Frequency, distribution and determinants of Helicobacter pylori infection in adults and adolescents with gastric symptoms: cross-sectional epidemiological inquiry in district Haripur, Pakistan

Abstract Helicobacter pylori (HP) is a vital element in the etiology of peptic ulcers and gastric cancer. This research aimed to determine the frequency, distribution, and determinants of HP infection in adults and adolescents with gastric symptoms in district Haripur, Khyber Pakhtunkhwa, Pakistan. This cross-sectional study was performed from June 2018 to June 2020 at the Medical Laboratory Technology Department, The University of Haripur, Pakistan. Presence of HP was a research variable, while sex, age groups, education status, overcrowding, dining habits, milk intake, drinking water source and animal contact were grouping variables. Immuno-chromatographic technique (ICT) was used to for serological detection of HP antibodies. All variables were represented by frequency and percentage with 95%CI. Prevalence of HP and its distribution by eight socio-demographic variables was testified by the chi-square goodness-of-fit test while association was testified by chi-square test of association. Out of total 1160 cases, 557 (48%) were positive for HP. Population prevalence was higher in men, in the age group 20-40 years, illiterate, family size ≤ 10 persons, taking restaurant food, using tetra pack, using municipal water, and having animal contact. The observed prevalence of HP was similar to its expected prevalence in the population. The observed distribution of HP in the sample was different from its expected distribution in population by eight socio-demographic variables. Presence of HP was associated with all eight socio-demographic variables besides age groups.

Incidence of Vestibular Schwannoma in Patients with Unilateral Tinnitus: A Systematic Review and Meta-Analysis

OBJECTIVES

Vestibular schwannoma (VS) is a tumor of the vestibulocochlear nerve. Current literature indicates that 1.6% of patients undergoing magnetic resonance imaging of the internal auditory meatus (MRI IAM) for audiovestibular symptoms are diagnosed with a VS. However, there is limited research reporting on patients who present with unilateral tinnitus without asymmetrical hearing loss. This study is a systematic review and meta-analysis evaluating how many of those patients had a VS diagnosed on MRI IAM.

DATABASES USED

Online searches of PubMed, Medline, and Embase databases were performed up to October 2022.

METHODS

This meta-analysis was undertaken aligning with PRISMA guidelines. Articles reporting on patients having MRI IAM for unilateral tinnitus without asymmetrical hearing loss were included. Outcomes measures were patient demographics, VS cases, incidental findings, size, and management of tumor. A meta-analysis of proportions was performed using a random-effects model with the restricted maximum likelihood method. Quality assessment was performed using the Joanna Briggs Institute critical appraisal checklist.

RESULTS

Seven case series were included in the review: a total of 1,394 patients. Seven patients had a VS, with a median size of 4 mm. The pooled detection rate for VS was 0.08% (95% confidence interval = 0.00-0.45). Subsequent management was reported in six cases of which four were actively monitored and two surgically excised. The most common incidental finding was sinus disease (49 patients).

CONCLUSION

Our findings indicate that MRI IAM has a low diagnostic yield for VS detection in patients presenting with unilateral tinnitus without asymmetrical hearing loss, with mostly small tumors that are conservatively managed.

Influence of mechanical debridement with adjunct probiotic therapy on clinical status and salivary cortisol levels in patients with periodontal inflammation

OBJECTIVE

The null hypothesis is that there is no difference in periodontal parameters and salivary cortisol levels (CL) among patients with periodontal inflammatory conditions (PIC) who receive non-surgical mechanical debridement (NSMD) with or without adjunct probiotic therapy (PT). The aim of this study was to assess the influence of NSMD with and without adjunct PT on clinical status and whole salivary CL in patients with PIC.

PATIENTS AND METHODS

Participants were randomly divided into four groups: Group-1: NSMD alone (n=19); Group-2: NSMD + PT (n=18); Group-3: PT + oral hygiene instructions (OHI) (n=17); and Group-4: PT alone (n=18). Lactobacillus rhamnosus SP1 (2×107 colony-forming units/day) was used for PT. Plaque and gingival indices (PI and GI), probing depth (PD) and clinical attachment loss (AL) were assessed, and whole salivary CL was assessed at baseline and at 6-week follow-up. Marginal bone levels were assessed at baseline and demographic data was collected using a questionnaire. Sample-size estimation was performed, and statistical significance was determined at p<0.05.

RESULTS

At follow-up, PI (p<0.01), GI (p<0.01), and PD (p<0.01) were significantly higher in PT + OHI and PT alone groups compared with individuals who underwent NSMD + PT and NSMD alone. At baseline and follow-up, there was no significant difference in CL in all groups. There was no statistically significant correlation between age, gender, PI, PD, GI, clinical AL, salivary flow rate, education status and salivary CL in all groups at baseline and follow-up.

CONCLUSIONS

NSMD continues to be the "gold standard" and most reliable treatment strategy for managing PIC. It is imperative to reach a consensus regarding the duration, dosage, and frequency of PT that would yield optimal results for managing PIC.

Efficacy of adjunct subgingival minocycline delivery for treatment of peri-implantitis in moderate cigarette smokers

OBJECTIVE

Localized subgingival minocycline hydrochloride (MH) delivery as an adjuvant to with non-surgical mechanical debridement (NSMD) is useful for the treatment of periodontitis; however, there are no trials that have assessed the efficacy of subgingival MH delivery with NSMD for the treatment of peri-implantitis in cigarette-smokers and non-smokers. This randomized controlled trial assessed the efficacy of subgingival MH delivery with NSMD for the treatment of peri-implantitis in cigarette-smokers.

PATIENTS AND METHODS

Self-reported current cigarette-smokers and non-smokers with peri-implantitis were encompassed. These individuals were subdivided into 2-subgroups. Patients in test- and control groups received NSMD with and without a single delivery of subgingival MH. Modified-gingival-index (mGI), modified-plaque-index (mPI), probing-depth (PD) and crestal-bone-loss (CBL) were measured at baseline and at 6-months' follow-up. Demographic-data was also collected. Level of significance was set at p<0.01.

RESULTS

Twenty-four cigarette-smokers and 24 non-smokers with peri-implantitis were included. There was a significant reduction in mPI (p<0.01), mGI (p<0.01), PD (p<0.01) at 6-months among patients with and without type-2 DM in test- and control-groups. There was no significant difference in peri-implant mPI, PD and mGI, patients with and without type-2 diabetes in test- and control-groups at 6-months of follow-up. There was no significant difference in CBL in all patients at 6-months of follow-up.

CONCLUSIONS

A single application of subgingival MH delivery is as effective as NSMD alone for the treatment of peri-implantitis in cigarette-smokers and non-smokers.

Anti-nociceptive efficacy of essential oil-based extracts for the management of orofacial pain: a systematic review of available evidence

OBJECTIVE

Experimental studies have shown that essential oil (EO)-based extracts derived from medicinal plants exhibit antinociceptive activity. The aim of the present systematic review was to assess the anti-nociceptive efficacy of EO-based extracts for the management of orofacial pain (OFP).

MATERIALS AND METHODS

To address the focused question "Are EO-based formulations effective for the management of OFP disorders?", indexed databases were searched without time and language restrictions using the preferred reporting items for systematic reviews and meta-analysis guidelines. Risk of bias (ROB) was assessed.

RESULTS

Eight studies were included and processed for data extraction. Two studies were clinical (one in adults and one in children) and 6 were performed in rodents. Results from one clinical study showed that inhalation of EO-extracts does not affect subjective toothache scores; and results from the study on children reported that inhalation of lavender oil reduces anxiety and pain during and after tooth extraction. Results from all experimental studies showed that administration of EO-extracts reduces orofacial nociceptive behavior. The ROB was high in 50% and 83.3% of the clinical and experimental studies, respectively.

CONCLUSIONS

The anti-nociceptive efficacy of EO-extracts for the management of OFP remains debatable. Further well-designed and power-adjusted randomized clinical trials are needed in this regard.

AB0853 IGG4-RELATED DISEASE CAUSING OCULAR NERVE PALSIES AND ORBITAL APEX SYNDROME: CASE REPORT AND LITERATURE REVIEW

Background:

IgG4-Related Disease (IgG4-RD) is a systemic immune-mediated fibroinflammatory condition. The epidemiology is not well defined: it usually affects adults from middle-age onwards, predominantly male. Both B and T-cells are central in IgG4-RD pathogenesis, as demonstrated by the efficacy of B-cell depletion therapy.IgG4-RD can affect multiple organs including the central and peripheral nervous system, producing a constellation of clinical symptoms and signs, depending on the organ structures involved.

IgG4-related orbital disease is relatively rare can implicate all extra-ocular muscles, structures emerging from the Orbital apex, optic canal, or superior and inferior orbital fissure. Depending on the structures involved, it can produce different or sometimes subtle clinical presentations, posing diagnostic challenge. There were case reports of IgG4-related ophthalmic disease misdiagnosed as intraocular tumour.

Objectives:

IgG4-RD is increasingly recognised as an entity affecting the head and neck region. However, it rarely involves skull base and presents with orbital apex syndrome. In this current case report, we describe an interesting case of IgG-related orbital disease presenting with ocular nerve palsies and orbital apex syndrome.

Methods:

Case report.

Results:

A 36-year-old gentleman with cocaine and alcohol misuse presented with a 2-month history of left sided headache, diplopia, recurrent ear infections, otalgia and hearing loss. Initial imaging suggested left otomastoiditis and intravenous antibiotics were commenced. Contralateral partial third nerve palsy with pupil sparing was elicited. 2 months later, there was worsening right eye ptosis, proptosis, right relative afferent pupillary defect, reduced visual acuity and colour vision as well as a near-complete ophthalmoplegia. Subsequent imaging showed worsening soft tissue swelling centred on the upper left parapharyngeal and masticator space, with multiple perineural enhancement and lateral extension to right orbital apex and orbital fissures. Blood tests only revealed raised IgG4 subclass. Infectious aetiology was excluded. Left nasal mass biopsy performed showed no fungal organism or malignancy. There were lymphoplasmacytic proliferation but no storiform fibrosis or obliterative phlebitis. IgG4 immunostaining on two assessable fields revealed 22 and 17 positive plasma cells respectively, and an IgG4: IgG ratio of <10%, and 50% in the other. Significant improvement was seen clinically and radiologically with antibiotics and a tapering regime of oral Prednisolone. Patient was commenced on Azathioprine as long term immunosuppression.

Conclusion:

A high degree of clinical suspicion is necessary to diagnose IgG4-RD when presenting with orbital apex syndrome and ocular nerve palsies,IgG4-RD can mimic mastoiditis of infectious aetiology. Other differentials may include cocaine-induced midline destructive lesions and granulomatosis with polyangiitis. The diagnosis can be supported by elevated serum IgG, elevated IgG index and pathognomonic histopathological findings. . The diagnosis of IgG4-related orbital disease should be deliberated on by a multidisciplinary group, with every effort being made to exclude an infectious aetiology, before embarking on immunosuppressive therapy.Primary treatment is with steroids. However, immunotherapy using azathioprine can be utilised in recurrent disease or patients with steroid intolerance.

References:

[1]Goto H, Ueda S. Immunoglobulin G4-related ophthalmic disease involving the sclera misdiagnosed as intraocular tumor: report of one case. OculOncolPathol. 2016;2(4):285–8.

[2]Ohyama K, Koike H, Iijima M, et al. IgG4-related neuropathy: a case report. JAMA Neurol. 2013;70(4):502–5.

[3]AbdelRazek MA, Venna N, Stone JH. IgG4-related disease of the central and peripheral nervous systems. Lancet Neurol. 2018;17(2):183–92.

[4]Kamekura R, Takahashi H, Ichimiya S. New insights into IgG4-related disease: emerging new CD4+ T-cell subsets. Curr Opin Rheumatol. 2019;31(1):9–15.

Disclosure of Interests:

None declared

Acute otitis externa: Consensus definition, diagnostic criteria and core outcome set development

OBJECTIVE

Evidence for the management of acute otitis externa (AOE) is limited, with unclear diagnostic criteria and variably reported outcome measures that may not reflect key stakeholder priorities. We aimed to develop 1) a definition, 2) diagnostic criteria and 3) a core outcome set (COS) for AOE.

STUDY DESIGN

COS development according to Core Outcome Measures in Effectiveness Trials (COMET) methodology and parallel consensus selection of diagnostic criteria/definition.

SETTING

Stakeholders from the United Kingdom.

SUBJECTS AND METHODS

Comprehensive literature review identified candidate items for the COS, definition and diagnostic criteria. Nine individuals with past AOE generated further patient-centred candidate items. Candidate items were rated for importance by patient and professional (ENT doctors, general practitioners, microbiologists, nurses, audiologists) stakeholders in a three-round online Delphi exercise. Consensus items were grouped to form the COS, diagnostic criteria, and definition.

RESULTS

Candidate COS items from patients (n = 28) and literature (n = 25) were deduplicated and amalgamated to a final candidate list (n = 46). Patients emphasised quality-of-life and the impact on daily activities/work. Via the Delphi process, stakeholders agreed on 31 candidate items. The final COS covered six outcomes: pain; disease severity; impact on quality-of-life and daily activities; patient satisfaction; treatment-related outcome; and microbiology. 14 candidate diagnostic criteria were identified, 8 reaching inclusion consensus. The final definition for AOE was 'diffuse inflammation of the ear canal skin of less than 6 weeks duration'.

CONCLUSION

The development and adoption of a consensus definition, diagnostic criteria and a COS will help to standardise future research in AOE, facilitating meta-analysis. Consulting former patients throughout development highlighted deficiencies in the outcomes adopted previously, in particular concerning the impact of AOE on daily life.

152 The Relationship Between 25(OH) Vitamin D and Bone Mineral Density (BMD) in Patients 65 Years and Older with Prior Fragility Fractures

Introduction

25(OH) vitamin D [25(OH) D] levels are known to influence skeletal health as well as muscle function. Some studies suggest a positive association between 25(OH) D levels and BMD at various skeletal sites in men but not in women. These findings were mostly observed in younger (less than 50 year old) cohorts. Evidence for this association in older patients with prior fragility fractures is lacking. Aim: To assess the correlation of 25(OH) D levels with T-scores at the neck of femur, hip and spine in patients 65 years and older with prior fragility fractures and the effect of gender on the correlation.

Methods

A retrospective, cross-sectional analysis of patients 65 and older with previous fragility fractures in patients attending a fracture prevention service. Data was extracted from the electronic records. SPSS 26 statistical software was used for statistical analysis. Pearson correlation coefficient was used to calculate correlation and regression coefficient for gender.

Results

151 patients were included; 26 males and 126 females. Mean age was 76.2 and 74.1 years respectively. In the males there was good positive, statistically significant correlation between the 25(OH) D and T-scores at the neck of femur (r = 0.415; p &lt; 0.05) and hip (r = 0.413; p &lt; 0.05), but correlation with T-score of the spine was not statistically significant (r = 0.349; p = 0.103). In the females there was no statistically significant correlation between 25(OH) D and T-scores at the neck of femur, hip or spine (r = 0.163; p = 0.077), (r = 0.096; p = 0.299) and (r = 0.114; p = 0.217) respectively.

Conclusion

In males, 65 years and older, with prior fragility fracture, there is a positive significant correlation between 25(OH) D and BMD at the neck of femur and hip whereas there is no significant correlation in females.

Influence of mini-screw implant-assisted intrusion on orthodontically induced inflammatory root resorption: a systematic review

AIM

To systematically review indexed literature related to the influence of mini-screw implant (MSI)-assisted intrusion on orthodontically induced inflammatory root resorption (OIIRR).

METHODS

Indexed databases were searched without time and language restrictions using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The inclusion criteria were: (a) original studies; (b) patients/subjects undergoing MSI-assisted intrusion; and (c) tomographic and/or histological assessment of OIIRR. Letters to the Editor, commentaries, case reports/series, reviews, and studies based on two-dimensional radiographic assessment of OIIRR were excluded. For experimental and clinical studies, the risk of bias assessment was performed using the Systematic Review Centre for Laboratory animal Experimentation risk of bias tool and the Risk of Bias in Non-randomized Studies of Interventions guidelines, respectively.

RESULTS

The initial search yielded 453 studies, out of which 6 (3 clinical and 3 on animal-models) were included. The clinical studies were performed on males and females with a mean age ranging between 16.07 and 25.5 years. Duration of the clinical studies ranged from 3.8 to 9 months. The animal studies were performed on mini-pigs, rats, and dogs. The mean age in the studies on rats and mini-pigs was 2.76 and 18 months, respectively. In the study on canine models, mean age was not reported. In all studies, MSI-assisted intrusion was shown to cause OIIRR. Power analysis was performed in one study. All studies had a moderate risk of bias.

CONCLUSIONS

MSI-assisted intrusion is a risk factor for OIIRR; however, from a clinical perspective, further well-designed and power-adjusted studies are needed.

Influence of involuntary cigarette smoke inhalation on osseointegration: a systematic review and meta-analysis of preclinical studies

There are no studies that have systematically reviewed the influence of involuntary cigarette smoke inhalation (ICSI) on the stability of implants. The aim of the present study was to perform a systematic review and meta-analysis of preclinical studies that assessed the influence of involuntary cigarette smoke inhalation ICSI on osseointegration. Indexed databases (PubMed, Google-Scholar, Scopus, EMBASE, and Web of Knowledge) were searched till September 2017. Titles and abstracts of studies identified using the above-described protocol were independently screened by 2 authors. Full-texts of studies judged by title and abstract to be relevant were independently evaluated for the stated eligibility criteria. Nine studies were included. Six studies showed that ICSI compromised bone area contact around implants. In 4 studies, peri-implant bone mineral density was significantly higher in the control group than among subjects exposed to ICSI. For the effects of ICSI on the osseointegration of dental implants, significant differences could be observed for bone-to-implant contact for test subjects in cancellous (Z=-4.08, p<0.001) and cortical bone (Z=-4.31, p<0.001) respectively. ICSI may negatively influence osseointegration of dental implants. It is imperative to educate patients about the negative effects of passive smoking on dental and systemic health.

Does incorporating collagen and chondroitin sulfate matrix in implant surfaces enhance osseointegration? A systematic review and meta-analysis

Implant surface modification has been used to improve osseointegration. However, evidence regarding improved new bone formation (NBF) and osseointegration with the use of collagen-chondroitin sulfate (CS) matrix coated implants remains unclear. The aim of this study was to assess the efficacy of collagen-CS matrix coating on the osseointegration of implants. The focused question was "Does the incorporation of collagen-CS matrix in implant surfaces influence osseointegration?" To answer the question, indexed databases were searched up to July 2017 using various combinations of the key words "collagen", "chondroitin sulfate", "osseointegration", and "implants". The initial literature search identified 497 articles, of which 18 reporting experimental studies fulfilled the inclusion criteria. Thirteen of the studies included (72%) reported that implants coated with a collagen-CS matrix presented higher NBF, bone-to-implant contact, and/or bone volume density. The strength of this observation was supported by meta-analysis results. Nevertheless, the results should be interpreted with caution due to the lack of standardization regarding the dosage formulation of collagen-CS, short-term follow-up, and lack of assessment of confounders. On experimental grounds, the incorporation of collagen-CS matrix into implant surfaces appears to promote osseointegration. From a clinical perspective, the results from animal models support phase I studies in healthy humans.

Influence of implant location in patients with and without type 2 diabetes mellitus: 2-year follow-up

The aim of the present cross-sectional retrospective 2-year follow-up clinical study was to assess the influence of implant location on clinical and radiographic parameters around dental implants placed in patients with and without type 2 diabetes mellitus (T2DM). Twenty-seven patients with T2DM and 25 non-diabetic controls were included. Implants were classified into three zones according to their location: (1) anterior zone: implant/s replacing anterior teeth, (2) middle zone: implant/s replacing premolars, and (3) posterior zone: implant/s replacing molars. Peri-implant bleeding on probing (BOP), probing depth (PD), and crestal bone loss (CBL) were measured. P-values less than 0.05 were considered statistically significant. The mean age of patients with T2DM was 42.5 years and that of non-diabetic controls was 40.6 years. The mean fasting blood glucose levels of patients with and without T2DM were 74.5mg/dl (66-80mg/dl) and 82.5mg/dl (79-88.1mg/dl), respectively. The mean duration of T2DM was 4.3 years. There was no significant difference in BOP, PD, or CBL around implants placed in any of the zones in the jaws of patients with and without T2DM. There is no influence of implant location on clinical and radiographic parameters around dental implants placed in patients with and without T2DM.

Oral Candida carriage and species prevalence in denture stomatitis patients with and without diabetes

The objective of this study was to assess the oral Candida carriage and species prevalence in denture stomatitis (DS) patients with and without diabetes mellitus (DM). To address the focused question “In patients receiving dentures, how does having diabetes compared to no diabetes influences the carriage and species prevalence of oral Candida?” Indexed databases were explored without time or language restrictions up to and including February 2017. Nine studies were included. In these studies, the number of diabetics ranged between 14 patients and 405 individuals with mean ages ranging between 33 years and 66.4 years. In five studies, the percentage of hyperglycemic patients in the diabetic group ranged from 14.3% to 100%. In one study, all diabetic patients were normoglycemic. Seven studies reported Candida-associated DS to be significantly higher among diabetics than non-diabetics. Candida albicans was the most prevalent species isolated among diabetics and non-diabetics with DS. Denture-wearers with DM are more susceptible to Candida-associated DS as compared to non-diabetics.

Recent updates on electronic cigarette aerosol and inhaled nicotine effects on periodontal and pulmonary tissues

E-cigarette-derived inhaled nicotine may contribute to the pathogenesis of periodontal and pulmonary diseases in particular via lung inflammation, injurious, and dysregulated repair responses. Nicotine is shown to have antiproliferative properties and affects fibroblasts in vitro, which may interfere in tissue myofibroblast differentiation in e-cig users. This will affect the ability to heal wounds by decreasing wound contraction. In periodontics, direct exposure to e-vapor has been shown to produce harmful effects in periodontal ligament and gingival fibroblasts in culture. This is due to the generation of reactive oxygen species/aldehydes/carbonyls from e-cig aerosol, leading to protein carbonylation of extracellular matrix and DNA adducts/damage. A limited number of studies regarding the effects of e-cig in oral and lung health are available. However, no reports are available to directly link the deleterious effects on e-cigs, inhaled nicotine, and flavorings aerosol on periodontal and pulmonary health in particular to identify the risk of oral diseases by e-cigarettes and nicotine aerosols. This mini-review summarizes the recent perspectives on e-cigarettes including inhaled nicotine effects on several pathophysiological events, such as oxidative stress, DNA damage, innate host response, inflammation, cellular senescence, profibrogenic and dysregulated repair, leading to lung remodeling, oral submucous fibrosis, and periodontal diseases.

Role of diode lasers in oro-facial pain management

With the increasing use of low level laser therapy (LLLT) in clinical dentistry, the aim of the present study was to assess the effectiveness of diode lasers in the management of orofacial pain. Indexed databases were searched without language and time restrictions up to and including July 2016 using different combinations of the following key words: oral, low level laser therapy, dental, pain, diode lasers, discomfort and analgesia. From the literature reviewed it is evident that LLLT is effective compared to traditional procedures in the management of oro-facial pain associated to soft tissue and hard tissue conditions such as premalignant lesions, gingival conditions and dental extractions. However, it remains to be determined which particular wavelength will produce the more favorable and predictable outcome in terms of pain reduction. It is highly recommended that further randomized control trials with well-defined control groups should be performed to determine the precise wavelengths of the diode lasers for the management of oro-facial pain. Within the limits of the present review, it is concluded that diode lasers therapy is more effective in the management of oro-facial pain compared to traditional procedures.

A randomised controlled trial assessing the efficacy of co-phenylcaine nasal spray in flexible transnasal pharyngolaryngoscopy

INTRODUCTION The aim of this study was to assess whether using co-phenylcaine nasal spray before flexible transnasal pharyngolaryngoscopy results in reduced pain and discomfort during the procedure. METHODS This was a randomised controlled trial. Eighty-four patients were randomised to receive either co-phenylcaine nasal spray or placebo nasal spray before performing transnasal flexible pharyngolaryngoscopy. Patient reported outcome measures included pain, discomfort, unpleasantness and willingness to repeat the procedure while clinician reported outcome measures comprised ease of examination and quality of view obtained during the procedure. RESULTS There was no statistically significant difference in scores for pain, discomfort, unpleasantness and willingness to repeat the procedure between the co-phenylcaine and placebo groups. On the other hand, ease of examination scores were significantly better for the co-phenylcaine group than for the placebo group. CONCLUSIONS The majority of patients do not find flexible pharyngolaryngoscopy unpleasant or painful with or without topical nasal anaesthesia. However, the spray does appear to help the examiner in completing a satisfactory assessment.

Interventions for children with ear discharge occurring at least two weeks following grommet (ventilation tube) insertion

BACKGROUND

Ear discharge (otorrhoea) is common in children with grommets (ventilation/tympanostomy tubes); the proportion of children developing discharge ranges from 25% to 75%. The most common treatment strategies include oral broad-spectrum antibiotics, antibiotic eardrops or those containing a combination of antibiotic(s) and a corticosteroid, and initial observation. Important drivers for one strategy over the other are concerns over the side effects of oral antibiotics and the potential ototoxicity of antibiotic eardrops.

OBJECTIVES

To assess the benefits and harms of current treatment strategies for children with ear discharge occurring at least two weeks following grommet (ventilation tube) insertion.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the ENT Trials Register, CENTRAL (2016, Issue 5), multiple databases and additional sources for published and unpublished trials (search date 23 June 2016).

SELECTION CRITERIA

Randomised controlled trials comparing at least two of the following: oral antibiotics, oral corticosteroids, antibiotic eardrops (with or without corticosteroid), corticosteroid eardrops, microsuction cleaning of the ear canal, saline rinsing of the ear canal, placebo or no treatment. The main comparison of interest was antibiotic eardrops (with or without corticosteroid) versus oral antibiotics.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Primary outcomes were: proportion of children with resolution of ear discharge at short-term follow-up (less than two weeks), adverse events and serious complications. Secondary outcomes were: proportion of children with resolution of ear discharge at intermediate- (two to four weeks) and long-term (four to 12 weeks) follow-up, proportion of children with resolution of ear pain and fever at short-term follow-up, duration of ear discharge, proportion of children with chronic ear discharge, ear discharge recurrences, tube blockage, tube extrusion, health-related quality of life and hearing. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included nine studies, evaluating a range of treatments, with 2132 children who developed acute ear discharge beyond the immediate postoperative period. We judged the risk of bias to be low to moderate in most studies. Antibiotic eardrops (with or without corticosteroid) versus oral antibioticsAntibiotic eardrops with or without corticosteroid were more effective than oral antibiotics in terms of:- resolution of discharge at one week (one study, 42 children, ciprofloxacin eardrops versus amoxicillin: 77% versus 30%; risk ratio (RR) 2.58, 95% confidence interval (CI) 1.27 to 5.22; moderate-quality evidence);- resolution of discharge at two weeks (one study, 153 children, bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: 95% versus 56%; RR 1.70, 95% CI 1.38 to 2.08; moderate-quality evidence);- duration of discharge (two studies, 233 children, ciprofloxacin eardrops versus amoxicillin: median 4 days versus 7 days and bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: 4 days versus 5 days; moderate-quality evidence);- ear discharge recurrences (one study, 148 children, bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: 0 versus 1 episode at six months; low-quality evidence); and- disease-specific quality of life (one study, 153 children, bacitracin-colistin-hydrocortisone eardrops versus amoxicillin-clavulanate: difference in change in median Otitis Media-6 total score (range 6 to 42) at two weeks: -2; low-quality evidence).We found no evidence that antibiotic eardrops were more effective in terms of the proportion of children developing chronic ear discharge or tube blockage, generic quality of life or hearing.Adverse events occurred at similar rates in children treated with antibiotic eardrops and those treated with oral antibiotics, while no serious complications occurred in either of the groups. Other comparisons(a) Antibiotic eardrops with or without corticosteroid were more effective thancorticosteroid eardrops in terms of:- duration of ear discharge (one study, 331 children, ciprofloxacin versus ciprofloxacin-fluocinolone acetonide versus fluocinolone acetonide eardrops: median 5 days versus 7 days versus 22 days; moderate-quality evidence).(b) Antibiotic eardrops were more effective than saline rinsing of the ear canal in terms of:- resolution of ear discharge at one week (one study, 48 children, ciprofloxacin eardrops versus saline rinsing: 77% versus 46%; RR 1.67, 95% CI 1.04 to 2.69; moderate-quality evidence);but not in terms of tube blockage. Since the lower limit of the 95% CI for the effect size for resolution of ear discharge at one week approaches unity, a trivial or clinically irrelevant difference cannot be excluded.(c) Eardrops containing two antibiotics and a corticosteroid (bacitracin-colistin-hydrocortisone) were more effective than no treatment in terms of:- resolution of discharge at two weeks (one study; 151 children: 95% versus 45%; RR 2.09, 95% CI 1.62 to 2.69; moderate-quality evidence);- duration of discharge (one study; 147 children, median 4 days versus 12 days; moderate-quality evidence);- chronic discharge (one study; 147 children; RR 0.08, 95% CI 0.01 to 0.62; low-quality evidence); and- disease-specific quality of life (one study, 153 children, difference in change in median Otitis Media-6 total score (range 6 to 42) between groups at two weeks: -1.5; low-quality evidence).We found no evidence that antibiotic eardrops were more effective in terms of ear discharge recurrences or generic quality of life.(d) Eardrops containing a combination of an antibiotic and a corticosteroid were more effective than eardrops containing antibiotics (low-quality evidence) in terms of:- resolution of ear discharge at short-term follow-up (two studies, 590 children: 35% versus 20%; RR 1.76, 95% CI 1.33 to 2.31); and- duration of discharge (three studies, 813 children);but not in terms of resolution of discharge at intermediate-term follow-up or proportion of children with tube blockage. However, there is a substantial risk of publication bias, therefore these findings should be interpreted with caution.

AUTHORS' CONCLUSIONS

We found moderate to low-quality evidence that antibiotic eardrops (with or without corticosteroid) are more effective than oral antibiotics, corticosteroid eardrops and no treatment in children with ear discharge occurring at least two weeks following grommet insertion. There is some limited, inconclusive evidence that antibiotic eardrops are more effective than saline rinsing. There is uncertainty whether antibiotic-corticosteroid eardrops are more effective than eardrops containing antibiotics only.

A pilot randomized controlled trial comparing bismuth iodine paraffin paste external ear pack and no ear pack after middle ear surgery

To pilot a substantive randomized control trial comparing post-operative external ear canal pack with no ear pack after middle ear surgery, 32 adults undergoing primary posterior bony canal wall preserving middle ear surgery were randomized to have either a bismuth iodoform paraffin paste pack or no ear pack post-operatively. Outcome measures included clinician- and patient-recorded visual analogue scale scores for ear signs and symptoms at 3 weeks and 3 months and audiometric findings at 3 months post-operatively. There was no statistically significant inter-group difference in 3-week clinician and patient cumulative scores for ear signs and symptoms. There was also no significant difference in graft take rate, appearance of ear canals and audiometric results in either group at 3 months. No difference in ear symptoms, clinician findings or hearing was demonstrated between patients with a post-operative pack compared to those without a pack following middle ear surgery in this pilot study.

Decontamination methods for flexible nasal endoscopes

A national survey was carried out to investigate the current UK practice for decontaminating flexible nasal endoscopes. A postal questionnaire was sent to Sisters in Charge of 200 ear, nose and throat (ENT) outpatient departments in the UK, with an overall response rate of 60.5%. Decontamination with chlorine dioxide wipes was the most favoured method, used in 58% of the hospitals that participated in this survey. Automated machines were also used in many places (34%). Only a few hospitals used flexible sheaths (7%). Many departments do not use a separate protocol for high-risk patients.

Dental extraction as a risk factor for bisphosphonate related osteonecrosis of the jaw in cancer patients: an update

Osteonecrosis of the jaw (ONJ) is a complication related to the use of bisphosphonates (BPs). Patients receiving BPs for the treatment of malignancies are at an increased risk of developing bisphosphonate-related ONJ (BRONJ) as compared to patients receiving BPs for the treatment of other disorders such as osteoporosis. Additionally, tooth extractions have been suggested to increase the risk of BRONJ in individuals taking BPs.

OBJECTIVE

To review the role of dental extraction as a risk factor for BRONJ in cancer patients.

MATERIALS AND METHODS

Databases were searched from January 1999 up to and including July 2012 using various combinations of the following keywords: "bisphosphonate", "osteonecrosis of the jaw", "cancer", "oral" and "dental extraction".

RESULTS

Twenty two studies were included. Eighteen studies assessed the relationship between BRONJ and dental extractions in cancer patients, reporting the overall prevalence of BRONJ following extraction in this group as 3.25 +/- 2.23%. Four studies did not report a correlation between BRONJ and extractions, and recommended protocols to avoid the complication.

CONCLUSION

There is a plausible relationship between dental extractions and the development of BRONJ in cancer patients. Written informed consent must be obtained prior to dental procedures in patients at risk for developing BRONJ.

Pack or No Pack after Ear Surgery: A Randomized Controlled Trial

Objective: 1) To see if there is a difference in patient and clinician reported outcomes between patients randomized to postoperative ear packing, compared to those who did not have the ear packed after middle ear surgery. 2) To see if there is a also a difference in hearing outcome between both groups.

Method: Randomized controlled trial of adult patients to have either Bismuth Iodoform Paraffin Paste pack or no ear pack postoperatively after primary canal wall up middle ear surgery. Setting: tertiary teaching hospital, UK (2011). Outcome measures: clinicians/patients recorded visual analogue scale scores at 3 weeks and 3 months postoperatively. Audiometry was recorded at 3 months.

Results: Thirty-two patients of similar sex and age were randomized to the 2 treatment arms. There was no statistically significant inter-group difference in 3-week composite clinician and patients mean visual analogue scores (146 mm versus 184 mm [ P = .3]). The graft take rates and the appearance of the ear canals at 3 months were similar in both groups ( P = 1.0 for both outcomes). There was also no significant inter-group difference in the change in mean air conduction thresholds in response to surgery (11.3 dB and 3.5 dB) in the ear pack and no pack groups, respectively ( P = .08).

Conclusion: No differences in total patient symptoms and clinician findings or hearing were demonstrated between patients with a postoperative pack compared to those without a postoperative pack following middle ear surgery. This pilot study provides justification for a larger clinical trial to investigate the need for postoperative ear canal packing.

Areca-nut chewing habit is a significant risk factor for metabolic syndrome: a systematic review

BACKGROUND

Areca-nut (AN) chewing habit has been associated with oral diseases including oral cancer, oral submucous fibrosis and periodontal disease; however, some authors have reported that the AN-chewing abuse may also jeopardize the systemic health among its users.

OBJECTIVES

The objective was to review any reported association between AN-chewing and the metabolic syndrome (MetS).

METHODS

To address the research question "Is there an association between areca-nut chewing habit and the MetS?" the MEDLINE and PubMed databases were searched from 1991 up to and including April 2010. The search criteria included: human studies, metabolic syndrome, diabetes, areca nut (AN). Only articles published in English were included.

RESULTS

Eight cohort studies were included in the review. The sample size of the selected studies ranged from 210 to 56,116 individuals (age range 15-83 years). The daily frequencies of AN-chewing reported by the users ranged between once a day to 76 times daily. The duration of use ranged from 6 years to ≥ 20 years. Two studies associated AN-chewing habit with hyperglycemia and type 2 diabetes while five studies studies reported an association between AN-chewing and metabolic syndrome. Four studies related AN-chewing with obesity and an increased body mass index. Higher triacylglycerol levels were reported in one study among AN-chewers compared to non-chewers. Though the numbers of publications on this subject are limited, the available studies indicate that AN-chewing could be associated with the metabolic syndrome, and individually with two of the recognized components of the syndrome i.e. diabetes mellitus and central obesity.

Parotid cancer treatment with surgery followed by radiotherapy in Oxford over 15 years

INTRODUCTION

Primary parotid malignancies represent a rare diagnosis, making high-quality comparative research unfeasible. There is little U.K.-based evidence to guide practice. A review was therefore undertaken of a large series of patients treated by a multidisciplinary team in a National Health Service tertiary referral centre.

PATIENTS AND METHODS

Retrospective patient record review at the John Radcliffe Hospital in Oxford identified 401 patients who had undergone parotidectomy between 1995 and 2010, of whom 50 subjects were given a definitive diagnosis of primary parotid malignancy, treated with surgery and postoperative radiotherapy. Case notes, histology and imaging were reviewed by the study team.

RESULTS

The median follow up for the cohort was 60 months (range: 1-108 months). Facial nerve function was preserved in all patients undergoing partial or total conservative parotidectomy. Although histology showed microscopically close or positive margins in 82% of cases, all patients underwent postoperative radiotherapy and locoregional recurrence was identified in only two (4%) patients.

CONCLUSIONS

The data presented demonstrate a reasonable and practical multidisciplinary approach to a complex management problem. Facial nerve sparing surgery and postoperative radiotherapy result in good control of locoregional disease.

UK survey of the present role of ear, nose and throat surgeons in lacrimal surgery

INTRODUCTION

The objective of this study was to evaluate the current involvement of ear, nose and throat (ENT) surgeons in lacrimal surgery.

SUBJECTS AND METHODS

A postal survey was distributed to 796 practicing UK consultant otorhinolaryngologists listed at the drfoster website.

RESULTS

Overall, 531 questionnaires were returned, giving a response rate of 66.7%. Of these, 108 (20.6%) respondents indicated they were involved in lacrimal surgery. The majority of otolaryngologists seem to work in collaboration with ophthalmologists. In our survey, 98% (106) perform endoscopic dacryocystorhinostomy (DCR). Most respondents believed lacrimal intubation and dilation to have limited success, endoscopic DCR to have moderate success and external DCR to have high success.

CONCLUSIONS

Lacrimal surgery is carried out in a spirit of collaboration with ophthalmologists rather than competition. Endoscopic DCR is the favoured surgical procedure of otolaryngologists. The perceived success rate for endoscopic DCR reported in this survey coincides with that reported in the literature.

Effects of leather industry on health and recommendations for improving the situation in Pakistan

The leather industry and its associated sectors contribute significantly to the Pakistani economy. There are around 600 tanneries in Pakistan that are concentrated in 3 major cities (Kasur, Karachi, Sialkot). Waste discharge from tanneries pollutes the air, soil, and water, causing serious health problems. Exposure to such contaminated environmental milieu has been seen to culminate in a multiple array of disease processes such as asthma, dermatitis, hepatic and neurological disorders, and various malignancies. An overall dearth of research on the occupational hazards of employment in the leather industry as well as its effects on pediatric population was observed during literature review with particular reference to Pakistan. It is recommended that research should be conducted about the health hazards in the leather industry in Pakistan as well as globally to gather data that can be translated into effective prevention programs for both adults as well as pediatric populations.