-analyses for these and additional outcomes.

RESULTS

We identified 2,889 unique citations, that yielded 23 relevant publications describing 18 unique RCTs (n = 1,231 patients). Overall, risk-of bias appraisal suggested the evidence base to be at unclear or high risk of bias. Amongst pharmacologics, we constructed treatment networks of five intervention groups that included placebo, intratympanic (IT) gentamicin, oral high-dose betahistine, IT steroid and IT steroid plus high-dose betahistine for NMAs of hearing change (improvement or deterioration) and complete vertigo control. IT steroid plus high-dose betahistine was associated with the largest difference in hearing improvement compared to placebo, followed by high-dose betahistine and IT steroid (though 95% credible intervals failed to rule out the possibility of no difference), while IT gentamicin was worse than IT steroid. The NMA of complete vertigo control suggested IT gentamicin was associated with the highest probability of achieving better complete vertigo control compared to placebo, followed by IT steroid plus high-dose betahistine. Only two studies related to surgical interventions were found, and data suggested no statistically significant difference in hearing changes between endolymphatic duct blockage (EDB) versus endolymphatic sac decompression (ESD), and ESD with or without steroid injection. One trial reported that 96.5% of patients in EDB group compared to 37.5% of the patients in ESD group achieved complete vertigo control 24 months after surgery (p = 0.002).

CONCLUSION

To achieve both hearing preservation and vertigo control, the best treatment option among the pharmacologic interventions compared may be IT steroid plus high-dose betahistine, considering that IT gentamicin may have good performance to control vertigo but may be detrimental to hearing preservation with high cumulative dosage and short interval between injections. However, IT steroid plus high-dose betahistine has not been compared in head-to-head trials against other interventions except for IT steroid alone in one trial, thus future trials that compare it with other interventions will help establish comparative effectiveness with direct evidence.

Middle Ear and Temporal Bone Nonkeratinizing Squamous Cell Carcinomas With DEK-AFF2 Fusion: An Emerging Entity

Primary squamous cell carcinomas (SCCs) of the middle ear and temporal bone are rare and usually keratinizing by morphology. Nonkeratinizing, basaloid SCCs arising in this area are exceedingly rare, and, due to the anatomic proximity to the skull base, nasopharynx, and nasal sinuses, the differential diagnosis is broad. Most tumors with squamous differentiation arising in these subsites are either viral-induced (human papillomavirus/Epstein-Barr virus) or rarely may have specific molecular alterations (BRD4-NUT, EWSR1-FLI translocations). Occasional tumors are negative for these findings, and their pathogenesis is unknown. A recently discovered DEK-AFF2 fusion was clinically detected in a series of 2 cases known to the authors. This fusion has been previously reported in the literature in a patient with a base of skull tumor who was an exceptional responder to programmed cell death protein 1 inhibitor therapy. We examine here the histomorphologic and molecular findings of 2 additional cases of an emerging entity. Two male patients were identified. Each had a primary middle ear/temporal bone mass with locally advanced disease. The histology was reviewed, and immunohistochemistry was performed. RNA-based next-generation sequencing was performed for clinical detection of diagnostic or actionable fusions. Both patients had basaloid/nonkeratinizing tumors on biopsy. They were positive for markers of squamous differentiation (HMWK, CK5, and p40). By RNA sequencing, they demonstrated the presence of a DEK-AFF2 fusion and were negative for EWSR1 and NUT translocations. The DEK-AFF2 fusion may define a novel diagnostic category of middle ear and temporal bone nonkeratinizing/basaloid SCCs. This fusion also may represent a potential avenue for immunotherapy in these patients. Further studies are needed to fully explore whether this fusion defines a location-specific clinicopathologic entity.

AutoAudio: Deep Learning for Automatic Audiogram Interpretation

Hearing loss is the leading human sensory system loss, and one of the leading causes for years lived with disability with significant effects on quality of life, social isolation, and overall health. Coupled with a forecast of increased hearing loss burden worldwide, national and international health organizations have urgently recommended that access to hearing evaluation be expanded to meet demand. The objective of this study was to develop 'AutoAudio' - a novel deep learning proof-of-concept model that accurately and quickly interprets diagnostic audiograms. Adult audiogram reports representing normal, conductive, mixed and sensorineural morphologies were used to train different neural network architectures. Image augmentation techniques were used to increase the training image set size. Classification accuracy on a separate test set was used to assess model performance. The architecture with the highest out-of-training set accuracy was ResNet-101 at 97.5%. Neural network training time varied between 2 to 7 h depending on the depth of the neural network architecture. Each neural network architecture produced misclassifications that arose from failures of the model to correctly label the audiogram with the appropriate hearing loss type. The most commonly misclassified hearing loss type were mixed losses. Re-engineering the process of hearing testing with a machine learning innovation may help enhance access to the growing worldwide population that is expected to require audiologist services. Our results suggest that deep learning may be a transformative technology that enables automatic and accurate audiogram interpretation.

Otolaryngology needs among an adult homeless population: a prospective study

BACKGROUND

Homeless individuals frequently experience poor access to healthcare, delayed clinical presentation, and higher disease burden. Providing subspecialty otolaryngology care to this population can be challenging. We previously reported on the prevalence of hearing impairment in Toronto's homeless community. As a secondary objective of this study, we sought to define otolaryngology specific need for this population.

METHODS

One hundred adult homeless individuals were recruited across ten homeless shelters in Toronto, Canada using a stratified random sampling technique. An audiometric evaluation and head and neck physical examination were performed by an audiologist and otolaryngology resident, respectively. Basic demographic and clinical information was captured through verbal administration of a survey. Descriptive statistics were used to estimate frequency of otolaryngology specific diseases for this population.

RESULTS

Of the 132 individuals who were initially approached to participant, 100 (76%) agreed. There were 64 males, with median age of 46 years (IQR 37-58 years). The median life duration of homelessness was 24 months (IQR 6-72 months). Participants had a wide range of medical comorbidities, with the most common being current tobacco smoking (67%), depression (36%), alcohol abuse (32%), and other substance abuse (32%). There were 22 patients with otolaryngology needs as demonstrated by one or more abnormal findings on head and neck examination. The most common finding was nasal fracture with significant nasal obstruction (6%). Eleven patients required referral to a staff otolaryngologist based on concerning or suspicious findings, including two head and neck masses, 6 were later seen in follow-up.

CONCLUSION

There were substantial otolaryngology needs amongst a homeless population within a universal healthcare system. Future research should focus on further elucidating head and neck related issues in this population and expanding the role of the otolaryngologist in providing care to homeless individuals.

Health-related quality of life (HRQOL) burden in patients with relapsed/refractory diffuse large B-cell lymphoma (RR-DLBCL) and non-Hodgkin’s lymphoma (RR-NHL)

e20070

Background: CAR T therapy is being investigated as 2nd line therapy in RR-DLBCL. To evaluate its impact on patients’ HRQOL, it is essential to understand the HRQOL of patients receiving current standard of care (SOC) therapy for DLBCL and NHL patients. Methods: A systematic literature review (SLR) of studies reporting HRQOL in RR-DLBCL patients was conducted in March 2019 (updated to include RR-NHL in May 2019) using EMBASE, MEDLINE, Cochrane (all from 2007), Northern Light and International Society for Quality of Life Research abstracts (both from 2017). A targeted literature review (TLR) for untreated or 1st line patients was conducted in July 2019 using PubMed. Search terms included diseases, lines of therapy and patient-reported outcome (PRO) measures. Abstracts and publications were screened for eligibility and data were extracted. Results: Of the 977 publications screened for the SLR, 26 met the inclusion criteria. Another 18 studies were included from the TLR. The most commonly used PRO measures were the SF-36 (10 studies), EORTC QLQ-C30 and FACT-Lym (8 studies each). The EORTC QLQ-C30 showed statistically significant or clinically meaningful changes in a greater number of domains (86%) than the FACT-Lym (75%) and SF-36 (62%). Additional results in table. Conclusions: While research is limited, RR-DLBCL patients receiving current SOC therapy report decreases in HRQOL and health utility. Further research is needed on how existing and future therapies may affect HRQOL among RR-DLBCL patients. [Table: see text]

Hearing loss and hearing needs in an adult homeless population: a prospective cross-sectional study

BACKGROUND

Given that hearing loss is associated with increased social isolation, reduced earning potential and neurocognitive disease, findings of uncorrected hearing loss in the homeless population have important policy implications. We sought to estimate the prevalence of hearing impairment in an adult homeless population.

METHODS

We recruited adult (age ≥ 18 yr) homeless people across 10 homeless shelters in Toronto between April and June 2018 using a 2-stage sampling technique. Participants were interviewed by 1 interviewer using a modified survey that had been used in previous studies looking at other health needs in homeless populations. A comprehensive head and neck examination and audiometric evaluation were performed in each participant by an otolaryngologist and an audiologist. Descriptive statistics were estimated. Audiometric data were standardized directly for age and sex to facilitate direct comparisons with the general Canadian population.

RESULTS

Of the 132 people invited, 100 (75.8%) agreed to participate. The median age was 46 (interquartile range [IQR] 37-58) years. The median duration of homelessness was 24 (IQR 6-72) months. Although most participants (78) had some form of extended health care benefits through social assistance, only 22/78 (28%) were aware that hearing tests and hearing aids were covered through these programs. After direct standardization for age and sex, the proportions of participants with a speech-frequency and high-frequency hearing loss were 39.5% (95% confidence interval [CI] 30.4%-49.3%) and 51.9% (95% CI 42.2%-61.4%), respectively. Nineteen participants were hearing aid candidates, only 1 of whom owned functional hearing aids. Rates of speech-frequency hearing loss (39.5%, 95% CI 30.4%-49.3% v. 19.2%, 95% CI 16.9%-21.7%) and high-frequency hearing loss (51.9%, 95% CI 42.2%-61.4% v. 35.5%, 95% CI 33.1%-37.7%) were substantially higher than in the general Canadian population.

INTERPRETATION

Our results suggest that homeless adults have a high prevalence of hearing impairment, even when living within a system of universal health insurance; awareness of health care benefits through social assistance programs was poor. Results from this study may prompt initiatives surrounding homeless outreach and health screening.

Pharmacologic and surgical therapies for patients with Meniere's disease: a protocol for a systematic review and meta-analysis

BACKGROUND

Hearing loss is one of the leading causes of disability in Canada and worldwide, with more than one million Canadians enduring a hearing-related disability. Meniere's disease (MD) is a chronic condition of the inner ear, manifesting as a triad of disabling symptoms, including attacks of vertigo, fluctuating sensorineural hearing loss (SNHL), and tinnitus. Impacts on quality of life are severe, particularly with respect to restrictions in social participation and physical activity, fatigue, and reduced capacity to work. Anxiety and other psychological disorders may result from the restrictions imposed on life, the constant uncertainty of vertigo attacks, and fluctuating SNHL, with neuroses and depression affecting 40 to 60% of sufferers of intractable MD. There is a need to establish the benefits of previously studied interventions with greater certainty. The planned systematic review and meta-analyses/network meta-analyses (NMAs) will assess the relative effects of competing pharmacologic and surgical interventions for management of MD in adults.

METHODS

An experienced medical information specialist in consultation with the review team will develop the electronic search strategies. We will search various databases including MEDLINE, Embase, and the Cochrane Library with no date or language restrictions for published literature, and key clinical trial registries for in-progress and completed trials. Screening of the literature will be performed by two reviewers independently using pre-specified eligibility criteria, and quality of the included studies will be assessed using the Cochrane Risk of Bias tool. We will resolve disagreements through consensus or third-party adjudication. When applicable, meta-analyses and NMAs will be pursued to compare interventions in terms of their effects on outcomes, including frequency and severity of vertigo, occurrence and intensity of tinnitus, changes in hearing and speech recognition, quality of life, and harms. Separate analyses exploring the effects of pharmacologic and surgical approaches will be performed.

DISCUSSION

Our planned systematic review will provide informative evaluations of existing treatments for management of Meniere's disease. The findings will inform practitioners as to the relative benefits and harms of the existing competing interventions for MD, offer optimal clinical treatment strategies, identify evidence gaps, and determine promising therapies for evaluation in future trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019119129.

Cone beam CT for perioperative imaging in hearing preservation Cochlear implantation - a human cadaveric study

Background

Knowledge of the cochlear implant array’s precise position is important because of the correlation between electrode position and speech understanding. Several groups have provided recent image processing evidence to determine scalar translocation, angular insertion depth, and cochlear duct length (CDL); all of which are being used for patient-specific programming. Cone beam computed tomography (CBCT) is increasingly used in otology due to its superior resolution and low radiation dose. Our objectives are as followed:

Validate CBCT by measuring cochlear metrics, including basal turn diameter (A-value) and lateral wall cochlear duct length at different angular intervals and comparing it against microcomputed CT (uCT).

Explore the relationship between measured lateral wall cochlear duct length at different angular intervals and insertion depth among 3 different length electrodes using CBCT.

Methods

The study was performed using fixed human cadaveric temporal bones in a tertiary academic centre. Ten temporal bones were subjected to the standard facial recess approach for cochlear implantation and imaged by CBCT followed by uCT. Measurements were performed on a three-dimensional reconstructed model of the cochlea. Sequential insertion of 3 electrodes (Med-El Flex24, 28 and Soft) was then performed in 5 bones and reimaged by CBCT. Statistical analysis was performed using Pearson’s correlation.

Results

There was good agreement between CBCT and uCT for cochlear metrics, validating the precision of CBCT against the current gold standard uCT in imaging. The A-value recorded by both modalities showed a high degree of linear correlation and did not differ by more than 0.23 mm in absolute values. For the measurement of lateral wall CDL at various points along the cochlea, there was a good correlation between both modalities at 360 deg and 720 deg (r = 0.85, p < 0.01 and r = 0.79, p < 0.01). The Flex24 electrode displayed consistent insertion depth across different bones.

Conclusions

CBCT reliably performs cochlear metrics and measures electrode insertion depth. The low radiation dose, fast acquisition time, diminished metallic artifacts and portability of CBCT make it a valid option for imaging in cochlear implant surgery.

Otology/Neurotology recommendations - Choosing Wisely campaign

The Choosing Wisely Canada Campaign aims to raise awareness amongst physicians and patients regarding unnecessary tests and treatment. The otology/neurotology subspecialty group within the Canadian Society of Otolaryngology – Head & Neck Society developed a list of five common otologic presentations to help physicians deliver high quality effective care: (1) Don’t order specialized audiometric and vestibular testing to screen for peripheral vestibular disease, (2) Don’t perform computed tomography or blood work in the evaluation of sudden sensorineural hearing loss, (3) Don’t perform auditory brain responses (ABR) in patients with asymmetrical hearing loss, (4) Don’t prescribe oral antibiotics as first line treatment for patients with painless otorrhea associated with tympanic membrane perforation or tympanostomy tube, and (5) Don’t perform particle repositioning maneuvers without a clinical diagnosis of posterior canal benign paroxysmal positional vertigo.

A systematic review and network meta-analysis of existing pharmacologic therapies in patients with idiopathic sudden sensorineural hearing loss

BACKGROUND

Hearing loss is one of the leading causes of disability worldwide. Patients with hearing loss experience impaired quality of life, as well as emotional and financial consequences that affect both themselves and their families. Idiopathic sudden sensorineural hearing loss (ISSNHL) is a common but difficult to treat condition that has a sudden onset of ≤ 72 hour associated with various etiologies, with the majority of cases being idiopathic. There exists a wide range of therapeutic options, however, the uncertainty surrounding their comparative efficacy and safety makes selection of treatment difficult. This systematic review and network meta-analysis (NMA) assessed the relative effects of competing treatments for management of ISSNHL.

METHODS

A protocol for this review was registered with PROSPERO (CRD42017073756). A detailed search of MEDLINE, Embase and the Cochrane Library from inception to February 8th, 2018 was carried out by an experienced information specialist. Grey literature was also searched. Screening full-text records, and risk of bias assessment were carried out independently by two reviewers, and disagreements were resolved through consensus or third party adjudication, while data was collected by one reviewer and verified by a second reviewer. Bayesian network meta-analyses (NMA) were performed to inform comparisons between interventions for a priori specified outcomes that included pure tone average (PTA) improvement and hearing recovery.

RESULTS

The search identified a total of 1,138 citations, of which 613 remained for review after removal of duplicates. Of these, 23 publications describing 19 unique studies (total sample size of 1,527) met our a priori eligibility criteria, that were assessed to be at unclear or high risk of bias on several domains. We identified data on several interventions for ISSNHL therapy and were able to construct treatment networks consisting of six intervention groups that included placebo; intratympanic (IT) steroid; IT plus systemic steroid; per oral (PO) steroid; intravenous (IV) steroid; and IV plus PO steroid for our NMAs. IT plus systemic steroids demonstrated the largest difference in PTA improvement compared to placebo (25.85 dB, 95% CrI 7.18-40.58), followed by IV plus PO steroids (22.06 dB, 95% CrI 1.24-39.17), IT steroids (18.24 dB, 95% CrI 3.00-29.81). We observed that the difference of PTA improvement between each intervention and placebo diminished over time, attributed to spontaneous recovery. The binary outcomes of hearing recovery demonstrated similar relative ordering of interventions but were less sensitive than PTA improvement to capture the significant differences between interventions and placebo.

CONCLUSION

Unclear to high risk of bias trials rated IT plus systemic steroid treatment as the best among the six interventions compared, and all active treatments were better than placebo in improving PTA. However, it should be noted that certain comparisons were based on indirect evidence only or few studies of small sample size, and analyses were unable to control for steroid type and dosage. Given these limitations, further data originating from methodologically sound and rigorous trials with adequate reporting are needed to confirm our findings.

Simulated image doubling and visual acuity: effects of doubling magnitude, orientation, and ghost image intensity

PURPOSE

The effects of image doubling on logarithmic progression chart visual acuity were investigated by simulating diplopia on a computer monitor.

METHODS

Ten participants (6M, 4F) aged 21-28 years (mean 22.4 ± 2.3) were assessed viewing with their left eye while wearing their best correction. Stimuli were eight rows of five Sloan letters, from 0.4 to -0.3 logMAR (6/15 to 6/3) arranged in logarithmic progression format, generated on an HD monitor. Stimuli were generated with different magnitudes of doubling, different directions of doubling, and different intensity ratios between the ghost image and main images.

RESULTS

When the ghost image had the same intensity as the main image, there was a significant effect of doubling magnitude on visual acuity, with the mean acuity being -0.11 logMAR (6/4.7) for no doubling. Acuity thresholds (logMAR) increased when doubling exceeded 1 min of arc, reaching a level of 0.12 logMAR (6/7.9) for doubling of 16 min of arc. There were no significant effects of orientation on acuity, nor were there significant orientation-doubling magnitude interaction effects of visual acuity. Image doubling magnitude level affected visual acuity differently for different ghost image intensities, with the highest acuity elevation occurring when ghost and main images were equal or nearly equal. For faint ghost image intensities (10% and 20%) image doubling did not significantly affect visual acuity.

CONCLUSIONS

Image doubling will degrade visual acuity if doubling is greater than 1 min of arc, and ghost images are sufficiently intense. However, even with very obvious visually-disturbing image doubling, visual acuity remains only slightly reduced.

Effectiveness of skull X-RAY to determine cochlear implant insertion depth

BACKGROUND

Cochlear implant (CI) insertion depth can affect residual hearing preservation, tonotopic range coverage, and Mapping. Therefore, determining insertion depth has the potential to maximize CI performance. A post-op skull X-RAY is commonly used to assess insertion depth, however its effectiveness has not been well established. Our primary objective was to assess the accuracy of post-op skull X-RAYs to determine insertion depth, compared to CT as the gold standard. Secondary objectives were to compare experience level of raters and different skull X-RAY views.

METHODS

Thirteen patients with Advanced Bionic HiRes 90 K implants, and post-operative temporal bone CT scans were selected from the CI database at Sunnybrook Health Sciences Centre. Medical students, otology fellows, and CI surgeons evaluated insertion depths on post-op skull X-RAYs, while neuroradiologists evaluated CT scans. Descriptive statistics, regression analysis, and paired t-tests were used to compare the two types of imaging.

RESULTS

X-RAYs and CTs provided an equivalent mean insertion depth of 337 degrees (p = 0.93), a mean difference of - 0.9 degrees and a standard deviation of paired differences of 43 degrees. Although means were similar across rater groups, CI surgeons (45 degrees) had the lowest standard deviation of paired differences. Comparing X-RAY views, Caldwell (29 degrees) had less variation than Towne (59 degrees) for standard deviation of paired differences.

CONCLUSIONS

Skull X-RAYs provide accurate and reliable measurements for CI insertion depth. The Caldwell view alone may be sufficient for evaluations of insertion depth, and experience has a minor impact on the variability of estimates.

A protocol for a network meta-analysis of interventions to treat patients with sudden sensorineural hearing loss

BACKGROUND

Hearing loss is one of the leading causes of disability worldwide, with greater than 20% of Canadian adults having measurable hearing loss in at least one ear. Patients with hearing loss experience impaired quality of life, and emotional and financial consequences that affect themselves and their families. Sudden sensorineural hearing loss (SSNHL) is a common but difficult to treat form of hearing loss that has a sudden onset of ≤ 72 h associated with various etiologies, with the majority of cases being idiopathic. Some patients may partially or completely recover hearing ability, but for 32 to 65% of patients whose hearing does not recover, feelings of social isolation elevate the risk of anxiety and depression. Hearing loss is also associated with poorer functional status, including difficulty with sound localization and hearing in noise. There exists a wide range of therapeutic options; however, treatment of idiopathic SSNHL is controversial because some patients recover spontaneously. The planned systematic review and network meta-analysis (NMA) will assess the relative effects of competing treatments for management of idiopathic SSNHL in adults.

METHODS

Electronic search strategies were developed by an experienced medical information specialist in consultation with the review team. We will search MEDLINE, Embase, and the Cochrane Library with no date or language restrictions. Key clinical trial registries will also be searched for in-progress and completed trials. Two reviewers will independently screen the literature using pre-specified eligibility criteria, and assess the quality of included studies using the Cochrane Risk of Bias tool. Disagreements will be resolved through consensus or third party adjudication. Bayesian NMAs will be pursued to compare interventions in terms of their effects on hearing (including audiometric thresholds and speech recognition scores), extent of hearing recovery, quality of life, and incidence of harms (including vestibular dysfunction, incidence of infections, and withdrawals due to adverse events).

DISCUSSION

This systematic review and NMA will offer new and informative evaluations of current therapies for SSNHL. The results will inform clinicians as to the relative benefits of the currently available interventions for managing this difficult condition, provide optimal clinical treatment strategies, establish evidence gaps, and identify promising treatments for evaluation in future trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD 42017073756 .

A rapid review of treatment literacy materials for tuberculosis patients

OBJECTIVE

To assess available treatment literacy materials for patients undergoing treatment for tuberculosis (TB).

DESIGN

We conducted a rapid review by searching the US Centers for Disease Control's Find TB Resources website and the websites of health departments and TB-focused organizations. We included English-language documents intended to educate TB patients about anti-tuberculosis treatment. We evaluated the format, readability, and content of documents, and audience. We defined 12 essential content elements based on those previously identified as facilitating human immunodeficiency virus treatment literacy.

RESULTS

Of the 205 documents obtained, 45 were included in our review. The median reading grade level was 7 (IQR 5-8). The median number of essential content elements present was 6 (IQR 4-8), with the most comprehensive document containing 11 of the 12 elements. Only two documents were written for children with TB or their care givers, and two for patients with drug-resistant TB. Many documents contained paternalistic and non-patient-centered language.

CONCLUSION

We found few examples of comprehensive, patient-centered documents. Work is needed to achieve consensus as to the essential elements of TB treatment literacy and to create additional materials for children, patients with drug-resistant TB, and those with lower literacy levels.

Development and face validation of a Virtual Reality Epley Maneuver System (VREMS) for home Epley treatment of benign paroxysmal positional vertigo: A randomized, controlled trial

PURPOSE

To develop and validate a smartphone based Virtual Reality Epley Maneuver System (VREMS) for home use.

METHODS

A smartphone application was designed to produce stereoscopic views of a Virtual Reality (VR) environment, which when viewed after placing a smartphone in a virtual reality headset, allowed the user to be guided step-by-step through the Epley maneuver in a VR environment. Twenty healthy participants were recruited and randomized to undergo either assisted Epleys or self-administered Epleys following reading instructions from an Instructional Handout (IH). All participants were filmed and two expert Otologists reviewed the videos, assigning each participant a score (out of 10) for performance on each step. Participants rated their perceived workload by completing a validated task-load questionnaire (NASA Task Load Index) and averages for both groups were calculated.

RESULTS

Twenty participants were evaluated with average age 26.4±7.12years old in the VREMS group and 26.1±7.72 in the IH group. The VR assisted group achieved an average score of 7.78±0.99 compared to 6.65±1.72 in the IH group. This result was statistically significant with p=0.0001 and side dominance did not appear to play a factor. Analyzing each step of the Epley maneuver demonstrated that assisted Epleys were done more accurately with statically significant results in steps 2-4. Results of the NASA-TLX scores were variable with no significant findings.

CONCLUSION

We have developed and demonstrated face validity for VREMS through our randomized controlled trial. The VREMS platform is promising technology, which may improve the accuracy and effectiveness of home Epley treatments.

LEVEL OF EVIDENCE

N/A.

The Role of Preoperative Steroids for Hearing Preservation Cochlear Implantation: Results of a Randomized Controlled Trial

Objectives: To determine whether preoperative steroids can improve hearing outcomes in cochlear implantation (CI). Methods: This is a randomized controlled trial involving 30 postlingual deaf CI patients. Subjects had preoperative thresholds of better than or equal to 80 dB at 125 and 250 Hz, and better than or equal to 90 dB at 500 and 1,000 Hz. The subjects were randomized to a control group, an oral steroid group (receiving 1 mg/kg/day of prednisolone for 6 days prior to surgery), or a transtympanic steroid group (receiving a single dose of 0.5 mL of 10 mg/mL dexamethasone at 24 h prior to surgery). Results: The subjects receiving transtympanic steroids had a significant decrease in the pure tone average over 3 months compared to the control and oral steroid group, which persisted over 12 months (p < 0.05). Conclusion: A single dose of preoperative transtympanic steroids prior to CI appears to have a beneficial effect, at least in the short term, with minimal effects seen in the longer term.

The Canadian Otolaryngology–Head and Neck Surgery Workforce in the Urban-Rural Continuum: Longitudinal Data from 2002 to 2013

Objectives

To evaluate the proportion of otolaryngology–head and neck surgery (OHNS) providers who are rural versus urban based from 2002 to 2013. Secondary objective was to present perspectives of rural primary care providers on unmet needs for OHNS services.

Study Design

Mixed methods database analysis and prospective survey.

Setting

National administrative database.

Subjects and Methods

The Canadian Medical Association OHNS provider Masterfile and the Statistics Canada postal code file were used to determine provincial, urban, rural, and Aboriginal group care coverage. The Society of Rural Physicians of Canada was surveyed to explore care delivery and unmet needs for OHNS and audiology. Descriptive statistics and linear regression were used to describe results.

Results

Ontario and Quebec had the largest annual OHNS physician growth (6.38 providers/year; r2 = 0.94) versus stagnant growth in the territories. The clear majority of OHNS providers are in urban centers, and rural OHNS coverage is decreasing annually (–0.33 providers/year, r2 = 0.28). There are no OHNS providers in 485 population centers where Aboriginal groups are located. A survey of 40 rural primary care providers reported that OHNS care is most commonly delivered through seasonal visits to a local facility, with otology (hearing loss, chronic ear disease) and rhinology (nonmalignant nasal or sinus conditions) as the most frequently reported unmet needs.

Conclusion

From 2002 to 2013, OHNS coverage showed a trend for urban consolidation. Most Aboriginal groups may have decreased access to care, as there are no OHNS providers in 485 population centers where reserves are located. There is an unmet need for specialized OHNS services reported by rural primary care physicians, especially otology and rhinology.

More than a virus: a qualitative study of the social implications of hepatitis B infection in China

Background

China has the largest absolute number of people living with hepatitis B with up to 300,000 people estimated to die each year from hepatitis B related diseases. Despite advances in immunisation, clinical management, and health policy, there is still a lack of accessible and affordable health care for people with hepatitis B. Through in-depth interviews, this study identifies the personal, social and economic impact of living with hepatitis B and considers the role of stigma and discrimination as barriers to effective clinical management of the disease.

Methods

Semi-structured qualitative interviews were held with 41 people living with hepatitis B in five Chinese cities. Participants were recruited through clinical and non-government organisations providing services to people with hepatitis B, with most (n = 32) being under the age of 35 years.

Results

People living with hepatitis B experience the disease as a transformative intergenerational chronic infection with multiple personal and social impacts. These include education and employment choices, economic opportunities, and the development of intimate relationships. While regulations reducing access to employment and education for people with hepatitis B have been repealed, stigma and discrimination continue to marginalise people with hepatitis B.

Conclusions

Effective public policy to reduce morbidity and mortality associated with hepatitis B needs to address the lived impact of hepatitis B on families, employment and educational choices, finances, and social marginalisation.

Preoperative steroids for hearing preservation cochlear implantation: A review

Preoperative steroids have been shown to be beneficial in reducing the hearing loss associated with cochlear implantation. This review article discusses the mechanism of action, effects of differing routes of administration, and side effects of steroids administered to the inner ear. Studies on the role of preoperative steroids in animal and human studies are also examined and future directions for research in this area are discussed.

Management and treatment of relapsed or refractory Ph(-) B-precursor ALL: a web-based, double-blind survey of EU clinicians

BACKGROUND

The prognosis for adult patients with Ph(-) B-precursor acute lymphoblastic leukaemia (ALL) who are refractory to treatment or experience relapse (R/R), is poor; over 90% of these patients die from the disease, typically within a few months. While there are some national guidelines published for the treatment of adult patients with ALL, and local working group recommendations do exist, there is very little detail and no preferred treatment regimens for adult patients with R/R Ph(-) B-precursor ALL. The aim of this study was to describe current real-world clinical practice in Europe for the management and treatment of adult R/R Ph(-) B-precursor ALL.

METHODS

A web-based, double-blind survey was conducted in November/December 2013 in France, Germany, Italy, Spain, and the UK. The survey was developed following consultation with specialist clinicians and a critical review of published literature. Eligible clinicians (15 per country) were board-certified in haemato-oncology or haematology; had at least 4 years of experience in their current role and had treated at least five patients with adult ALL in the 36 months before the survey, including at least one with R/R Ph(-) B-precursor ALL.

RESULTS

Clinicians across the five countries consulted 16 guidelines and local working group recommendations for the diagnosis and treatment of R/R Ph(-) B-precursor ALL. Thirty three regimens for salvage therapy were reported; the most frequently cited was augmented hyper-CVAD (15%), with vincristine the most commonly used agent. Salvage therapy regimens involved a range of agents, and most respondents reported using at least one cytotoxic agent; across respondents 10 different cytotoxic agents were cited. All respondents reported that toxicity was common for the regimens they used to treat R/R Ph(-) B-precursor ALL.

CONCLUSIONS

This study provides evidence of current management and treatment patterns of R/R Ph(-) B-precursor ALL in the real-world clinical practice in Europe. The approach to the treatment of R/R Ph(-) B-precursor ALL is heterogeneous, reflecting the lack of any clearly superior chemotherapeutic option, thus it appears that clinicians are trying a wide variety of therapies. These findings show a clear need for effective, tolerable treatments for R/R Ph(-) B-precursor ALL.

The role of extended preoperative steroids in hearing preservation cochlear implantation

INTRODUCTION

Steroids have been shown to reduce the hearing threshold shifts associated with cochlear implantation. Previous studies have examined only the administration of steroids just prior to surgery. The aim of this study is to examine the role of extended preoperative systemic steroids in hearing preservation cochlear implantation.

METHODS

An animal model of cochlear implantation was used. 24 Hartley strain guinea pigs with a mean weight of 768 g and normal hearing were randomised into a control group, a second group receiving a single dose of systemic dexamethasone one day prior to surgery, and a third group receiving a daily dose of systemic dexamethasone for 5 days prior to surgery. A specially designed cochlear implant electrode by Med-EL (Innsbruck) was inserted through a dorsolateral approach to an insertion depth of 5 mm and left in-situ. Auditory brain stem responses at 8 kHz, 16 kHz and 32 kHz were measured preoperatively, and 1 week, 1 month and 2 months postoperatively. Cochlear histopathology was examined at the conclusion of the study.

RESULTS

At 1-week post operative, both groups receiving dexamethasone prior to implantation had smaller threshold shifts across all frequencies and which was significant at 32 kHz (p < 0.05). There were no differences among the three groups in the area of electrode related fibrosis. Spiral ganglion neuron (SGN) density was significantly higher in the group receiving steroids for 5 days, but only in the basal cochlear turn.

DISCUSSION

This is study demonstrates the benefits of extended preoperative systemic steroids on hearing outcomes and SGN density in an animal model of cochlear implantation surgery.

The economic and societal benefits of adult cochlear implant implantation: A pilot exploratory study

BACKGROUND

Cochlear implantation has been shown to result in significant improvements in communication and quality of life, but little is known about the effect of cochlear implantation and changes in a person's employment status and earning potential. The purpose of this study is to measure the extent to which personal income changes in people who receive a cochlear implant.

METHODS

We mailed a survey to a random selection of 150 cochlear implantees who receive health services in a large urban setting. Of the 93 respondents, 65 were eligible for inclusion. Demographics, current income and income prior to implantation were recorded into income categories.

RESULTS

With a 6.6-year mean duration from cochlear implantation, it was found that 31% of respondents had increased income enough to move income brackets, with a mean category rise of $10 021. Forty participants reported working pre-implant, while 49 reported working post-implant.

IMPLICATIONS

Our results suggest preliminary evidence for an association between cochlear implantation and income. Increased accesses to cochlear implantation may provide opportunities for competitive employment and associated economic benefits for the individual, their families, and society.

Bilateral sequential adult cochlear implantation: who should receive priority in the context of a constrained health care system?

Resource allocation decisions have become increasingly necessary as the cost of health care habitually increases. Bilateral (second side) adult cochlear implantation (CI) is an example of a novel technology with accruing evidence of benefit, yet expense has limited universal employ. Currently at our centers, bilateral implantation is only provided under research protocol. In this article, we discuss the need for a principled approach concerning the distribution of a second device, both during this period of investigation and if ultimately an insured service. Allocation strategies, while extensively addressed in some arenas, have yet to be developed for second-side sequential adult CI. We advocate that physicians must assume an explicit role when both caring for individual patients as well as administering health care programs. We review social justice theories that inform resource allocation macrodecisions, and include a defence of age-based considerations. Our approach to patient selection for adult second-side CI sequentially considers clinical criteria (directly addressed in the article), a willingness to participate in rigorous research, and a 65 year cut-off. Ultimately, we employ random blinded selection for allocating bilateral CI among the remaining similarly situated individuals. This approach functions impartially and in a manner that is transparent for both patient and physician.

Cochlear implantation: a personal and societal economic perspective examining the effects of cochlear implantation on personal income

OBJECTIVE

Although cochlear implantation has been shown to improve quality of life, the socioeconomic benefit to the individual and society has not been thoroughly investigated. Our objective was to determine the economic impact of profound deafness and subsequent effects of unilateral cochlear implantation.

DESIGN

Retrospective analysis of a prospectively collected cochlear implantation database.

SETTING

An academic, tertiary care hospital.

METHODS

A prospectively collected cochlear implantation database of 702 patients was reviewed. Known Canadian economic surrogates were used to estimate the personal economic impact of both deafness and unilateral cochlear implantation.

MAIN OUTCOME MEASURES

The main outcome measures included employment rates and personal income prior to and following cochlear implantation.

RESULTS

A total of 637 patients had sufficient occupational data for inclusion in the study; 36.7% suffered a negative economic impact as a result of their deafness. Cochlear implantation was associated with a significant increase in median yearly income compared to preimplantation ($42 672 vs $30 432; p = .007).

CONCLUSIONS

Cochlear implantation not only improves quality of life but also translates into significant economic benefits for patients and the Canadian economy. These benefits appear to exceed the overall costs of cochlear implantation.