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Despite the plethora of publications on the subject of paediatric obstructive sleep apnoea, there seems to be wide variability in the literature and in practice, regarding recourse to surgery, the operation chosen, the benefits gained and post-operative management. This may reflect a lack of high-level evidence.
A systematic review of four significant controversies in paediatric ENT was conducted from the available literature: tonsillectomy versus tonsillotomy, focusing on the evidence base for each; anaesthetic considerations in paediatric obstructive sleep apnoea surgery; the objective evidence for the benefits of surgical treatment for obstructive sleep apnoea; and the medical treatment options for residual obstructive sleep apnoea after surgical treatment.
Results and conclusion:
There are many gaps in the evidence base for the surgical correction of obstructive sleep apnoea. There is emerging evidence favouring subtotal tonsillectomy. There is continuing uncertainty around the prediction of the level of post-operative care that any individual child might require. The long-term benefit of surgical correction is a particularly fertile ground for further research.
Paediatric obstructive sleep apnoea is a common clinical condition managed by most ENT clinicians. However, despite the plethora of publications on the subject, there is wide variability, in the literature and in practice, on key aspects such as diagnostic criteria, the impact of co-morbidities and the indications for surgical correction.
A systematic review is presented, addressing four key questions from the available literature: (1) what is the evidence base for any definition of paediatric obstructive sleep apnoea?; (2) does it cause serious systemic illness?; (3) what co-morbidities influence the severity of paediatric obstructive sleep apnoea?; and (4) is there a medical answer?
Results and conclusion:
There is a considerable lack of evidence regarding most of these fundamental questions. Notably, screening measures show low specificity and can be insensitive to mild obstructive sleep apnoea. There is a surprising lack of clarity in the definition (let alone estimate of severity) of sleep-disordered breathing, relying on what may be arbitrary test thresholds. Areas of potential research might include investigation of the mechanisms through which obstructive sleep apnoea causes co-morbidities, whether neurocognitive, behavioural, metabolic or cardiovascular, and the role of non-surgical management.
The advent of supraglottoplasty clearly has transformed the surgical management of severe laryngomalacia. The condition, however, generally runs a milder course, with spontaneous resolution the norm.
To identify gaps in the knowledge and identify topics for future study.
Systematic review of the literature.
The literature suggests that there is a range of abnormalities leading to the typical collapsing upper airway, and that neurological disease, other airway abnormalities, syndromes and gastroesophageal reflux all contribute to disease severity and influence outcomes. The procedures involved in supraglottoplasty are rarely specified, the indications for surgery are vaguely defined and the role of medical therapy is unclear.
Every review article or survey of opinion suggests that there is still a marked variation in individual practice and a lack of consensus.
Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.
Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.
Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) < 0.01]. The structure of EPDS responses significantly differed between Europe and the USA (∆*CFI > 0.01), but not between European countries (∆*CFI < 0.01).
Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.
We evaluated A/H1N1 influenza in healthcare workers (HCWs) and in a flu room during the 2009 pandemic. The flu room aided HCW care and management by facilitating rapid diagnosis and treatment. Absence of fever was common, and symptoms were nonspecific. A higher rate of H1N1 occurred in HCWs deployed in acute services.
The binder burn-out behavior in PMMA/glass powder composites was studied as a function of glass composition in the PbO-SiO2-B203 system. The PbO content was varied to obtain glasses having optical basicities in the range of 0.62-0.81. TGA measurements on PMMA/glass composites show that the main decomposition end temperatures of PMMA increase with decreasing PbO content, and therefore, decreasing optical basicity. This indicates that PMMA interacts strongly with more acidic surfaces. The effect of the milling fluid was also studied. Milling in toluene does not significantly alter the behavior. Milling in water of a PbO-rich glass leads to significant leaching of lead. During drying, the leached lead deposits on the glass particle surfaces and drastically alters the thermal behaviour of the glass powder and PMMA/glass composites.
Recent progress in the field of liquid crystal materials and oriented polymers studied by nearfield scanned probe microscopies (SPM) is presented here. The investigations were focused on scanning tunneling microscopy (STM) results of antiferroelectric liquid crystalline molecules observed at different elevated temperatures corresponding to different bulk mesophases of the material, and on surface morphological studies of a liquid crystalline polymer by scanning force microscopy (SFM). In the field of oriented thermoplastic polymers, SFM images of the morphology and molecular packing in the outermost surface of poly(butene-1) films are presented.
This study characterized the current epidemiology of vibrio infections in Florida and examined cases reported from 1998 to 2007. Logistic regression was used to determine risk of death. There were 834 vibrio infections in 825 individuals (average annual incidence rate 4·8/1 000 000). Common Vibrio species reported were Vibrio vulnificus (33%), V. parahaemolyticus (29%), and V. alginolyticus (16%). Most exposures were attributed to wounds (42%), and the most common clinical syndromes were wound infections (45%) and gastroenteritis (42%). Almost half of individuals reported an underlying health condition. Risk of death was associated with any underlying condition and increased with the number of conditions (P<0·0001). In Florida, incidence of vibriosis associated with raw oyster consumption has decreased while incidence associated with wound infections has increased. Most prevention efforts to date have focused on oyster consumption. New educational messages focusing on the risk of vibriosis from wound infections should target high-risk populations.
We report a rare case of avascular necrosis of the maxilla secondary to oral bisphosphonates.
Case report and review of the world literature concerning avascular necrosis as a result of bisphosphonate therapy.
A 62-year-old woman presented with unilateral nasal obstruction, swelling of the cheek and an ulcerating lesion of the upper alveolus. She had a past medical history of osteoporosis, for which she took oral bisphosphonates. Investigation revealed necrosis of the maxilla, and avascular necrosis secondary to oral bisphosphonates was diagnosed.
There have been several documented cases of avascular necrosis of the mandible and maxilla following intravenous bisphosphonates or dental procedures. In our case, bisphosphonates were only taken orally and no dental work had been undertaken. This patient's clinical presentation was highly suggestive of malignancy, and we would like to communicate this unusual case to other otolaryngologists.
Epidemiological aspects of infection with leptospires of the Ballum serogroup in black rats (Rattus rattus) and brown rats (Rattus norvegicus) are described. Rats inhabiting a variety of habitats were investigated and isolates identified as belonging to the Ballum serogroup were obtained from 21 of 61 black rats (34%) and 63 of 243 brown rats (26%). The high level of endemic Ballum serogroup infection in these species reported here has not been described in other countries.
A statistical relationship was shown between the prevalence of infection in brown rat populations and population density but this was not evident for black rats. Epidemiological data indicates that the black rat is a maintenance host for leptospires of the Ballum serogroup in New Zealand. The brown rat does not appear to be an efficient maintenance host for these leptospires, however endemic infection can be maintained in high-density populations inhabiting synanthropic foci.
An hypothesis of ‘competitive exclusion’ (preferential maintenance of a particular serovar by a host species) is introduced with regard to leptospiral infection in brown rats. It is concluded that the establishment and maintenance of an endemic focus of leptospirosis is dependant on: introduction of a particular serovar; a suitable host; and a suitable host habitat. Within a maintenance population direct transmission appears to be more important than indirect transmission via the environment.
Piglets between 1 and 40 days of age were inoculated with varying numbers and with different isolates of Streptococcus suis type 2 by the intranasal, intravenous and subarachnoid routes. Less than 100 organisms of an isolate cultured from apparently normal pigs caused subclinical infection in 1-day-old piglets after intranasal inoculation. This infection was naturally transmitted between litter mates. Intravenous inoculation of a similar isolate in 7-week-old pigs resulted in a sub-clinical bacteraemia in 3 of 8 piglets. One other piglet developed a bacteraemia 7 days after inoculation and concurrently developed signs of lameness and nervous dysfunction. Ten piglets were inoculated by the subarachnoid route with a porcine isolate and two with an isolate from a person with clinical disease. Only the latter two pigs developed the classical signs of nervous disease associated with infection by S. suis type 2. It is concluded that strains of S. suis type 2, of varying pathogenicity for both pigs and man, are endemic in New Zealand. It is suggested that the occurrence of disease is associated with both exposure to a pathogenic strain and other, as yet undetermined, secondary factors.
Streptococcus suis types 1 and 2 were detected in nasal swabs taken from five litters of piglets sampled twice weekly from birth. The two types had been detected in all pigs by the time they were 38 and 25 days old respectively with mean ages of first detectable infection being 13·5 and 8·5 days. The prevalence of infection was not affected by housing conditions or the population density of pigs. Piglets originating from a sow with vaginal swabs positive for S. suis type 2 were infected earlier than piglets from non-vaginal carriers. It is concluded that infection of piglets with S. suis type 2 may occur during the birth process.