Evolution and Otitis Media: A Review, and a Model to Explain High Prevalence in Indigenous Populations

Inflammation of the middle ear (otitis media) comprises a group of disorders that are highly prevalent in childhood, and indeed are amongst the most common disorders of childhood. Otitis media is also heritable, and has effects on fecundity. This means that otitis media is subject to evolution, yet the evolutionary selection forces that may determine susceptibility to otitis media have never been adequately explored. Here I undertake a critical analysis of evolutionary forces that may determine susceptibility to middle ear inflammation. These forces include those determining function of the middle ear, those affecting host immunity, and those affecting colonization by, and pathogenicity of bacteria. I review existing mathematical evolutionary models of host-pathogen interaction and co-evolution, and apply these to develop a better understanding of the complex evolutionary landscape of middle ear infection and inflammation in humans. This includes an understanding of factors determining the transition between stable evolutionary strategies for host and bacterial pathogens. This understanding will be later applied to analysis of otitis media in indigenous populations. In the second part of this article, I apply the approach of population genetics to devise a new theory for the high prevalence of otitis media in certain indigenous populations: the Australian Aborigine, the Native American, the Inuit, and the Maori. I suggest that high prevalence in such groups may have occurred as a result of colonization of these previously isolated populations by European immigrants in the 15th and 16th Centuries. This exposed them to new strains of bacteria to which their immune system had not evolved immunity, perturbing a previously stable host- pathogen co-evolutionary state

Environmental impact and life cycle financial cost of hybrid (reusable/single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy

Background Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. The environmental and financial costs of such instruments have not previously been evaluated. Methods We used Life Cycle Assessment to evaluate the environmental impact of hybrid laparoscopic clip appliers, scissors, and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro and ReCiPe midpoint and endpoint methods to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis of products, taking into account unit cost, decontamination, and disposal costs. Results The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%. The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1756 g vs 7194 g CO2e per operation) and saved an estimated 1.13 e−5 DALYs (disability adjusted life years, 74% reduction), 2.37 e−8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated that environmental performance of hybrid instruments was better even if there was low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel-rich energy sources, or changing carbon intensity of instrument transportation. Total financial cost of using a combination of hybrid laparoscopic instruments was less than half that of single-use equivalents (GBP £131 vs £282). Conclusion Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery and also save money

Re: The Carbon Footprint of Single-Use Flexible Cystoscopes Compared with Reusable Cystoscopes: Methodological Flaws Led to the Erroneous Conclusion That Single-Use Is "Better"

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ENT from afar : opportunities for remote patient assessment, clinical management, teaching and learning

Remote communication in ENT has been expanding, spurred by the COVID-19 pandemic. Conferences and teaching have moved online, enabling easier participation and reducing financial and environmental costs. Online multi-disciplinary meetings have recently been instigated in Africa to discuss management of cases in head and neck cancer, or cochlear implantation, expanding access and enhancing patient care. Remote patient consultation has also seen an explosion, but existing literature suggests some caution, particularly because many patients in ENT need an examination to enable definitive diagnosis. Ongoing experience will help us to better understand how remote communication will fit into our future working lives, and also where face-to-face interaction may still be preferable.http://www.wileyonlinelibrary.com/journal/coahj2022Speech-Language Pathology and Audiolog

Plastics in healthcare: time for a re-evaluation

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Minimising carbon and financial costs of steam sterilisation and packaging of reusable surgical instruments

Background: The aim of this study was to estimate the carbon footprint and financial cost of decontaminating (steam sterilization) and packaging reusable surgical instruments, indicating how that burden might be reduced, enabling surgeons to drive action towards net-zero-carbon surgery. Methods: Carbon footprints were estimated using activity data and prospective machine-loading audit data at a typical UK in-hospital sterilization unit, with instruments wrapped individually in flexible pouches, or prepared as sets housed in single-use tray wraps or reusable rigid containers. Modelling was used to determine the impact of alternative machine loading, opening instruments during the operation, streamlining sets, use of alternative energy sources for decontamination, and alternative waste streams. Results: The carbon footprint of decontaminating and packaging instruments was lowest when instruments were part of sets (66-77 g CO2e per instrument), with a two- to three-fold increase when instruments were wrapped individually (189 g CO2e per instrument). Where 10 or fewer instruments were required for the operation, obtaining individually wrapped items was preferable to opening another set. The carbon footprint was determined significantly by machine loading and the number of instruments per machine slot. Carbon and financial costs increased with streamlining sets. High-temperature incineration of waste increased the carbon footprint of single-use packaging by 33-55 per cent, whereas recycling reduced this by 6-10 per cent. The absolute carbon footprint was dependent on the energy source used, but this did not alter the optimal processes to minimize that footprint. Conclusion: Carbon and financial savings can be made by preparing instruments as part of sets, integrating individually wrapped instruments into sets rather than streamlining them, efficient machine loading, and using low-carbon energy sources alongside recycling

The carbon footprint of products used in five common surgical operations: identifying contributing products and processes

Objectives Mitigating carbon footprint of products used in resource-intensive areas such as surgical operating rooms will be important in achieving net zero carbon healthcare. The aim of this study was to evaluate the carbon footprint of products used within five common operations, and to identify the biggest contributors (hotspots). Design A predominantly process-based carbon footprint analysis was conducted for products used in the five highest volume surgical operations performed in the National Health System in England. Setting The carbon footprint inventory was based on direct observation of 6–10 operations/type, conducted across three sites within one NHS Foundation Trust in England. Participants Patients undergoing primary elective carpal tunnel decompression, inguinal hernia repair, knee arthroplasty, laparoscopic cholecystectomy, tonsillectomy (March 2019 – January 2020). Main outcome measures We determined the carbon footprint of the products used in each of the five operations, alongside greatest contributors through analysis of individual products and of underpinning processes. Results The mean average carbon footprint of products used for carpal tunnel decompression was 12.0 kg CO2e (carbon dioxide equivalents); 11.7 kg CO2e for inguinal hernia repair; 85.5 kg CO2e for knee arthroplasty; 20.3 kg CO2e for laparoscopic cholecystectomy; and 7.5 kg CO2e for tonsillectomy. Across the five operations, 23% of product types were responsible for ≥80% of the operation carbon footprint. Products with greatest carbon contribution for each operation type were the single-use hand drape (carpal tunnel decompression), single-use surgical gown (inguinal hernia repair), bone cement mix (knee arthroplasty), single-use clip applier (laparoscopic cholecystectomy) and single-use table drape (tonsillectomy). Mean average contribution from production of single-use items was 54%, decontamination of reusables 20%, waste disposal of single-use items 8%, production of packaging for single-use items 6% and linen laundering 6%. Conclusions Change in practice and policy should be targeted towards those products making greatest contribution, and should include reducing single-use items and switching to reusables, alongside optimising processes for decontamination and waste disposal, modelled to reduce carbon footprint of these operations by 23%–42%

Genome-wide association analysis reveals variants on chromosome 19 that contribute to childhood risk of chronic otitis media with effusion

To identify genetic risk factors of childhood otitis media (OM), a genome-wide association study was performed on Finnish subjects, 829 affected children, and 2118 randomly selected controls. The most significant and validated finding was an association with an 80 kb region on chromosome 19. It includes the variants rs16974263 (P = 1.77 x 10(-7), OR = 1.59), rs268662 (P = 1.564 x 10(-6), OR = 1.54), and rs4150992 (P = 3.37 x 10(-6), OR = 1.52), and harbors the genes PLD3, SERTAD1, SERTAD3, HIPK4, PRX, and BLVRB, all in strong linkage disequilibrium. In a sub-phenotype analysis of the 512 patients with chronic otitis media with effusion, one marker reached genome-wide significance (rs16974263, P = 2.92 x 10(-8)). The association to this locus was confirmed but with an association signal in the opposite direction, in a UK family cohort of 4860 subjects (rs16974263, P = 3.21 x 10(-4), OR = 0.72; rs4150992, P = 1.62 x 10(-4), OR = 0.71). Thus we hypothesize that this region is important for COME risk in both the Finnish and UK populations, although the precise risk variants or haplotype background remain unclear. Our study suggests that the identified region on chromosome 19 includes a novel and previously uncharacterized risk locus for OM.Peer reviewe