Bone metabolic activity in hyperostosis cranialis interna measured with 18F-fluoride PET

F-18-Fluoride PET/CT is a relatively undervalued diagnostic test to measure bone metabolism in bone diseases. Hyperostosis cranialis interna (HCI) is a (hereditary) bone disease characterised by endosteal hyperostosis and osteosclerosis of the skull and the skull base. Bone overgrowth causes entrapment and dysfunction of several cranial nerves. The aim of this study is to compare standardised uptake values (SUVs) at different sites in order to quantify bone metabolism in the affected anatomical regions in HCI patients. Nine affected family members, seven non-affected family members and nine non-HCI non-family members underwent F-18-fluoride PET/CT scans. SUVs were systematically measured in the different regions of interest: frontal bone, sphenoid bone, petrous bone and clivus. Moreover, the average F-18-fluoride uptake in the entire skull was measured by assessing the uptake in axial slides. Visual assessment of the PET scans of affected individuals was performed to discover the process of disturbed bone metabolism in HCI. F-18-Fluoride uptake is statistically significantly higher in the sphenoid bone and clivus regions of affected family members. Visual assessment of the scans of HCI patients is relevant in detecting disease severity and the pattern of disturbed bone metabolism throughout life. F-18-Fluoride PET/CT is useful in quantifying the metabolic activity in HCI and provides information about the process of disturbed bone metabolism in this specific disorder. Limitations are a narrow window between normal and pathological activity and the influence of age. This study emphasises that F-18-fluoride PET/CT may also be a promising diagnostic tool for other metabolic bone disorders, even those with an indolent course

BMJ Open

INTRODUCTION: Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients. METHODS AND ANALYSIS: The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence. ETHICS AND DISSEMINATION: Ethical approval for the GOAL study has already been obtained from the Medical Review Ethics Committee region Arnhem-Nijmegen. Additionally and when necessary, approval will also be obtained from national or local institutional review boards in the participating centres. When needed, a standardised data transfer agreement will be provided for participating centres. We plan dissemination of our results in peer-reviewed international scientific journals and through conference presentations. We expect that the results of this unique study will lead to better understanding of worldwide differences in risk factors, causes and outcome of young stroke patients

Global Outcome Assessment Life-long after stroke in young adults initiative-the GOAL initiative : study protocol and rationale of a multicentre retrospective individual patient data meta-analysis

Introduction Worldwide, 2 million patients aged 18-50 years suffer a stroke each year, and this number is increasing. Knowledge about global distribution of risk factors and aetiologies, and information about prognosis and optimal secondary prevention in young stroke patients are limited. This limits evidence-based treatment and hampers the provision of appropriate information regarding the causes of stroke, risk factors and prognosis of young stroke patients. Methods and analysis The Global Outcome Assessment Life-long after stroke in young adults (GOAL) initiative aims to perform a global individual patient data meta-analysis with existing data from young stroke cohorts worldwide. All patients aged 18-50 years with ischaemic stroke or intracerebral haemorrhage will be included. Outcomes will be the distribution of stroke aetiology and (vascular) risk factors, functional outcome after stroke, risk of recurrent vascular events and death and finally the use of secondary prevention. Subgroup analyses will be made based on age, gender, aetiology, ethnicity and climate of residence.Peer reviewe

Tympanostomy tube otorrhea in children : prevention and treatment

PURPOSE OF REVIEW: One in two children treated with tympanostomy tubes, experience episodes of otorrhea whilst their tubes are in place. In this review, we present the results of the most recent publications on prevention and treatment of tympanostomy tube otorrhea (TTO). RECENT FINDINGS: Recent systematic reviews on water precautions for children with tympanostomy tubes support the American Academy of Otolaryngology - Head and Neck Surgery guideline recommendation against such preventive measures as there is no evidence that it protects against TTO. Studies on tympanostomy tube design and material suggest that silicone tubes have a lower TTO risk and that biofilms appear to be mainly located in the perpendicular junction of the T-tubes and the round rims of the Paparella-type tubes. Another study shows that the biofilm-component DNAB-II protein is present in otorrhea of half of children with TTO. Targeting this protein could lead to a collapse of the biofilm structure and as such a potential new treatment for chronic TTO. New systematic reviews show that antibiotic eardrops are the most effective first-line treatment of acute TTO and suggest that an antibiotic-corticosteroid combination is more effective than antibiotic only. Although in many countries, quinolone eardrops are the preferred choice because of being non-ototoxic, one study found a higher risk of persistent perforation after tube extrusion in children treated with quinolone eardrops as compared with children treated with aminoglycoside eardrops. SUMMARY: Recent evidence confirms that water precautions for children with tympanostomy tubes are not effective in preventing TTO. Antibiotic-corticosteroid eardrops are the most effective treatment of acute TTO

Tympanostomy tube otorrhea in children : prevention and treatment

PURPOSE OF REVIEW: One in two children treated with tympanostomy tubes, experience episodes of otorrhea whilst their tubes are in place. In this review, we present the results of the most recent publications on prevention and treatment of tympanostomy tube otorrhea (TTO). RECENT FINDINGS: Recent systematic reviews on water precautions for children with tympanostomy tubes support the American Academy of Otolaryngology - Head and Neck Surgery guideline recommendation against such preventive measures as there is no evidence that it protects against TTO. Studies on tympanostomy tube design and material suggest that silicone tubes have a lower TTO risk and that biofilms appear to be mainly located in the perpendicular junction of the T-tubes and the round rims of the Paparella-type tubes. Another study shows that the biofilm-component DNAB-II protein is present in otorrhea of half of children with TTO. Targeting this protein could lead to a collapse of the biofilm structure and as such a potential new treatment for chronic TTO. New systematic reviews show that antibiotic eardrops are the most effective first-line treatment of acute TTO and suggest that an antibiotic-corticosteroid combination is more effective than antibiotic only. Although in many countries, quinolone eardrops are the preferred choice because of being non-ototoxic, one study found a higher risk of persistent perforation after tube extrusion in children treated with quinolone eardrops as compared with children treated with aminoglycoside eardrops. SUMMARY: Recent evidence confirms that water precautions for children with tympanostomy tubes are not effective in preventing TTO. Antibiotic-corticosteroid eardrops are the most effective treatment of acute TTO

Cost-Effectiveness of Treatment of Acute Otorrhea in Children With Tympanostomy Tubes

BACKGROUND: Acute otorrhea is a common problem in children with tympanostomy tubes. We recently demonstrated that treatment with antibiotic-glucocorticoid eardrops is clinically superior to oral antibiotics and initial observation. The aim of this study was to assess the cost-effectiveness of these three common treatment strategies for this condition. METHODS: We performed an open-label pragmatic trial in which 230 children with acute uncomplicated tympanostomy-tube otorrhea were randomly allocated to receive 1 of 3 treatments: hydrocortisone-bacitracin-colistin eardrops, oral amoxicillin-clavulanate suspension, and initial observation (no assigned medication prescription to fill). Parents kept a daily diary capturing ear-related symptoms, health care resource use, and non-health care costs for 6 months. At 2 weeks and 6 months, the study doctor visited the children at home performing otoscopy. Using a societal perspective, treatment failure (otoscopic presence of otorrhea at 2 weeks) and number of days with otorrhea as reported in the daily diary were balanced against the costs. RESULTS: Antibiotic-glucocorticoid eardrops were clinically superior to oral antibiotics and initial observation both at 2 weeks and 6 months. At 2 weeks, mean total cost per patient was US $42.43 for antibiotic-glucocorticoid eardrops, US$70.60 for oral antibiotics, and US$82.03 for initial observation. At 6 months, mean total cost per patient was US$368.20, US$420.73, and US$640.44, respectively. Because of the dominance of eardrops, calculating incremental cost-effectiveness ratios was redundant. CONCLUSIONS: Antibiotic-glucocorticoid eardrops are clinically superior and cost less than oral antibiotics and initial observation in children with tympanostomy tubes who develop otorrhea

Parent-Reported Otorrhea in Children with Tympanostomy Tubes: Incidence and Predictors

<div><p>Purpose</p><p>Although common in children with tympanostomy tubes, the current incidence of tympanostomy tube otorrhea (TTO) is uncertain. TTO is generally a sign of otitis media, when middle ear fluid drains through the tube. Predictors for otitis media are therefore suggested to have predictive value for the occurrence of TTO.</p><p>Objective</p><p>To determine the incidence of TTO and its predictors.</p><p>Methods</p><p>We performed a cohort study, using a parental web-based questionnaire to retrospectively collect data on TTO episodes and its potential predictors from children younger than 10 years of age with tympanostomy tubes.</p><p>Results</p><p>Of the 1,184 children included in analyses (total duration of time since tube placement was 768 person years with a mean of 7.8 months per child), 616 children (52%) experienced one or more episodes of TTO. 137 children (12%) had TTO within the calendar month of tube placement. 597 (50%) children had one or more acute TTO episodes (duration <4 weeks) and 46 children (4%) one or more chronic TTO episodes (duration ≥4 weeks). 146 children (12%) experienced recurrent TTO episodes. Accounting for time since tube placement, 67% of children developed one or more TTO episodes in the year following tube placement. Young age, recurrent acute otitis media being the indication for tube placement, a recent history of recurrent upper respiratory tract infections and the presence of older siblings were independently associated with the future occurrence of TTO, and can therefore be seen as predictors for TTO.</p><p>Conclusions</p><p>Our survey confirms that otorrhea is a common sequela in children with tympanostomy tubes, which occurrence can be predicted by age, medical history and presence of older siblings.</p></div

Optimizing orthopedic trauma care delivery during the COVID-19 pandemic: A closed-loop audit of implementing a virtual fracture clinic and fast-track pathway in a Dutch level 2 trauma center

Background: Guidelines concerning outpatient management of patients during the coronavirus pandemic required minimized face-to-face follow-up and increased remote care. In response, we established a virtual fracture clinic (VFC) review for emergency department (ED) patients with musculoskeletal injuries, meaning patients are reviewed 'virtually' the next workday by a multidisciplinary team, instead of routine referral for face-to-face fracture clinic review. Patients wait at home and are contacted afterwards to discuss treatment. Based on VFC review, patients with minor injuries are discharged, while for other patients an extensive treatment plan is documented using injury-specific care pathways. Additionally, we established an ED orthopedic trauma fast-track to reduce waiting time. This study aimed to evaluate the extent to which our workflow supported adherence to national coronavirus-related guidelines and effects on ED waiting time. Methods: A closed-loop audit was performed during two 4-week periods using predefined standards: (1) all eligible ED orthopedic trauma patients are referred for VFC review; (2) reached afterwards; and follow-up is (3) patient initiated, or (4) performed remotely, whenever possible. Total ED waiting time, time to review, time for review, and time after review were assessed during both audit periods and compared with previous measurements. Results: During both audits, the majority of eligible ED patients were referred for VFC review (1st: n=162 (88.0%); 2nd: n=302 (98.4%)), and reached afterwards (1st: 98.1%; 2nd: 99.0%). Of all referred patients, 17.9% and 13.6% were discharged 'virtually' during first and second audits, respectively, while 45.0% and 41.1% of scheduled follow-up appointments were remote. Median total ED waiting time was reduced (1st: -36 minutes (p<0.001); 2nd: -33 minutes (p<0.001)). During the second audit, median ED time to review was reduced by -13 minutes (p<0.001), as well as time for review: -10 minutes (p=0.019). Discussion: In line with national guidelines, our VFC review allowed time-effective review and triage of the majority of ED orthopedic trauma patients, supporting patient-initiated and remote follow-up, whenever possible. ED waiting time was reduced after implementing the VFC review and orthopedic trauma fast-track. Level of evidence: IV

Prevalence and Antimicrobial Resistance of Bacteria in Children With Acute Otitis Media and Ear Discharge: A Systematic Review

BACKGROUND: Of children with acute otitis media (AOM), 15%-20% present with acute onset ear discharge due to a spontaneous perforation of the tympanic membrane (AOMd). This review aims to quantify the prevalence and antimicrobial resistance (AMR) status of bacteria in children with AOMd in the pneumococcal conjugate vaccine (PCV) era.METHODS: Systematic searches were performed in PubMed, EMBASE and Cochrane Library from inception to June 7, 2019. Two reviewers extracted relevant data and assessed risk of bias independently. All English studies reporting any prevalence and/or AMR data of bacterial middle ear isolates from children with AOMd were included. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal checklist.RESULTS: Of 4088 unique records retrieved, 19 studies (10,560 children) were included. Overall quality was judged good. Streptococcus pneumoniae (median 26.1%, range 9.1%-47.9%), Haemophilus influenzae (median 18.8%, range 3.9%-55.3%), Staphylococcus aureus (median 12.3%, range 2.3%-34.9%) and Streptococcus pyogenes (median 11.8%, range 1.0%-30.9%) were the most prevalent bacteria. In 76.0% (median, range 48.7%-100.0%, 19 studies, 1,429 children) any bacterium was identified. AMR data were sparse and mainly limited to S. pneumoniae. We found no evidence of a clear shift in the prevalence of bacteria and AMR over time.CONCLUSIONS: In children with AOMd, S. pneumoniae and H. influenzae are the 2 predominant bacteria, followed by S. aureus and S. pyogenes in the post-PCV era. AMR data are sparse and no clearly change over time was observed. Ongoing surveillance of the microbiology profile in children with AOMd is warranted to guide antibiotic selection and to assess the impact of children's PCV status.</p